Handbook of Religion and Health [3 ed.] 0190088850, 9780190088859

Citation preview

Handbook of Religion and Health

Harold G. Koenig, M.D., M.H.Sc. Professor of Psychiatry & Behavioral Sciences Associate Professor of Medicine Duke University Medical Center, Durham, North Carolina Adjunct Professor, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia Adjunct Professor of Public Health, Ningxia Medical University, Yinchuan, P.R. China Editor-​in-​Chief, International Journal of Psychiatry in Medicine Tyler J. VanderWeele, Ph.D. John L. Loeb and Frances Lehman Loeb Professor of Epidemiology Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health Boston, Massachusetts Director, Human Flourishing Program, Institute for Quantitative Social Science, Harvard University, Cambridge, Massachusetts John R. Peteet, M.D. Associate Professor of Psychiatry Harvard Medical School Dana-​Farber Cancer Institute and Brigham and Women’s Hospital Boston, Massachusetts

HANDBOOK OF RELIGION AND HEALTH THIRD EDITION

H A RO L D G . K O E N I G T Y L E R J . VA N D E RW E E L E JOHN R. PETEET

Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2024 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Names: Koenig,Harold G., author. | VanderWeele, Tyler J., author. | Peteet, John R., 1947– author. Title: Handbook of religion and health / Harold G. Koenig, Tyler J. VanderWeele, John R. Peteet. Description: 3rd edition. | New York, NY, United States of America : Oxford University Press, [2024] | Includes bibliographical references and index. Identifiers: LCCN 2022027305 (print) | LCCN 2022027306 (ebook) | ISBN 9780190088859 (hardback) | ISBN 9780190088873 (epub) Subjects: LCSH: Health—Religious aspects. Classification: LCC BL65. M4 K597 2024 (print) | LCC BL65. M4 (ebook) | DDC 201/.661—dc23/eng20221006 LC record available at https://lccn.loc.gov/2022027305 LC ebook record available at https://lccn.loc.gov/2022027306 DOI: 10.1093/​oso/​9780190088859.001.0001 Printed by Sheridan Books, Inc., United States of America

To our wives who have so faithfully supported us in this work

Contents

Foreword (Howard K. Koh)  ix Preface (Jeff Levin)  xi Introduction  xv

8. Anxiety  123

SECTION I. RESEARCH METHODOLOGY

10. Substance Use and Substance Use Disorders  163

1. Definitions  3 2. Measurement  15 3. Research Design  30

9. Schizophrenia and Other Psychoses  143

11. Personality Traits and Disorders  189

SECTION II. MENTAL HEALTH

12. Psychological Well-​Being and Positive Emotions  211

4. Coping with Stress  45

SECTION III. SOCIAL HEALTH

5. Depression  66

13. Delinquency and Crime  237

6. Bipolar Disorder  89

14. Marital and Family Stability  254

7. Suicide  103

15. Social Support  282

 • vii

SECTION IV. EXPLANATORY MECHANISMS: MENTAL AND SOCIAL HEALTH

16. Understanding the Religion, Mental, and Social Health Relationship  301 SECTION V. HEALTH BEHAVIORS

17. Cigarette Smoking  317 18. Exercise  328 19. Diet and Weight  344 SECTION VI. PHYSICAL HEALTH

20. Heart Disease  369 21. Hypertension  397 22. Cerebrovascular Disease  416 23. Alzheimer’s Disease and Other Dementias  437

28. Physical Disability  545 29. Chronic Pain  565 30. Disease Prevention, Detection, and Treatment  587 SECTION VII. EXPLANATORY MECHANISMS: PHYSICAL HEALTH

31. Understanding the Religion–​ Physical Health Relationship  611 SECTION VIII. PUBLIC HEALTH AND HEALTH POLICY

32. Public Health and Human Flourishing  629 33. Health Policy Implications  645 SECTION IX. CONCLUSIONS

34. Summary and Conclusions  663

24. Immune Function  458 25. Stress Hormones  481 26. Cancer  505 27. Mortality  523

viii •  C ontents

Appendix: Studies on Religion and Health (by Health Outcome)  675 References  863 Index  1053

Foreword

Sometimes the sheer audacity of a vision lifts everyone into a state of awe. Pioneers creating that vision, daring to go big and broad, invite us to gaze up at the horizon, not down at our narrow views of life. Their courage and commitment inspire our minds and stretch our souls. They push us to wonder—​and ponder anew—​ what it fundamentally means to be human. That’s what Drs. Harold Koenig, Tyler VanderWeele, and John Peteet have accomplished through this stunningly ambitious third edition of The Handbook of Religion and Health. In it, these three pioneers combine forces to push us out of our comfortable siloes. We should all be grateful to them for daring to offer the broadest interdisciplinary approach for comprehending human well-​being. Doing so requires utter humility, of course. Trying to fathom how the search for the sacred influences health and well-​being is not for the faint of heart. Few of us feel expert in navigating

fields as disparate as physical health, health behavior, social health, and social support through the lens of religion and spirituality. Even fewer would summon the courage to propose potential explanatory mechanisms to explain the rainbow of religion, spirituality, physical health, and mental health. And almost no one has tried to imagine what this all means for medical practice, health policy and public health. Drs Koenig, VanderWeele and Peteet do all this—​and more. As far back as around 350 bce, Aristotle proposed that “the soul is the full actualization of a person, incorporating body, purpose and ultimately the sum of total operations of being human.” Over ensuing centuries, thought leaders have attempted to probe, with varying success, this profound concept. The twenty-​ first century finally brought forward some evidence that the idea was here to stay. In 2001, Dr. Koenig first published his historic

 • ix

Handbook; a second edition was published in 2012 (in collaboration with colleagues Drs. Dana King and Verna Carson). These editions, systematically compiling research dating back to the late 1800s, established the Handbook as the seminal reference for the field. Dr. Koenig’s historic contributions nudged the modern-​ day concept of health closer to what the World Health Organization first envisioned in 1948 as “a state of complete physical, mental, social well-​being and not merely the absence of disease or infirmity.” In this third Edition, Drs. VanderWeele and Peteet join to elevate an already stunning work. Dr. VanderWeele contributes not only his nationally recognized expertise in research methods and rigorous study evaluation, but also seminal concepts of human flourishing shaped by dimensions of spirituality, meaning, and purpose. Dr. Peteet brings to bear his lifetime of clinical expertise in patient care, as well as decades of dedication to physician training about religion and health. Together, the three authors rank studies according to a hierarchy of evidence, focus on the highest-​quality ones, and widen the Handbook’s appeal for audiences that can be theoretical, practice-​based, theological, and/​or secular. Their work informs and animates investigators and practitioners in the psychological, social, behavioral, and medical sciences, as well as those in clinical medicine and public health. With their help, everyone can better appreciate the kaleidoscope of complete well-​being—​from the individual to the societal level. Every reader will reflect on how these profound themes relate to their own life. It did

x •  F oreword

so for me. As I read, I started thinking about my own upbringing when my beloved father, Dr. Kwang Lim Koh, repeatedly warned against living life too narrowly—​ “be broad like the sky!” he would always exclaim. As a young physician traditionally taught to view health in terms of organ systems and disease mechanisms, I unexpectedly found Yale Chaplain Reverend William Sloane Coffin to be my most powerful teacher. He loved to trumpet that “the glory of God is a human being fully alive” and demanded that doctors be true healers who “never treat a patient as an uninteresting appendage to an interesting disease.” Now, Drs. Koenig, VanderWeele, and Peteet build on such teachings to demonstrate, with powerful evidence, that spiritual well-​being ranks as a fundamental, though still underappreciated, aspect of human health. Their work helps me, as a public health professional, better recognize that helping people reach their “highest attainable standard of health” essentially means much more attention to the soul and spirit. So be prepared to be delivered into a state of awe. Reading this Handbook will leave you stretched in ways you never could have imagined. And in the end, you will feel not only wiser—​but also healthier and more fully alive. Howard K. Koh, M.D., M.P.H. Harvey V. Fineberg Professor of the Practice of Public Health Leadership Harvard T.H. Chan School of Public Health and Harvard Kennedy School US Assistant Secretary for Health for the Department of Health and Human Services (2009–​2014)

Preface

A decade has passed since the second edition of Oxford University Press’s Handbook of Religion and Health, and 20 years have passed since the landmark first edition. I was privileged to write the Foreword to the first edition and the Preface to the second edition. Lead author Harold Koenig has once again invited me to offer my remarks on this new edition, which is coauthored by his Harvard colleagues Tyler VanderWeele and John Peteet. The growth of the research field defined by the broad intersection of religion, spirituality, and faith with health, healing, medicine, public health, and healthcare can be seen by the progressively accelerating size of each new version of the Handbook. Indeed, for many years when lecturing on this topic, I have been using metrics describing the content of these books as a marker of the rapid expansion of this field. The present numbers are mind-​boggling, and that is hardly an overstatement.

At the time of the first edition, published in 2001, Harold Koenig and his coauthors had located about 1,200 research studies, and their results were tabulated in a 75-​page table at the back of the book. By the second edition, published in 2012, an additional 3,000-​plus studies had appeared, and they were summarized in a table that now took up in the neighborhood of 400 pages. In the present third edition, the corresponding numbers are indeterminate. Due to the size of the literature and to the page limitations from the publisher, the authors had to restrict coverage to only the highest-​ quality studies. Harold informed me, though, that a Google Scholar search turned up over 3.28 million hits on the intersection between “religion” and “health,” and a PubMed search on the same terms identified 13,468 publications in those medical journals indexed by the National Library of Medicine. Clearly, the oft-​ repeated claim that not much research has been

 • xi

done on this topic, or that “no one’s ever looked at that”—​claims that we have been hearing for over 35 years—​is no longer even remotely plausible, if it ever was. Of course, noting these numbers is just bean counting. The impact and influence of a field of research can be seen in other more significant ways. For religion and health, the past decade has seen many important developments, and these are well documented in this edition of the Handbook. There are multiple scholarly journals devoted to this topic; there have been both government and foundation-​sector Requests for Proposals for research in this area; there are more academic centers and programs than can be listed here; there have been annual and one-​ off research conferences, as well as dedicated panels at the annual meetings of innumerable learned societies across scholarly disciplines and medical specialties; there are courses on this subject in more colleges and universities than anyone can keep track of; and there are many hundreds of active researchers, some of whom have distinguished or named chairs, both in North America and throughout the world. There is also a second and third generation of scholars and scientists, some of whom have by now attained seniority and have their own endowed faculty positions, the most notable example being the Handbook’s coauthor Tyler VanderWeele. For me, and I know for Harold as well, there is some personal satisfaction in these developments. As we have both noted, there was a time back in the mid-​1980s when the entire field of active researchers could fit around a table at an academic meeting. Indeed, this happened quite a few times. The coalescence of the scattered work in this area into a field qua field is owed in largest part to the labors of our late colleague Dave Larson, dearly missed physician, epidemiologist, professor, and Public Health Service officer. That there is now a large global field of research with thousands of published studies by innumerable scientists and scholars located at universities and medical centers in every corner of the world is, it could be said, a living tribute to Dave. For these reasons, after Dave’s passing in 2002, Harold and I established the annual David B. Larson Memorial Lecture in Religion and Health, held every March at xii •  P reface

Duke University School of Medicine. At the time of this writing, the next Larson Lecture will be the twentieth one. It is meaningful to recognize that the time since Dave left us corresponds, precisely, to the appearance of the three editions of the Handbook, the first of which he coauthored. We trust that Dave would be mightily pleased. As someone who, along with Harold and Dave and a few others prominently cited in this book, goes back to the earliest days of this field, I believe that I have a sober perspective on the most significant landmarks and signposts in the history of the religion and health field. In my opinion, nobody who is familiar with this field could possibly debate that publication of the Handbook, collectively in its now three editions, is the most important development that there has ever been for the study of religion and health. Harold is the most published scholar on this topic, by far, and the Handbook is his masterwork. As stellar as are his hundreds of research papers, as important as his research center at Duke has been and his research training programs, as significant as his dozens of books have been for clinicians and researchers, nothing matches the contribution and impact of the Handbook. This will be his most lasting contribution to medicine and science, and the third edition is a crowning achievement. I suspect that this is what Harold will be most remembered for within academic medicine. While it may be somewhat cliché to say this, the Handbook is an indispensable reference that belongs on the bookshelf of everyone who cares about the interconnections of faith and medicine. No matter where one comes down on the matter of faith—​pro or con—​this sourcebook is the definitive catalogue of contemporary research and merits its place as the ultimate arbiter of the empirically validated significance of the human spirit for health and wellness. Lots of well-​meaning people—​health professionals, pastoral professionals, academics, laypeople, skeptics, believers—​ seem to have strong opinions about this subject, but the Handbook is indispensable for a simple reason: it contains actual data, from every important study, bearing on the relationship between religion and health.

I do not know if there will someday be a fourth edition. If so, I suspect it will take an army of editors and research assistants to compile everything, given the accelerating rate of publication of research studies. But then, for the same reasons, I never imagined that there would be a third edition. My hat is off to Harold and Tyler and John for this remarkable achievement. My greatest wish is that a new generation of scientists and scholars will read this book and become inspired to pursue research in this fascinating field. Collectively, we have come a long way, but as with any area of medical research there remain important questions

to be asked and answered, and following up on the research studies compiled in this edition of the Handbook promises to lead intrepid young investigators down paths that probably cannot yet be imagined. Jeff Levin, Ph.D., M.P.H. University Professor of Epidemiology and Population Health Professor of Medical Humanities Director, Program on Religion and Population Health Baylor University Waco, TX

Preface • xiii

Introduction

The first edition of the Handbook reviewed almost 1,600 articles on religion, spirituality, and health published in peer-​ reviewed academic journals. This included approximately 1,200 quantitative research studies conducted from the 1800s through the year 2000. By 2007, the first edition was the most cited of any work on religion and health. At the beginning of 2018, the second edition of the Handbook was the most cited of any book or article on religion and health published between 2012 and 2018 (5,323 citations). This was nearly 10 times more than the second and third most cited works (Handbook of the Psychology of Religion and Spirituality, 2014, with 598 citations, and Handbook of Psychotherapy and Religious Diversity, 2014, with 586 citations). The third edition of the Handbook is a complete rewrite of the second edition. The content

has been revised to reflect current thinking, describes the latest approach to measurement, and provides an update on research in the field of religion, spirituality, and health (RSH), with several additional features. First, in previous editions, we included all studies on RSH based on a systematic review of the literature. In the third edition, however, we focus only on the highest-​quality studies (emphasizing large longitudinal studies and randomized controlled trials). Second, at the conclusion of each chapter, we make recommendations on how to apply the research to clinical practice (which was addressed only briefly in the first edition and was missing entirely from the second edition). Third, we have extended our review of the research summarized in the appendices of the first edition (1872–​2000) and second edition (2001–​2010) to include studies published from 2010 to 2020, with selected articles from 2021 and 2022.

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/oso/9780190088859.001.0001

TARGET AUDIENCES The third edition is primarily designed for researchers and academicians, as the previous editions were. However, we have now expanded the audience to include healthcare providers, public health experts, and public policymakers, both in the United States and around the world. This volume will provide readers with a central place to (a) locate the best studies on RSH, (b) find a summary of those research reports, (c) identify research gaps that remain and the highest priority areas for future research, and (d) find recommendations on methodological approaches to maximize scientific advances in this field. Academicians, including faculty at both secular and theological schools, will find in this third edition a treasure trove of information on the religion-​health connection that will be useful for teaching and further research. This includes instructors in schools of public health and public policy, as well as those in schools of medicine, nursing, psychology, sociology, and allied health. Connections between religion and health identified here will be of particular interest to students in divinity school, clinical pastoral education, and pastoral counseling training programs. Clinical providers in all healthcare disciplines will find recommendations on how to integrate the findings from research into practice in a way that is sensible and sensitive. This includes keeping such discussions patient-​centered, honoring boundaries in the health professional–​patient relationship, and viewing patients’ religious beliefs and practices as resources (or liabilities in some cases) for addressing spiritual needs during illness. Finally, public health professionals and public policymakers will find the research and discussions here informative (if not sobering). In the days ahead, these individuals will need to confront the increasing challenge of aging populations with mounting chronic illnesses that threaten to overwhelm the capacity of healthcare systems to provide comprehensive economically viable care. The information provided here will help them to do so.

BRIEF MODERN HISTORY Although the first and second editions of the Handbook provided a complete and thorough xvi •  I ntroduction

history of events that shaped the religion and health field up through 2010, we briefly review here both earlier and more recent events relevant to the scientific exploration of RSH. Francis Galton—​a statistician and cousin of Charles Darwin—​was one of the first scientists to examine the impact of religion on health. He conducted a retrospective case-​control study of intercessory prayer in 1872. Galton (1872) found that members of British royal houses had the lowest average life span of all groups in the population, despite “traditions of praying for the sovereign.” He also found that mortality rates among missionaries were no better than rates among individuals engaged in other occupations (and possibly worse). He further examined rates of stillbirth among members of the “praying and the non-​praying classes,” finding no difference. Galton concluded that there was no scientific evidence that prayer or other forms of religious involvement provided any benefits to health. In his rush to judgment, however, Galton failed to consider that the groups being prayed for (or highly religious persons such as missionaries) were also those at highest risk for mortality due to murder, disease, or poverty. In one of the first and most comprehensive reviews on religion and physical health, epidemiologist Jeff Levin (Levin & Schiller, 1987) examined the results of over 200 published studies on this topic. Included in this review were studies on cardiovascular disease, hypertension, stroke, general health status, cancer, mortality, and clergy health. Levin observed that most studies focused on religious affiliation, rather than on the centrality of religion in life or degree of religious involvement. He also emphasized other deficiencies in the existing research, such as lack of cross-​cultural studies, lack of studies of minorities, lack of studies of religion in disease prevention, lack of geographical diversity (many conducted in New York City), and a limited focus on studies of women (most examining only reproductive system disorders or sexual behavior). Levin concluded, “If religious factors are indeed associated with health—​ and we have presented overwhelming evidence suggestive of this—​ perhaps the next question researchers should ask is, ‘Why?’ ” (p. 24). Levin has spent the last

30 years trying to answer that question (Levin, 1996, 2018, 2020). Even before this seminal review, those in sociology (David O. Moberg), psychology (Ken Pargament), and psychiatry (Dan G. Blazer and the late David B. Larson) had been conducting research on religion and mental health. Their work was built on even earlier studies by sociologist Emile Durkheim (1897) and psychologist William James (1902). Moberg’s PhD dissertation at the University of Minnesota (1951) was titled “Religion and Personal Adjustment in Old Age,” and the results were later published in two key papers (Moberg, 1953a, b). Similarly, one of Pargament’s first publications following graduate school examined the mental health of church and synagogue members (Pargament et al., 1979). Over the years, he would motivate and guide dozens of young graduate psychology students who would later join university faculties and conduct research in this area. Shortly after psychiatrist Dan G. Blazer joined the Duke University faculty in the mid-​1970s, he analyzed data from the first Duke Longitudinal Study, finding a positive association between religious activity, personal adjustment, and happiness (Blazer & Palmore, 1976). Blazer would continue to periodically publish on this topic during his remaining years at Duke and after retirement (Blazer, 2016). Psychiatrist David B. Larson spent his entire academic career devoted to conducting research on RSH and inspiring others to do so. In his first of over 300 publications, Larson (then a resident at Duke) and William P. Wilson (professor of biological psychiatry at Duke) reported on the religious lives of alcoholics (Larson & Wilson, 1980). More than just conduct research, Larson would encourage an entire generation of young researchers to explore the religion-​health relationship. He also argued that it was time for clinicians to apply the growing body of research to clinical practice. Before his untimely death at the age of 54 on March 5, 2002, Larson had accomplished an enormous amount. With support from Sir John Templeton, whom he excited about the connections between spirituality and health, Larson in 1991 founded the National Institute for Healthcare Research (NIHR; later renamed the International

Center for the Integration of Health and Spirituality). He worked closely with internist Dale Matthews at NIHR and later with psychologist Michael McCullough. Not only was Larson a researcher, but he was also a networker par excellence. He encouraged many young investigators, connected them with others interested in similar research, and often funded small projects (with support from the Templeton Foundation). NIHR held a series of research conferences in the 1990s that brought together hundreds of researchers from all over the world to discuss RSH. These activities helped to jump-​start the field of RSH in the 1990s. Momentum soon began to build as research on religion and health began appearing in mainstream academic journals, including several studies led by Larson. Other researchers at major academic institutions (Arjan Braam, Verna Carson, Christopher Ellison, Terrence Hill, Frank Gillum, Ellen Idler, Gail Ironson, Jeff Levin, Lisa Miller, Dana King, Harold Koenig, Neal Krause, Ken Pargament, David Rosmarin, David Williams, and Tyler VanderWeele) helped to maintain that momentum throughout the 1990s and extend it into the first two decades of the twenty-​first century, conducting research and publishing in sociology, public health, psychology, nursing, medicine, and other health-​ related fields. In 1995, physician Harold Koenig started the Program on Religion and Health at Duke University with a focus on religion and aging. By 1998, with support from the Templeton Foundation, the program evolved into the Center for the Study of Religion, Spirituality, and Health. This interdisciplinary group included mainstream academic researchers in gerontology, sociology, psychiatry, theology, and medicine, including research leaders such as Dan Blazer, Harvey Jay Cohen, Linda George, and Keith Meador. During its eight-​ year existence, the Center conducted over a dozen research studies on religion and health, published hundreds of papers in peer-​reviewed medical and psychiatric journals, operated a two-​year postdoctoral fellowship, put on workshops that provided training on how to conduct RSH research (which have continued to the present day), and educated clinicians on how to integrate spirituality into patient care. Introduction • xvii

In 2006, psychiatrist and theologian Keith Meador joined forces with Koenig to transform (and rename) the Duke Center into the Center for Spirituality, Theology, and Health (CSTH), which the Templeton Foundation supported for another five years through 2011. The purpose of the new Center was to bring together a community of scholars for regular discussions on religion and health issues, continue the postdoctoral program, develop an independent national network of researchers, clinicians, and laypersons called the Society for Spirituality, Theology, and Health, and hold the Society’s annual conference. While many of these activities stopped as funding ran out in 2011, CSTH has been self-​sustaining since then to the present (2023) under the leadership of Koenig and his colleagues with research grants and support from private donors. Formed in 2006, the Religion and Public Health Collaborative (RPHC, 2022) at Emory University has sought “to engage scholars and practitioners in world religions and public health to understand the sometimes converging, sometimes conflicting relationships of religion and public health, through teaching and research.” Led by sociologist and epidemiologist Ellen Idler, RPHC has partnered with the Interfaith Health Program (IHP) at Emory’s Rollins School of Public Health. The IHP, which began at the Carter Center in 1992, has sought to advance the health of individuals and communities, particularly through prevention and health promotion. Around the same time (mid-​ 2000s), the Program on Religion and Medicine was initiated at the University of Chicago by medical internists Farr Curlin and Daniel Sulmasy. This program focused on studying American physicians’ attitudes toward religion in healthcare and engage both researchers and clinicians in dialogue regarding this topic. Their annual Medicine and Religion conference has attracted hundreds of healthcare professionals over the years. Soon after Curlin became a Duke University faculty member in 2014, he joined forces with psychiatrist and theologian Warren Kinghorn to form the Theology, Medicine, and Culture Initiative at Duke Divinity School. The TMC Initiative now offers a Certificate in Theology, Medicine, and Culture that focuses xviii •  I ntroduction

on integrating spirituality into healthcare. Another prominent US program is the Institute for Spirituality and Health at Texas Medical Center led by physician John Graham, which evolved out of the Institute of Religion, which started in 1955. The mission of ISH has been to enhance well-​being by exploring the relationship between spirituality and health, doing so by bringing scholars, healthcare professionals, religious leaders, and the public together to engage in education, research, and direct services. More recently, the Spirituality Mind Body Institute at Columbia University Teachers College (New York City) was established by psychologist Lisa Miller and colleagues in 2012 to explore the intersection of science and spirituality through the framework of psychology. The Institute has been committed to conducting studies that explore the effects of spirituality across the life span, examining spirituality as a protective factor against mental illness, a source of resilience in cultivating relationships, and a gateway to personal fulfillment. The Institute now offers a master’s degree in Spiritual-​Mind-​Body health, designed to train future leaders in this field. In 2013, the Initiative on Health, Religion, and Spirituality was launched at Harvard University with support from the Templeton Foundation (renewed in 2016). The goal of the initiative has been to involve faculty from across the disciplines of public health, medicine, and divinity to support research and engage in interdisciplinary dialogue on RSH. The primary question being addressed by this initiative has been: “How may religion and spirituality in concert with public health and the practice of medicine alleviate illness and promote human well-​being?” This initiative, led by radiation oncologist Tracy Balboni, theologian Michael Balboni, public health specialist and statistician Tyler VanderWeele, and psychiatrist John Peteet, has brought in speakers from around the world to Harvard to address the topic of spirituality and health. Dozens of research studies on the relationship between religion and health, with a particular focus on palliative care and public health, have resulted from this initiative. VanderWeele also leads the Human Flourishing Program at

Harvard, founded in 2016, which includes religious involvement as a key component. Programs, centers and institutes have also emerged in the United Kingdom and Europe. In 2004, the Research Institute for Spirituality and Health (RISH) was founded by cardiologist and psychosomatic medicine expert Rene Hefti in Langenthal, Switzerland, with links to the University of Bern. RISH has sponsored a biennial European Conference on Religion, Spirituality, and Health since 2008, bringing together researchers from across the continent. The British Association for the Study of Spirituality (BASS) emerged in 2010, holding biennial conferences (sometimes together with RISH). Beginning in 2011, BASS started publishing a peer-​reviewed journal, the Journal for the Study of Spirituality. Most recently, psychiatrist and theologian Christopher Cook initiated the Centre for Spirituality, Theology, and Health in 2018 at Durham University, England, whose mission is to support interdisciplinary dialogue, training, and research on RSH. Indeed, there are now research and clinical centers at many different academic institutions in the United States and abroad, including George Washington University (George Washington Institute for Spirituality and Health; GWISH), University of Minnesota (Center for Spirituality and Healing), University of Aberdeen, Scotland (Centre for Spirituality, Health, and Disability), Baylor University (Program on Religion and Population Health), University of Florida (Center for Spirituality and Health), Indiana State University (Center for the Study of Health, Religion, and Spirituality), and Yale University (Program on Medicine, Spirituality, and Religion, an innovative joint program with the Yale Divinity School, led by internal medicine and pediatrics specialist Benjamin Doolittle). Most of these centers, institutes, and programs were initiated after the publication of the first edition of the Handbook in 2001, which helped to provide the scientific framework on which these centers and programs have been grounded. The research findings on RSH coming out of these programs and centers have begun to influence the training of healthcare professionals and clinical practice. The integration of spirituality into medical training received a boost

in 1995 when the Templeton Foundation provided funding to NIHR to begin awarding small grants to medical schools to start up courses on religion, spirituality, and medicine. The program was initially developed and administered by David Larson and Dale Matthews (Larson & Matthews, 1996) and was later continued by Christian Puchalski at GWISH (Puchalski & Larson, 1998). Over the next 10 to 15 years, the number of US medical schools including course material on spirituality and health increased dramatically. In the early 1990s, five schools at most had such courses. By 2009, 90% of the 125 US medical schools had something on spirituality and health in their curriculum, with 73% having content in required courses addressing other topics, 7% having a required course dedicated to spirituality and health, and many others offering an elective on this topic (Koenig et al., 2010b). These courses, however, varied greatly in quality and scope, and might involve anything from one or two lectures on the topic (or a related area) to a required 12-​ week course on religion, spirituality, and medicine with readings, simulated patients, and faculty role modeling. Residency programs have also begun to include training in this area (De Oliveira et al., 2020). Although training in medical schools and residencies has increased the number of physicians who assess patients’ spiritual needs, nurses and chaplains have traditionally taken the lead in this area. In 2001 the Joint Commission for the Accreditation of Hospital Organizations (JCAHO), now the Joint Commission, emphasized the importance of integrating spirituality into patient care by providing guidelines for the spiritual assessment of patients cared for in hospitals, nursing homes, and home health agencies (JCAHO, 2017). JCAHO standards require that health professionals “respect the patient’s cultural and personal values, beliefs, and preferences” (which include religious or spiritual beliefs) (RI.01.01.01 EP 6; JCAHO, 2009). The Joint Commission does not require a spiritual assessment on everyone. However, it does require a spiritual assessment on certain kinds of patients: those treated for emotional or behavioral disorders (to identify “patient’s religion and spiritual beliefs, values, and preferences” (PC.01.02.13 EP 3); those treated for Introduction • xix

substance use disorders (PC.01.02.11, EP 5); and patients at the end of life (PC.02.02.03, EP 1, PC.01.01.01, EP 4) (JCAHO, 2009). For patients cared for in hospices, the Centers for Medicare and Medicaid Services’ State Operations Manual requires that the spiritual needs of patients and families be assessed and documented in order to receive payment for services by Medicare (CMS, 2015). Although nurses and other health professionals have increasingly included a spiritual history as part of their assessments, once again the extent of such assessments varies widely. As a result of (a) the expanding evidence base on RSH, (b) the increasing number of researchers conducting studies in this area, (c) the increasing number of academic programs, centers, and institutes at major universities focusing on this topic, (d) the growing inclusion of spirituality into healthcare professional training programs, and (e) the establishment of guidelines (and requirements) by the Joint Commission and CMS, more and more healthcare providers are now addressing the spiritual needs of patients. A number of professional societies have also begun to emphasize the need to conduct a spiritual assessment to identify spiritual needs and determine the influence of religious or spiritual beliefs on healthcare decision-​making, particularly within the mental health field. This includes such groups as the American Psychiatric Association (1990), Royal College of Psychiatrists (Cook, 2013), American Psychological Association (Pargament et al., 2013a, b), and World Psychiatric Association (Moreira-​Almeida et al., 2016). This has raised the awareness of psychiatrists and other mental health professionals concerning the spiritual needs of patients and the importance of assessing and addressing those needs (Koenig 2013; Peteet et al., 2019). The increasing integration of spirituality into patient care underscores the need for research to determine the consequences (both benefits and harm) of doing so. Such research has begun within the Adventist Health System, the largest Protestant healthcare system in the United States (Koenig et al., 2017 a–​d), although more studies are needed in both faith-​ based and non-​ faith-​ based systems. Just as medical schools are now training future doctors xx •  I ntroduction

to integrate spirituality into patient care, some of the top schools of public health have recently begun educating future researchers about the relationship between religion and health, training them to conduct research in this area and form partnerships with faith communities (VanderWeele & Koenig, 2017; Oman, 2018; Idler et al., 2019). Not surprisingly, then, interest in research on religion and health has continued to increase rapidly since publication of the first edition of the Handbook in 2001. A Medline (PubMed) search between 1872 and 2000 using the words “religion” and “health” uncovered 9,024 research studies, reviews, and commentaries. The same search conducted between 2001 and 2010 on those same words revealed 9,397 publications (more articles published during that 10-​ year period than the previous 128 years). Repeating that search between 2011 and 2020 (October 18, 2020) uncovered 13,468 additional publications, an increase of 43% over the 2001–​2010 period. This rapid increase in attention paid to religion and health in academic journals in mental health, social, and nursing/​medical fields signals the growing maturation of the field since the Handbook was first published in 2001. Critiques of the research and its clinical application have also helped the field to mature (Sloan et al., 1999, Sloan et al., 2000; King 2014), as many of the concerns raised about earlier research have been addressed in more recent studies (Balboni et al., 2022). This third edition promises to set the stage for an even more rapid growth that may ultimately lead to a deeper understanding of the relationship between religion and health. Indeed, what we know now may represent only the tip of an iceberg, one that future research will increasingly uncover.

IDENTIFYING AND SUMMARIZING THE RESEARCH In the chapters that follow, we summarize research published on RSH, but as noted earlier, focus only on the highest-​quality studies. This review is cumulative in that the best studies from the first and second editions of the Handbook are also included in this edition (see Appendix), along with a systematic review of

studies published since 2010. To identify that research for this third edition of the Handbook, we searched the literature using Google Scholar (first 100 studies listed for a particular health outcome), PubMed, and PsycINFO to systematically and exhaustively identify quantitative studies on RSH. In this manner, we located literally thousands of more recent studies examining RSH during the last 10 years up through 2020. These studies were retrieved and their methods carefully examined. We estimate that the resulting review covers about 75% of the existing research and perhaps 90% of the best studies. Bear in mind that many, many more qualitative studies have now examined RSH in patients with medical or psychiatric illness, but these are simply too numerous to include here. Likewise, many additional good quantitative studies did not make the “cut” in terms of quality, and were not included in this third edition. As in the first and second editions, the studies identified by this systematic review are listed in the Appendix of this volume. Many past readers have told us that the Appendix itself is worth the price of the Handbook since it organizes a tremendous amount of information in a way that saves readers time locating studies on specific health topics. Studies are ordered by date of publication and include the citation, study design, sampling method, types of subjects, location of study, religious measures used, findings, variables controlled in analyses, and a quality rating from 1 to 10. Although we focus in this edition primarily on studies rated 8 or higher, also included are studies of lower quality that were conducted in special populations, in religions other than Christianity, in regions of the world outside the West, or that examined a mental, social, behavioral, or physical health condition on which there is little research. As in the first two editions, we follow a hierarchy of evidence (Guyatt et al., 1995) in grading the quality of studies, where the first level of evidence comes from randomized controlled trials; the second level of evidence is from prospective cohort studies, particularly large studies (>1,000 participants) that measure and control for outcomes at baseline; and the third level of evidence is from large cross-​sectional surveys. Because of the newness of this field and the ethical issues involved in double-​blinded

randomized controlled trials of religious interventions on health, studies providing first-​level evidence are relatively few. By far, most of the research in this area involves second-​and third-​ level evidence, i.e., data from prospective and cross-​ sectional studies. Despite the limited number of clinical trials examining the effects of religious interventions, much evidence can be gathered from observational studies—​ particularly from prospective studies with long-​term follow-​up and control for baseline outcomes (VanderWeele, 2015; VanderWeele et al., 2016a). When multiple large longitudinal studies with control for baseline outcomes are available, and these are also at least moderately robust to unmeasured confounding in sensitivity analysis, the evidence for causation can in fact be quite strong. We will thus point out the contexts in which this is so, and these considerations will also shape recommendations for guiding future research. The quality ratings provided in the Appendix of this edition (1–​7, 8, 9, and 10) are based on the following criteria (following guidelines outlined by Cooper, 1984): (1) quality of the peer-​reviewed journal in which the study was published; (2) quality of the study design: (a) cross-​sectional studies received the lowest rating, depending on sample size, (b) prospective studies received higher ratings, especially those with long follow-​up periods, and (c) randomized controlled trials (RCT) received higher ratings, especially those whose design, execution, and presentation met RCT quality standards; (3) quality of the sampling method for observational studies (convenience, systematic, random); (4) quality and size of the sample, with larger sample sizes (>1,000) receiving higher ratings; (5) the particular type of sample (clinical vs. community population); (6) quality of religious/​spiritual measures (absence of tautology); (7) quality of the health outcome measure; (8) degree of control for confounders (and distinguishing confounders from mediators); (9) quality and sophistication of statistical methods; and (10) quality of presentation and interpretation of findings. In order to maintain continuity between the first, second, and third editions of the Handbook, the same reviewer (HGK) assigned quality scores to each study using the above approach, Introduction • xxi

one that proved reliable in the first and second editions. To recap that method from the first edition, we compared our quality ratings on 75 studies with scores independently assigned to those studies by an outside reviewer (Andrew Futterman, Ph.D., a professor of psychology at the College of the Holy Cross, who is also a scientist familiar with these scoring criteria and active in RSH research). Continuous scores were moderately correlated with each other (Pearson r =​0.57). The kappa of agreement (K) between the author’s and the outside reviewer’s scores differentiating higher from lower quality studies was 0.49 (where Ks of 0.40 to 0.75 indicate good agreement, according to Landis & Koch, 1977), and there was 75% overall agreement in category assignments (56 of 75 studies).

OVERVIEW OF CONTENT The general structure of this volume involves nine major sections: (I) research methodology, (II) mental health, (III) social health, (IV) explanatory mechanisms for mental health, (V) health behaviors, (VI) physical health, (VII) explanatory mechanisms for physical health, (VIII) public health and health policy, and (IX) conclusions. Section I focuses on definitions, measures of religiosity, and research design. The controversial subject of definitions is tackled first, differentiating between religion, spirituality, and secular humanism. Next, measures to quantify various dimensions of religiosity are discussed, along with a description of weaknesses known to characterize recent measures of spirituality. Finally, we discuss the topic of research design and make recommendations in this regard, with a particular focus on large prospective studies and RCTs. Section II examines the role that religion plays in common mental disorders (mood, anxiety, psychotic, substance abuse, and personality disorders) and positive emotions (psychological well-​being, happiness, life satisfaction, meaning and purpose, hope and optimism). Each chapter begins with a brief description of what is known about the particular mental condition and is then followed by a case to illustrate the influence that religion may have on the condition. Next, we review the research findings from the best designed studies, both early and more recent xxii •  I ntroduction

ones. Again, this approach contrasts with previous editions of the Handbook where virtually all studies were reviewed, regardless of quality. Not only is it impossible to review all studies given the enormous number now in the literature, but this approach is not particularly useful to readers who need to identify the best recent studies to cite in their work. Recommendations are then made on what studies are needed to fill knowledge gaps and move the field forward. Each chapter concludes with a discussion of what the findings mean for clinical practice and a summary of chapter content. Section III follows the same pattern for social issues, with chapters on delinquency and crime, marital and family stability, and social support. These chapters are key to understanding the important role that religiosity plays in maintaining societal health, which is the basis for individual and public health. Section IV then describes a life-​span model that explains how religious involvement can impact mental and social health from birth (even before birth) to death through psychological and social mechanisms. Section V follows the same chapter format as Sections II and III, but focuses on health behaviors—​ cigarette smoking, exercise, diet, and weight. This section is particularly important since poor health behaviors (smoking cigarettes, being physically sedentary, eating an unhealthy diet, being overweight or obese) are responsible for nearly 80% of all chronic diseases, reducing survival by nearly 50% and shortening life span by 12–​14 years (Knoops et al., 2004; Ford et al., 2009; Lee et al., 2009; Kvaavik et al., 2010; Byrne et al., 2016; Adams et al., 2019). Chronic disease is the number one cause of health problems, disability, and death, and is responsible today for most of the healthcare expenditures in the United States (and around the world, particularly in developed countries), making it a key factor in future public policy and healthcare-​ financing decisions (Bauer et al., 2014). When the effects of health behaviors are combined with those of mental (Walker et al., 2015; Scott et al., 2016) and social factors (Cockerham et al., 2017), the overall contributions to chronic disease are enormous. Devout religious practice could have a particularly large impact on health and health expenditures because it has the potential to influence all three major determinants of

chronic disease (mental, social, and behavioral health). Section VI again follows the chapter format in Sections II, III, and V. The focus here is on the relationship between religiosity and physical health. Chapters are devoted to (a) major physical conditions that adversely impact health, including heart disease, hypertension, stroke, dementia, and cancer; (b) physiological systems that influence physical health, such as immune and endocrine functions; and (c) cumulative indicators of physical health such as overall mortality, physical disability, and chronic pain. Disease detection and prevention round out this section. Section VII discusses mechanisms that may help to explain how religious involvement affects physical health. While some may find it easy to understand how religious beliefs/​practices can influence mental, social, and behavioral health, less obvious are the effects of religiosity on physical health. These effects are also more difficult to demonstrate. As emphasized throughout this volume, mental, social, and behavioral indicators of health are more “directly” affected by religious involvement and are therefore more “proximal” to religion. For religion to impact physical health, in contrast, it must do so “indirectly” through psychological, social, and behavioral pathways. The indirect nature of religion’s effects on physical health weakens the effect that can be demonstrated. This must be considered when interpreting the results of such studies. Section VIII examines implications that findings from research on religion and health have for population health and health policy decisions. As readers will see in this section, the implications are huge, yet often are underestimated and misunderstood, often leading to their neglect by public health planners and public policy experts. The goal of these chapters is to discuss how religious involvement can maximize human flourishing in terms of both psychological well-​being and physical health, as well as healthcare costs, particularly down the road as countries become more scientifically oriented and as old cultural and religious traditions fade with increasing secularization. Section IX ends the Handbook with a chapter that (a) reinforces our comments on research

methodology, (b) summarizes the research findings on mental, social, behavioral, and physical health, (c) discusses the quality of the research findings reported (underscoring the complexity of religion-​health effects), (d) reviews the clinical, public health, and health policy implications of the research findings, (e) describes priorities for future research, and (f) provides a few final thoughts about the religion-​health relationship.

MOVING INTO THE MAINSTREAM In the 1980s and 1990s, studying the religion-​ health relationship was not good for a young investigator’s career. In fact, pursuing this area of study became known as the “anti-​tenure factor” (Sherill & Larson, 1994). Many of those who sought to conduct research and engage in academic activity in RSH found themselves marginalized and excluded by colleagues. If the first edition of the Handbook helped to put the study of RSH onto the radar screen of researchers and healthcare providers and the second edition moved it from the edge of the screen to a slightly more central position, this third edition, we think, will move it into the mainstream. Ignoring the impact that religious involvement may have on health is becoming harder and harder—​given the quality of the evidence now available, the academic credibility of those now doing this research, and common sense that would argue that religion must serve some function if it has persisted for thousands of years and continues to be engaged in by the vast majority of humans today. Open-​minded scientists and experienced practitioners are beginning to recognize that religion plays an important role in human well-​being and flourishing, whether that be positive or negative. Based on the research summarized in this volume, our understanding of the role that religion plays in overall health and well-​being has been greatly advanced yet still remains incomplete. While much has already been done, much further work lies ahead. This third edition of the Handbook, even more so than previous editions, provides an unprecedented source of information on what has been done, what needs to be done, and a road map on how to do it. Introduction • xxiii

SECTION I Research Methodology IN THIS SECTION we describe the definitions of terms to be used in this book (religion, secular humanism, spirituality), review

measures used to assess religiosity, and discuss the different research designs for studying the relationship between religion and health.

1 Definitions A religion that gives nothing, costs nothing, and suffers nothing, is worth nothing. —​Martin Luther

DEFINITIONS ARE CONTROVERSIAL when it comes to terms such as religion and spirituality. Clarity with regard to definitions, however, is crucial if successful communication is to occur, and it is especially important when definitions vary across individuals. Because religion and spirituality are both emotionally and politically charged terms, people hold on to their own definitions with great fervor, often defending them at all costs. Although we do not claim to have any universal authority over determining such definitions, we are obligated to describe how we will use these terms in this text. Oman (2013) provides a nice historical overview within psychological research that describes the origins of the terms “religion” and “spirituality” and reviews selected definitions for each. The title of this volume is the Handbook of Religion and Health, and so the focus is squarely on religion and the effects that religion and religiosity have on health and well-​being. However, there are other terms that are often used when

discussing this topic. Among those terms are secular humanism and spirituality. Each of these terms has their place depending on the situation and circumstances in which they are used. Of particular interest—​given the focus of this book on scientific research—​are definitions for research purposes. However, religion, spirituality, and secular humanism are used not only to describe results from research studies, but also to address the needs of those with medical or psychiatric illness in clinical settings. Thus, we begin by describing the requirements for each term when (a) conducting quantitative research and (b) addressing needs in clinical practice. Those requirements are quite different because the purpose in each setting is different.

CONSTRUCTS FOR RESEARCH PURPOSES Because of the importance of replicating re­ sults, the definition of a term used in scientific

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0001

research should be clearly stated. This is especially true when the definition will be used to develop measures of a construct in order to examine evidence concerning its relationship to other constructs in quantitative studies. When conducting quantitative research, the investigator is charged with developing empirical assessments that provide some form of numerical quantification related to the construct of interest (e.g., religion or spirituality) to determine the extent to which the construct might be said to be present under that assessment. This is needed so that the relationship of such a numerical assessment with other quantifiable variables (e.g., health) can be examined. For example, when examining the relationship between blood pressure and likelihood of stroke, blood pressure is measured in specific units that indicate how high the blood pressure is. Likewise, when examining the impact of depression on likelihood of suicide, depression is quantified in terms of the presence and severity of depressive symptoms to determine whether depression symptom severity increases suicide risk. In the psychological, social, and behavioral sciences, the extent to which a construct is present is typically quantified by responses to a set of questions on a scale. These responses are then often summed to produce a score that provides an assessment of the construct phenomenon. The scale is typically made up of questions that tap into core aspects of the construct based on its definition. The degree to which a scale reliably and accurately assesses a construct is determined both on conceptual grounds and by its psychometric properties (see Chapter 2). What is sometimes called the construct validity of a scale is especially important in this discussion of definitions. Construct validity is the extent to which a scale adequately captures the underlying construct that is being assessed based on the definition of that construct. There are both theoretical and empirical assessments of construct validity (see Chapter 2). Empirical assessment of construct validity is sometimes called criterion validity, which is evaluated by how well a given measure satisfies one or more external criteria. In many classical schemes, criterion validity has 4 •  R esearch M ethodolo g y

four components: convergent, discriminant, concurrent, and predictive validity. More discussion of these topics is given in the next chapter, but we will briefly comment here on convergent validity and discriminant validity. Discriminant validity is what we are after here, and is a very important characteristic that will become more evident below. As indicated earlier, definitions of constructs are important because they will be used to develop assessments related to the construct, which will then be used to quantify in research surveys the extent to which the construct might be said to be present in some respect. Definitions, like the scales that result from them, should also satisfy various criteria. When conducting research, it is essential to clarify the extent to which definitions of constructs do or do not overlap with definitions of similar constructs, particularly with outcomes in which the researcher may wish to evaluate evidence concerning relationships between phenomena relating the construct of focus to other possible constructs of interest. Overlap across constructs has been a major problem in the field of religion and health, especially as it applies to spirituality, the definition of which sometimes overlaps with aspects of the health outcomes to which spirituality may be associated with, particularly mental health, thus violating the principle of discriminant validity described above. We now apply these principles to research on religion and spirituality in determining the qualities that must characterize such definitions if they are to be useful for empirical research. (1) The definition of the construct should be operationalized in a way that allows for some aspect of its extent or presence to be measured and quantified, since quantitative research seeks to examine associations between quantitative numerical scores related to various phenomena and constructs. (2) The definition of the construct should be clear and unambiguous, since measures to quantify the construct when conducting quantitative research will be based on that definition. (3) The definition of the construct and measures derived from it should be distinct

and unique, not overlapping with similar constructs which researchers may wish to examine for evidence of potential causal relationships (i.e., health outcomes). In other words, the definition and measures derived from it must not violate the principle of discriminant validity.

CONSTRUCTS FOR CLINICAL PURPOSES The criteria for definitions of constructs in clinical settings (at least for the constructs we are discussing here) need not be as rigorous as those required for conducting quantitative research and therefore have more flexibility. Definitions for clinical purposes must address the needs of a wide range of patients in a personal and sensitive manner, particularly when assessing beliefs and practices that are emotionally charged without universal agreement. Below, then, are the characteristics of definitions of constructs such as religion or spirituality that should be present when addressing these issues with patients. (1) The definition of the construct does not always need to be clear and exact. In fact, ambiguity may be an advantage when dealing with topics that are sensitive and the potential for disagreement or misunderstanding is high. (2) The definition of the construct may have some overlap with similar constructs, including the psychological states that the construct may affect or influence. (3) Having a definition of the construct that can be precisely measured and quantified is less important, since addressing the construct in a qualitative manner takes priority during clinical encounters. (4) Definitions of the construct can be broader in order to be relevant to patients with a wide range of experiences and perspectives. (5) The definition of the construct should promote conversation and focus on similarities, since the use of the construct in clinical settings should stimulate dialogue and engagement (in contrast to quantitative research, where the definition requires objective assessment and comparison).

MAPPING RELIGION AND SPIRITUALITY ONTO THE PRECEDING CRITERIA How do the definitions of the constructs in which we are interested (religion, secular humanism, spirituality) map onto the criteria listed above for use in research studies and clinical practice?

Religion The construct “religion” possesses many of the characteristics necessary for conducting research. Religion involves beliefs, practices, and commitments that are measurable and quantifiable and that often do not conceptually overlap with the outcome of interest here (health). Religion is a specific construct that has multiple dimensions as described below (Koenig, 2011a), each of which is quantifiable and non-​overlapping with mental or physical health: • Religious affiliation (major religious tradition and denomination within the tradition) • Orthodoxy of belief (based on original teachings of one’s faith tradition) • Public religious practices (attendance at services or other religious group activities) • Private religious practices (private prayer, reading religious scriptures, watching religious television, listening to religious programs or music) • Subjective religiousness (importance or salience of religion, self-​rated religiosity) • Religious motivation (intrinsic vs. extrinsic) • Religious connection or attachment (quality of relationship to God or the transcendent, love of God, etc.) • Religious coping (overall religious coping or specific ways of using religion to cope) • Religious history (exposure to religious beliefs/​activities/​commitments over a lifetime) • Religious support (support received, support given, and conflict within faith community setting) • Religious experience (including mystical experiences)

Definitions • 5

• Religious giving (proportion of income given to religious causes) • Religious volunteering (time spent volunteering for religious reasons) • Religious knowledge (knowledge about religious scriptures of one’s faith tradition) • Religious growth (deepening and maturing of religious faith over time) • Religious quest (probing and questioning religious beliefs).

and does not overlap with health states that researchers might want to examine.

Spirituality

One of the first mentions of the word “spirit” was perhaps in Genesis 1:2 (“And the Spirit of God moved upon the face of the waters”) (written approximately 1500 bce to 1400 bce; Hayut-​ Man, 2019). For many centuries since then, the term spiritual had been used to describe deeply religious persons, These religious beliefs and activities may also often the clergy—​people whose lives revolved be grouped into three major categories: organi- around and centered on their religious faith zational, non-​ organizational, and subjective/​ (Sheldrake, 2007). Over the past 20–​30 years, intrinsic religiosity (Koenig & Futterman, however, the meaning of spiritual (and spir1995b). Organizational religiosity involves ituality) has changed. Spirituality is now an religious practices performed in organized increasingly popular term used in those setsocial settings, such as attending religious ser- tings where religion is in disfavor (often in vices, involvement in group religious rituals, research or academic settings). Spiritual is now group prayer, group Scripture study, etc. Non-​ used to describe those who are religious and organizational religiosity involves religious those who are not religious (e.g., those who call activities performed in private, such as prayer themselves “spiritual but not religious”). These or meditation, reading religious scriptures, individuals may be compared to those who are viewing religious TV, or listening to religious religious and spiritual, those who are religious radio or music. Subjective religiosity has to but not spiritual, and those who are neither do with the cognitive dimension of belief that religious nor spiritual. Spirituality, then, has reflects the importance or centrality of religion become a nebulous construct that religious and in a person’s life. Regardless of how religiosity non-​religious persons can both fit under, which is categorized, religious beliefs, practices, and explains its popularity. Consequently, there is commitments are quantifiable, unique, and little agreement on exactly what the term spirindependent constructs readily distinguishable ituality means today, or on the components from mental or physical health. that define and comprise it (other than by self-​ identification). In an attempt by researchers to further identify the components of spirituality Secular Humanism when conducting studies, the definition of spirSecular humanism represents an alternative ituality has expanded to also include states of to transcendent religiosity/​ spirituality, and positive mental health (e.g., having meaning includes naturalism, materialism, atheism/​ and purpose, connectedness to others, sense of agnosticism, and what has been called by peace, feeling deep inner harmony, and experiCharles Taylor (2007) the “immanent frame” encing existential well-​being) (Koenig, 2008). (i.e., a way of being in the world that provides As a result, this construct has become difficult significance, meaning and purpose, but with- to use in research, particularly quantitative out necessarily involving transcendence). Like research that seeks to examine its relationship religion, this construct has little or no overlap to health—​especially mental health. with mental or physical health. As a result, the The expansion over time of the territory health of these individuals can be compared to that the term spirituality covers is illustrated the health of persons who describe themselves in Figures 1.1–​1.4. As noted earlier, the traas religious. Again, this term fulfills the criteria ditional meaning of spiritual was to describe for use in research: a construct whose definition the deeply religious person (Figure 1.1). In the is largely agreed-​ upon, distinct, measurable, modern understanding, however, spirituality 6 •  R esearch M ethodolo g y

Source

Mental Health

Physical Health

Religion Meaning

Purpose Connectedness Exist. wellbeing

Suicide

Anxiety

Peace

Secular

Hope

Psychoneuroimmunology

Depression

Spirituality

vs.

Cardiovascular Disease

Cancer

Addiction

Mortality

FIGURE 1.1.  Traditional understanding of spirituality (Koenig, 2008).

has expanded to include (a) those who are religious and (b) those who are not religious but describe themselves as spiritual (Figure 1.2). This latter understanding of spirituality has created a dilemma for researchers trying to study the construct. The challenge has been to measure spirituality in a way that goes beyond simple self-​description as a member in one of these four categories (spiritual but not religious; religious but not spiritual; spiritual and religious; neither spiritual nor religious). The category “spiritual but not religious” has become the most challenging to define. This is also how many individuals in the United States now describe themselves (more than 25% of US adults; Lipka & Gecewicz, 2017). However, this category has defied characterization, apart from simple acknowledgment that one is spiritual but not religious. Such self-​description has not been enough for researchers who wish to further refine this category in order to measure it. What types of questions can be asked to identify those who are using a religious word (“spiritual”) to describe themselves, yet insist that they are

not religious? The challenge of determining a richer description of those in this self-​defined category has resulted in a further expansion of spirituality by researchers to now include positive emotions and character traits (Figure 1.3). In our view, the positive emotions and character traits indicative of good mental health (i.e., having meaning and purpose in life, deep inner peace and harmony, feeling connected to others, being moral and altruistic, etc.) may be the result or outcome of a deep spiritual life, but they are not a way to define and measure spirituality itself, which is something quite different. A major goal of researchers in the social, psychological, and behavioral sciences is to identify the “sources” of good mental health that may be targets for intervention. Defining and measuring spirituality as good mental health to start with does not contribute to this goal. The definition and measurement of spirituality in research studies with indicators of positive mental health has caused concern about the interpretability of findings from studies that have examined the relationship between Definitions • 7

Source

Mental Health

Physical Health

Spirituality Meaning

Cardiovascular Disease

Depression

Purpose Suicide Connectedness

vs.

Exist. wellbeing

Anxiety

Peace

Psychoneuroimmunology

Religion

Cancer

Addiction

Secular

Hope

Mortality

FIGURE 1.2.  Modern understanding of spirituality (Koenig, 2008).

Source

Mental Health

Religion Purpose

Spirituality

Connectedness Exist. wellbeing

Suicide

Anxiety

Peace

vs. Hope

Cardiovascular Disease

Depression

Addiction

Psychoneuroimmunology

Meaning

Physical Health

Cancer

Mortality

Secular

FIGURE 1.3.  Modern understanding of spirituality—​tautological version (Koenig, 2008). 8 •  R esearch M ethodolo g y

Source

Mental Health Positive Meaning

Physical Health

Negative Cardiovascular Disease

Depression

Purpose Connectedness

Spirituality

Well-being

Suicide

Anxiety

Peace

Secular

Hope

Psychoneuroimmunology

Religion

Cancer

Addiction

Mortality

FIGURE 1.4.  Modern understanding—​clinical version (not for research) (Koenig, 2008).

spirituality (measured in this way) and health, particularly mental health (Koenig, 2008). Some of these concerns are listed below. (1) Atheists and agnostics who deny any connection with spirituality may rightly claim that their lives have meaning and purpose, that they have strong social connections with others, that they practice forgiveness and altruism, and that they have times of great inner peacefulness, and hold high moral values and ethical standards. As a result, they may object to defining spirituality using the terms above. (2) Because of the importance of having clear, distinct constructs with boundaries when conducting research, the use of religious language (spiritual or that having to do with the spirit) to characterize non-​ religious persons adds confusion to an already complex area of study. (3) Investigators can now no longer examine the relationship between spirituality and mental health because many measures of spirituality are

now conceptually confounded by indicators of mental health. (4) Such confounding also influences findings on the relationship between spirituality and physical health because mental health is intimately connected to physical health, as reflected in the now widely accepted bio-​ psycho-​social model of health. (5) Those burdened with psychiatric disorders such as major depression, anxiety disorders, or schizophrenia often struggle with meaning and purpose in life, feel socially disconnected, and rarely feel deep inner peace, harmony, and well-​being. Does this mean that these unfortunate individuals are not spiritual, as low scores on recent spirituality measures would suggest? (6) Finally, if spirituality is defined a priori as good mental health, researchers can no longer study the negative effects of spirituality on health because spirituality has already become synonymous with good mental health, excluding the possibility that spirituality may Definitions • 9

have negative effects on mental health. Thus, spirituality has become a construct whose relationship with mental health has already been determined before a single study is done. When spirituality is defined and measured in this way, positive associations reported by researchers between spirituality and mental health could be considered tautological (correlating a construct with itself) and meaningless. Thus, the modern understanding of spirituality is a construct that does not map well onto the requirements necessary for conducting research on its relationship to mental or physical health, though as discussed below, may still be useful in clinical practice. How common is research using measures of spirituality contaminated by mental health indicators? A systematic review of research examining the relationship between spirituality and mental health found that 26 of 58 published studies (45%) used spirituality scales where psychological well-​being items made up 25% or more of the scale items, thus resulting in tautological findings (Garssen et al., 2016a; see also Salander, 2006, 2012; Garssen & Visser, 2016b). Given the considerations above, we now provide definitions of religion, secular humanism, and spirituality as they will be used in this text, and will relate these to research and clinical practice.

A DEFINITION OF RELIGION We define religion as the phenomenon wherein a system of beliefs and practices unites adherents into a community with a shared vision for attaining union with, or the experience of, the divine or transcendent.1 The definition here has both a horizontal dimension—​constituted by a community of adherents to religion’s beliefs and practices—​and also a vertical dimension, wherein the individuals in that community are seeking an experience of or union with the divine or transcendent. The transcendent here may be called God, Allah, or HaShem in Western

religious traditions. In Eastern religious traditions, the transcendent is often referred to as Brahman (the Supreme God), Buddha, Dharma, Ultimate Truth, or Ultimate Reality. Some faith traditions, as in Christianity, believe that the transcendent exists both outside of the ego-​self (God or Jesus) and within the self (Holy Spirit); largely outside of the self, as in Judaism and Islam (with perhaps the exception of the mystical branches in these traditions); or merges with the self and universe, as in some Eastern faith traditions. Religious beliefs may also include aspects of the supernatural, including beliefs about spirits, angels, or demons. Religions usually have specific beliefs about the afterlife and rules to guide behaviors and interactions with others during the present life. Religion is typically organized and practiced with others in community, a community which itself arises from the religion’s system of beliefs and practices. The practices typically include various rituals carried out either individually or within a community. For a particular individual, religion can also in principle be practiced alone and in private, outside of a group. The latter might involve personal beliefs about the transcendent and private activities such as prayer, meditation, scripture study, private religious rituals, watching religious television, online access to religious programming, listening to religious programs on the radio, or listening to religious music (as described earlier). However, even in this private context, the practices themselves, when they are referred to as “religious,” are still typically shaped by or pertain to the beliefs, practices, and rituals of a broader community. The term religiosity refers to how involved and committed a person is to their religious beliefs, rituals, and practices. Thus religion, as we define it, not only involves attending religious services or other institutional forms of religious involvement, but also includes many other aspects that are personal and private. However, religions are usually rooted in an established tradition shared by a group of people with common beliefs about the

1. Although phrased differently and updated, there is strong overlap between the definitions of religion, secular humanism, and spirituality provided here and those provided in Koenig, 2011a; Koenig et al., 2012; and Koenig, 2018a.

10 •  R esearch M ethodolo g y

transcendent, accompanied by devotional practices that involve reverence for and worship of the transcendent. The definition given here bears similarities to many other definitions given elsewhere (Oman, 2013) including that given by Durkheim. In Elementary Forms of Religious Life, Durkheim in 1912 defined religion as follows: “A religion is a unified system of beliefs and practices relative to sacred things, that is to say, things set apart and forbidden . . . which unite into one single moral community . . . all those who adhere to them” (Durkheim & Swain, 2008, p. 47). Durkheim’s definition makes reference to the “sacred” or “things set apart,” and the community that is described in his formulation is a “moral community.” Our proposed definition borrows heavily from Durkheim’s but makes reference to the “transcendent” rather than the “sacred”; moreover, the community we refer to is constituted by a “shared vision for attaining union with, or experience of, the . . . transcendent,” rather than a “single moral community.” While it is certainly the case that religions do produce communities with moral systems and shared values, the ultimate aim of these religions, and of the systems of morality which they produce, is arguably the experience of or communion with the divine or transcendent itself, that which extends beyond ordinary experience. It is the shared vision of this union or experience, we would argue, that draws adherents and brings them to participate in the religion’s beliefs and practices and moral conduct.

A DEFINITION OF SECULAR HUMANISM Secular humanism we define as an understanding of human existence that is not grounded in religion. It often does not involve the transcendent at all. The focus is on the rational self, science, and the human community as the ultimate sources of power and meaning. What counts is the observable and measurable. Secular humanism includes various humanistic philosophies such as naturalism, materialism, atheism/​ agnosticism, and other manifestations of the secular immanent frame, as noted above (in contrast to the transcendent frame).

A DEFINITION OF SPIRITUALITY We define spirituality as a set of individual beliefs, practices, and ways of being that are intended to assist in attaining union with, or experience of, the divine or transcendent. This definition is largely but not entirely equivalent to the traditional, historical definition of spirituality, which views the spiritual person as one who is deeply religious and whose life centers on and revolves around their religious faith (Figure 1.1) insofar as the individual beliefs, practices, and ways of being in the world are often derived from the beliefs, practices, and rituals of a religious community. According to our definition, spirituality is, like religion, distinguished from everything else, by its link to the transcendent (God, Allah, HaShem, Higher Power, Brahman, the Supreme God, Ultimate Truth, Ultimate Reality, the Dharma, or the Buddha). We do not define spirituality by its consequences (i.e., high ethical standards, morality, meaning and purpose, peace, feeling connected to others, or feelings of wonder or awe), though it may be the ultimate source of these positive moral and emotional states. The definition given above is very similar to our definition of religion since both definitions concern beliefs, practices, and rituals or ways of being related to the transcendent. The difference is the emphasis on whether these beliefs, practices, and rituals pertain to the individual or to the community. In many cases, beliefs, practices, and rituals will be both spiritual and religious—​they not only pertain to the individual’s relation to the transcendent, but also are grounded in a broader community context. The definition for spirituality given here, however, does extend beyond the purely traditional understanding of spirituality in Figure 1.1 in that certain practices might be “spiritual” but not “religious” if they concern the individual’s relation to the transcendent but are not connected to the practices, beliefs, or rituals of a community. A walk within nature that gives rise to a sense of the oneness of all reality, but that is unconnected to beliefs or rituals of a broader community, might be one such example. Likewise, it is, in principle, possible for an Definitions • 11

activity to be religious but not spiritual. An atheist who feels no relation to the transcendent and yet participates in a community’s rituals (perhaps on account of a spouse) might be said to participate in religion without having spirituality. We recognize that this definition in some instances departs from the way spirituality is usually defined today. In the clinical arena, spirituality has been defined by Puchalski and colleagues (2014a) as: “. . . [an] individuals’ search for meaning and purpose; it includes connectedness to others, self, nature, and the significant or sacred; and it embraces secular and philosophical, as well as religious and cultural, beliefs and practices” (p. 10). Elsewhere, spirituality is defined as “a search for the sacred” (Pargament, 2013, p. 257). While a search for the sacred comes closest to our definition, what is “sacred” in a person’s life may not be in any way related to the transcendent. Instead, what is treated as sacred in a person’s life may be material possessions, public recognition and power, success in one’s occupation, or even a personal relationship (girlfriend, boyfriend, spouse, child, etc.). In our opinion, neither of the definitions above are specific enough for research purposes, particularly research where “the transcendent” is front and center in the construct being examined. Nevertheless, these broader notions of spirituality may still be useful in understanding what is most important in a person’s life. Zahl (2019), relatedly, makes the case that we all pursue what he calls “seculosity” as “what we lean on to tell us we’re okay, that our lives matter.” Seculosity is “another name for all the ladders we spend our days climbing toward a dream of wholeness. . . . Our small-​r religion is the justifying story of our life” (Zahl, 2020). This could refer to career, romance, technology, politics, even food. His approach seems consistent with Ken Pargament’s way of thinking about spirituality as a search for the sacred, and one that presumably even a secular person could recognize in himself as potentially universal. Although this would not easily lend itself to a researchable definition, to the extent that it has explanatory power (going beyond the cognitive implications of the notion of worldview, or the private and interior implications that the 12 •  R esearch M ethodolo g y

modern notion of spirituality often has), it is one way of thinking more broadly about these issues.

Non-​Contaminated Spirituality Although many approaches to spirituality today utilize contaminated definitions and measures, this is not universally true. One could assess “spiritual practices” such as meditation, taking walks in nature, walking around a labyrinth (Artress, 1996), or contemplating oneness with the cosmos, all the while contemplating the transcendent (however the person understands the transcendent). Again, the primary focus is on the transcendent. Measures of this type could then be examined in their relationship with health and well-​ being without concern for contamination or tautology. Approaches to spirituality in this way we consider to be methodologically sound.

Spirituality in the Clinic The same characteristics (nebulous, vague, universal in nature, overlapping with mental health) that make spirituality difficult to assess when conducting research make it an ideal term for use in healthcare settings where a construct with a crisp and distinct definition is not required. Instead, as noted earlier, a broadly inclusive term that fosters dialogue, conversation, and engagement is ideal (Figure 1.4). Spirituality, as it is understood and defined today, maps perfectly onto the requirements for use when providing clinical care. A “spiritual” history is taken, and then “spiritual” needs are identified and addressed in a broad and open fashion, where spirituality is defined by patients themselves. This will not work, however, when conducting research that seeks to identify the determinants of health and well-​being.

RECOMMENDATIONS Based on the preceding discussion, we recommend the following—​ all depending on whether the intention is to conduct quantitative research or to assess and address spiritual needs in clinical settings.

Research Construct definitions are crucial for developing measures to quantitatively examine relationships with health. There must be clarity on these definitions for communication between researchers and for replicability of results across studies. The definitions must be operationalizable in such a way that each construct can allow for some form of assessment in a reliable and valid manner, accurately quantifying what it intends to measure. The constructs of interest here are religion/​spirituality (as predictors) and mental/​physical health (as outcomes). Religion as we have defined it above is a specific, generally agreed-​upon construct that can be measured and quantified in various ways and whose definition does not overlap with health outcomes. Thus, when conducting research that examines relationships with and effects on health outcomes, we recommend measures of religiosity or, as described above, very specific “non-​contaminated” constructs of spirituality (Figure 1.5). These measures should be based on a relatively broad but specific definition of religion that grounds it in the transcendent.

Source

Clinical Practice Clinical practice is different from research. Because spirituality is a sensitive topic and because all patients need to be given a seat at the table, whether they are religious or not, spirituality as currently defined (the expanded

Mental Health

Meaning

Negative

Suicide

Connected-

ness

Spirituality

Anxiety

Peace Hope

Cardiovascular Disease

Depression

Purpose

Well-being

Physical Health

Addiction

Psychoneuroimmunology

Positive Religion

Spirituality, as understood based on the historical definition above, may often be synonymous with a deeply committed version of religion. Defined in this manner, spirituality is also a specific and clear construct that does not overlap with mental or physical health and that can be assessed using measures of religiosity. The historical definition of spirituality above has evolved over time, resulting in a broad, nebulous, nonspecific construct on which there is little consensus. Attempts to quantify spirituality defined in this manner have resulted in measures that are heavily contaminated with indicators of good mental health, resulting in research findings that are tautological, uninterpretable, and meaningless. Thus, we do not recommend defining or measuring spirituality in this way for research purposes.

Cancer

Mortality

Secular Humanism

FIGURE 1.5.  Model recommended for conducting research. Definitions • 13

modern version that applies to everyone) is recommended for use in clinical interactions with patients (Figure 1.4). Because of its nebulous and vague nature, a broad conceptualization of spirituality (defined by patients themselves) is ideal for use in clinical practice because it allows for engagement and conversation. In contrast to what is required for research, there is no need to quantify spirituality. Instead, qualitative descriptions of interactions with patients on this subject are sufficient for communication among providers. Sometimes this will involve religious beliefs and practices; sometimes mental health topics such as meaning and purpose in life, well-​being and peace, or social connections with others; and sometimes moral, ethical, or a variety of other issues. These interactions will be guided by how patients define spirituality (determined by the spiritual history). Spiritual needs will be identified in this way and addressed as patients direct.

SUMMARY AND CONCLUSIONS Definitions of constructs in quantitative research are crucial because they determine the content of measures that will be used to assess those constructs. In this chapter we have focused on definitions of religion, secular humanism, and spirituality. First, guidelines for constructs to be used in research were presented, followed by guidelines for constructs in clinical practice. The construct of religion was first examined to determine

14 •  R esearch M ethodolo g y

the extent to which it maps onto the requirements for conducting research, finding that religion fulfills many of these criteria. Second, the construct of secular humanism was examined and likewise was found to have potential for definitions that are specific and distinct enough for use in research. Third, spirituality was examined as it has evolved over time from its historical/​traditional definition to a much broader construct that has expanded to include those who are religious, not religious, and even those who do not acknowledge they are spiritual (i.e., everyone). Attempts by researchers to quantify spirituality in this broad manner have led to an encroachment on mental health by including indicators of good mental health in its definition and measurement. This has made it difficult if not impossible to examine relationships with health outcomes without producing meaningless, tautological findings. Fourth, we presented definitions for religion and spirituality that will be used in this text, and have recommended these definitions for future research that seeks to examine how these constructs relate to and influence health outcomes. The recommendations for research provided here, however, contrast with those for use in clinical practice, where it is argued that the modern definition for spirituality fits perfectly. This is because of its nonspecific, nebulous nature that allows for patients to define spirituality themselves and for healthcare providers to address it in that manner, keeping such interactions patient-​centered and patient-​directed.

2 Measurement Not everything that can be counted counts, and not everything that counts can be counted. —​Albert Einstein

AS INDICATED IN the previous chapter, measurement of a construct should closely reflect the definition of that construct. This is especially true for quantitative measurement in the social and behavioral sciences, which requires the development of a set of questions that ideally capture numerous relevant aspects of a construct based on its definition. The objective is often to come up with a “score” with which statistical relations with various health or other outcomes, similarly quantified, can be examined. In this way, descriptive relationships between religion and health can be examined (in cross-​ sectional studies), and researchers can examine evidence for the potentially causal impact that religion may have on health, or vice versa (in prospective studies and randomized controlled trials). In this chapter, we examine different ways that various aspects of religion can be measured, describe the methods used in scale administration, examine single and multi-​item

measures of religiosity, explore religion-​specific scales, illustrate commonly used measures of religiosity and spirituality, recommend some of the best measures for assessing religiosity, and finally, discuss how to develop new measures of religiosity (if needed), establish their psychometric properties, and translate them (or existing measures) into other languages.

TYPES OF MEASUREMENT There are three basic types of measurement when assessing religious involvement: quantitative (which is the focus of this chapter and entire Handbook), qualitative, and mixed quantitative-​qualitative.

Quantitative As noted earlier, quantitative measurement involves assessing the extent to which a construct can be said to be present as expressed

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0002

on some numeric scale, i.e., determining its “quantity.” This method of measurement is what most healthcare professionals are familiar with and value the most because of its seeming objectivity. Social and behavioral science research is constantly seeking more objective ways of testing claims about how beliefs, attitudes, behaviors, and other characteristics impact health outcomes. Unfortunately, quantitative measurement is often constrained by its relatively superficial assessment of complex constructs due to the limited number of questions that can be asked in a questionnaire and the inability to measure everything that might be relevant to the construct and that may impact health. Furthermore, the “objective” nature of quantitative assessment in studying psychological, social, and behavioral constructs like religiosity is often restricted by the self-​report nature of answers to questions that are subjective and prone to response error. This error may be due to difficulty remembering, the desire to provide socially acceptable answers, or sometimes, simply lying. Contributing to this error is the vagueness in the phrasing of the questions and responses offered. Thus, quantitative assessment can sometimes carry with it a false sense of security about its objectivity (Choy, 2014).

Qualitative Qualitative assessment likewise carries with it concerns about objectivity and replicability, which can sometimes be even more serious than those involving quantitative research. There is perhaps truth in the old saying that “quantitative methods are reliable but not valid and qualitative methods are valid but not reliable” (Britten & Fisher, 1993, p. 271). There are at least six approaches to qualitative research: phenomenology, grounded theory, ethnography, historical, discourse analysis, and triangulation (where triangulation involves a combination of two or more of the other five approaches). Qualitative studies focus on finding answers to questions centered on social experience, how that experience is created, and how it gives meaning to life, allowing for multiple perspectives of the same reality to surface (Glaser & Strauss, 2017). 16 •  R esearch M ethodolo g y

Qualitative assessments usually involve the researcher asking a series of open-​ended questions during a guided interview, a series of observations made by the researcher, or both. Rather than participants responding to questions by marking answers on a numerical scale, they instead provide complete answers to questions in a detailed and in-​depth manner. Qualitative research is a good way to elicit details about the participant’s unique experiences and life story, which quantitative assessment cannot do because of the limitations noted above. Such information may be crucial in terms of understanding mechanisms and causal inference, which can then be later confirmed in quantitative studies. Qualitative data are often used in this way to help design prospective studies and randomized controlled trials. However, concerns about the subjective nature of the data being collected and the researcher’s view influencing the findings are numerous, leading to questions about bias and generalizability of results. First, the questions are developed by the researcher, and the reliability and validity of the interview questions are seldom determined, as would be required in testing the psychometric characteristics of a quantitative scale. Second, the researcher asks the questions, and so may bias participants’ responses by the way the questions are asked, i.e., by the investigator’s tone of voice, facial expression, and/​ or unconscious reactions to participants’ responses. Third, while the interview is usually taped, transcribed, and subject to standard methods of qualitative analyses that produce common themes in the data, the qualitative researcher may selectively emphasize certain responses over others, thereby further contributing to lack of objectivity in the data collected. Critics of this method emphasize that the researcher may hear whatever he or she wants to hear from the responses given by participants, and then may craft reports to confirm their own preexisting biases. Soliciting feedback from participants to ensure that the researcher understands their responses correctly can mitigate but not entirely eliminate the possibility of researcher bias affecting data collection. Finally, qualitative methods are often unfamiliar to quantitative researchers and healthcare

providers who are used to quantitative assessment of health outcomes using measures that are precise and unambiguous. Thus, qualitative research is seldom given the same credibility as quantitative research. This is despite the fact that great advancements have been made during the past several decades in the way that qualitative research is conducted, efforts that have increased objectivity and reduced researcher bias (Creswell & Creswell, 2017).

answers. This method requires more resources (to hire an interviewer) and may also influence the reliability and validity of responses (e.g., increasing the likelihood of socially desirable answers). A third method of scale administration is interviewer-​ rated, which depends to some extent on the participant’s subjective responses but also includes information that the researcher observes during the interview. Based on all information (participants’ responses and interviewer observations), the researcher then rates on a numerical scale the score for Mixed Methods each question based on their overall judgment. Given the strengths and weaknesses of Examples include the Hamilton Depression both quantitative and qualitative methods, Rating Scale, the Structured Clinical Interview researchers are now increasingly using both for DSM-​5, and the Clinical Global Impressions when conducting studies. The combination Scale. Interviewer-​rated measures are considof quantitative and qualitative approaches is ered a more objective and comprehensive way called “mixed methods.” In this way, research- of collecting information, but again one that is ers are able to objectively identify correlations subject to interviewer bias. and relationships using quantitative methods, A fourth method of administration involves while at the same time collecting in-​ depth a combination of both self-​ ratings and explanations from participants that help to interviewer-​ratings. Here, the participant self-​ explain how those relationships came about. rates some questions, and the researcher rates others based on their observations. An example is the 3-​item Religious Coping Index (RCI; METHODS OF Koenig et al., 1992). The first question on the ADMINISTRATION RCI asks the open-​ ended question: “What Scales can be administered in a variety of ways enables you to cope with your current situato collect quantitative data (Koenig, 2011a). tion?” The respondent then is given a chance to First, there are self-​administered scales. The respond and is encouraged to elaborate. If reliparticipant completes the scale on his/​her own gious coping behaviors are among the responses without help. This is typically the way that self-​ given, then this question is given a score of 10, rated scales are psychometrically validated, and whereas if only non-​religious responses are prois probably the most common way that scales vided, the score is marked by the interviewer as are administered due to the ease, cost, and 0. Next, the interviewer asks the participant to minimal amount of investigator time required. mark on a 0–​10 scale the extent to which she or Examples of self-​rated scales include the Beck he uses religion to cope (0 =​“not at all”; 10 =​“the Depression Inventory, Symptom Checklist-​90, most important factor that keeps me going”). the Duke Social Support Index, and many oth- Finally, the interviewer engages the participant ers. Self-​rated scales may also either be entirely in an open-​ended conversation about how he completed by the participant themself, or the or she uses religion to cope and the last time questions on the scale may be read to the par- they did so, and then rates the participant on ticipant by an interviewer, who records their 0–​10 scale based on the interviewer’s judgment. responses. The latter may often be done when Scores are then summed to create a scale rangparticipants are elderly, frail, have problems ing from 0 to 30. with vision or reading, or are less cooperative. Finally, novel methods other than adminThe interviewer may either simply be present istering questionnaires have also been used to and assist in minor ways, or may read all of the collect quantitative data. These methods are questions to the participant and record their designed to collect more objective data, reduce Measurement • 17

errors in memory, and rely less on participants’ subjective responses. Examples include continuous monitoring (using a beeper to page participants at random times and inquire about thoughts or behaviors within the past few minutes or hours), tests of application (manipulating situations and observing responses), questioning informants (family, friends, co-​ workers), or having participants play a computer game that presents choices that indicate beliefs, attitudes, and behavior. These methods are less frequently employed, but may be used in some circumstances, depending on the research question and resources available. The next sections examine single-​and multi-​item measures that seek to quantify religious involvement and are frequently used in research studies.

SINGLE-​I TEM MEASURES OF RELIGIOSITY Religious Affiliation Although not necessarily a measure of religiosity, religious affiliation should be recorded in studies examining the relationship between religion and health. The purpose is to obtain a general sense of the person’s religious background (e.g., Christian, Jewish, Muslim, Buddhist, Hindu, other, none, atheist, agnostic). The specific denomination within the faith tradition should also be identified. For Christians, participants should be asked to specify whether they are Protestant, Catholic, Orthodox, or other. If possible, further breakdown should also be sought, although there are limits here. For example, there are literally thousands of Protestant denominations (World Christian Database, 2019), numerous Catholic denominations (e.g., Roman, Armenian, Byzantine, Coptic, Ethiopian, East Syriac, West Syriac, Maronite), and other Christian groups (e.g., Mormons, Jehovah’s Witnesses, Christian Scientists). There are also intermediate options that assess certain broad categories of denomination without doing this fully. For example, in the United States, the RELTRAD classification is such an approach (Steensland et al., 2000; Dougherty et al., 2007). Relevant categories of Christian affiliation will often vary by country. 18 •  R esearch M ethodolo g y

Jewish traditions include ultra-​ Orthodox, Orthodox, Conservative, Reconstructionist, and Reform traditions. For Muslims, the major subgroups are Sunni, Shia, and Sufi, although even these faith branches are broken down into smaller categories (e.g., Sunni Islam consists of four major schools—​Hanafi, Maliki, Shafi’i, and Hanbali). Buddhism consists of three major branches (Theravada, Mahayana, Vajrayana), in addition to other sub-​categories (Pure Land, Tantric Buddhism). Likewise, there are numerous branches of Hinduism (e.g., Vaishnavism, Shaivism, Shaktism, and Smartism), although most Hindus would not subscribe to a particular group or denomination. While documenting religious affiliation is important, it says very little about how religious the person is (except perhaps for atheists or agnostics).

Religious Non-​Affiliation There is often confusion about what the beliefs are of those who indicate “none” when asked to specify a religious affiliation. The 2018 General Social Survey found that 23.1% of Americans gave this response when asked (Smith, 2019). Many have interpreted this to mean the person is atheist, agnostic, or has no religion, which is frequently not correct. It is true that those who report none for religious affiliation do not acknowledge affiliation with a formal religious group or denomination. However, these individuals may often believe in God or other divinities, consider themselves spiritual in various ways, or have other personal beliefs, sometimes quite strong, involving the transcendent. Moreover, many who respond “none” on such a survey may report affiliation with a religious group as soon as a year later, and vice versa (Lim et al., 2010). Atheists and agnostics are also in the group of “nones,” but make up only a small proportion (10% each), leaving the overwhelming majority having religious or spiritual beliefs of some sort (Frost & Edgell, 2018).

Religious Attendance A commonly used single-​ item measure of religious involvement, perhaps the most frequent measure used in large epidemiological surveys, is frequency of religious attendance.

Among all measures of religiosity included in longitudinal studies, this single-​item measure is perhaps the most powerful and consistent predictor of health outcomes (see Appendix). Religious attendance (assessed by a question such as “How often do you attend religious services?”) is often measured on a 5-​or 6-​point Likert scale ranging from “never” to “more than once/​week.” Attending at least once per week appears to be the threshold when health effects are most often observed.

Tori, 1997) asks for degree of agreement with the statement, “The teachings of the Buddha are very important in my life.” Similar assessments could be made for teachings in other faith traditions, such as: “The teachings of Jesus are very important in my life”; “The teachings of Muhammad are very important in my life”; “The teachings of the Jewish Law are very important in my life”; or “The teachings of the Hindu Scriptures are very important in my life.”

Prayer

Religious Giving

Frequency of prayer may be asked in surveys by a question such as “How often do you pray?” or “How often do you pray or meditate?” Response options typically range on a 4-​to 6-​point Likert scale from “never” to “more than once per day.”

Less often, a single-​item measure of religious giving may be asked, such as “What percentage of your gross annual income do you give to your religious organization or other religious causes?” Response options typically range from 0% to greater than 15%. This may need to be adapted for Muslims, where a more appropriate question would be “Do you give Zakat to the poor each year?” Response options may range on a 5-​point Likert scale from “never” to “very often” or “always.”

Scripture Reading Although used less often than questions on religious attendance or prayer, and more likely to appear as part of a multi-​item measure of private religious activity, a single item may be asked about frequency of reading religious scriptures or other religious literature. For example, “How often do you read religious scriptures (e.g., the Bible, Qur’an, Bhagavad Gita, Dhammapada) or other religious material?” Response options typically range on a 4-​ to 6-​point Likert scale from “never” to “several times per day.”

Religious Salience or Importance Single-​item measures of religious salience may involve asking about self-​rated religiosity or importance of religion. Self-​rated religiosity is often assessed by a question such as “All things considered, how religious would you say you are?” Response options typically range on a 5-​ point Likert scale from “not at all” to “very” or “extremely.” Importance of religion may involve a question such as “How important is religion in your daily life?” with similar response options. Likewise, questions may also be asked about how important religious teachings are to the individual. For example, the Buddhist Beliefs and Practices Scale (Emavardhana and

Religious Coping Many multi-​item measures of religious coping exist (see below). On occasion, however, a single question may be asked, such as “To what extent do your religious beliefs help you to cope with stress in your life?” Response options may range on a 4-​to 5-​point Likert scale from “not at all” to “very or extremely often.”

MULTI-​I TEM MEASURES OF RELIGIOSITY Intrinsic-​Extrinsic Religious Motivation Intrinsic religiosity (IR) has been described as the pursuit of religion as an end in itself—​ and in the words of Paul Tillich, the extent to which religion is the object of a person’s “ultimate concern” (Tillich, 1957). In contrast to IR is extrinsic religiosity (ER). ER is the use of religion as a means to an end, i.e., to some other more important goal other than religion (e.g., to make social contacts, achieve Measurement • 19

community recognition, seek economic gain, etc.). A common mistake that researchers make is equating frequency of religious attendance with ER, which is not correct since there is a specific meaning for ER, as described above. The most widely known effort to measure and distinguish IR and ER was made by Gordon Allport, a psychologist at Harvard, who developed the 20-​item Religious Orientation Scale (9 intrinsic and 11 extrinsic items; Allport & Ross, 1967). A shortened 10-​item version of the scale (Intrinsic Religious Motivation Scale; IRMS) was soon developed by sociologist and theologian Dean Hoge at Princeton Theological Seminary (7 intrinsic, 3 extrinsic items; Hoge, 1972). Later, the psychologist Richard Gorsuch developed a 14-​item and 3-​item version, the Religious Orientation Scale-​Revised. The 3-​item version includes one item each assessing (1) IR, (2) personally oriented extrinsic religiosity (Ep), and (3) socially oriented extrinsic religiosity (Es) (Gorsuch & McPherson, 1989). The 5-​ item Duke University Religion Index (DUREL; Koenig et al., 1997c) has a 3-​item IR subscale derived from the IRMS that is frequently used in studies to briefly assess the most important components of IR. Response options for IR and ER items on most of these measures range on a 4-​or 5-​point Likert scale from “strongly disagree” to “strongly agree” or “definitely not true of me” to “definitely true of me.”

Religious Commitment Several multi-​item measures of religious commitment seek to comprehensively assess level of religious involvement. The 10-​item Religious Commitment Inventory (RCI; Worthington et al., 2003) is composed of two subscales: a 6-​ item intrapersonal religious commitment scale and a 4-​item interpersonal religious commitment scale. The Centrality of Religion Scale (CRS), used mainly in European studies, comes in 5-​item, 10-​item, and 15-​item versions, each assessing the intellectual, belief, public practice, private practice, and experience dimensions of religion, seeking to measure the degree to which religion plays a central role in the participant’s life (Huber, 2003). The authors claim that it has been used in more than 100 studies 20 •  R esearch M ethodolo g y

in 25 countries, involving more than 100,000 participants (Huber & Huber, 2012). A more recently developed measure of religious commitment is the 10-​ item Belief into Action Scale (BIAC; Koenig et al., 2015b, 2015c). The BIAC is a comprehensive measure that assesses religiosity across three major dimensions: organizational religious activity (religious service attendance, other public religious activity, religious volunteering), private religious activity (prayer, scripture reading, religious TV/​radio viewing/​listening, religious giving), and cognitive/​ subjective degrees of religious commitment (priority placed on God in life, personal decision-​making regarding the divine, and adherence to religious teachings). The scale is based on how people spend their time and their money (as more objective evidence of what is really important to them). The 10 items are rated on a horizontal visual analogue scale ranging from 1 to 10 and summed to create a scale with a total score ranging from 10 to 100. The psychometric properties of the BIAC are strong: a single dominant factor, high internal reliability (α =​0.89, 95% confidence interval [CI] =​0.86–​0.91), high test-​retest reliability (ICC =​0.92, 95% CI =​0.87–​0.95), and acceptable convergent, discriminant, and factor analytic validity (Koenig et al., 2015b).

Religious Coping Multi-​item measures of religious coping assess either overall use of religion when adapting to stress, or specific ways that people use religion to cope. An example of an overall measure of religious coping is the 3-​item RCI discussed earlier (Koenig et al., 1992). Another example is the 4-​item religious coping subscale of the COPE (Carver et al., 1989). The 60-​item COPE assesses 15 different strategies used to cope with life stressors, including religion. The 28-​ item Brief COPE includes a 2-​item religious subscale that measures (a) the degree to which the participant seeks comfort in religion or spiritual beliefs, and (b) frequency of praying or meditating (Carver, 1997). With regard to specific ways that people use religion to cope, Ken Pargament has developed religious coping scales ranging in length from the 14-​item Brief RCOPE (Pargament et al., 1998) to the

105-​item RCOPE (Pargament et al., 2000). The Brief RCOPE and RCOPE are by far the most frequently used measures of religious coping. The RCOPE scales measure both positive and negative forms of religious coping.

Religious History Unfortunately, multi-​ item measures of religious history are seldom used in religion-​health research, despite the importance of assessing religious involvement over a person’s lifetime to determine overall exposure to religion. The two scales today that measure religious history are the Spiritual History Scale (SHS; Hays et al., 2001) and the Brief Religious History scale (BRH; George, 1999). The 21-​item BRH scale assesses religious involvement across five different life epochs (ages 20–​29, 30–​39, 40–​49, 50–​64, and 65+​). Frequency of attendance at religious services, private religious practices, and strength of religious faith are measured for each age period, in addition to asking about religious participation as a young child/​teenager and also currently.

Religious Experiences William James (1902) wrote the classic text on religious experiences, and there exists at least one measure of religious experience based on his findings (Hood, 1970). Instruments used more frequently today to assess religious experiences include the 6-​item and 16-​item versions of the Daily Spiritual Experiences Scale (by far the most frequently used; Underwood & Teresi, 2002); the 32-​item Mysticism Scale (assessing Eastern religious experiences; Hood, R.W., Jr., 1974); the 7-​item Index of Core Spiritual Experiences (assessing beliefs and experiences related to God or a Higher Power; Kass et al., 1991); and the 12-​item Religious Experience Questionnaire (assessing experiences of feeling God’s love and forgiveness, along with feelings of anger and resentment toward God; Edwards, 1976).

Religious Attachment Attachment to God has received increasing attention within the field of psychology as interest in the impact of attachment in early life

on psychological and social outcomes in adults has grown (Bowlby, 2018). The most widely used measures of attachment to God are the 28-​item Attachment to God Inventory (Beck & McDonald, 2004) and the 9-​item Attachment to God Scale (Rowatt & Kirkpatrick, 2002). These measures assess three dimensions focused on anxiety about abandonment and avoidance of intimacy with God: insecure-​avoidant, insecure ambivalent, and secure attachments. Levin and Kaplan (2010) developed short 4-​item and 8-​ item Love of God scales that focus on the positive aspects of attachment to God. Rosmarin and colleagues (2011a) have developed 6-​item and 16-​item Trust in God scales that measure trust and mistrust in God and that also reflect degree of attachment.

Religious Well-​Being To our knowledge there is only one widely used scale that assesses religious well-​being, and that is the 10-​item religious well-​being subscale of the Spiritual Well-​Being Scale (SWBS; Paloutzian & Ellison, 1982). This subscale of the SWBS measures a construct similar to attachment to God, but has more to do with the quality of a person’s relationship to God. The SWBS is one of the most widely used scales in the world, and consists of an existential well-​being (EWB) subscale (often labeled as “spirituality”) and the religious well-​being (RWB) subscale above (often labeled as “religiosity”). This is an unfortunate distinction, since it basically equates spirituality to psychological well-​being and religiosity to the quality of one’s relationship to God. When EWB is examined in a model together with RWB when attempting to predict mental health outcomes, scores on the EWB subscales (“spirituality”) are generally more predictive than RWB. However, this is often because EWB has a very substantial conceptual overlap with psychological well-​being more generally, whereas RWB is not confounded with psychological well-​being in the same way. The erroneous conclusion that is sometimes drawn is that “spirituality” (EWB) impacts mental health, while religiosity (RWB) does not (once the existential component is controlled or accounted for). These scales are probably more suitable as outcomes than as predictor variables. Measurement • 21

A concept related to RWB is “relational spirituality,” which emphasizes the personal nature of one’s relationship to the transcendent as an ever changing process that continues throughout a person’s life (see Counted et al., 2018). This has been viewed as an important aspect of human development that helps to create meaning in life through connecting with the divine, both through cognitive struggles with existential issues and through personal experiences of the divine presence (Winter, 1971). More recently, it has been argued that to adequately assess religious or spiritual well-​ being, tradition-​specific measures are needed (VanderWeele, 2019b; VanderWeele et al., 2020c). Generic religious or spiritual well-​being scales, such as that of Paloutzian and Ellison (1982), are generally not specific enough to capture the principal ends and concerns of most particular religious communities, and are also inapplicable to most non-​theistic or non-​ monotheistic religions. The development of a range of tradition-​specific spiritual well-​being measures would better facilitate the study of spiritual well-​being. A preliminary proposal for a distinctively Christian measure of spiritual well-​being has been put forward (VanderWeele et al., 2020c), and measures for other religions could likewise be developed.

research studies nearly as often as the Krause scales.

Religious Quest/​Religious Doubt Religious quest is an aspect of religiosity developed by Daniel Batson that involves “an endless process of probing and questioning generated by the tensions, contradictions, and tragedies in their own lives and in society” as it applies to religion (Batson, 1976, p. 32). This concept also captures lack of certainty in religious belief and degree to which those beliefs and practices are questioned. Religious quest is measured by the 12-​item Quest Scale (Batson & Schoenrade, 1991a, 1991b). This scale is seldom used by researchers today; when used, it is often related to worse mental health (compared to those who indicate they are more confident and assured in their religious faith). A related construct, religious doubt, has been measured by the 12-​item Quest Scale (Batson & Schoenrade, 1991b), by the 10-​item Religious Doubt Scale (Altemeyer, 1988), or by short religious doubt scales developed by Neal Krause (e.g., Krause, 2006d). Religious doubt, like religious quest, is often related to poor health.

Religious Struggles

Religious struggles have been called by many different names, including negative religious As part of the Fetzer Institute’s Brief coping, spiritual struggles, spiritual distress, Multidimensional Measure of Religiousness/​ and religious distress. Developed initially by Spirituality (BMMRS), Neal Krause (1999) Ken Pargament in his studies on religious coping developed an 8-​ item and 12-​ item measure (Pargament et al., 1988, 1998, 2000) and furof religious support that assesses emotional ther refined by Julie Exline (Exline et al., 2014), support received, emotional support given, the concept of religious struggles has recently negative interactions, and anticipated support received enormous attention in the literature. if needed. Versions of this scale have been fre- One reason is that it is almost always related to quently used by Krause and others to assess poor mental or physical health. The most widely religious support, although we are not aware used measure of religious struggles is the 7-​ of any publications that have rigorously estab- item subscale of the Brief RCOPE (Pargament et lished the psychometric properties of these al., 1998), although the 26-​item Religious and scales. Fiala and colleagues (2002) developed Spiritual Struggle Scale (RSSS) is increasingly a 21-​item Religious Support Scale (RSS) that being used as well (Exline et al., 2014). assesses support from God, support from one’s congregation, and support from church RELIGION-​S PECIFIC SCALES leaders. The psychometric properties of the RSS are reported in the publication. The RSS, Most of the scales mentioned thus far largely because of its length, is not utilized in were developed and validated in Protestant

Religious Support

22 •  R esearch M ethodolo g y

Christians and may or may not be as relevant to members of other religious faiths. Many of these scales, however, are not specific to Christianity and assess religious beliefs and activities quite broadly. As a result, they are often quite useful for assessing religious involvement by Christians of all denominations, Jews, and Muslims. The scales may be less useful when assessing devoutness among Hindus, Buddhists, and members of other more pantheistic religious traditions, but even in these religions, they can provide important information about level of religiosity. In this section, we briefly examine scales assessing religiosity or religious coping in Jews, Muslims, Hindus, Buddhists, Native Americans, and members of New Age religious traditions.

Jews There are few overall measures of religiosity developed specifically for members of the Jewish faith. The 26-​item Jewish Religiosity Scale developed by Ben-​ Meir and Kedem (1979) contains a 6-​item subscale that assesses Jewish beliefs (e.g., belief in God, coming of the Messiah) and a 20-​item subscale assessing Jewish practices (e.g., attending synagogue, praying with phylacteries, wearing a yarmulke for males or covering hair for females). The 16-​item Jewish COPE (JCOPE) was developed by David Rosmarin and colleagues (2009) and examines Jewish coping behaviors focused on God, including struggles with God.

Muslims There are now a number of Muslim religiosity scales available for use in research studies. The 13-​item Muslim Religiosity Scale assesses organizational, non-​organizational, and intrinsic religiosity (the three major dimensions of religious involvement) in Muslim populations (Koenig et al., 2015a, pp. 551–​553). The scale’s reliability and validity have been established in Arabic-​ speaking Muslims with end-​ stage renal disease (Al Zaben et al., 2015a, 2015b). The BIAC, with slight modification in wording, is another highly reliable and valid measure of overall religious involvement in Sunni

(Alakhdhair et al., 2016) and Shia (Hafizi et al., 2016) Muslim populations. Several other measures of Muslim religiosity or Muslim coping also exist (e.g., Abou El Azayem and Hedayat-​ Diba, 1994; Ghorbani et al., 2000; Abu Raiya et al., 2008).

Hindus Few psychometrically valid measures exist for assessing religiosity in Eastern religions compared to those used in monotheistic Western traditions. The 19-​ item Santosh-​ Frances Attitude toward Hinduism Scale assesses attitudes toward Hindu rituals and beliefs (Francis et al., 2008b). The Hindu RCOPE is a 15-​item scale with three 5-​ item subscales: one that focuses on God in solving problems (“God-​ focused”); one focusing on spirituality without reference to a deity (“spirituality-​ focused”); and one reflecting negative expressions of religious coping involving guilt, anger, and passivity in relationship to God (“religious struggle”) (Tarakeshwar et al., 2003). To our knowledge, these are the only two measures of Hindu religiosity published in the literature. Thanissaro (2011) has developed a 24-​ item Attitude toward Sikhism Scale for assessment of religiosity in the Sikh tradition, which emerged out of Hinduism in the fifteenth century and shares many common beliefs and practices with Hinduism.

Buddhists Similarly, there are few scales assessing religiosity in the Buddhist tradition. The 17-​item Buddhist COPE assesses positive and negative forms of religious coping from a Buddhist perspective for non-​Asians in the United States (Phillips et al., 2012). The 11-​item Buddhist Beliefs and Practices Scale by Emavardhana and Tori (1997) assesses Buddhist religiosity based on a study of Buddhists in Thailand. Although this appears to be a useful scale, accessing the full scale is difficult. Finally, the 24-​item Attitude toward Buddhism Scale was developed in a sample of teenagers attending high schools in London (only 5% of whom were Buddhist) (Thanissaro, 2011). This measure assesses attitudes toward Buddhist beliefs and practices, Measurement • 23

although it was not developed in Buddhists and so may prove less useful.

2018a), the most commonly used multi-​item measures of religiosity, in order of most frequent, were the Religious Orientation Scale (ROS; Allport & Ross, 1967); Attitude toward Native Americans Church Scale (ACS; Thurstone & Chave, 1929); Few attempts have been made to assess reli- Religious Orientation Scale-​ Revised (ROS-​ giosity/​ spirituality in Native Americans, R; Gorsuch & McPherson, 1989); Intrinsic partly because many different tribes exist, Religiosity Scale (IRMS; Hoge, 1972); and and each has somewhat different belief sys- the Duke University Religion Index (DUREL; tems. However, there have been at least two Koenig et al., 1997c). Between 2011 and 2016, attempts to assess Native American spirituality the most commonly used scales were the ROS, (Greenfield et al., 2015; Bear et al., 2018). The ROS-​R , Religious Commitment Inventory-​10 12-​item Native American Spirituality Scale con- (RCI-​10; Worthington et al., 2003), DUREL, sists of an 8-​item subscale focusing on spiritual IRMS, and the Brief Multidimensional Measure behaviors and a 4-​item subscale assessing spir- of Religiousness/​ Spirituality (BMMRS; Idler itual beliefs. This measure appears to have solid et al., 2003). For the most recent years (2016–​ psychometric characteristics based on the origi- 2020), determined for this edition of the nal study (Greenfield et al., 2015). The scale was Handbook, the ranking was ROS, DUREL, RCI-​ developed in 83 Native Americans from a sin- 10, BMMRS, IRMS, and ROS-​R . gle tribe on a rural Southwestern reservation. The most commonly used multi-​ item Bear and colleagues (2018) have developed an measures of religious coping, based on the 8-​item measure of tribal cultural spirituality in same Google Scholar search noted above Northern Plains American Indians, although between 1929 and 2016, were the Brief most of the items are very broad and are not RCOPE (Pargament et al., 1998); the RCOPE specific to Native Americans. (Pargament et al., 2000); the 2-​item or 4-​item religious coping subscale of the COPE (Carver et al., 1989); the Religious Coping Activities New Age Believers Scale (Pargament et al., 1990); and the Religious The 22-​item New Age Orientation Scale (NAOS) Coping Index (Koenig et al., 1992). Note that assesses the typical beliefs of New Age believers these rankings were the same for the period (Granqvist & Hagekull, 2001). The initial scale 2011–​2016 and for the period 2016–​2020. validation was performed in Sweden among The most commonly used multi-​item spiritu83 adolescents (average age 17.7 years) and 50 ality scales (based on a Google Scholar search adults drawn from vegetarian cafes, alterna- from 1982 to 2020 for the Handbook) were tive bookstores, and health/​medicine centers the Spiritual Well-​ Being Scale (Paloutzian frequented by individuals exhibiting a New & Ellison, 1982); FACIT-​ Sp (Peterman Age orientation. Agreement or disagreement is et al., 2002); Spiritual Transcendence Scale sought on statements such as “The position of (Piedmont, 1999); Daily Spiritual Experiences the stars at birth affects how one will live one’s Scale (Underwood & Teresi, 2002); and the life or how one’s personality will develop”; “I World Health Organization Quality of Life-​ am convinced that thought transference and/​ Spirituality, Religiousness, and Personal Beliefs or the ability to move things by mere thinking scale (WHOQOL-​ SRPB, 2006). Nearly all of actually do work”; and “With the assistance of a these scales are characterized by contamina‘medium’ it is possible to get in touch with dead tion with indicators of positive emotions (see people or with life on other planets.” The scale Chapter 1). has not been used very much.

COMMONLY USED SCALES Based on a 2016 assessment conducted using Google Scholar from 1929 to 2016 (Koenig, 24 •  R esearch M ethodolo g y

RECOMMENDED SCALES The scale that we recommend for studying the relationship between religiosity/​religiousness and health will depend on at least four

considerations: (1) the researcher’s purpose (the research hypothesis being tested); (2) the particular aspect of religiosity the researcher wishes to measure; (3) the particular health outcome being examined (and reason why and how religiosity ought to influence it); and (4) the amount of room available in the questionnaire (a practical but important issue). For researchers looking for the best overall measure of religious involvement when assessing the relationship between religiosity and health outcomes, we recommend either the 10-​ item Religious Commitment Inventory (Worthington et al., 2003) or the 10-​ item Belief into Action Scale (BIAC; Koenig et al., 2015b, 2015c). The BIAC is substantially more sensitive than the 5-​item DUREL in detecting relationships with psychological and social outcomes, and is now available in English, Arabic, Moroccan Arabic, Farsi, and Chinese versions (Koenig et al., 2015c). The Fetzer Institute’s 31-​item BMMRS is another option (perhaps without the meaning, values, and forgiveness subscales, which are not distinctively religious). The psychometric properties of each of the short scales that comprise the BMMRS (Idler et al., 2003) are not as firmly established as for the other measures. Regardless of scale used, all three dimensions of religiousness (organizational, non-​organizational, and intrinsic) ought to be measured (Koenig & Futterman, 1995b). If the researcher wishes to assess religious coping, the 14-​item Brief RCOPE (Pargament et al., 1998) is the best measure to use, followed by the 2-​item or 4-​item religious coping subscale of the COPE (Carver et al., 1989). There is also a 6-​item version of the Brief RCOPE (3 items assessing positive religious coping and 3 items assessing negative religious coping) that is contained in the BMMRS. If space is available in the questionnaire, the most comprehensive way to assess religiosity is by combining scales. In that case, the 10-​item Intrinsic Religious Motivation Scale (Hoge, 1972), the first two items of the DUREL (organizational and non-​organizational religiosity), the 8-​ item Religious Support Scale (Krause, 1999), and the 7-​item negative religious coping subscale of the Brief RCOPE (Pargament et al., 1998) are recommended. Doing so would cover all three dimensions of religious involvement,

as well as capture religious support and religious struggles. For investigators looking for the shortest measure, the 5-​item DUREL or the 3-​item version of the Religious Orientation Scale-​ Revised (Gorsuch & McPherson, 1989) is recommended, although the ROS-​ R measures only IR and ER. The DUREL has the advantage of assessing all three major dimensions of religiousness as noted above (organizational religious activity [ORA], non-​ organizational religious activity [NORA], and intrinsic religiosity [IR]). If there were room for only one question, then the best measure would be frequency of religious attendance—​given its strong relationship with both mental and physical health (especially physical health and longevity). Next in line would be the intrinsic religiosity item “My religious beliefs are what really lie behind my whole approach to life” from the IRMS (Hoge, 1972). Of the 10 IRMS items, this single statement has the strongest correlation with the total score (r =​0.74) and is the strongest predictor of recovery from depression over time (Koenig & Bussing, 2010a). A recent meta-​ analysis suggests that importance of religion is also a strong predictor of lower depression in longitudinal studies (Garssen et al., 2021; see commentaries by Koenig et al., 2021, and VanderWeele, 2021a), but we prefer the single IRMS item. It should be remembered that when using scales that constitute a composite measure of religiosity, associations with health outcomes are in fact capturing a variety of relations between different aspects of religiosity and health. As noted in Chapter 1, religious participation is a complex phenomenon that involves behaviors, beliefs, experiences, social relationships, and understandings of one’s identity, each of which may affect health or other outcomes in a variety of diverse ways. It is entirely possible that certain aspects of religiosity will positively affect health and that others may not. There is no such thing as the effect of religion on health. The summary scales for religiosity can still be useful in assessing how a range of behaviors, beliefs, experiences, relationships, and understandings might, taken together, shape health overall, but it should be remembered that the mechanisms by which Measurement • 25

these relationships arise are diverse and complex. Each measure may capture a slightly different composite of the effects of the various aspects of religion, and many measures are focused on only more specific aspects. There is, moreover, no measure that is capable of assessing all relevant aspects of religion, though some measures may be more adequate than others. However, once again, even the more adequate measures are (a) imperfect and (b) will inevitably capture a variety of diverse aspects related to religion. For this reason, even when using well-​established scales, it can be helpful, when data permit, to also examine one indicator at a time concerning its association with health. While this is perhaps not currently standard practice, additional insight may be possible if this were done more frequently (VanderWeele, 2022). Doing so will require relatively large sample sizes, but when this is feasible, such analyses may contribute more to our understanding of how different aspects of religiosity affect health. Overall summaries will remain important, but as our knowledge in this field advances, more nuanced evaluations, when feasible, may give yet deeper insights.

MISCELLANEOUS TOPICS IN MEASUREMENT Many aspects of measurement in the field of religion and health could be addressed, but space limitations prevent these areas from being covered. We now briefly address three areas of particular importance: how to develop a new scale, how to determine the psychometric properties of a scale, and how to translate a scale into another language.

Developing a New Scale There are now literally hundreds of scales measuring religiosity (Hill & Hood, 1999; Hill et al., forthcoming). Researchers interested in studying the health effects of religious involvement have a tremendous range of instruments to choose from. Thus, careful thought and survey of the existing measures should be pursued before deciding on whether yet another measure is needed. Nevertheless, there may be aspects of religious involvement that are of 26 •  R esearch M ethodolo g y

interest to the researcher for which no psychometrically valid scale is available. There are also many religious traditions or population groups in which no scale fully captures the beliefs and practice of that tradition (e.g., Christian Scientists, Mormons, Jehovah’s Witnesses, Orthodox Christians, indigenous religions, etc.). In these and other cases, the researcher may need to develop a new measure. The procedure for developing a new scale typically involves generating a large group of possible questions/​ statements that might be included in the scale. This is often done by conducting focus groups consisting of 8–​12 individuals made up of experts in the field or persons making up the population to be studied, or both. Once a list of items is generated, each item is then examined and potentially refined concerning its relevance, phrasing, and clarity, perhaps by cognitive interviewing and pilot testing the items in a small sample of those in whom the final scale will be used. Based on the results of this pilot study (often qualitative, but possibly quantitative, or both), items are eliminated or rephrased to enhance clarity. Next, the semi-​ final scale is administered to a larger sample to determine its psychometric characteristics (reliability and validity), with further reduction of items as indicated to a manageable number. Finally, the scale is administered to a large random sample of the intended population to obtain scale norms. An excellent description of the steps involved in new scale development related to religion-health research is provided by Krause (2002a).

Determining Psychometric Properties The psychometric properties of a new scale will need to be established. Likewise, there are many existing scales whose psychometric properties have not yet been tested in different religious traditions, languages, countries, or cultural settings. The psychometric properties of a scale or assessment may potentially vary across settings. In some sense there is no such thing as the psychometric properties of a scale; this will in part be relative to context, population, and use. However, when a scale’s properties are relatively similar across different contexts, one

might reasonably hope that the same will be true in a new setting as well. Determining the psychometric properties of a measure requires a certain set of skills related to operating statistical software programs, often requiring input from a statistician. The psychometric properties of particular interest are a scale’s reliability and validity, which we will now briefly review below. Reliability is the degree to which the measure in view is consistent across different aspects of assessment. Reliability may concern (a) how strongly responses to each question are correlated with each other (called “internal reliability” or internal consistency), and (b) the extent to which the responses given are stable over time (i.e., the same responses are given when the questions are asked a second time one to two weeks later). The latter is called test-​ retest reliability. A Cronbach’s alpha (α) tests the internal reliability of a scale (range 0.00–​1.00). Alphas of 0.70 or higher are considered acceptable (Cronbach, 1951). Test-​ retest reliability is determined by calculating an intraclass correlation coefficient (ICC) between scale scores obtained at two different time points (range 0.00–​1.00). Again, values of 0.70 or higher are sometimes considered acceptable (Shrout & Fleiss, 1979). However, this is relative to the amount of time between the test and retest, and also the nature of the construct under study. In archery terms, reliability is the degree to which an archer hits the same target over and over again (consistency). While the archer may be very consistent and reliable in hitting the target over and over again, it may be the wrong target. For example, a scale that measures a person’s weight may indicate the same weight as the person steps on and off the scale repeatedly. However, if the scale is not calibrated correctly, the weight indicated will be wrong. In contrast to reliability, the validity of a scale—​called construct validity—​is the extent to which the scale assesses the correct target that the researcher intends to measure. A measure’s construct validity is established on both theoretical and empirical grounds. The theoretical assessment of validity is determined in part by face validity and content validity. Face validity is how well the indicators on the

scale appear to be a reasonable measure of the construct “on its face.” Content validity is how well the items on a scale cover all aspects of the construct based on its definition. Precise construct definitions are thus an important part of the measure-​development process, and this is perhaps too often neglected or may be carried out in a careless manner. Both face validity and content validity are usually determined by an expert panel of judges who assess the degree to which each scale item is relevant to the construct. The empirical assessment of validity has to do with how strongly a scale is related to one or more external criteria (called criterion validity). In some classical schemes, there are four types of criterion validity: convergent, discriminant, concurrent, and predictive validity. Convergent validity is the degree to which a scale relates to the construct it is supposed to measure. This is conventionally established by examining the scale’s correlation with existing reliable/​valid measures of the construct (ideally, a “gold standard” of the construct). Unfortunately, there is no gold standard for religiosity or for many other constructs. Attempts to establish criterion validity have asked clergy (who are presumed to be experts on religion and thus a type of “gold standard”) to answer scale items in a way that a deeply religious person would answer them. Of course, this may differ depending on the religious tradition. Discriminant validity (as noted in Chapter 1) is the degree to which a scale does not overlap with other constructs, i.e., discriminates between the intended construct and similar already established constructs. This is determined by demonstrating a comparatively weak, or even negative, correlation between the scale and those other constructs. Measures of spirituality that are often confounded by indicators of mental health thus ignore this crucial psychometric principle. Predictive validity is demonstrated by a strong correlation between the scale and a construct assessed in the future that it should theoretically be related to (e.g., SAT test scores on future academic performance). The theoretical arguments are often based on what are thought to be causal relationships with the behavior. Unfortunately, in practice, little or no control Measurement • 27

for confounding is made when examining such associations, thus potentially invalidating their usefulness if the latter is not done. Concurrent validity is the final measure of criterion validity. Concurrent validity is how strongly the scale’s scores correlate with scores on another construct/​outcome that it should be related to and that is measured at the same time (vs. in the future, as in predictive validity). Although concurrent validity and convergent validity appear to be quite similar, they are different. Concurrent validity differs from convergent validity in that it focuses on a scale’s ability to predict scores on another construct or outcome. Convergent validity refers to the observation of strong correlations between two scales that are assumed to be measuring the same construct. Some social science researchers feel that predictive and concurrent validity are less important indicators of criterion validity than are convergent and discriminant validity. Validity is sometimes assessed by exploratory factor analysis in one sample and then by confirmatory factor analysis using structural equation modeling in a second sample (Boateng et al., 2018). Unfortunately, however, such methods can be misleading if potentially causal factors affect one another (VanderWeele, 2022). In conclusion, the internal reliability, test-​ retest reliability, and criterion validity should be examined for a religiosity (or spirituality) scale that researchers plan to use in quantitative research, particularly research that examines relationships with health outcomes whose psychometric properties have likewise been established. The scale’s psychometric properties should ideally meet or exceed the standards that have been set for those metrics. For a comprehensive review of current scale psychometrics, see DeVellis (2017).

Translating a Scale There are many instances when the researcher might want to translate a scale from English into a different language in order to use it in studying people in a different country or region of the world. There are established procedures for doing so. The researcher should not simply

28 •  R esearch M ethodolo g y

translate a scale from English into the foreign language and then administer it to individuals who speak that language. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR), for example, has provided guidelines for scale translation that describe the set of procedures that should be followed (Lenderking, 2005; Wild et al., 2005). In brief, this set of procedures requires at least two experienced translators who are fluent in both languages and a team that oversees the process (the researchers, language experts, and for our purposes, experts in religion). First, the measure is translated from English into the foreign language by one bilingual translator. Next, the second bilingual translator independently translates the scale back into English, which is then compared to the original English version by the team. The team and the two translators then get together and work out any discrepancies until the back-​translated foreign-​language version matches the original English-​language version. This entire process may be repeated a second time by a different set of bilingual translators to ensure that the back-​ translated version of the scale matches that of the English version. Next, the psychometric properties of the foreign-​language version of the scale are determined in a sample of those who speak that language.

SUMMARY AND CONCLUSIONS The focus of this chapter has been on the measurement of religiosity. First, different types of measurement were discussed (quantitative, qualitative, mixed methods). Second, methods of scale administration were summarized, including self-​ administered, interviewer-​ administered, and a combination of the two. Third, single-​and multi-​item measures of religious involvement were examined. Fourth, scales used to assess religiosity or religious coping in religions other than Christianity were examined. Fifth, commonly used scales in religion and health research were reviewed (including measures of spirituality), and recommendations were made on the best scales to use in future research, depending on the

researcher’s purpose and available space in their questionnaire. Finally, we explored a variety of topics in measurement, including how to develop a new scale from scratch, how to determine the psychometric properties of a scale, and how to translate a scale into a different

language. Research findings on the relationship between religion and health will depend heavily on choosing the most relevant measure of religiosity and examining well-​measured health outcomes, which religiosity is expected to influence based on underlying theory.

Measurement • 29

3 Research Design Without data, you’re just another person with an opinion. —​W. Edwards Deming

THE RESEARCH DESIGN of a study is a strong determinant of its quality and of the interpretation of its findings. Knowing the basics of research design, then, is important not only for researchers, but also for anyone who reads the results of research published in academic journals. In this chapter, the basics of study design are described, beginning with identification of the research question and hypothesis of what is expected to be found. Next, a description of the various research designs is provided, along with a discussion of their strengths and weaknesses. Recommendations are made for the study designs most needed in order to advance the field of religion and health. Determination of sample size, sampling method, response rate, and information on nonresponders are then examined, with special emphasis placed on observational studies (cross-​sectional and prospective). The statistical analysis of data is briefly addressed, along with miscellaneous issues related to conducting research in this

area (use of existing data sets, importance of research teams, and the need to publish study results). Throughout this chapter, special emphasis is placed on prospective longitudinal studies and randomized controlled trials when conducting future research.

THE RESEARCH QUESTION All studies begin with a research question, and most also include an informed prediction (hypothesis) of the answer to that question. The research question typically comes first before all other aspects of study design. There are many reasons why the research question is so important, although the two most significant are the following. First, the research question directs everything that follows—​the choice of design; the size, type, and recruitment of the sample; the analysis of the data; and interpretation of the findings. All other aspects of research design must flow naturally from the

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0003

research question, which acts as the “conductor” for the entire study—​just as a symphony conductor directs musicians in an orchestra to produce a masterful performance, all in harmony together. Second, the research question protects against lack of focus. Lack of focus is one of the most common pitfalls of inexperienced researchers whose broad interests may easily lead them into tangents not directly related to the purpose of the study. When conducting research, the aim should generally be to go deep, not broad. Precisely answering one research question leads to other research questions, like the branches of a tree spreading out from the trunk. This is how knowledge about a subject accumulates, and there is much that is not known about the relationship between religion and health.

Identifying the Research Question The research question is based on a thorough review of the literature to identify what is known about the subject, what remains unknown, and what small piece of this unknown can be answered by the researchers with the resources they have available. The research question is usually determined after discussion with colleagues and experts in the field who help to refine it into one that is answerable, feasible, novel, ethical, and relevant. A N S W E RA BL E

There must be a research design capable of answering the question. Not all questions can be answered by known scientific methods. For example, there is no research design possible to answer the question of whether or not God exists. F E A SI BL E

Carrying out a study that can answer the research question must be feasible in terms of the resources available. Doing so will likely require funding support, time, access to subjects, ability to recruit subjects, skills in project management, experience analyzing the data collected, and the capacity to write up the results and get them published.

N OVEL

The research question must contribute to knowledge—​adding to what is already known by providing new information or by replicating or buttressing previous findings that were determined using a less rigorous design. ETH ICAL

The study to answer the research question must be designed in a way that will not violate the rights or well-​being of participants. For example, randomizing dying subjects at the end of life to either see a chaplain or not see a chaplain to assess the benefits of a chaplaincy intervention may not be ethical—​even if subjects agree to participate with full knowledge of the study’s benefits and risks. REL EVAN T

Determining the answer to the research question must provide information that will affect public health, improve the quality of healthcare, influence healthcare costs, or alter healthcare policy.

Specifying the Hypothesis Once a research question is developed, the researcher will generally make an educated guess as to what the answer to the research question will be. This is called the hypothesis. Like the research question that generates it, the hypothesis should ideally be focused and exact. This should also include how large an effect is expected, which will enable a power analysis to determine the sample size and resources necessary to conduct the research. For example, a correctly specified hypothesis might be: “We hypothesize that Southern Baptists in North Carolina who attend religious services weekly or more will have an average 5 mmHg lower diastolic blood pressure than those who attend services less than weekly.” The hypothesis must be based on information published in the literature or on results from previous pilot work. Regardless, there should be a solid rationale for the hypothesis based on existing data and/​or theory. In the next section, we examine types of research designs. Research Design • 31

OBSERVATIONAL RESEARCH DESIGNS The research design chosen will depend on the research question. There are two basic kinds of designs: observational and experimental. Observational designs involve both qualitative and quantitative studies. The focus here is on designs used in quantitative research.

Cross-​sectional For research questions that seek to determine if there is an association between religious involvement and a health outcome at a single point in time, a cross-​sectional design is sufficient though such cross-sectional studies rarely provide causal evidence. For cross​sectional studies, a questionnaire is developed that includes measures of the primary independent variable (i.e., religion) and dependent variable (i.e., a health outcome), along with control variables. A sample is identified, the questionnaire is distributed, data are entered into a datafile, the datafile is linked to an analysis program, and correlations between independent and dependent variables are examined. In a case-​ control study, cases with a health outcome of interest (e.g., heart disease) are identified, and control subjects without the health outcome are matched by age, gender, race, education, and other relevant characteristics. The questionnaire is administered to both cases and controls, and the difference between the two groups on the independent variable of interest (e.g., religiosity) is examined. If the independent variable (e.g., religiosity) is significantly lower or higher among cases (e.g., heart disease), this indicates an association between the two variables. Cross-​sectional studies cannot in general provide information on causal inference, i.e., whether religiosity causes better or worse health, or whether poor health causes more or less religiosity. This type of design can determine if two variables are correlated and whether this varies by group, but cannot solve the chicken vs. egg question. Case control (and sometimes cross-​ sectional design) can only contribute evidence for causality if the exposure or independent variable (e.g., religiosity), along with all possible confounders, is assessed 32 •  R esearch M ethodolo g y

retrospectively concerning a time considerably prior to the outcome measurement. However, in these instances, these designs can still be problematic due to errors in memory and recall bias. Studies using cross-​ sectional designs are relatively simple, take little time, and are usually inexpensive to carry out depending on sample size. As a result, in the field of religion and health where funding support is not widely available, cross-​sectional studies are common (over 90% of published research). There are now literally thousands of such studies in the literature on religion and health. While these studies provide little or no information on causal inference, this does not mean that cross-​ sectional studies have no value, particularly early on, when relatively little is known about the relationship between religiosity and a particular health outcome. Cross-​sectional studies are able to determine whether or not an association exists, and whether further study may be warranted. Cross-sectional studies are also valuable for descriptive purposes. The quality of a cross-​sectional study depends on the measures used, the sample size, the recruitment method, the response rate, and the statistical methods used to analyze the data (see below).

Prospective or Longitudinal For research questions that seek to determine whether a characteristic (e.g., a certain aspect of religiosity) predicts changes in health over time, a prospective cohort design will be necessary. A sample of participants (cohort) who meet certain inclusion and exclusion criteria complete a questionnaire assessing predictors and outcomes at one point in time and then complete the questionnaire (or parts of it) again at some time in the future (3 months, 6 months, 12 months, etc.). This allows the researcher to determine whether the occurrence of the predictor (e.g., religiosity) precedes changes in the outcome (e.g., health), or vice versa. There is a related research design, called a “retrospective” cohort design, in which records (e.g., electronic medical records) exist that (a) document level of religiosity at some point in the past and (b) provide information on changes in health status during the time after religiosity was assessed. This design also

allows for determination of whether religiosity predicts changes in physical health over time. However, since the information on religiosity and health already exists, the researcher has no control over how these variables are measured, which is often poor and sometimes is not based on psychometrically valid scales. Prospective studies, while more difficult to conduct, time-​consuming, and costly than cross-​ sectional studies, have numerous advantages. Studies with this design can provide evidence for, though generally cannot prove, causality. This is because while prospective studies can determine both association and whether religiosity precedes changes in the health outcome, they cannot definitively rule out the possibility that a third characteristic might be related to both religiosity and the health outcome and therefore explain the association (when in fact no true association exists). Measuring all “confounders” related to both health and religiosity is often attempted in these studies but cannot be guaranteed, since researchers may not be aware of all factors that might be related to both religiosity and health. Ideally, to help establish causality, these studies would also control for the outcome measured at baseline, as this can help rule out the possibility of “reverse causation,” i.e., that the health outcome may itself affect the religious participation exposure (VanderWeele et al., 2016a; VanderWeele, 2021b). Such prospective studies should also report sensitivity analysis measures that assess how much confounding would be needed to explain away the remaining association by a third unknown variable (Lash et al., 2021). If substantial additional confounding were needed, above and beyond the measured covariates, then this can help provide further evidence for causation. The E-​ value is one straightforward way to report such sensitivity or robustness to unmeasured confounding (VanderWeele & Ding, 2017c) and has become popular quite quickly. A study design that is sometimes capable of definitively establishing causality is a randomized controlled trial (RCT), where the process of randomization allows for an equal distribution of unmeasured confounders between the two groups (the group receiving the intervention and the control group). Like cross-​sectional studies, the quality of prospective cohort studies depends on the

measures used, the sample size, the confounders being adjusted for, and statistical methods used to analyze the data. In addition, the quality also depends on the length of follow-​up and dropout rate. Follow-​up must be long enough to allow for changes in the health outcome to occur, otherwise there will be nothing for the predictor (e.g., religiosity) to predict. In addition, study dropouts must be minimized, or this may introduce hard-​to-​predict biases into the study findings.

Sample Size, Selection, and Response Rate For all research designs (including experimental studies below), sample size requirements can be determined using a statistical procedure called a “power analysis” prior to study initiation. In general, it is preferable to design studies with even larger sample sizes than these calculations suggest because of potential dropouts, smaller effect sizes than hypothesized, or the desire to obtain greater precision in the estimates. Observational studies usually require relatively large sample sizes, particularly those using a cross-​sectional design. For cross-​­ sectional studies to provide reliable results concerning associations, sample size usually needs to exceed 200 participants, depending on the magnitude of the association that is estimated (used in the power analysis). Again, much larger sample sizes are preferable for reliable inference. For research described in this volume of the Handbook, we have mostly focused on studies with samples of 1,000 or more (particularly for cross-​sectional studies), although we have included other studies with smaller sample sizes because of the unique characteristics of the population or outcome variable. Study quality increases with increasing sample size and with the sampling method. For cross-​ sectional designs, random sampling is usually the preferred method, and this is especially desirable for descriptive purposes. Once the population is defined, i.e., those to whom the study’s results are to be generalized, a computer algorithm is often used to identify a list of random participants from that population to be included in the study. After random sampling, the next most preferable method of Research Design • 33

identifying a sample is systematic sampling. Systematic sampling might involve assessing consecutive patients seen in a clinic or admitted to the hospital. Although this is a form of selective sampling (in contrast to random sampling), it does provide a way to systematically identify a sample in a way that can be replicated in other settings. The weakest and least generalizable method is convenience sampling, meaning that those who participate are anyone immediately available to the researcher who agrees to complete the questionnaire. Identifying a “response rate” is also important for determining the generalizability of study findings. This means that the researcher keeps a record of the number of persons approached to participate in the study and a ratio is calculated of the number who agree to participate (y) over the number who participate (y) plus those who refuse or are unavailable (x), i.e., y/​(y +​ x). Ideally, response rates would exceed 75%–​ 80%, especially if the sample is not randomly selected. Achieving these rates is often difficult for the researcher. Nevertheless, the higher the response rate, the higher the study quality and the more generalizable the study results. In contrast, a study that recruits a convenience sample of less than 200 participants with a low response rate and no information on nonparticipants provides the least reliable and generalizable information. Unfortunately, many published studies in the religion and health area are of this type, often because research funding to conduct a better study is not available. Most of the above criteria also apply to prospective cohort studies, although some are not as stringently required and there are new criteria as well. Random sampling may be less important, whereas sample size, length of follow-​up, and minimization of dropouts are a priority. Prospective studies involving 1,000 or more participants, followed for 10 years or more, with multiple assessments of religious and health characteristics and few dropouts (< 25%) provide the most dependable results.

EXPERIMENTAL RESEARCH DESIGNS Experimental studies involve the application of an intervention (e.g., a religious intervention) 34 •  R esearch M ethodolo g y

to participants in order to determine whether the intervention causes change in a particular health outcome (thereby helping to establish causal inference). There are three basic types of experimental design: single group experimental study, nonrandomized controlled trial, and randomized controlled trial (RCT).

Single Group Experimental This research design involves the application of an intervention to a single group of study participants who are assessed at baseline prior to the intervention and then at some future time after the intervention to determine whether the intervention causes changes in a particular health outcome. Since there is no control group, however, it is not possible to determine whether the health changes result from simply the passage of time or from the intervention. Studies with such designs are relatively easy to carry out and are less expensive, but they provide limited evidence toward the establishment of causality. Studies with this design are often helpful in detecting an effect size prior to conducting a more sophisticated experimental study (see below).

Nonrandomized Controlled Trial In this design, there is a control group that is followed over time along with the intervention group, but participants are not randomized to intervention and control groups. Instead, participants self-​ select themselves into one group or the other, choosing to either receive the intervention or participate in a control condition (active or passive). In some cases, the researcher may assign subjects to one group or another based on certain criteria. Having a nonrandomized control group is better than having no control group (i.e., single group experimental study), but it does not accomplish what randomization does. If those in the intervention group improve more quickly on the health outcome compared to those in the control group, there might be certain characteristics of those choosing to be in the intervention group that influence the health outcome and that therefore bias results (such as expectation of benefit that may be

self-​ fulfilling). The quality of single-​ group experimental studies and nonrandomized controlled trials is sometimes comparable to that of a prospective cohort study.

Randomized Controlled Trial (RCT) The RCT design involves a group that receives an intervention and a control group of participants followed forward in time with health outcomes (the target of the intervention) assessed repeatedly in both groups from baseline onward. The goal is to determine whether the health of those in the intervention group improves more quickly than the health of those in the control group, therefore demonstrating that the intervention causes changes in the health outcome. Rather than the researchers identifying and contacting potential participants, RCTs typically rely on volunteers who are willing to participate and meet strict inclusion and exclusion criteria. Participants are often those with a health condition of interest who respond to flyers or advertisements about the study. Because sample sizes are usually much smaller than in prospective studies, study dropouts are an even more serious problem in RCTs. Therefore, considerable effort is made by the research team to support participants to ensure that they remain in the study (support that often has benefits of its own). The most important feature of this design is that participants are randomly assigned to either the intervention or the control group. The process of randomization is a powerful tool that equalizes, on average, all characteristics (known and unknown confounders) between the two groups. This allows such studies to determine whether an intervention actually causes changes in the health outcome. RCTs are expensive and difficult to carry out as planned, which explains why studies of this type make up only a small percentage of the research examining religion and health. Of particular importance, besides randomization, is the nature of the control group. The control group may be a “usual care” control or no intervention, a wait-​listed control (participants receive the intervention later), an attention control (control group receives equal social attention

as the intervention group), or most stringently, an active intervention control (who receive an established intervention with proven effectiveness). RCTs also have a number of weaknesses that can influence the ability to generalize and interpret trial results. The first is that RCTs are “staged,” which means they involve volunteers who must meet strict inclusion and exclusion criteria, making the sample different in many respects. Participants also receive a lot of attention in an RCT, which often involves close monitoring with repeated assessments and lots of support from the research team to keep them in the trial (in order to minimize dropouts). All these factors make it difficult to apply the results from RCTs to individuals in the general population who may not be as motivated or cooperative, may not have the same characteristics as volunteers, do not meet the strict inclusion/​exclusion criteria of participants in trials, or do not receive the kind of support that those in RCTs do. Furthermore, a poorly designed or not well-​managed RCT can produce misleading results, e.g., finding that an effective treatment does not work when in fact it does (“type II error”).

RECOMMENDED DESIGNS Unfortunately, the preferred research designs for studying the relationship between religion and health are the most expensive and difficult to carry out (prospective studies and RCTs). Given the research that already exists, more cross-​ sectional or case-​ control studies are probably not needed. There are exceptions, however. Cross-​sectional studies may still be helpful in examining associations between religious involvement and health in religions other than Christianity, and in areas of the world other than the United States, particularly in countries where little research on religion and health has been done (such as in developing countries with limited funding opportunities to conduct research). Again, these cross-​ ­sectional studies would still need to be followed up by more rigorous prospective studies. Cross-​ sectional studies can also be very helpful for understanding the demographic distribution of different aspects of religiosity. Research Design • 35

Prospective Cohort Studies Prospective longitudinal studies are a high priority, especially those involving large samples (e.g., over 1,000) with multiple waves of data collection conducted over an extended time period (e.g., 10 years or more). VanderWeele and colleagues (2016a) have described a hierarchy of evidence for robustness to confounding and reverse causation and consequent evidence for causality for individual studies using research on the relationship between religious attendance and depression as an example (Table 3.1). Cross-​sectional studies that measure religious attendance and depression at the same time point are ranked lowest on this hierarchy (Level 6). Moving up the hierarchy, next are longitudinal studies that measure religious attendance prior to depression while controlling for characteristics that may confound this relationship (demographics, etc.) (Level 5). Higher up still are longitudinal studies that measure religious

attendance at baseline (T1), depression at baseline (T1), and depression again at some future time point (T2) (Level 4). At this level, baseline confounders, including demographics and especially Time 1 depression, are controlled for when T1 attendance is examined as a predictor of T2 depression. Still further up on the hierarchy are longitudinal studies involving three waves of data collection (T0, T1, T2) that allow not only for control of T1 depression, but also for T0 religious attendance (measured prior to T1 religious attendance) when determining the effect of T1 religious attendance alone on T2 depression (Level 3). The control for prior levels of religion/​spirituality can help rule out unmeasured confounding and allows one to examine the potential effects of changes in religious/​spiritual participation. At the top of the hierarchy of observational studies are longitudinal studies that assess religious attendance and depression repeatedly over multiple waves of data collection (three or more

Table 3.1  Oxford Centre vs. VanderWeele et al. Levels of Evidence (LOE) Oxford Centre LOE1 Level 1a Systematic review of RCTs (with homogeneity) Level 1b Individual RCT (with narrow confidence interval) Level 1c All or none (based on survival before and after availability of Rx) Level 2a Systemic review of cohort studies (with homogeneity) Level 2b Individual cohort study (includes low-​quality RCT) Level 2c Outcomes research; ecological studies Level 3a Systemic review of case-​control studies (with homogeneity) Level 3b Individual case-​control study Level 4 Case series (and poor-​quality cohort and case-​control studies) Level 5 Expert opinion without critical appraisal VanderWeele et al. LOE2 Level 1 Randomized trial of the exposure (minimal dropouts, high compliance) Level 2 Longitudinal data using time-​varying exposures3 Level 3 Longitudinal studies controlling for baseline outcome and exposure3 Level 4 Longitudinal data with control for baseline outcome3 Level 5 Longitudinal studies with exposure preceding outcome3 Level 6 Cross-​sectional studies (including case control, case series) 1 Oxford Centre for Evidence-​based Medicine (https://​www.cebm.net/​2009/​06/​oxf​ord-​cen​tre-​evide​nce-​based-​medic​ine-​ lev​els-​evide​nce-​march-​2009/​). 2 Modified from VanderWeele, T. J., Jackson, J. W., & Li, S. (2016a). Causal inference and longitudinal data: a case study of religion and mental health. Social Psychiatry and Psychiatric Epidemiology, 51(11), 1457–​1466. Note: Levels of evidence are reversed to correspond to Oxford Centre criteria. They also only concern rankings of individual studies (rather than systematic reviews). See also VanderWeele (2021b) for further discussion of evidence from observational studies using multiple studies or designs. 3 Controlling for baseline confounders (other than outcome). RCT =​randomized controlled trial; Rx =​treatment.

36 •  R esearch M ethodolo g y

times), accounting for time-​ varying exposures and employing marginal structural models to analyze the data (Level 2) (Robins et al., 2000; VanderWeele et al., 2016a). One study that implements this design was reported by Li and colleagues (2016a). The investigators analyzed data collected during the Nurses’ Health Study (NHS), a 16-​year prospective study of 48,984 U.S. nurses in which religious attendance and depression were repeatedly measured every four years from 1992 to 2008 and marginal structural modeling was used to analyze the data (see Chapter 5). Finally, Level 1 evidence is that obtained from rigorous RCTs of the exposure, with few dropouts and high compliance. These randomized studies, if well done, can rule out confounding and often provide the strongest evidence for causality. The Oxford Centre Level of Evidence (Table 3.1) extends this to include systematic reviews of multiple studies (Oxford Centre, 2009; VanderWeele, 2021b). Thus, longitudinal (prospective cohort) studies are vastly preferred over cross-​sectional studies. However, other considerations do of course come into play when assessing the quality of the evidence (VanderWeele, 2021b). A longitudinal study with a very short follow-​up is not much different from a cross-​sectional study. Again, follow-​up must be long enough to allow a substantial change in the health outcome to occur. Otherwise, there is no reason to expect a psychosocial construct such as religiosity to detect changes in the health outcome. For example, prospective studies examining predictors of change in depression should ideally be at least 12 months long, since the natural history of a depressive episode is about 9–​12 months. Follow-​up may be shorter if participants are undergoing significant psychosocial stressors and their emotional state is changing rapidly. The amount of change necessary in physical health outcomes will depend on the age of participants. For young persons (under age 50), changes in physical health occur slowly because of the large physiological reserve of middle-​ aged and younger persons. Thus, follow-​ up will need to be at least several decades to allow for significant physical health changes to take place, thus allowing sufficient power and “variability” in the outcome for psychosocial factors such as religiosity to explain. For those over

age 50, follow-​up of 10 years or longer may be necessary for sufficient health change to occur. For participants with physical health conditions that are rapidly changing in response to treatment and are influenced by psychosocial factors, follow-​up may be shorter. Bear in mind, however, that physical and mental health stressors often cause participants to turn to religion for comfort and hope, which almost always affects cross-​ sectional findings and sometimes longitudinal results unless time to follow-​up exceeds a certain minimum. With regard to the ideal number of follow-​ up assessments in prospective studies, there should be at least three follow-​up evaluations, if possible, when both predictor and outcome variables are assessed. More than three follow-​ up assessments are even better, thus allowing for the use of advanced statistical methods such as marginal structural models or growth curve models to analyze the data over time. In fact, the ideal prospective study would assess religious involvement during childhood and would follow participants with multiple assessments during the remainder of their lifetime, examining exposure to religiosity across the life span and assessing changes in both mental and physical health across time. There is no reason why exposure to religion as a predictor of health outcomes should be viewed any differently from other psychosocial exposures that public health experts examine. Assessing the impact of lifetime exposure of risk factors on changes in physical health in other areas of public health research is commonplace. This is particularly true when studying the effects of psychological, social, or behavioral health-​risk predictors whose effects may be difficult to examine in RCTs. For example, the effect of cigarette smoking on the development of lung cancer is examined in terms of pack-​years, i.e., the number of packs per day that a person has smoked over their lifetime. Researchers cannot randomize participants to smoking cigarettes or not, given their known deleterious effects on health. Likewise, it would be difficult for researchers to randomize individuals to either religious involvement or no religious involvement. As a result, prospective studies should seek to assess lifecourse exposure to religious involvement over a person’s lifetime in order to Research Design • 37

determine the overall effect that religion may have on health. The longer the follow-​up and the greater number of assessments, the better.

Randomized Controlled Trials (RCTs) At the top of the evidence hierarchy for causality is the RCT. Theoretically, a study might randomize non-​attending depressed participants (who are religious but not actively involved) to either a group that attends religious services regularly or to a control group (one that perhaps attends a nonreligious social function). Assuming that (a) randomization is successful, (b) noncompliance and dropouts are minimal, and (c) the social attention paid to participants in both groups is equal, one could then examine whether attending religious services causes a greater reduction in depressive symptoms compared to non-​attendees in the control group. In this way, the effect of religious attendance on depression could be examined and causal inference determined. However, in practice, such a design is subject to numerous ethical and philosophical concerns. Researchers (and participants) may be reluctant to randomize nonreligious subjects to religious activity (and likewise ensure that those in the control group do not attend services). If participants are fully informed about the study and agree to participate, then even a study of this type would be feasible. Fortunately, such a trial is not necessary. Since most people in the United States and many other areas of the world are already religious to some degree, one need not conduct such a study in nonreligious persons in order to assess the benefits of religious involvement. Much easier (and more ethical) would be to conduct the RCT with participants who are already religious. A religious intervention might seek to increase religiousness by utilizing participants’ existing religious resources to impact their mental or physical health. In fact, a number of RCTs have sought to do exactly that. For example, there are numerous RCTs that have examined religiously integrated psychotherapies for the treatment of anxiety or depression by utilizing participants’ religious beliefs and practices as part 38 •  R esearch M ethodolo g y

of the therapy, which have resulted in a significant reduction in symptoms (e.g., Rosmarin et al., 2010; Worthington et al., 2011; Koenig et al., 2015d). Likewise, a number of RCTs have examined simple religious interventions such as prayer or meditation in the treatment of depression (Badrasawi et al., 2013), anxiety (Hosseini et al., 2013), quality of life (Jafari et al., 2013), postoperative pain (Beiranvand et al., 2014; Nasiri et al., 2014), migraine headache (Wachholtz & Pargament, 2008; Tajadini et al., 2017), gene expression (Kaliman et al., 2014; Akbari et al., 2016), metabolic syndrome or glycemic control (Paul-​ L abrador et al., 2006; Gainey et al., 2016), inflammatory markers (Kurita et al., 2011), and recovery from anesthesia (Ikedo et al., 2007). Thus, RCTs involving religious interventions can be conducted. Not surprisingly, the benefits of such interventions are greatest among those who are more religious to begin with (Razali et al., 2002).

MISCELLANEOUS DESIGN ISSUES In this final section, we examine issues related to the statistical analysis plan, the use of existing data sets, the importance of research collaboration, and the need to publish research results regardless of the findings.

Analysis Plan Once the data are collected, the particular statistical analyses used to analyze the data will be important in determining the findings. An analysis plan should be developed prior to analyzing the data, and even better, prior to initiating the study. An analysis plan will help keep researchers on track and focus their attention on testing the initial hypotheses. Failure to do so may result in the wandering off into fishing expeditions where “type I error” will be a problem. Type I error is the finding of a “statistically significant” result by chance alone (possibly due to multiple statistical comparisons) when there is no true association. Any departure from the a priori analysis plan is called “exploratory analysis” and should be reported as such in the description of the research methods. In studies

conducting multiple comparisons, p values indicating statistical evidence can be corrected (reduced) to avoid type I error, although the often used Bonferroni correction is thought by some experts to be too conservative (Perneger, 1998), though it has some attractive properties as well (VanderWeele and Mathur, 2019). Controlling confounders in multivariate models is now a standard practice that all analysis plans intended to assess causality with observational data should follow. Confounders are characteristics related to both religiosity and health that could explain an association in the absence of any true effect. There has been some confusion, however, about the difference between “mediating” variables and “confounders.” Mediating variables explain how the relationship came about, i.e., are involved in the mechanism by which religion influences health. “Confounders,” in contrast, explain away the relationship between religion and health. Religiosity may affect health outcomes through natural, scientifically plausible mechanisms, likely by acting through psychological, social, and behavioral pathways. For example, this might involve reducing psychological stress by improving coping, enhancing meaning and purpose in life, increasing optimism or hope, promoting forgiveness, increasing social support, or improving health behaviors, all of which would be considered mediators, not confounders. In contrast, confounders are characteristics that might be related to both religiosity and health—​such as age, race, education, and socioeconomic status. In prospective studies, baseline physical health may also be a confounder. However, baseline physical health may have been influenced by prior religious involvement, so it could serve as a mediator rather than a confounder in that case. Some variables, like smoking behavior, may be both a mediator and a confounder. Past smoking may affect subsequent service attendance and thus be a confounder, but later smoking may be affected by current service attendance and thus be a mediator. The best way to address these issues is to control for all covariates in the wave prior to the primary religious/​spirituality exposure variable whose effects are being assessed. Thus, for example, if the effects of Wave 2 religion/​spirituality are being assessed,

one could control for all social, demographic, and health behavior variables at Wave 1. In that case, these variables can only be confounders, not mediators. If they were adjusted for in Wave 3, they could only be mediators; if they were adjusted for in Wave 2, then they might be confounders or mediators and it is difficult to know which. Thus, to control for confounding it is best to control for them at Wave 1—​they can then only be confounders (VanderWeele, 2015; VanderWeele et al., 2020b). Also important is examining whether religiosity moderates the relationship between a mental health risk factor such as stress or childhood trauma/​abuse and a mental or physical health outcome. Assessment of moderators requires testing the interaction between religiosity and the stressor in statistical models predicting the health outcome. If the interaction term is substantial, then this may justify conducting stratified analyses that provide the relationship between the stressor and health outcome at high and low levels of religiosity. If the strength of the relationship is weaker in those who are more religious, this means that religiosity moderates the relationship between the stressor and the health outcome. However, there are complexities in the interpretation of moderation analyses that should be taken into account (Lash et al., 2021). Sociodemographic and other characteristics may also moderate the relationship between religiosity and mental or physical health outcomes, and so should be examined in statistical analyses as interaction terms. For example, based on previous research, the relationship between religiosity and a health outcome may be stronger in women, African Americans, those with less education, those living in rural areas, the poor, or those undergoing high levels of stress or trauma. For a more extended discussion of this topic, as well as how to choose a statistical test and how to enter religious variables into statistical models when conducting health-​related research, see Koenig (2011a). For a more advanced discussion of the statistical methods and approaches used for assessing mediation and moderation and for analyzing longitudinal data, particularly as it relates to causal inference, see VanderWeele (2015) and VanderWeele et al. (2016a, 2020b). Research Design • 39

Use of Existing Data Sets

Importance of Collaboration

Many well-​designed studies have produced data sets that include religious variables that are now available to the public. Investigators can download these “public-​use” data sets to their personal computer, analyze the results, and publish the findings (if not already published). The Association of Religion Data Archives (ARDA; http://​www.thea​rda.com/​) has many large national U.S. and international data sets that can be downloaded free from the website. Study design and methodology are described in detail on the site. The Templeton Foundation has supported a research project led by Dr. Alexandra Shields at Harvard’s Genomics’ Center that has encouraged the inclusion of religious measures in ongoing large prospective cohort studies in the United States and around the world (Shields, 2016–​2019). The purpose is to provide data sets with religious variables that can be analyzed and reported on by researchers. This project includes the development of a religious/​ spiritual (R/​S) Atlas that allows researchers to identify R/​S variables included over the past several decades in questionnaires administered in 20 large U.S. cohort studies (Shields, 2019). Studies that have measured religious involvement and a wide range of mental and health outcomes can now be examined. The Atlas has a query tool that allows users to search for religious variables in these large data sets, along with information about the exact religious question asked, sample size of the original cohort, number of participants who responded to the religious question, and a breakdown by gender and race. Obtaining access to those data sets for conducting analyses, however, need to be addressed with the cohort leader. Finally, a more detailed though somewhat dated description of public-​use data sets with religious variables at the National Center for Health Statistics (NCHS) is available (Gillum & Dupree, 2007). This article provides an overview of the public-​use data sets at NCHS and a bibliography of prior research using these data. Thus, analyzing existing data can save the researcher a huge amount of time and resources, when these datasets have the needed information.

In this day and age, it takes a team to design a high-​quality research study and obtain the necessary funding support to carry it out. Collaboration with other researchers is almost always required for successful grant applications. There are many reasons for this, including the need for persons in a number of disciplines to help design and carry out the study, and analyze the data. Such persons include the study’s principal investigator (PI), individual site PIs (in multicenter studies), a statistician, research co-​­investigators with access to the population being studied, along with consultants with experience in r­ eligion-​health research and the health outcomes being studied. A multidisciplinary team also helps to better ensure a correct interpretation of the study findings, as well as adequate monitoring of the study so that the research is carried out and reported in an ethical and responsible manner.

40 •  R esearch M ethodolo g y

Necessity of Publishing Designing a research study, obtaining a grant to fund the study, and then carrying out the study take an enormous amount of effort, time, and energy. This is even true for unfunded studies and when analyzing existing data sets. It is important, then, to publish the findings in peer-​ reviewed journals, providing evidence that such work has been done and giving credit to the researchers responsible. We recommend that investigators publish only in peer-​reviewed journals, avoiding some of the more suspect predatory journals that now advertise for manuscript submissions at a fee (Strielkowski, 2018; see also Elliott, 2012). Peer-​reviewed journals with an “impact factor” (IF) often help to ensure that the research will be seen and cited; they are also the journals least likely to accept a study for publication unless it is methodologically rigorous. There are several different groups that report journal IFs, although the IF assigned by Thomson-​ Reuter (now Clarivate Analytic InCites) is the most widely used. We recommend publishing in non-religious journals of the researcher’s particular discipline whenever possible, rather than in religious journals where a report may be

more easily accepted but may have less ultimate impact. This field will only advance if research on religion and health is increasingly published in mainstream journals. That will happen regularly only when research on religion/​spirituality and health achieves a certain methodological rigor. Whether the findings are positive, negative, or neutral, it is important to publish the findings. Much can be learned from a well-​designed study that finds no relationship between religion and health, which is often due to the complexity of the relationship.

SUMMARY AND CONCLUSIONS Understanding different research designs, with their strengths and weaknesses, is essential for those conducting research on religion and health. This is important not only for researchers designing high-​ quality studies that will advance the field of religion and health, but also for educators and clinicians who must interpret the findings and apply them in their work. In this chapter, we began by emphasizing the research question, describing how to identify it, and illustrating how to specify a research hypothesis. We next examined different research designs, including observational

designs (qualitative, cross-​ sectional, longitudinal) and experimental designs (single-​group experimental study, nonrandomized controlled trial, randomized controlled trial). We recommended the research designs that are most needed (prospective cohort studies and randomized controlled trials). Sample size calculation, method of sample selection, and response rates were then examined, particularly with reference to observational studies. Length of follow-​up and number of assessments were then discussed as they apply to prospective studies, emphasizing the need for long-​term follow-​up that allows time for health outcomes to change and multiple assessments of both religious characteristics and health outcomes. In addition, we stressed the need to assess lifetime exposure to religion in order to identify the “overall” impact that religion has on health across the life span. Next, we examined the possibility of conducting RCTs that examine the efficacy of religious interventions (the only methodology capable of definitively establishing causal inference) and provided examples of such research. We then briefly examined issues related to analyzing data, use of existing public data sets, the importance of collaboration and team-​building, and the necessity of publishing all findings regardless of their nature, doing so in credible peer-​reviewed secular journals whenever possible.

Research Design • 41

SECTION II Mental Health IN THIS SECTION we examine the relationship between religion and mental health. As with social and behavioral health to come, the effects of religiosity are likely “proximal” and “direct” on mental health, perhaps mediated

in some cases by social and behavioral factors. This contrasts with how religion influences physical health, which is entirely “indirect,” acting through mental, social, and behavioral pathways.

4 Coping with Stress There are no atheists in foxholes. —​William T. Cummings

IN THIS CHAPTER, the first in Section II on religion and mental health, we focus on the role that religion plays in coping with stress. If religion is related to better mental health, then this is likely at least in part due to its power as a coping behavior in the face of stress and change. Religious beliefs and religious coping continue to persist despite rapid growth in education, science, and technology. The bestselling books today and of all time continue to be religious texts (Griese, 2010; Guinness World Records, 2019). If religious beliefs served no adaptive purpose, why would more than 90% of the world’s population continue to have them? To start out, we briefly examine the state of affairs with regard to stress, anxiety, and religion in the United States. We then explore various psychological coping theories and specific ways that people adapt to stress. Next, a case vignette is presented, religious coping (RC) is defined, and its frequency is examined

in various countries around the world. This leads to the heart of the chapter, which examines research on RC and mental health. Finally, we discuss how religion might serve as a coping behavior as understood within the context of modern coping theory.

STRESS AND RELIGION IN THE UNITED STATES Psychiatrist M. Scott Peck sums it up succinctly in the first sentence of The Road Less Traveled (Peck, 1978) with the statement, “Life is difficult.” The 2019 Gallup Poll Global Emotions Report confirms this, especially for those living in the United States (Gallup Poll, 2019a). There are few countries in the world as gifted with resources—​ natural, financial, educational, occupational—​ as the United States. Additionally, this country often seems to be a land of almost unlimited opportunity compared to many other countries, and one that

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0004

presents a free and relatively safe society that has not experienced war on its continent for over a century. Indeed, the United States was the #1 destination of immigrants worldwide in 2017, and it held that rank by a long shot (Migration Policy Institute, 2017). Everyone wants to experience the “American Dream.” Despite these overwhelmingly positive circumstances, there appears to be an epidemic of stress, worry, and anger among the citizens of this country. The above Gallup Poll, which involved a random survey of the adults throughout the world, found that in 2018 over half of Americans (55%) indicated they experienced stress during “a lot of the day” and nearly half (45%) said they worried a lot (Gallup Poll, 2019a). In this survey of 143,000 persons in 143 countries, only 3 countries reported higher stress levels than the United States (Greece, Philippines, Tanzania). This means that people in Bangladesh, Yemen, and Afghanistan (all war-​torn countries with few resources) reported less stress than did those in the United States. In contrast, the top 5 countries that reported the most positive emotions were Paraguay, Panama, Guatemala, Mexico, and El Salvador (all Latin American countries, again with relatively few material resources). Research has shown that while material resources lead to greater life “evaluation,” psychosocial resources (greater autonomy, use of one’s talents and skills, quality of social relationships, use of resources to benefit others, and the acquisition of experiences rather than possessions) are what lead to positive emotions (Diener et al., 2010; Dunn et al., 2014; Mogilner & Norton, 2016). Having lots of material resources can itself be stressful. Many who live in resource-​rich countries such as the United States are not content with what they have. Those who have a lot, have a lot to lose. Therefore, they must spend time and effort protecting those resources, often having little time to savor and enjoy them (Quoidbach et al., 2010). Furthermore, those who have a lot are seldom completely satisfied with what they have, and often desire more and more to fill the empty places inside them that no amount of material possessions can fill. After one’s basic needs are met, increasing material resources are not associated with 46 •  M ental H ealth

increasing levels of happiness or well-​ being (Myers & Diener, 1996) and often carry with them a cost—​the cost of peace of mind. Besides the many who are seeking to fill their lives with material possessions, there are also plenty of “have nots” in the United States. Believing that everyone around them has more than they do, this “upward comparison” causes a sense of deprivation and dissatisfaction, leading to stress, worry, and anger (Suls & Wills, 1991). Both of these dynamics—​the stress of having too much and the belief that others have it better—​may help to explain the high levels of distress reported by Americans (at least North Americans). But what about religion? Isn’t the United States also one of the most religious countries in the world? In 2001, following the terrorist attacks on the World Trade Centers in New York City, a random survey of the US population published in the New England Journal of Medicine found that 90% of Americans turned to religion to cope with the stress of these events (Schuster et al., 2001). If most of the populace uses religion to cope with stress and if religion improves coping, why are the majority of people in this country so stressed and worried? This might lead some to conclude that religion really does not help that much and, as Sigmund Freud suggested, is simply an obsessional neurosis that in the long term increases stress and anxiety (Freud, 1927). Conclusions based on regional or country-​level data alone, however, are often erroneous. This is called the “ecological fallacy” (Piantadosi et al., 1988; Rothman et al., 2008). If it were not for the religious faith of many of those in the United States, perhaps stress levels would be even higher. Only research at the individual level can sort out whether religion is truly either a help or a hindrance (see below). Furthermore, the United States is not as religious today as many often believe. According to a 2009 Gallup Poll, the United States ranked 106th in religiosity out of the 149 countries surveyed (Gallup Poll, 2009). Similarly, in a 2015 Gallup Poll, it was ranked 41st out of 65 countries (Gallup Poll, 2015). While the United States may be more religious than many Western countries, it certainly is not one of the most religious countries in the world, and there

is evidence that religiosity is on the decline here (Voas & Chaves, 2018). The most religious countries in the 2009 survey were Bangladesh, Somalia, Ethiopia, Niger, and Yemen, four of which are Muslim-​majority countries. In those countries, 99%–​ 100% of respondents indicated that religion was important (compared to the US, where 69% indicated the same, and only 56% in the 2015 Gallup Poll described themselves as religious persons). All of these countries reported lower stress levels than the United States in the above 2018 Gallup Poll. Note that many of the Latin American countries with high levels of positive emotions in that 2018 survey were also more religious than the United States.

DEFINITION OF STRESS Stress means different things to different people and depends on their current life situation, past experiences, and individual personality. Stress may be defined as the tension experienced from not having the resources to meet needs, desires, and responsibilities. Numerous approaches to conceptualizing, defining, and measuring stress have been put forward (Epel et al., 2018). Not all stress, however, is bad. When there is little or no stress, life may begin to feel boring, like there is no progress being made. The term eustress is used to describe a state of low to moderate psychological stress that is considered healthy—​increasing alertness, improving memory, and enhancing readiness to compete with others (Selye, 1956; Fink, 2010). Eustress is also necessary to enhance growth and to foster the development of coping resources that are essential for resilience. Stress is only bad when it is so severe or prolonged that it causes dysfunction in a person’s social, occupational, or recreational pursuits. Psychological stress is also associated with physiological changes in the body, which if continuously activated can damage the ability to respond to various diseases by adversely affecting immune and endocrine functions necessary for survival (Cuesta & Singer, 2012). However, stress is ubiquitous. Everyone experiences stress—​ the healthy, the physically ill, the mentally ill. Those who are mentally and physically healthy often must deal

with stressors in their family, relationships with friends, colleagues at work, finances, and efforts to achieve personal life goals. Stressful events will vary in intensity depending on how invested a person is in whatever is lost or changed and how permanent that change is. The way that individuals cope with such stressors will determine whether mental and physical health continues or deteriorates into a state of dysfunction. Individuals who suffer from physical illness, especially chronic illness, must deal with many challenges on top of those that healthy people confront. These include unpleasant physical symptoms such as pain, fatigue, loss of endurance, difficulty sleeping, loss of independence, costs of medical care, and difficulty maintaining social relationships. Physical illness may interfere with the ability to engage in tasks of daily living, such as the ability to work, maintain a home, take care of the yard, shop, prepare meals, and even leave the house. Those with severe physical disability may have a hard time with bathing, toileting, eating, and other basic tasks of living, often making them feel like a burden on those who must help out, such as beloved family members. Treatments for medical illness can themselves be stressful, enough in some cases to induce post-​traumatic stress disorder (PTSD) (Tedstone & Tarrier, 2003). Like those with medical illness, people with mental illness have a unique set of stressors and, in addition, may be particularly sensitive to normal life stressors due to their greater psychological vulnerability (Mueser et al., 1998). Those with psychiatric disorders (and their families) must deal with the stigma of these conditions and accompanying social exclusion. The mentally ill often struggle with obtaining and maintaining employment, poor self-​ esteem, and symptoms of mental disorder, ranging from sadness with profound fatigue and loss of interest, to paralyzing anxiety, to paranoia and frightening psychotic symptoms. Repeated hospitalizations and sometimes chronic institutionalization, which may against their will, are also severely stressful. All of these can seriously challenge a person’s ability to cope, quickly overwhelming all but the most resilient of coping strategies (Seow et al., 2016). Coping with Stress • 47

WAYS OF COPING

above, Carver and colleagues identified three broad categories of behavior used to cope According to the Transactional Theory of Stress with stressful events: problem-​focused stratand Coping (TTSC) developed by the psychol- egies (active coping and planning); emotion-​ ogists Richard Lazarus and Susan Folkman, a focused strategies (positive reinterpretation stressor initiates a series of cognitive processes and growth); and mental/​ behavioral disenwithin seconds of the event (Lazarus, 1966; gagement strategies (drugs and alcohol, giving Lazarus & Folkman, 1985; Folkman & Lazarus, up, sleeping, or other attempts at avoidance). 1980, 1988a,b). These cognitive processes are In order to measure these coping behaviors, divided into (1) the primary appraisal of the Carver and colleagues developed the 60-​item stressor and (2) the secondary appraisal of the COPE scale, which assesses a range of adaptive stressor, followed by (3) a coping response. and maladaptive behaviors. The COPE meaPrimary appraisal involves an evaluation of sures 15 coping behaviors, assessed by 4 items whether there is anything at stake in the event each. The COPE has been used even more often that has occurred—​i.e., is it benign, positive, in research studies than the Ways of Coping threatening, or harmful? Is it insignificant, or Questionnaire. There is also a 28-​item version does it represent a challenge to the person’s of the COPE, the Brief COPE, which is used integrity (physical, psychological, or social)? more often than the 60-​item COPE because of Secondary appraisal involves an assessment of its length (2 items assessing each of 14 coping whether anything can be done to overcome the behaviors) (Carver, 1997). Table 4.1 lists these potential harm (i.e., to alter, avoid, or prevent 14 behaviors, categorized by whether they are it in some way). These cognitive appraisals are considered by experts in the field to be healthy followed by a coping response. or unhealthy. According to this theory, there are two main Mobilized as part of coping efforts are copcategories of coping response: problem-​focused ing resources. These include financial resources coping and emotion-​focused coping. Problem-​ (which increase the options available to deal focused coping involves defining the problem, with stressors, including the ability to afford generating possible solutions, identifying the professional help when needed); exercise (a solution’s costs, considering the solution’s ben- form of self-​distraction, distancing, or avoidefits, and acting directly to implement the solu- ance); pets (distraction, distancing, or emotion and resolve the problem. Emotion-​focused tional support); volunteering (self-​soothing by coping consists of attempts to relieve negative helping others, downward comparisons, posemotions by tolerating, escaping, avoiding, or itive reframing); and seeking medical or psyotherwise blocking or minimizing them. The chiatric care (a form of active coping). While 66-​item Ways of Coping Questionnaire opera- religion is usually considered a coping strategy, tionalizes the Transactional Theory of Stress it may also be a coping resource, particularly and Coping by assessing eight major categories if sustained over time, rather than used only of coping behavior (Lazarus & Folkman, 1984; when dealing with stressors (e.g., long-​term Folkman et al., 1986a,b): confrontive coping involvement in a faith community that pro(aggressive efforts to alter the situation); dis- vides ongoing support, encouragement, and tancing (denying there is a threat); self-​control; guidance). seeking social support; accepting responsibility; escape-​avoidance (numbing with drugs or alcohol); planful problem-​solving (taking direct ADAPTIVE AND action to resolve the problem); and positive MALADAPTIVE reappraisal (emphasizing the positive about the COPING STRATEGIES situation). Coping strategies are often categorized into Another approach to categorizing coping those that are adaptive and those that are behaviors was developed by Charles Carver maladaptive (Folkman & Moskowitz, 2000; (Carver et al., 1989). Based on the foundational Day et al., 2001). Whether a coping behavior work of Lazarus and Folkman (1984) described is adaptive or maladaptive, as noted earlier, 48 •  M ental H ealth

Table 4.1  Healthy and Unhealthy Coping Behaviors Assessed by the Brief COPE (Carver, 1997) Healthy/​Adaptive 1. Active coping (PF) 2. Planning (PF) 3. Positive reframing (EF or PF) 4. Acceptance (EF) 5. Humor (EF) 6. Religion (EF or PF) 7. Seeking emotional support (seeking comfort and understanding) (EF) 8. Using instrumental support (seeking help and advice) (EF) Unhealthy/​Maladaptive 9. Self-​distraction (MBD) 10. Denial (MBD) 11. Venting (EF) 12. Substance use (MBD) 13. Behavioral disengagement (MBD) 14. Self-​blame (EF) PF =​Problem focused EF =​Emotion focused MBD =​Mental/​behavioral disengagement or avoidant. * Note that Carver does not recommend dividing the COPE strategies into adaptive or maladaptive, or designating them as emotion-​focused, problem-​focused, etc. (http://​local.psy.miami. edu/​facu​lty/​ccar​ver/​sclBrC​OPE.html). However, these coping strategies have been grouped above in a way that makes logical sense to the current authors (religion is usually placed in the adaptive category by other authors as well). Be aware that a coping strategy may be PF or EF, maladaptive or adaptive, depending on the particular situation with which a person is faced.

depends to some extent on the stressor. When action is possible and necessary to resolve a stressor, then problem-​ solving and direct action are most effective. When the situation is out of a person’s control, then repeatedly taking action that is ineffective is not adaptive. In circumstances where a stressor cannot be changed, the most adaptive strategies are positive reframing, acceptance, and seeking emotional support and understanding (or maybe, turning to religion). Positive adaptive coping strategies include problem-​ focused coping (a systematic effort to define the problem and directly deal with it by taking action) and positive reappraisal or cognitive reframing (where the negative event is interpreted more positively by infusing it

with meaning) (Folkman & Moskowitz, 2000). Positive reappraisal and cognitive reframing involve focusing on the good, looking for opportunities for personal growth, or responding to negative stressors in a way that benefits others (e.g., a parent who loses a child to gun violence becomes an advocate for gun control to prevent others from experiencing a similar loss). Other adaptive emotion-​focused strategies include acceptance, creation of positive events (transforming ordinary events into positive events that are meaningful and stimulate positive emotions), seeking social support, and accepting responsibility (while avoiding self-​ blame when the individual bears little or no responsibility for the outcome). Negative or maladaptive coping strategies include avoidant forms of coping, where a person may deny there is a problem, avoid the problem entirely, or disengage from the problem, allowing it to simmer unresolved. A classic example is the person with PTSD, who rather than processing the traumatic event, makes every effort to avoid reminders of the event, which burst through into consciousness in the form of nightmares and flashbacks. Alcohol or drug use is a form of avoidant coping that can have serious consequences as tolerance builds, requiring more and more of the substance, while the stressor remains unresolved. Mental or behavioral disengagement is also often maladaptive since it involves numbing out, shutting down, or withdrawing into a passive state. Other coping strategies (e.g., distancing, venting of negative emotions, accepting the problem) may be adaptive or maladaptive depending on the situation. What about religion? Is religion adaptive or maladaptive? Who is the Almighty, that we should serve him? What would we gain by praying to him? (Job 21:15)

Case Vignette CK is a 63-​year-​old married White woman who lives with her husband and has two adult children (who are now out of the home). She is deeply religious and active

Coping with Stress • 49

in her local church, serving as a deacon and prayer minister who frequently volunteers to prepare meals for those in need, to support other church members in distress, and to counsel younger women in the church as requested. Although CK has dealt with multiple orthopedic issues throughout life involving her shoulders and knees due to her unusual joint flexibility, other physical health problems have developed over the past several years. Hyperthyroidism has left her with an autoimmune disorder that attacks her peripheral nerves, leading to numbness and severe, unrelenting neuropathic pain in her extremities. This pain has become progressively more and more resistant to narcotic analgesics, as tolerance has developed. In addition, she is experiencing problems with her eyes (bulging), hearing (requiring a hearing aid), problems with balance, severe muscle cramps and spasms (in addition to the peripheral neuropathy), and chronic back pain due to disc degeneration in her spine. One health problem after another has occurred, threatening her independence, interfering with mobility, disrupting sleep at night, and interfering with her volunteering at church, an activity that has always provided great meaning and purpose in past years. Given her constant physical suffering and increasing disability, she wonders why God has allowed this to happen to her and fears what will happen in the future. Despite these challenges, she holds tightly to her faith. She believes that God loves her, that the pain has a purpose (even though she does not know what that purpose is), and that no matter what happens, God is in control, will remain close to her, and will give her the necessary strength to deal with it. In this way, she continues to cope with her pain and disability, has not become depressed or given up, has continued to remain active in church (to the extent possible), and continues to pray with and counsel others who are

50 •  M ental H ealth

suffering (those within and outside of her faith community). But “life is difficult” and questions remain.   

RELIGIOUS COPING DEFINED For the purposes of this volume, RC involves the mobilization of religious beliefs or practices in response to physical, psychological, or social threats to well-​being. The form that RC takes will depend on religious tradition. In Western monotheistic traditions, this might involve praying to God for comfort and relief; reading the Torah, Bible, or Qur’an for guidance and support; attending religious services to relieve negative emotions through prayer and worship with others; seeking social support from members of a faith community or from clergy; and volunteering for religious reasons to provide a sense of meaning and purpose. RC behaviors in Eastern religious traditions such as Hinduism or Buddhism may involve focused meditation, mindfulness meditation, reading religious scriptures such as the Bhagavad-​Gita or the Dhammapada (teachings of the Buddha), or performing religious rituals at home or in the temple that involve prayer, sacrifices, and/​or expressions of reverence or worship. Religious beliefs that provide comfort may include belief in a loving God who is active in the world and has a purpose for every person, belief in life after death, or belief in reincarnation and progression toward Nirvana. Thus, RC involves both behaviors and cognitive processes that may serve to relieve stress by giving meaning to negative experiences, providing ways to deal with negative emotions, and furnishing resources to help persons directly or indirectly cope with life stressors (adapted from Koenig, 2018a, p. 51).

FREQUENCY OF RELIGIOUS COPING RC is common around the world, although it varies depending on where in the world a person resides and on the historical and cultural context of that region. The religiosity

of others in a geographical area is one of the strongest determinants of RC, since support from peers who also utilize religion to cope is a powerful motivating factor. Although many studies throughout the world have examined RC, it is difficult to determine the proportion of those who use religion to cope since these studies seldom report the actual percentage of the population doing so. However, studies in many countries have used the Brief COPE (B-​ COPE; Carver, 1997) to assess the frequency of praying or meditating and seeking comfort in religious beliefs, in addition to 13 other coping behaviors. Studies that use the B-​COPE, then, provide information on which coping strategies are used most often to confront life stressors across a range of behaviors without focusing on RC alone. In this way, rates of RC may be determined in a more balanced and potentially more accurate manner (less affected by social desirability), right along with other common nonreligious coping behaviors. We now examine studies that report either (1) the percentage of the sample using religion to cope; (2) the percentage using RC based on the B-​COPE; or (3) the frequency of RC based on the average score in relationship to other B-​ COPE behaviors. This is done by geographical region, from the most religious to the least.

Middle East RC is most common in the Middle East, where Islam is the dominant religion, and where a long history of war and conflict have created a high-​stress environment. RC rates across studies range from, on the low end, 64% of cancer patients with pain in Iran (Tabriz et al., 2018) to 100% of parents of children with cancer in the United Arab Emirates (Eapen & Revesz, 2003). RC was the most common coping behavior (out of 13 B-​COPE scales) reported by 198 mothers of children with autism in Kuwait (Al-​ Kandari et al., 2017). Among 62 women with breast cancer in Iran, RC was also the most frequent among 14 coping behaviors assessed by the B-​COPE (Khalili et al., 2013). In contrast to Middle Eastern Muslim-​ majority countries, RC is relatively uncommon in Israel, where only 30% of the population describe themselves as religious (Israel was

ranked 58th on religiosity out of 65 countries in the 2015 Gallup Poll above). In a study of 100 Jewish patients with malignant melanoma in Israel, 79% reported no increase in religious activities since childhood (or presumably since the diagnosis of cancer) and only 3% indicated they had increased religious practices “a good bit” (Baider et al., 1999). Among 124 spouse caregivers (age 60+​) of patients with cancer in Israel, religion was the 9th most frequent coping behavior out of 10 B-​ COPE scales, compared to the 8th most common among 65 healthy controls of the same age (Goldzweig et al., 2012). Although participants were not broken down by religion in that study, one may assume that most were Jewish since proficiency in Hebrew was an inclusion criterion. In a survey of 450 Israeli adults living in the Gaza Strip, an area with strong exposure to terrorism and high stress, 42% indicated they used religion to cope either a “medium” amount or “a lot,” although religion was still ranked only 5th out of seven B-​COPE scales, slightly more frequent than denial/​ disengagement and substance use (Dickstein et al., 2012). Religious affiliation was not assessed in that study, although the questionnaire was translated only into Russian and Hebrew, suggesting that the majority of participants were Jewish. The rate of RC among Jews in Israel is different from that of Muslim Arabs in Israel, among whom RC is quite common (Goldblatt et al., 2013).

South Central Asia and Malaysia RC is prevalent in India (whose religious composition is 80% Hindu and 14% Islam), Pakistan and Afghanistan (95% and > 99% Islam, respectively), and Malaysia (61% Islam, 20% Buddhist, 9% Christian). Studies among cancer patients indicate that RC is the most common form of coping in India when assessed using the 14 B-​ COPE scales (Kumar & Parashar, 2015; Garg et al., 2018). Religion was also the most common form of coping based on the B-​COPE scales administered to cancer patients in Malaysia (Yusoff et al., 2010; Yahaya et al., 2015). In a study of coping behaviors in Afghanistan, Scholte and colleagues (2004) found that 98% of 1,011 community-​dwelling adults indicated Coping with Stress • 51

that Allah was their main source of comfort, followed by family (81%). Among 129 undergraduate students at the University of Karachi, Pakistan, 84% performed prayers to seek help from Allah or identify solutions to problems (Khan & Watson, 2006).

coping behavior of 14 assessed by the B-​COPE (García et al., 2018).

United States

RC is common in the United States, where the perceived stress level is surprisingly high, as noted earlier. This is perhaps due to materialAfrica istic pursuits, although racial disparities and The combination of devout Christianity (in conflict also contribute to stress in a country Central and South Africa) and devout Islam (in where there are deep divides among White North Africa), along with difficult living circum- Caucasians, Blacks, and Hispanics. Rates of stances and frequent war, have also resulted in RC in the United States vary widely, ranging high rates of RC among countries on this con- from 20% to 80% (average 68%, 95% CI =​62%–​ tinent. Absolute rates of RC range from, on the 75%) based on a review of 33 studies (Koenig, low end, 51% for those coping with the conse- 2018a). The likelihood of turning to religion quences of divorce in largely Christian South to cope depends on many factors, including Africa (Greeff & Van Der Merwe, 2004) to more the geographical location, type of population than 90% of Muslim patients with cancer in (­community-​dwelling vs. medically ill), gender Egypt (Kesserling et al., 1986) and Morocco (more common in women than men), race (more (Errihani et al., 2008). More recently, RC was common in African Americans and Hispanics), the most common form of coping of 14 B-​ and method of assessing religious coping. For COPE strategies among 385 women with post- example, in a study of 399 consecutive outpapartum depression in Ethiopia (95% Orthodox tients with cancer at the MD Anderson Cancer Christian) (Azale et al., 2018). Likewise, among Center in Houston, Texas, religion was the 3rd 529 youth ages 16–​23 years in Sierra Leone most common form of 14 B-​COPE strategies, (51% Christian, 49% Muslim), RC was the 2nd with only acceptance and seeking emotional most common form of coping of 14 B-​COPE support ahead of it (Dev et al., 2019). types (Sharma et al., 2017).

Mexico, Central, and South America RC is also widespread in Latin American countries where the religious tradition is overwhelmingly Christian, most often Catholic. In a study of 149 Mexican citizens (US immigrants), religion was the 3rd most common coping behavior of 14 B-​COPE behaviors (outranked only by acceptance and positive reframing) (Farley et al., 2005). Praying or meditating was the most common form of coping (44.2% “medium” or “a lot”) among 122 undocumented Hispanics in Arkansas and Texas (Cobb et al., 2016). In a small qualitative study of 27 women with breast cancer in Chile, half indicated their cancer had caused their religious faith to increase, and almost all (26/​27) indicated that spiritual faith can help cancer patients recuperate (Choumanova et al., 2006). In a large study of 1,847 stressed community-​dwelling adults in Chile, religion was the 7th most common 52 •  M ental H ealth

Southern Europe Southern Europe, including Italy, Malta, Spain, and Portugal, is the most religious part of Europe, although other Catholic countries, such as Ireland, Northern Ireland, and Poland, are also quite religious. The rest of Europe, however, has become quite secular over the past several decades, including some of the historically religious Catholic countries noted above. In a survey of 1,580 persons living in Italy with psoriasis, a distressing but not terminal illness, religious coping was the 9th most common of the 14 B-​COPE strategies (Finzi et al., 2007). However, in 61 women with breast cancer from southern Italy, De Feudis et al. (2015) found that religion was the 3rd most common of the 14 B-​COPE strategies, with only planning and acceptance being more common. Likewise, a study of 115 patients with terminal cancer in Milan, Italy, found that RC was also ranked 3rd most common of 14 B-​COPE behaviors (Bovero

et al., 2016). In a study of 1,626 relatively young nonstressed pregnant women in Spain, however, RC was the 11th most common of 14 B-​COPE scales (Gutiérrez-​Zotes et al., 2016).

Western Europe Germany and France are the largest countries in Western Europe. Luszczynska and colleagues (2007) examined the coping strategies used by 321 cancer patients one week after surgery at four hospitals in Berlin. They used cluster analysis to divide participants into three groups: accommodative coping (lack of general coping efforts, but relatively high degree of acceptance and humor; n =​99), disengaged coping (denial, disengagement, self-​blame, venting; n =​82), and assimilative coping (active coping, positive reframing, support seeking; n =​140). Among 13 B-​COPE strategies assessed, RC was ranked 7th most common among accommodative copers, 6th among disengaged copers, and 9th among assimilative copers. RC was positively associated in that study with active coping, seeking emotional support, and venting. In contrast, a study of 2,187 college students in France found that RC was tied for 13th out of 14 B-​ COPE scales (Doron et al., 2014). Nevertheless, among 49 patients with the deadly diagnosis of amyotrophic lateral sclerosis (ALS), RC was tied for 8th most frequent among the 14 scales (Montel et al., 2012). Germany and France have become some of Europe’s most secular countries, with Germany ranked 55th and France ranked 48th in religiosity out of 65 countries (Gallup Poll, 2015).

Eastern Europe and Russia Due to years of Communist rule, which sought to purge religion from the populations of Eastern Europe and Russia, return to the once vibrant Orthodox religious faith has been slow. In a study of 80 parents of children with cancer in Lithuania, researchers found that religion as a coping response was ranked 9th most frequent in those without depressive symptoms and 7th most frequent in those with depression among 14 B-​COPE coping behaviors (Digryte & Baniene, 2017). In a study of 83 parents of children with developmental disorders in Poland,

researchers found that religion was ranked 8th out of 14 strategies (Wrona & Wrona, 2016). Results were similar in a study of 61 older hospitalized patients with osteoarthritis preparing for surgery in Poland, where RC ranked 8th in frequency among 14 coping strategies (Stecz et al., 2017). In a study of 80 paramedics experiencing traumatic events at their workplaces in Poland, RC ranked 10th most common of 14 B-​ COPE strategies (Oginska-​Bulik & Kobylarczyk, 2015). Not many studies have examined RC in Russia (34th among 65 countries on religiosity in the 2015 Gallup Poll, surprisingly ahead of the US at 41st). However, in a study of 240 HIV+​patients (96% heterosexual) at the Leningrad Regional AIDS Center (LRAC) or Botkin Hospital for Infectious Diseases, 80% indicated that they “called on God or a Higher Power for help, healing, or protection” (Pecoraro et al., 2016). Interestingly, those who did so were more likely to be compliant with their antiretroviral treatment.

Great Britain, Canada, and Australia Great Britain and its former colonies with their rich Anglican Protestant history have, like other European countries, become less and less religious over the years. RC is relatively uncommon even among those with cancer in the United Kingdom, which was ranked 58th in religiousness out of 65 countries in the 2015 World Gallup Poll. A study of 155 women receiving surgery for breast cancer found that RC ranked 10th most common out of 13 B-​ COPE strategies, barely ahead of denial, self-​ blame, and substance use (Thune-​Boyle et al., 2011). Similar results were reported by Lake et al. (2019) in a study of 136 breast cancer patients in the United Kingdom, where RC was ranked 12th out of 14 coping behaviors ahead of behavioral disengagement and substance use. In Canada (ranked 47th out of 65 countries on religiosity), RC is not common except among those with severe distress. A study of 522 persons with chronic pain (CP) and 188 with CP characterized by neuropathic characteristics (CPNC) found that RC was used in 34% of those with CP (ranked 12th out of 14 on Coping with Stress • 53

B-​COPE) compared to 61% of those with CPNC (ranked 9th) (Mann et al., 2018). A survey of 42 Canadian patients with chronic kidney disease reported that about one-​ half (48%) prayed, meditated, or sought comfort in religion (but RC was ranked 21st out of 28 B-​COPE strategies) (Schick-​Makaroff et al., 2018). However, an earlier study of 132 French-​ Canadian women with breast cancer found that religious coping was tied for 1st (most common) among 8 scales on a shortened version of the B-​COPE (Fillion et al., 2002). Therefore, results vary widely depending on health characteristics and degree of stress. Australia is similar to the United Kingdom and Canada in terms of religiosity, with the 2015 Gallup Poll ranking it 53rd among 65 countries. A survey of 178 women with breast cancer in Australia found that depending on their use of the Internet, RC ranked surprisingly high, the 5th most common among 14 B-​ COPE strategies among internet users and 2nd most common among non-​users (Fogel, 2004). Likewise, a survey of 209 men with prostate cancer in Australia found that RC ranked 4th most frequent among 14 B-​COPE strategies, with only active coping, acceptance, and humor more common (Pascoe & Edvardsson, 2016).

with a possible heart attack in Denmark, 74% indicated “not at all” when asked about comfort received from religious or spiritual beliefs; similarly, 70% indicated “not at all” for comfort received from prayer or meditation (Bekke-​ Hansen et al., 2014).

Far East (China and Japan)

China was ranked last on religiosity in the 2015 World Gallup Poll (65th out of 65 countries). Likewise, the World Values Survey (2010–​ 2014a) found that 72% of the population of China did not believe in God. Another study found that China has more convinced atheists than any other country in the world (an estimated 200 million of the 400–​500 million total atheists worldwide are in China) (Keysar & Navarro-​Rivera, 2017). With regard to coping with stress, a study of 100 newly diagnosed patients with breast cancer in China found RC ranked 13th out of 14 B-​COPE scales, more frequent only than substance use (Li & Lambert, 2007). Likewise, in a study of 92 caregivers of patients hospitalized with acute stroke in China, researchers found that RC was again ranked 13th of 14 strategies, barely ahead of substance use (Qiu & Li, 2008). More recently, Su and colleagues (2015) examined 258 HIV-​ positive patients in China, finding that after Northern Europe factor analyzing the B-​COPE to come up with Denmark (ranked 46th most religious of 65) 6 subscales, RC ranked last in frequency (6th). and the Scandinavian countries (where Sweden The persecution of religion in China over the was ranked 63rd out of 65) are known to be past several decades helps to explain the low some of the least religious countries in the religiosity and the low rate of RC in this counworld, despite their long Protestant Lutheran try (Ochab, 2019), even among those who are history, which has formed the social policies highly stressed. Religious beliefs are viewed as for these nations. Early studies found that the competing with Communist philosophy, and as use of RC in Sweden ranged from 1% of adults a result, the Chinese government has forbidden at risk for mental disorder (Cederblad, 1995) any member of the Communist Party to practo 10% of those with terminal brain cancer tice a religion (Parke, 2019). (Strang & Strang, 2001). In a more recent surWith regard to Japan, the second least relivey of 3,738 employees (average age 44) in 91 gious country (64th out of 65 countries assessed organizations in Norway, researchers reported by the 2015 Gallup Poll), Kitano and colleagues that RC ranked 11th in frequency among 14 (2015) examined the coping behaviors of 320 B-​COPE strategies (just ahead of denial, sub- women who had screened positive for possible stance use, and behavioral disengagement) breast malignancy, finding that among nonde(Nielsen & Knardahl, 2014). At 2-​year follow-​ pressed women RC was ranked 10th in frequency up in this longitudinal study, RC continued of 14 B-​COPE strategies and was tied for 11th to hold the same rank as it did at baseline. In among depressed women. Similarly, in a sample a survey of 97 acutely ill patients hospitalized of outpatients being treated for lymphedema 54 •  M ental H ealth

at a hospital clinic in Tokyo, RC ranked 12th (ahead of denial and substance abuse) (Okajima et al., 2013). The reason why religion and RC are uncommon in Japan is less clear than the explanation for China. Although little formal research exists on the topic, some experts say that religion has become synonymous with culture in Japan and has consequently lost its original role that involved addressing life problems (Unseen Japan, 2018). Religious rituals and customs are performed today because “that’s just what Japanese do.” Low rates of religious involvement in Japan may have been initiated by the outlawing of religion as an unwanted foreign influence between 1600 and 1860 (reducing missionary activity in this country). During that time and later, Shinto Buddhism (the most common Japanese religion) was transformed into more of a national creed than a religion, focusing instead on worship of the Japanese emperor.

Summary The research above suggests that RC is more common among people experiencing significant psychosocial stressors—​those with serious medical problems, parents of children with medical problems, or those suffering from the stress of terrorism or war. When life is going smoothly, many individuals may feel little need for religion, particularly if not supported by the surrounding culture. When life feels relatively normal, human drives for food, shelter, sex, pleasure and excitement, socialization, and status within the community are a priority. However, when life is not going well, when there are problems meeting basic needs, when there is loss or disruptive change, when health problems occur with pain and disability, when life spirals out of control—​it is then that people need something more—​and this may lead some to religion, perhaps to gain a sense of control. Nevertheless, the greatest influence on the use of religion to cope appears to be the religiosity of the geographical region in which people live, based on historical and cultural factors. In countries with low religiosity, it takes more stress to drive people to religion, particularly when religion is not supported by others in the community. In secular communities where few

people are religious, those who are religious may be excluded or marginalized because of their religious beliefs, creating additional stress that adds to whatever they need to cope with.

OUTCOMES OF RELIGIOUS COPING Does dependence on religion to cope make a difference in terms of mental health and ability to adapt to life stressors? Systematic research can help to answer this question, although the ability to do so may be limited by the complexity of the relationship between RC and mental health. Stress, mental health, and RC are all changing over time, often responding to changes in one another, making it difficult to determine how one affects the other—​especially in observational studies. An example serves to illustrate this complexity. Well-​ known is the positive impact that antidepressant medication has on relieving depression. However, if one were to examine the relationship between antidepressant use and depressive symptoms in an observational study, it is likely that a strong positive relationship would be found. The reason is not because antidepressants cause depression, but rather because they are taken by those who are depressed. Those who are happy don’t need antidepressant medication. The same may be true for religious coping. Even if RC helps people to cope with life stressors, those without stress may have little need for religion, are less likely to use religion to cope, and are more likely to have good mental health, particularly when compared to those using religion to cope because they are stressed. As with the antidepressant medication illustration above, one would expect RC to be associated with greater stress and worse mental health because that is when people need religion (not when they are happy and life is going well). Religion is mobilized in response to distress because it is a coping behavior used in an attempt to relieve distress, just as antidepressants are taken to relieve depression. As discussed earlier in the book, such dynamics make clear the need for rigorous longitudinal studies with control for baseline outcome (VanderWeele et al., 2016a) and randomized controlled trials of religious coping interventions. Coping with Stress • 55

Causal effects can also operate in the opposite direction. Severe trauma and loss may impact religious beliefs and practices, adversely affecting religious faith (rather than increasing it) as people question why God allows such terrible things to happen in spite of a person’s prayers for help and comfort. Theodicy is a word used to describe attempts to answer why a good God permits terrible evils. The classic book, When Bad Things Happen to Good People, by Harold Kushner (1981), addresses this common experience, as does the Book of Job in the Hebrew Bible. Such events may cause a person to question their religious faith or lose it entirely. Likewise, negative experiences with religious people, including clergy and members of a faith community, may adversely affect religious involvement and push individuals away from religion when they need it the most. Finally, religion may not always help people cope. Whether or not there are benefits may depend on many factors. In some circumstances, religious beliefs may increase anxiety and arouse unhealthy guilt over failure to live up to the high moral and ethical standards that religious teachings often require. Teachings about hell and suffering in the afterlife for those who fail, while intended to restrain selfish drives and antisocial activities for most of the populace, may cause severe distress that adversely affects mental health in vulnerable individuals. However, this dynamic, too, is a complex one. What may be distressing in the short term may lead to much less distress in the long term. Thus, the real questions may involve what kind of religion and religious belief, in what kind of circumstance and person, and at what particular time (short-​ or long-​term) religion helps or hinders a person’s ability to cope. The discussion above provides only a glimpse into how difficult it may be to interpret the results from research in this area.

The Ideal Study The most powerful research design to determine whether RC results in better or worse mental health is a randomized controlled trial (RCT). For example, persons undergoing a particular life event that evokes a similar amount of stress for all participants might be randomized to either a RC coping intervention or a 56 •  M ental H ealth

control group that receives a nonreligious treatment to improve coping. The amount of time, social attention, and zeal in administering the intervention would need to be similar between the two intervention groups. Level of religiosity might be assessed at baseline to determine if the RC intervention were more or less effective depending on the initial religiosity of participants. Participants would then be followed over time, and changes in their mental health examined and compared. As noted in Chapter 3, RCTs are difficult to carry out and usually are very costly. Such a study would be difficult, but not impossible. The closest to the ideal study described here may be RCTs examining the effect of religiously integrated psychotherapies in persons with depression or anxiety (see Chapters 5 and 8). However, those studies are somewhat different from the ideal study above since participants in religiously integrated psychotherapy trials are usually significantly depressed or anxious, which is quite different from RC that occurs in everyday life in response to stressful life events in generally healthy populations. Moreover, even an ideal RCT such as that described above is usually time-​limited, demonstrating short-​term effects, and may not provide information on the impact on mental health of a consistent pattern of RC over prolonged periods of time in more natural settings. After the RCT, the next most rigorous research design would be a prospective cohort study in which a large sample of participants experiencing a severe stress (e.g., a natural disaster, terrorist attack, or severe traumatic loss) might be followed over time, assessing religious coping and mental health outcomes at baseline (preferably even before the trauma) and conducting follow-​up assessments periodically over an extended period, say perhaps 5 or 10 years or even longer, adjusting analyses for perceived severity of the stressor, other events going on in participants’ lives, and a history of psychiatric or emotional problems. This study would also be challenging, given the difficulty of identifying individuals before a major stressor occurs and following them for a considerable period of time. Like the RCT described earlier, such a prospective study would be expensive and would require a research team whose composition might have to change over time

as members of the team age, drop out due to relocation, etc. In contrast to RCTs and prospective cohort studies, cross-​sectional studies examining religious coping and mental health outcomes at one point in time are unlikely to add much to the evidence base, as they are incapable of answering questions about causality or mechanism. This does not mean that cross-​sectional studies have no value. As indicated in Chapter 3, large population-​based studies of this type for establishing prevalence rates of RC and determining how prevalence varies with mental health and other stressors may still be useful, particularly if conducted in non-​Western countries, non-​ Western religions, and perhaps supplemented by qualitative interviews that help to explain whether and how religion influences coping.

(2007) examined the association between RC (assessed by the 4-​item subscale of a 56-​item version of Carver’s COPE), suicidal ideation (assessed by the Adult Suicidal Ideation Scale), and perceived stress (Police Stress Inventory). Logistic regression analyses indicated that suicidal ideation was significantly lower among police officers who scored higher on RC. The correlation between perceived stress and RC, however, was positive (r =​0.05, p < 0.05, uncontrolled analysis). Thus, those using religion to cope were more stressed, although this cross-​sectional study was unable to determine how this relationship came about. L ON GITUD IN AL

Several studies have examined the relationship between RC and level of perceived stress, often using the 10-​item Perceived Stress Scale (PSS; Cohen, 1988), the most widely used instrument to assess this construct.

Whitehead and colleagues (2011) followed a convenience sample of 244 community-​ dwelling adults age 55–​ 80 years in Indiana over a 56-​day period, examined the effects of daily spiritual experiences (assessed by a 5-​ item Daily Spiritual Experiences Scale; DSES) on perceived stress (assessed by PSS), and negative affect and positive affect assessed by the Positive and Negative Affect Scale. All measures were completed on a daily basis for 56 days. Multilevel regression models were used to examine associations between measures over time. Results indicated that DSES scores were inversely related to perceived stress (r =​−0.18, p < 0.01, based on within-​day correlations across 56 days). Perceived stress was positively related to negative affect, although no significant main effect was found for DSES on negative affect. A significant interaction, however, was found between DSES and perceived stress on negative affect (p =​0.005), such that those with higher DSES scores experienced a weaker effect of perceived stress on negative affect, indicating positive stress buffering. Both DSES and perceived stress were correlated with positive affect (in opposite directions), although the interaction between DSES and perceived stress on positive affect was not significant (as it was for negative affect).

C RO SS -​SE C TI ONAL

RAN D OM IZED CON TROL L ED TRIAL S

Studying a random sample of 1,794 police officers in South Africa, Pienaar and colleagues

At least three RCTs have examined the effects of a spiritual or religious intervention on perceived

RESEARCH ON RELIGIOUS COPING AND HEALTH OUTCOMES The ideal studies described above—​ an RCT examining an RC intervention or a large prospective study on RC and mental health with long-​term follow-​up—​have not yet been done. However, a number of studies have come close, and these will now be reviewed below. This is not a systematic review, but rather a selective review of studies (see Appendix for a systematic review of the best studies). We examine here the relationship between RC (or similar religious activity) and perceived stress level, stress-​ related growth, stress buffering, and other psychological outcomes, discussing these studies by category of research design (cross-​ sectional, prospective, RCT) and year of publication.

Perceived Stress

Coping with Stress • 57

stress, with two of three reporting a significant effect on reducing levels of perceived stress. A study in 58 health professionals found that “passage meditation” reduced perceived stress (assessed by PSS) after 8 weekly sessions (Oman et al., 2006). Passage meditation involves silent, focused repetition of memorized selections from scripture such as the St. Francis Prayer or Psalm 23. The second study conducted in Turkey examined the effects of a spiritual care intervention on perceived stress in 62 mothers of children hospitalized in the ICU, finding a significant reduction in ICU-​specific stressors in the intervention group (Alemdar et al., 2018). The spiritual care intervention involved prayer, reading from the Qur’an, and placing amulets with prayers in the infant’s crib or placing other objects to ward off the Evil Eye. The third study in 93 HIV+​patients involved randomization to either a control group or an intervention group (who repeated a “spiritual mantram,” i.e., “Om mani padme hum” from Buddhism, “Rama, Rama” from Hinduism, “Lord have mercy” from Christianity, and so forth). This study found no significant effect of the intervention on perceived stress level (assessed by the PSS) after 10 weeks (Bormann et al., 2006).

Stress-​Related Growth (SRG) SRG, sometimes called post-​traumatic growth (PTG), is the psychological growth that occurs as a result of undergoing severe life stressors. SRG is often assessed by the 50-​item Stress-​Related Growth Scale (SRGS; Park et al., 1996), whereas PTG is assessed by the 21-​item Post-​traumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996). There is also a 10-​item short form of the PTGI (Cann et al., 2010). RC is often related to both SRG and PTG using these scales, although all scales include several items assessing spiritual growth, which may confound these results.

(sample sizes 1,838 and 2,718, respectively), Tsai and colleagues (2016, 2017) found that higher scores on the Duke University Religion Index (DUREL) were cross-​sectionally related to greater PTG assessed by the 10-​item PTGI-​ SF, independent of control variables. In the 2-​year follow-​up, multivariate analyses demonstrated that higher religiosity scores at baseline predicted consistently high PTG and increasing PTG scores over time (Tsai et al., 2016). Similarly, in the 4-​year follow-​up, latent growth curve models indicated that those scoring high on the DUREL at baseline experienced higher and increasing PTG scores over time (Tsai et al., 2017). The DUREL, however, measures level of religiosity, not level of RC (although private religious coping activities such as prayer are part of this measure). Two other prospective studies have reported that RC predicts increased PTG in stressed populations. In a 2.5-​year prospective study of 262 medical patients following cardiac surgery, Ai and colleagues (2013) found that “positive religious coping” (PRC) assessed by the 7-​item subscale of the Brief RCOPE, measured preoperatively, predicted increased SRG (assessed by the 50-​ item SRGS) 30 months later. However, SRG at baseline was not assessed or controlled for in these analyses. Chan and Rhodes (2013) followed 386 low-​income mothers affected by Hurricane Katrina shortly after the hurricane (T1), 1 year later (T2), and 4 years later (T3). Church attendance and importance of religion were assessed at T1 and T2, PRC at T3, and PTG was assessed at T3 with the 21-​item PTGI. Regression analyses revealed that religious attendance and importance at T1 and T2 positively affected PTG at T3 indirectly by their association with PRC at T3 (again, PTG at T1 was not assessed or controlled for).

Stress Buffering C ROSS -​SE C TI O N AL

No high-​quality studies exist at this time. LO N G I TU D I N A L

In a 2-​year and 4-​year prospective study of a national random sample of US veterans 58 •  M ental H ealth

One way to determine if religious involvement helps people to cope is to examine the buffering effects of high levels of RC/​religiosity on the relationship between life stressors and mental health outcomes. This is usually determined by examining the interaction between religious measures and life stressors in predicting

mental health as the dependent variable using regression analyses. C RO SS -​SE C TI ONAL

Mitchell and colleagues (1993) surveyed a random sample of 868 persons age 65–​101 in eastern North Carolina to examine the buffering effect of RC on the relationship between life strain and depression. Life strain was assessed by impairments in activities of daily living (ADLs), hearing impairment, and poverty level. RC was assessed by a 7-​item scale assessing belief in religious healing (e.g., “Have you been cured of an illness through prayer? Do you believe in religious miracles? How strongly do you believe that prayer will heal illness?”). Depression was measured by the 15-​ item Geriatric Depression Scale. Regression analyses indicated a significant interaction between belief in religious healing and ADL impairment in predicting depressive affect, such that among those who coped by belief in religious healing, the relationship between ADL impairment (life strain) and depressed affect was stronger. This finding was the opposite of that expected (i.e., involved negative stress buffering). Chang et al. (2001, 2003) analyzed cross-​ sectional data from representative samples of 3,632 female and 2,427 male veterans receiving ambulatory Veterans Affairs (VA) healthcare services, examining the buffering effects of religious attendance and RC (religion as a source of strength/​comfort) on the relationship between sexual assault and mental health (assessed by Mental Health Component score of SF-​36 and Center for Epidemiologic Studies Depression scale). In both samples, the negative effect of sexual assault on mental health was significantly lower among those attending services more frequently and in those indicating strength or comfort from religion (positive stress buffering). Krause (2006c) analyzed data from a systematically identified national sample of 906 community-​ dwelling Christian older adults, examining the buffering effects of “gratitude to God” on the relationship between neighborhood deterioration (the stressor, assessed by a 5-​item scale) and subjective physical health (the outcome). Regression analyses indicated

that the positive relationship between neighborhood deterioration and poor physical health was significantly weaker among those scoring high on gratitude to God, especially among females. A number of other cross-​ sectional studies involving relatively large random samples exceeding 1,000 participants have also examined religion’s buffering effects on health outcomes of financial stressors (positive; Bradshaw et al., 2010); gender identity stress (positive for heterosexuals, negative for LGBT; Rostoksy et al., 2010); social isolation and chronic illness (both positive; Momtaz et al., 2011, 2012); psychological stress (no buffering; Archibald et al., 2013); adverse life events in adolescents (positive; Kabiru et al., 2014); poor health (positive; Wang et al., 2014); and other life stressors (see Appendix). All of these cross-​sectional studies, however, must be interpreted cautiously since, as noted above, the associations potentially reflect causal effects in both directions. L ON GITUD IN AL

Williams et al. (1991) conducted a 2-​year longitudinal study of a random sample of 720 community-​ dwelling adults in New Haven, Connecticut, examining the buffering effects of religious affiliation and attendance assessed at T1 on the association between stressful life events/​health problems and psychological distress at T2, controlling for T1 psychological distress. Regression analyses indicated that frequency of religious attendance (but not affiliation) significantly moderated the impact of both stressful life events and physical health problems on psychological distress, such that these stressors had a weaker effect on psychological distress in those with higher rates of religious attendance. Dzivakwe and Guarnaccia (2014) analyzed data from 2,508 community-​ dwelling adults age 50 or over assessed during the US Health and Retirement Survey between 2008 (T1) and 2010 (T2). Results indicated that T1 religiosity, assessed by religious attendance and religious importance, buffered the inverse relationship between T1 perceived diabetic control and T2 total number of weeks depressed (with T1 weeks depressed in the model). The relationship Coping with Stress • 59

between diabetic control and weeks depressed was significantly stronger among those who were more religious, compared to those who were less religious (i.e., negative stress-buffering). This is despite the fact that religiosity was positively related to diabetic control and negatively related to depressive symptoms in both 2008 and 2010 cross-​sectional analyses. Helms et al. (2015) examined the buffering effects of T1 intrinsic religiosity (assessed by the 3-​item subscale of the DUREL) on the relationship between T1 peer victimization and T2 depressive symptoms (Mood and Feelings Questionnaire) in 313 adolescents in North Carolina. Participants were assessed at two times 12 months apart. Peer victimization (T1) was positively associated with T2 depressive symptoms only among those with low intrinsic religiosity (with T1 depressive symptoms in the model), indicating a positive buffering effect. Ironson et al. (2020) examined the moderating effects of religious coping on the relationship between stressful deaths/​divorces and viral load in 157 HIV-​positive patients over a 12-​month period (45 with deaths/​divorce and 112 controls). RC was assessed specific to HIV concerns/​ problems with the 4-​item religion subscale from the 60-​item COPE. Changes in RC buffered the relationship between stressful deaths/​ divorce and change in viral load over time, such that among those in whom RC increased, increases in viral load (outcome) were slower in those experiencing a stressful death/​divorce (predictor). Increases in social support, in contrast, did not moderate or buffer this relationship. Jung et al. (2018) analyzed data from a random sample of 1,635 US adults (MIDUS study) to examine whether religiosity buffered the effects of childhood adversity on positive and negative emotions experienced during adulthood. Participants were assessed in 1995 (T1; average age 46) and 2005 (T2). Childhood adversity was measured using a 14-​item measure of physical or emotional abuse, family instability, and financial strain. Negative and positive affect were each assessed by 6-​item scales. Religious involvement was measured at T1 by frequency of religious attendance, importance of religion in life, importance of sending one’s child for religious instruction, closeness of identification with members of one’s religion, 60 •  M ental H ealth

and importance of marrying others from the same religion. Childhood abuse (but not family instability or financial strain) assessed at T1 predicted lower levels of T2 positive affect with T1 affect in the model. There was a significant interaction between T1 religiosity and childhood abuse on T2 positive affect. Among those with low religiosity, childhood abuse significantly decreased adult positive affect, while among those with high religiosity, no adverse effect on positive affect was observed. The same finding was reported for those who scored high on a 2-​item measure of self-​rated spirituality. Bierman et al. (2018) examined the buffering effects of religiosity on the relationship between discrimination and sleep problems in a random national sample of 7,130 adults over age 50 (US Health and Retirement Study). Religiosity was assessed by attendance at religious services and a 4-​item scale measuring importance of religion; discrimination was measured by a 5-​ item scale of chronic discrimination; and sleep problems by a 4-​item measure of insomnia. Participants were assessed in 2006, 2010, and 2014. All measures were administered at the three time points. Regression analyses indicated a significant association between chronic discrimination and sleep problems, but only in women who did not regularly attend religious services. No such relationship was found for the importance of religion, nor were there any significant interactions identified in men. Using a different approach, Bradshaw and colleagues (2018) investigated the buffering effects of “attachment to God” (ATG) on the relationship between prayer and psychological well-​being. ATG was assessed with a 6-​item measure examining the closeness of a person’s relationship with God, feeling near to God, and knowing God listens, protects, and is a source of strength and guidance during crisis. Prayer was assessed by a single item asking, “How often do you pray by yourself?” Psychological well-​ being outcomes included self-​ esteem, optimism, and life satisfaction, all using standard multi-​item measures of these constructs. Multivariate analyses examined the impact of prayer assessed at T1 (2001) on measures of well-​being assessed at T2 (2004), controlling for T1 measures of well-​being. Results indicated a significant interaction between ATG and prayer,

indicating that T1 prayer was associated with T2 measures of psychological well-​being only in those with high levels of ATG at T1. These results replicated those from an earlier study examining the impact of ATG on the relationship between prayer and anxiety, which showed similar moderating effects (Ellison et al., 2014).

the 3-​item Religious Coping Index) on changes in depressive symptoms (Geriatric Depression Scale) in 202 of 850 hospitalized male medical patients during a 6-​month period following hospital discharge (from T1 to T2). RC was inversely related to depressive symptoms in the overall sample at baseline (T1), independent of other covariates. After controlling for T1 medical diagnoses (the only other significant preOther Psychological Outcomes dictor of outcome), those with high RC at T1 Associations between religious involvement experienced a significant decline in depressive and emotional distress in older adults and per- symptoms from T1 to T2 (p =​0.002). Likewise, sons with severe medical illness also provide in a prospective study of 86 hospitalized male evidence toward the effectiveness of RC. and female medical patients with major or minor depressive disorder, Koenig et al. (1998a) reported that intrinsic religiosity at T1 preC RO SS -​SE C TI ONAL dicted a faster speed of remission from depresHank and Schaan (2008) analyzed cross-​ sive disorder over an 11-​month follow-​up (T1 sectional data from the 2004 Survey of Health, to T2) independent of other predictors (quality Aging and Retirement in Europe, which recruited of life, admitting service, change in functional a random sample of 14,500 community-​ status, family psychiatric history) in a Cox prodwelling adults aged 50 or over in Sweden, portional hazards regression model. In a third Denmark, Germany, Netherlands, France, study that followed nearly 1,000 medical inpaSwitzerland, Austria, Italy, Spain, and Greece. tients with heart failure or chronic pulmonary Frequency of prayer was the only religious char- disease for an average of 6 months, the combiacteristic measured, and in this study serves as nation of frequent religious attendance, prayer, a proxy for RC. Four regression models exam- Bible study, and high intrinsic religiosity at ined relationships between frequency of prayer baseline (T1) predicted a 53% increase in the and poor self-​perceived physical health, chronic speed of remission from depression (HR =​1.53, conditions, functional limitations, and depres- 95% CI =​1.20–​1.94, p =​0.0005) from T1 to T2 sive symptoms, controlling for demographics, after controlling for other T1 predictors in a socioeconomic status, social resources, and Cox regression model (Koenig, 2007a). health behaviors. In all cases, daily prayer was Tix and Frazier (1998) tracked 174 patients more common among those with worse mental receiving renal transplants at University of and physical health (poorer self-​rated health, Minnesota Hospital and 123 significant othOR =​1.11; more chronic conditions, OR =​1.14; ers from 3 months post-​transplantation (T1) more functional limitations, OR =​1.15; and to 12 months post-​ transplantation, exammore depressive symptoms, OR =​1.26; all p < ining the effects of RC on psychological dis0.01). Again, this fits well with our earlier expla- tress and life satisfaction over time (T2). RC nation that RC may serve as a marker of distress was assessed with a 10-​item scale specific to in relatively healthy populations in areas of the transplant-​related stresses. Psychological disworld where religion is less supported by the tress was measured by a 17-​item version of the social and cultural environment. Brief Symptom Inventory and life satisfaction by Diener’s 5-​item Satisfaction with Life Scale. Results from regression models indicated that L O N G I TU D I N AL RC at 3 months (T1) was related to greater life A series of three prospective studies in medical satisfaction at 3 (T1) and 12 months (T2) in inpatients found a positive effect of baseline both patients and significant others. However, religiosity on changes in depression follow- RC at T1 did not predict measures of psychoing hospital discharge. Koenig and colleagues logical distress or life satisfaction at T2 after (1992) examined the effects of RC (assessed by T1 measures were controlled. When analyses Coping with Stress • 61

were stratified by Catholics vs. Protestants, RC at T1 predicted greater life satisfaction at T2 in patients and significant others for Protestants but not for Catholics, after controlling for T1 life satisfaction. More recent prospective studies in persons with medical illness followed over time have reported positive effects of religiosity and positive RC on mental health outcomes, with the reverse true for negative forms of RC (Sherman et al., 2009; Ramirez et al., 2012; Jang et al., 2013; Reynolds et al., 2014; Stecz & Kocur, 2015; Laffey et al., 2020; Gall & Bilodeau, 2020).

HOW MIGHT RELIGION HELP? How does religious involvement affect a person’s ability to cope with stress? Based on Lazarus and Folkman’s Theory of Coping, religious responses may impact perceptions of stress by affecting primary cognitive appraisal, secondary appraisal, and expanding the repertoire of available coping resources. However, religion is likely to have such an impact only if religious commitment is strong enough to influence a person’s cognitive appraisals. For example, take belief in God among those in monotheistic religious traditions, which is common around the world. Only approximately 5% of the world’s population are atheist, the majority coming from Communist countries where religion is outlawed (World Values Survey 2010–​2014b). Belief in God, then, is widespread, but without integration into other areas of life it is unlikely to impact mental health in a substantial way. If, however, belief in God is the ruling principle in life, as the traditional scriptures of Judaism, Christianity, and Islam insist it should be (e.g., teachings such as “thou shalt have no other gods before me”), this could impact mental health, particularly when attachment to God is the person’s primary attachment. The core Buddhist principle of non-​attachment to material possessions, people, even to oneself, accomplishes much the same thing.

Primary Appraisal Recall that primary appraisal involves an evaluation of how threatening a life event is to 62 •  M ental H ealth

psychological, social, or physical well-​being. If a stressor involves loss or change in material possessions, relationships, or health, and those objects of attachment are less important than the attachment to God, then that stressor may be appraised as less threatening (since the primary attachment—​ relationship with God—​ remains unaffected).

Secondary Appraisal Secondary cognitive appraisal involves the person’s evaluation of whether anything can be done to overcome, cope with, or adapt to the stressor. If one believes that God is loving, concerned about the person, is willing to help, and is able to help, then these cognitions may help the person feel less alone in their situation, believing that powerful help is available. Such beliefs could influence the perception that he or she can cope with the stressor, that God is in control of the situation, and that there is some purpose to whatever has taken place. For example, according to Romans 8:28 in the Christian scriptures, “all things work together for good to them that love God, to them who are the called according to his purpose” (KJV). These simple beliefs, based on faith, have the potential to influence the coping process. Of course, the belief that God is angry and punishing, or has little power to make a difference, or the feeling of being abandoned by one’s faith community (characteristics of negative RC), is likely to have the opposite effect.

Coping Resources These are resources that help a person deal with or adapt to stressful life experiences. The religious person has many such resources at their disposal, including (a) religious beliefs like those described above, (b) behaviors that provide a sense of control over the stressor, and (c) support from a group of like-​minded individuals readily available to assist them. Personal beliefs are those indicated under secondary appraisal, e.g., that he or she is not alone, that God will assist and has purpose in allowing the events to take place, and that if rightly responded to and endured (vs. numbing emotions with alcohol or drugs or avoiding

the issue), stress will result in something good. In addition, the religious scriptures of the person’s faith tradition often provide role models of individuals undergoing similar tragedies and loss, who endured and came through the experience stronger and better off (such as Job in the Hebrew scriptures). Beliefs like these facilitate acceptance of situations that cannot be changed. Behaviors that can increase a sense of control include prayer to God or the Divine as understood, meditation, and performance of various religious rituals or acts of devotion. These behaviors may help to transform negative events and enable the person to get through the experience. There may be opportunities within the faith community to volunteer or otherwise involve oneself in activities that represent a positive investment in the lives of others, helping to distract the individual from their own losses and expose them to others who may be worse off than they are (allowing for downward comparisons). Most religions discourage negative behaviors such as taking drugs, using alcohol, or going on sexual or spending sprees to avoid or suppress negative feelings. Religion may also assist with coping by providing a framework within which to find meaning in suffering. For example, religious teachings, in the context of suffering, may help one to aim toward spiritual rather than material ends, to re-​evaluate one’s purpose, to find ways to grow in character, and to turn to God in prayer (VanderWeele, 2019a). Finally, the religious person has a readily available support system in their faith community and religious leaders1 who can reinforce religious beliefs, listen and help process negative experiences, offer guidance and advice on how to deal with the stressor, and provide emotional support and practical resources as necessary to minimize its impact. Given religious teachings on the importance of family, the sanctity of marriage, and the value of children, the religious person may also be more likely to have an intact family that will be available for

support, encouragement, and practical assistance when needed (see Chapters 14 and 15). Recall that Carver and colleagues included religion as one of the coping behaviors assessed by their COPE scales. These investigators categorized religion as a form of emotion-​focused coping, explaining that “religion might serve as a source of emotional support, as a vehicle for positive reinterpretation and growth, or as a tactic of active coping with a stressor” (Carver et al., 1989, p. 270). Religion, then, was originally viewed as a healthy way of coping, an assessment that has been confirmed in later studies that found the COPE’s religion subscale related to greater meaning in life (Park et al., 2008), stress-​related growth (Lechner et al., 2006), positive reappraisal (Bishop et al., 2001), lower anxiety (Tuncay et al., 2008), less alcohol use (Pence et al., 2008), and more negative attitudes toward suicide (Pienaar et al., 2007). Lazarus and Folkman also inquired about religion as a coping behavior (e.g., praying, seeking solace in God’s decision, etc.) in their Ways of Coping Questionnaire. These investigators viewed religious forms of coping as fitting in nicely under both problem-​focused and emotion-​focused dimensions, particularly those emphasizing the positive, seeking social support, and avoiding self-​isolation. In fact, Folkman and her colleagues published research showing that spiritual activities (attending religious or spiritual services, doing personal meditation, reading spiritual or metaphysical literature, talking to others about spiritual concerns, consulting a spiritual or religious leader) serve a protective role against high-​risk sexual behaviors (Folkman et al., 1992). Folkman, with Lazarus and colleagues, also developed their own 4-​item measure of spiritual beliefs for use in the Berkeley Stress and Coping Project (Folkman et al., 1992). These items include “Meditation/​prayer helps me to find solutions to my problems”; “Believing in the higher self/​ God gives meaning to my life”; “Meditating/​ praying makes me feel better”; and “Events

1. Given that clergy spend on average 15 hours per week providing support and counseling to members of their congregation, religious professionals are known as the first line of defense for psychological and social problems among persons living in the community (Weaver, 1995; Koenig, 2005).

Coping with Stress • 63

in my life reflect an overall purpose and plan” (described in Folkman et al., 1992, p. 219). Finally, in a 2-​year longitudinal study of the effects of caregiving and bereavement on the mental health of partners of men with AIDS, Folkman (1997) reported a significant positive association between religious beliefs/​activities and positive affect, planful problem-​ solving, and positive appraisal. In particular, spiritual/​ religious beliefs and positive appraisal were strongly correlated in a path analysis model among caregivers (B =​0.47, p < 0.0001). In the qualitative part of that study, 56% of the bereavement narratives included spontaneous references to spiritual issues. The early founders of psychological coping theory, then, seemed to believe that religious/​spiritual beliefs and practices were indeed forms of adaptive coping. Religious beliefs and activities may be particularly useful in coping with stress and adverse life situations because they are so widely available and easily accessible, especially in situations where other coping behaviors may be difficult or not possible. For example, coping through distracting physical activities (hobbies, sports) or through seeking social support (attending social events) may be difficult for a person with health problems, limited physical mobility, or problems with eyesight and/​or hearing. The person with few material resources may also have difficulty responding to life stressors given their limited coping options. However, as long the cognitive capacity to mobilize religious beliefs is present, the person may pray or utilize such beliefs to provide meaning to difficult situations or reframe them in a more positive light, reducing the likelihood that he or she will be overwhelmed by the stressor.

SUMMARY AND CONCLUSIONS Stress, change, loss, and various forms of trauma are ubiquitous. Stress is normal and required for growth and development. However, severe and/​or prolonged stress can result in dysfunction and mental health problems (such as PTSD) unless it is processed and coped with. There are numerous ways that people cope with adversity (both adaptive and 64 •  M ental H ealth

maladaptive). Religious coping (turning to prayer, seeking support from God and/​or one’s faith community, searching for guidance in the holy scriptures) is one way that many persons deal with stress. The prevalence of RC depends on the part of the world where a person resides and the extent to which the surrounding culture supports religious beliefs and practices. In the Middle East and parts of Africa, RC may be engaged in by 90%–​100% of those undergoing difficult life circumstances; in Northern Europe or China, few people—​ even when undergoing severe stress or even dying—​turn to religion; instead, they utilize other forms of coping (e.g., active planning, distraction, seeking support from family and friends, etc.). Despite the tremendous resources available to those in the United States (compared to other countries), stress and worry are surprisingly common in this country, which has been known (at least in the past) for its strong religious traditions. The possession of great wealth and many resources can itself be stressful, particularly when these are not handled in light of the wisdom that is contained in the scriptures of every major world religion. Research, both cross-​ sectional and longitudinal, has shown that religious involvement may often buffer the effect that negative life experiences have on mental health, but not always. This is particularly true with respect to negative forms of religious coping. The relationship between RC and mental health is a complex one, requiring scientific methodology that is often expensive and difficult to carry out. In this area of research that has long been neglected in the social and behavioral sciences, few investigators have the necessary resources and funding support to conduct such research well. Currently, the vast majority of published research on RC and mental health is observational, and most of it is cross-​sectional, which cannot explain the relationships between the two, particularly since RC and mental health are not static phenomena, but rather are changing over time and responding to changes in one another. In this chapter, we have described considerations concerning causal inference in the context of RC. The ideal study has yet to be carried

out given the technical difficulties, cost, and time required. However, we have reviewed the research that has been done, examining some of the best studies exploring the relationship between religious coping/​ activity and perceived stress, stress-​related growth, stress buffering, and the distress resulting from aging and chronic medical illness—​studies that have provided a variety of results—​both positive and negative. We have also discussed the possible mechanisms by which religion may help people to cope with negative life events, using the coping frameworks provided by Lazarus, Folkman, and Carver. Experts in coping theory (Folkman,

Carver) have long considered RC to be an adaptive form of coping, since it may help one to cognitively reframe negative events in a more positive light, provide practices (e.g., prayer or meditation) and powerful rituals (e.g., holy eucharist, confession) that may help calm disturbed emotions, and offer a readily available social group for emotional support and practical assistance. In the chapters to follow, we examine the relationship between religious involvement and a wide range of mental health outcomes, starting first with the condition that often results when coping efforts fail, i.e., depression.

Coping with Stress • 65

5 Depression When it is dark enough, you can see the stars. —​Persian proverb

IN THIS CHAPTER we examine the relationship between religious involvement and depression. First, we provide some background on depression. Depression is the most common, disabling, and economically costly of all mental disorders, so its causes and consequences are important. Next, we present a case of depression, and discuss the possibility that religiosity might prevent depression or be inhibited by depression (reverse-​causality). We then review research on the relationship between religion and depression, emphasizing results from large cohort studies and randomized controlled trials (RCTs). Conclusions based on that review are made and recommendations for future research are provided. Finally, we describe how to apply what is known from the research to clinical practice.

BACKGROUND Among all health conditions, depression is one of the leading causes of disease burden

worldwide. The 2013 Global Burden of Disease (GBD) Study found that major depression was the second most common cause of global disease burden among 301 acute and chronic diseases and injuries in 188 countries (Vos et al., 2015; Vigo et al., 2016). These results were confirmed in the 2016 GBD Study, which reported that major depression was one of the world’s five leading causes of “years lived with disability” (YLD), along with low back pain, migraine, hearing loss, and iron-​ deficiency anemia (Vos et al., 2017). This estimate was based on YLD for 328 diseases and injuries in 195 countries in 2016. In that year, mental disorders were the most common cause of YLD (150,476) among all disease categories, and depressive disorders overall accounted for 44,208 thousand YLD, far more than any other mental condition (Table 5.1). Thus, depression is a common, serious, and disabling disorder.

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0005

Table 5.1  Worldwide Causes of Years Lived with Disability (YLD) with 95% Uncertainty Level (UI) (2016 counts) DI S OR DE R

Y L D ( T HO U S A ND S)

95% UI

150,476 44,208 26,417 14,607 13,414 10,031 137,832 101,472

109,498–​194,542 30,573–​59,878 18,440–​35,634 10,464–​19,045 9,859–​16,714 6,883–​13,787 100,146–​178,438 72,326–​136,902

69,426 62,287

47,199–​92,890 44,312–​84,848

55,358 33,482 30,594 5,180

37,181–​78,689 24,477–​43,376 25,068–​37,362 3,830–​6,697

Mental, substance use disorders (total) Depressive disorders Anxiety disorders Drug use disorders Schizophrenia Alcohol use disorders Musculoskeletal disorders Communicable (infectious), maternal, neonatal, and nutritional disorders Neurological disorders Diabetes, urogenital, blood, and endocrine diseases Injuries Cardiovascular disease Chronic respiratory disease Cancer

Source: Global Burden of Disease, 2017 (data obtained from Table, pp. 1214–​1226; Vos et al., 2017).

DIAGNOSIS Depression can refer to either symptoms or a disorder. Depressive symptoms range from mild to very severe and life-​threatening, and are often assessed by either self-​ rated or observer-​rated scales that identify the number and severity of depressive symptoms. The clinical diagnosis of a depressive disorder is made by mental health professions or by structured psychiatric interview administered by trained lay interviewers. Depression becomes a disorder when the symptoms cause clinically significant distress or significant impairment in social, occupational, or recreational functioning. There are several types of depressive disorder described by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-​ 5) (American Psychiatric Association, 2013).

Major Depressive Disorder (MDD) The most serious depressive disorder is major depression, which may present with or without psychotic symptoms. To qualify for this

diagnosis, a person must have five or more of the following nine symptoms for at least two weeks or longer, present most of the day and nearly every day: (1) depressed or sad mood (or irritable mood for adolescents or children) by self-​ report or observation; (2) markedly diminished interest in almost all activities; (3) significant unintended weight loss or gain (e.g., greater than 5% of body weight in a month); (4) psychomotor agitation (increased motor restlessness) or retardation (slowed down thoughts or physical movements); (5) fatigue or loss of energy; (6) feelings of worthlessness or inappropriate guilt; (7) decreased ability to concentrate or make decisions; (8) difficulty sleeping or sleeping too much; and (9) recurrent thoughts of death or desire to end life by suicide. The diagnosis of MDD requires that one of the preceding symptoms be depressed mood (1) or loss of interest (2). The symptoms must be accompanied by significant distress or impaired functioning in social, occupational, or other important areas of life. Finally, the symptoms cannot be due to the physiological effects of a substance (alcohol or drugs) or due to a medical condition. Depression • 67

Persistent Depressive Disorder (PDD) Previously called “dysthymia” or “chronic depression,” PDD is a diagnosis made when depressed mood is present for most of the day, for more days than not, for a period of two years or more by self-​report or observation by others (one year for children or adolescents). During that time, the person cannot be depression free for more than two months at a time. In addition, two or more of the following six symptoms must be present during depression: (1) decreased appetite or overeating; (2) decreased or increased sleep; (3) fatigue or decreased energy; (4) low self-​esteem; (5) hopelessness; and (6) poor concentration or difficulty making decisions. There are additional criteria outlined in DSM-​5, but these are the core symptoms.

Substance-​Induced Depressive Disorder (SIDD)

however, is not diagnosed when the depressive symptoms are due to an adjustment to the psychological distress caused by a disabling medical condition (called an adjustment disorder; see below).

Other Specified Depressive Disorder This is a catch-​ all category that used to be called Depression Not Otherwise Specified, or Depression NOS. This category includes brief or short periods of depressed mood or loss of interest lasting 4 to 13 days, including at least four other depressive symptoms. This category includes depressive episodes characterized by depressed mood or loss of interest for two weeks or longer, accompanied by at least one of the other symptoms of MDD, but not the full criteria. This condition is sometimes called “minor depressive disorder.”

Adjustment Disorder

SIDD involves a persistent mood disturbance characterized by sadness and depressed mood or markedly decreased interest in almost all activities. However, (a) the symptoms occur during or soon after substance intoxication or withdrawal or after taking a prescribed medication, and (b) the substance is capable of producing depressive symptoms. Substances include alcohol, opioids, inhalants, amphetamines (and methamphetamines), methylphenidate, cocaine, hallucinogens, phencyclidine, etc., and medications such as dexamethasone, propranolol, other antihypertensives, immunological agents, L-​dopa, and a wide range of other prescription drugs.

No longer included as a category of depressive disorder in DSM-​5, adjustments disorders (AD) with depressed mood or anxiety are now classified in the Trauma and Stress-​ Related Disorders category. ADs are diagnosed when depressive symptoms are a reaction to a traumatic stressor, such as an acute medical illness, breakup of a romantic relationship, or other distressing life change or loss. Symptoms must develop within 3 months of the stressor, cause significant impairment in functioning, and last not more than 6 months after the stressor has occurred.

Depressive Disorder Due to a Medical Condition (DDMC)

Bereavement involves depressive symptoms (grief or mourning) that develop after the death of a loved one. Bereavement is considered a normal reaction to a significant loss or unwanted change. However, when depressive symptoms persist in duration (more than 6 months), or their severity extends beyond the “normal” boundaries of mourning, it is called “persistent complex bereavement disorder” in DSM-​ 5 (also known as “complicated grief”). Bereavement was excluded from the depressive disorder category in versions of the DSM

DDMC involves prominent and persistent symptoms of depressed mood or diminished interest occurring in the presence of laboratory findings that indicate the symptoms are a direct physiological consequence of a medical condition. These include pancreatic cancer, stroke, Parkinson’s disease, Huntington’s disease, Cushing’s disease, hypothyroidism, multiple sclerosis, and other medical disorders. DDMC, 68 •  M ental H ealth

Bereavement

prior to DSM-​5, but that has now changed with DSM-​5. If the full symptom duration and severity for MDD are met, even if they occur within a few weeks after the death of a loved one, then MDD is diagnosed.

from the depression module in the National Comorbidity Survey Replication) was 7.1% overall in the 2017 National Survey of Drug Use and Health (NSDUH; NIMH, 2019). Rates were highest among those age 18–​25 (13.1%), lowest in those age 50 or over (4.7%), highest in white Caucasians (7.9%), and again, Depressive Symptoms lowest in Asians (4.4%). In a report based on Many clinicians make the diagnosis of depres- data collected by the NSDUH between 2005 sion based on the number and severity of depres- and 2015 (600,000 persons over age 12 in the sive symptoms identified through self-​ rated US), past 12-​month rates of MDD appeared to depression scales such as the Zung Depression be increasing, especially among younger perScale, the Beck Depression Inventory (BDI), sons age 12–​17 (Weinberger et al., 2018), conor the Center for Epidemiologic Studies—​ tinuing a trend seen between 1991 and 2001, Depression scale (CES-​D). These scales have when MDD increased from 3.3% to 7.1% in the established cutoffs for the number and sever- United States (Kessler et al., 2003). The latest ity of symptoms that are considered clinically estimates place the 12-​ month prevalence of significant. The Patient Health Questionnaire-​ MDD at 10.1% and the lifetime prevalence at 9 (PHQ-​ 9) is another common self-​ rated 20.6% (Hasin et al., 2018). symptom scale used in primary care settings The worldwide prevalence of depressive disto assess patients for depression. The PHQ-​9 orders (MDD, dysthymia, depressive episodes assesses the nine symptoms of MDD, each on a using ICD-​10, DSM-​IV, or DSM-​III-​R criteria), 0–​3 scale depending on how many days in the according to the World Health Organization’s past two weeks the symptoms have been pres- Global Burden of Disease Study, was estimated ent, along with an assessment of their impact at 4.4% in 2015 (12-​ month) and depended on work, care of things at home, or personal on geographical region and country (WHO, relationships. 2017a). In the European region, rates ranged from 3.8% in Tajikistan to 6.3% in the Ukraine; in the African region, from 3.5% in Chad and PREVALENCE Liberia to 4.7% in Ethiopia and Botswana; in In the United States, one out of every six the Western Pacific region, from 2.9% in the adults will experience a depressive disorder at Solomon Islands to 4.2% in China to 5.9% in some time during their lifetime (Kessler et al., Australia; in the Eastern Mediterranean region, 2005a). A recent estimate (2013–​2016) of the from 2.9% in Somalia to 5.1% in Djibouti, Qatar, point prevalence (current, rather than lifetime and the United Arab Emirates; in the Southeast prevalence) of depression in the United States Asia region, from 3.0% in Timor-​ Leste to based on a score of 10 or more on the PHQ-​ 4.5% in India; and in the Americas, from 3.7% 9 in a 2-​week period among those age 20 or in Guatemala to 5.9% in the United States. older was 8.1% (National Health and Nutrition Interestingly, developing countries appeared Examination Survey; CDC, 2018a). The rate to have lower rates of depressive disorder than was highest among those age 40–​59 (8.4%), developed ones (e.g., Guatemala vs. the US). In lowest in those age 20–​39 (7.7%), and about all regions, depression was more common in twice as high in women compared to men. Non-​ women than in men. The highest rates occurred Hispanic Blacks had the highest rate (9.2%) at age 55 to 69. With regard to YLD, depressive and Asians the lowest rate (3.3%). Those with disorder was responsible for the highest overall the highest level of family income had lower YLD from all causes in Uganda and Paraguay rates of depression (3.5%) compared to those at 10.5% (8.4% in US) and the lowest in Papua with the lowest income level (15.8%), especially New Guinea at 4.7% and Kiribati, Nepal, and among women (19.8%). Afghanistan at around 5.4% (WHO, 2017a). The past 12-​ month prevalence of MDD The latter countries had more physical causes based on DSM-​5 criteria (questions adapted of disability that competed with depression Depression • 69

in terms of YLD. As noted earlier, depressive disorder is common and disabling, no matter where one lives.

particularly important when trying to understand how religious involvement may affect depressive symptoms.

ECONOMIC BURDEN

Environmental

In the United States, the economic burden of MDD increased from $173.2 billion in 2005 to $210 billion in 2010 based on inflation-​ adjusted dollars, with an incremental annual healthcare cost of $6,400 per person compared to nondepressed patients (Greenberg et al., 2015). In both 2005 and 2010, about half of these costs were due to direct care (45%) and half due to days missed at work (50%). Interestingly, more than one-​third (38%) of the costs were due to comorbid conditions, such as anxiety disorders, adjustment disorders, post-​ traumatic stress disorder (PTSD), and chronic pain disorders. National expenditures for outpatient treatment of depression have been steadily increasing, from $12.4 billion in 1997 to $15.5 billion in 2007 and then to $17.4 billion in 2015 (a 40% increase from 1997 to 2015, inflation adjusted) (Hockenberry et al., 2019). These increases are due to several factors, including increased population size, increased prevalence of depression, and increased insurance coverage for outpatient care (prompting more treatment seeking). Based on the cost estimates above, the total economic burden of MDD approaches that of many chronic common medical conditions in the United States, such as diabetes (American Diabetes Association, 2013). Besides cost in dollars, MDD is also associated with an increased likelihood of comorbid medical disorders that increase all-​cause and cardiovascular mortality (Evans et al., 2005; Wei et al., 2019). MDD is also one of the most important factors contributing to suicide worldwide, particularly among young adults and the elderly (Hegerl & Heinz, 2019).

Environmental causes have long been known to account for 60%–​ 70% of depression risk (Sullivan et al., 2000). Particularly important with regard to religion are environmental factors, since the mechanism by which religion affects depression may be largely due to the role it plays in helping people cope with psychological, social, and physical health stressors (vs. affecting biological or genetic causes). Stressful life events (SLEs) have long been known to increase depressive symptoms and lead to the development of MDD (Mazure, 1998; Stroud et al., 2008; Shapero et al., 2014). Environmental stress and trauma are known to cause depression, depending on the severity of the stressor, vulnerability of the person, coping style, and presence of coping resources. Repeated stressors over a lifetime, more than a single stressor, influence vulnerability to depressive disorder. Early research demonstrated that the most severe stressors in this regard were death of a child, death of a spouse, physical illness, divorce, and incarceration, in order of importance (Skodol & Shrout, 1989). Kendler and colleagues (2004) reported that the strongest predictors of MDD among women were childhood sexual abuse, stressful life events during adulthood, and the personality trait of neuroticism. They concluded that a combination of early environmental stressors and genetic factors increased the likelihood of depression following life stressors. Similarly, Shapero et al. (2014) also reported that emotional abuse during childhood (controlling for physical and sexual abuse) increased future reactivity to stressful life events, leading to depression. More recently, Kendler et al. (2016) examined the impact of underlying genetic risk and adverse life experiences on the etiology of MDD among men and women in the Virginia Adult Twin Study. The results of this study again confirmed that the presence of SLEs among those at genetic risk predicted an increased likelihood of developing MDD over time. They also reported that repeated episodes of depression

ETIOLOGY The causes of depressive disorder are many, involving environmental and social risk factors, biological risk factors, and a combination of the two (Saveanu & Nemeroff, 2012). Understanding the causes of depression is 70 •  M ental H ealth

could adversely affect personality, cognitive style, and relationship quality, further increasing later vulnerability to depression. Finally, they discovered that the time interval between SLEs and depression was short, i.e., less than one month, and that SLEs predicted future SLEs, which predicted depression onset. This research suggests that genetic vulnerability interacts with stressful experiences in both childhood and adulthood to increase risk of depressive disorder (see below). Recent epidemiological studies in the United States have shown that those at greatest risk for depressive disorder are women, white Caucasians, younger adults (age 18–​29), and those with low incomes (increasing the likelihood of experiencing SLEs) (Hasin et al., 2018; CDC, 2018a; NIMH, 2019). In one large population-​based study of 36,309 US adults, 12.9% of those with lifetime MDD and 15.5% of those with past 12-​month MDD had depression episodes soon after the death of someone close (Hasin et al., 2018). These findings underscore the importance of environmental factors in the etiology of serious depression. In addition to loss of loved ones and emotional, physical, or sexual abuse during childhood, other environmental factors that increase risk of depression include poverty, adverse sociodemographic circumstances, habits and lifestyle, negative family relationships, intimate partner violence, parental divorce, chronic health problems with accompanying physical disability, physical trauma, natural disasters, and SLEs more generally (Kohler et al., 2018). Many of these environmental risk factors are influenced by religious involvement (see other chapters in this volume).

Biological Biological risk factors for depression include dietary factors (vitamin D, magnesium, zinc, or iron deficiency; low fish, fruit, and vegetable intake), illicit and prescription drug use, alcohol abuse, physiological effects of medical illnesses (infection, cancer, endocrine and metabolic disorders), and physiological changes that occur during pregnancy and after birth (Kohler et al., 2018). Depression is also known to be more common in members of specific

families (Lohoff, 2010). As a result, recent years have seen an explosion in interest in inherited or genetic causes of depression (Dunn et al., 2015). Twin studies by Kendler and others have found that about 30%–​40% of depression risk is due to genetic factors (Sullivan et al., 2000). Studies have sought to identify specific genes responsible for depression (called “candidate genes”). The focus has been on genes regulating serotonin, dopamine, and norepinephrine production, i.e., biogenic amines in the brain known to be altered in depression and targeted by antidepressant drugs. Unfortunately, these efforts have not met with much success in terms of identifying single genes that increase depression risk. More emphasis has now been placed on genome-​wide association studies (GWAS) to identify genes or forms of genes (polymorphisms) that cause depression, but again with disappointing results. Currently, genetic causes of depression are thought to involve entire networks of genes that interact with each other and the environment to increase depression risk, with over 100 independent gene variants thought to be involved (Dunn et al., 2015; Howard et al., 2019).

Gene-​Environment Interactions As suggested above, gene-​environment interactions strongly influence the development of depression (Saveanu & Nemeroff, 2012; Lopizzo et al., 2015; Dunn et al., 2015). Caspi and colleagues (2003) were one of the first groups to report a gene-​ environment interaction between a functional length polymorphism (S allele) of the serotonin transporter gene (5-​HTTLPR) and SLEs in predicting the onset of depression, a finding that has now been confirmed by several meta-​analyses (Karg et al., 2011; Bleys et al., 2018). Other genetic variants have also been studied, including polymorphisms of the monoamine oxidase A (MAOA), brain derived neurotropic factor (BDNF), ­catechol-​O-​­methyltransferase (COMT), FK506 binding protein (FKBP5), and corticotropin releasing hormone receptor (CRHR1) genes. According to the review by Dunn and colleagues (2015), gene-​ environment interactions with FKBP5 and CHRH1 variants have been more consistently reported than with the 5-​HTTLPR Depression • 71

polymorphism, particularly among those exposed to abuse or adversity during childhood or other stressors during adulthood. As noted above, it is likely that there are many genes, each with relatively weak effects, that combine to increase susceptibility to depression in the face of environmental stressors.

RELIGIOUS INVOLVEMENT AND DEPRESSION Of all the mental disorders, the depressive disorders have been most closely correlated with ordinary spiritual experience (Blazer, 2011). This reflects the frequency in depression of existential concerns related to identity (“I’m not the same person”); meaning/​purpose (“My life is meaningless”); hope (“I’m hopeless”); morality (“I’m guilty”); and relationship to others, including God (“I’m ultimately alone”) (Peteet, 2010). Since religious traditions offer answers to such existential concerns, depressed individuals may explain their depression on this basis (e.g., believing that they do not have enough faith or are not praying or reading scriptures enough), and/​or feel even more discouraged when unable to sustain faith when depressed. Given the importance of environmental factors in the etiology of depression, and the potential for religious beliefs and practices to influence many of those factors, religious involvement is especially likely to affect situational or stress-​related depressions. As seen in the previous chapter, religion can play a powerful role in coping with stress, thus affecting the perception of environmental events. Religion may also impact depressions that are primarily biological or genetic in etiology due to increasingly recognized gene-​ environment interactions. Clearly, the relationship between religion and depression is not a simple one. We begin this section with a case vignette that illustrates how complex the relationship between religion and depression can be. Case Vignette Sally is a 35-​ year-​ old housewife and mother of three children, ages 1, 3, and 5. In addition to her childrearing

72 •  M ental H ealth

responsibilities, Sally also works part-​ time at a local restaurant to supplement their family income. She has been married for about 10 years and the marriage is a stable one. However, she has struggled throughout much of her life with bouts of depression, some quite severe, beginning shortly after leaving home for college. She has a strong family history of depression in her mother, grandmother, and one of her sisters, all of whom have required treatment. On her father’s side, there is also depression and a history of alcohol abuse, and an uncle is known to have committed suicide. Although her parents were strict disciplinarians, she has no history of emotional, physical, or sexual abuse during childhood, and does not drink alcohol due to her religious beliefs. Sally was raised in a religious home, and has attended religious services for as long as she can remember. She remains active in her church as a volunteer when able, and shares childcare responsibilities with several women in her congregation with whom she has close ties. Her relationship with her husband, who shares her strong religious beliefs, has improved substantially after ironing out difficulties earlier in their marriage helped by counseling with their pastor. Both she and her husband place a high priority on their relationship and their relationships with their children, based largely on their religious beliefs. Despite her tendency toward depression and increased stress due to caring for three children under the age of 6 and her part-​time job, Sally has been able to cope with bouts of depression without seeking formal treatment due to support from church members, occasional counseling with her pastor, prayer (alone and with her husband), and reading her Bible for support and guidance. However, during some of periods of depression, symptoms have been severe enough to interfere with her attendance

at religious services due to fatigue and no desire to be around others at these times. Although she usually forces herself to go, this last bout of depression has lasted for about a month and she has skipped several church services. Sally has discussed with her husband and her pastor the possibility of her seeking formal treatment for her depression, but they have not been supportive, encouraging her to rely on her religious resources instead.   

CORRELATION VS. CAUSATION Many studies have reported an inverse relationship between religious involvement and depression. In the first and second editions of this Handbook, we found that of the 444 studies examining this relationship, 61% reported less depression among those who were more religious, 6% found more depression, and 33% found no association. Of those studies, nearly 80% were cross-​sectional in design, i.e., the relationship was examined at only one point in time, making it difficult to determine how that association came about. Were these inverse correlations because religious involvement helped to prevent the onset of depression or to reduce its severity by mobilizing adaptive coping strategies, avoiding maladaptive ones, and increasing psychological and social resources? In other words, did religiosity cause less depression? Alternatively, since most of these were cross-​ sectional findings, could those inverse associations be due to the impact that depression had on religious involvement (adversely affecting concentration, energy, interest level, and desire for social interaction) so that depressed people simply participate less? The latter explanation is sometimes called “reverse causation” and could account for the inverse correlations observed in cross-​sectional studies. A third possibility is that both dynamics are present, i.e., religious involvement helps to prevent depression, and depression has a negative impact on religious involvement. The case

vignette above illustrates how devout religious beliefs and activities can prevent or lessen depression, can worsen depression (by interfering with professional treatment), and can be affected by depression. Bear in mind, though, that while nearly 80% of studies on religiosity and depression are cross-​sectional, more than 20% of the 444 studies in the first two editions of the Handbook were prospective studies, experimental studies, or RCTs, designs that have the potential to contribute to the question of causality. Sorting out these dynamics has been one of the primary goals of research on religion and depression over the past decade.

RESEARCH ON RELIGION AND DEPRESSION In this section, we focus on the best studies that have examined the relationship between religiosity and depression over the past 50 years, primarily large cohort studies and RCTs, as well as other noteworthy studies. These are described by study design and year of publication.

Prospective Studies As noted in Chapter 3, prospective or longitudinal studies follow participants forward in time, assessing predictors and outcomes at multiple time points. When studying religion’s effect on depression, this design ensures that religious involvement precedes changes in depression, one of the criteria for causal inference. We only review research here that presents Level 2, Level 3, or Level 4 evidence (see Chapter 3) where, at a minimum, religious activity is assessed prior to changes in depression status (depression onset) or religious involvement predicts future depressive symptoms after controlling for baseline symptoms (Level 4) (VanderWeele et al., 2016a). If control is also made for prior religious involvement, this is considered Level 3 evidence. If, in addition, trajectories of religious involvement over time are considered, then this qualifies for Level 2 evidence. One of the first studies that met Level 4 evidence was by Idler and Kasl (1992), who examined the relationship between religiosity and depressive symptoms in a random sample of 2,812 adults age 65 or over living in New Haven, Depression • 73

Connecticut, in 1982 (T1), whom they followed through 1985 (T2) (Yale Health and Aging Study). Religiosity was assessed by public religious activity (attendance at religious services and number of congregation members known) and by private religiosity (self-​reported importance of religion and strength/​comfort received from religion). Depression was assessed by the 20-​item CES-​D in 1982 and 1985. Analyses controlled for physical health status (chronic conditions, institutionalization in past year, blood pressure, number of prescription medications, functional disability), age, education, sex, race, perceived income adequacy, smoking, alcohol consumption, exercise, body mass index, social network, and optimism. In the overall sample, with all control variables in the model (confounders and possible mediators), no overall relationship was found between public or private religiousness at T1 and depressive symptoms at T2, with T1 depressive symptoms in the model. However, in men, there was an interaction between private religiousness and change in disability such that greater private religiousness at T1 protected men with worsening disability from becoming depressed at T2, after adjusting for T1 depression (b =​−0.50, p =​0.029). The next study that provided Level 4 evidence was conducted in 1990 by Koenig et al. (1992). As noted in Chapter 4, these investigators examined the effects of religious coping (RC) assessed by the 3-​item Religious Coping Index on changes in depressive symptoms (Geriatric Depression Scale) in 202 of 850 hospitalized male medical patients age 65 or over during a 6-​ month period following hospital discharge. RC was inversely related to depressive symptoms in the overall sample (n =​850) at baseline (T1), independent of other covariates (b =​−0.14, p < 0.001). After controlling for T1 medical health status and T1 depressive symptoms, RC at T1 predicted significantly fewer depressive symptoms at T2 (F =​10.4, p =​0.002). Next, Kennedy at al. (1996) surveyed a random sample of 1,855 older adults identified from the Medicare Master Beneficiary file in the Norwood area of the North Bronx, New York, examining the relationship between religiosity (frequency of religious attendance) and depressive symptoms assessed by the CES-​D. 74 •  M ental H ealth

Participants were surveyed at baseline (T1) and 2 years later (T2), and were divided into four categories based on their change in depressive symptoms from T1 to T2: persistently nondepressed, persistently depressed, emergence of depressive symptoms, and remission of depressive symptoms. Logistic regression analyses at baseline (T1) controlling for health status, functional disability, living situation, sex, social support, education, cardiovascular conditions, and religious affiliation, revealed that those not attending religious services were 60% more likely to score high on depressive symptoms (OR =​1.60, 95% CI =​1.38–​1.86). When change in depressive symptoms from T1 to T2 was examined, the percentage of persons not attending services was significantly greater in both the depression-​emerged and depression-​ persisted groups. However, when other variables were controlled for (demographics, baseline physical disability, change in disability, baseline and change in health status, cognitive impairment, Jewish religious affiliation, social support), T1 religious attendance no longer distinguished (1) never depressed from those in whom depression emerged or (2) persistently depressed from those who remitted. Also as reviewed in Chapter 4, Koenig and colleagues (1998a) followed 86 medical inpatients with major or minor depressive disorder (DD) for a period of 48 weeks after hospital discharge, examining the speed of remission of DD during follow-​up. Frequency of religious attendance, private religious activity, and intrinsic religiosity were assessed at baseline. Remission of DD was assessed every 12 weeks (T1 to T4) using standard criteria for remission (decrease in symptoms below a threshold). Cox proportional hazards regression was used to examine baseline predictors of depression remission. Although effects were in the expected direction, frequency of church attendance (HR =​1.35, 95% CI =​0.91–​ 1.97) and private religious activities (HR =​1.09, 95% CI =​0.77–​ 1.66) were unrelated to time to remission. However, after controlling for significant predictors of remission (quality of life, admitting service, change in functional status, family psychiatric history), intrinsic religiosity at T1 predicted a 70% faster speed of DD remission from T1 to T4 (HR =​1.70, 95% CI =​1.05–​2.75, p =​0.03).

Musick and colleagues (1998) analyzed data from a prospective study involving a random sample of 3,007 community-​ dwelling adults aged 65 or over assessed in 1986 (T1) and 1989 (T2), examining the relationship between religiosity at T1 and depression at T2 among those with cancer at T1, stratifying analyses by race. Religiosity was assessed by religious attendance, private religious activities, and viewing or listening to religious programs on TV or radio. Depression was assessed by the CES-​D at T1 and T2 (broken down by its four subscales: somatic-​retarded, depressed affect, positive affect, interpersonal relations). At baseline, 251 participants had cancer (n =​103 Blacks; n =​148 Whites). No associations were found between T1 religiosity and depressive symptoms at T2 among Whites, with or without covariates in the model. Among Blacks, however, T1 religious attendance predicted fewer somatic-​ retarded cases, less depressed affect, and more positive affect, after controlling for T1 outcomes and other religious activity measures. When analyses further controlled for age, sex, education, marital status, functional ability, social interaction, and satisfaction with social interactions, religious attendance remained associated only with positive affect (b =​0.17, p < 0.01). Strawbridge and colleagues (2001) conducted a 28-​year prospective study of a random sample of 2,676 community-​ dwelling adults age 17–​65 in northern California, examining the effect of religious attendance on depressive symptoms between 1965 (T1) and 1994 (T2). Depressive symptoms were assessed by an 18-​ item scale similar to the CES-​D and BDI, dichotomized into depressed and nondepressed based on a cutoff score of 5. After controlling for age, gender, education, and self-​rated health, weekly religious attendance predicted remission of depression at T2 among those who were depressed at T1 (OR =​2.31, 95% CI =​1.23–​ 4.35), an effect that was particularly strong in women (OR =​3.56, 95% CI =​1.64–​7.73). Braam and colleagues (2004b) analyzed data from a national random sample of 1,844 community-​dwelling older adults (age 55–​85) in the Netherlands assessed at baseline (T1), 3 years later (T2), and 6 years later (T3), examining the effects of religiosity on the course

of depressive symptoms. Religious involvement was assessed by religious attendance (T1 and T3), religious orthodoxy (T2), and religious salience (T2). Depressive symptoms were measured by the CES-​D at all three waves (T1–​T3). Control variables included age, sex, marital status, and education; modifying variables included number of chronic diseases, functional disability, and urbanization; and mediating variables included social network size, instrumental support, emotional support, sense of mastery, self-​esteem, and alcohol use. Generalized Estimating Equations (GEE) were used to analyze the data, which allowed for the analysis of cross-​sectional (between-​ subjects) and longitudinal (within-​ subjects) relationships simultaneously, controlling for the correlation of within-​person repeated measures over time. Results indicated that religious attendance was associated with a more favorable course of depressive symptoms, an effect that persisted after control of confounders, mediators, modifiers, and other religious variables (b =​−0.29, p < 0.01). Religious salience and orthodoxy were unrelated to course of depressive symptoms, except after other religious variables (particularly attendance) were added to the model, when a positive association between religious salience and depressive symptoms emerged (b =​0.09, p < 0.05). Van Voorhees (2008) followed 4,791 adolescents over 12 months (T1 to T2) examining protective and vulnerability factors predicting new-​ onset depressive episodes during that period. Participants were part of the National Longitudinal Study of Adolescent Health, a random sample of US adolescents in grades 7–​ 12. Depressive symptoms were measured by the 20-​item CES-​D, and a new episode of depression was defined as at least one core symptom (depressed mood or anhedonia) most of the time for the past week, plus at least three other DSM-​III depression symptoms of similar severity. Religious affiliation, youth group participation, frequency of church attendance, frequency of prayer, and importance of religion were assessed at T1. After controlling for T1 depressive symptoms, race, income, age, and gender, results indicated that having a religious affiliation (OR =​0.57, 95% CI =​0.34–​0.96), praying at least once/​week (OR =​0.52, 95% Depression • 75

CI =​0.29–​0.94), and attending youth religious services at least once/​month (OR =​0.37, 95% CI =​0.15–​0.88) predicted a lower likelihood of new-​onset depression. In a study of 94 patients with MDD consecutively admitted to a geropsychiatric ward in Australia, Payman and Ryburn (2010) assessed depressive symptoms at baseline, 6, 12, and 24 months with the 15-​item Geriatric Depression Scale, examining the effect of religiousness at baseline on changes in depressive symptoms over time. Religious variables were religious attendance, private religious activities, and intrinsic religiosity (assessed by the DUREL). Controlling for social support, frequency of attendance at club or social functions, history of stroke, exercise, and T1 depressive symptoms, high intrinsic religiosity on admission (T1) was the strongest predictor of lower depressive symptoms at 24 months (T2) among all baseline characteristics (b =​0.252, p < 0.05). Rasic and colleagues (2011a) analyzed data from a 10-​year prospective study of a random sample of 1,091 community-​ dwelling adults participating in Waves 3 and 4 of the Baltimore Epidemiologic Catchment Area Study (1994–​ 2004). Religious attendance and seeking spiritual comfort were assessed at Wave 3 (T1) and MDD was assessed at Waves 3 (T1) and 4 (T2). Religious attendance was dichotomized into “never attends” vs. “attends less than once a month to more than once per week”; seeking spiritual comfort was dichotomized into “never” vs. “rarely to almost always.” Controlling for sociodemographic factors, social supports, chronic conditions, along with MDD at T1, no association was found between either religious attendance or spiritual support and MDD at T2. Why investigators dichotomized their religious variables in this manner, reducing power to detect effects, is not clear. Miller and colleagues (2012) at Columbia University in New York City prospectively followed 114 adult offspring of depressed and nondepressed parents, examining the relationship between importance of religion or spiritualty (R/​S) at baseline (T1) and the development of MDD between T1 and the 10-​year follow-​up (T2). Controlling for gender, age, history of depression, and risk status (based on parental depression), those who indicated that R/​S was 76 •  M ental H ealth

“very important” at T1 were 76% less likely to experience a new episode of MDD between T1 and T2 (OR =​0.24, 95% CI =​0.06–​0.95, p =​0.04); religious affiliation and frequency of religious attendance, however, had no significant effect. Among individuals at high risk due to parental depression, those indicating that R/​S was very important at T1 were over 90% less likely to experience a new episode of MDD during follow-​ up (adjusted OR =​0.09, 95% CI =​ 0.01–​0.82, p =​0.03). These researchers also later reported a structural MRI study finding that those who indicated R/​S as “very important” showed significantly less thinning in multiple areas of the cerebral cortex compared to those who said R/​S was only “somewhat” or “not at all important” (Miller et al., 2014). In that study, R/​S was measured 5 years prior to MRI assessment (T1) and at the same time as MRI assessment (T2). The findings were significant for high R/​S assessed at either T1 or T2, or both (high stable), were similar for religious attendance measures (but not significant after R/​S importance was controlled), and were greatest in those at high risk for MDD. Maselko and colleagues (2012) analyzed data from a 7-​to 12-​year follow-​up (1987–​ 1991 to 1996–​2001) involving three random samples totaling 2,097 persons in Rhode Island (National Collaborative Perinatal Project). A total of 488 participated in both follow-​ ups and the average age at last follow-​up was 37 years. Lifetime MDD was assessed by a structured psychiatric interview (the CIDI), along with age at first MDD onset among those experiencing MDD (defined as childhood MDD if before age 18 and adult MDD if age 18 or older). Religious attendance was assessed both currently and retrospectively “when growing up,” and dichotomized into “once in a while or regularly” (attended) vs. “never” (did not attend). Four categories were created from these responses: always attended, started after childhood, stopped after childhood, and never attended. Covariates controlled for were gender, age, race, religious affiliation, and socioeconomic status. The main independent variable in these analyses was the timing of MDD onset (childhood vs. adulthood vs. never), and the main dependent variable was category of

religious attendance assessed in three models: stopped after childhood among 1,900 childhood attendees; started attending among 204 non-​attenders in childhood; and multiple changes among 488 with more than one follow-​ up. GEE was used to analyze the data, and analyses were stratified by gender. Results indicated that 56% of women with childhood-​onset MDD (n =​59) stopped attending religious services in adulthood, compared to 44% of women with adult-​onset MDD (n =​108), and 37% of never depressed women (n =​290). Multivariate analyses revealed that women with childhood-​ onset depression were 42% more likely to stop attending services than women without MDD or those with adult-​onset MDD (RR =​1.42, 95% CI =​1.19–​1.70). This widely cited study is the first to provide evidence for reverse-​causality in the relationship between religious attendance and MDD, although no evidence was found for this pattern in men. Study limitations included a relatively small number of women with early-​onset MDD stopping attendance (n =​59), and dependence on retrospective reports of childhood-​onset MDD and childhood attendance. Given that early-​ onset MDD (before the age of 21) is known to be a major risk factor for MDD recurrence and comorbid personality disorders (Greden, 2001), it is possible some of the women at the time of retrospective assessment may have had mood symptoms, coloring their memory of religious attendance and MDD onset. In a 14-​year prospective study of a random sample of 12,683 nondepressed community-​ dwelling adults in Canada, Balbuena and colleagues (2013) examined the relationship between religious involvement (religious attendance, self-​rated R/​S, importance of spiritual values) and development of MDD (diagnosed by the CIDI1) from 1994 (T1) to 2008 (T8). Weibull proportional hazards regression was used to examine the effects of T1 frequency of religious attendance on likelihood of developing MDD during follow-​up, controlling for age, sex, marital status, education, income adequacy, social support, and family and personal history of depression. Attendance at religious services

monthly or more often predicted a 22% lower likelihood of developing an episode of MDD during follow-​up (HR =​0.78, 55 CI =​0.63–​ 0.95) compared to non-​attenders. Self-​rated R/​ S and importance of spiritual values did not significantly predict new-​onset MDD. Leurent and colleagues (2013) analyzed data from a 12-​month prospective study of a convenience sample of 8,318 medical outpatients in Europe and Chile, examining the effects of religious beliefs on likelihood of developing a new episode of MDD during follow-​up. The Royal Free Interview for Spiritual and Religious Beliefs was used to assess religious beliefs. This measure begins with the statement: “In using the word religion, we mean the actual practice of a faith, e.g., going to a temple, mosque, church or synagogue. Some people do not follow a religion but do have spiritual beliefs or experiences. For example, they believe that there is some power or force other than themselves, which might influence their life. Some people think of this as God or gods, others do not. Some people make sense of their lives without any religious or spiritual belief.” Respondents were then asked to indicate whether based on this description they were primarily religious, spiritual, or neither. If religious or spiritual, they were asked if they practiced a specific religion. Finally, they were asked to indicate on a scale from 1 to 6 how strongly they held “their life view.” Logistic regression was used to examine predictors of new onset MDD within the past 6 months (diagnosed by the CIDI), adjusting for age, sex, education, employment, social support, past history of depression, and country. Participants were interviewed at baseline (T1), 6 months (T2), and 12 months (T3). Results indicated that those who said they were “spiritual” at T1 were nearly one-​third more likely (32%) to experience a new episode of MDD between T1 and T3 (OR =​1.32, 95% CI =​1.02–​1.70), especially if they lived in the United Kingdom (OR =​2.68, 95% CI =​1.52–​ 4.71). If they said “religious” at T1, however, no association was found. Among the 6,094 participants who indicated a spiritual or religious life view, strength of belief predicted

1. Composite International Diagnostic Interview, a structured psychiatric interview.

Depression • 77

an increased risk of MDD during the next 12 months (OR =​1.08, 95% CI =​1.00–​1.15), although the association was weak. In contrast, change in strength of belief between T1 and T2, after adjustment for T1 strength of belief and other covariates, predicted a different outcome. Those whose R/​S belief decreased were at greater risk of MDD during the ensuing 6 months (T3), whereas for those whose belief increased, the risk of MDD was lower. These contrasting results are somewhat difficult to reconcile. Rosmarin et al. (2013a) followed 47 psychiatric patients with acute symptoms from baseline to discharge in a day treatment program (Harvard’s McLean Hospital), examining RC on admission (T1) as a predictor of change in psychosis, depression, anxiety, and psychological well-​being from admission to discharge (T1 to T2, an average of 8 days). This study differs from many of the other reports above in that it was a treatment study. Religious coping was measured at baseline on admission (T1) using the 14-​ item Brief RCOPE to assess positive religious coping (PRC) and negative religious coping (NRC). Psychosis, depression, anxiety, and psychological well-​ being were assessed using standard measures of these constructs. After symptom change scores (T2 minus T1) were calculated, partial correlations (with Bonferroni correction) were used to examine the effect of pre-​treatment RC on change in mental health outcomes independent of other predictors (age and race). Results indicated that PRC predicted a significant decline in depressive (partial r =​0.50, p < 0.01) and anxiety symptoms (r =​0.60, p < 0.001) and an increase in psychological well-​being (r =​−0.37, p < 0.05), while NRC was unrelated to changes in depression after controlling for PRC. Ronneberg et al. (2014) analyzed data from a 2-​year prospective study of a US national random sample of 7,732 adults over age 50, examining the impact of religiosity on new-​ onset depression and recovery from depression between 2006 (T1) and 2008 (T2). Religiosity was assessed by religious attendance (low, moderate, and high), friends/​ relatives in congregation, importance of religiosity, and a 4-​ item measure of intrinsic religiosity. Depression was assessed by the 8-​item CES-​D, 78 •  M ental H ealth

with scores dichotomized into depressed (3 or higher) and nondepressed (less than 3). Covariates included age, gender, race, marital status, income, living situation, chronic medical conditions, recent stroke, heart attack or cancer, self-​ reported health, physical functioning, alcohol abuse, history of emotional or psychiatric problems, social support, stressful life events, and nursing home residence. Two logistic regression models examined predictors of new-​onset depression at T2 (among T1 nondepressed) and depression recovery at T2 (among T1 depressed). Among nondepressed participants (n =​5,740), those who attended religious services once/​week or more were less likely to experience new-​onset depression at T2 (OR =​0.65, p =​0.001) compared to moderate attendees (2–​ 3 times/​ month). Likewise, and surprisingly, those who infrequently or never attended were less likely than moderate attendees to experience depression at T2 (OR =​0.75, p =​0.04). No other religious variables predicted new-​onset depression. Among depressed participants (n =​1,992), greater frequency of private prayer at T1 predicted recovery from depression at T2 (OR =​0.93, p =​0.015); no other religious variables predicted recovery. Zou et al. (2014) conducted a 20-​year prospective study of a random sample of 754 children and teenagers in New York age 9–​19 at baseline, examining the effects of frequency of religious attendance on depressive symptoms, with attendance and depression assessed in 1983 (T1), 1986 (T2), 1992 (T3), and 2003 (T4). The average age of participants in 1983 was 13 years. Depressive symptoms were assessed using the Hopkins System Checklist-​ 90. Growth curve models (linear mixed effects models) were used to analyze the data, controlling for gender, race, family socioeconomic status, lifetime trauma, and recent negative life events. When dichotomized into “never” vs. “any” frequency of attendance, religious attendance predicted a lower level of depressive symptoms over time (b =​−0.52, p < 0.005); when attendance was left at weekly, monthly, and yearly, and compared to “never” in the growth curve model (Model 3), the findings demonstrated a gradient of effect, with b =​−0.63 (p < 0.005), b =​−0.50 (p < 0.05), and b =​−0.47 (p < 0.01), respectively.

Croezen and colleagues (2015) conducted a 6-​year prospective study of a random sample of 9,068 community-​dwelling adults over age 50 (Survey of Health, Aging and Retirement in Europe; SHARE study), examining the impact of social participation on depressive symptoms among participants in Austria, Belgium, Denmark, France, Germany, Italy, Spain, Sweden, Switzerland, and the Netherlands. Depressive symptoms were assessed using the 12-​item EURO-​D, where a score of 4 or higher indicates significant depression. The EURO-​D was administered at all three waves in 2004/​ 2005 (T1), 2006/​2007 (T2), and 2010/​2011 (T3). Changes in depression score over time was the primary outcome. Five different forms of social participation were assessed, including “participation in religious organizations,” which were measured at T1 and T2. Covariates included age, gender, education, geographical region, employment status, financial difficulties, self-​ rated health, long-​ term health problems, physical activity limitations, and physician diagnosed diseases. Results indicated that among all forms of social participation, only involvement in religious organizations predicted a significant decrease in depressive symptoms over time (β =​−0.19, 95% CI =​−0.365 to −0.016) with all covariates in the model. Interestingly, involvement in political/​ community organizations predicted an increase in depressive symptoms. As mentioned in Chapter 3, Li and colleagues (2016) at the Harvard School of Public Health analyzed data collected during the Nurses’ Health Study (NHS) over a 16-​ year period involving 48,984 nurses (largely Caucasian; average age 58 in 1996). Religious attendance was measured every 4 years from 1992 (T1) to 2008 (T5). Several measures of depression were obtained. Participant-​reported physician diagnosed depression was assessed in 2000 (T3), 2004 (T4), and 2008 (T5); clinician-​ diagnosed depression based on the Mental Health Index score cutoff was assessed in 1996 (T2) and 2000 (T3); use of antidepressants was determined in 1996 (T2) and every 2 years thereafter; self-​ rated depressive symptoms on the 10-​item CES-​D were collected in 2004 (T4) and 2008 (T5); and for secondary analyses, depressive symptoms in 2008 (T5) were

measured by the 15-​item Geriatric Depression Scale (GDS). Depression measures in 2004 (T4) were the primary outcome. Covariates included were sociodemographic, social, lifestyle factors, smoking status, alcohol consumption, postmenopausal hormone use, health/​medical conditions, and physical functioning. Covariate information was updated during follow-​ up, and for each exposure period, covariates were adjusted based on the questionnaire data prior to the exposure assessment. The effects of religious attendance assessed in 1996 and 2000 on depression (CES-​D) in 2004 and the effects of depression (participant self-​reported physician diagnosis of depression or clinician-​diagnosed depression assessed in 1996 and 2000) on religious attendance in 2004 and 2008 were examined. Multivariate logistic regression and marginal structural models were used to analyze the data (providing Level 2 evidence with multiple waves of longitudinal data, the highest for an observational study). Compared to women who never or almost never attended religious services (the reference category), those who attended religious services once/​ week or more experienced a 25% lower odds of developing depression (OR =​0.75, 95% CI =​0.67–​0.84) and those who attended services more than weekly had nearly a 30% lower odds of developing depression (OR =​0.71, 95% CI =​0.62–​0.82), with both analyses controlling for 1992 religious attendance. Compared to women who were not depressed, those who were depressed in 2000 were less likely to subsequently attend religious services once/​week or more in 2004 (OR =​0.74, 95% CI =​0.68–​0.80). These findings indicated that religious attendance decreased subsequent depression (giving evidence for a causal effect of attendance on depression) and depression decreased subsequent religious attendance (giving evidence for reverse-​causation), effects that were of approximately equal in magnitude. Ahrenfeldt and colleagues (2017) analyzed data from a 9-​year prospective study of 14,255 persons ages 50+​participating in Wave 1 and at least one additional wave (Waves 2, 4, and/​ or 5) of the SHARE study (same cohort as the Croezen et al. study above). The time period of observation was between 2004–​2005 (T1) and 2013 (T5). Three measures of religiosity Depression • 79

were administered at T1 to the 71% of participants who indicated they belonged to a religion (n =​10,151): “Thinking about the present, about how often do you pray?” (with responses dichotomized into praying [65.4%] vs. not praying); “Have you been educated religiously by your parents?” (yes [74.0%] vs. no); and “Have you done any of these activities in the last month?” (of the 7 options presented, one chosen by 13.3% of participants was “Taken part in a religious organization [church, synagogue, mosque, etc.]”). Religiousness was categorized as (1) “religious” (praying, being religiously educated, and taking part in a religious organization) (n =​900, 8.9%); (2) “less religious” (praying, but without taking part in a religious organization or being religiously educated) (n =​823, 8.1%); and (3) “non-​religious” (neither praying, taking part in religious activities, or religiously educated) (n =​1,674, 16.5%). Among health outcomes assessed were depressive symptoms (4 or more symptoms on the 12-​item EURO-​D scale vs. < 4 symptoms). Logistic regression and mixed effects logistic regression models were used to analyze the data, with depression dichotomized as above. Results were adjusted for baseline (T1) depression, gender, region, age, education, marital and employment status, and study Wave, and p values were adjusted for multiple comparisons. Praying (T1) predicted a higher likelihood of depression at T2, T4, or T5. In contrast, participation in a religious organization (T1) predicted a lower likelihood of depression. Being religiously educated was unrelated to depression. Those who were “religious” (positive on all three religious measures at T1) were less likely to experience depressive symptoms at T2, T4, or T5 (OR =​0.77, 95% CI =​0.64–​0.92). When “religious” persons were compared to “less religious” individuals (praying only), the former experienced fewer depressive symptoms (OR =​0.66, 95% CI =​0.50–​0.87). When compared to the “non-​religious,” the “less religious” (praying only) were more likely to have depressive symptoms (OR =​1.46, 95% CI =​1.15–​ 1.86). Researchers suggested that there were two types of religiousness: one that is restful religiousness (praying, taking part in a religious organization, and being religiously educated) that predicts less depression, and one that is 80 •  M ental H ealth

crisis religiousness (praying without other religious activities) that predicts more depression. Fancourt and Steptoe (2018) analyzed data from a 10-​year prospective study involving a national random sample of 2,548 adults age 50 or over participating in the English Longitudinal Status of Aging (UK). The purpose was to examine the relationship between community group membership and mood over time. Negative mood (depression) was assessed by the 8-​item CES-​D and positive mood by the CASP-​15. After controlling for baseline values of mood (along with sex, age, marital status, ethnicity, education, employment status, wealth, eyesight, hearing, chronic health conditions, health conditions in past 2 years, and chronic pain), membership in church or religious groups was associated with 21% lower odds of negative mood (OR =​0.79, 95% CI =​0.65–​0.98, p < 0.05) and 54% higher odds of positive mood (OR =​1.54, 95% CI =​1.25–​1.90, p < 0.001). Church or religious group membership was the only club or social membership associated with positive mood in this study. Finally, Chen and colleagues (2020a) from the Harvard School of Public Health analyzed prospective data from three cohort studies of young adults (n =​9,862), middle-​aged adults (n =​68,376), and older adults (n =​13,770) followed over a period of 3–​12 years. Frequency of religious attendance was the primary predictor, categorized as once/​week or more, less than once/​week, and never; those who attended at least once/​ week were compared to those who never attended. Controlled for in analyses were age, gender, race/​ethnicity, marital status, geographic region, employment status, night-​ shiftwork schedule, socioeconomic status, health-​ insurance status, childhood maternal attachment, and childhood-​ abuse victimization. In addition, mental and physical health outcomes at baseline were also controlled for, as well as attendance at religious services prior to baseline attendance (which eliminated the cumulative effects of past religious attendance on outcomes). Level of significance was adjusted for multiple comparisons using the Bonferroni correction. In the combined sample, attendance at religious services weekly or more predicted fewer physician depression diagnoses (RR =​0.84, 95% CI =​0.80–​0.89) and

fewer depressive symptoms (b =​−0.11, 95% CI =​−0.13 to −0.09, p < 0.002). Significant or near significant effects were also present in all three cohorts for both depression diagnoses and symptoms. In a systematic review of longitudinal studies up through 2017, Braam and Koenig (2019) examined the pattern of associations between the measures of religiosity/​spirituality (R/​S) and depressive disorder or depressive symptoms in 157 prospective studies. Overall, excluding measures of religious struggle, 52% of studies reported at least one association between R/​S and a better course of depression, 38% showed no significant association, and 10% found a positive association with depression or mixed results. Combining all the data produced an overall Cohen’s d effect size equal to −0.18 (SD =​0.28), equivalent to an OR =​1.39. In other words, those who were more R/​S were nearly 40% more likely to be in the nondepressed group. Effects were particularly protective among psychiatric patients, whereas they were somewhat less protective in younger samples and medically ill patients. Finally, studies that extensively controlled for confounding variables and higher quality studies were more likely to report that greater R/​S predicted less depression over time. Similar findings were reported by Garssen and colleagues (2021) in a meta-​analysis of prospective studies examining religiosity as a predictor of low distress states (primarily the absence of depression).

Randomized Controlled Trials (RCTs) While prospective studies and modern methods of analysis (marginal structural models) can go a long way toward demonstrating causality, they cannot establish it, since there could always be some unmeasured variable related to both religiosity and depression that could explain the association. The RCT is the only study design capable of proving causality (Level 1 evidence), since as noted earlier, the process of randomization equalizes between groups all known and unknown characteristics associated with both religion and depression. If, on the one hand, RCTs show that religious interventions reduce depressive symptoms

among depressed patients compared to those in a control group, then this represents powerful evidence favoring the therapeutic benefits of religious involvement. If, on the other hand, RCTs show that religious interventions have no effect or a negative effect on depression, then the opposite may be true. The most rigorous test of whether a religious intervention decreases depressive symptoms depends on the control group. As noted in Chapter 3, the lowest level of evidence is provided by an RCT involving a control group that receives no treatment (i.e., “usual care” or placed on a wait list). More evidence is provided if the control group is an “attention control,” i.e., participants in the control group receive equal social attention and interaction as those receiving the religious intervention. The highest level of evidence is provided in studies where the control group receives an active intervention for depression, such as standard secular psychotherapy with proven effectiveness based on prior RCTs. Again, we discuss the studies in order of year of publication and review only the highest-​quality studies (see Appendix). In one of the first high-​quality RCTs, Propst and colleagues (1992) compared the effectiveness of religiously integrated cognitive-​ behavioral psychotherapy (RCBT) to (1) traditional secular CBT, (2) pastoral counseling (PCT), and (3) a no-​therapy group (wait-​listed control) (WLC). A total of 59 mild to moderately depressed religious patients (mean age 40) in Oregon were randomized to each of the four groups. RCBT consisted of Christian religious rationales and arguments to counter irrational thoughts, along with the use of religious imagery. Subjects were assessed before treatment, at the end of treatment, and at 3 and 24 months after treatment. The intervention groups received eighteen 50-​minute sessions over 12 weeks. Results indicated that the RCBT group had a significant decrease in self-​rated BDI scores compared to the WLC group on post-​treatment evaluation (p < .001), although standard CBT and PCT groups also experienced therapeutic benefit (p =​0.02 for CBT vs. WLC, and p =​0.02 for PCT vs. WLC). With regard to observer-​ rated Hamilton Depression Rating scores, only the RCBT group and PCT scored significantly lower than the WLC group (p < 0.05 Depression • 81

for both comparisons) at the end of treatment. When comparing the proportion of subjects in each treatment group that experienced a “meaningful change” in depressive symptoms, only PCT (80%, p < .001) and RCBT (68.4%, p < .05) were significantly different from the WLC group (27.3%). By 3 months and 24 months post-​treatment, no significant differences were found between treatment groups. Razali and colleagues (1998) randomized 203 religious Muslim patients seen for the first time at a university psychiatry clinic in Malaysia (100 with MDD and 103 with generalized anxiety disorder) to either “religious-​sociocultural psychotherapy” (n =​52) or a control group (n =​48). Both groups received standard treatment for these disorders, i.e., antidepressants and supportive psychotherapy. In addition, the intervention group participated in discussions of religious issues related to depression and received religious-​sociocultural psychotherapy (religiously integrated CBT based on the Holy Qur’an and Hadith), which was used to modify negative thoughts. Participants were seen weekly for the first 4 weeks, every 2 weeks until the 12th week, and then monthly thereafter (11 sessions). Intervention and control groups were followed for 26 weeks, and were assessed at baseline, 4 weeks, 12 weeks, and 26 weeks by psychiatrists blinded to treatment group using the Hamilton Rating Scale for Depression (HRSD). There were no differences between treatment groups at baseline. Significant differences favoring the intervention group were identified at 4 weeks (t =​3.53, p < 0.001) and 12 weeks (t =​2.81, p < 0.01), but no difference between groups was found at 26 weeks. Thus, those receiving the religious intervention improved more quickly than those in the control group, but by 26 weeks, both groups had improved equally. Rye et al. (2005) randomized 192 persons divorced within the past 5 years (average 2.6 years) to either a secular forgiveness intervention, a religious forgiveness intervention, or a non-​treated control group. Secular and religious interventions were administered during eight weekly 90-​minute group therapy sessions using the same format (based on the REACH model of forgiveness), although in the religious intervention, participants were encouraged to 82 •  M ental H ealth

draw on their religious beliefs, religious sources of support, prayer, and scripture to help them to forgive their former spouse. Depressive symptoms were assessed by the self-​rated 21-​ item BDI at baseline, post-​intervention, and 6-​ week follow-​ up (mailed surveys). The 149 participants who completed at least four sessions and study surveys were included in the per-​protocol analysis. Hierarchical linear modeling was used to analyze growth curves of change in depressive symptoms between the three groups. Results indicated that there was no difference between secular and religious groups on change in depressive symptoms, although only those in the secular intervention decreased depressive symptoms significantly more than those in the untreated control group (b =​−1.079, SE =​0.367, p < 0.005). Kristeller and colleagues (2005) randomized 118 cancer patients to receive either a single 5-​to 7-​minute spiritual history taken by their oncologist (intervention) or no spiritual history (controls), with outcomes assessed at baseline and 3 weeks later. Every other patient was assigned to each group to minimize burden on any one oncologist. The overall length of the visit was 14.8 minutes for the intervention group and 13.1 minutes for the usual care control group. Depressive symptoms were assessed by the 7-​item self-​rated Brief Symptom Inventory. Results indicated that average depressive symptoms decreased from 4.54 at baseline to 1.80 at 3 weeks in the spiritual history intervention group, compared to 3.89 at baseline to 3.10 at 3 weeks in the control group (F =​7.57, p < 0.01). Miller et al. (2008) randomized 60 inpatients with severe substance use disorders to either a spiritual direction group (SG) or a treatment as usual (TAU) control group. The SG received up to 12 additional sessions of spiritual guidance based on a manualized spiritual direction protocol over a period of 4 months. Those in the SG were guided by three experienced spiritual directors following the spiritual disciplines developed by Richard Foster: acceptance, celebration, fasting, gratitude, guidance, meditation, prayer, reconciliation, reflection, service to others, solitude, and worship. The average number of sessions actually completed was 4.8 per participant, 2.0 sessions as an inpatient

and the remainder as an outpatient. All participants were assessed at baseline, 4 months (immediately post-​ treatment), 6–​ 8 months, and 12 months. Depressive symptoms were self-​assessed by the BDI. There were no differences in depressive symptoms between groups at baseline. However, by the 4-​month follow-​ up, depressive symptoms in the SG had become more severe compared to the TAU control group (t =​−3.93, p < 0.001); by the 6–​8-​and 12-​month follow-​up, however, the differences decreased to non-​significance. Koenig et al. (2015d) randomized 132 persons (religious and non-​religious) with MDD and chronic medical illness to either conventional CBT (CCBT; n =​67) or religiously integrated CBT (RCBT; n =​65). Participants received ten 50-​minute weekly sessions over 12 weeks. The two interventions were similar in all respects except RCBT used religious rationales based on scriptures to combat dysfunctional cognitions, provided scripture verses on which to meditate, and encouraged faith community involvement (using Christian, Jewish, Muslim, Buddhist, and Hindu treatment manuals, depending on the participant’s faith tradition). Both treatments focused on forgiveness, meaning/​ purpose, gratitude, and generosity, and CCBT included mindfulness meditation (comparable to prayer in RCBT). Participants completed assessments at baseline and at 4, 8, 12, and 24 weeks from baseline, using the self-​ rated Beck Depression Inventory-​II administered blind to treatment group. By the 12-​week assessment (primary endpoint), both RCBT and CCBT significantly reduced depressive symptoms from baseline to follow-​up (Cohen’s d =​3.02 for RCBT, d =​2.39 for CCBT). We initially reported that the effects of RCBT and CCBT on depressive symptoms were similar overall, but a larger effect for RCBT among those who were more religious at baseline (Koenig et al., 2015d). Later reanalysis of the data confirmed no significant overall “group” effect (B =​0.33, SE =​1.80, p =​0.86) or “group by time” effect (B =​0.54, SE =​0.64, p =​0.40) as originally reported. However, while the “religiosity by group” interaction was significant (B =​−0.09, SE =​0.03, p < 0.05), the “religiosity by group by time” interaction was not (B =​0.003, SE =​0.025, p =​0.88), indicating

that RCBT was not more effective than CCBT over time in those who were more religious (in contrast to what was initially reported). Nevertheless, other researchers have reported that religiously/​spiritually integrated psychotherapies are more effective among more religious individuals (Razali et al., 2002; Wade et al., 2007). We found in the study above that religious clients receiving RCBT were somewhat more likely to comply with the treatment compared to those who were less religious (85.7% vs. 65.9%, p =​0.10), further justifying its use in religious patients. Ysseldyk and colleagues (2016) conducted two experimental studies in Christians and atheists to examine the impact on mental and physical health of “immersion” in religious compared to nonreligious spaces. In the first study, 97 adults (half Christians and half atheists) were recruited at a cathedral, a castle, and a shopping district in a British city. Participants were randomized to one of two conditions designed to “differentially manipulate immersion in the space.” In the immersion condition (n =​48), participants were asked to consider their surroundings (buildings/​landmarks). In the non-​immersion condition (n =​49), participants were asked to consider their internal feelings and emotions (not their surroundings). Both groups were then asked to complete a questionnaire that included the Positive and Negative Affect Schedule (PANAS) and a 3-​item measure of self-​esteem. Results indicated that regardless of religious belief, mood was better in the immersion condition at the cathedral than at the other two places, whereas no difference in mood based on place was found in the non-​ immersion condition. Nevertheless, Christians’ self-​esteem increased when in the immersion condition at the cathedral, whereas atheists’ self-​esteem was higher when in the non-​immersion condition at the cathedral. In the second experimental study, 124 women (half Christian and half atheists) were recruited from a Canadian university to study the effects of “virtual tourism.” Based on religious beliefs, participants were equally assigned to one of three virtual locations by watching an online video of a cathedral, a mosque, or a museum. Half of participants viewed the video through virtual reality goggles Depression • 83

and were encouraged to imagine themselves in the place (immersion condition), while the other half viewed the video on a computer screen and were asked to evaluate video quality (non-​ immersion), and then both groups completed the PANAS, 3-​item self-​esteem measure, and a self-​rated physical health measure. Results indicated no significant differences in mood or self-​esteem as a function of location, religious belief, or immersion. However, atheists reported better health when watching the cathedral video on a computer screen (non-​ immersion condition) than when watching the cathedral video with virtual reality goggles (immersion condition). Based on these results, researchers concluded that immersion in belief-​ affirming places influences psychological and physical health, helping to explain why those who were more religious in previous clinical trials benefited more from religious interventions (and were more compliant with treatment than less religious subjects).

weekly 2-​ hour training sessions, followed by monthly 2-​ hour sessions for 4 months. Outcomes were assessed during the initial 8 weeks and for 52 weeks thereafter (60 weeks total). Participants were stratified by number of prior episodes of depression (3 or more vs. 2 or less). Cox proportional hazards regression was used to determine time to the primary outcome, relapse or recurrence of MDD based on DSM criteria. No differences between treatment groups were present at baseline, except for age (40.7 for intervention group, 46.2 for TAU group). Results indicated that among participants in the intervention group with 3 or more prior episodes of MDD (77% of sample), those receiving MBCT were less likely to have relapse/​recurrence compared to those in the control group (HR =​0.47, CI =​0.27–​0.84). In terms of percentages, 40% (22/​55) of subjects receiving MBCT had a relapse/​recurrence, compared to 66% (33/​50) of those in the control group. No difference between groups was found for those with a history of two or fewer episodes of MDD (23% of sample). MI N D F U L N E S S ME DITAT ION Foley and colleagues (2010) randomized 115 There is some debate about whether cancer patients in Australia to either Buddhist-​ mindfulness-​ based therapies are religious, based MBCT or a wait-​ listed control group. spiritual, or secular. Many have argued that Those in the intervention group received 8 mindfulness therapies are secular. However, weekly 2-​hour sessions focused on mindfulthere are obviously also close connections to ness, meditated 1 hour/​day, and attended an Buddhist practice. At the core of Buddhist teach- additional full-​day session during treatment. ings is the Eightfold Path. The seventh step on Depressive symptoms were assessed blind to the Eightfold Path is “right mindfulness,” and treatment group at baseline and post-​treatment related to it is the eighth step, “right concentra- using the HDRS. The MBCT group was assessed tion” (made up of three components: samadhi, a third time 3 months later to see if effects practice, and mindfulness). Thus, mindfulness-​ persisted. There were no differences at basebased treatments have strong Buddhist origins. line between groups. By the end of treatment, Assuming for now this religious identity (which depressive symptoms had decreased signifimany clinicians and researchers deny), we now cantly in the intervention compared to the conreview a few of the better mindfulness stud- trol group (group by time interaction b =​18.8, p ies here. < 0.001). Post-​treatment effect size (ES) for the In one of the earliest RCTs examining MBCT group was 1.34; ES difference between mindfulness as an intervention, Teasdale groups was 0.83 (large). Benefits persisted at and colleagues (2000) randomized 137 recov- the 3-​month follow-​up. A recent meta-​analysis ered patients with recurrent MDD to either of brief mindfulness training on negative affecBuddhist-​based mindfulness cognitive therapy tivity (i.e., depression, rumination, anxiety, (MBCT) (n =​76) or to a control group (n =​69) stress) based on 65 RCTs involving 5,489 subthat received TAU. Participants were recruited jects reported an overall ES (Hedge’s g) of 0.21 from two cities in the United Kingdom (Bangor (small but significant) (Schumer et al., 2018). and Cambridge) and from Toronto, Canada. There are many forms of meditation and Those in the intervention group received 8 “centering prayer” anchored within Western 84 •  M ental H ealth

religious traditions that are more frequently engaged in than mindfulness (in both Western and Eastern faith traditions). Unfortunately, these Western interventions have seldom been subjected to scientific study in the form of RCTs. As a result, Western forms of meditation and prayer are much less likely to be promoted in mental healthcare settings than mindfulness-​ based treatments. However, at least one RCT has compared “Christian-​ accommodative” mindfulness training (CMT) with conventional mindfulness training (MT). Ford and Garzon (2017) randomized 78 Christian college students to either CMT or MT, with both groups completing 3 weeks of treatment that included psychoeducational group sessions and daily application of mindfulness techniques. Post-​treatment differences were compared between the two groups using the Depression Anxiety and Stress Scale (DASS) and the Perceived Stress Scale (PSS). Results indicated significant differences both within and between groups, both favoring those in the CMT group. On the DASS, within group differences indicated an average 3.5-​point reduction (t =​3.5, p =​0.001, ES =​0.60) in the CMT group compared to a 1.7-​point reduction (t =​1.56, p > 0.10) in the MT group. Between-​group differences at the end of treatment also favored CMT over MT (t =​−2.08, p =​0.04, ES =​0.50). On the PSS, both groups experienced significant within-​group decreases in perceived stress (t =​3.42, p =​0.002, for CMT; and t =​2.63, p =​0.012, for MT), and between-​group differences were not significant. Subjects were also more compliant with CMT than with MT (p < 0.001). ME TA-​A N A LYS E S OF P SY C H OTH E RAPY RCTS

There have been at least five meta-​analyses of RCTs (the highest level of evidence) examining the impact of religiously integrated psychotherapies in the treatment of emotional problems, depression in particular (McCullough, 1999; Smith et al., 2007; Hook et al., 2010; Worthington et al., 2011; Gonçalves et al., 2015; Anderson et al., 2015; Captari et al., 2018). All of these reported some level of benefit in terms of reducing depressive symptoms,

with small to moderate average effect sizes (where an ES > 0.80 is considered large). For example, in one of the more recent meta-​ analyses (which did not include the Koenig et al., 2015d, or the Ford & Garzon, 2017, clinical trials above), Anderson and colleagues (2015) conducted a systematic review and meta-​ analysis of RCTs examining religiously adapted versions of standard psychotherapies for depression or anxiety. They identified 16 such studies published between 1984 and 2013. All used cognitive or cognitive behavioral types of therapies (called F-​ CBT for faith-​ adapted CBT). ESs (Hedge’s g) were reported by outcome and study type. For depression, where F-​CBT was compared to wait-​listed or TAU controls, the average between-​group post-​test ES for two Christian CBT studies (n =​44) was g =​−1.47 (95% CI =​−2.09 to −0.70, p < 0.0001). For two Muslim CBT studies (n =​164), after one outlier was excluded (due to 3-​armed trial), the ES was g =​−0.30 (95% CI =​−0.60 to 0.01, p =​0.06). For two “spiritual” CBT studies (n =​96), the ES was g =​−0.48 (95% CI =​–0.88 to −0.07, p < 0.02). Three of these studies (including the one outlier in Muslims) examined ESs between 4 to 12 weeks after the intervention to determine if benefits persisted. In the two that involved “spiritual” CBT, ES became non-​significant (g =​−0.30, 95% CI =​−0.71 to 0.10); in the one Muslim CBT study (n =​31), ES remained robust (g =​−2.75, 95% CI =​−3.76 to −1.73) when compared to TAU controls. When F-​CBT was compared to conventional secular CBT, the average post-​test ES for four Christian CBT studies (n =​124), after one study was excluded as an outlier, was g =​−0.59 (95% CI =​−0.95 to −0.23, p < 0.05). For one Muslim CBT study (n =​32), the study excluded earlier as an outlier when compared to TAU, the ES was g =​−0.31 (95% CI =​−1.01 to 0.39, p =​ns) when compared to conventional CBT. For the one study examining “spiritual” CBT (n =​43), the ES was g =​−0.55 (95% CI =​−1.17 to 0.06, p =​ns). In the most recent meta-​analysis, Captari et al. (2018) summarized the results of 97 outcome studies (the majority targeting depression or psychological distress) involving 7,181 subjects that examined the efficacy of tailoring psychotherapy to patients’ R/​S beliefs Depression • 85

(R/​ S -​ adapted psychotherapy). Compared to no treatment, R/​ S‐adapted psychotherapy resulted in significant improvement in clients’ psychological outcomes (g =​0.74, p < 0.000). When compared to any form of secular psychotherapy, effects were likewise superior (g =​0.33, p < 0.001). In more rigorous additive studies (where R/​S was added to a standard treatment and then compared with the standard treatment), R/​S‐accommodated psychotherapies were equally as effective as standard approaches (g =​0.13, p =​0.258).

Conclusions A majority of the prospective cohort studies reviewed above suggest that devout religious involvement predicts lower future depressive symptoms, controlling for baseline symptoms, or predicts a decrease in depressive symptoms or disorder over time compared to baseline levels. This is confirmed in meta-​ analyses of longitudinal studies (Braam & Koenig, 2019; Garssen et al., 2021). Reverse-​ causation remains an issue when conducting observational studies, such that depression itself can also affect religious involvement and this must be accounted for in prospective studies. Although reverse-​causation is highly plausible, the empirical evidence for this (thus far) has been found in women only; the effect was not observed among men in the Maselko et al. (2012) study, and the Li et al. (2016) study involved only women. The majority of RCTs reviewed above, including meta-​analyses of RCTs, support the notion that religious interventions for depression reduce depressive symptoms. Recall that RCTs, unlike other research designs, have the capacity to more definitively establish causality. Thus, both results from prospective studies and RCTs are consistent with the hypothesis that religion is an effective coping behavior that may reduce stress and the depression that often results from it. Future research should focus on prospective studies and RCTs when possible, although as noted in Chapter 3, these study designs are often hard to carry out well, challenging to analyze correctly, and difficult to support financially, in an era where funding support 86 •  M ental H ealth

for research on religion and mental health is not easily obtained. Prospective studies should be designed so that reverse-​causation can be assessed using methodology capable of doing so. RCTs, even more challenging and costly than prospective studies, should focus on comparing religious interventions for depression to conventional therapies, while taking into consideration the religiosity of participants. Even if no difference is shown between religious and conventional therapies overall, the former may be preferred, may be more effective, and may be associated with greater compliance among those who are religious, a large proportion of those who suffer from depression.

CLINICAL APPLICATIONS Given the research that currently exists, many applications are now appropriate for implementing into clinical practice. These include taking a spiritual history, simple religious interventions, religiously integrated psychotherapy, and referral.

Spiritual History One immediate clinical application involves the taking of a spiritual history. Regardless of whether religion decreases or increases depressive symptoms, we know that the two are related in some way and likely affect each other. This makes it imperative for clinicians to take a spiritual history on all patients presenting with depressive symptoms. This recommendation is consistent with the position of the American Psychiatric Association (1990), Royal College of Psychiatrists (Cook, 2013), and World Psychiatric Association (Moreira‐Almeida et al., 2016). The contents of a mental health spiritual history have been described elsewhere for older adults (Peteet et al., 2019), although they are applicable to adults of any age. In brief, a spiritual history involves questions about the patient’s religious or spiritual background, current beliefs and practices, faith community involvement, importance of religion, use of religion to cope, religious experiences while growing up, negative and positive past experiences with religion, impact of religious beliefs on current depressive symptoms, and influence

of religious beliefs on willingness to take medication or engage in psychotherapy. The spiritual history should reflect an openness to religious beliefs, whether they appear beneficial or even if they are contributing to depressive symptoms. The goal of the clinicians is to learn more about these beliefs and how they relate to current symptoms, not to endorse or challenge them, at least initially. When time is limited, one-​or two-​ item queries can be used, such as “How is your spiritual life going for you?”; “Is religion or spirituality important to you and does it relate to any symptoms of depression you are having?”; or “Do you have, or would you like to have, someone to talk to about religious or spiritual matters?” The latter question may help to determine referral needs. Such questions can be asked whether or not the provider shares similar religious beliefs as the patient (Balboni et al., 2021).

Simple Religious Interventions Simple interventions include supporting and encouraging religious beliefs and practices, if they appear helpful or adaptive. Such interventions should always be patient-​ centered and patient-​directed. Supporting healthy religious beliefs/​practices will help to boost the patient’s ability to use them in coping. If religious beliefs appear maladaptive or contributing to the patient’s emotional problems, careful listening and clarification through reflective listening is indicated. Clinician inquiry (spiritual history) and patient-​centered support are the least active forms of religious intervention, but may be particularly helpful to religious patients. After support, the next more active step in religious patients is to encourage religious practices such as prayer, meditation, scripture reading, religious rituals, attending religious services or involvement in other faith-​community activity such as religious volunteering, particularly if the patient has been previously engaged in such activities but has reduced or stopped them because of depressive symptoms. Finally, in the most active form of intervention, clinicians may consider participation in religious practices with the patient, an activity that should only be done with religious patients and at their request (Peteet, 1994;

Koenig, 2013). This might involve praying with patients, recommending supportive verses from scripture, or sharing one’s own religious experiences with patients. These interventions lie at the boundary of what many clinicians feel is appropriate behavior by health professionals, and therefore must be done carefully and only at the patient’s request or, at a minimum, with the patient’s permission. There is potential for coercion here, which must be avoided, even if patients give permission (which may be forced, given the patient’s desire to please the clinician). Proselytizing is one example of transgression or violation of a therapeutic boundary.

Religiously Integrated Psychotherapy As described above, a number of religiously integrated psychotherapies, particularly religious CBT, have been shown to reduce depressive symptoms in religious patients. Thus, licensed mental health professionals, with appropriate training, may utilize one of the manualized therapies now available to implement this form of treatment. Religious CBT therapy manuals and patient workbooks in six different religious traditions (Christian, Jewish, Shia Muslim, Sunni Muslim, Buddhist, and Hindu) are now available for free download (CSTH, 2019). There has also been discussion of establishing competencies for performing religiously and spiritually integrated psychotherapies, although general agreement on the exact nature of those competencies has not yet been worked out (Oxhandler & Pargament, 2018; Pearce et al., 2019).

Referral For clinicians who feel reluctant to engage in either simple or more advanced religious interventions to treat depression, due to lack of interest or training, referral or co-​therapy is an option. If depression is relatively mild, and the patient is religious, a health professional may encourage the patient to talk with their pastor or a chaplain. Pastoral care, as this is called, can be very helpful and may be one of the most common forms of intervention for minor mental health problems in the United Depression • 87

States. Indeed, the more than 350,000 clergy in the United States spend an average of 15 hours/​ week providing counseling (Weaver, 1995). Not all clergy, however, have training in counseling or mental healthcare and so must know their limits. This requires a willingness to refer the person to a mental health professional if the depression worsens or fails to improve. Referral for pastoral counseling conducted by a licensed pastoral counselor is another option. If the patient agrees, and there are licensed professional counselors trained in religiously integrated CBT, this is a third possibility. Even if clinicians refer clients for religious help, they can always continue their ongoing treatment so that patients do not feel abandoned. Co-​ therapy with clergy or a licensed mental health professional providing religiously integrated therapy is yet another option.

SUMMARY AND CONCLUSIONS In this chapter we gave a brief background on depression, examined the impact on disability, and provided information on diagnosis, prevalence, economic cost, and causes (environmental, biological, and gene-​environment interactions). We noted that religious beliefs and practices are most likely to affect depressions related to life stressors, i.e., situational depressions that are a reaction to negative environmental events. This is because of the impact that religion may have on the coping process. Religious involvement, however, may also affect biological depressions by reducing the stress that often precipitates or worsens these disorders. Regardless, the relationship between religion and depression is not a simple one. We presented a case that illustrates this complexity, leading to a discussion of whether religion

88 •  M ental H ealth

affects depression or vice versa (causal inference). This was followed by a review of the best studies that have examined effects of religious involvement on depression. Many prospective studies, those that have controlled for baseline depression or have examined depression course over time, have found that religious belief/​ activity often predicts a decline in symptoms over time. However, there is also evidence for reverse-​causation, in that depression also can affect religious activity. Finally, a number of RCTs were reviewed that found religious interventions to be effective in reducing depressive symptoms (including meta-​analyses of such trials). While the effects are not always large, they often produce meaningful improvements in symptoms either equal to or greater than those produced by conventional psychotherapy, particularly among those who are religious. The findings from these clinical trials provide further evidence for the causal nature of religion’s beneficial effects on depression. Although much research remains to be done, there are a number of sensible clinical applications that can be implemented based on the existing research findings. Many of those applications are non-​controversial, such as taking a spiritual history or supporting the patient’s healthy use of religious resources. More controversial, though, are encouraging religious attendance or engaging in religious practices with patients, such as prayer, or reading or quoting scripture. Religiously integrated psychotherapy has become less controversial, given the current evidence base from RCTs, allowing clinicians to seriously consider such interventions when treating depressed patients who are religious. In the next chapter we examine a mood disorder closely related to depression, bipolar disorder, and the influence religion has on this condition that disrupts the lives of so many.

6 Bipolar Disorder I am the moon, and sometimes I shine full in my dark, and sometimes I shine half in my dark, and sometimes I am the darkness myself. —​Juansen Dizon

BIPOLAR DISORDER (BPD), also known as “manic depressive” disorder, is a mood disorder characterized by mood swings from deep, dark depression to the heights of happiness, energy, and productivity, and then back down to paralyzing depression, occurring repeatedly in a cyclic pattern. Bipolar disorder is an important psychiatric disorder for our context here because of its close relationship with religiosity. In fact, one of the symptoms of mania is hyper-​ religiosity, at times reaching a psychotic degree. The manic person may believe that he or she is Jesus, Mary, God, or the Devil, losing complete contact with reality. Some experts have reported that religious conversion or salvation experiences may actually precipitate a manic episode (or result from one) (Gallemore et al., 1969; De Fazio et al., 2016). Readers should not forget, though, that religious beliefs may also be used to cope with whatever causes a manic episode, or with the symptoms themselves. Furthermore, when conversion experiences

have been reported in patients with BPD, they have usually occurred during a period of symptom remission (Gallemore et al., 1969).

DIAGNOSIS OF BIPOLAR DISORDER According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-​ 5), the diagnosis of bipolar disorder type I (BPD-​I) is made when the following criteria are met (American Psychiatric Association, 2013): the occurrence of one or more manic episodes, described as periods of persistently elevated mood (or irritable mood) and increased activity or energy that last at least one week or more, and are present most of the day nearly every day (any duration of symptoms is allowed if hospitalization is required to control symptoms). In addition, at least three or four (if irritable mood) of the following symptoms must be present: inflated self-​esteem or grandiosity;

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0006

decreased need for sleep; unusual talkativeness; racing thoughts; distractibility; increased goal-​directed activity; or excessive involvement in pleasurable activities with high potential for painful consequences. Symptoms must be severe enough to cause marked impairment in social or occupational functioning, to necessitate hospitalization, or associated with psychotic symptoms. These symptoms cannot be due to the direct physiological effects of a drug, medication, or medical condition, and symptoms cannot be explained better by another psychiatric disorder. Note that depression is not required for the diagnosis of BPD-​I. Bipolar disorder type II (BPD-​II), in contrast, requires at least one episode of major depression (MDD) and one episode of hypomania (and no history of a full manic episode). Hypomania is defined as a period of persistently elevated, expansive, or irritable mood, along with increased activity or energy, that lasts at least 4 consecutive days and is present most of the day, nearly every day (representing a significant change from normal for that individual). In addition, three or more of the symptoms required for a manic episode (above) must be present. Symptoms must not be so severe that they cause marked impairment in social, occupational, or other areas of functioning, necessitate hospitalization, or include psychotic symptoms, in which case a manic episode is diagnosed. Like mania, the symptoms cannot be due to the direct physiological effects of a drug, medication, or medical condition, or cannot be explained better by another psychiatric disorder. However, for BPD-​II to be diagnosed, episodes of MDD must be present and cause significant problems with social, occupational, or other areas of functioning, or the unpredictability caused by frequent alternation in mood must cause such dysfunction. The distinctions between BPD-​I and BPD-​II are important not only because treatments differ, but also because the prognosis for BPD-​II is much better than for BPD-​I. Although the DSM has made a clear distinction between major depressive disorder (MDD) and BPD, it is now being recognized that BPD exists on a spectrum ranging from pure depression, as seen in recurrent MDD where individuals may cycle between periods of normal mood 90 •  M ental H ealth

and periods of depression, to classic BPD where individuals cycle between periods of depressed mood and periods of mania, with many different patterns in between (Cassano et al., 2004; Benvenuti et al., 2015). In fact, it has been suggested that mental health professionals assess persons with mood disorders using a “bipolarity index,” which rates how “bipolar” a person is based on their symptoms, psychiatric history, and family psychiatric history (Aiken et al., 2015). Low scores on the index indicate someone who primarily has episodes of depression, whereas high scores describe those whose mood cycles between MDD and severe mania, with periods of normal mood in between.

PREVALENCE The latest estimates of the 12-​ month and lifetime prevalence of DSM-​ 5 BPD-​ I in the United States were 1.5% and 2.1%, respectively (Blanco et al., 2017). In this survey of 35,309 community-​dwelling adults, rates were similar in men and women. Rates were higher in Native Americans and Whites, compared to Blacks, Hispanics, and Asians. Rates were also higher in younger than in older persons, those who were widowed/​separated/​divorced (vs. married), and those with less education or lower incomes. Less than one-​half (46%) had received treatment for their disorder within the past 12 months. The 12-​month and lifetime prevalence rates of DSM-​4 BPD-​II in the United States were 0.3% and 1.1%, respectively, based on an earlier survey of 43,093 community-​ dwelling adults (Hoertel et al., 2013). For comparison, note that the 12-​month and lifetime prevalence rates of DSM-​5 MDD are 10.1% and 20.6%, respectively (Hasin et al., 2018). Worldwide, a meta-​analysis of 25 population-​ based studies involving 276,221 adults repor­ ted the 12-​month prevalence of BPD-​I at 0.7% (95% CI =​0.6–​0.9) based on data from 8 countries and the lifetime prevalence at 1.1% (95% CI =​0.8–​1.3) based on surveys from 12 countries (Clemente et al., 2015). The 12-​month and lifetime prevalence rates of BPD-​ II in that report were 0.5% (95% CI =​0.4–​0.6) and 1.6% (95% CI =​1.2–​2.0), respectively. The 12-​ month rates for BPD-​I were highest in China and Chile at 1.4%, whereas lifetime rates of

BPD-​I were highest in the United States (2.2%) and Hungary (2.2% by DSM-​III-​R) and lowest in Taiwan (0.2% by DSM-​III). For BPD-​II, 12-​month rates based on data from 5 countries were highest in the United States (1.0% by DSM-​IV-​TR) and lowest in Italy (0.2% by DSM-​III); lifetime rates were highest in China (2.2% by DSM-​IV) and lowest in Israel (0.6% by Research Diagnostic Criteria). For comparison, the worldwide 12-​month prevalence of depressive disorders, according to the World Health Organization’s Global Burden of Disease Study, was estimated at 4.4% in 2015 (WHO, 2017).

excess unemployment) at $148,725 ($229,037) (Begley et al., 2001). Costs have surely risen above those figures today. WHO has estimated that psychiatric disorders are the cause of nearly one-​third of life-​years lost to disability worldwide, and BPD is the fourth leading cause among psychiatric disorders of life-​years lost (Prince et al., 2007). In 2016, the WHO Global Burden of Disease (GBD) study estimated that BPD was responsible for 8,954,000 years lived with disability worldwide from 1990 to 2016, making it one of the most disabling of all psychiatric disorders (Vos et al., 2017).

CONSEQUENCES

CAUSES AND INFLUENCES

BPD-​ I has many negative consequences for individuals with the disorder, for family members, and for society. Persons with BPD-​I are at substantial risk for psychiatric and medical comorbidity, including premature mortality, functional disability, decreased quality of life, and completed suicide (Vancampfort et al., 2013; Crump et al., 2013; Plans et al., 2019). With regard to suicide completions, those with BPD-​I have a rate of suicide that is 20–​30 times that of the general population (Plans et al., 2019). One-​third to one-​half of those with BPD-​ I will attempt suicide, and 15%–​20% of suicide attempts will be successful (Vieta et al., 2018). Comorbid anxiety, substance use, and personality disorders are particularly common in BPD-​ I, making the management of these disorders difficult and adversely affecting prognosis. In a study of 244 adults with BPD-​I or BPD-​II, Parker and colleagues (2018) found that these individuals experienced a 44% to 127% greater likelihood of having difficulty with debts, completing their education, receiving speeding fines, and avoiding pregnancy or delaying parenthood. The economic consequences of BPD (I and II) have been estimated at $151 billion per year in the United States, with most of these costs (nearly 80%) due to lost productivity (Dilsaver, 2011). In a study now over 20 years old, the average direct lifetime cost for a person with BPD in the United States (including mental health services, direct medical care, alcohol and drug abuse treatment) was estimated at $84,234 in 1998 ($129,720 in 2020 dollars) and the indirect cost (morbidity, mortality, and

Like depression, BPD has multiple etiologies that interact with each other in a complex web of causation, including genetic, acquired biological, developmental, and environmental influences. In addition, social and behavioral factors impact the course of disease due to interactions with these other primary causes. Knowing the pathways that lead to the development of or that affect the course of BPD will help us to understand how religious involvement might influence this relatively uncommon but disabling and dangerous disorder. GEN ETICS

Genetics are thought to play a major role in the etiology of BPD, even more so than in MDD (Goes et al., 2016). The heritability of BPD is estimated to be as high as 85% (Vieta et al., 2018). In the Bipolarity Index, having a family history of BPD is one of the strongest risk factors for the disease. Schizophrenia may be the only psychiatric disorder that has a greater hereditary basis than BPD, and these two disorders share many features. One recent study found that BPD-​I is more strongly genetically correlated with schizophrenia, whereas BPD-​II is more strongly correlated with MDD (Stahl et al., 2019). BIOL OGICAL LY ACQUIRED

BPD can be caused or influenced by a host of medical conditions such as cerebrovascular disease, multiple sclerosis, systemic lupus erythematosus, and endocrine disorders such as Bipolar Disorder • 91

Cushing’s syndrome and Addison’s disease (Vieta et al., 2018). This is particularly true for late-​ onset bipolar disorder that occurs for the first time after the age of 55, which is often associated with stroke and cerebrovascular diseases that cause changes in brain structure (Fujikawa et al., 1995; Cassidy & Carroll, 2002; Haller et al., 2011). However, our understanding of BPD has evolved from viewing it as a brain-​specific condition to that of a whole-​body, multisystem disorder, since hypertension, heart disease, diabetes and endocrine disorders (including metabolic syndrome), and allergic or atopic conditions such as asthma and allergic rhinitis, are substantially more common in older persons with BPD than in the general population (Lala & Sajatovic, 2012). ENVI RO N M E N TAL

Although genetic and biological factors are primary causes of BPD, environmental factors can substantially influence the onset and course of the disorder, particularly developmental experiences early in childhood and even during infancy or before. These include maternal smoking during pregnancy (Talati et al., 2013; Marangoni et al., 2016), maternal physical or emotional stress during pregnancy (Marangoni et al., 2016), sexually transmitted diseases (STDs) during the perinatal period (Barichello et al., 2016), poor child-​parent relationships (Tsuchiya et al., 2003), other childhood adversity (Palmier-​Claus et al., 2016; Bortolato et al., 2017), marijuana or other drug use during adolescence (Tohen et al., 1998; Marangoni et al., 2016), and stressful life events (Tsuchiya et al., 2003; Aldinger & Schulze, 2017). S O C I A L A N D BE HAV IORAL FACTORS

Family interactions (expressed emotion and affective style) following hospital discharge have long been known to predict the course of BPD, particularly relapse and readmission (Miklowitz et al., 1988). Being married has also been shown to be protective against the development of BPD in many studies (Tsuchiya et al., 2003; Scott et al., 2010; Pignon et al., 2019). Likewise, social support has been shown to increase speed of recovery following relapse and to improve symptoms in patients with 92 •  M ental H ealth

BPD, and lack of support has the opposite effect (Johnson et al., 1999; Dunne et al., 2018). As we will see in future chapters, many of these developmental, environmental, and social factors that affect the onset and course of BPD are influenced by religious beliefs, practices, and commitments.

RELIGION AND BIPOLAR DISORDER We now examine how religious involvement affects the development and course of BPD. Much less research has been done on the relationship between religion and BPD than on depression, anxiety, substance use, or most other psychiatric disorders. We begin by presenting a case that illustrates how religion can affect the course of BPD.

Case Vignette Brenda is a 52-​year-​old divorced woman with a diagnosis of BPD-​I with an onset in her mid-​ twenties. She experienced a religious conversion shortly after her divorce about 15 years ago. Since then, her religious faith has been very important to her. This has been the one constant in her life when experiencing depression or mania, or when euthymic. She gets up at 5:00 a.m. every morning and reads her Bible for 2–​3 hours before leaving for work at 8:30 a.m. When in a manic spell, she may get up even earlier to pray, worship, and read scriptures for hours. During manic episodes, she may actually hear God’s voice speaking to her and believe that she is a prophet. During depressive episodes, in contrast, she may hear Satan’s voice and believe that she is being persecuted by demons. Brenda works as a secretary in a law firm, a job that she has held for nearly 20 years despite her mood swings. She is thankful for a flexible boss who himself is quite religious and understands her condition. Brenda’s BPD is relatively fragile in that she has required multiple

hospitalizations for both mania and depression. When not ill, she is somewhat hypomanic at baseline, which makes her an outgoing and productive secretary (a reason why she has kept her job). However, when depressed, her productivity stops and she has to take time off from work. When this occurs, she becomes almost unrecognizable in appearance and disposition. Her psychiatrist has been treating her for years with lithium and a low-​ dose antipsychotic, and this has kept her relatively stable and functioning about 90% of the time. However, after doing well for a while, she starts believing that God has healed her and asks her psychiatrist to take her off the medication to prove it. Brenda’s psychiatrist has strongly recommended against this, and has even had family meetings including her two adult children and the pastor of her church, all of whom support the doctor’s recommendation to continue treatment. Despite this, she will insist on being taken off the medication as a way to demonstrate faith in her healing. When her psychiatrist relents and begins to taper her off, she ends up in the hospital with either a depressive or manic episode. She admits after such hospitalizations that she may have misunderstood what God was telling her, and agrees to resume her medication. This cycle—​ believing she is healed, stopping her medication, hospitalization, and recovery—​ occurs about once every five years. Nevertheless, her family, pastor, church members, and employer continue to support her, which has been essential in keeping her on medication and enabling her to cope during episodes of illness, thus allowing her to live a relatively productive professional and family life.   

This case demonstrates the complex impact that religion can have on the life and symptoms of a person with BPD, both as a source of support and as a negative influence on treatment,

all interacting with a person’s baseline personality. As in the case above and as indicated earlier, episodes of mania or depression in BPD-​I can be associated with psychotic symptoms. Among BPD-​I patients with delusions, about one-​third experience religious delusions, depending on in what part of the world the studies are conducted; this makes the overall prevalence of religious delusions in BPD-​I patients about 15%–​ 22% (Koenig, 2011b), with a lifetime prevalence of psychopathology with either religious or supernatural content approaching 38% in one report from India (Grover et al., 2016).

IMPACT OF RELIGIOSITY ON BIPOLAR DISORDER (AND VICE VERSA) In this section, we will consider empirical research examining the relationship between religiosity and BPD. However, as will be seen, almost all of the existing studies are relatively weak, making it difficult to draw definitive conclusions. In evaluating that evidence and trying to form a holistic picture of the relationship between religiosity and BPD, it may also be useful to consider the pathways relevant to this relationship, especially those pathways between religiosity and predictors of BPD that have been better studied. Hypothetically, based on what is known about the etiology of BPD, religious involvement could impact the disorder by influencing many of the environmental, social, and physical risk factors known to affect its onset and course. Again, these factors are smoking during pregnancy, physical or emotional stress during pregnancy, STDs during the perinatal period, poor child-​parent relationship, stressful family interactions, marital status (unmarried), poor social support, marijuana or other drug use, stressful life events, and cardiovascular and cerebrovascular diseases (late-​life onset BPD). First, religiosity is inversely related to cigarette smoking, whether that be during pregnancy or any other time in life, and the relationship is a strong one, with 90% of studies (many done in populations of child-​ bearing age) finding an inverse relationship (see Chapter 17). The religiously active person Bipolar Disorder • 93

is both less likely to start smoking (Koenig et al., 1998f) and more likely to quit smoking, especially if a woman (Strawbridge et al., 2001). Religious involvement is also associated with being married, greater marital stability, and greater likelihood of having a mother and a father in the home (see Chapter 14). This means that the pregnant woman will often experience less stress during pregnancy and have the support she needs. If not married or with a stable partner, the pregnant woman may need to work outside the home to financially support herself, creating additional stress. If the marriage is characterized by conflict or if the child is not wanted, then this too will add stress to the pregnancy. Since religiosity is related to safer sexual practices, i.e., fewer partners and sex confined to marriage, STDs during pregnancy are also likely to be less frequent, since religiosity is associated with fewer STDs more generally (see Appendix, Miscellaneous Health Behaviors: Risky Sexual Activity). Family relationships, particularly child-​ parent relationships, have also been shown to be stronger and more stable in religious homes (Spilman et al., 2013; Poorsheikhali et al., 2015; Goeke-​ Morey et al., 2013). Social support from family and friends is another factor known to affect the course of BPD, and there are many studies demonstrating that religious involvement is related not only to greater social support, but also to a higher quality of support that endures over time (see Chapter 15). Drug or alcohol use/​abuse is common in BPD and often adversely affects the course of the disease. One of the strongest relationships between religion and mental health is in the areas of substance use disorders. Hundreds of studies, including many with large samples and rigorous research design, indicate that religious persons are less likely to use, abuse, or become addicted to drugs or alcohol (see Chapter 10). Alcohol and drug problems often lead to stressful life events (SLEs), including imprisonment, relationship breakups, accidents with physical injuries, job loss, or other problems. As noted above, SLEs may precipitate an episode of mania or depression in BPD. Not only are religious persons less likely to experience such SLEs, but religious coping is known to help 94 •  M ental H ealth

buffer the effects of SLEs on mental health (see Chapter 4). Finally, because religiosity may help to reduce stress, improve coping, and contribute to a healthier lifestyle, cardiovascular disease is less common, including heart disease, hypertension, and stroke, thus reducing vulnerability to late-​onset BPD due to vascular risk factors. Thus, there are many pathways, from intrauterine development to infancy, childhood, adolescence, young adulthood, middle age, and later life, that could help explain how religious involvement might affect the onset and course of BPD. However, in some cases, the opposite might be true. As noted in the case above, religiosity may adversely affect BPD in cases of powerful conversion experiences and compliance with treatment. Sudden religious conversion experiences have the potential to precipitate a manic episode in vulnerable individuals or worsen disease course. More than a half-​century ago, Gallemore and colleagues (1969) examined the history of 62 patients with severe and prolonged affective disorder, approximately half with active symptoms, comparing them to a matched group of 40 healthy persons. Twelve patients (20%) were experiencing manic symptoms. Lifetime religious conversion experiences were reported by 52% of patients compared to only 20% of healthy controls. In the majority of cases, however, these conversion experiences happened when patients were not ill. More recently, religious experiences precipitating manic episodes have been reported during Eastern meditation (Yorston, 2001), as well as during various expressions of Western religious activity (Hempel et al., 2002). Intense religious experiences may precipitate transient episodes of psychosis, some with manic features, such as occurred in the Welsh revival of 1904–​1905 (Linden et al., 2010). Thus, there is the potential for religious experiences to lead to early-​ onset manic episodes among those with genetic vulnerability or to destabilize the course of BPD. Finally, as in the case above, religious patients may stop their medications, which are perceived as conflicting with deeply held religious beliefs, or they may believe they have been healed and no longer need medication. Likewise, religious leaders or other members of the religious community may discourage them

from taking medication, instead encouraging prayer, scripture reading, or seeking relief from symptoms through other religious strategies. Not only may religion affect BPD, but BPD may also affect a person’s religious faith, either increasing religiosity or decreasing it. As in the case above, there may be hyper-​religiosity during manic episodes. While this may be meaningful to patients even after their mood has stabilized, it may also cause some to question their religious faith when they are not ill. In addition, or alternatively, those experiencing manic, depressive, or mixed states may turn to religion to cope with mood symptoms and situations caused by these symptoms. During periods of depression, persons with BPD may have difficulty engaging in religious activity, with symptoms affecting their ability to concentrate, pray/​meditate, or engage in religious community activity (80% of BPD episodes are depression, 20% mania). Finally, the chaotic lives of those with BPD may result in exclusion from religious communities because of their unpredictable and erratic behavior, which may not fit in well with the proper conduct expected of religious persons interacting together in social settings. Thus, there are many ways that religion may impact BPD.

RESEARCH ON RELIGION AND BIPOLAR DISORDER The above musings are largely speculative or are based on only a few case reports. What has empirical research discovered about the relationship between religious involvement and BPD? Does religiosity reduce or delay the onset of BPD, precipitate or prevent episodes of mania, help to shorten or prolong episodes of depression, or otherwise improve or worsen the course of BPD? Unfortunately, quantitative research on religion and BPD is relatively rare. Few studies of BPD have included measures of religious involvement, particularly prospective studies that might reveal how religion affects or is affected by BPD. For this reason, we review both cross-​sectional and prospective longitudinal studies below, again by year of publication. To date, there have been no randomized controlled trials examining religious interventions for BPD.

Cross-​sectional Studies Most research that has examined religion and BPD is cross-​sectional (10 of the 11 studies listed in the Appendix). Recall that cross-​ sectional studies provide information on associations, but generally provide no information on causality. One of the first to examine the relationship between religiosity and BPD was conducted by Baetz and colleagues (2006), who analyzed data from a national random sample of 37,000 community-​ dwelling adults in Canada. Two aspects of religiosity were assessed: (1) frequency of religious attendance, and (2) importance of spiritual values to find meaning in life, strength in dealing with difficulties, and understanding life’s difficulties. Lifetime psychiatric disorders, including mania, were assessed by a structured psychiatric interview, the DSM-​ IV-​based Composite International Diagnostic Interview (CIDI). Analyses were controlled for age, sex, education, income, marital status, chronic conditions, and social support. High religious attendance was related to a 13% lower likelihood of experiencing mania (OR =​0.87, 95% CI =​0.82–​0.92), whereas high spiritual values were associated with a 21% greater likelihood of lifetime mania (OR =​1.21, 95% CI =​1.12–​1.32). As noted above, high spiritual values scores indicated finding meaning, dealing with difficulties, and understanding life’s difficulties, which based on the way this question was worded, could have been the cause or the result of having manic episodes. Of course, since this was a cross-​sectional study, the same applies to the association between religious attendance and lower risk of mania (either a protection against manic episodes or a negative effect of manic episodes on religious attendance, i.e., reverse-​causation). While the study by Baetz and colleagues (2006) above was cross-​sectional, it had the advantage of being a national sample and relatively large. However, in the other cross-​ sectional studies described below, the samples consist entirely of individuals with BPD. Those studies are essentially each a case series. This is an even weaker design than a typical cross-​ sectional study because there is no one in the sample without the BPD that is under study. Bipolar Disorder • 95

Restricting the sample to only those with BPD can introduce selection biases that can effectively induce associations between variables even when none would be present cross-​ sectionally in the population (Hernán et al., 2004; Smith & VanderWeele, 2019). In a longitudinal study that begins only with individuals with BPD this is not as problematic because one follows the sample over time and the outcome of the study (e.g., symptomatology, recovery, relapse, etc.) is at a later period. However, with cross-​ sectional studies in which the entire sample has BPD, it is effectively impossible to study associations between various factors and the BPD outcome. With that in mind, we now review the other studies. Cruz et al. (2010) examined the relationship between religious involvement and clinical status in 334 veterans with BPD being seen at a Veterans Affairs (VA) medical center in Pittsburgh. Clinical status was determined by patient self-​ report rather than by clinical evaluation, using the Internal State Scale. Religiosity was assessed using the 5-​ item Duke University Religion Index (DUREL). The DUREL assesses organizational religiosity (ORA), non-​ organizational religiosity (NORA), and intrinsic religiosity (IR). Bivariate analyses revealed that ORA, NORA, and IR were all higher among patients in a euthymic state (in clinical remission, vs. having active symptoms) and in those with mixed states (having both depressive and manic symptoms, vs. depressed only or manic only). However, when sociodemographic characteristics, anxiety, psychiatric disability, and hazardous drinking were controlled for, the relationship between NORA (private religious activities) and euthymic state switched direction, such that NORA was now significantly less common during remission (OR =​0.84, 95% CI =​0.72–​0.99) and continued to be more common in mixed states (OR =​1.29, 95% CI =​1.10–​1.52). Controlling for explanatory variables may have resulted in the former. All other associations lost statistical significance. There was no association between any aspect of religiosity and pure mania in either controlled or uncontrolled analyses. Dervic and colleagues (2011) conducted a retrospective case-​ control study of 149 depressed patients with BPD (DSM-​ II-​ R) at 96 •  M ental H ealth

the New York State Psychiatric Institute and the Pittsburgh Western Psychiatric Institute, examining the relationship between religious affiliation, moral/​ religious objections to suicide, and suicide attempts. Multiple standard symptom measures were administered. Religious affiliation (present vs. absent) was assessed, and a 4-​item moral or religious objections to suicide (MROS) subscale of the Reasons for Living Inventory was administered. Participants with a religious affiliation (75%) were more likely to have children and to score higher on family-​oriented social network (frequency of contact and network composition). They were also (1) less likely to have a lifetime suicide attempt and made fewer attempts (63.1% vs. 80.4%, p =​0.02, and 1.6 vs. 2.3 attempts, p =​0.03), (2) less likely to have a first-​ degree relative commit suicide (2.8% vs. 14.0%, p =​0.003), (3) more likely to be older at first suicide attempt (age 24.5 vs. 20.4, p < 0.05), (4) more likely to be older at first manic episode (age 25.3 vs. 20.3, p =​0.004), (5) more likely to be older at first hospitalization (age 29.1 vs. 24.3, p =​0.03), (6) more likely to score lower on the Brown-​Goodwin Aggression Inventory (20.1 vs. 22.1, p < 0.05), (7) less likely to have a past history of combined substance and alcohol abuse (49.7 vs. 74.5%, p =​0.002), (8) less likely to have a history of childhood abuse (44.1% vs. 63.3%, p =​0.02), (9) more likely to have more child-​related concerns (9.8 vs. 7.2, p =​0.01, since they were more likely to have children), and (10) more likely to have significantly higher MROS scores (11.2 vs. 6.4, p < 0.001). Logistic regression analyses indicated that lower MROS was the strongest predictor of lifetime suicide attempts (OR =​2.0, 95% CI =​1.4–​3.1, p < 0.001), controlling for religious affiliation, having children, family-​oriented social network, and lifetime aggression. MROS was found to mediate the relationship between religious affiliation and suicide attempt in these analyses. Stroppa and Moreira-​Almeida (2013) surveyed 168 outpatients with BPD (DSM-​IV-​TR) being seen at a university hospital psychiatric clinic in Brazil. Religiosity was measured by the DUREL and by the Brief RCOPE, which assesses positive religious coping (PRC) and negative religious coping (NRC). Mental health was assessed by symptoms of mania, depression,

and quality of life (QOL) using standard scales. Religious disagreement with treatment and religious interference with treatment were also examined. One-​ third (31%) of patients indicated that their religious beliefs conflicted with treatment, and one-​quarter (23%) indicated that religious leaders interfered with treatment. After controlling for sociodemographic characteristics (age, gender, ethnicity, marital status, education, employment status), IR (intrinsic religiosity) was related to less depression (OR =​0.19, 95% CI =​0.06–​0.57, p =​0.003). PRC was also related to less depression (OR =​0.25, 95% CI =​0.09–​0.71, p =​0.01). Those reporting no religious affiliation were over four times more likely to be depressed (OR =​4.21, 95% CI =​1.2–​14.5, p =​0.02). Greater IR was related to better physical, psychological, social, and environmental QOL (p all < 0.01), and greater PRC was related to significantly better psychological and environmental QOL. No relationships were found between any religious variable and mania, suicide attempts, or need for hospitalization. Azorin and colleagues (2013) surveyed a consecutive sample of 493 clinically ill outpatients meeting DSM-​IV criteria for a clinical diagnosis of MDD made by psychiatrists working in 15 centers in France (Phase I). Patients with classic BPD, however, were excluded. During Phase I, “bipolarity” was assessed by the Multiple Visual Analog Scales of Bipolarity (MVAS-​BP). Religiosity was measured by the DUREL (based on the description in the manuscript, it was unclear when religiosity was measured), and participants were dichotomized into groups with high and low religiosity. During Phase II, 4 weeks later, hypomanic episodes using a semi-​structured interview were assessed, along with sociodemographic information, illness course, family history, psychiatric comorbidity, and affective temperament. The final sample for analysis was 424, after removal of patients with BPD or missing religiosity. All analyses appeared to be cross-​sectional and most were bivariate, although stepwise logistic regression was used to examine sociodemographic and clinical correlates of higher religiosity (HR). Bivariate analyses indicated that HR was associated with later age of affective illness onset (33.4 vs. 29.3, p =​0.0001) and lower

likelihood of substance use other than alcohol (0.4 vs. 1.7, p =​0.0008). However, HR was also associated with more hospitalizations, suicide attempts, hypomanic features, switches to mania with antidepressant treatment, comorbid obsessive-​compulsive disorder, and family history of BPD. Regression analyses indicated that HR was positively associated with having a first episode characterized by mixed polarity (OR =​3.37, 95% CI =​1.02–​11.04), a depressive temperament (OR =​1.58, 95% CI =​1.04–​2.49, p =​0.03), and chronic depression (OR =​2.78, 95% CI =​1.01–​7.82, p =​0.04). High religiosity was not, however, related to the total MVAS-​ BP (bipolarity) score (HR =​28.4 vs. LR =​27.5, p =​ns). Caribe et al. (2015a) surveyed 164 euthymic outpatients with BPD-​I (DSM-​IV) being seen in four specialized BPD centers in Brazil, examining the relationship between religiosity and suicide attempts. The DUREL was again used to assess religiosity. Participants were divided into lifetime suicide attempters (SA; 41% of patients) and non-​suicide attempters (non-​SA, 59%). Also assessed were many clinical variables, including the Barratt Impulsivity Scale. Bivariate analyses indicated that all aspects of religiosity were related to a reduced likelihood of being in the SA group (all p < 0.01). Logistic regression controlling for impulsiveness and clinical and sociodemographic characteristics revealed that both NORA and IR were related to lower odds of being in the SA group (NORA: OR =​0.66, 95% CI =​ 0.50–​0.86, p =​0.002; IR: OR =​0.70, 95% CI =​ 0.60–​0.81, p < 0.001). Grover et al. (2016) surveyed 185 outpatients with BPD (by ICD-​10) in India (62% Hindu and 34% Sikh), examining religious beliefs and treatment-​ seeking practices. All patients were in remission at the time of assessment. This report was primarily descriptive. Results indicated that 52% believed in God “very much”; 20% had psychotic symptoms with religious content; and 31% reported a religious etiology for BPD (31% due to God’s will, 25% due to bad karma, 16% due to punishment by God). Nearly half (45%) first sought treatment from a religious healer (only 38% first with a psychiatrist). Of the 41% with suicidal ideation, 15% said they had not attempted suicide because of their religious beliefs. A few Bipolar Disorder • 97

(8%) said religious beliefs positively influenced their decision to take medication, although 9% stopped medication due to religious beliefs. Nearly 30% indicated that God helped them with their BPD; 23% said participating in religious community activities helped. Nearly all (99.4%) indicated “not much” or “not at all” when asked if their doctor asked sufficient questions to understand their religiosity. Mizuno et al. (2018) surveyed 120 clinically stable outpatients with BPD-​I (DSM-​IV) (Group 1), comparing them to 112 with paranoid schizophrenia (Group 2), and 137 healthy controls (Group 3). Participants were recruited from Austria and Japan, both largely secular countries. Religiosity was assessed by attendance at religious services and personal importance of religion or spirituality. Also assessed were resilience, social functioning, and clinical symptoms (psychotic, manic, depressive) using standard measures. Resilience, the primary dependent variable, was assessed by the 25-​ item Resilience Scale. Results indicated that the association between religious attendance and resilience was not significant, after controlling for group and correcting p values (Bonferroni). However, a two-​way interaction was present (F =​2.2, p =​0.03) in that the difference in resilience between patients and healthy controls was larger in individuals who “never” attended religious services. The association between religious/​ spiritual importance and resilience was likewise not significant, and no two-​way interactions were present. The association between religious attendance and social functioning was not significant, but came close (F =​2.3, p =​0.06). Results were similar for religious/​spiritual importance. Finally, there were no significant associations between religiosity and psychopathology, except for an association between religious importance and manic symptoms (F =​3.1, p =​0.03). Those indicating that religion was “highly important” scored higher on the Young Mania Rating Scale than those indicating religion was only “slightly important” (2.6 vs. 0.7, p =​0.03). When stratifying analyses by country, results indicated a significant association between higher religious attendance and greater resilience in the Austrian cohort (F =​2.8, p =​0.03); Austrians who “never” attended religious services had 98 •  M ental H ealth

significantly lower resilience compared to individuals who attended services “about once a month” (129.4 vs. 142.2, p =​0.04). Gawad et al. (2018) surveyed 688 patients acutely admitted to a psychiatric facility in Houston, Texas, of whom 443 (64%) had BPD. Subscale scores on the DUREL were correlated in the overall sample with severity of psychotic symptoms using a standard scale. Bivariate analyses revealed that severity of psychotic symptoms was positively related to each of the three DUREL subscales. Logistic regression analyses controlling for age, race, gender, and primary diagnosis indicated that those scoring high on IR were over 50% more likely to have psychotic symptoms (OR =​1.53, 95% CI =​1.04–​2.25), but 41% less likely to have suicidal ideation (OR =​0.59, 95% CI =​0.41–​ 00.84); religious attendance was also related to fewer past suicide attempts. Multivariate analyses indicated no effect of any DUREL subscore on 30-​day readmission rate. Ouwehand et al. (2019) surveyed 196 outpatients with BPD-​I (70%) and other forms of BPD in the Netherlands. They compared the religiosity of patients with that of the general population of the Netherlands, the general European population, and the general US population. Religious/​spiritual (R/​S) experiences of BPD patients were assessed, and participants were asked if these experiences had lasting influence. Religiosity was measured by religious affiliation and by self-​categorization as religious and spiritual, spiritual but not religious, religious but not spiritual, or neither. Only bivariate relationships were examined. Compared to the general Dutch population, patients were more likely to have a religious affiliation (48% vs. 32%). With regard to self-​categorization, patients were more likely to indicate they were both religious and spiritual (35%) compared to the general Dutch population (20%), similar to the general European population (37%), but less likely than the general US population (48%). Lifetime R/​S experiences were common, with 44% of patients having an intense experience of the divine presence (22% with lasting influence); 37% having a sudden profound spiritual insight (17% lasting); 21% seeing a R/​S apparition (16% benevolent, 4% evil); 12% hearing a divine voice (9% benevolent, 2% evil);

and 20% feeling like an “important religious person” (Christ, Mary, the Prophet, etc.) (4% with lasting influence). Religious experiences were more common in mania than in depression. The most common experience during mania was feeling like an important religious person (89%), whereas the most common experiences during depression were absence of faith (63%) and absence of divine presence (68%). BPD-​I patients had (a) more positive R/​ S experiences overall and (b) more positive R/​S experiences with lasting influence compared to BPD-​II patients (4.5 vs. 2.8, p < 0.001, and 2.0 vs. 1.1, p =​0.02, respectively). In a further report from the sample above, Ouwehand et al. (2020) examined seven categories of participants’ explanations for their religious experiences (66% of all participants): part of their spiritual development of deepening faith (46%); both religious/​ spiritual and pathological (42%); tried to keep distance from such experiences (31%); not sure if authentic or pathological (30%); pathological only (15%); keep distance because due to illness (4%); and signified a spiritual crisis (10%). Greater religiosity was positively associated with interpreting religious experiences as part of their spiritual development and was negatively associated with explaining them as pathological only. More than half (56%) indicated it was important to discuss such experiences as part of their treatment.

religious characteristics on T2 mental health outcomes, controlling for T1 gender, age, skin color, and marital status. Three-​ quarters of patients (75.3%) were euthymic at T2. Positive religious coping (PRC) and intrinsic religiosity were both associated with lower depression scores at T1. PRC at T1 predicted significantly better T2 physical QOL (b =​10.2, 95% CI =​4.2–​ 16.1), mental QOL (b =​13.4, 95% CI =​7.1–​ 19.7), social QOL (b =​10.5, 95% CI =​3.6–​17.3), and environmental QOL (b =​11.2, 95% CI =​6.2–​16.1). Intrinsic religiosity at T1 predicted greater T2 environmental QOL (b =​9.6, 95% CI =​2.8–​16.4). In contrast, NRC at T1 predicted higher T2 manic symptoms (b =​4.1, 95% CI =​0.6–​7.5), lower mental QOL (b =​−28.1, 95% CI =​−52.0 to −4.2), and poorer environmental QOL (b =​−20.5, 95% CI =​−39.3 to −1.64). No other significant relationships were identified. Since T1 mental health outcomes were not controlled in these analyses, the impact of religiosity on change in mental health outcomes over time could not be determined. CON CL USION S

As noted above, most studies on religiosity and BPD are cross-​sectional, preventing determination of direction of effect (i.e., whether greater religiosity affects BPD, or whether BPD affects religiosity). Even the one prospective study discussed above did not control for baseline symptoms, making it difficult to say if religiosity predicted an improvement in clinical Longitudinal Studies symptoms or quality of life. There appears to Only one such study could be identified in be a trend indicating that religiosity is associour systematic review. Stroppa and colleagues ated with more psychopathology among those (2018) followed 158 outpatients in Brazil with with BPD in countries that are secular (France, a DSM-​IV-​TR diagnosis of BPD in treatment Netherlands, Japan), whereas the findings are for at least 1 year over a period of 2 years. The more mixed in religious countries (US, Canada, purpose was to examine the effect of religiosity Brazil). Any conclusions, however, are princiand religious coping assessed in 2011 (T1) on pally speculative as the quality of the available symptoms of mania, depression, and quality of data is poor. Religiosity is related to later age life in 2013 (T2). Religiosity was assessed by the of onset of the mood symptoms, lower suicidal DUREL and Brief RCOPE as in their baseline ideation and attempts (except in France), and cross-​sectional study described earlier. Mania is positively associated with family support, symptoms were assessed by the Young Mania which is an important factor affecting disease Rating Scale; depression by the Montgomery-​ course. Religious delusions and hallucinations Asberg Depression Rating Scale; and quality of are also common in those with BPD-​I (15%–​ life (QOL) by the WHOQoL-​BREF. Regression 38%), although these are usually benevolent, analyses were used to examine the effects of T1 at least in the Netherlands, and positive R/​S Bipolar Disorder • 99

experiences are more common in BDI-​I than in BDI-​II. Religiosity may interfere with treatment of BPD in Brazil and India, although doctors in India seldom ask patients about their religiosity. In Canada, mania is less common in those who attend religious services more frequently, but appears to be more common in those who have spiritual values related to dealing with difficult life experiences. In Austria, resilience also appears to be lower among BPD patients who infrequently or never attend religious services. However, highly religious BPD patients in France, Austria, and Japan are likely to have manic symptoms; those in the Netherlands with BPD are more likely to describe themselves as both religious and spiritual compared to the general population; and those in the Netherlands with mania and those in India with BPD have many R/​S experiences, some quite long-​lasting and some quite positive. In Brazil, positive religious coping and overall religiosity are related to fewer suicide attempts and better quality of life in those with BPD. In the United States, religious objections to suicide and religious affiliation are associated with fewer suicide attempts, although private religious practices may be less common in euthymic patients with BPD when other factors including mediators are controlled. Thus, there are few consistent patterns on the relationship between religiosity and BPD, at least based on the current research that is now almost entirely cross-​sectional.

RECOMMENDATIONS FOR FUTURE RESEARCH Of highest priority for future research are prospective cohort studies studying the course of BPD, examining change in symptoms over time. To our knowledge, no such study had yet been published as of April 2023. Participants need to be followed for long enough periods so that there is sufficient time to allow for change in clinical symptoms. The fact that BPD is associated both with manic symptoms involving unusual perceptions of wellness, happiness, and energy, followed by periods of deep sadness, fatigue, and exhaustion, makes examining the course of symptoms even more challenging. Likewise, the presence of religious delusions during either manic or depressive 100 •  M ental H ealth

spells makes it difficult to differentiate positive from negative forms of religiosity, which likely interact with and influence each other. The possibility that both religiosity affects BPD and BPD affects religiosity, with effects varying depending on polarity of illness, adds further to the complexity. All of these factors make it difficult to interpret findings from observational studies. Questions that need answering more urgently are: (a) Do more religious persons at genetic or biological risk for BPD experience a delay in onset of BPD? (b) Do those who are more religious spend less time ill (or more time in euthymic states) compared to those who are less religious? Long-​term prospective studies are needed to answer those questions. Such prospective studies would need to be very large to have adequate power since, as noted earlier in the chapter, BPD is relatively rare. Randomized controlled trials of religiously integrated interventions (such as religious CBT) in BPD may help to circumvent some of the challenges with observational studies, although such treatments specific for BPD have yet to be developed or tested. However, there has been some discussion of the role that religious interventions may play in the treatment of religiously oriented psychiatric patients with BPD (Raab, 2007). If religious interventions improve clinical course (manic symptoms, depressive symptoms, quality of life, resilience, suicidal ideation, etc.), then this might argue for the positive effects of religious involvement on BPD. Alternatively, if religious interventions worsen symptoms or are clearly inferior to secular therapies, perhaps by precipitating or worsening religious delusions, then this too will provide important information on how religiosity affects BPD.

CLINICAL APPLICATIONS Although there is not much research to guide clinicians and religious professionals on how to best treat or support the person with BPD, common sense and the current literature base can help to some extent in this regard. SP IRITUAL H ISTORY

As usual, the most important application for clinicians treating patients with BPD is taking

a spiritual history, either directly from the patient, or if patient is too ill, from a close family member or friend. Clinicians should ask about the importance of religion during childhood and adulthood, prior and current involvement in a religious community, the use of religion to cope with symptoms of the disorder (and what kind of support they have received from religious leaders or member of their faith community), the change of religious beliefs or activities during periods of mania or depression, the overall impact of the disorder on their religious faith, and the influence that their religious beliefs might have on decisions about treatment (taking medications, receiving counseling, etc.). Importance of religion to family members with whom patients are living or to influential persons in their life should also be explored. S U P P O RT/​E N COURAG E

If religion is important to the patient and is not clearly pathological (e.g., religious delusions or excessive religious activity), then the clinician may consider supporting the religious beliefs/​practices that the patient finds helpful. We base this recommendation on research that, in general, supports the hypothesis that religious belief and community involvement, if not pathological, are either helpful or at least not harmful. Involvement in a supportive faith community may be particularly helpful to a patient who was once involved but has withdrawn from participation and has become socially isolated as a result. I N TE RV E N TI ONS

At the present time, as noted above, we are aware of no religious interventions specifically developed for those with BPD in the midst of a manic episode. The primary need of such patients is for medication to control the mania and prevent future manic episodes from occurring. However, during depressive episodes (which make up 80% of mood episodes in BPD, as noted earlier), religiously integrated psychotherapies may be quite helpful, just as research has shown them to be in treating unipolar depression (see Chapter 5). For religious

patients, therapies such as religiously integrated cognitive behavioral therapy (CBT) may be especially helpful based on the success of secular CBT in BPD. A meta-​analysis of 19 studies involving 1,384 patients with BPD found that CBT reduced relapse rates, improved depressive symptoms, decreased mania severity, and improved psychosocial functioning (Chiang et al., 2017). Psychosocial interventions for BPD patients in the depressive phase are particularly important because of concerns that the use of antidepressant medication in such individuals may lack effectiveness and/​or in some cases may cause harm (e.g., induce rapid cycling or precipitate mania) (Goodwin et al., 2016; Baldessarini et al., 2019). During a depressive phase, such patients need support to help them get through this period of dysphoria, which is extremely painful but may be self-​limited. Whoever is providing support or therapy, however, must be careful to assess for suicidal thoughts throughout treatment, since as noted earlier, the suicide rate in those with BPD is 20–​ 30 times that of the general population. REL IGIOUS P ROF ESSION AL S

Religious professionals should not attempt to provide support or counsel to persons they suspect have BPD without first referring these individuals to a mental health professional for evaluation and ongoing treatment (usually pharmacological). BPD is a biologically driven chronic mental disorder that can be unpredictable and deadly. For the religious person with BPD, however, as seen in the case example above, the combination of professional mental healthcare and religious support may be the best way to support recovery (although this recommendation is admittedly not yet based on systematic research). Religious professionals can also help to educate their faith communities about how to best welcome individuals with BPD given their particular vulnerabilities.

SUMMARY AND CONCLUSIONS In this chapter, we have examined the diagnosis, prevalence, and impact of BPD, both in the United States and worldwide. Genetic, Bipolar Disorder • 101

biological, environmental, and social influences on the development and course of BPD were reviewed. Environmental and social pathways were emphasized, given research demonstrating that many of these factors are affected by religious involvement. After presenting a case vignette, the hypothetical impact of religiosity on BPD and the impact of BPD on religiosity (reverse-​causation) were discussed. The possibility of religious delusions and hallucinations in BPD (15%–​38%) was also acknowledged. The heart of this chapter, though, was the review of systematic research that has examined the relationship between religious involvement and BPD. The results of that research appear to vary depending on the religiosity of the country, perhaps with some indication of worse outcomes among highly religious persons in secular regions (Europe and the Far East) and somewhat better outcomes in more religious areas (North and South America). The greatest weakness of most of this research is that more than 90% is cross-​sectional (and most of it restricted to studies consisting entirely of those with BPD, i.e., a case series), with only one prospective study where it was

102 •  M ental H ealth

unclear whether change in symptoms was examined over time. To our knowledge, there have also been no randomized controlled trials. One thing for certain is that in religious areas of the world (such as Brazil and India), religiosity and symptoms of bipolar disorder are closely interwoven, and in some cases, religiosity may conflict with and hence interfere with pharmacological treatment of the disorder. Finally, we discussed a number of clinical applications, including taking a careful spiritual history, supporting nonpathological religious beliefs and activities, and considering the possible benefits of religiously integrated cognitive behavioral therapy in treating depressive episodes. Religious support and counsel by religious professionals were also emphasized, at least tentatively since this recommendation was not based on evidence but rather on clinical experience and common sense. In the next chapter we examine the most feared of all consequences that those caring for persons with depression or BPD must try to prevent—​ suicide—​and the impact that religious involvement can have on the likelihood that this will happen.

7 Suicide Thou shalt not kill. —​Exodus 20:13

ACCORDING TO THE latest data from the World Health Organization, one person dies from suicide every 40 seconds (Hunt, 2019). Suicide is the most serious and feared consequence of a psychiatric disorder. In fact, 90% of those who attempt suicide have a psychiatric disorder, most commonly mood disorders, substance abuse disorders, or schizophrenia (Qin, 2011). The remaining 10% likewise have been found to suffer from significant psychopathology (Ernst et al., 2004). The same is true for completed suicide. An early review of 46 cohort and case-​control studies found that five factors were consistently associated with completed suicide: depression, anxiety, hopelessness, impulsivity/​aggression, and self-​ consciousness/​ social disengagement (Conner et al., 2001). Between one-​half and two-​thirds of those who commit suicide have major depressive disorder or bipolar disorder, making mood disorders the most common psychiatric conditions associated with suicide (Mann et al.,

2005). The prevention and treatment of mood disorders, then, is key in preventing suicide. Recent genetic studies show that the genes that increase vulnerability to major depression increase suicide risk across all psychiatric disorders, underscoring the role that depression plays—​whether diagnosed or not—​in driving suicidal behavior (Mullins et al., 2019). This chapter examines the role that religion plays in preventing suicide, building on research in previous chapters that described associations between religious involvement and stress buffering, depression, and bipolar disorder. First, however, let us examine the prevalence, cost, and causes of suicidal thoughts, attempts, and completed suicide.

PREVALENCE Completed suicide, while infrequent, is the second most common cause of death among persons age 15–​34 in the United States (Murphy

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0007

et al., 2013) and is the 10th leading cause of death overall (CDC, 2017a). Between 1999 and 2017, the suicide rate in the United States increased by 33% from 10.5/​100,000 to 14.0/​ 100,000, with the greatest increase coming between 2006 and 2017 (Hedegaard et al., 2018). The highest suicide rates in 2017 were in men (30.1/​100,000) and in women (9.7/​ 100,000) age 45–​64, particularly in men age 75 or older (40/​100,000 per year). In that year, suicide rates were more common in rural areas (20.0/​ 100,000) than in urban areas (11.1/​ 100,000). Age-​adjusted suicide rates increased more rapidly in women than in men; the rate in women increased from 4.0/​100,000 in 1999 to 6.1/​100,000 in 2017 (52.5%) compared to an increase from 17.8/​100,000 to 22.4/​100,000 in men (25.8%). The suicide rate also increased more rapidly in rural counties from 13.1/​ 100,000 to 20.0/​100,000 (52.7%), compared to the increase in urban counties from 9.6 to 11.1/​ 100,000 (15.6%). The suicide rate is especially increasing in young people. Among Americans age 10–​ 24 years, the suicide rate between 2007 and 2017 increased by 56% from 6.8/​100,000 to 10.6/​100,000, representing nearly 20% of all deaths in that age group (Curtin & Heron, 2019), and shows no evidence of slowing in the most recent report (10.7/​100,000 in 2018) (Curtin, 2020). The highest rates (16.6 to 31.8/​100,000) in 2018 were in the states of Alaska, South Dakota, Montana, Wyoming, North Dakota, Idaho, Utah, Colorado, and Arizona. Increasing suicide rates in young persons are consistent with the rate of serious psychological distress in the past month among young adults age 18–​ 25, which increased by 71% between 2008 and 2017 (Twenge et al., 2019). Worldwide, suicide is the second leading cause of death among persons age 17–​ 29, and the seventh leading cause in those age 30–​ 49 years (WHO, 2017b). In 2016, the global suicide rate was 10.6/​100,000 (7.7 in women, 13.5 in men). Rates were highest in Europe at 15.5/​ 100,000 and lowest in the Eastern Mediterranean region (3.9/​100,000). Among specific countries, rates were highest in Lithuania (31.9/​100,000) and Russia (31.0/​ 100,000), and lowest among countries in the Caribbean and Middle East (WHO, 2018a). 104 •  M ental H ealth

Trends in worldwide suicide rates over time have also been examined. Until 1999, suicide rates were declining in Japan, the United States, Eastern Europe, and the rest of Europe, but were increasing sharply in Russia (WHO, 2017b). In a more recent analysis of World Health Organization mortality data collected in 28 countries from 1990 to 2015, Alicandro et al. (2019) found that suicides continued to decline in most countries during first decade of the twenty-​first century (due to the better management of psychiatric disorders), except in Greece, the Netherlands, the United Kingdom, Brazil, Mexico, the United States, Philippines, and Australia, where there was an increase in the suicide rate. Russia and other Eastern European countries and Japan showed decreasing trends, although they were still ranked among the countries with the highest suicide rates. The authors emphasized that the global economic downturn in 2008 may have influenced these trends.

CAUSES OF SUICIDE In this section we examine known risk factors for suicide. This is a particularly important section since it provides information that may help to identify pathways by which religious involvement may affect suicide rates. We examine psychological, biological, and social factors that influence risk of suicide.

Psychological As noted above, psychiatric disorders are present in 90% or more of those who commit suicide, and mood disorders are the most common psychiatric disorder for individuals at risk. One of the strongest predictors of completed suicide is previous suicide attempts (Hawton et al., 2013). But what predicts suicide attempts? In a recent 12-​year prospective study of 663 individuals at high risk for depression (offspring of parents with mood disorders in the US), the strongest predictor of suicide attempt (occurring in 10.7% during follow-​up) among all symptom trajectories (including hopelessness, impulsivity, aggression, impulsive aggression, and irritability) was a trajectory of high mean depressive symptoms (OR =​4.72, 95%

CI =​1.47–​15.21) (Melhem et al., 2019). Other predictors were lifetime history of unipolar depressive disorder, lifetime history of bipolar disorder, a history of childhood abuse, a parent who attempted suicide, and younger age. Besides previous suicide attempts, in their classic systematic review and meta-​analysis of risk factors for completed suicide, Hawton and colleagues (2013) also identified Axis II personality disorder (OR =​4.95, 95% CI =​1.99–​12.33); hopelessness (OR =​2.20, 95% CI =​1.49–​3.23); more severe depression (OR =​2.20, 95% CI =​1.05–​4.60); alcohol or drug abuse (OR =​2.17, 95% CI =​1.77–​2.66); male gender (OR =​1.75, 95% CI =​1.08–​2.86); comorbid disorders such as anxiety (OR =​1.59, 95% CI =​1.03–​2.45); and a family history of psychiatric disorder (OR =​1.41, 95% CI =​1.00–​1.97). Across the 19 studies reviewed, factors not substantially influencing completed suicide risk (after these other predictors were accounted for) were family history of suicide, history of psychiatric admission, psychotic features, guilt, reduced sleep, weight loss, psychomotor retardation, loss of concentration, hypochondriasis, psychomotor disturbance, voluntary vs. involuntary patient status, and surprisingly, current antidepressant treatment or electroconvulsive therapy (ECT). In a 20-​year prospective study of 6,891 psychiatric outpatients (1% of whom committed suicide during follow-​up), multivariate survival analysis revealed only three significant and unique predictors of completed suicide: suicidal thoughts, major depression, and bipolar disorder (Brown et al., 2000). More recent meta-​ analyses and reviews of predictors of suicidal behavior and completed suicide confirm those findings (Franklin et al., 2017; Conner et al., 2019). Likewise, in Northern Europe, where suicide rates are known to be high, a 24-​year prospective study of 56,826 patients hospitalized for the first time with depressive disorder in Scandinavia examined predictors of completed suicide (Aaltonen et al., 2019). Researchers found that prior suicide attempts (adjusted hazard ratio =​2.11, 95% CI =​1.85–​2.40) once again were the strongest predictor, followed by male gender (AHR =​2.07, 95% CI =​1.91–​ 2.24); psychotic depression (AHR =​1.45, 95% CI =​1.30–​1.62); comorbid alcohol dependence (AHR =​1.25, 95% CI =​1.13–​1.41); and severity

of depression (AHR =​1.19, 95% CI =​1.08–​ 1.30). Finland, where this study was conducted, has one of the highest suicide rates in the world at 15.5/​100,000 (23.9/​100,000 in men). This is the 23rd highest rate among 182 countries (WHO, 2018a).

Biological Biological risk factors for suicide include medical and genetic factors. Among the medical factors are chronic illness, disability, and chronic pain, conditions which increase suicide risk in adolescents and older adults (Fässberg et al., 2016; Ferro et al., 2017). This is especially true for those suffering from chronic pain, which is often associated with feeling mentally defeated, catastrophizing about pain, feeling hopeless in the face of unrelenting suffering, perceiving pain as a burden, and having a sense of thwarted belongingness due to activity limitations (Racine, 2018). Genetic factors may also independently affect risk of suicide. Based on family and twin studies, genetic factors may account for as much as 50% of the variance in suicide risk depending on study, suggesting that genetic causes of suicide may operate independently of having a psychiatric disorder (Brent & Mann, 2005; Erlangsen et al., 2020). As with depression, gene-​environment interactions are also likely to be influential (Lloyd & Raikhel, 2018).

Social Early research identified social factors as a key determinant of suicide risk. Murphy and Robins (1967) observed that depression and alcoholism accounted for the majority of urban suicides. Compared to the general population, depressed persons in that report frequently lived alone, and alcoholics were more often divorced, separated, or living alone. Nearly one-​third experienced a disruption of a significant relationship within six weeks of suicide. More recent research suggests that social environment, family relationships, and social support are strong correlates of suicide attempts, especially in certain subgroups of the population such as low-​ income African Americans (Compton et al., 2005). In their model of suicide Suicide • 105

risk in clinical practice, Turecki and Brent (2016) emphasized the role that lack of social cohesion, rapid changes in social structure or values, family history of social disruption, and early-​life adversity played in predisposing individuals to suicide. In a study of 7,140,589 Swedish adults followed for 8 years that examined predictors of suicide mortality, being unmarried was one of the strongest risk factors for suicide, second only to psychiatric disorder and having chronic obstructive lung disease (Crump et al., 2014). Finally, in a meta-​analysis of 40 observational studies on social isolation and suicidal thoughts and behaviors (the majority of studies being in young persons), Calati et al. (2019) reported that the main social constructs associated with suicide outcomes were being unmarried, socially isolated, and alienated from others. Both the objective condition of living alone and the subjective feeling of loneliness were strongly related to suicide outcomes. Other social determinants of suicide risk include unemployment (Brown et al., 2000), and in Finland, higher socioeconomic status (surprisingly) and, again, living alone (Aaltonen et al., 2019). Based on these studies and reviews, social factors appear to be important in whatever ultimately drives a person to suicide, and may be one of the key mechanisms by which religious involvement influences suicide risk.

SUICIDE PREVENTION Research has also examined factors that may help to prevent suicide. In a comprehensive 10-​year review of suicide prevention strategies (2005–​2014), Zalsman and colleagues (2016) synthesized the results from 23 systematic reviews, 12 meta-​ analyses, 40 randomized control trials (RCTs), 67 cohort trials, and 22 population-​based studies. They found strong evidence (Level 1a) that suicide was prevented by drugs such as lithium in bipolar and unipolar depression, clozapine and atypical antipsychotics in schizophrenia, serotonin reuptake inhibitors (SSRIs) in major depression, and psychosocial interventions in patients with a history of self-​harm. By “strong evidence,” was meant that there was a published systematic review or meta-​analysis of RCTs involving the 106 •  M ental H ealth

intervention (not necessarily that the effect of the intervention was strong). In the systematic review of psychosocial treatments, Crawford and colleagues (2007) identified 18 RCTs examining the impact of psychosocial interventions following an episode of self-​harm in reducing the likelihood of future suicide. Interventions included outpatient problem-​ oriented counseling, dialectical behavioral therapy (cognitive-​behavioral and mindfulness), 24-​hour access to telephone contact with a doctor, interpersonal problem-​ solving skills training, home visits by a community nurse to assure treatment adherence, hospital admission to “talk about problems,” short-​term intensive program to improve family functioning, cognitive behavioral therapy (CBT), psychodynamic interpersonal therapy, group therapy, telephone interventions, and nurse-​led case management. Since there were only 37 completed suicides out of 3,918 subjects in these RCTs, the power to detect an effect was low. Overall, there was a small nonsignificant decrease in completed suicide from these interventions. The largest effects were for manual-​assisted cognitive therapy, outpatient CBT, and intensive outpatient care. In a systematic review of prevention strategies for suicide conducted around the same time, Mann and colleagues (2005) expanded the outcome criteria to include suicide attempts and suicidal ideation (rather than completed suicide, which as noted earlier is relatively rare). In that review, CBT approaches were found to be particularly effective in reducing suicidal attempts and ideation. Not surprising, no RCTs in either review above involved religious interventions. Social pathways for reducing suicidal risk factors are also essential for suicide prevention. These include social support from peers and family (Kleiman & Liu, 2013) and efforts to combat the social withdrawal that occurs as persons are drawn toward suicide (Amitai & Apter, 2012; Cramer & Kapusta, 2017). Kleiman and colleagues (2014) have found that social support among 379 college students had a direct protective effect on suicide ideation and helped to buffer the relationship between negative life events and suicidal ideation. Likewise, combating stressors common in older adults, including family discord, social isolation, and bereavement,

through social interventions may help to prevent suicide in this age group (Conwell, 2014). One of the most common reasons given by suffering people for why they do not commit suicide is the impact it would have on children, spouse, other family members, or loved ones. Given (a) the strong emphasis in religious scriptures on cognitive and behavioral processes that parallel many aspects of cognitive behavioral therapy (e.g., Matthew 15:11; Romans 12:2; Philippians 4:8), (b) the important role that religion plays in marital and family stability (Chapter 14), and (c) the impact that religious involvement has on quality of social interactions in combating social withdrawal (Chapter 15), this now provides a segue into how religious beliefs and practices might impact suicidal thoughts, attempts, and completed suicide.

RELIGION AND SUICIDE Case Vignette Phillip is a 45-​ year-​ old married Black man who about 10 years ago suffered a back injury when falling off a truck while on the job. The result was repeated back surgeries that left him unable to work and with severe chronic pain in his back and legs. While he has survived on his small monthly workers’ compensation check, the injury has forced his wife to find a job outside the home to make ends meet. Phillip now has difficulty maintaining the car, taking care of the yard, and can barely assist with housework, which makes him feel like a burden on his family. Medical bills have also built up, given that workers’ compensation insurance pays for only part of these costs. Every possible surgical method to relieve his pain has failed, including foraminotomy, laminectomy, spinal fusion, and implantation of a spinal cord stimulator. His physicians have diagnosed him with neuropathic pain syndrome, since the pain is resistant to narcotic analgesics (oxycodone, morphine, methadone), which do

nothing for the pain except put him to sleep. Treatment with nerve stabilizers such as gabapentin and pregabalin have not been effective, nor has acupuncture and other alternative medicine therapies. The pain interferes with his sleep, requiring frequent repositioning of his body to partially ease the discomfort. As a result, he has developed severe depression for which he is receiving psychiatric care. However, in the setting of severe chronic pain, antidepressant medication and psychotherapy have done little to improve his mood, his feeling of being a burden on his family, and his desire to get away from the pain by ending his life. For years now, he has longed to end the pain by committing suicide. There is one thing, however, that stands in the way between him and that solution to his problem: his faith. Phillip tells his psychiatrist that if it were not for his religious beliefs, he would have long ago ended his life. He says that his strong Christian beliefs forbid him to take his own life. “Only God has that right,” he says. Phillip is a member of a Black Baptist church and has friends there who have been very supportive, one of whom calls him every day and prays with him on the phone. As a result, he has resisted the near constant suicidal thoughts that circulate in his mind. However, he is getting tired and at times wonders how much longer he can take the pain. He questions why God has allowed him to suffer so. He asks himself what he has done to deserve this. Phillip thinks that perhaps he is being punished for the sins of his youth. Yet he holds on, day by day, to his faith and his life.   

RELIGIOUS VIEWS ON SUICIDE All major religions in the world have prohibitions against suicide for personal suffering. Religions with particularly strong teachings Suicide • 107

in this regard are Judaism, Christianity (especially Catholics and conservative Protestants), and Islam (Simpson & Conklin, 1989). Within Judaism, Exodus 20:13 in the Torah commands: “Thou shalt not murder” (‫)לא תרצח‬, and contemporary Jews consider it their duty to preserve life, as an overarching principle of the faith. Prohibition of suicide is explicitly stated in the Bible, the Talmud, and Jewish writings up to the present (Witztum & Stein, 2012). Since God gave life, only God is permitted to take life (Deuteronomy 32:39). Suicide, then, is the seizing of a right that belongs to God alone. Augustine of Hippo, an early church father in Christianity, said in his classic text City of God that the commandment to not kill is not qualified in terms of who should not be murdered. He emphasized that there are no circumstances in which suicide is allowable, including suffering, concluding that “suicide is monstrous” (see Cook, 2014). In Catholicism, which strongly condemns suicide, the Church’s teaching has considered suicide a “mortal sin” because it cannot be pardoned since the person cannot confess the sin and be absolved before death (Makinen, 2014). However, recent versions of the Catechism of the Catholic Church (CCC, 1993a) note that: “Grave psychological disturbances, anguish, or grave fear of hardship, suffering, or torture can diminish the responsibility of the one committing suicide. We should not despair of the eternal salvation of persons who have taken their own lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives” (CCC, 1993a, Part 3, Section 2, Chapter 2: 2282–​2283). Protestant teachings vary greatly depending on whether the denomination is fundamentalist, conservative, moderate, or progressive. Overall, Protestant Christians may be more lenient than Catholic Christians in this regard. Many Protestants do not grade sins as Catholics do, nor do they have a category of “mortal sins.” Durkheim (1897) observed that suicide was more common in Protestants than Catholics, arguing that there was greater social control and integration among Catholics compared to Protestants. 108 •  M ental H ealth

ISL AM STRON GLY CON D EM N S SUICID E

In Surah (chapter) 4, verse 29, the Qur’an says: “Nor kill (or destroy) Yourselves: for verily Allah hath been to you Most Merciful!” Among the sayings of the Prophet Muhammad as recorded in Sahih al-​Bukhari (2:23:446), the most credible of all Hadiths in Sunni Islam, is: “Narrated Abu Huraira: The Prophet said, ‘He who commits suicide by throttling shall keep on throttling himself in the Hell Fire (forever) and he who commits suicide by stabbing himself shall keep on stabbing himself in the Hell Fire.’ ” There is no more recent version of the Qur’an or Hadith (sayings of the Prophet) that qualifies this statement. EASTERN REL IGION S’ VIEWS ON SUICID E

While Buddhist, Tao, Confucian, and Hindu traditions are generally opposed to suicide (based on the overarching principle of reverence for life), they provide a bit more leniency in this regard (Kok, 1988; Keown, 1996). For the Buddhist, while suicide is wrong for the unenlightened, it may be permissible once enlightenment has been achieved (based on Pali Canon) (Attwood, 2004). In Taoism and Confucianism, the Tao Te Ching says that if a person takes up the act of killing, instead of letting life take its natural course, then the person will emerge with blood on their hands; this is particularly true for the young and for those who continue to have family responsibilities (Commentary, 2007). While Hindu scripture condemns suicide as an escape from life and emphasizes the bad karma that it creates, in cases of terminal disease or severe disability, religious self-​ willed death through fasting is allowed (prayopavesa). However, there are conditions that must be met, including that this action be conducted under community regulation (Subramuniyaswami, 1992).

RESEARCH ON RELIGION AND SUICIDE In this central section, we review the best-​ designed studies examining the relationship between religion and suicidal thoughts,

attempts, and completed suicide. As throughout this edition of the Handbook, emphasis is placed on prospective studies and RCTs whenever possible. A major challenge in conducting such prospective research with suicide is the low rate of completed suicide, requiring the study of very large samples. Thus, much research has instead focused on suicidal thoughts and attempts, the strongest risk factors for suicide, since they are more frequent and more easily studied than completed suicide. A crude way of determining the relationship between religiosity and completed suicide is to examine the relationship between suicide rate and religiosity at the national level. As noted in previous chapters, this method is vulnerable to the “ecological fallacy,” i.e., that regional associations may not always reflect what is going on at the personal level, although such comparisons do provide preliminary information that can be investigated further. Table 7.1 presents national suicide rates per 100,000/​year by level of country religiosity. This comparison reveals that suicide rates are inversely related to country religiosity (r =​−0.57, p < 0.0001), a moderate to large correlation. The same observation has been reported by numerous previous studies (Lester, 1992; Neeleman & Lewis, 1999; Fernquist, 2003; Stack & Kposowa, 2008; 2011). When country religiosity is not available from survey data, the number of religious books published per year in the country has been used (Breault & Barkey, 1982; Stack, 1983a, 1983b; Fernquist, 1995–​1996). Again, countries producing more religious books report lower suicide rates. In the first and second editions of the Handbook, we identified 141 studies that examined the relationship between religiosity and suicidal thoughts, attempts, or completed suicide, finding that 106 (75%) reported significant inverse relationships. However, of the 141 studies, 137 (97%) were cross-​sectional or retrospective studies, three were prospective, and one was an experimental study. Since 2010, several additional prospective studies have now been published. We review earlier and more recent studies here, beginning with an important study that appears to be a longitudinal panel study, yet is simply reporting prevalence at different time points. Lubin and colleagues (2001) examined suicide incidence rates from 1984 to 1994 in the

country of Israel, comparing rates between Jews and Muslim Arabs. All residents of Israel (n =​5.4 million) during this period comprised the study population (approximately 80% Jews and 20% Arabs). In addition to suicide rates, “undetermined external causes” (UEC) of death were also examined. Suicide rates per 100,000 were calculated in Jews and Arabs, and compared by a simple chi-​square test, without control for covariates, although analyses were stratified by age and gender. Results indicated that Jews experienced a suicide incidence three times that of Arabs (9.8 vs. 2.9 per 100,000). When UEC were accounted for, the difference remained, although decreased in size (13.7 vs. 7.2 per 100,000). Significant differences were found in both men and women, and across all age groups. There was also a significant increase over the 10-​ year period among Jewish men (from 11.0 to 15.9), particularly those in the 18–​21 age group (and when UEC of death were considered, this pattern was also present among Arab men, with suicide rates increasing from 5.5 to 10.2). Taking into consideration UEC of death is particularly important among Muslims since, as the authors noted, there are pressures in this faith tradition to record suicide as UEC, given that suicide carries substantial stigma for surviving relatives in Muslim families. Others have likewise noted that the differences in completed suicide between Jews and Muslims tend to decrease substantially when UEC are included, although the difference persists (Levav & Aisenberg, 1989). More recent research, however, indicates that Muslims are no more likely to hide suicidal behaviors than members of other religious groups (Eskin et al., 2019).

Longitudinal Studies The focus here is on large prospective cohort studies examining the relationship between religious involvement and suicidal thoughts, attempts, and completion, examined from the earliest studies to the most recent ones. Studies are presented by year of publication to demonstrate how the research and findings have progressed over time (see Appendix for a complete list of all high-​quality studies). In a true prospective study, Thompson et al. (2007) examined the effects of subjective Suicide • 109

Table 7.1  National Suicide Rates and Country Religiosity (r =​−0.57) C O U N T RY

C OM PL E T E D S U IC I DE RANK1

Lithuania Russia South Korea Belarus Ivory Coast Kazakhstan Ukraine Latvia Belgium Hungry Slovenia Japan Uruguay Estonia France Switzerland Croatia India Poland Moldova Finland Serbia Austria United States Taiwan Sweden Sri Lanka Thailand Portugal Cuba El Salvador Trinidad and Tobago Germany Luxembourg Australia Slovakia Denmark Netherlands Canada Hong Kong Norway

R AT E

R E L IGIO SI T Y R A N K 2 IMPORTA N T 3

V E RY IMPORTA N T 4

R E L IG IO U S 5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

31.9 31.0 26.9 26.2 23.0 ** 22.5 22.4 21.2 20.7 19.1 18.6 18.5 18.4 17.8 17.7 17.2 16.5 16.3 16.2 15.9 15.9 15.6 15.6 15.3 15.1 ** 14.8 14.6 14.4 14.0 13.9 13.7 13.6

119 127 117 130 62 116 107 128 134 126 114 144 121 145 138 118 102 54 88 95 132 106 109 103 115 143 10 4 94 129 76 50

42% 34% 43% 34% 88% 43% 46% 39% 33% 39% 47% 24% 41% 16% 30% 41% 70% 90% 75% 72% 28% * 54% 55% * 69% 45% * 17% 99% 97% 72% 34% * 83% 92% *

—​ 16% —​ —​ —​ —​ —​ —​ —​ —​ —​ 10% 29% —​ 11% —​ —​ 80% —​ —​ —​

—​ 70% 44% —​ —​ 64% 73% 40% 44% —​ —​ 13% —​ —​ 40% 38% —​ 76% 86% —​ 56%

—​ 53% —​ 10% —​ —​ —​ —​ —​ —​

34% 56% —​ 19% —​ 94% 60% —​ —​ —​

33 34 36 37 38 39 40 41 42

13.6 13.5 13.2 12.8 12.8 12.6 12.5 12.3 ** 12.2

123 125 136 113 135 133 120 140 142

40% 39% 32% 47% * 19% 33% * 42% 24% 21% *

10% —​ 18% —​ —​ —​ 27% —​ 19%

34% —​ 39% —​ 42% 26% 40% 26% —​

110 •  M ental H ealth

Table 7.1  Continued C OU N T RY

C OM PL E T E D S U IC I DE RANK1

Nicaragua Cameroon Bolivia New Zealand United Kingdom Haiti South Africa Ireland Bulgaria Zimbabwe Chile Czech Republic Romania Montenegro Uganda Singapore Dominican Republic Benin China Togo Paraguay Nigeria Botswana Argentina Burundi Nepal Chad Bosnia-​ Herzegovina Spain Namibia Laos Yemen Kyrgyzstan Italy Georgia Sudan North Macedonia Costa Rica

R AT E

R E L IGIO SI T Y R A N K 2 IMPORTA N T 3

V E RY IMPORTA N T 4

R E L IG IO U S 5

43 44 45 46 47

12.2 12.2 12.2 12.1 11.8 **

75 25 57 131 139

84% 96% 89% 33% * 27%

—​ —​ —​ —​ 10%

—​ —​ —​ —​ 30%

48 49 50 51 52 53 54 55 56 57 58 59

11.7 11.6 11.5 11.5 10.7 10.6 10.5 ** 10.4 10.3 9.9 9.9 9.9

87 69 108 122 61 101 141 74 98 47 100 65

75% * 85% 54% 34% * 88% 70% 21% * 84% 71% 93% 70% 87%

—​ —​ —​ —​ —​ 41% —​ —​ —​ 86% —​ —​

—​ 91% 45% 52% —​ —​ 23% 77% —​ —​ —​ —​

60 61 62 63 64 65 66 67 68 69 70

9.9 9.7 9.6 9.5 9.5 9.3 9.2 9.1 8.8 8.8 8.8

44 146 81 49 18 85 97 12 43 45 84

93% * —​ 80% * 92% 96% 77% * 65% 98% 93% 95% 77%

—​ 3% —​ —​ 88% —​ —​ —​ —​ —​ —​

—​ 7% —​ —​ 83% —​ 72% —​ —​ —​ 65%

71 72 73 74 75 76 77 78 79

8.7 8.7 8.6 8.5 8.3 8.2 8.2 8.1 8.0 **

112 48 17 9 93 92 78 42 86

49% 92% * 97% * 99% 72% 72% 81% 93% 76%

22% —​ —​ —​ —​ —​ —​ —​ —​

37% —​ —​ —​ —​ 74% 93% —​ —​

80

7.9

83

79%

—​

—​ (continued) Suicide • 111

Table 7.1  Continued C O U N T RY

Myanmar Burkina Faso Central African Republic Malta Uzbekistan Turkey Vietnam Ethiopia Columbia Ecuador Liberia Turkmenistan Rwanda Djibouti Qatar Armenia Brazil Guinea Albania Zambia Senegal Republic of the Congo Bangladesh Bahrain Democratic Rep of Congo Malaysia Tanzania Israel Ghana Cambodia Mexico Greece Peru Mozambique Mali Somalia Belize Angola Afghanistan

C OM PL E T E D S U IC I DE

R E L IGIO SI T Y

RANK1

R AT E

81 82 83

7.8 7.7 7.7

16 60 37

97% 88% * 94%

—​ —​ —​

—​ —​ —​

84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102

7.5 7.4 7.3 7.3 7.2 7.2 7.1 6.8 6.7 6.7 6.7 6.6 6.6 6.5 6.3 6.3 6.1 6.0 5.9

67 105 77 137 1 72 77 36 80 31 53 30 91 64 15 124 29 23 28

86% 59% 82% 30% 100% 83% 82% 94% 80% 95% 90% 95% 73% 87% 97% * 39% 95% 96% 95% *

—​ —​ 68% —​ 98% —​ —​ —​ —​ —​ —​ —​ —​ 72% —​ —​ —​ —​ —​

—​ —​ 79% 34% —​ 82% 68% —​ —​ —​ —​ —​ 93% 79% —​ —​ —​ —​ —​

103 104 105

5.9 5.9 5.7

2 35 34

100% 94% 94% *

—​ —​ —​

93% —​ —​

106 107 108 109 110 111 112 113 114 115 116 117 118 119

5.5 5.4 5.4 5.4 5.3 5.1 5.0 4.9 4.9 4.8 4.7 4.7 4.7 4.7

22 56 110 27 21 90 96 73 66 26 7 104 59 13

96% 89% 51% 95% 96% 73% 71% 84% 86% * 95% 100% * 62% * 88% * 97%

—​ —​ 36% —​ —​ 45% 56% —​ —​ —​ —​ —​ —​ —​

72% —​ 30% —​ —​ 68% 71% 82% —​ —​ —​ —​ —​ 87%

112 •  M ental H ealth

R A N K 2 IMPORTA N T 3

V E RY IMPORTA N T 4

R E L IG IO U S 5

Table 7.1  Continued C OU N T RY

C OM PL E T E D S U IC I DE RANK1

Niger Mauritania Panama Iran Egypt Madagascar Venezuela Malawi Cyprus Tunisia Indonesia Lebanon Saudi Arabia Philippines Kenya Algeria Iraq Pakistan Morocco Jordan Honduras United Arab Emirates Guatemala Azerbaijan Tajikistan Kuwait Jamaica Syria

R AT E

120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141

4.6 4.4 4.3 4.1 4.0 3.9 3.7 3.7 3.6 ** 3.4 3.4 3.3 3.2 3.2 3.2 3.2 3.0 2.9 2.9 2.9 2.9 2.8

142 143 144 145 146 147

2.7 2.6 2.5 2.3 2.2 1.9

R E L IGIO SI T Y R A N K 2 IMPORTA N T 3

V E RY IMPORTA N T 4

R E L IG IO U S 5

6 11 79 89 14 41 82 8 86 39 5 63 38 20 33 24 71 46 13 19 70 52

100% 98% 80% 73% * 97% 93% * 79% 99% 75% 93% 99% 87% 93% 96% 94% 95% 84% 92% 97% 96% * 84% 91%

—​ —​ —​ 78% 72% —​ —​ —​ —​ —​ 93% —​ —​ —​ —​ —​ —​ 94% —​ —​ 90% —​

—​ —​ 81% —​ —​ —​ —​ —​ —​ —​ 82% 80% —​ 86% 89% 90% —​ 88% 93% —​ —​ —​

58 111 68 51 99 55

88% 50% 85% 91% 70% * 89%

—​ —​ —​ —​ —​ —​

—​ 34% —​ —​ —​ —​

Sources: 1 Rank based on World Health Statistics data visualizations dashboard for suicide rate per 100,000 per year. World Health Organization (WHO), latest update 5-​4-​2018. Retrieved on 6-​10-​2019 from http://​apps.who.int/​gho/​data/​node.sdg.3-​4-​data?lang=​en. 2 Rank based on 2009 Gallup Poll (https://​en.wikipe​dia.org/​wiki/​Import​ance​_​of_​reli​gion​_​by_​coun​try) for consistency; however, also taken into consideration when ranks were close was the percent indicating religion was very important in the 2008–​2017 Pew Research Center poll (https://​www.pewfo​rum.org/​2018/​06/​13/​how-​religi​ous-​com​mitm​ent-​var​ies-​by-​coun​try-​among-​peo​ple-​of-​all-​ages/​) and a 2015 Gallup Poll that assessed “religiousness” at the country level (https://​www.gal​lup-​intern​atio​nal.bg/​en/​33531/​los​ing-​our-​relig​ion-​ two-​thi​rds-​of-​peo​ple-​still-​claim-​to-​be-​religi​ous/​). 3 Crabtree, S. (2010). Religiosity highest in world’s poorest nations. Retrieved on 6-​11-​2019 from https://​news.gal​lup.com/​poll/​142​ 727/​reli​gios​ity-​high​est-​world-​poor​est-​nati​ons.aspx (based on 2009 Gallup Poll of 114 countries). 4 Pew Research Center (2008–​2017). How religious commitment varies by country among people of all ages. Retrieved on 6-​11-​2019 from https://​www.pewfo​rum.org/​2018/​06/​13/​how-​religi​ous-​com​mitm​ent-​var​ies-​by-​coun​try-​among-​peo​ple-​of-​all-​ages/​. 5 Gallup Poll (2015). Losing our religion? Two thirds of people still claim to be religious. Retrieved on 6-​13-​2019 from http://​gal​lup-​ intern​atio​nal.bg/​en/​Publi​cati​ons/​2015/​223-​Los​ing-​Our-​Relig​ion-​Two-​Thi​rds-​of-​Peo​ple-​Still-​Claim-​to-​Be-​Religi​ous. * Data based on older 2008 Gallup Worldview Survey ** Other source: List of countries by suicide rate. Retrieved from Wikipedia on 6-​11-​2019 from https://​en.wikipe​dia.org/​wiki/​List_​o​f_​ co​untr​ies_​by_​s​uici​de_​r​ate.

Suicide • 113

religiosity on suicidal behaviors among 15,034 adolescents age 12–​ 17 over a 7-​ year period (National US Longitudinal Study of Adolescent Health, i.e., the Add Health Study). Subjective religiosity was assessed by a single question asking how important religion was to the adolescent, ranging from not at all important to very important (dichotomized into not at all or fairly unimportant vs. fairly or very important). Suicidal behaviors included thoughts, attempts, and treatment for attempts within the past 12 months. Participants were assessed at baseline (T1), one year later (T2), and seven years later (T3). Predictors (including religiosity) were assessed at T1. Suicidal behaviors were assessed at T2 and T3. Among those who had not attempted suicide at T1, controlling for age, gender, urban residence, minority status, problem drinking, self-​ esteem, impulsivity, depression, and delinquency, results indicated high importance of religion was associated with a 57% reduction in likelihood of requiring medical care for attempted suicide at T3 (adjusted OR =​0.43, 95% CI =​0.19–​0.93), although it was not significantly associated with suicidal thoughts or self-​reported attempted suicide at T3, or any suicidal behaviors at T2. Spoerri et al. (2010) conducted a longitudinal study linking Switzerland census data in year 2000 to mortality through 2005. The study consisted of about 3.6 million persons (46% Catholic, 42% Protestant, and 12% with no religious affiliation). After adjustment for age, marital status, education, type of household, language, and degree of urbanization, the rate of suicide was lower for Catholics than Protestants (for men age 35–​64, HR =​0.80, 95% CI =​0.73–​0.88; for men age 65–​94, HR =​0.60, 95% CI =​0.53–​0.67; for women age 35–​64, HR =​0.90, 95% CI =​0.80–​1.03; and for women age 65–​94, HR =​0.67, 95% CI =​0.59–​0.77). Suicide rates were higher for those with no religious affiliation than for Protestants (men age 35–​64, HR =​1.09, 95% CI =​0.98–​1.22); men age 65–​94, HR =​1.96, 95% CI =​1.69–​2.27); women age 35–​64, HR =​1.46, 95% CI =​1.25–​ 1.72; and women age 65–​94, HR =​2.63, 95% CI =​2.22–​ 3.12). This study suggests that Durkheim’s observation continues to be true, at least in Switzerland, even when analyses are conducted at the individual level. 114 •  M ental H ealth

Rasic and colleagues (2011a) followed a random sample of 1,091 community-​dwelling adults over 10 years (Baltimore Epidemiologic Catchment Area study), examining relationships between religious attendance, seeking spiritual comfort, and suicide attempts. Participants were assessed at baseline (T1; 1993–​ 1996) and 10 years later (T2; 2004–​ 2005). Frequency of religious attendance (dichotomized into never vs. any level of attendance) and seeking spiritual comfort (dichotomized into “never” vs. “rarely” to “almost always”) were assessed at T1. Suicidal ideation and attempts were assessed by single questions with yes-​no response options at T2 (not T1); the time frame for suicide attempts was from baseline onward (i.e., from T1 to T2) and present suicidal ideation was assessed at T2. Covariates adjusted for included T1 sociodemographic characteristics, mood, anxiety, and substance use disorders, as well as social support, social network size, and chronic physical condition. Results indicated that participants attending religious services at T1 (any frequency) were 67% less likely to have reported a suicide attempt at T2 (adjusted OR =​0.33, 95% CI =​0.13–​0.84). Likewise, those seeking any level of spiritual comfort at T1 were 45% less likely to report suicidal ideation at T2 (OR =​0.55, 95% CI =​0.31–​0.98). When religious attendance and spiritual support were left as ordinal variables (both with 5 levels), the relationship between religious attendance and suicide attempts persisted (OR =​0.42, 95% CI =​0.09–​0.76), although the relationship between seeking spiritual support and suicidal ideation did not. T1 suicidal attempts/​ ideas were not controlled for in these analyses, although T1 mental disorders were controlled. In a complex study, Nkansah-​ Amankra (2013) analyzed 13-​year follow-​up data gathered on 9,421 adolescents age 11–​19 involved in the Add Health Study (see above), examining the effects of religiosity on suicidal behaviors (defined as suicidal thoughts and attempts). Suicidal behaviors within past 12 months were assessed at baseline (T1), 1 year (T2), 7 years (T3), and 13 years later (T4). Participants were divided into four groups: suicidal behavior reported at all four time points, suicidal behaviors only in adolescence, suicidal behaviors only

in young adulthood, and no suicidal behavior at any of the four time points. Religiosity was assessed at T1 by religious attendance (never, less than once/​week, once/​week or more), frequency of prayer (never, less than once/​week, once/​day or more), and importance of religion (dichotomized into not important vs. important). General estimating equations (GEE) were used to analyze the data, controlling for age, race, gender, and for some reason, frequency of prayer. Results indicated that regular attendees at religious services compared to those who never attended were less likely to engage in suicidal behaviors during the follow-​up period (OR =​0.64, 95% CI =​0.0.48–​0.85); however, when depression, social support, and self-​ esteem were controlled (which may have been mediators of the effect), the relationship was attenuated (OR =​0.76, 95% CI =​0.54–​1.07). Similar results were found for importance of religion and suicidal behaviors (OR =​0.72, 95% CI =​0.54–​0.96), but like religious attendance, the association was attenuated when controlling for the possible mediating variables above (OR =​0.80 95% CI =​0.57–​1.12). Significant relationships were found between religious variables and suicidal behaviors in the adolescents, but not in the young adult group. Kleiman and Liu (2014) analyzed data on religious attendance assessed at baseline between 1988 and 1994 (T1) and the occurrence of completed suicide through 2006 (T2) in a national random sample of 20,014 adults (Third US National Health and Nutrition Examination Survey, or NHANES-​III). A total of 25 persons died by suicide during follow-​ up. Data were analyzed using Cox proportional hazards regression models. Among those attending religious services at least 24 times/​ year (twice/​month), the risk of dying from suicide was HR =​0.06 (95% CI =​0.01–​0.54), i.e., a 94% lower likelihood of death from suicide compared to less frequent attendees. After controlling for gender, age, size of household, marijuana use, and previous suicide attempt (some of which were likely mediators), frequent attendees were 68% less likely to die by suicide (HR =​0.32, 95% CI =​0.01–​0.99). O’Reilly and Rosato (2015) analyzed mortality data on 1,106,104 non-​institutionalized persons aged 16–​ 74 from 2001 to 2009 in

Northern Ireland, examining the relationship between religious affiliation and completed suicide. Religious affiliation was assessed in the 2001 census. The groups examined were: (1) no affiliation (12.6%); (2) Roman Catholic (39.5%); (3) mainline Protestant (e.g., Presbyterian, Church of Ireland, Methodist) (41.6%); and (4) conservative Protestant (e.g., Free Presbyterians, Baptists, Brethren) (6.3%). Roman Catholic was the comparison group. Completed suicide was identified from a database kept at the Northern Ireland Statistics and Research Agency. Cox proportional hazards models were adjusted for demographic (age, gender, marital status, living situation) and socioeconomic (social class, housing situation, car availability, area of residence) characteristics. During the 9-​year follow-​up, 1,119 deaths were recorded as suicide or undetermined intent. Protective factors were being married, living with someone (vs. alone), being employed, and not having a chronic physical illness. Controlling for demographic and socioeconomic characteristics, compared with Catholics, those affiliated with conservative Protestant traditions were significantly less likely to commit suicide (HR =​0.71, 95% CI =​0.52–​0.97). There were no significant differences in suicide rate between Catholics and mainline Protestants or those with no religious affiliation. When results were broken down by age group (16–​34, 35–​54, 55–​74), Catholics had the lowest suicide rate among those age 55–​74 years (7.4 per 100,000) compared to Protestants (8.0–​8.2 per 100,000) and those with no religious affiliation (11.8 per 100,000), although significant differences between groups were not present in fully adjusted models. Among those in the middle-​age group (age 35–​54), the suicide rate in conservative Protestants was 50% lower than in Catholics (HR =​0.50, 95% CI =​0.29–​0.85, fully adjusted). Burshtein et al. (2016) analyzed data from a population-​ based sample of 4,914 young adults in Israel (average age 29 years) who were followed over a 25-​year period during which mortality data were collected from the national vital statistics registry database of the Israeli Ministry of Health. Religiosity was assessed by a single question that asked, “How do you define yourself religiously?” with Suicide • 115

the following response options: secular, partially observant, religious, and ultra-​religious (religious and ultra-​religious were combined). Lifetime suicidal ideation and attempts were assessed along with religiosity at baseline. Cox proportional hazards regression was used to examine predictors of death by suicide during the follow-​up period, without covariates in the model (due to the small number of suicides, n =​8). With regard to attempted suicide at baseline, controlling for marital status, ethnicity, education, drug use, and psychological distress, those who were “secular” were nearly four times more likely to have attempted suicide (adjusted OR =​3.84, 95% CI =​1.14–​13.01). With regard to completed suicide during the follow-​ up period, seven of the eight were secular, one was partially observant, and none was religious (χ2 =​3.24, p =​0.09). Secular Israelis were 8.5 times more likely to complete suicide compared to Israelis who were partially observant (HR =​8.47, 95% CI =​ 1.02–​71.43). Mandhouj et al. (2016) tracked 88 patients for 18 months after hospitalization following a suicide attempt in Versailles, France, seeking to identify factors predicting suicide attempt recurrence. Spiritual and religious beliefs at baseline were assessed with the 32-​ item WHO Quality of Life Spirituality, Religion and Personal Beliefs scale (WHOQOL-​SRPB). The WHOQOL-​SRB assesses eight aspects: spiritual connectedness, meaning of life, awe, wholeness and integration, spiritual strength, inner peace, hope and optimism, and faith. “High spirituality” was defined as scoring above the 75th percentile on the WHOQOL-​SRPB scale. Logistic regression was used to identify the effects of “high spirituality” (T1) on re-​attempted suicide during follow-​up (T2), controlling for T1 demographic and clinical variables. Participants were 46% Catholic, 3% Jewish, 9% Muslim, 5% agnostics, and 33% atheists. During the 18-​ month follow-​ up, 26% re-​ attempted suicide. WHOQOL-​ SRPB total score predicted attempted suicide recurrence (OR =​0.56, 95% CI =​ 0.37–​0.99, p =​0.05), driven primarily by “meaning of life.” Although this measure of religiosity/​spirituality is clearly contaminated by items assessing mental health, the report is discussed here because of the clinical nature 116 •  M ental H ealth

of the sample and its location in France, where few studies of this kind have been done. VanderWeele et al. (2016b) analyzed data from a prospective study of 89,708 women aged 30–​55 years (98% white) participating in the Nurses’ Health Study I, examining predictors of completed suicide during a 14-​year follow-​up from 1996 (T1) to 2010 (T2). Religious service attendance was assessed in 1992 (T0) and 1996 (T1) with the question “How often do you go to religious meetings or services?” (never, almost never, less than once per month, 1–​3 times per month, once a week, or more than once a week). Death by suicide was documented using state mortality files, the US National Death Index, and reports from next of kin, using a standard definition contained in the eighth version of the International Classification of Disease (ICD-​ 8). Multiple covariates known to be related to suicide were assessed and controlled for, including age, employment status, family history of alcoholism, body mass index (BMI), physical activity level, caffeine intake, alcohol intake, smoking status, depressive symptoms, history of chronic medical illness, living situation, social integration (including marital status, group participation, number of close friends, number of close relatives, number of close friends seen at least once per month, number of close relatives seen at least once per month), and religious service attendance in 1992. Religious attendance in 1996 (T1) was examined as a predictor of completed suicide through 2010 (T2). To ensure that depressive symptoms or chronic health problems at baseline were not responsible for low religious attendance (reverse causation), women who were depressed or used antidepressant medications or had a history of cancer or other cardiovascular condition in 1996 were excluded from the analysis. Cox proportional hazards regression models were used to analyze time to completed suicide (T1 to T2), and mediation analysis was used to examine factors that might explain the relationship (depressive symptoms, alcohol intake, social integration). In addition, sensitivity analysis was used to assess the robustness of the results. There were 36 suicides during follow-​ up (2/​ 100,000 in Catholics, 3/​ 100,000 in Protestants). Women who attended religious

services at least once per week in 1996 were 84% less likely to commit suicide between 1996 and 2010 than women who never attended services (hazard ratio =​0.16, 95% CI =​0.06–​0.46), with more than a 5-​fold reduction in suicide incidence from 7 per 100,000 person-​years to 1 per 100,000 person-​years. Results were similar when excluding women who were depressed or had chronic illness at T1 in 1996. Effects were particularly strong among Catholic women (HR =​0.05, 95% CI =​0.006–​0.48). Religious service attendance was more strongly predictive of suicide than any other social integration variable (marital status, number of close friends or time spent with them, number of close relatives or time spend with them, hours in social groups, and their composite summary). Sensitivity analysis indicated that unmeasured confounders would have to both increase the likelihood of religious attendance and decrease the likelihood of suicide by 12-​fold above and beyond the measured confounders to explain the effect (highly unlikely). See commentary by Koenig (2016c). Svob and colleagues (2018) at Columbia University in New York City examined the effects of parental religiosity on offspring suicidal behaviors (ideation/​ attempts) in a 30-​ year three-​ generation prospective study (G1 original cohort, G2 children of G1, G3 children of G2). The 326 participants included 112 G2 parents (mean age 40 years) and 214 G3 offspring (mean age 13 years). Approximately half of G3 offspring were girls, most were Christian (85%), and the majority were Catholic (59%). A structured psychiatric interview (Schedule for Affective Disorders and Schizophrenia) was used to diagnose psychiatric disorders in G2 parents and G3 offspring, and also provided data on suicidal ideation and attempts during the 20-​ year follow-​up from year 10 (T1) to year 30 (T2). Parental and offspring religious attendance at T1 was assessed by the question, “How often, if at all, do you attend church, synagogue, or other religious or spiritual services?” Importance of religion/​spirituality (R/​S) was assessed by the question, “How important to you is religion or spirituality?” Among G3 offspring, 44% indicated religious attendance at least once a week (vs. 38% of G2 parents) and

60% indicated moderate or high importance of R/​S (vs. 78% of parents). Although offspring religious attendance and importance of R/​S at T1 were unrelated to offspring suicidal ideation/​attempts over the next 20 years (T1 to T2), high parent R/​S importance predicted a nearly 40% lower likelihood of offspring suicidal ideation/​attempts (OR =​0.61, 95% CI =​0.41–​0.91). There was also a significant interaction with offspring gender, such that the likelihood of suicidal ideation/​attempts in girls was significantly lower for those who indicated either high R/​S importance or high religious attendance, and this was true for both offspring and parental importance of R/​ S. No association was found in boys. When both parent and offspring R/​ S importance were considered simultaneously, researchers found that parental R/​S importance predicted a lower suicide risk in offspring, which was independent of offspring R/​S importance (OR =​0.61, 95% CI =​0.39–​0.96). Finally, Chen et al. (2020b) used data on 66,492 women from the Nurses’ Health Study II (note this is a different sample from Nurses’ Health Study I of VanderWeele et al., 2016b) and on 43,141 men from the Health Professionals Follow-​ up Study to examine effects of religious service attendance on “deaths of despair” (deaths related to suicide, drug use, and alcohol poisoning). One of the analyses restricted the outcome to suicide deaths. In each cohort, analyses were controlled for numerous characteristics, including age, race, geographic region, income, health status, health behaviors, smoking, mental health, other forms of social support, and numerous other variables as well. The women in the Nurses’ Health Study II were followed from 2001, when religious service attendance was assessed, through 2017. Compared to those who never attended religious services, participants who attended at least once a week were, after multivariate covariate control, 75% less likely to die by suicide (HR =​0.25; 95% CI =​0.10–​0.60) during the 16-​year follow-​up. For the men in the Health Professionals Follow-​ Up Study, followed from 1988 through 2014, those attending weekly, compared to not at all, were, after multivariate control, 48% less likely to die by suicide (HR =​0.52; 95% CI =​0.34–​ 0.82) during the 26-​year follow-​up. Suicide • 117

Experimental Studies and Randomized Controlled Trials Two studies conducted more than 35 years apart fall into these categories. Although not rated particularly high in quality (6 on a 1–​10 scale in the first edition of the Handbook), the following experimental study is the first to examine whether feelings about suicide in college students might be influenced by different experts (psychologist, psychologist-​ minister, minister alone). Best and Kirk (1982) administered a religiosity scale and a suicide acceptance scale to 66 college students in an introductory psychology class at Eastern Illinois University. Suicide acceptability was rated on a scale from 0–​6, with higher scores indicating greater acceptance. At baseline, highly religious subjects (those scoring above the median on a religiosity scale) were significantly less accepting of suicide than less religious subjects (1.27 vs. 2.24, respectively, p < 0.01). Eight weeks later, all subjects were shown a 10-​minute videotape of an “expert” counselor who spoke on accepting a suicidal person’s feelings. Participants were randomly assigned to three groups. In the first group, the expert in the videotape presented himself as a clinical psychologist who did therapy with suicidal people; in the second group, as a pastoral minister who did suicide counseling; and in the third group, as both a clinical psychologist and a pastoral minister. Participants were pointedly told to keep in mind the stated credentials of the expert as they watched the videotape. The suicide acceptance scale was re-​administered after participants viewed the videotape. There was a significant increase in acceptance of suicide in those who viewed either the psychologist or the psychologist/​minister videotapes. In contrast, those who viewed the minister videotape showed a significant decrease in suicide acceptance. These effects occurred regardless of whether participants were high or low on religiosity. The authors concluded that college students’ attitudes toward suicide acceptance could be modified by expert opinion, whether they were religious or not. In an RCT, Ramos et al. (2018) examined the effects of religious cognitive behavioral therapy (RCBT) compared to conventional CBT (CCBT) 118 •  M ental H ealth

on suicidal thoughts in 132 persons with major depressive disorder and chronic medical illness (67 receiving CCBT, 65 receiving RCBT). All participants were to receive ten 50-​minute sessions over 12 weeks. Religiosity was assessed at baseline using a 29-​item multidimensional measure. Suicidal thoughts were assessed by three different measures (combined for analyses) at baseline, 4, 8, 12, and 24 weeks of follow-​up. Mixed effects growth curve models were used to analyze differences between treatment groups in reducing suicidal thoughts. In the intention-​to-​treat analysis, there was little evidence that RCBT was more effective than CCBT in reducing suicidal thoughts (group by time interaction B =​−0.18, SE =​0.12, t =​−1.41, p =​0.16, favoring CCBT). The effect size (Cohen’s d) for CCBT in reducing suicidal thoughts over 24 weeks was d =​1.00, compared to d =​0.71 in those receiving RCBT, both indicating large effects. Among those with low religiosity at baseline, CCBT was more effective in reducing suicidal thoughts than RCBT (B =​−0.37, SE =​0.17, t =​−2.14, p =​0.03), while RCBT tended to be more effective in reducing suicidal thoughts in the highly religious (B =​0.18, SE =​0.13, t =​1.34, p =​0.18). Overall, higher baseline religiosity predicted a more rapid decrease in suicidal thoughts, regardless of treatment group (B =​−0.14, SE =​0.007, t =​−1.95, p =​0.05). Thus, CCBT and RCBT appeared equally effective in reducing suicidal thoughts, although among those with low religiosity, CCBT was particularly effective.

Conclusions Countries whose populations are more religious, no matter how country religiosity is measured (by survey or by religious book production rates), experience lower suicide rates. Muslim countries generally report lower suicide rates than non-​ Muslim countries, and Muslims, particularly those who are highly religious, report fewer suicidal thoughts and attempts (although underreporting may be an issue). Among Christians in Northern Ireland, conservative Protestants tend to have lower suicide rates than Catholics. This is in contrast to other studies which indicate that Catholics tend to have lower suicide rates, as in Switzerland

and in the US Nurses’ Health Study (2 vs. 3 per 100,000, respectively). The latter studies in the Switzerland and the United States, however, examined all Protestants, not conservative Protestants (as in Northern Ireland). Most research does not examine these finer denominational distinctions. Likewise, most research does not distinguish levels of devoutness of Catholics or of other religious groups. Many cross-​ sectional and retrospective studies (75%) find lower suicidal thoughts, attempts, and completed suicide in those who are more religious. Likewise, prospective studies, especially the high-​ quality studies, generally report lower suicidal attempts and completed suicide in those who are more religious. Finally, one RCT found that a religious intervention significantly reduced suicidal thoughts with a relatively large effect size, but was not as successful in those who were less religious, where a conventional intervention was more effective. Thus, religious involvement appears to decrease the risk of suicide, independent of other factors, although further research is needed to confirm this conclusion (to rule out underreporting and/​or reverse causation).

EXPLANATIONS AND MECHANISMS How might religious involvement reduce risk of suicide? Several pathways may help to explain the inverse relationship found between religiosity and suicide. Two explanations focus on how religion might actually reduce suicide (religious prohibitions and reduction of risk factors), and two explanations emphasize on how such a relationship could be an artifact of other processes (reverse causation and underreporting). We now discuss all these possibilities.

Religious Prohibitions Religious beliefs may reduce suicide both by placing emphasis on the value of life and by instilling fear of the ultimate consequences of committing suicide. Religious reasons sometimes given for prohibitions against suicide include that life is a gift from God, suicide is against the natural order, suicide causes injury to the community, suicide encourages others

to follow a similar course, and death is life’s greatest evil (Catechism of the Catholic Church, 1993; Aquinas [1274] 1948). Although the Catholic Church has qualified the teaching that suicide is a mortal sin, many Catholics may not be aware of this recent change in the Church’s teachings. They live with the concern that suicide means separation forever from loved ones, which could deter some individuals at risk from contemplating such action. In Islam, suicide remains a sin that destines one to hell, without qualification. There is little question that beliefs of this kind may cause devout Muslims to think twice before committing suicide. Christians and Muslims are not alone in such teachings. No major world religion condones suicide to escape personal problems or suffering, but rather offers alternative ways of dealing with stress and pain.

Reduction of Risk Factors Religious beliefs and practices may also prevent suicide by reducing states that lead to suicide, i.e., depression, anxiety, hopelessness, pessimism, meaninglessness, alcohol or drug abuse/​ addiction, social isolation, loneliness, disability, and chronic health problems. For 20 years now, the various editions of this Handbook (including the present one) have documented systematic research showing inverse relationships between religiosity and negative mental, social, behavioral, and physical health states. Religious persons tend to be, on average, less depressed, less anxious, more optimistic, have more purpose and meaning, and are less likely to abuse alcohol or drugs. They are less socially isolated, less lonely, and are more likely to be prosocial. They live healthier lives in terms of less smoking, more exercising, eating a better diet, complying with medical treatment, and therefore are less likely to experience chronic illness, disability, and cognitive impairment with aging. It makes sense, therefore, that if religious people are mentally, socially, behaviorally, and physically healthier, they will be less likely to want to commit suicide.

Correlation vs. Causation Just as depression may impact religious involvement, whatever leads a person to Suicide • 119

attempt or commit suicide may also affect religious involvement. This reverse-​causation hypothesis argues that factors leading a person to commit suicide, such as depression, hopelessness, lack of meaning or purpose, and/​or substance abuse, may adversely affect religious beliefs and practices, resulting in an inverse relationship between religiosity and suicidal thoughts, attempts, or completed suicide. More than likely, religious involvement both (a) prevents suicide and (b) is affected by factors leading up to suicide. Teasing out which influence is stronger, religion affecting suicide vs. suicidal risk factors affecting religion, will require further research to tease out these questions of causality.

religious involvement and suicide are probably not needed, except in special circumstances (i.e., population groups or religions in which religiosity and suicide have been little studied). Instead, prospective cohort studies and randomized controlled trials are needed to determine if religiosity actually prevents suicidal thoughts, attempts, or completed suicide, or whether other processes may explain the inverse relationship. As noted previously, completed suicide is not common, requiring large samples that are followed over long periods of time. The low suicide completion rate is even a bigger issue for RCTs than for prospective studies given the costs and design issues involved. However, these research designs can be utilized to study the effect of religiosity on suicidal thoughts, attempts, or other suicidal behaviors, which are Underreporting much more frequent and are strong predictors The possibility that a low rate of suicide among of future suicide. Determining causal direction Muslims is due to underreporting could also in the relationship between religiosity and suiapply to other religions, particularly conser- cide will be a high priority for future studies. vative or fundamentalist Protestants, devout There is now relatively strong evidence for at Catholics, or Orthodox Jews, where suicide least some of the association between religious is strongly prohibited. In fact, anyone raised service attendance and lower suicide rates being in a religious atmosphere that discourages causal. However, it would also be good to betsuicide might be more likely to minimize sui- ter understand the causal effects in the reverse cidal thoughts and/​or deny suicide attempts. direction: that is, the extent to which suicidal Similarly, family members and members of ideation or attempts may either increase or their faith community may minimize the pos- decrease subsequent religious participation. sibility that a person committed suicide. As RCTs can of course be important in evaluwith the correlation vs. causation argument, ating various treatment and prevention stratsome degree of underreporting may be pres- egies, including those that compare religious ent that influences the relationship between vs. secular interventions on suicidal thoughts religion and suicide, but probably does not in those with mental health problems. For account entirely for the inverse relationship example, studies of religiously integrated psybetween the two. Religion likely influences sui- chotherapies in depressed individuals, which cide beyond simply underreporting or reverse-​ focus on reducing suicidal thoughts, will help causation, although the question is how much. to determine whether there is anything unique In summary, there are both plausible reasons about religion that is particularly effective in why religion prevents people from committing this regard. suicide, and other possible explanations that Another design that has become increasmake it only appear that religious people are ingly popular to study risk factors for comless likely to attempt or commit suicide. pleted suicide is the “psychological autopsy” study. This methodology involves the sensitive but detailed interview of family members or RECOMMENDATIONS friends of the deceased person to identify facFOR FUTURE RESEARCH tors that may have led to the suicide. Seldom, As we have suggested in earlier chapters and will if ever, have such studies included questions emphasize throughout this volume, more cross-​ about the deceased person’s religious life. Given sectional studies of the relationship between the strong and consistent inverse relationship 120 •  M ental H ealth

between religiosity and suicide, there is every reason to include questions about religion in such studies. A short religiosity scale, such as the 5-​item DUREL or the 10-​item BIAC, could be administered to a close family member who is asked to answer the questions in the way that the deceased person might answer. Responses could then be compared to responses given by close relatives/​friends of a matched group of persons dying from natural causes. This would be considered a more rigorous type of retrospective case-​control study.

PUBLIC HEALTH IMPLICATIONS As noted earlier, there has been a sharp increase in the suicide rate in the United States over the past 15–​20 years, increasing by one-​third, despite the wide availability of treatments for depression and other psychiatric disorders that cause suicide. Between 1999 and 2014, the Centers for Disease Control reported that the suicide rate in the United States increased from 10.5 per 100,000 to 13.0 per 100,000 (Curtin et al., 2016) and, more recently, to 14.0 per 100,000 (Hedegaard et al., 2018). This trend was especially strong in women, where the incident suicide rate increased from 4.0 per 100,000 in 1999 to 6.1 per 100,000 in 2017 (53% increase), and among white women in particular, where the rate increased from 4.7 per 100,000 in 1999 to 7.5 per 100,000 in 2014, a 60% increase. Rates of suicide have been increasing during the same time period when rates of church membership and attendance have been declining (Jones, 2019; Newport, 2018). Based on their study of the effects of religious attendance on suicide rates in the Nurses’ Health Study I, VanderWeele and colleagues (2017d) extrapolated the estimates from their study to indicate that approximately 40% of the increase in the US suicide rate during the past 15 years could be attributed to the decline in weekly religious attendance between 1999 and 2014.

CLINICAL APPLICATIONS Clinicians should ask about suicidal thoughts or plans every time they see patients with

psychiatric disorders, which is now the standard of care (asking about suicidal thoughts). For religious professionals who are providing counsel to those with emotional problems, the same applies. In addition, clinicians should ask about the patient’s involvement in a faith community, and for patients who have found it helpful in the past, consider encouraging such activity to reduce social isolation, increase social engagement, and enhance social support, given the research findings above. Furthermore, clinicians should ask religious individuals with suicidal ideation what their religion says about committing suicide, determine if such beliefs are important to them, and if so, whether those beliefs might influence their decision to commit suicide. Needless to say, such questions should be explored in a sensitive, open, and nonjudgmental manner. In addition to asking specific questions, clinicians should listen for the ways that patients may be struggling with a loss of identity (as in the case example above), meaninglessness, hopelessness, unrealistic guilt, or loneliness, and explore how their faith may relate to these concerns. What religious resources have they called upon in the past? What is making it difficult for them to do so now? Is their faith a source of distress because they feel unable to meet the high ethical standards and other faith expectations? Beyond listening reflectively, clinicians can address emotional and practical obstacles to harnessing the power of the patient’s faith to help prevent suicide. A more active intervention might be to encourage religious attendance or ask family members to encourage the patient to engage or re-​engage in a faith community, and encourage family to make it easier for the patient to do so (provide transportation, accompany them, etc.). In exploring prayer as a potential resource, some clinicians may feel comfortable praying with patients or offering to pray for the patient outside of the session—​demonstrating care and compassion to the patient, which goes beyond their concern about the patient’s mental or physical health. Clearly such interventions must be undertaken with an understanding of what they mean to the patient, with attention to transference and countertransference effects (especially for mental health specialists). For patients who are not religious based on the Suicide • 121

spiritual history, clinician interventions should probably be limited to asking questions and reflective listening. Finally, religiously integrated psychotherapy may be considered for an underlying emotional disorder such as depression that may be driving suicidal thoughts. At least one RCT has shown that RCBT may reduce suicidal thoughts over the course of 10 sessions (see above). If the clinician does not have the time, training, or expertise to provide this treatment, she or he might consider referring the religious patient to someone with experience in conducting RCBT or a similar faith-​based counseling approach.

SUMMARY AND CONCLUSIONS Suicide rates are increasing both in the United States and in many countries around the world. This is happening despite rapid advances in psychopharmacological and psychotherapeutic treatments (and increasing availability of such treatments through broader insurance

122 •  M ental H ealth

coverage). The increased suicide risk, particularly in certain segments of the population, is at a level now that qualifies as a public health problem. Increasing secularization and reduction of religious involvement could explain a significant portion of the increase in suicide rate in some parts of the world. There is much systematic research, including well-​ designed prospective and experimental studies, that suggests religious involvement reduces suicide risk, either because of religious prohibitions against suicide based on the value of life, or because of the beneficial effects that religion has on factors that cause or prevent suicide. While further research is needed to determine the degree to which religion’s beneficial effects are due to reverse-​causation or underreporting, enough is now known to cautiously recommend that clinicians sensitively utilize patients’ religious resources to help reduce suicide risk, if only through asking questions about religious beliefs and reflective listening. In the next chapter we examine anxiety symptoms and disorders, which, like depression, may both increase suicide risk and be affected by religion.

8 Anxiety There is no fear in love. But perfect love drives out fear. —​1 John 4:18

ANXIETY IS WIDESPREAD and a normal reaction to threat. When anxiety is so severe and protracted that it impairs the ability to function in important areas of life, it becomes a disorder that needs attention. Anxiety disorder is the most common of all psychiatric disorders in the United States and worldwide, and it is responsible for an enormous amount of distress, robbing people of the energy and pleasure necessary for productive and enjoyable activities and leading to serious mental and physical health consequences. Given the stress-​buffering properties of religious beliefs and practices (Chapter 4) and the role that psychological stress plays in the onset and course of anxiety disorders, religious involvement may be particularly helpful in relieving anxiety symptoms. Once again, however, the relationship between religion and anxiety is a complex one that fluctuates over time and is likely bidirectional in terms of causal effects. While religion may affect anxiety levels, those who are

more anxious may also be more likely to engage in religious activity (such as prayer or meditation) to cope with anxiety. Even if such activity relieves distress, it may not eliminate anxiety symptoms or reduce them below that experienced by those who are not distressed and therefore have no need for religion. Likewise, religious beliefs may increase anxiety as well as decrease it. Pulitzer Prize winner Finley Peter Dunne said that newspapers “afflict the comforted, and comfort the afflicted” (Dunne, 1902). The same description has been applied to religion.

DIAGNOSIS We begin this chapter by examining the diagnosis, costs, consequences, and causes of anxiety disorder. As with depression, anxiety is assessed either in terms of the number and severity of symptoms, or as a set of discreet disorders. Anxiety symptoms are usually

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0008

measured by having a person complete a self-​ rated anxiety scale such as the Beck Anxiety Inventory (BAI), State-​Trait Anxiety Inventory (STAI), Generalized Anxiety Disorder-​7 (GAD-​ 7), or Hospital Anxiety and Depression Scale (HADS). Alternatively, a clinician may rate a patient’s level of anxiety based on an observer-​ rated scale such as the Hamilton Anxiety Rating Scale (HARS). Each of these scales has “cutoff” points that indicate significant anxiety in those who score above them. Alternatively, a diagnosis of anxiety disorder can be made based on criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-​ 5; American Psychiatric Association, 2013). These criteria are determined either by a clinical evaluation performed by a mental health professional or by a structured psychiatric interview such as the Structured Clinical Interview for DSM-​ 5 (SCID-​ 5) or the Composite International Diagnostic Interview (CIDI) administered by a trained (non-​clinician) interviewer. Anxiety disorders included in DSM-​5 are now described.

Generalized Anxiety Disorder (GAD) GAD is diagnosed when there is excessive, persistent anxiety and worry about many different things that affect performance at work, at school, or at home. This is often accompanied by physical symptoms such as feeling restless, keyed up, on edge, or tired all the time, with difficulty concentrating, muscle tension, and problems sleeping. When one worrisome situation is resolved, there is usually a long list of other concerns ready to take its place. Individuals with GAD worry about everything (children, spouse, job, finances, health problems), often having a haunting and overwhelming sense of lack of control. Many have a history of always being a worrier, dating back to childhood.

Panic Disorder Panic disorder is diagnosed when a person experiences recurrent unexpected panic attacks and chronic worry of having another panic attack (at least 1 per month or more) that causes changes in behavior in an attempt to avoid 124 •  M ental H ealth

them. Panic attacks are characterized by the sudden onset of intense fear or discomfort that peaks within minutes and is accompanied by physical symptoms such as palpitations (rapid heartbeat), shortness of breath, trembling, dizziness, sweating, choking, and numbing or tingling sensations. Cognitive symptoms such as difficulty concentrating, fear of losing control, and/​or fear of dying often accompany panic attacks. At least four such physical or cognitive symptoms must be present along with intense anxiety. Symptoms do not usually last for more than about 10 minutes, but the fear that they will recur may precipitate additional attacks. Panic attacks may also be expected when a person comes into contact with a feared object or situation, as in phobias.

Agoraphobia Agoraphobia literally means “fear of the marketplace.” Agoraphobia is diagnosed as a disorder when a person experiences intense fear or anxiety in at least two of the following situations: public transportation by car, bus, train, ship, or airplane; being in open spaces such as parking lots, marketplaces, or bridges; being in enclosed places such as shops or theaters; standing in line or being in a crowd; or being anywhere alone outside the home. The fear involves thoughts that escape might be difficult or that immediate help might not be available if (a) panic-​like symptoms occur, (b) they become incapacitated (fall down and cannot get back up), or (c) they have embarrassing symptoms (such as incontinence).

Specific Phobia Specific phobia is diagnosed when an individual experiences severe fear or anxiety if she or he comes into contact with an object or situation (spiders, mice, blood, traveling in an airplane, heights, bridges, etc.). The fear/​anxiety is out of proportion to the actual danger. Coming into contact with the feared object or situation causes immediate anxiety every time and must last for at least six months to qualify for the diagnosis. The fear/​anxiety causes the person to change their behavior in order to avoid the object or situation, and the level of distress

must be severe enough to impair their social or occupational functioning. Specific phobia is the most common anxiety disorder both in the United States and worldwide (see below).

Social Anxiety Disorder Previously called “social phobia,” this disorder involves the experience of intense fear or anxiety when in social situations where the person believes they are being scrutinized by others. These situations include social interactions such as having a conversation with people in a group, meeting those who are unfamiliar with the person, eating or drinking in public, or giving a talk or speech in front of a group. Individuals with social phobia fear that they will be humiliated or embarrassed by their conduct. The anxiety experienced is out of proportion to the threat caused by the social situation, and must last at least six months.

Selective Mutism Selective mutism is a relatively rare disorder typically diagnosed only in children. It involves difficulty speaking in specific social situations such as in school or at work, where there is an expectation for the person to speak. Instead, he or she does not speak or respond to others when spoken to. The condition must interfere significantly with educational achievement, occupational functioning, or social communication. Other than in situations specific to where mutism is a problem, the individual has no problem speaking or responding otherwise (such at home with family).

Separation Anxiety Disorder This disorder is also usually diagnosed during childhood but can occur in (or persist into) adulthood. The criteria are excessive fear or anxiety related to separating from a person who serves as a major attachment figure (such as mother, spouse, etc.). The anxiety must be inappropriate for the person’s developmental age. At least three of the following symptoms must be present: chronic excessive distress when anticipating separation or separating from home or the attachment figure; worry

about losing the attachment figure due to harm to the person; worry about getting lost, being kidnapped, becoming sick, or having an accident, resulting in separation from the attachment figure; refusal to leave home to go to school, work, or visit friends or relatives because of anxiety over separation from the attachment figure; fear of being left alone without the attachment figure; difficulty sleeping away from home without being near the attachment figure; recurrent nightmares involving separation; or physical symptoms such as headaches, stomach aches, or nausea when separated from the attachment figure.

Obsessive-​Compulsive Disorder (OCD) Previously considered an anxiety disorder, OCD in DSM-​5 now has its own category: Obsessive-​ Compulsive and Related Disorders. This category includes body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder. OCD is diagnosed when there are recurrent thoughts, urges, or images that are intrusive, unwanted, and cause severe distress, fear, or anxiety. The person tries to ignore or suppress the thoughts, urges, or images, or seeks to counteract them by having a particular thought or by behaving in a certain way (i.e., the compulsion that is thought to reduce the anxiety). The obsessive thoughts or compulsive actions take up at least one hour per day and cause significant distress or impaired functioning.

Post-​Traumatic Stress Disorder (PTSD) Previously considered an anxiety disorder, DSM-​5 has also now placed PTSD in a new category: Trauma and Stressor-​Related Disorders. This category includes reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorder (American Psychiatric Association, 2013). In PTSD, the person must have experienced a severely traumatic stressor, i.e., death, actual or threatened death or serious injury, or sexual violence through (1) direct exposure, (2) witnessing the event, (3) learning that a close Anxiety • 125

relative or friend was traumatized in this way, or (4) repeated indirect exposure to severe trauma as part of work (e.g., as first responders, firemen, medics, police, emergency room personnel). Exposure must cause significant distress or problems with social, occupational, or recreational functioning, and must last for at least one month. Exposure must be accompanied by intrusive symptoms (nightmares or flashbacks), avoidant behaviors (attempts to avoid thoughts or situations that remind them of the trauma), negative changes in mood or cognition (negative thoughts, exaggerated blame of self, social isolation, etc.), and increased arousal or reactivity (hypervigilance, increased startle response, irritability, aggression, etc.).

Moral Injury (MI) Although not included in DSM-​5 as a disorder, MI is a syndrome recently acknowledged by mental health professionals and frequently found in the setting of severe trauma (Litz et al., 2009). While there is some overlap with PTSD (Koenig et al., 2020), MI is not a “fear-​based” disorder like PTSD. Instead, MI involves persistent feelings of guilt, shame, sense of betrayal, feelings of moral transgression, loss of meaning, loss of trust, difficulty forgiving, self-​condemnation, religious struggles, and loss of religious faith that result from transgressing moral values or observing others do so (Koenig et al., 2019a). As noted, these symptoms often accompany severe or repeated trauma and are particularly common among veterans or active duty military returning from combat (as well as health professionals during the COVID-​19 pandemic, first responders following disasters, and those experiencing rape or torture). MI has been significantly associated with PTSD symptom severity, anxiety, depression, and risk of suicide. This syndrome is often neglected because the clinician’s attention is focused on treating the coexisting PTSD. However, MI is thought to make PTSD more difficult to treat and could be one reason why PTSD is so resistant to treatment. MI is also thought to underlie the burnout now commonly experienced by health professionals due to difficult decisions that transgress their 126 •  M ental H ealth

moral values, often due to requirements of the job (Mantri et al., 2020). Religious professionals such as chaplains or pastoral counselors are ideally suited to address MI, and there are spiritually integrated treatments for MI that are now being developed and tested (Harris et al., 2011, 2018; Pearce et al., 2018). Given the importance of religious belief in recovery from PTSD and MI treatments, we refer the reader elsewhere for a more comprehensive discussion of these topics (Koenig et al., 2019b). In anxiety disorders, the intense anxiety, fear, and other emotions that accompany them must impair social, occupational, or other important areas of functioning. Anxiety, however, is not always bad. Anxiety is often adaptive, improving alertness needed to avoid harmful situations and increasing motivation when necessary. Only when it is out of proportion to the actual harm or danger, and begins to interfere with the person’s ability to function in a healthy way, does anxiety become a problem and require treatment. The same is true for moral injury.

PREVALENCE The most reliable data on the national and international prevalence of anxiety disorders is relatively dated (as for many other psychiatric disorders). The last major epidemiological study of psychiatric disorders in the United States was the National Comorbidity Survey Replication survey conducted between February 2001 and April 2003. Using DSM-​IV criteria to guide structured psychiatric interviews, this study reported that the 12-​month prevalence of anxiety disorders was 18.1%, higher than any other mental disorder (Kessler et al., 2005c). The same was true for lifetime prevalence of anxiety disorders at 28.8% (Kessler et al., 2005b), and the lifetime prevalence by age 75 has been estimated to be 36.0%, making up 65.1% of all psychiatric disorders in this country (Kessler et al., 2007). The most common anxiety disorders are specific phobia (12.5% lifetime prevalence); social phobia (12.1%); PTSD (6.8%); GAD (5.7%); separation anxiety disorder (5.2%); panic disorder (4.7%); OCD (1.6%); and agoraphobia without panic

(1.4%) (Kessler et al., 2005b). More than 50% of veterans and active duty military with PTSD symptoms experience significant levels of MI (Koenig et al., 2018d; Volk & Koenig, 2019). Worldwide, the prevalence data on anxiety are based on rates of mental disorder reported by the World Health Organization’s (WHO) World Mental Health Surveys, which used the WHO’s CIDI, a structured psychiatric interview based on ICD-​10 and DSM-​IV. Initiated in 1998, these surveys were designed to identify psychiatric disorders in 17 countries (n =​85,052) and were eventually expanded to include 28 countries by 2005 (Kessler et al., 2009). These surveys found that the lifetime prevalence of (any) anxiety disorder ranged from a low of 4.8% in China and 5.2% in Israel to a high of 31.0% in the United States (Kessler et al., 2007). Specific phobia was the most common anxiety disorder in these surveys, with a 12-​month prevalence of 4%–​8% and lifetime prevalence of 6%–​12% worldwide (Kessler et al., 2009). In a systematic review and meta-​regression analysis, based on prevalence studies published between 1980 and 2009 (87 studies across 44 countries), Baxter et al. (2013) estimated that the global prevalence of anxiety disorders was 7.3%, ranging from 5.3% in African cultures to 10.4% in Euro/​Anglo cultures. The most recent data are from the 2017 Global Burden of Disease Study (Ritchie & Roser, 2018) that found a worldwide prevalence of anxiety disorders of 3.8% (considerably lower than earlier estimates), with the highest rates in New Zealand (6.1% men, 10.8% women) and Norway (5.8% men, 9.4% women) and the lowest rates in Vietnam (1.5% men, 2.6% women) and Tajikistan (1.9% men, 3.2% women).

COST AND CONSEQUENCES Although recent estimates of the economic burden of anxiety disorders are lacking, the financial cost in the United States alone was estimated at $42.3 billion in 1990 (cost of treatment and lost productivity), or $1,542 per person per year (Greenberg et al., 1999). In an unpublished doctoral dissertation using data from the 2009–​2010 US Medical Expenditure Survey, Shirneshan (2013) estimated that the annual overall direct medical costs attributed

to anxiety disorders was $1657.52 per person, or $33.71 billion in total (ambulatory care alone). In the Netherlands, the annual per person cost of anxiety disorders in 2003 was 3,587 euros (€) ($4,053), compared to mood disorders at 5,009€ ($5,660) and alcohol-​related disorders at 1,431€ ($1,617) (Smit et al., 2006). Far greater than the economic burden of these disorders are the human costs. Anxiety disorders are second only to depression among mental disorders in terms of disease burden. They are the sixth leading cause of disability worldwide based on years lived with disability (YLD) in both high-​and low-​income countries (after low back pain, major depression, other musculoskeletal disorders, neck pain, falls, and COPD) (Baxter et al., 2014). Based on the 2013 Global Burden of Disease study, anxiety disorders were responsible for nearly 15% of mental illness disability worldwide in terms of disability-​adjusted life years (DALY; Vigo et al., 2016). Not only are anxiety disorders disabling, they can also be dangerous, accounting for 7% of global suicide mortality (Baxter et al., 2014). For example, PTSD increases the risk of completed suicide by 5-​to 10-​fold (Gradus et al., 2010). Bandelow and Michaelis (2015) reported considerable overlap between anxiety disorders and other mental disorders, especially major depressive disorder (r =​0.62) and dysthymia (r =​0.55). There is evidence from a number of longitudinal studies that depression may give rise to subsequent anxiety, and that anxiety may give rise to subsequent depression (Jacobson & Newman, 2017). Anxiety disorders may often progress to major depression, bipolar disorder, and schizophrenia, perhaps due to common genetic influences (Meier & Deckert, 2019). Comorbid medical diseases are also common in anxiety disorders. Scott et al. (2016) reported an increased likelihood of chronic physical conditions among those with anxiety disorder. These include arthritis (a 40%–​80% increase, especially among those with GAD and PTSD); chronic pain (a 80%–​ 110% increase, especially in GAD, OCD, and PTSD); heart disease (a 30%–​110% increase, especially in panic disorder and PTSD); stroke (a 50%–​ 120% increase, especially in panic disorder and social phobia); hypertension (a Anxiety • 127

30%–​70% increase, especially in panic disorder); diabetes mellitus (a 20%–​80% increase, especially in panic disorder); asthma (a 30%–​ 90% increase, especially in panic disorder and PTSD); chronic lung disease (a 60%–​ 150% increase, especially in GAD and panic disorder); peptic ulcer disease (a 50%–​ 130% increase, especially in PTSD, OCD, and panic disorder); and cancer (a 0%–​80% increase, especially in OCD and panic disorder). Anxiety disorders, then, are not benign conditions.

CAUSES OF ANXIETY As with depression, understanding the causes of anxiety will help identify pathways by which religious involvement may prevent or lessen anxiety or buffer the effects of stressors that lead to anxiety. The causes of anxiety and the resources that protect against it can be divided into demographic, genetic, environmental, psychological, social, and physical/​medical factors.

Demographic Women are about twice as likely as men to have an anxiety disorder, possibly due to neurobiological and genetic factors (Bandelow & Domschke, 2015). Age of onset is typically in childhood or early adolescence (median age 11 years), peaks in middle age, and then slowly decreases in later life (Bandelow & Michaelis, 2015). Anxiety disorders tend to be chronic, although not necessarily lifelong. Specific phobias and separation anxiety disorder have their origins earliest in life (median age 7 years), while panic disorder most often begins in young adulthood (median age 24 years) and GAD even later (median age 31 years) (Kessler et al., 2005b; Kessler et al., 2012).

Genetic Genetic causes are thought to be prominent, with 30%–​50% heritability reported in twin studies (Shimada-​Sugimoto et al., 2015; Meier & Deckert, 2019). As with depression, anxiety disorders do not result from a single genetic mutation. Instead, they result from a complex genetic inheritance pattern that involves interactions among multiple susceptibility 128 •  M ental H ealth

genes, each having a small individual effect. Epigenetic factors are also likely influential. For example, genetic polymorphisms of the serotonin transporter gene may interact with childhood traumas to impact stress responses and vulnerability to anxiety disorders later in life (Caspi et al., 2002).

Environmental The effect of traumatic childhood experiences on the later development of anxiety disorders has been emphasized for over 20 years (Pynoos et al., 1999). In their article, The Developmental Origins of Anxiety, Gross and Hen (2004) noted that early environmental trauma can cause long-​term changes in the brain that make individuals more susceptible to fear and anxiety during adulthood. They base their hypothesis on experimental studies in non-​ human primates and rodents, as well as on human studies. Rhesus monkey infants raised by their mothers have fewer anxiety-​related behaviors than infants raised by inanimate surrogates or infants raised by a group of peers. Likewise, infant rats who receive care by “high-​licking” mothers experience lower anxiety in adulthood than do those raised by “low-​licking” mothers, and these infants have this trait themselves and appear to pass on this licking trait to their own offspring, due to genetic changes induced by ­licking maternal behavior. Gross and Hen stress that genetic factors, intrauterine environment, and early postnatal environment all influence later susceptibility to anxiety disorders, underscoring the importance of gene-​ environment interactions. Gene-​ environment interactions of this type may also be present in humans, as Caspi and colleagues have shown for both childhood trauma and adult stressful life events (Caspi et al., 2002, 2003). Gross and Hen hypothesize that the formation of anxiety circuits in the brain, particularly those responsible for anxiety disorders in adulthood, may be especially vulnerable to environmental influences during developmental periods when synaptic connections are being formed and brain circuits are highly plastic. These developmental periods extend from mid-​ gestation during maternal pregnancy through adolescence. The impact

of environmental factors is underscored by the effect that psychiatric disorders in childhood can have on behavior that influences vulnerability to anxiety disorder later in life. For example, attention deficit and hyperactivity disorder (ADHD) may cause a child to receive painful negative feedback from parents and peers in response to their inappropriate social behaviors, which then causes a pattern of social withdrawal, manifested later as social anxiety disorder (Koyuncu et al., 2018).

Psychological Stressful life events, regardless of the age when they occur, have long been known to influence the onset of anxiety disorders such as GAD (Blazer et al., 1987; Kendler et al., 2003). The anxiety disorder most likely to result from severely stressful traumatic events is PTSD. However, even when stressful life events are not severe enough to meet the threshold for a traumatic stressor, they can still influence the onset or course of anxiety disorders, especially if those stressors are chronic (Shin & Liberzon, 2010; Radley et al., 2015). The presence of adequate coping resources may be particularly important in buffering such stressors.

thyroid disease, pheochromocytoma), caffeine-​ containing beverages, over-​the-​counter drugs (e.g., decongestants), illegal drugs (amphetamines, cocaine), and prescription medications (e.g., steroids, theophylline, albuterol).

Social Social support from friends or family may help to prevent, delay the onset of, or mitigate the effects of anxiety disorders, through both psychological and physiological mechanisms, one of which involves the release of oxytocin (Labuschagne et al., 2010). This may be particularly true for certain disorders such as social anxiety disorder (Levine et al., 2015; Rapee et al., 2015), GAD, and PTSD (Neria et al., 2010). Social support has also been shown to mediate the effects of psychological interventions such as cognitive behavioral therapy on anxiety symptoms among medical patients (Dour et al., 2014).

RELIGION AND ANXIETY We now examine how religious involvement might affect anxiety or impact the onset or course of anxiety disorders. We begin with a case vignette.

Physical Anxiety is common among individuals with chronic medical illness, particularly neurological illness, where nearly 50% of patients have been found to meet DSM-​IV criteria for an anxiety disorder using the PRIME-​MD (far above the prevalence in the general population) (Gili et al., 2010). This is especially true for GAD and panic disorder, where prevalence rates in neurological disorder are 29.4% and 24.2%, respectively. Other medical illnesses such as chronic obstructive pulmonary disease (COPD) are likewise commonly associated with anxiety disorders. Among those with COPD, panic disorder is up to 10 times more common than in the general population (Livermore et al., 2010). Life-​limiting diseases may also be associated with severe anxiety as individuals attempt to cope with the prospect of dying (Atkin et al., 2017). Anxiety can also be due to the direct physiological effects of certain illnesses (i.e.,

Case Vignette Antonio is a 52-​year-​old married physician assistant with a lifelong history of anxiety, which he says he inherited from his parents. He describes his mother as a chronic worrier who took Valium on and off for as long as he can remember, and says that he thinks his father self-​ medicated his anxiety with alcohol. Antonio worries about everything. When he takes care of one problem, he finds there is a long list of other concerns ready to take its place. He worries about his wife’s health, whether he will have enough money to retire, and whether his adult son will lose his job because he drinks too much, to mention just a few. He tells himself that if he worries about bad things, then those things won’t

Anxiety • 129

actually happen, or at least he will be prepared for them when they do. He has had a couple of panic attacks in his life, but these are rare. Antonio has sought help from his primary care physician who prescribed Paxil, which has relieved some of the symptoms, but he still worries a lot. Antonio’s family immigrated from Mexico to the United States about 40 years ago. He was raised in a devout Catholic home, although he stopped practicing Catholicism soon after he went off to college. About a year ago, a friend invited him to attend Mass (Catholic church service) with him, which he accepted. During the church service, Antonio felt surprisingly calm, peaceful, and enjoyed singing the hymns that reminded him of when he had gone to church with his family as a youth. On returning home, he told his wife about it, who agreed to go with him to church the following week (and bring their teenage son). His wife, also raised Catholic, had periodically attended services in the past, but because Antonio had been reluctant to join her, she stopped. Antonio liked the peaceful feeling he had at church, and so he decided to start praying again and even occasionally pull out his Catholic Bible to review passages the priest had mentioned in the sermon. He was especially attracted to the Psalms, written by King David who struggled with all sorts of problems similar to the ones Antonio often dealt with. Antonio also found that he was developing friendships with other men in the church, particularly those in the healthcare field, with whom he felt comfortable talking about issues that came up at work. Knowing that others were going through situations similar to the ones he was facing helped him to worry less about his own problems. Over time, following his return to religious activity, Antonio noticed his anxiety symptoms began to lessen. He still worried about a lot of things and had to take his Paxil, but things were definitely

130 •  M ental H ealth

better, including his relationship with his wife and teenage son, who had joined a youth group at church that seemed to have a good influence on him.   

ETIOLOGIC PATHWAYS AND MECHANISMS How might religion affect anxiety? What are some pathways by which religious involvement could affect the onset or course of anxiety disorders or influence the severity of anxiety symptoms? We examine five possible mechanisms, following the known causes for anxiety described above: genetic, environmental, psychological, physical, and social.

Genetic Although religious beliefs and practices are unlikely to alter the sequence of amino acids that make up a person’s DNA, it is possible through epigenetic influences that religion might affect other parts of gene structure that influence vulnerability to stress and possibly are transmitted to offspring, thereby extending religion’s effects across generations. Furthermore, there is evidence that religiosity is associated with certain genetic polymorphisms that impact risk of comorbid psychiatric disorders affecting anxiety, such as substance use disorders (Dew & Koenig, 2014; Dew et al., 2017).

Environmental The quality of parental nurturing during infancy and early childhood (due to parental religious beliefs and commitments) and/​or the perceived nurturing from religious figures (such as God or other divine beings) may influence the onset or course of anxiety disorders through epigenetic pathways described earlier. More direct intrauterine influences of parental religious involvement on brain development due to reduced maternal drug use, smoking, and marital conflict could influence later vulnerability to stress. Reduction of childhood trauma from family violence, parental divorce, stress of being raised by

a single parent, exposure to antisocial peers, and use of alcohol or drugs during adolescence could influence susceptibility to anxiety disorder later in life. As noted above, should these religious influences occur over several generations, this could lead to changes in gene structure that lead to healthier stress-​responses and lower susceptibility to anxiety.

the need for treatments that have anxiety as a side effect. Likewise, if religious involvement reduces stress levels, then cardiovascular, cerebrovascular, and other psychosomatic diseases may be less frequent, and less likely to cause anxiety or mood disorders that lead to anxiety.

Psychological

Religious involvement has been related to greater social support, greater marital stability, and healthier family functioning (Chapters 14 and 15). Given the role that social support plays in buffering stress and preventing or relieving anxiety symptoms (e.g., in social phobia, GAD, and PTSD), this could help explain how religious activities could impact the development or course of anxiety disorders. However, religious involvement may also create a sense of social commitments and obligations, which themselves might generate anxiety. Thus, there is rationale for both the positive and negative effects of religion on anxiety. Systematic research can help to objectively assess the theoretical possibilities above.

Religious beliefs may help individuals to perceive and interpret stressful life events in a way that reduces or buffers the anxiety cause by these stressors (Chapter 4). Religious beliefs may also reduce the number of life stressors directly due to religious teachings that endorse prosocial behaviors and discourage antisocial ones (e.g., drugs, alcohol, delinquency, crime). Furthermore, religion may provide resources (prayer, meditation, inspirational scriptures and role models, support from clergy or members of the congregation) to combat anxiety symptoms that arise from stressors that cannot be prevented. In contrast, Freud described religion an “obsessional neurosis” (Freud, 1927). Neurosis is known to be one of the strongest of all predictors of anxiety disorder (Paulus et al., 2016). Religious beliefs might exacerbate anxiety symptoms by inducing guilt over failure to live up to the high standards to which adherents are accountable. Religious beliefs about the consequences of sin in the afterlife may arouse anxiety due to fear of eternal condemnation to hell, as strongly emphasized in both Christianity and Islam, the two largest religions in the world.

Physical/​Medical If religion helps people to cope better with the stress of medical illness, then it may help to reduce anxiety symptoms from this cause. Likewise, if religiosity reduces the likelihood of chronic medical illness through psychological, social, and behavioral pathways (see Section VI), this could also positively affect anxiety symptoms related to physical illness and disability. For example, if religion prevents cigarette smoking, it will decrease the likelihood of developing chronic lung disease and reduce

Social

RESEARCH ON RELIGION AND ANXIETY In the first two editions of the Handbook, our systematic reviews identified 299 quantitative studies that had examined the relationship between religiosity and anxiety. Of those, 49% reported inverse relationships (less anxiety or fear among the more religious), 11% reported positive relationships (greater anxiety among the more religious), and the remainder (40%) found no association or complex results. These findings are in some tension with Freud’s description of religion above. Furthermore, the finding that a large percentage of these studies (nearly one-​half) report lower anxiety among the more religious is particularly surprising given that anxiety is such a powerful motivator of religious belief and behavior. This “reverse-​ causation” dynamic would lead us to expect a positive association between religiosity and anxiety (reported in only 1 of 10 studies), particularly in cross-​sectional research. Unfortunately, the vast majority of studies are cross-​ sectional, and thus capable of Anxiety • 131

determining association only (not causality). As in all chapters of this Handbook, we now focus on prospective cohort studies and randomized controlled trials (RCTs). A number of high-​quality studies of both types have examined religion’s relationship to and effect on anxiety (23 prospective studies and 24 RCTs; see Appendix). We have selected 11 prospective studies and 10 RCTs to review here, focusing on the higher-​quality studies and, when available, those conducted in psychiatric patients with more severe symptoms.

Prospective Cohort Studies These studies assess religiosity prior to the measurement of anxiety, thereby seeking to determine the effect of religiosity on changes in anxiety symptoms over time. One of the first of these studies, led by Harvard sociologist David R. Williams, followed a random sample of 720 community-​dwelling adults examining the effect of religious attendance on “psychological distress,” which was measured by the Gurin Symptoms Checklist that assesses symptoms of anxiety and depression (Williams et al., 1991). Religious affiliation and attendance were assessed at baseline in 1967 (T1). Psychological distress was assessed at both T1 and T2. Stressful life events (SLE) and physical health (PH) problems occurring between T1 and T2 were also determined. Results indicated that frequency of religious attendance at baseline (T1) predicted lower levels of psychological distress two years later (T2), after controlling for age, gender, education, race, marital status, and sociodemographic variables (b =​0.84, p < .01). However, when T1 distress was controlled for in the model, the relationship was substantially attenuated and no longer statistically significant (b =​0.16, p =​ns). When examining the interaction between T1 religious attendance and SLEs and PH problems (between T1 and T2) on psychological distress at T2 (controlling for T1 distress), investigators found that frequent religious attendance buffered the negative mental health consequences of SLEs (b =​0.43, p < 0.05) and PH problems (b =​0.52, p < 0.05) on T2 distress.

132 •  M ental H ealth

Zehnder et al. (2006) conducted an 11-​ month prospective study of 161 children age 6–​ 15 with accidental injuries or chronic medical illness in Switzerland, examining the effects of religious coping on PTSD symptoms. Religious coping was assessed by two questions: “Did you ask God for help?” and “Did you pray to God for comfort?” PTSD symptoms were assessed by the 20-​item Child Post-​Traumatic Stress Reactions scale (assessed at T1 and T2). Demographic variables, other coping strategies, behavioral problems, socioeconomic status, functional status, and traumatic life events were also assessed and controlled for in all analyses. Results indicated that T1 religious coping was related to fewer T2 PTSD symptoms, controlling for T1 PTSD symptoms (b =​−0.24, p < 0.05). Fauth and colleagues (2007) conducted a prospective study of a random sample of 1,315 Black and Latino adolescents age 9–​12 in Chicago, examining predictors of anxiety/​ depressive symptoms over time. Participants were assessed at baseline (T1, 1995–​ 1996), 3 years later (T2, 1998–​1999), and 5 years later (T3, 2000–​ 2001). After-​ school participation was assessed, including activities in “church groups” at T2 and T3 (the only religious variable). Anxiety/​ depression was assessed at T1, T2, and T3 by the 14-​item Child Behavior Checklist. Controlled for in analyses were demographics and other forms of after-​school participation (sports, arts, student government, community-​based clubs). Only participation in sports, not church groups, was related to lower average scores on anxiety/​depression over time. Rasic and colleagues (2011a) analyzed data from a 10-​year prospective study of a random sample of 1,091 community-​ dwelling adults participating in Waves 3 and 4 of the Baltimore Epidemiologic Catchment Area Study (1994–​ 2004), examining the relationship between religiosity and mental disorders identified by the Diagnostic Interview Schedule (using DSM-​ III-​R criteria). Religious attendance and seeking spiritual comfort were assessed at Wave 3 (T1) and anxiety disorder (any) was assessed at Wave 3 (T1) and Wave 4 (T2). Religious attendance was dichotomized into “never attends” vs. any attendance (“less than once a month to more

than once per week”). Seeking spiritual comfort predicted greater positive affect, but more was dichotomized into “never” and any seek- PTSD-​like cognitive intrusions at T2; however, ing (“rarely to almost always”). Controlling for high IR predicted a greater decline in cognitive sociodemographic factors, social supports, and intrusions over time (b =​−0.20, p < 0.001) comchronic conditions, along with anxiety disorder pared to low IR (b =​−0.14, p < 0.001) (IR × time at T1, the confidence intervals for the associa- interaction b =​−0.10, p < 0.01). tions between either religious attendance or Rosmarin et al. (2013a) prospectively folspiritual support and anxiety disorder at T2 lowed 47 psychiatric patients with acute sympincluded the null (OR =​0.65, 95% CI =​0.33–​ toms in a day treatment program (Harvard’s 1.26, and OR =​0.81, 95% CI =​0.41–​ 1.59, McLean Hospital), examining religious coping respectively) (indicating no effect), though on admission (T1) as a predictor of change in dichotomizing seeking spiritual comfort anxiety and other psychiatric symptoms from (including “rarely” with “almost always”) and admission to discharge (T1 to T2, an average frequency of religious attendance (including of 8 days). Religious coping was measured at “rarely” along with “weekly” attendance) may baseline (T1) using the 14-​item Brief RCOPE have reduced the power to detect effects. that assesses positive religious coping (PRC) McIntosh and colleagues (2011) conducted and negative religious coping (NRC). Anxiety a 3-​year prospective study of a national ran- was assessed using the 8-​item Penn State Worry dom sample of 890 community-​dwelling adults Questionnaire. Change scores in anxiety (T2 in the United States, examining the impact of minus T1) were calculated and partial correlaspirituality and religiosity on mental health tions (after Bonferroni correction) were used to outcomes following the 9/​11 terrorist attacks examine the effect of pre-​treatment religious in New York City. Participants were initially coping on change in anxiety independent of surveyed 2 months pre-​9/​11 (T0) and then other predictors (age and race). Results indiagain two months after 9/​11 (T1), in March/​ cated that T1 PRC predicted a significant decline April 2002 (T2), in September/​November 2002 in anxiety symptoms (r =​0.60, p < 0.001), while (T3), in March/​April 2003 (T4), in September/​ NRC was unrelated to change in anxiety. October 2003 (T5), and in September/​ Bradshaw and colleagues (2015) analyzed November 2004 (T6). Frequency of religious data from a 3-​year prospective study of a US service attendance prior to 9/​11 was assessed national random sample of 1,024 community-​ retrospectively at T1 (“Before the events of dwelling adults age 65 or over, examining the September 11th, how often did you attend impact of “listening to religious music” on services or meetings of a spiritual or religious death anxiety. At baseline (T1), participants organization?”). A 2-​item measure of current were asked: “How often do you listen to reliintrinsic religiosity (IR) was also administered at gious music outside church—​ like when you T1. Anxiety disorder and depression pre-​9/​11, are home or driving in your car?” and “Now T1, T2, and T3 were determined by a physician-​ I have some questions about gospel music diagnosed composite index (0 =​none, 1 =​anxi- only. How often do you listen to gospel music?” ety or depressive disorder, 2 =​both). New onset Response options for both items ranged from anxiety/​ depressive disorder between waves 1 (never) to 8 (several times a day). Death anxwas the primary outcome assessed, using mul- iety was assessed by a 4-​item scale developed tilevel modeling. Age, gender, marital status, from the literature at T1 and T2 (3 years later). ethnicity, education, household income, 9/​11-​ Controlled for in analyses were age, race, marrelated exposure, stressful life events at T1, ital status, gender, perceived financial strain, and pre-​9/​11 anxiety/​depressive disorder were self-​ rated health, and frequency of religious controlled for in all analyses. Researchers found attendance. Interactions with race, gender, and evidence that pre-​9/​11 frequency of religious social economic status were also examined. attendance predicted a somewhat lower inci- After additionally controlling for T1 death dence of new-​onset anxiety/​depressive disor- anxiety and the variables above, regression der over time (incidence rate ratio [IRR] =​0.88, analyses indicated that listening to religious 95% CI =​0.79–​0.98). Intrinsic religiosity (T1) music (T1) predicted a significant decrease in Anxiety • 133

T2 death anxiety (b =​−0.035, p < 0.001), as did listening to gospel music (b =​−0.22, p < 0.05). Listening to religious music was also associated with increases in life satisfaction, self-​esteem, and sense of control over time. No interactions with demographic variables were present. Peterman et al. (2014) analyzed data from a multi-​site US study of 839 adolescents followed over a 3-​to 4-​year period from age 11–​12 (T1) to age 15 (T2), examining the relationship between religiosity and anxiety. Religious commitment was assessed at T1 and T2 by a 6-​item scale that assessed frequency of religious attendance, importance of religious faith, influence on major life decisions, frequency of prayer, belonging to a young group, and having had powerful religious experiences. Changes in religious attendance across time were categorized as consistent high attendance, consistent low attendance, increasing attendance, and decreasing attendance. Anxiety was assessed by a 16-​item subscale of the Childhood Behavior Checklist at T1 and T2. Gender, ethnicity, religious affiliation, and T1 anxiety were controlled for in analyses. Results indicated that those who increased religious attendance over time (T1 to T2) were more likely to experience increased anxiety from T1 to T2 than those who reported a decrease in attendance (b =​0.12, p < 0.01). Likewise, those who had consistently low religious attendance at T1 and T2 experienced a significant decrease in anxiety symptoms from T1 to T2 compared to those who increased religious attendance (b =​−0.16, p < 0.05). Self-​reported guilt mediated the relationship between increasing religious attendance and increased anxiety. Currier and colleagues (2015) examined religiosity/​spirituality (R/​S) as a predictor of change in PTSD symptoms among 532 US veterans completing a 60-​to 90-​day residential treatment program for severe combat-​related PTSD. R/​S was assessed during the first week after admission (T1) and then again on program discharge (T2) using items from the Brief Multidimensional Measure of Religiousness/​ Spirituality (BMMRS). PTSD symptoms (the primary outcome) were measured using the 17-​item PTSD Checklist-​Military version (PCL-​ M) at T1 and T2. Investigators also examined the cross-​lagged effects (T1 R/​S predicting T2 PTSD symptom severity vs. T1 PTSD symptom 134 •  M ental H ealth

severity predicting T2 R/​S) and the extent to which the two cross-​ lagged effects differed from each other, with the intention of identifying direction of greatest effect. Results indicated that T1 R/​S predicted significantly fewer PTSD symptoms at discharge (T2), independent of T1 PTSD severity. Analyses indicated that the cross-​lagged effect of T1 R/​S predicting T2 PTSD severity (b =​−0.10, p < 0.05) was stronger than the cross-​ lagged effect of T1 PTSD predicting T2 R/​S (b =​0.03, p =​ns), which persisted after controlling for demographic factors. These results suggested that the effect of R/​S on PTSD symptoms over time was stronger than the effect of PTSD on R/​S. Chen and VanderWeele (2018) analyzed data from the Growing up Today Study (GUTS), a prospective study of 5,681–​ 7,458 adolescents, average age 14.7 years, in 1999 (T1) and followed up for 8–​14 years in 2007–​2013 (T2). Investigators examined the effects of religious service attendance and prayer/​meditation on mental health, including anxiety symptoms and the presence of probable PTSD. T1 religious service attendance was assessed by, “How often do you go to religious meetings or services?” with response categories “never,” “less than once per week,” and “at least once per week.” Frequency of prayer/​ meditation at T1 was assessed with the question “How often do you pray or meditate?” with responses “never,” “less than once per week,” “1–​6 times per week,” and “once per day or more.” Anxiety and probable PTSD outcomes were assessed by standard measures of these constructs used in this age group. Controlled for in analyses were sociodemographic characteristics, psychological well-​ being, character strengths, physical health, other indicators of mental health, health behaviors, maternal health, and prior values of the mental outcomes when available. Results indicated that attendance at religious services at least weekly at T1 (compared to those who never attended) predicted a lower likelihood of experiencing probable PTSD during follow-​up (risk ratio [RR] =​0.72, 95% CI =​0.57–​0.93). Those who prayed/​meditated less than once/​ week at T1 (compared to never praying/​meditating) were also less likely to experience probable PTSD during follow-​up (RR =​0.72, 95% CI =​0.53–​0.97). No effect was found for

religious activities on other anxiety symptoms or diagnoses. Chen et al. (2020a) analyzed data on a sample of 9,862 young adults in the Growing Up Today Study (GUTS, using later waves than the adolescent study described above) with 3 years of follow-​up and 68,376 participants from the Nurses’ Health Study II (NHSII) with 12 years of follow-​up. They examined associations between at least weekly religious service attendance and subsequent anxiety symptoms, controlling for a rich set of social, demographic, economic, psychological, and health related-​variables (as well as, in the GUTS sample, prior religious service attendance). In the meta-​analytic estimate combining these samples, at least weekly religious service attendance predicted a slightly lower level of subsequent anxiety symptoms (b =​−0.05, 95% CI =​−0.07 to −0.03). The effect size estimate, while statistically significant, was quite small at only one-​twentieth of a standard deviation.

(GAD; n =​103). We focus here on the GAD group. Participants were randomized to either standard care (SC; n =​49) or to standard care plus “religious socio-​ cultural psychotherapy” (RP; n =​54). RP involved the identification and modification of negative thoughts using cognitive-​behavioral techniques based on the Qur’an and Hadith; discussion of religious issues and cultural beliefs related to the illness (advice provided on how to follow the teachings of the Prophet Muhammad); and encouraging participants to pray regularly, read the Qur’an, and develop a close relationship with Allah. SC involved benzodiazepines for up to 6 weeks, supportive psychotherapy, and/​or simple relaxation exercises. Both intervention and control groups were assessed by psychiatrists blinded to treatment group at baseline, 4, 12, and 26 weeks using the Hamilton Anxiety Rating Scale. No difference between groups was present on anxiety scores at baseline (RP =​21.2, SC =​21.3, p =​ns). By 4 weeks, a significant difference emerged between groups, favoring RP (RP =​12.8 vs. SC =​15.2, p < 0.002); this Randomized Controlled effect persisted through 12 weeks (RP =​6.8 vs. Trials (RCTs) SC =​8.6, p < 0.01); although by 26 weeks, there RCTs that examine the effects of a religious was no difference (RP =​2.0 vs. SC =​2.6, p =​ns). intervention on anxiety symptoms or disor- Researchers concluded that patients receiving der have the potential to determine whether the additional RP responded more quickly than certain forms of religious practice may affect those in the SC only group. anxiety (i.e., determine the causal relationship Rye and Pargament (2002) randomized 58 between religious involvement and anxiety). Of distressed college women (average age 18.8) the 24 RCTs involving religious interventions who had been “wronged in a romantic relalisted in the Appendix, 18 reported significant tionship” to secular forgiveness group therapy benefits in terms of reducing anxiety compared (n =​20), religiously integrated forgiveness to a control group or other intervention, one group therapy (n =​19), or a no-​intervention reported reduced anxiety symptoms similar to control group (n =​19). The two intervention Present-​ Centered Group Therapy, one found groups received six weekly 90-​minute group that “spiritual direction” increased anxiety in sessions. The secular group received guided alcoholics, one found reduced anxiety in the meditation, shared the nature of the wrongdoreligious intervention group compared to con- ing they experienced and how the wrongdoing trols but equal to non-​religious breathing tech- had affected them, explored feelings of anger, niques, and two reported no effect. We now examined positive and negative functions of review some of these studies. anger, identified maladaptive and adaptive In a study conducted in Malaysia, Razali cognitions, and practiced strategies for dealing and colleagues (1998) recruited 203 Muslim with anger (no reference was made to religion/​ “religious patients with a strong cultural back- spirituality). The religiously integrated group ground.” Participants were diagnosed using included these elements but were asked to the Structured Clinical Interview for DSM-​ draw on their Christian religious beliefs and III-​ R with either major depressive disorder resources (prayer, scriptures) to help them for(MDD; n =​100) or generalized anxiety disorder give. Those in the control group received no Anxiety • 135

intervention, other than telephone numbers to call for help if needed. Participants completed self-​rated scales at baseline, 1 week, and 6 weeks post-​intervention. One of these scales was the 9-​item Costello and Comrey Anxiety Scale. Results indicated no significant Time × Group interaction in predicting anxiety scores (F =​0.91, p =​ns), although both intervention groups improved significantly more than the comparison group on measures of forgiveness and existential well-​being. Note that anxiety was not a focus of this study, most participants did not have clinically significant anxiety, and sample sizes were low. Chen (2005) randomized 177 college students in psychology classes at Rutgers University to either a conventional trauma writing (CTW; n =​87) or a religious trauma writing intervention (RTW; n =​90). Those in the CTW group were instructed to write about the most traumatic experience of their life (following a standard set of instructions). Those in the RTW group received the same instructions except were asked to write about the traumatic experience from a religious perspective, reflecting their own beliefs about God, religion, or spirituality. Participants engaged in three writing sessions within a 7-​day period. Both groups were assessed at baseline and one month after the third session using 14-​ items from the Impact of Events Scale-​Revised, a measure of PTSD symptoms (intrusions and hyperarousal). Traumas reported included rape, witnessing death/​ violence, physical abuse, terminal illness, and death of a family member. Results indicated no difference in treatment effects between CTW and RTW groups (Time × Group interaction p > 0.60). However, moderator analysis revealed a significant interaction between Group and trauma severity such that CTW was effective for reducing PTSD symptoms in the low-​severity group but not in the high-​severity group, whereas the positive effects of RTW were equally effective in both low-​and high-​ severity groups. There was also a significant interaction with gender. RTW was more effective than CTW in reducing PTSD symptoms in women than in men, where the opposite trend was observed. Wachholtz and Pargament (2008) randomized 83 persons, mean age 19, with vascular 136 •  M ental H ealth

migraine headache (diagnosed using standard criteria) into four groups: spiritual meditation (SpM; n =​22); internal secular meditation (ISM; n =​21); external secular meditation (ESM; n =​20); and relaxation (RL; n =​20). Those in the SpM group were instructed to choose one of four spiritual meditative phrases: “God is peace,” “God is joy,” “God is good,” or “God is love.” Those in the ISM group chose from “I am content,” “I am joyful,” “I am good,” or “I am happy.” The ESM group chose one of “Grass is green,” “Sand is soft,” “Cotton is fluffy,” or “Cloth is smooth.” Participants meditated for 20 minutes/​day for 30 days. Those in the relaxation group practiced progressive muscle relaxation for the same period. Trait anxiety was assessed with the 20-​item STAI subscale. Groups were similar on all baseline characteristics. Results indicated a significant Time × Group interaction on anxiety symptoms such that those in the SpM group experienced a significantly greater reduction in trait anxiety symptoms compared to those in other groups (F =​3.31, p < 0.05). Subgroup analyses demonstrated that the SpM group experienced a significantly greater decrease in trait anxiety than the ESM group (p < 0.01) and marginally greater decrease compared to the ISM group (p < 0.10). In addition, pain tolerance increased significantly more in the SpM group compared to the other three groups. Foley et al. (2010) randomized 115 cancer patients in Australia to either Buddhist mindfulness-​based cognitive therapy (MBCT; n =​55) or to a wait-​list control group (WLC; n =​60). Participants in the MBCT group participated in 8 weekly 2-​hour group mindfulness sessions, meditated for up to 1 hour daily, and attended an additional full-​ day retreat (including 5 hours of silent meditation) as part of the intervention. Right mindfulness and concentrated meditation, as practiced by those in the MBCT group, are steps 7 and 8 on the Eightfold Path, which involves the core teachings of Buddhism. Assessments were conducted at baseline, 10 weeks (immediately post-​intervention), and 3 months post-​ intervention. Those in the WLC group received no intervention other than completing assessments. The observer-​rated Hamilton Anxiety Rating Scale (HARS) and self-​rated Depression,

Anxiety, and Stress Scale (DASS) were used to assess anxiety symptoms. Results indicated a significant Time × Group interaction for both HARS and DASS scores, such that those in the MBCT group experienced a significantly greater reduction in anxiety symptoms than those in the WLC group. Rosmarin and colleagues (2010) randomized 125 religious Jews with elevated stress and worry scores (subclinical anxiety) to either an Internet-​ delivered spiritually integrated treatment (SIT; n =​36); progressive muscle relaxation (PMR; n =​42); or a wait-​listed control group (WLC; n =​47). The SIT and PMR groups viewed a 10-​minute orientation video and were asked to participate in the online treatment once per day for 14 days. SIT focused on Jewish cognitive and behavioral strategies for coping with stress and worry, including reading inspiring stories and excerpts from Jewish religious literature and practicing spiritual exercises to increase gratitude and prayer. PMR was conducted using a standard protocol. Participants were assessed at baseline (T1), immediately post-​treatment (T2), and 6 weeks later (T3) using the 14-​item Perceived Stress Scale, 16-​item Penn State Worry Questionnaire (anxiety), and other mental health measures. Results indicated a significant Time × Group interaction for perceived stress (F =​3.73, p < 0.05) and worry/​anxiety (F =​7.20, p < 0.001) at T2, which persisted through T3 for both stress (F =​5.83, p < 0.005) and worry/​anxiety (F =​12.2, p < 0.001). Researchers concluded that SIT was efficacious for the treatment of subclinical anxiety symptoms in religious Jews. Hosseini et al. (2013) randomized 66 Shia Muslims undergoing coronary artery bypass graft surgery in Iran to either a preoperative religious/​spiritual intervention (RSI; n =​33) or a control group receiving usual care (UCC; n =​33). RSI consisted of five 45-​to 60-​minute group spiritual/​ religious sessions (in groups of 5–​7 participants) on five consecutive days during the week prior to surgery. The intervention was exclusively religious, focusing on verses from the Qur’an and Hadith, trusting and relying on Allah, seeking blessings of Allah, thinking of Allah, reading the Qur’an, and making supplication to Allah (Du’aa). The UCC received routine nursing care, including

routine perioperative care that included physical care and emotional support. However, the ethics committee at the hospital required that the UCC group also receive “some spiritual care” prior to surgery (which reduced the likelihood of detecting an effect). The primary outcome, anxiety, was measured using the Hamilton Anxiety Rating Scale, which was administered at baseline and 2 hours prior to surgery. There were no differences in anxiety level at baseline between RSI and UCC groups (31.9 vs. 31.0), nor were there any differences in gender, age, marital status, occupation, educational status, previous hospitalization, or previous surgery. Within-​ group analyses indicated a significant decline of anxiety from baseline to post-​intervention in the RSI group (31.9 to 19.5, p < 0.001) compared to a significant increase in anxiety in the UCC group (31.0 to 43.3, p < 0.001). Since there were no differences between groups at baseline, a simple t-​test was used to compare post-​intervention anxiety levels in the RSI and UCC groups (19.5 vs. 43.3, p < 0.001). Oman and Bormann (2015) randomized 132 US veterans with PTSD to either an intervention group that repeated a spiritual mantra throughout the day (MRP; n =​63) or to a usual care control group (UCC; n =​69). The group MRP intervention, using a standard protocol, was conducted in six weekly sessions, 90 minutes/​week (3–​9 veterans per group). UCC received usual case management visits and medication maintenance. Participants chose a short phrase to repeat as their mantra as frequently as possible throughout the day (e.g., “Jesus,” “Ave Maria,” “Barukh attah Adonai,” “Namu Amidabutsu,” “Om mani padme hum”), while slowing down their thoughts and developing one-​pointed focus. PTSD symptoms were assessed by both the clinician-​rated CAPS and self-​rated PCL-​C at baseline and every week during the 6-​ week intervention. Estimated treatment effects were computed as “change since baseline in the treatment group, minus the change since baseline in the control group.” Results indicated a significantly greater decline in both CAPS and PCL-​C scores in the treatment group compared to the control group, a change that was mediated by an increase in self-​efficacy. Anxiety • 137

Harris and colleagues (2018) randomized 138 US veterans to either the Building Spiritual Strengths intervention (BSS; n =​71) or Present-​ Centered Group Therapy (PCGT; n =​67). BSS and PCGT groups were led by chaplains with master’s degrees in counseling, who administered both treatments in religious community settings. BSS is an 8-​week manualized group intervention focused on treating PTSD and trauma-​induced spiritual distress. BSS emphasizes the participant’s relationship with a higher power, theodicy (why God permits evil), forgiveness, and other religious/​ spiritual subjects related to trauma. PCGT is a group therapy intervention that provides support and addresses participants’ current problems related to PTSD. Participants in PCGT were specifically instructed not to discuss spiritual issues in this study, although recall that chaplains led these groups. PTSD symptoms were assessed at baseline and post-​treatment with the Clinician Administered PTSD Scale (CAPS) and the self-​ rated PTSD Symptom Checklist (PCL). PTSD symptoms decreased significantly in both groups from baseline to the end of treatment on the CAPS (p < 0.001) and PCL (p =​0.003). Although both treatments had large effect sizes, no difference was found between groups (Time × Group interaction was not significant). Researchers concluded that BSS was as effective as PCGT in reducing PTSD symptoms, replicating their earlier findings of BSS efficacy when compared to a wait-​listed control group (Harris et al., 2011). Nikfarjam et al. (2018) randomized 72 patients with anxiety in Iran to either a group religious intervention (RI; n =​36) or to a usual care control group (UCC; n =​36). Anxiety was determined by the Structured Clinical Interview for DSM-​5 (for diagnostic purposes at baseline) and by the self-​rated Spielberger’s STAI (for baseline and follow-​up assessments). Those in the UCC group received drug treatment with short-​term use of benzodiazepines and selective serotonin reuptake inhibitors. Those in the intervention group received drug treatment plus the group RI, which consisted of five 90-​ minute sessions at 3-​ week intervals delivered by clergy addressing religious concepts, relationship with God, engagement in prayer and repentance meetings, and 138 •  M ental H ealth

participation in religious rituals on a daily basis. Also addressed was the role of divine predestination in Islamic lifestyle (Qadar, one of Islam’s six articles of faith having to do with God’s will and knowledge about the future). Reciting the Qur’an and holy religious texts and thematic interpretation of these texts were part of the intervention, along with spiritual meditation and spiritual imagination, writing about and discussing spiritual feelings, resolving spiritual ambiguities, worshiping God, and involvement in healthy religious recreation. No differences between groups were present on sociodemographic characteristics, anxiety, or history of anxiety at baseline. The STAI was administered at baseline and after 2 months of the intervention. Results indicated that after 2 months of the intervention, reduction in overall anxiety scores was greater in the RI group compared to the UCC group (93.4 vs. 100.3, between-​group t-​test, p =​0.01). Finally, although not included in the top 10 studies discussed above because of lower quality, a single study reported negative effects of a religious/​spiritual intervention on anxiety. Miller and colleagues (2008) randomized 60 hospitalized patients following acute detoxification for severe substance abuse to either a manual-​guided Spiritual Guidance intervention (SG; n =​30) or a usual care control group (UCC; n =​30). Those in the intervention group were “offered” 12 sessions of SG after hospital discharge delivered by experienced certified professional spiritual directors. Participants were “offered” 13 spiritual disciplines from which to choose (e.g., celebration, fasting, gratitude, guidance, meditation, prayer, reconciliation, service to others, worship, etc.), which they were expected to discuss and practice between sessions. Outcome assessments included anxiety measured by the STAI at baseline, 4-​ month, 8-​ month, and 12-​ month follow-​ ups. Note that 12 of the 30 participants assigned to the SG group had dropped out by the 4-​ month assessment, and the average number of sessions attended by all participants in the SG group was 4.8 (out of 12). At the 4-​month follow-​up, those in the UCC group experienced a significant improvement in anxiety symptoms, whereas the SG group did not (t =​−3.95, p < 0.001, relative to UCC). This difference was

no longer significant at the 8-​and 12-​month follow-​ups.

Summary Of the 11 prospective studies summarized here, 8 reported that baseline religiosity predicted a decline in distress or anxiety symptoms over time, most controlling for baseline anxiety or examining anxiety change scores. Two studies found no association, and one study reported that increased religious attendance by adolescents predicted an increase in anxiety symptoms, an effect that was mediated by guilt. Of the 10 RCTs reviewed, 8 reported that a religious or spiritual intervention significantly decreased anxiety symptoms compared to usual care controls or another active treatment, and 2 reported that effects on anxiety were similar to other active treatments. Finally, one RCT reported that “spiritual guidance” by spiritual directors increased anxiety in patients with severe substance abuse, although many dropped out and few completed the full 12 sessions of the intervention. Thus, the results from prospective cohort studies and RCTs reviewed here generally support the hypothesis that religious involvement reduces anxiety symptoms, with some exceptions. However, many of these studies were small, and both prospective studies and RCTs reported here should be replicated before any of these interventions can be clearly recommended. The small sample sizes may have resulted in under-​powered studies for those with no evidence of effects. However, small samples may have also made it more likely that spurious positive results were reported, especially if multiple hypotheses were tested (or if there were numerous similarly small unpublished studies that were unsuccessful).

RECOMMENDATIONS FOR FUTURE RESEARCH As suggested elsewhere in the Handbook, conducting more cross-​ sectional studies will probably not have a major impact in terms of advancing our knowledge in this area. This is particularly true since anxiety and fear are such strong stimulators of religious involvement,

making cross-​ sectional associations difficult to interpret due to the possibility of reverse-​ causation. People turn to religion when they get anxious. Indeed, based on studies of war veterans (Wansink & Wansink, 2013; Henrich et al., 2019), there is now scientific evidence to support a weaker version of the principle, “there are no atheists in foxholes.” Nevertheless, if cross-​sectional research has not yet been done on religiosity and anxiety in a particular religious tradition or population subgroup, or for a particular anxiety disorder, then such a study might contribute to the literature. Prospective studies and RCTs are both needed to advance our knowledge, despite their cost and the challenges involved in successful execution. Large prospective studies conducted over long periods of follow-​up (long enough for anxiety levels to change to maximize power to detect effects) with assessments of different aspects of religious involvement and anxiety are a priority. Prospective studies examining effects of religiosity on the course of specific anxiety disorders, such as panic disorder, social phobia, PTSD, and other common anxiety syndromes (including moral injury), are especially needed. In our survey of the existing longitudinal research above, other aspects of religion and spirituality, such as prayer or religious coping, may be more strongly associated with lower subsequent anxiety than is religious service attendance. If so, this would be in contrast to what is observed for many other health outcomes such as depression (Chapter 6) or mortality (Chapter 27) for which religious service attendance appears to be the strongest religious/​ spiritual predictor. However, further investigation is warranted. With respect to religious service attendance, future research could also investigate potential moderators or effect modifiers to examine whether religious service attendance might relieve anxiety for some, but increase anxiety for others. Likewise, RCTs are needed to test the efficacy of religious interventions for anxiety symptoms and disorders, particularly religiously integrated cognitive behavioral interventions conducted in religious patients. Religious interventions need to be developed and tested in specific anxiety disorders, especially GAD, panic disorder, PTSD, social phobia, Anxiety • 139

separation anxiety disorder, and possibly OCD. Again, these studies are difficult and expensive to conduct correctly, and usually require teams of investigators to carry out well. Nevertheless, even small studies on low or no budgets can provide pilot data that may help to increase the chances of obtaining funding for larger studies. Qualitative studies are also needed to help inform the development of quantitative prospective studies and RCTs. These types of studies, while time-​intensive on the researcher’s part, may be more practical for many investigators, particularly when conducted as part of a complete research program that may eventually include more quantitative work.

CLINICAL APPLICATIONS We currently know enough about the impact of religious involvement on anxiety to make at least preliminary recommendations in terms of application to clinical practice.

The Spiritual History Although this may sound like a broken record, taking a careful and detailed spiritual history is the primary intervention that all health professionals should undertake when treating patients with anxiety disorders or significant anxiety symptoms. As recommended in Chapter 5, the specific questions included in a mental health spiritual history have been described (Koenig, 2018a, p. 342) and summarized (Peteet et al., 2019) elsewhere. The purpose of the spiritual history is to identify religious beliefs and practices that may serve as resources in combating anxiety (prayer, meditation, confession, etc.), and to determine if there are any rigid religious beliefs (for example, as seen in OCD manifesting as religious scrupulosity) that may be exacerbating anxiety by inducing unhealthy guilt or excessive worry.

Simple Religious Interventions Based on the results of RCTs summarized above and in the Appendix, encouraging simple religious practices may help religious patients reduce anxiety. For example, for patients who positively self-​ identify as religious, the 140 •  M ental H ealth

clinician or pastoral care provider might encourage attending religious services or volunteering for religious reasons. This may be particularly helpful for the person with social phobia or PTSD who is at risk for social isolation (Chen & VanderWeele, 2018). The individual may be encouraged to take time to pray or meditate or repeat a mantra (a religious phrase or word) frequently throughout the day, while slowing their thoughts and focusing attention on the present moment (Oman & Bormann, 2015). Regular times of worship, practicing the presence of God, and/​or repetition of religious scriptures throughout the day might be recommended to Muslims or Christians—​ if consistent with their faith tradition (Nikfarjam et al., 2018). For the religious patient with anxiety symptoms due to trauma, religious writing is another option. In that case, as noted above (Chen, 2005), the patient is instructed to write about the trauma from a religious perspective, processing the traumatic event(s) in light of their religious faith (in the Judeo-​ Christian tradition, perhaps reflecting on the Psalms or the Book of Job). Whatever religious practice suggested, however, must be patient-​centered, i.e., based on the patient’s faith tradition (not the health professional’s tradition) to avoid proselytizing.

Pastoral Care or Counseling Individual pastoral care or religious group counseling might be helpful for those with milder forms of anxiety, such as that experienced in medical settings (Hosseini et al., 2013). Religious persons with PTSD might benefit from the Building Spiritual Strengths intervention, as demonstrated in at least two RCTs (Harris et al., 2011, 2018). A comprehensive examination of the role that religion can play in recovery from PTSD is now available (Koenig et al., 2019b). Individual pastoral approaches for the treatment of moral injury in the setting of severe trauma are also being developed across multiple faith traditions (Ames et al., 2018). There is evidence to suggest that spiritual direction should be used carefully in those with severe substance abuse problems, since this may exacerbate anxiety (Miller et al., 2008). The tremendous success of spiritual approaches such as Alcoholics

Anonymous and Narcotics Anonymous in those with substance abuse problems (Kelly et al., 2020) justifies not ruling out spiritual interventions in patients with anxiety. Further work and counseling could also help us better understand how religious participation can increase anxiety in some individuals and the degree to which this is disabling for them.

Religious Psychotherapy Randomized controlled trials have suggested that religiously integrated cognitive-​behavioral approaches (RCBT) are effective in the treatment of anxiety (Razali et al., 1998; Rosmarin et al., 2010) and in the treatment of mood disorders often accompanied by anxiety (see Chapter 5). Experience is now accumulating on the benefits and safety of spiritually integrated cognitive processing therapy (SICPT) for the treatment of MI and PTSD (Pearce et al., 2018; O’Garo & Koenig, 2019), and an RCT of SICPT compared to standard CPT is now being conducted in US veterans (Ames & Koenig, 2019). Finally, RCBT holds particular promise for religious clients, given the large evidence base showing the effectiveness of conventional CBT more generally in the treatment of anxiety disorders (Olatunji et al., 2010; Carpenter et al., 2018).

SUMMARY AND CONCLUSIONS Anxiety is widespread, and anxiety disorders are the most common psychiatric conditions in the United States and around the world, causing significant disability and increasing the risk of other comorbid psychiatric disorders and medical illnesses. We began this chapter by providing a description of the DSM-​5 diagnostic criteria for anxiety disorders and related conditions now placed in a separate category (PTSD and OCD). The cost and consequences of anxiety disorders were then examined, followed by a description of the demographic, genetic, environmental, psychological, medical, and social causes of anxiety. Next, a case vignette was presented that illustrates the complex role that religion can play in anxiety disorder, GAD in particular. We then examined theoretical pathways by which religion might affect anxiety

based on the known causes of anxiety. The focus of the chapter, however, was on research examining the relationship between religiosity and anxiety. We first summarized research from the previous two editions of the Handbook, which documented nearly 300 quantitative studies on the religion-​anxiety relationship. Of those, we noted that 49% found significant inverse relationships between religiosity and anxiety, 40% no relationship, and 11% a positive relationship with anxiety. We also acknowledged that the vast majority of these studies were cross-​ sectional (preventing causal inferences). Next, we focused on best-​ designed and highest-​ quality research, i.e., 23 prospective longitudinal studies and 24 RCTs. Eleven prospective studies and 10 RCTs were then selected and reviewed. Of the 11 prospective studies, 8 found that religiosity predicted a decrease in anxiety symptoms over time, 2 found no effect, and 1 reported an increase in anxiety. This last study reported that adolescents who increased religious attendance between age 11 and 15 (while still at home under parental control, presumably) experienced an increase in anxiety, a relationship mediated by guilt. With regard to prospective studies, there is less strong evidence that religious service attendance on average decreases anxiety than there is for depression (Chapter 5). It is possible that religious service attendance increases anxiety for some and decreases it for others. It is also possible that other forms of religion and spirituality, such as prayer or religious coping, have a more important role in preventing anxiety than does religious service attendance. Further understanding and uncovering of potential moderators will be an important direction for future research. Of the 10 RCTs reviewed, 8 reported that a religious intervention significantly reduced anxiety when compared to usual care controls or other active treatments, and 2 studies found similar effects compared to other active treatments. Of the 24 RCTs, only one reported negative effects for a spiritual intervention. In that study, a “spiritual guidance” intervention in those with severe substance abuse following acute detoxification increased anxiety over time, although noncompliance and dropouts were high. The need for future large prospective Anxiety • 141

studies and RCTs and replication studies was emphasized, especially for specific anxiety disorders. Finally, based on the research above, we made tentative recommendations for health professionals and pastoral care providers, emphasizing the importance of taking a spiritual history, encouraging the use of simple religious behaviors (prayer, meditation, religious attendance), and for licensed therapists, utilizing religiously integrated psychotherapy (particularly RCBT) for the treatment of anxiety disorders in religious clients. The latter recommendation was

142 •  M ental H ealth

based on (1) controlled trials of RCBT for anxiety in Muslim and Jewish patients; (2) studies of RCBT effectiveness in mood disorders (where anxiety is often comorbid); (3) anecdotal clinical experiences with spiritually integrated cognitive processing therapy for MI and PTSD in veterans; and (4) the overall effectiveness of conventional CBT in the treatment of anxiety disorders more generally. In the next chapter, we focus on the role that religion might play in the development, course, and treatment of chronic mental disorders such as schizophrenia and related psychoses.

9 Schizophrenia and Other Psychoses The psychotic drowns in the same waters in which the mystic swims with delight. —​Joseph Campbell

IN THIS CHAPTER we examine the relationship between religion and psychotic disorders, with an emphasis on schizophrenia. Besides schizophrenia, psychotic disorders include a wide range of mental conditions, including schizoaffective disorder, delusional disorder, brief psychotic disorder, major depressive disorder (MDD) with psychotic features, bipolar disorder (BPD) with psychotic features, and medical or drug-​induced psychotic disorder. Psychotic episodes may be relatively transient and not recur, or may be chronic and long-​lasting, fluctuating in severity over time in response to treatment, life events, and the intrinsic nature of the illness. Chronic psychotic disorders are among the most severe of all mental disorders and are those most likely to have a biological or genetic etiology. Whether the psychosis is temporary or chronic, psychological stress can play a role in the onset or exacerbation of the psychosis, as well as adversely affect compliance with pharmacological treatments. Social

support and adaptive coping behaviors, in turn, may help to prevent or relieve symptoms and improve compliance. Social and cultural contexts may also influence symptom severity and course of illness based on how the person with a psychotic disorder is treated by others in their surroundings. There are cultures in which the person with psychotic symptoms may be viewed as a spiritual person gifted with the ability to communicate with other worlds and therefore revered and honored. In such societies, psychotic disorders such as schizophrenia may have a more benign course over time, compared to modern societies where individuals with psychotic symptoms are viewed as sick or diseased (and often feared because of the perception that they are unpredictable and potentially violent). Thus, religious beliefs, practices, and the faith community may influence psychotic symptoms through many different avenues, either for better or for worse. Likewise, psychotic

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0009

symptoms, experiences, and disorders may influence religious belief and spiritual experiences. Differentiating psychotic symptoms (hallucinations, delusions) from normative religious beliefs can also be a challenge, as we will discuss later in this chapter.

disorganized behavior, or catatonia (repetitive or purposeless overactivity, resistance to passive movement, and negativism); and negative symptoms such as a reduction in emotional expression or avolition. One of these symptoms must be hallucinations, delusions, or disorganized speech. In addition, there must be impairment in ability to function at work, DEFINITION, DIAGNOSIS, in relationships with others, or ability to care PREVALENCE, AND COURSE for self. These symptoms, including negative Psychosis is a term used to describe a mental symptoms, must last for 6 months or longer state characterized by delusions (fixed false (or less if treated). Other psychotic disorders, beliefs that are resistant to logic or persuasion such as schizoaffective disorder or mood disorto the contrary) and/​or hallucinations (audi- der with psychotic features, must be ruled out. tory, visual, tactile, other sensory perceptions). This means that no episodes of mania or major People with psychosis do not typically have depressive disorder (MDD) have occurred at insight into the false or pathologic nature of the same time as psychotic symptoms, and their thoughts or sensory experiences. Rather, if mood symptoms have been present, their they are often convinced that these ideas and total duration can be only a minority of the experiences are real or factual. As a result, there time that psychotic symptoms are present. is significant impairment in reality testing (i.e., Finally, psychotic symptoms cannot be due to determining what is real and what is not) and drug intoxication or withdrawal or to a medical sometimes loss of ego boundaries (inability condition such as delirium. Persons who meet to determine where the self ends and non-​ criteria for schizophrenia but whose sympself begins). These characteristics of psychosis toms last between 1 and 6 months are given interfere with the person’s ability to function the diagnosis of schizophreniform disorder. in many areas of life. The lifetime prevalence Schizophrenia should also be distinguished of psychotic disorders (all types) in the United from schizoid and schizotypal personality disStates is 3.1% (95% CI =​2.7–​3.5%) (Perälä et orders, which may present with similar sympal., 2007). We now describe the DSM-​5 diag- toms (see Chapter 11). nostic criteria for the major psychotic disorThe latest available data on the prevalence ders, beginning with the chronic psychoses and of schizophrenia are nearly 20 years old. The then describing more transient, time-​limited 12-​ month prevalence of diagnosed schizoforms of psychosis. phrenia in the United States was estimated at 0.51% in 2002, based on Medicaid/​Medicare claims data (Wu et al., 2006), whereas the lifeChronic Psychoses time prevalence in 2001–​2003 in the general Psychotic disorders in this category are schizo- US population was estimated at 0.87% (95% phrenia, schizoaffective disorder, and delu- CI =​0.3–​1.6%) (Kessler et al. 2005b; Perälä et al., sional disorder, conditions which may be 2007). The worldwide age-​standardized prevalifelong, with exacerbations and remissions lence of schizophrenia in 2016 was estimated over time. at 0.28% (95% CI =​24%–​31%), with the highest rates found in China (0.42%, 95% CI =​0.38–​ 0.48) and the lowest rates in Africa, Russia and Schizophrenia Eastern Europe, the Middle East, Mexico, and The DSM-​5 diagnostic criteria for schizophre- South America (0.16%–​0.22%) (Charlson et al., nia (Criterion A) require that two or more of 2018). Intermediate rates were found in the the following symptoms last for at least one United States, Canada, Indonesia, and Japan month or longer: hallucinations (auditory, in (0.27%–​0.33%), while somewhat lower rates particular); delusions (often bizarre in nature were reported in Europe and Southern Asia and not plausible); disorganized speech, (India and Pakistan) (0.22–​0.27%). The average 144 •  M ental H ealth

age of onset for the first psychotic episode is early twenties among men and late twenties in women. When schizophrenia was first described by Kraepelin in 1896, he called it “dementia praecox” (i.e., premature dementia). He used that term because he observed that these individuals lost their ability to function in society steadily over time, similar to what occurred among older adults with dementia. With regard to course of illness, Rangaswamy and Greeshma (2012) described several studies in their review of the literature. One was a 2-​year prospective multi-​ site study of 386 patients experiencing their first psychotic episode in India, finding that two-​thirds (66%) had a good outcome. A good outcome was predicted by regular compliance with drug therapy, short duration of illness, lack of financial difficulties, non-​ avoidance by others, lack of dangerous behavior, rural background, absence of schizoid traits, and interestingly, an increase in religious activities (Verghese et al., 1989). In a later 25-​year follow-​ up of 90 patients (Madras, India), 26% had died and 21% were lost to follow-​up; of the remaining 47 patients, outcome was considered good in 28% (n =​13), poor in 19% (n =​9), and intermediate in 52% (n =​25) (Rangaswamy, 2012). Note, however, that if those who had died or were lost to follow-​up are added to those with a poor outcome, then a poor or only intermediate outcome would be present in 86% of the original 90 patients (or 66%, assuming all of those lost to follow-​up had a good outcome, which is unlikely). In a 5-​year follow-​up of 321 patients in Ethiopia, where only 6% complied with antipsychotic medication throughout follow-​ up, 45% remained continuously symptomatic and about 20% experienced a continuous remission (Teferra et al., 2012). In a more recent review, consistent with these earlier findings, Vita and Barlati (2018) indicated that schizophrenia is a chronic lifelong condition in 75% of cases, characterized by alternating periods of remission and relapse, despite medical treatment and psychosocial interventions; however, between 14% and 50% of patients recover or improve significantly over time with treatment, depending on how recovery and improvement are defined.

SCH IZOAF F ECTIVE D ISORD ER

Schizoaffective disorder is diagnosed when symptoms of both schizophrenia and mood disorder are present. To fulfill criteria for this diagnosis, there must be an episode of mania or MDD that occurs at the same time that Criterion A symptoms of schizophrenia are present (i.e., psychotic symptoms). There must also be at least 2 weeks where psychotic symptoms are present in the absence of a major mood disorder. However, mood symptoms must be present for the majority of the course of the illness. Finally, symptoms cannot be due to a drug or medical condition. Schizoaffective disorder is specified as bipolar or depressive type. The prevalence of schizoaffective disorder in the general population is about 0.3%, and is higher in women than in men, which is largely due to the depressed type being more common in women (Perälä et al., 2007). Although there is not much research on the longitudinal course of schizoaffective disorder, one early 10-​year follow-​up of 210 patients with schizophrenia, schizoaffective disorder, or mood disorder with psychotic features found that those with schizoaffective disorder had a better outcome than those with schizophrenia but a worse outcome than those with mood disorders (Harrow et al., 2000). D EL USION AL D ISORD ER

Delusional disorder has special significance with regard to religion, given the possibility of overlap with regard to the content of experiences. According to DSM-​5, delusional disorder is diagnosed when a delusion (one or more) has been present for at least one month or longer. A delusion is a fixed false belief based on an incorrect perception of external reality. The belief is “fixed” because it is resistant to logic or persuasion to the contrary and persists in spite of undisputable evidence that it is not true. More important with regard to the current context is that the belief is not usually accepted by other members of the person’s subculture or religious group. A delusion may also be a value judgment, but only if the judgment is so extraordinary that it defies evidence to the contrary and is inconsistent with the person’s cultural or faith tradition. Schizophrenia and Other Psychoses • 145

Besides having one or more delusions, the criteria for a delusional disorder require that the person has not met Criterion A for schizophrenia in the past; hallucinations, if present, are not prominent and are related to the theme of the delusion; functioning is not markedly impaired or obviously bizarre; mood episodes make up only a small proportion of the time that the person has the delusion; and, the delusion cannot be due to the direct physiological effects of a drug or medical condition, or due to a related psychiatric disorder such as body dysmorphic disorder or obsessive-​compulsive disorder. There are several subtypes of delusional disorder including erotomanic (belief that another person is in love with him/​her), grandiose (belief that one has an unusual talent, has made unusual achievements, or is a famous person [Jesus, a prophet, or other major religious figure]), jealous (belief that a lover or spouse has been unfaithful), persecutory (belief that someone is trying to conspire against, steal from, or otherwise harm them), or somatic (belief that there is something wrong with one’s physical body or body part). The lifetime prevalence of delusional disorder has been estimated at 0.18% (95% CI =​0.11–​ 0.30) based on DSM-​ IV criteria (Perälä et al., 2007), which makes it less common than other chronic psychotic disorders (schizophrenia, schizoaffective disorder) and more common than others (schizophreniform disorder), with which it may be confused. Among those being seen in mental healthcare settings, the prevalence of delusional disorder may be as high as 1.2% (Yamada et al., 1998). The prevalence of delusional disorder is similar in men and women, although the condition increases with age (0.46% among those age 65 or older, especially in women, where the rate is 0.59%) (Perälä et al., 2007). The longitudinal course of delusional disorder is poorly understood. Based on an early study of 94 psychiatric inpatients in Norway who met DSM-​III criteria for “paranoid disorder” followed for an average of 30 years, the outcome was better compared to patients with schizophrenia with delusions, but was similar to those with schizophreniform disorder and schizoaffective disorder with delusions, and worse than those having a mood disorder with delusions (Opjordsmoen, 1989). 146 •  M ental H ealth

Time-​Limited Psychoses These disorders are usually time-​limited and do not typically persist for long periods of time as in the case of chronic psychoses, although they may remit and recur. In this category are brief reactive psychosis, substance-​ induced psychosis, psychosis due to an underlying medical condition, and psychosis associated with a mood disorder (BPD-​I with psychotic features or MDD with psychotic features). BRIEF P SYCH OTIC D ISORD ER

Brief psychotic disorder in DSM-​5 is characterized by one or more psychotic symptoms that have a sudden onset and last more than one day but remit fully within 30 days (1 month). Duration of symptoms (less than 1 month) is what distinguishes this psychotic disorder from schizophrenia (more than 6 months) and schizophreniform disorder (1–​6 months). Before this diagnosis is made, other conditions characterized by transient psychotic symptoms must be ruled out, including MDD with psychotic features, mania with psychotic features, substance-​ induced psychotic disorder, psychosis due to a general medical condition, and psychotic disorder not otherwise specified (NOS), all of which are more common. The lifetime prevalence of brief psychotic disorder is estimated to be 0.05% (95% CI =​0.02–​0.14) based on DSM-​IV, making it one of the least common psychotic disorders along with “other” substance-​induced psychotic disorders (besides alcohol-​ related) (Perälä et al., 2007). Among those admitted to psychiatric hospitals with psychotic symptoms, brief psychotic disorder (then called brief reactive psychosis) made up 2.0% according to an early US study (Schwartz et al., 2000). SUBSTAN CE-​IN D UCED P SYCH OSIS

Prescription medications, over-​the-​counter drugs, illicit drugs, or alcohol may precipitate hallucinations or delusions during or soon after ingestion of the substance or during withdrawal. Symptoms must not be due to delirium (psychosis due to an underlying medical condition) and must cause significant distress or impairment of functioning. The lifetime prevalence

of substance-​induced psychoses is estimated at 0.44%, with the majority due to alcohol-​induced psychosis (only schizophrenia is a more common cause of psychotic symptoms than alcohol-​ induced psychosis) (Perälä et al., 2007). P SY C H O SI S DUE TO AN U N D E RLY I N G ME DICAL OR N E U RO L O G I CAL CONDIT ION

Many medical and neurological conditions can precipitate psychotic symptoms, including endocrine disorders, metabolic processes, neurodegenerative disorders (dementia), and delirium. Delirium is an acute mental disturbance associated with confusion, difficulty concentrating, and disorientation that fluctuates in intensity over time, often due to electrolyte disturbances, infection, low blood sugar, or insufficient oxygen. The lifetime prevalence is estimated at 0.21% (95% CI =​0.14–​0.32%) (Perälä et al., 2007).

may improve or worsen these conditions. As with most psychiatric illnesses, psychotic disorders have genetic, environmental, gene-​ ­environment, and acquired medical causes that affect the onset and course of illness. However, for psychoses (unlike other emotional and behavioral disorders), genetic causes are particularly important.

Genetic

Among all psychotic disorders, schizophrenia is arguably the disorder most influenced by genetic factors. Heritability rates for schizophrenia approach 80% or higher, based on twin studies (Sullivan et al., 2003; Hilker et al., 2018). This means that genetic factors account for approximately 80% or more of the risk of developing schizophrenia, while common environmental effects (environmental factors that affect both twins in the same way) make up only about 11%, and individual-​ specific environmental effects (environmental influences that BI P O L A R D I S ORDE R T YPE I affect one twin but not the other, or affect each W I TH P SY C H OT IC FE AT URE S twin differently) account for the remaining 8%. This condition is diagnosed when a manic epi- While there have also been concerns about the sode is accompanied by psychotic symptoms. quality of these genetic studies and the precise The lifetime prevalence in the US general pop- estimates within these results in light of the ulation is estimated at 0.12% (95% CI =​0.06–​ difficulty of replication (Fosse et al., 2016), a 0.23%) (Perälä et al., 2007). substantial component does seem genetic. As noted for bipolar disorder in Chapter 6, genetic influences are not thought to be due to a sinMA J O R D E P RE S S IV E DIS ORDE R gle gene, but rather to the influence of a large W I TH P SY C H OT IC FE AT URE S number of different genes, each of which has a The diagnosis is made if psychotic symptoms are small effect (over 100 schizophrenia-​­associated present during an episode of MDD. The lifetime alleles have been identified in genome-​ wide prevalence in the US general population is similar association studies) (Ripke et al., 2014). to that of mania with psychotic features (0.12%). However, when the effects of all these genes Thus, there are many causes for psychotic are added up, this explains only about 20% of symptoms—​both those that are chronic and the familial risk of developing schizophrenia. those that are relatively temporary. These have Thus, there remain single genes still to be idenbeen described above, and should be consid- tified, and non-​genetic factors may also play ered when attempting to differentiate religious an important role and/​or interact with these beliefs from psychotic symptoms. genes (Agerbo et al., 2015; Misiak et al., 2018).

CAUSES OF SCHIZOPHRENIA AND OTHER PSYCHOSES Identifying factors that influence the onset or course of schizophrenia and other psychotic disorder can help to explain how religion

Environmental Parental socioeconomic status prior to birth (income, employment status, educational level) and family psychiatric history (a parent or sibling with a diagnosis of schizophrenia or Schizophrenia and Other Psychoses • 147

related psychosis, bipolar disorder, or any other psychiatric disorder) account for a significant proportion of the risk for developing schizophrenia (Agerbo et al., 2015). Socioeconomic problems often increase family stress and lead to early life trauma and childhood maltreatment or neglect. Likewise, social factors such as social exclusion (based on the “social defeat hypothesis”) may also increase baseline activity of the mesolimbic dopamine system or sensitize it in a way that increases risk of psychosis (Selten et al., 2017). This may help to explain the increased risk of psychotic disorders among migrants, ethnic minority groups, those with low IQ or hearing problems, and individuals victimized during youth—​ groups that often suffer from social exclusion (van Os et al., 2010). Other social influences found to affect the development of psychotic disorders include dysfunctional parenting, parental separation, unwanted pregnancy, disturbed attachment to caregivers, feeling abandoned, or exposure to severe trauma (serious illness, injury, or assault; bullying; domestic violence; or sexual abuse, rape, or physical assault during adulthood) (Longden & Read, 2016). There is also growing neurobiological evidence that psychological stress during childhood, adolescence, or adulthood can alter physiology in a way that increases risk of psychosis more generally and schizophrenia in particular, affecting both onset and course over time (Howes & McCutcheon, 2017).

Gene-​Environment Interactions Specific genes by themselves and the environment by itself appear to explain only a relatively small part of the risk for developing schizophrenia. Gene-​environment interactions may help to fill the gap between genetic and environmental risk factors. In a comprehensive review of such interactions, Misiak and colleagues (2018) noted that genes coding for catechol-​O-​ ­methyltransferase (COMT), FK506-​binding protein 5 (FKBP5), and brain-​derived neurotrophic factor (BDNF) interact with life stressors during childhood and with drug use during adolescence (cannabis, in particular) to affect outcomes. This could help explain Eugene Bleuler’s observation in 1911 that schizophrenia might be “the effect 148 •  M ental H ealth

of a particularly powerful psychological trauma on a very sensitive person . . .” (Bleuler, 1911, p. 300). Bleuler was the psychiatrist who coined the term schizophrenia.

Acquired Medical Medical illnesses that are acquired with aging can lead to chronic psychotic symptoms in later life. Alzheimer’s disease, Lewy body dementia, frontotemporal dementia, and vascular dementia (due to multiple small or large strokes) are often accompanied by psychotic symptoms (poorly formed, non-​bizarre delusions, particularly of the paranoid type) that interfere with caregivers’ ability to care for these individuals at home. Likewise, late-​life schizophrenia may develop as a result of changes in the brain, including those resulting from stress-​induced inflammation that increase vulnerability (Van Assche et al., 2017). Beliefs and behaviors that reduce the risk of hypertension, stroke, cardiovascular disease, and dementia in later life may impact the risk of developing psychotic symptoms through these pathways. In conclusion, there are many ways by which religious beliefs, practices, and commitments of at-​risk individuals and their primary caregivers can influence the kind of environmental exposures that increase the likelihood of developing a psychotic disorder.

RELIGION, SCHIZOPHRENIA, AND OTHER PSYCHOTIC DISORDERS The following case illustrates the complex interaction between religiosity and the development, manifestation, and treatment of psychotic disorder.

Case Vignette Asher is a 22-​year-​old unmarried man who works for his father. He was raised in a devout Orthodox Jewish family with six siblings, all younger than he. His father operates a convenience store, and his mother has a part-​time business that

she runs out of the home. Asher has two uncles on his father’s side who had mental health problems requiring medication, one of whom was institutionalized for many years. Asher has always been somewhat introverted, and there was some concern as a child that he might be autistic, although this was ruled out by their pediatrician. He has a lifelong history of unconventional beliefs and acting oddly in social situations, resulting in relatively few friends in high school and college. Most of his unconventional beliefs revolved around religion, beliefs which he seldom shared with others given their negative reactions. In college, he began smoking marijuana and hanging out with the crowd that did likewise. His friends noticed that Asher got “higher” than others in the group and tended to stay that way a lot longer than his friends. His performance in college began to deteriorate over time, and eventually he dropped out and began working for his father in the store. Of late, Asher has been having strange experiences, including hearing a voice that he believes is God telling him he must tell others to repent from their sins or disaster will strike the community. He has thrown himself into studying Jewish scriptures, spending many hours each day on this activity, which sometimes interferes with his work at the store. He begins to think that he has been “chosen” as a prophet, like Jeremiah or Isaiah in the scriptures that he has been studying. Asher is also becoming increasingly paranoid about his co-​ workers at the store and even his father, who he thinks is observing him through store cameras and recording his interactions with customers. His work performance has begun to decline, prompting several warnings from his father. However, his father has given him slack because he is worried about his behavior. Eventually, Asher’s ability to function decreases to the point that he can

no longer work at the store, and he is now spending most of his time at home focused on his religious studies. He has become quite withdrawn and often seems preoccupied with his thoughts. His parents, who have become increasingly alarmed, pressure him to seek evaluation by a psychiatrist. During his intake evaluation, Asher excitedly talks to the psychiatrist about his religious beliefs and his prophetic calling. The psychiatrist listens carefully in a supportive manner. However, when the clinician raises the possibility that he might be experiencing symptoms that warrant treatment, Asher says that he is a man of faith and has no desire for any kind of treatment for what he considers to be his special gift.   

IMPACT OF RELIGIOSITY ON PSYCHOTIC DISORDERS Religiosity may influence the development, presentation, and course of schizophrenia and other psychotic disorders, as illustrated in the case above. We offer speculations below on how religion might exert influence on psychosis, focusing on how religious involvement could (a) precipitate or exacerbate psychotic disorder, (b) be confused with it, or (c) possibly delay the onset of illness or improve its course.

Precipitating or Exacerbating Psychosis The energy released from a sudden life-​changing religious conversion experience or other religious practices can be considerable. This could be due to an increased release of dopamine in the brain which, in a vulnerable person, may precipitate psychosis or destabilize an existing psychotic disorder (Newberg, 2017; Ferguson et al., 2018). This possibility, however, remains largely theoretical. Studies to document neurochemical changes in the brain as a result of such experiences are challenging since such life-​ changing spontaneous religious experiences are relatively rare and individuals do not typically Schizophrenia and Other Psychoses • 149

seek out psychiatric care for them. However, there has been a growing number of attempts to study such experiences, particularly during meditation, which is a more controlled religious activity that can be performed on demand. In fact, at least one neuroimaging study (PET scan) has reported a change in dopamine tone during meditation (Kjaer et al., 2002). This hypothesis has been further strengthened by several case reports indicating the development of psychotic symptoms during meditation (Yorston, 2001; Sethi & Bhargava, 2003; Kuijpers et al., 2007), religious conversion experiences (Witztum et al., 1990; Penzner et al., 2010), and other spiritual practices, sometimes followed by improvement in mental functioning (Nakaya & Ohmori, 2010). Research has also reported that religious/​ spiritual experiences may be related to polymorphisms of the dopamine receptor gene, DRD4, and polymorphisms of various activating proteins that play a role in regulating dopamine transport and metabolism (Perroud, 2009). The DRD4 gene has polymorphisms involving repeat alleles in the third exon of the gene that involves between 2 and 11 repeats (2R–​ 11R). Long-​ form polymorphisms of the DRD4 gene (≥ 5 repeats) have also been associated with lower affinity for dopamine and an increased risk of schizophrenia (Lung et al., 2011). Comings et al. (2001) found that greater scores on the personality trait “spiritual acceptance” were associated with those having > 4 repeat alleles of the DRD4 gene compared to those with < 4 repeats. However, the spiritual acceptance scale used in this study was an atypical one, which asked questions about the ability to predict the future, personal experiences of extrasensory perception (ESP), and belief in other paranormal phenomena,1 which have little to do with traditional religious beliefs and practices. Regardless, the point is that spiritual tendencies have been associated with the polymorphisms of the DRD4 gene linked to schizophrenia, providing a genetic basis for the relationship between religiosity and chronic psychotic disorder.

Religious beliefs may also adversely affect the course of schizophrenia or other psychotic disorders by potentially suggesting that the mentally ill person is “demon possessed,” thus increasing the likelihood of social exclusion and, in some cases, the implementation of rituals designed to expel the demon from the person. This practice was quite common during the Middle Ages in the Catholic church, and there has been a resurgence of interest more recently in Evangelical Protestant circles. The practice of exorcism is now rarely done today, and if performed by mental health professionals could likely result in a malpractice lawsuit (Karanci, 2014; Scrutton, 2015). However, an early publication written by Kenneth McAll (1910–​2001), a British psychiatrist and member of the Royal College of Psychiatrists, reported a high prevalence of “possession states” among patients with schizophrenia (McAll, 1982). If demonic possession plays a role in the etiology of schizophrenia, then rituals to remove the demon(s), if effective, might be thought to substantiate this claim and lead to an improvement in symptoms. Exorcism, however, has not thus far empirically proven helpful in the treatment of schizophrenia or other psychotic disorders. McAll noted that while some patients exhibited less dramatic and violent manifestations of psychosis following exorcism, they invariably remained schizophrenic and required pharmacologic treatment (Wilson, 1998). Former Duke University biological psychiatrist, the late William P. Wilson (who believed in demonic possession and was a proponent of exorcism in some cases) described the differences he perceived between the demon-​possessed person and the person with schizophrenia. According to Wilson (1998), the possessed person does not have the affective changes (blunting of affect), the disturbances of thought (looseness of associations), or the ambivalence that is usually seen in schizophrenia. There is little evidence, then, that schizophrenia or other psychotic disorders are the result of demonic possession or evil spirits (Peck, 1983) that might justify exorcism as a form of treatment.

1 Example of items: “I seem to have a ‘sixth sense’ that sometimes allows me to know what is going to happen”; “I sometimes feel a spiritual connection to other people that I cannot explain in words”; etc.

150 •  M ental H ealth

A little-​ known fact today is that every Catholic diocese is still required to have a specially trained priest who can perform exorcisms (Cuneo, 1999). Note that Catholic church leaders have maintained that demonic possession is very rare and that most individuals suspected of such, after the rigorous examination required by the church prior to performance of exorcism, turn out to have mental illness (Squires, 2014). Although highly frowned on by mental health professionals, reports on the mental health benefits of exorcism in some cases of dissociative identity disorder have been published (Khan & Sahni, 2013; Irmak, 2014). One mechanism by which exorcism may have such positive effects is by hypnotic suggestion. For a recent review of the risks and benefits of what seems like an archaic and somewhat dangerous practice, see Sanford (2016). Finally, religious involvement may negatively impact the course of psychotic disorder when psychotic symptoms are confused with devout religious activity and are mistakenly reinforced, rather than identified as pathological and in need of treatment. In primitive societies, the mentally ill person may have been designated a “shaman” endowed with supernatural powers that enabled him or her to “see” into the spiritual realm and telepathically influence individuals in the present world (Thomas & Humphrey, 1996). Likewise, in some charismatic Christian settings today, it is common for the devotee to hear God’s voice speaking to him or her (although not usually audibly) or to be “slain in the spirit” in response to a light touch on the forehead. There is also the belief that certain persons have been gifted with “prophetic powers” (based on Ephesians 4:11) that allow them to have personal knowledge about an individual and their future. Such beliefs may easily border on the psychotic, and may be supported by those who share these beliefs in their religious subculture. As noted earlier, though, social acceptance and inclusion of those with psychotic disorders may actually have a positive effect on the course of illness (Murphy & Taumoepeau, 1980; Lin & Kleinman, 1988). While this frequently made point has been questioned due to relatively weak evidence substantiating the claim (Rangaswamy & Greeshma, 2012), there is little doubt that culture has a

powerful effect on the context in which gene-​ environment interactions shape the presentation and course of psychotic disorders.

Differentiating Religion from Psychosis Sometimes it may be difficult to distinguish authentic religious experiences from psychotic symptoms, particularly since these may exist on a continuum where cases on the borderline can be challenging to clinicians. Freud referred to normative religion as an “illusion” (Freud, 1927). An illusion is technically defined as an incorrect perception interpreted by the senses that includes hallucinations and misapprehensions of reality. As noted earlier, religious delusions or hallucinations can occur in psychotic disorders. The prevalence of religious delusions and hallucinations in schizophrenia ranges from 6.0% to 63.3%, averaging around 36% of all delusions and 25% of all persons with schizophrenia, with rates varying based on where the study is conducted (Koenig, 2011b; Grover et al., 2014; Cook, 2015). The prevalence of religious delusions in bipolar type I disorder (either during mania or depression) averages around 33% of all those who present with delusions and 15% of all patients with BPD-​ I (Koenig, 2011b). Religious delusions have also been associated with a worse treatment response in persons with schizophrenia (Doering et al., 1998; Kilicaslan et al., 2016), although not always (Siddle et al., 2004; Mishra et al., 2018). This may be due to poorer compliance with treatment resulting from patients’ religious convictions or to higher polygenic schizophrenia risk, which has been associated with religious delusions (Anderson-​Schmidt et al., 2019). Psychotic symptoms with religious content are more common among those who reside in highly religious countries (e.g., African, Afro-​ Caribbean, Middle Eastern) than in secular countries such as Japan or China. Religious delusions/​ hallucinations are of intermediate frequency in moderately religious countries. For example, in a study of 73 patients with schizophrenia in South Africa, 70% reported religious delusions (Connell et al., 2015). A small study of 53 patients with schizophrenia in Pakistan Schizophrenia and Other Psychoses • 151

found that 48% of less religious patients had religious delusions compared to 75% of highly religious patients (Suhail & Ghauri, 2010). In one of the few studies that reported the prevalence of religious delusions in the United States, Getz and colleagues (2001) examined psychotic patients with schizophrenia, schizoaffective disorder, or mood disorders with psychosis at a Cincinnati hospital, finding that 33.8% (45 of 133) experienced religious delusions. Delusions were more frequent in Protestant patients (43.0%). A study of older adult patients in the Netherlands (one of the few studies examining religious delusions in major depression) reported that 49% of patients with MDD and psychotic features had religious delusions, compared with 32% of those with schizophrenia; in both disorders, religious delusions were the third most common type of delusion (Noort et al., 2018). As Suhail and Ghauri found in Pakistan, research from Germany suggests that religious delusions may be more common in patients who are more religious. Compared to those without a religious affiliation, those who were highly religious were over three times more likely to have delusions (OR =​3.60, p =​0.01), whereas there was no difference between those with low or moderate religiosity and those with no affiliation (Anderson-​Schmidt et al., 2019). In that study of 262 patients with schizophrenia or schizoaffective disorder, the lifetime prevalence of religious delusions was 39%. The content of delusions was 38% grandiose (“being chosen”), 14% being possessed, 10% being Jesus, 4% being God, and 3% being damned. Interestingly, there were no Holy Spirit delusions, apocalyptic delusions, erotic religious delusions, or delusions of resurrection, which had been reported by others. As noted above, religious delusions were also associated with polygenic schizophrenia-​ risk scores (loci on chromosomes 9q and 2q) (OR =​1.40, p =​0.02), indicating a possible genetic susceptibility. In a study of patients with schizophrenia in China, the prevalence of religious or supernatural delusions was only 1.1% (2 out of 171 patients) (Kim et al., 1993). Similarly, the prevalence of religious delusions in Japan has been reported to be 6.8% (22 out of 324 patients with schizophrenia) (Tateyama et al., 1993). 152 •  M ental H ealth

The content of religious delusions tends to be drawn from the dominant religion of the culture in which the studies are done (Yip, 2003). Later in this chapter we will examine how clinicians can distinguish religious delusions from normative religious beliefs.

Delaying or Improving Psychosis Finally, there is the possibility that religious involvement may have a positive impact on schizophrenia or other psychotic disorders, delaying the onset of symptoms or improving the course of illness. How might religiosity improve the prognosis of psychotic disorders, conditions that are often so biologically driven? We review here possible genetic, biological, environmental, psychological, and behavioral pathways by which this might occur. GEN ETIC

It is not clear how religious involvement might affect the influences that heredity has on susceptibility to schizophrenia and other psychotic disorders. Already discussed is the possibility that the personality trait “spiritual acceptance” may be associated with polymorphisms of the DRD4 dopamine receptor gene, which affect the postsynaptic action of dopamine and risk of developing schizophrenia. This suggests that those who are more spiritually accepting (as assessed by the spiritual acceptance subscale based on paranormal beliefs, which, as noted earlier, has little to do with religion) may be at increased risk of psychotic disorders. However, Akbari and colleagues (2016) found that a 10-​ session spiritual intervention in breast cancer patients significantly decreased DRD4 gene expression, which, as noted earlier, is known to be increased in schizophrenia (Lai et al., 2010), suggesting quite the opposite. DRD4 polymorphisms may also interact with religion to affect behavior. For example, one study found that individuals with 2R or 7R alleles of the DRD4 dopamine receptor gene were more willing to volunteer when primed with religion (unscrambling words God, prophet, spirit, sacred, or divine), whereas the religion prime did not affect volunteering behavior in those without these alleles (Sasaki et al., 2013). This

interaction has also been shown for religious affiliation, where those with the non-​4R/​4R allele of the DRD4 gene were more likely to be altruistic if they were Christian (vs. non-​ Christian) (Jiang et al., 2015). Thus, there is evidence from genetic studies that while those who are more spiritually accepting (at least in a paranormal manner) may be at increased genetic risk for psychotic disorders, religious/​ spiritual interventions may actually reduce dopamine gene expression and thereby decrease psychotic symptoms. Furthermore, certain polymorphisms of the DRD4 gene may sensitize religious individuals to engage in prosocial behaviors, which at least theoretically might affect the course of psychotic disorders (see discussion of social pathways below). Further research is clearly needed to sort out the complex interactions between genes that control dopamine activity in the brain and receptivity to religious/​spiritual experiences, religious behaviors, and level of long-​term religious commitment. BI O L O G I CA L

There is evidence that religious involvement may reduce the risk of stress-​related cardiovascular disease, stroke, inflammation, and other risk factors for dementia, reduce the rate of cognitive decline with aging, delay the development of dementia, improve the course of dementia, and positively affect dementia-​related health behaviors (e.g., heavy alcohol use related to alcoholic dementia) (see Chapter 23). If so, then the likelihood of developing a dementia-​related psychosis may be lessened. To our knowledge, studies have not yet examined the longitudinal relationship between religious involvement and the development of dementia-​related psychosis, although doing so would be an important contribution. Similarly, research on the effect of religious involvement on medical illnesses (immune disorders, endocrine disorders, medical causes of delirium) that may give rise to psychotic symptoms is also needed (see Chapters 24 and 25). E N VI RO N M E NTAL

Religion is related to a number of the environmental risk factors linked to the onset of

schizophrenia and other psychotic disorders. As noted earlier, these include low parental socioeconomic status, poor quality of parenting, parental separation, domestic violence, unwanted pregnancy, early childhood trauma, and increased psychological stress in childhood, adolescence, and early adulthood. By increasing family stability and emphasizing the value of children and their treatment, religious involvement may neutralize some of these risk factors (Chapter 14). With regard to parental socioeconomic status, religiosity tends to be related to poorer socioeconomic status (recall that Karl Marx said that religion is “the opiate of the masses,” and “the masses” tend to be poor). However, since family religious environment is associated with better academic performance and greater likelihood of staying in school (Chapter 14), this may help to compensate for this risk factor. Nevertheless, lower parental socioeconomic status (as a proxy for environmental stress) will likely place the religious person at greater, not lower risk, and therefore needs to be controlled for when examining the relationship between religiosity and psychotic disorders. SOCIAL

With regard to social influences on schizophrenia and other psychotic disorders, religious involvement has been consistently correlated with greater social support in more than 80% of studies (Chapter 15). Involvement in a religious community provides positive social contacts, support, and encouragement of pro-​ social behaviors (e.g., “love thy neighbor as thyself”). Supportive relationships of this kind can help to buffer the negative effects of stressful life events that otherwise might precipitate a psychotic episode or worsen the course of illness. Again, early environmental stressors (poor parenting, parental separation/​divorce, domestic violence, unwanted pregnancy) are all likely to be lower in religious families given the emphasis placed on the importance of children, marriage, marital fidelity, and positive relationships within the family (Chapter 14), thus lowering the risk of early childhood stress, abuse, and neglect. Finally, the moral values taught in religious settings may help to reduce Schizophrenia and Other Psychoses • 153

the number of negative life events (out of wedlock pregnancy, incarceration, alcohol or drug addiction, job loss, etc.) that could otherwise increase stress and bring on a psychotic episode or destabilize a psychotic disorder. PSY C H O L O GI CAL

Not only might religious involvement reduce the number of negative life events, but when such events occur, as will inevitably happen, religiosity may provide coping resources to buffer the adverse effects on mental health (Chapter 4). Religion’s impact as an adaptive coping behavior has the potential not only to combat the psychological stress caused by unavoidable negative life events, but also to help persons with schizophrenia or another psychotic disorder cope with the symptoms of their disease—​frightening hallucinations, paranoid delusions, loneliness and isolation from social withdrawal. Thus, by providing cognitive resources to cope with life adversities and disease symptoms, religion may benefit those struggling with psychotic symptoms (Das et al., 2018). Furthermore, the lower risk of suicide among those who are more religious (Chapter 7) and those with psychotic disorders in particular (Gawad et al., 2018) may literally help save the lives of those with psychosis in whom the suicide rate is particularly high. This is especially the case for schizophrenia, where the suicide rate is 477 per 100,000, nearly 40 times that of the general population (Hor & Taylor, 2010).

RESEARCH ON RELIGION AND PSYCHOTIC DISORDERS The above speculations on the impact that religion may have on worsening, being confused with, or benefiting schizophrenia and other psychotic disorders ought to be examined by objective systematic research. As with all mental disorders, the relationship between religion and psychotic illness is a complex one, changing over time, with likely bidirectionality in causal effects (i.e., religiosity affecting psychotic symptoms, and psychotic symptoms affecting religious involvement). As in previous and subsequent chapters, we would like to draw special attention to large cohort studies and randomized clinical trials. Unfortunately, both types of high-​quality research studies are uncommon in this particular area. The deep divide between religion and psychiatry over the past 100 years has made it unpopular to conduct research on religion and mental health, resulting in little funding support for research and therefore few well-​ designed studies. The research done thus far has usually been accomplished without funding from either private foundations or government programs (e.g., the National Institutes of Health and National Science Foundation, the primary sources of research support in the US). We now review some of the research that has examined the relationship between religiosity and psychosis, focusing on the higher-​quality studies (see Appendix for all of the higher quality studies).

Large Cross-​Sectional Studies B EH AV I O RA L

Religiosity has been shown to reduce negative health behaviors (physical inactivity, obesity, poor diet, unsafe sexual practices), cigarette smoking, alcohol use/​ abuse, and drug use (marijuana and other substances likely to precipitate psychosis) (Chapters 10, 17–​ 19), which are common comorbid conditions in those with chronic psychoses. As noted earlier, negative health behaviors may precipitate psychotic disorders, worsen their course, or lead to other mental and physical health problems that adversely affect psychotic symptoms. By reducing these behaviors, religiosity may help to stabilize psychotic disorders. 154 •  M ental H ealth

Nimgaonkar and colleagues (2000) examined the prevalence of psychoses among Hutterites, members of an isolated religious community located primarily in Western Canada and the upper Great Plains of the United States. Investigators analyzed data from two data sets, one involving a comprehensive case-​ finding survey of all Hutterites in the United States and Canada between 1950 and 1953 (n =​8,542), and one involving health insurance claims between 1993 and 1997 from Manitoba, Canada (n =​ 7,020). Based on the 1950–​1953 survey, the prevalence of schizophrenia in Hutterites was 1.3 per 1,000 population; based on the 1993–​ 1997 Manitoba database, the prevalence was

1.2 per 1,000. These prevalence rates were significantly lower than for members of the general population in Manitoba (RR =​0.48, 95% CI =​0.21–​0.94). Likewise, the prevalence of affective psychoses (RR =​0.32, 95% CI =​0.16–​0.58) and other functional psychoses (RR =​0.28, 95% CI =​0.10–​0.62) were significantly lower than in the general population. Researchers explained that lower psychotic disorder rates were due to environmental, cultural, and genetic causes, although the Hutterites are also a devoutly religious group with strong community and family ties. Lewis-​ Fernandez et al. (2009) analyzed data from a random sample of 2,554 Latino adults from across the United States, examining relationships between religious coping and psychotic-​ like symptoms. Psychotic-​ like symptoms included having “visions” and interactions with “mysterious” or “strange” forces trying to influence the person (many of which could have been interpreted as related to divine or satanic forces, which are normative for many Latinos who are devout Catholics). Religious coping was assessed using a single item, i.e., reliance for comfort on religious or spiritual practices. Cross-​ sectional analyses indicated a positive association between religious coping and psychotic symptoms (OR =​2.33, 95% CI =​1.50–​ 3.64). There was no relationship, however, between religious coping and psychiatric hospitalization, outpatient psychiatric care, disability due to mental health problems, or suicidal ideation, indicating that psychotic symptoms associated with religious coping in this sample were rarely pathological. Psychotic-​ like experiences have also been associated with greater religious involvement in other large random national samples of community-​ dwelling Latino, Black, and White Americans (Oh et al., 2018, 2019). To what extent these psychotic-like experiences were due to the measure assessing those experiences (which may have been contaminated with normative religious beliefs held by these racial groups, particularly Blacks and Latinos) or resulted in negative health consequences was not examined in these latter studies. Kovess-​Masfety and colleagues (2018) analyzed data from 25,542 adults from 18 countries (Colombia, Iraq, Nigeria, Peru, China,

Brazil, Lebanon, Mexico, Romania, US, eight European countries), examining the relationship between religiosity and psychotic experiences. The majority of participants (86%) indicated a religious affiliation. Assessed were importance of religion at present and during childhood, frequency of religious attendance, seeking comfort through religion, and impact of religion on daily decision-​making. Psychotic experiences (PEs) were assessed by asking two questions on hallucinations (saw a vision; heard voices) and four questions on delusions (thought insertion, mind control/​ passivity, ideas of reference, plot to harm/​ follow). Analyses controlled for gender, age, country, lifetime mental disorders, and lifetime general medical conditions in sequential models. Among those with a religious affiliation (n =​21,860), based on the final model with all control variables, no difference in PEs (or PE type) were found between individual religious affiliations. Likewise, frequent religious attendance was unrelated to frequency of PEs, having more than one type of PE, or frequency of PEs per year. However, PEs were 30% more common in those indicating that religion was very important when growing up (OR =​1.3, 95% CI =​1.1–​1.6), 70% more common in those indicating religion was very important currently (OR =​1.7, 95% CI =​1.4–​2.0), 70% more common in those whose decisions were influenced by religion/​spirituality (R/​S) (OR =​1.7, 95% CI =​1.4–​2.0), and 80% more common in those who sought comfort in R/​S (OR =​1.8, 95% CI =​1.5–​2.2). Again, participants were from the general population, not psychiatric patients, and so the psychotic symptoms identified in this study were largely nonpathological (and again may have overlapped with normative religious beliefs/​experiences).

Prospective Cohort Studies We review all five longitudinal studies listed in the Appendix. Follow-​up periods ranged from 8 days to 39 years. In a 2-​year prospective study, Benda (2002a) followed 600 homeless US veterans age 45–​65 admitted to a 30-​day inpatient detoxification program, examining time to readmission to the hospital for psychiatric or substance abuse Schizophrenia and Other Psychoses • 155

treatment. Although not all veterans had chronic psychotic illnesses, many did in this homeless sample. Religiosity was measured with a 5-​item scale assessing prayer, Bible study, discussion of religion, church attendance, and belief in a supernatural being. Cox proportional hazards regression was used to determine time to hospitalization following discharge from the inpatient detoxification program. Controlled for in the analysis were age, education, race, employment, years of substance abuse, number of previous hospitalizations for substance abuse, number of previous psychiatric admissions, family attachment, childhood physical and sexual abuse, depression, childhood family attachment, self-​ esteem, self-​ efficacy, and social support. Nearly three-​quarters of participants were readmitted to the hospital during the follow-​up period. Six characteristics predicted a lower likelihood of being readmitted: current family attachment, childhood family attachment, self-​ esteem, self-​ efficacy, social support, and religiosity (HR =​0.66, 95% CI =​0.39–​0.92). Thus, greater religiosity independently predicted a lower likelihood of readmission for an acute exacerbation of psychiatric illness or substance abuse. Rosmarin and colleagues (2013a) conducted a prospective study of 47 psychiatric patients with current or past psychosis admitted to a day-​treatment program at Harvard’s McLean Hospital in Boston. The mean age of participants was 30 years, 49% were currently in a psychotic episode, and 36% had no religious affiliation. All patients received case management, psychopharmacology, vocational counseling, milieu therapy, and group therapy treatments. The average length of stay was 8 days. On admission to the day-​treatment program, participants completed measures of general religious involvement (belief in God, importance of religion, religious attendance, private religious activity) and religious coping (RC; with 7 items assessing negative RC and 7 items assessing positive RC using the 14-​item Brief RCOPE). Psychosis, depression, anxiety, and psychological well-​being were assessed with standard self-​ rated scales at the beginning and the conclusion of the day-​treatment program; change scores were calculated and used as 156 •  M ental H ealth

the dependent variable. On admission, there was no cross-​ sectional relationship between positive RC and any of the symptom scales, although negative RC was significantly and positive related to all symptom measures (especially frequency and intensity of suicidal ideation). In the longitudinal analysis, controlling for age and race, positive RC at baseline predicted a significant change in depressive symptoms (partial r =​0.50, p < 0.005), in anxiety symptoms (partial r =​0.60, p < 0.001), and in psychological well-​being (partial r =​−0.37, p =​0.05) from baseline to follow-​up; however, there was no association between any baseline religious measures and change in psychosis. Only positive RC, not negative RC, predicted a decrease in depressive symptoms when both types of RC were included in the model. Thus, positive RC predicted improvement of emotional symptoms, but not psychotic symptoms, in patients admitted with schizophrenia, schizoaffective disorder, or major depression with psychotic features. Thygesen et al. (2013) analyzed data from a cohort of 5,614 Seventh Day Adventists (SDAs) and 3,663 Baptists followed from 1970 to 2009, comparing psychiatric hospitalizations in these groups with those in members of the general population of Denmark. Psychiatric hospitalizations and reasons for admission were determined by the national Danish Psychiatric Central Register (PCR), which contains information on psychiatric hospitalizations for the entire country. A standardized incidence ratio (SIR) was estimated as the ratio of the observed and expected number of psychiatric admissions. All analyses were stratified by gender. In women, admission for schizophrenia was significantly less common among Baptists (SIR =​45, 95% CI =​18–​92) compared to that in the general population (no significant difference was found in SDAs). In men, admission for schizophrenia also tended to be less common among Baptists (SIR =​44, 95% CI =​14–​103) compared to that in the general population (no significant difference was found in SDAs). When compared directly, admissions for schizophrenia were significantly less in Baptists than in SDAs for both men and women. Among SDA men (but not SDA women), admissions for schizophrenia were lower if their parents were

also SDA (HR =​0.17, 95% CI =​0.05–​0.66). Thus, admissions for schizophrenia were less common in Baptists than in the general population or in SDAs, and among SDA men, if their parents were also SDA, admissions were less common than if parents were not. Unfortunately, this study did not assess psychotic symptoms at baseline or follow-​up (only hospital admissions during the observation period). Steenhuis and colleagues (2016) examined 337 children with and without auditory or visual hallucinations (AVHs) participating in a case-​ control study in the Netherlands. Participants were assessed at age 7–​8 and again at age 12–​ 13. Religiosity was measured by a 5-​item Dutch Spirituality and Religiosity Questionnaire, adapted for the current study in children and adolescents; asked were questions about belief in God, engagement in religious behaviors, whether raised in a religious family, if currently a member of a religious community, and if their religious belief was helpful or not (categorized into nonreligious [44%], moderately religious [33%], strongly religious [24%]). AVHs were assessed using the Auditory Vocal Hallucination Rating Scale. Religiosity was examined as a predictor of trajectories of change in AVHs over time. Trajectories were (1) persistent AVHs (both at baseline and 5-​ year follow-​ up), (2) remitted (present at baseline, absent on follow-​up), (3) incident (present at follow-​up, but not baseline), and (4) control subjects (never present). Logistic regression was used to analyze the data. Results indicated that 16.3% had AVHs at baseline (n =​55). There was no significant difference on overall summed religiosity scores between those with and without AVHs. However, moderately religious participants were more likely to have AVHs than nonreligious (24.5% vs. 11.0%, p < 0.05), whereas highly religious youth had AVHs intermediate (15.2%) between moderate and nonreligious youth. Persistent AVHs were not significantly more common in moderately or strongly religious compared to nonreligious youth; similarly, remitted AVH trajectory was unrelated to religious group. Incident AVHs were more common in moderately religious vs. nonreligious youth (OR 3.57, 95% CI =​1.05–​12.05) and in moderately religious vs. highly religious youth (OR =​7.87, 95% CI =​1.00–​64.31), although

confidence intervals were wide due to the small number of cases (4 in nonreligious, 10 in moderately religious, 1 in highly religious). Interestingly, religious beliefs were reported to be supportive, useful, or neutral by 82% of participants regardless of level of religiosity or presence of AVHs. Again, it is doubtful that the experiences labeled as “AVHs” were actually symptoms of psychosis, since the authors acknowledged that there was no difference in psychiatric service use during follow-​ up between those with and without AVHs. Finally, in a 4-​week follow-​up of 67 patients with schizophrenia in India, Mishra et al. (2018) found that private religious activities were positively associated with delusions cross-​ sectionally at baseline, but that there was no difference in treatment outcomes between those with religious delusions and those with nonreligious delusions.

Randomized Controlled Trials (RCT) To our knowledge, only one RCT and one single group experimental study of reasonably high quality have examined the effects of a religious intervention in psychotic patients. The RCT examined the effects of adding psychiatric medication to a religious intervention (rather than vice versa as is usually the case). Ofori-​Atta and colleagues (2018) randomized 139 psychiatric inpatients (80% with schizophrenia, average age 33) to either an intervention group (n =​71) or a control group (n =​ 68). All participants attended an Evangelical Pentecostal 6-​week prayer camp, where they engaged in prayer, religious services, Bible study, and fasting (eating only one meal of porridge and snacks of sugarcane each day). Prayer camp is a common form of treatment for persons with psychiatric disorder in Ghana, given their limited mental healthcare resources. In addition to participating in the prayer camp, the intervention group received psychiatric and psychopharmacological treatment; the control group participated only in prayer camp activities. In addition to receiving medication, participants in the intervention group were assessed daily by a psychiatric nurse who evaluated side effects and serious adverse events. Schizophrenia and Other Psychoses • 157

Participants were assessed blind to treatment indicated significant improvements in spiritual group at baseline, 2, 4, and 6 weeks. There were self-​reliance (p =​0.001), drug-​taking behavno differences between groups at baseline in iors (p =​0.03), and drug-​ taking acceptance terms of age, gender, marital status, education, (p < 0.001). Earlier, in another single-​group diagnosis, global assessment of functioning experimental study, Raguram and colleagues (GAF), Brief Psychiatric Rating Scale (BPRS), (2002) had found that 31 Hindu persons with or Brief Symptom Inventory (BSI) scores. The psychotic disorder (23 with schizophrenia) primary outcome was overall BPRS score and who stayed at a Hindu temple for an average of BPRS subscale scores. 6 weeks experienced a significant reduction of Results indicated that the overall BPRS score psychotic symptoms during their stay, equivaof those in the intervention group at the 6-​ lent to the effect that antipsychotic medication week follow-​up (end of trial) was significantly had on controlling symptoms. lower in the intervention group compared to the control group (1.95 vs. 2.39, p =​0.003, Summary Cohen’s d effect size =​−0.48). Between-​group differences, determined using repeated-​Much less research is available on religion measures mixed-​ effects modeling, revealed and psychotic disorders than on other mensimilar findings. Thinking disturbance and hos- tal health disorders reviewed in earlier chaptile/​suspiciousness BPRS subscale scores were ters. Large cross-​ sectional studies indicate also significantly lower in the intervention that schizophrenia and other psychotic disorgroup compared to controls at 6 weeks. The ders are less common in Hutterites compared effect sizes were slightly larger in those with to rates in the general population. A study of schizophrenia for the overall BPRS (d =​−0.87) community-​dwelling Latino Americans found and for thinking disturbance (d =​−0.65) and that psychotic symptoms were more common hostile/​suspiciousness (d =​−0.60) subscales. among those using religion to cope, although Researchers concluded that psychotropic med- the types of psychotic symptoms assessed may ication and daily nurse clinician visits resulted have included normative religious experiences in better outcomes compared to prayer camp in this ethnic group. Similarly, an internaattendance alone. However, note that the total tional study of community-​dwelling adults in BPRS score also decreased in the prayer camp 18 countries around the world found that psyalone control group from 2.78 (SD 0.99) to 2.39 chotic experiences were more common among (SD 0.87) or an average of 0.39 points (com- those who were more religious, but again, difpared to an average decline of 0.63 points in the ferentiating normative religious experiences intervention group). Furthermore, daily visits from true psychotic symptoms has been diffiby the nurse may have resulted in the interven- cult when studying nonclinical populations. tion group receiving more attention and social Prospective studies indicate that religiosity support, which could have accounted for some is associated with fewer hospital readmissions of the difference between groups as well. There in homeless veterans (many with severe menwas no evidence that involvement in the prayer tal illness) initially admitted to an inpatient camp resulted in a worsening of symptoms, detoxification program. Likewise, patients hoseven without psychotropic medication or clini- pitalized with psychotic disorders who rely on cian nurse visits. positive forms of religious coping improved Finally, in a single-​ group experimental more quickly on depression, anxiety, and psystudy, Dwidiyanti et al. (2020) examined the chological well-​being (but not psychotic sympeffects of a spiritual mindfulness intervention toms) during an average 8-​day inpatient stay. in the treatment of 45 patients hospitalized A longitudinal study of community-​dwelling with schizophrenia in Indonesia. The interven- adults in Denmark found that Baptists (partion (including an emphasis on God in prayer) ticularly women) were less likely to be hospiwas administered over 6 sessions by nurses talized for schizophrenia, although no such who had undergone training in spiritual mind- effect was found for Seventh Day Adventists. fulness. Pre-​and post-​ intervention results Finally, a 5-​year follow-​up of 337 children with 158 •  M ental H ealth

and without AVH found that religiosity was not associated with persistence or remission of AVH symptoms, although differentiating normative religious experiences from true hallucinations, especially in this age group, may have again been an issue. In the only RCT to examine a religious intervention in psychiatric patients with psychotic disorders (80% with schizophrenia), adding psychotropic medication and daily nurse clinician visits to 6 weeks of participating in a prayer camp in Ghana resulted in significantly greater improvement in psychotic symptoms in those receiving the intervention compared to those in the control group (prayer camp participation only). However, psychotic symptoms also decreased (on average) among those participating in the prayer camp, even though they did not receive psychotropic medication or daily clinician nurse visits. Furthermore, there was no indication that psychotic symptoms worsened with prayer, Bible study, participation in religious services, or religious fasting. Finally, a single-​group experimental study conducted in hospitalized patients with schizophrenia demonstrated a significant improvement in drug-​taking attitudes/​behaviors. Thus, the existing research reports a variety of findings with no clear pattern of results in terms of whether religious involvement is more or less common among those with psychotic symptoms or is beneficial to those with psychotic disorder. Experimental studies indicate that religious involvement does not appear to harm those with schizophrenia or other psychotic disorders. Further research, however, is clearly needed.

RECOMMENDATIONS FOR FUTURE RESEARCH As noted in previous chapters, cross-​sectional studies provide relatively little information about the effect that religious involvement has on the development or course of mental disorders. Long-​term prospective studies and randomized clinical trials utilizing religious interventions are needed to study the effects of religious involvement on individuals with psychotic symptoms or disorders, despite the cost, complexity, and lack of funding to

support such research. Prospective studies and randomized clinical trials of those with serious mental illness are constantly being funded and carried out for other reasons, but to our knowledge, few if any of these have assessed religiosity at baseline or follow-​up. Inclusion of a brief measure of religious involvement would not be costly and could provide important information about the impact of religiosity on the course of psychotic disorders and on the response to conventional treatments. With regard to religious interventions, of highest priority in our estimation is testing the efficacy of religiously integrated cognitive behavioral psychotherapy in those with psychotic disorders in addition to medication treatment, especially in religious patients. We recommend this because research has shown that standard secular CBT reduces disease severity in schizophrenia and other chronic psychoses, especially symptoms such as poverty of speech and thought, apathy, anhedonia, reduced social drive, loss of motivation, lack of social interest, and other negative symptoms (Velthorst et al., 2015; Naeem et al., 2016; Laws et al., 2018). Religiously integrated CBT, then, could help to address distinctively religious aspects of psychotic experience.

CLINICAL APPLICATIONS Although much future research is needed, a number of clinical applications are warranted based on what we know about the relationship between religious involvement and psychotic disorders. We focus here on five applications: (1) taking a spiritual history; (2) distinguishing normative religious beliefs and experiences from symptoms of psychosis; (3) supporting and encouraging healthy religious beliefs and practices; (4) consideration of religious interventions; and (5) networking with faith communities to help include and support those with schizophrenia and other psychotic disorders.

Spiritual History Based on systematic research, experience, and common sense, taking a spiritual history (as with all emotional and mental disorders) is the first step. The spiritual history reveals the person’s Schizophrenia and Other Psychoses • 159

past and current experiences with religion, identifies how religion is used to cope, and determines to what extent religious beliefs and practices may be contributing to psychotic symptoms and functional disability, or serving to relieve them. The spiritual history will also provide information that will assist clinicians and pastoral care providers in distinguishing community-​ sanctioned normative religious beliefs and experiences from psychotic symptoms.

Distinguishing Religion from Psychosis Over 20 years ago, Pierre (2001) described several ways to distinguish religious delusions from normative religious beliefs. He emphasized the importance of input from family members, fellow congregants, and religious professionals familiar with the patient’s ­community-​sanctioned religious beliefs. Most persons within the psychotic individual’s family and extended social faith network will recognize that there is something wrong. He stressed, however, that one must be careful in assuming blindly that informants are capable of making such distinctions, since there are entire subcultures where delusional thinking may be the norm. Pierre also noted that for religious delusions to be pathological, they must have a negative impact on the client’s social or occupational functioning. No matter how unusual or bizarre religious beliefs may be, if functioning is not impaired, then no psychotic disorder is present. For a condition to be a “disorder,” functioning must be impaired in some way, manifested by interference with social, occupational, or recreational activities. Many people are convinced that they have been abducted by aliens or that Bigfoot exists, and yet function perfectly normally within their families and society. Having strange ideas or beliefs, then, does not mean that a psychotic disorder is present. Many times, especially in borderline cases, such determinations will require multiple assessments over time, both with the client and with family members. Besides determining whether the patient’s beliefs are shared by his or her family and faith community, it is helpful to ascertain how they correspond in time to the presence of other psychotic symptoms. 160 •  M ental H ealth

Thus, even when some religious beliefs are strange, or unconventional, or when religious illusions or hallucinations are present, this does not mean that they are pathological. Furthermore, even if religious beliefs and sensory experiences are pathological and disrupt functioning, there may still be healthy normative religious beliefs and behaviors that coexist in those with a psychotic disorder. Thus, the clinician must make efforts to separate out religious beliefs, perceptions, and behaviors that are symptoms of psychosis from those that are healthy and may help the person cope with their symptoms (Koenig, 2011b).

Providing Support Once normative, socially sanctioned, healthy and functional religious beliefs/​practices of clients are identified, these should be supported and encouraged. This is especially true for social engagement in the religious community, where social support and reality-​testing may occur, as well as practical assistance provided (including transportation to clinic visits and encouragement of compliance with medical treatment). As noted earlier, social exclusion can exacerbate psychotic symptoms, and social withdrawal may be a natural reaction to that exclusion, thus leading to social isolation. Although further research is needed, involvement in a faith community may help the person with serious mental illness feel they are part of something greater than themselves and provide meaning and purpose to life, thus helping to lower the risk of substance abuse, violence against others, and suicide.

Religious Interventions Given the possible physiological (Akbari et al., 2016) and psychosocial benefits (Ofori-​ Atta et al., 2018) of religious interventions and the logic behind developing religiously integrated cognitive-​behavioral treatments for psychotic disorders (based on the success of standard CBT approaches), clinicians may consider such approaches as complementary to pharmacological treatments. Pharmacological treatment of psychotic disorders must be considered first-​ line in order to control psychotic symptoms,

but once stabilized on medication, clients must then deal with all of the psychological, social, and environmental stressors that often characterize the lives of such individuals. Research indicates that positive forms of religious coping are associated with better outcomes in patients with psychotic disorders (Rosmarin et al., 2013a; Hustoft et al., 2013) and religious interventions at a minimum do not appear to cause harm (Raguram et al., 2002; Ofori-​Atta et al., 2018; Dwidiyanti et al., 2020). Since secular CBT and psychosocial treatments have benefit in schizophrenia and other psychotic disorders (Mueser et al., 2013; Laws et al., 2018), religiously integrated interventions of this type in religious clients may help to improve well-​ being, quality of life, and relationships with family and friends. At a minimum, religious or spiritual issues should be considered when implementing secular psychotherapy, and support provided for religious clients with chronic psychoses (Mizock et al., 2012). Pastoral care by clergy and chaplains also plays an important role in the treatment of persons with schizophrenia and other psychoses, as they do for all mental disorders, since clergy—​as the first line of defense—​are often the first professionals likely to come into contact with such individuals (Larson et al. 1988; Weaver, 1995). Rapid identification and sensible approaches, including timely referral for pharmacological treatment, are necessary. Religious rituals such as exorcism (see above) play little role in the current treatment of those with psychotic disorders, and we caution that this practice has at least potential to cause harm to some individuals. On the other hand, religious rituals such as supportive prayer, Eucharistic and confessional practices in the Catholic tradition, and gentle laying on of hands as part of healing rituals within a faith community setting may provide comfort and hope for those struggling with fear, emotional pain, and alienation.

Networking with Faith Communities In order to provide support for those with psychotic disorders and to ensure that those disorders are diagnosed and treated, mental

health professionals should consider networking with faith communities in order to promote bidirectional referrals. However, there are barriers that prevent this from taking place. On the mental health professional’s side, there is a long history of negative interactions between mental health service providers and religious organizations. As noted earlier, Freud emphasized the neurotic nature of religious belief and many of his followers did likewise, creating a deep divide between mental healthcare and religious communities. Referring persons with schizophrenia or other psychotic disorders to religious communities for support and inclusion, then, may be naturally resisted. With regard to religious communities, negative attitudes toward mental health professionals have often served to undermine members’ seeking mental healthcare, taking psychotropic medications, or engaging in psychotherapy, thereby discouraging formal mental healthcare and instead emphasizing religious forms of healing. As a result, referral of congregants with evidence of psychosis to mental health professionals for care may be resisted. Faith communities may also resist including persons with serious mental illnesses such as schizophrenia and other psychotic disorders in their congregations. There is considerable stigma toward those with serious mental illness among the general public (which includes faith communities). Frequent media reports appear of persons with schizophrenia, bipolar mania, or severe depression committing violent crimes. As a result, there is a common misperception that those with serious mental illness are unpredictable and dangerous. One study found that over 50% of media reports on those with mental illness involved violent acts, whereas only 14% described successful treatment or recovery (McGinty et al., 2016). Consequently, faith communities may be resistant to including those with mental illness who might disrupt the environment, one that has become a safe haven for families and children. However, the fact is that only 4%–​10% of persons with schizophrenia are violent (vs. 2% of the general population), and this usually occurs only when they are off medication or under the influence of alcohol or drugs (Swanson et al., Schizophrenia and Other Psychoses • 161

1990; Elbogen et al., 2009; Varshney et al., 2016). Furthermore, most of that violence is perpetrated against family members (87%), not strangers or casual acquaintances who might be encountered in faith-​ community settings (Monahan et al., 2001). In fact, those with serious mental illness are more likely to be victims of violence than perpetrators (Khalifeh et al., 2015; Varshney et al., 2016). Thus, faith communities need education about the prevalence and predictors of violence among those with schizophrenia and other psychotic disorders, which may allay some of the fears that prevent inclusion. Faith communities can also require as a pre-​condition of inclusion that those with chronic psychoses take their medication and seek regular psychiatric care.

SUMMARY AND CONCLUSIONS We began with a definition of psychosis and psychotic disorder. Diagnostic criteria were reviewed for three common chronic psychotic disorders (schizophrenia, schizoaffective disorder, delusional disorder) and three more time-​limited psychoses (brief psychotic disorder, affective disorders with psychotic features, medical or drug-​induced psychotic disorder), along with a description of their prevalence and likely outcomes. Causes for schizophrenia and other psychotic disorders were reviewed with an emphasis on genetic factors, environmental influences, gene-​environment interactions, and acquired medical disorders such as dementia. A case of a young religious man with a psychotic disorder was then presented to illustrate the complex interaction between religiosity and

162 •  M ental H ealth

mental pathology, and the challenges this often poses to treatment. This was followed by speculations on how religion might (a) precipitate a psychosis or destabilize a psychotic disorder, (b) be difficult to distinguish from psychosis, and (c) delay the onset or improve the course of schizophrenia and other psychotic disorders, based on the known genetic, biological, environmental, social, psychological, and behavioral causes of psychotic disorder. We also reviewed systematic quantitative research that has explored the relationship between religiosity and psychosis. Although there are relatively few studies and the quality of those studies may be less than ideal, they provide some evidence for a connection between religious involvement and psychotic disorder, even though the results vary widely. Although much further research is needed, especially well-​ designed prospective studies and RCTs, religious involvement and religious interventions do not appear to exacerbate or worsen psychotic illness on average and may in different ways benefit some of those struggling with these conditions. Finally, applications to clinical practice were reviewed with an emphasis on the spiritual history, distinguishing normative religious beliefs/​experiences from psychotic symptoms, supporting and encouraging healthy religious beliefs/​ practices, considering religious interventions, and networking with faith communities. In the next chapter, we examine the relationship between religiosity and substance use disorders, conditions that are often present in those with severe mental disorders such as schizophrenia, often worsening the course of illness and complicating its treatment.

10 Substance Use and Substance Use Disorders They ask you about wine and gambling. Say, “In them is great sin and benefit for people. But their sin is greater than their benefit.” —​Qur’an 2:219

THE SUBSTANCES OF particular interest in this chapter are alcohol, caffeine, tobacco, prescription drugs (particularly opioids), marijuana, and street drugs (cocaine, methamphetamine, phencyclidine, heroin, designer drugs, hallucinogens). Chapter 17 will address cigarette smoking and tobacco use. Here we examine the relationship between religious involvement and the use and misuse of these substances, and the impact of religiosity on these behaviors, particularly the development of substance use disorders (SUDs). Also examined here briefly is the relationship between religiosity and other behavioral problems such as eating disorders, gambling disorders, and Internet or gaming disorders that can reach the severity of alcohol or drug addictions. SUDs are common in the United States and throughout the world. According to the US National Surveys on Drug Use and Health, conducted between 2002 and 2012, the overall past-​year prevalence of SUDs among women

was 5.9% (95% CI =​5.7–​6.1%) and among men was 13.9% (95% CI =​13.6–​ 14.2%); overall, nearly 1 out of 10 adults (Hoggatt et al., 2017). In the United States, where alcohol and drugs are more available and affordable, SUDs are more common than in other areas of the world. For example, the worldwide 12-​month prevalence of alcohol and drug use disorders combined ranges from 2.2% to 3.8% (Steel et al., 2014; Rehm & Shield, 2019). SUDs are lifelong illnesses. Even among those who recover, the relapse rate is 40%–​ 60% (McLellan et al., 2000; Daley & Douaihy, 2015). A 1953 study published in the American Journal of Psychiatry titled “What Happens to Alcoholics” reviewed life history data on 500 deceased alcoholics obtained from their children, grandchildren, and nieces and nephews (Lemere, 1953). Only 11% quit drinking exclusive of a terminal illness. The author noted, “In the generations covered by this survey, religion was often a powerful force in promoting

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0010

abstinence and 13, or 24% of these 53 who quit, did so in response to spiritual conversion” (pp. 674–​675). In almost no other area of mental health (except perhaps suicide) is there more evidence that religion makes a difference than in alcohol and drug use problems.

DEFINITIONS We begin by defining the terms abuse, dependence, substance use disorder, withdrawal, and addiction, and then examine the criteria for different SUDs as described in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-​ 5; American Psychiatric Association, 2013). Substance abuse and substance dependence were separate diagnoses with their own criteria in DSM-​IV. We describe criteria for DSM-​IV as well because there were substantial changes in classifications in DSM-​ 5, and much of the reported research has been based on DSM-​IV.

Substance Abuse Substance abuse in DSM-​ IV was defined by the presence of one or more of the following four criteria present within the past year: (1) using the substance in situations that would be considered hazardous (e.g., driving, operating machinery where someone might get hurt); (2) repeated legal problems as a result of using the substance; (3) substance use resulting in repeated failure to fulfill major role obligations (in school, at work, to family, etc.); and (4) repeated interpersonal problems caused by use of the substance. These criteria applied to intake of alcohol, drugs, or chemicals of any type. Ingestion may be via oral, smoked, vaped, or injected (intravenous or intramuscular) routes.

stopped or reduced in amount; (3) repeated use of more of the substance than intended; (4) having a persistent desire to cut back or stop using the substance, but being unable to do so despite repeated attempts; (5) continued use of the substance despite knowing that it is causing harm; (6) spending a lot of time acquiring the substance, using it, or recovering from its effects; and (7) giving up important activities due to use of the substance. SUBSTAN CE USE D ISORD ER

Substance abuse and dependence were combined in DSM-​5 into a single condition called “substance use disorder” (SUD). The 4 criteria for substance abuse and 7 criteria for substance dependence in DSM-​IV were added together. To fulfill criteria for an SUD, at least two of the 11 criteria need to be present. SUD is also categorized into mild, moderate, or severe, based on the number of criteria that the person fulfills (2–​3 for mild, 4–​5 for moderate, and 6 or more for severe). The criterion for having repeated legal problems, however, was replaced by having a strong desire or “craving” for the substance. Another way of categorizing these 11 criteria is “the 3Cs”: (1) loss of control, (2) cravings, and (3) negative consequences. Again, the “substance” can be any type of chemical—​alcohol, caffeine, prescription drugs, non-​prescription drugs, inhalants, marijuana, or illegal street drugs. WITH D RAWAL

Withdrawal is the experience of unpleasant symptoms after reducing or stopping a substance, which requires the ingestion of the substance (or a closely related substance) to avoid those symptoms. Withdrawal symptoms are usually distinct for each substance.

S U B STA N C E D E PE NDE NCE

AD D ICTION

Substance dependence in DSM-​IV was defined by the presence of 3 or more of the following 7 criteria that had occurred at some time in the past year: (1) development of tolerance (needing more and more of the substance to achieve the same effect); (2) development of withdrawal symptoms when the substance is

Addiction is another term commonly used for substance dependence. Both basically mean the same thing. Substance dependence, rather than addiction, is used to refer to physical dependence resulting from the treatment for chronic severe pain. In addiction the person has lost control over their use of a substance.

164 •  M ental H ealth

The substance now controls them. They experience less and less pleasure than when they started and the goal now is simply to avoid the terrible symptoms resulting from physiological withdrawal from the substance. The thrill and fun are gone. The person is trapped as a slave to the substance, which rules their lives (and the lives of everyone they love). This is called “enslavement.”

TYPES AND PREVALENCE OF SUDS The diagnostic criteria in DSM-​5 listed above for SUD are the same for each disorder. Prevalence rates below are provided in terms of substance use, substance misuse, and substance use disorder. Although substance use and misuse are strong risk factors for SUD, only a relatively small percentage of individuals who use or misuse these substances develop a true disorder (i.e., meet 2 or more of the 11 criteria above).

Alcohol Use Disorder (AUD) Although nearly three-​quarters of Americans drink alcohol-​containing beverages, often for recreational purposes, AUD is something quite different. Note how Bill Wilson, the founder of Alcoholics Anonymous, describes his dependence on alcohol: No words can tell of the loneliness and despair I found in that bitter morass of self-​pity. Quicksand stretched around me in all directions. I’d met my match. I had been overwhelmed. Alcohol was my master. . . . The fact is that most alcoholics, for reasons yet obscure, have lost the power of choice in drink. Our so-​called will power becomes practically nonexistent. We are unable, at certain times, to bring into our consciousness with sufficient force the memory of the suffering and humiliation of even a week or a month ago. We are without defense against the first drink. (Alcoholics Anonymous, 2001, pp. 8, 24) Alcohol use involves the ingestion of beer, wine, hard alcohol (vodka, gin, whiskey), or any other liquid that contains alcohol in it sufficient

to produce intoxication. With a 12-​month prevalence of 8.5% and a lifetime prevalence 30.3% in 2001–​2002, AUDs made up the lion’s share of those with SUDs in the United States (Hasin et al., 2007). A decade later, in 2012–​ 2013 (most recent national data available), the situation had not improved and had in fact worsened. Based on the National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-​ III), the 12-​ month prevalence of alcohol use in the United States was 72.7% (increased from 65.4% in 2001–​ 2002); the 12-​month high-​risk drinking prevalence was 12.6% (increased from 9.7% in 2001–​2002); and the 12-​month DSM-​IV prevalence of AUD was 12.7% (95% CI =​12.1–​13.3%) (increased from 8.5% in 2001–​ 2002, as noted above) (Grant et al., 2017). Based on US mortality data from the National Center for Health Statistics, the number of alcohol-​related deaths per year among people age 16 or older in the United States doubled from 1999 to 2017: from 35,914 to 72,558, increasing by over 50% from 16.9/​ 100,000 to 25.5/​100,000 (White et al., 2020). Worldwide, according to data obtained from the World Health Organization, United Nations, and 2015 Global Burden of Disease study, alcohol consumption per capita was highest in Eastern and Central Europe (12 liters[L]‌/​ year) and lowest in North Africa and the Middle East (0.9 L/​year) (Peacock et al., 2018), likely due to the high Muslim population in the latter two regions. Although AUD was not assessed in that study, rates of “heavy episodic drinking” were highest in Australasia (34.4% in past 12 months), Central Europe (33.3%), and Central sub-​Saharan Africa (32.8%), and lowest in North Africa and the Middle East (0.9%). STIM UL AN T USE D ISORD ER

Included in this category are plant-​ derived cocaine, cathinone from the khat plant, synthetic cathinone (bath salts), synthetic amphetamines (prescription and non-​ prescription), and other synthetic stimulants such as methylphenidate. Based on the 2015 and 2016 US National Surveys on Drug Use and Health (NSDUH), the 12-​month prevalence of stimulant use was 6.6% (95% CI =​6.4–​ 6.8%) (Compton et al., 2018). The highest rates were Substance Use and Substance Use Disorders • 165

among those age 18–​29 (13.0%), non-​Hispanic white (7.7%), and the never married (11.0%). Lowest use was in those age 50 or older (3.5%), non-​ Hispanic Black (3.9%), and those who were widowed (3.5%). Of the 6.6% who used stimulants, most did so without misuse. In the 2015–​2016 NSDUH, prescription stimulant misuse without a use disorder was present in 1.9%. By 2018, the number of Americans with prescription stimulant misuse exceeded 5 million (SAMHSA, 2019). In the 2015–​2016 NSDUH, stimulant use disorder was present in 0.2% overall and was highest among those population subgroups above most likely to use stimulants. Cocaine use in the United States based on the 2012–​ 2013 NESARC-​ III study was 1.02% (compared to 0.56% in 2001–​2002) (Kerridge et al., 2019). By 2018, about 5.5 million Americans had used cocaine in the past year (SAMHSA, 2019). With regard to methamphetamines, which are synthesized illicit stimulants, over 12 million people (4.7%) in the United States had used these substances at some point in their lives and 0.4% within the past 12 months (0.2% within the past month) based on the 2012 National Survey on Drug Use and Health (Courtney & Ray, 2014). By 2018, approximately 1.9 million Americans had used methamphetamine within the past 12 months (SAMHSA, 2019). Worldwide, 47 million people misused stimulants in 2017 (United Nations, 2019a). In 2010, there were an estimated 24.1 million stimulant-​dependent individuals (6.9 million cocaine users and 17.2 million amphetamine users) with an age-​ standardized prevalence rate for cocaine of 0.16% (95% CI =​0.11–​ 0.24%) and for amphetamines of 0.24% (95% CI =​0.17–​0.34%) (Degenhardt et al., 2014). After marijuana, amphetamines are the second most commonly used illicit drug worldwide. Rates of amphetamine use in 2010 were highest in Southeast Asia (0.42%) and Australasia (0.41%), and lowest in Eastern Europe and Andean South American countries (both at 0.14%) (Degenhardt et al., 2014). For cocaine, rates were highest in high-​ income North American countries (0.53%) and tropical Latin American countries (0.43%; where most cocaine is produced), and lowest in East Asia and Southeast Asia (both at 0.02%). 166 •  M ental H ealth

CAF F EIN E USE D ISORD ER

Coffee drinking is common in the United States, with 75% of the adult population reporting this practice (49% on a daily basis) (Loftfield et al., 2016). Caffeine is the most widely used drug in the world, and in the United States 90% of adults consume caffeine-​ containing products on the average of 150–​200 mg of caffeine/​day (Frary et al., 2005; Davis et al., 2013). This is roughly equivalent to drinking two 6-​oz cups of coffee or five 12-​oz soda drinks per day (Meredith et al., 2013). Caffeine use disorder is included in DSM-​5 as a condition for further study, largely due to concern over fatalities and increasing emergency room visits resulting from caffeine intoxication from ingesting high-​energy drinks, diet pills, and combination caffeine-​alcohol drinks. CAN N ABIS USE D ISORD ER

Marijuana is the most commonly cultivated, trafficked, and abused illicit substance worldwide (United Nations, 2019b). Marijuana is currently considered an illegal drug by the federal government in the United States, although as of November 12, 2020, 15 states and the District of Columbia have legalized the drug, and 36 states have legalized medical marijuana. Based on data from Wave IV of the US National Longitudinal Study of Adolescent Health (15,500 persons age 24–​32, interviewed in 2008–​2009), which compared lifetime rates of alcohol abuse/​dependence with that of cannabis abuse/​dependence, the rates for alcohol abuse and dependence were 11.8% and 13.2%, respectively, compared to those for cannabis abuse and dependence of 3.9% and 8.3%, respectively (Haberstick et al., 2014). Based on data from the 2012–​2013 NESARC-​III study of US adults, the 12-​month prevalence of marijuana use was reported to be 9.5% (increased from 4.1% in 2001–​2002) and cannabis use disorder was 2.9% (nearly double the rate of 1.5% in 2001–​2002) (Hasin et al., 2015). According to somewhat more recent data from the 2014 National Survey on Drug Use and Health, the 12-​month prevalence of marijuana use among adults in the United States was 13.2% and past-​ month prevalence was

8.4% (Azofeifa, 2016). Daily or almost daily marijuana use increased from 1.3% in 2002 to 2.5% in 2014, a 90% increase. The average age when marijuana use began for “users age 12 or older” was under age 19; for “users age 12–​17,” the average when marijuana use first began was under age 15. In other words, marijuana use on average begins in the teen years (despite the fact that in states where marijuana is legal, the age limit to buy or use marijuana is 21 years). Worldwide, an estimated 2.4% of adults use marijuana, making up a total of 188 million users in 2017, with the greatest use in North America (44.6 million) (United Nations, 2019b). Cannabis use disorder has a high comorbidity with other drug use disorders, including sedative (OR =​5.1, 95% CI 2.9–​ 9.0), cocaine (OR =​9.3, 95% CI =​5.6–​15.5), stimulant (OR =​4.3, 95% CI =​2.3–​ 7.9), club drug (OR =​16.1, 95% CI =​6.3–​40.8), opioid (OR =​4.6, 95% CI =​3.0–​6.8), and alcohol use (OR =​3.0, 95% CI =​2.5–​3.7) disorders (Hayley et al., 2017), making cannabis a “gateway” drug for many. Black and colleagues (2019), in a review of 83 studies involving 3,067 participants, found little evidence for using cannabinoids for the treatment of mental disorders, a practice that many in the popular press have advocated. In fact, their pooled analysis of all mental disorders involving 1,495 participants in 10 randomized controlled trials found that THC-​ containing pharmaceutical preparations did not improve the primary outcome and in fact were associated with double the adverse side effects compared to placebo (OR =​1.99, 95% CI =​1.20–​3.29). Likewise, study withdrawal due to adverse side effects in those taking THC preparations was nearly 3 times that of those taking placebo (OR =​2.78, 95% CI =​1.59–​4.86). H A L L U C I N O G E N US E DIS ORDE R

This diagnosis includes phencyclidine (PCP) use disorder and other hallucinogen use disorders involving ergolines (e.g., lysergic acid diethylamide [LSD] and morning glory seeds), indoleamines (e.g., psilocybin and dimethyltryptamine [DMT]), phenylalkylamines (e.g., mescaline, dimethoxy-​4-​methylamphetamine

[DOM or STP], and methylenedioxymethamphetamine [MDMA or Ecstasy]), and phenethylamines (e.g., 25I-​NBOMe, a synthetic hallucinogen). According to the NESARC-​ III study in 2011–​2012, the 12-​month prevalence of hallucinogen use in the United States was 0.62% and the lifetime use was 9.32% (Shalit et al., 2019). As with cannabis, there is a high comorbidity between hallucinogen use disorder and other SUDs. Among those who have used a hallucinogen at some time in their lives, the prevalence of nicotine use disorder is 45.7% and alcohol use disorder is 35.7%. Mental disorders are also frequently comorbid, with personality disorder present in 31.4% and depressive disorder present in 22.0%. IN H AL AN T USE D ISORD ER

Inhalants include glues and adhesives, aerosols, anesthetics, cleaning agents, and solvents or gases. These substances contain volatile hydrocarbon intoxicants such as toluene, trichloroethylene, n-​hexane, freon, and gasoline. Inhalants are widely available and used by young adults, often in their teens, with decreasing prevalence with increasing age. Lifetime inhalant use in the United States ranges from 7.8%–​10.8% in 8th grade to 6.5–​7.6% in 12th grade (Bowen et al., 2016). The average age of onset is 11.6 years. Inhalant use decreased among 9th–​12th graders from 16.0% in 1997 to 8.9% in 2013. Symptoms of inhalant intoxication include tremor, lethargy, nystagmus, poor coordination, slurring of speech, and when severe, stupor or coma. Long-​term inhalant use causes brain atrophy in multiple regions including the cerebrum, cerebellum, and brainstem (Bowen et al., 2016). TOBACCO USE D ISORD ER ( TUD )

TUDs (also called nicotine use disorders) are among the most common causes of physical mortality and morbidity in the world. Nicotine can be taken in by smoking cigarettes, pipes, or cigars; chewing tobacco or nicotine gum; using snuff; or by e-​cigarettes or vaping. Based on data from the 2012–​2013 NESARC-​III study, the 12-​ month prevalence of TUDs in the United States was 20.0% and the lifetime prevalence was 27.9% Substance Use and Substance Use Disorders • 167

(Chou et al., 2016). TUDs are more common in men (61% more frequent than in women), adults age 30–​44 years old, White Caucasians, those with less education or income, those who are not married, and those living in urban areas or in the Southern United States. Worldwide, the prevalence of tobacco smoking in 2015 was 15.2%, with the highest rates in Eastern Europe (24.2%) and Oceania (24.0%) (Peacock et al., 2018). See Chapter 17 for more details on the epidemiology of cigarette smoking. O PIO I D U S E D I SORDE R

The “opioid epidemic” in the United States (and around the world) is familiar to most these days (Murthy, 2016; Baker, 2017). The term “epidemic” has been used because of the recent 345% increase in opioid-​related deaths in the United States, which increased from 33.3 deaths per million in 2000 to 130.7 in 2016 (Gomes et al., 2018). Three major types of opioids exist: natural, semi-​synthetic, and fully synthetic. Natural opioids include morphine, codeine, and thebaine. Semi-​synthetic opioids include hydromorphone, hydrocodone, oxycodone (e.g., OxyContin), and heroin (made from morphine). Examples of fully synthetic opioids are fentanyl, pethidine, levorphanol, methadone, tramadol, and dextropropoxyphene. In order to obtain a more intense high, heroin has recently become laced with fentanyl, increasing the risk of overdose. Fentanyl is an extremely potent opioid. One gram of fentanyl (obtained legally online from China) can provide 7,000 doses of the drug. The use of fentanyl has now expanded to its inclusion in prescription opioids (oxycodone). As a result, pure oxycodone and fentanyl-​laced oxycodone may be difficult to tell apart. Based on results from the 2015 National Survey on Drug Use and Health (NSDUH), researchers estimated that 91.8 million adults (37.8%) of the civilian non-​ institutionalized adults age 18 or older in the United States used prescription opioids in the prior year; 4.7% (11.5 million) misused opioids; and 0.8% (1.9 million) had an opioid use disorder. Of those who used prescription opioids in the 2015 NSDUH, 12.5% indicated misuse of these drugs, and of those who misused opioids, 16.7% had a misuse disorder. The most 168 •  M ental H ealth

common reason given for opioid misuse was to relieve physical pain (63.4%). The majority of these individuals used opioids without a prescription (59.9%), and a large proportion obtained prescription opioids from friends or relatives (40.8%). According to the 2012–​2013 NESARC-​III study, heroin use in the United States increased from 0.3% in 2001–​2002 to 1.6% in 2012–​2013 (a 533% increase). Heroin use disorder, in turn, increased from 0.21% to 0.69% (a 329% increase) (Martins et al., 2017). The increase in heroin use was especially common among Whites (0.34% to 1.90%) compared to non-​W hites (0.32% to 1.05%) and in those age 18–​29 (0.21% to 1.00%) and age 30–​44 (0.20% to 0.77%). Among users, heroin dependence (DSM-​IV) was similar in both 2001–​2002 and 2012–​2013 at 25–​28%. The rate of non-​medical use of prescription opioids preceding heroin use increased among Whites from 35.8% to 52.8% during this period. Worldwide, there were 29.2 million people who used opiates such as heroin and opium in 2017, which was 50% higher than in 2016, just one year previously (19.4 million). North America is the region where heroin and opioid use is the highest (3.96% compared to the global estimate of 1.08%). The lowest rates are in East and Southeast Asia and South America (0.20%) (United Nations, 2019b). The largest producers of opium are Southwest Asia (Afghanistan), Southeast Asia (despite the low use in the general population), and Mexico. Opioid addiction is truly a neurobiological disorder (Koob & Volkow, 2010; Volkow et al., 2016). The dopamine-​mediated “craving” with opioid addiction goes far beyond that expected by the pleasure caused by the release of endorphins in the brain. Once addiction is established, the craving for the drug may become a lifelong problem, making the person vulnerable to relapse for many years, even after they have stopped using. Opioids literally hijack the reward centers of the brain originally intended to motivate individuals to act in ways that promote survival. These drugs exert a much greater stimulation of reward centers than the desire for food, sex, or anything else. Recent research based on functional magnetic resonance imaging (fMRI) brain scans in 19 devout Mormons revealed that the reward

and salience centers affected by opioids are the same ones activated during religious experiences and devotional practices (i.e., the nucleus accumbens, ventromedial prefrontal cortex, frontal attentional regions) (Ferguson et al., 2018). This may have implications for the kind of intervention necessary to recapture the hijacked reward systems, for example, through life-​ changing religious experiences. This is often the focus of 12-​step programs such as Narcotics Anonymous. Likewise, establishing or re-​establishing a connection with God (in monotheistic traditions) for some may be the only experience capable of replacing the cravings associated with opioid addiction. S E DATI V E , H Y PNOT IC, AND A N XI O LY TI C US E DIS ORDE R

Sedatives slow brain activity, and are often used to assist sleep or reduce anxiety. These drugs (previously called “tranquilizers”) can potentiate the effects of alcohol and other sedating medications. Drugs in this class include benzodiazepines (e.g., alprazolam, lorazepam, clonazepam, diazepam, chlordiazepoxide, flurazepam, temazepam), barbiturates (e.g., phenobarbital, secobarbital, amobarbital, pentobarbital), and other drugs (e.g., chloral hydrate, methaqualone, meprobamate). The benzodiazepines are today the most commonly used drugs in this category. Based on the National Health and Nutrition Examination Surveys (NHANES) conducted between 1999 and 2010, the prevalence of anxiolytic/​ sedative/​ hypnotic use in the general US population is 3.5%, and is higher among those age 65 or older (5.6%) (Breslow et al., 2015). Data on filled benzodiazepine prescriptions from the Medical Expenditure Panel surveys indicate that between 1996 and 2013, US adults filling a benzodiazepine prescription increased from 4.1% to 5.6% for an annual percent increase of 2.5% per year (Bachhuber et al., 2016). A recent review of 351 community studies found that benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the United States (2.2% of the population or 6 million persons aged 12 or over) (Votaw et al., 2019). This percentage was surpassed only by

prescription opioids (4%) and marijuana (15%), based on the 2017 National Survey on Drug Use and Health survey. In addition, another 0.5% (1.4 million Americans) misused sedatives. Tranquilizer use disorder was present in 0.3% (739,000) and sedative use disorder in another 0.1% (198,000). Therefore, of the 2.2% of the US population who used benzodiazepines and other tranquilizers, 0.1% met criteria for a sedative, hypnotic, or anxiolytic use disorder. Among countries outside of the United States, 2.2% of adults in Sweden misused benzodiazepines or tranquilizers within the past year, and 1%–​ 2% of residents of Thailand, Brazil, and Australia did likewise (Votaw et al., 2019). In 2017, the non-​medical use of sedatives and/​or tranquilizers across 14 countries in Western and Central Europe also occurred in approximately 2% of the general population, and was more common in women than in men; interestingly, use rate was higher than for cannabis in 8 of the 14 countries (United Nations, 2019b, p. 20). With regard to sedative, hypnotic, or anxiolytic use disorder, rates were reported to vary from 0.2% to 0.4% in Thailand and Australia, somewhat higher than those in the United States (Votaw et al., 2019). Sedative, hypnotic, or anxiolytic drug use is not without consequences. Bachhuber et al. (2016) found that because of increased prescribing practices in the United States between 1996 and 2013, the overdose death rate from benzodiazepines increased from 0.58 per 100,000 to 3.07 per 100,000, an increase of 529%. Benzodiazepine use and misuse have also been associated with increased suicidal ideation and attempts, poorer quality of life, greater pain severity, worse sleep problems, repeated emergency department visits, slowed thinking and altered mental status, physical health problems, and other SUDs (Votaw et al., 2019). This is especially true in the elderly, where benzodiazepine use is also associated with cognitive deficits, falls resulting in fractures, motor vehicle accidents, and increased overall mortality (Markota et al., 2016). CON CL USION

Alcohol and drug use and misuse are common in the United States and throughout the world, Substance Use and Substance Use Disorders • 169

and are increasing in prevalence over time. This trend is reflected in the prevalence of alcohol and drug use disorders. The overall past-​year prevalence of SUDs in the United States is approximately 10%, or 1 out of every 10 adults. Despite economic prosperity and abundant resources, rates of SUD in the United States are among the highest in the world. The consequences of SUD are devastating in terms of effects on quality of life, interpersonal relationships, and physical health, including increased mortality from intentional and unintentional overdose, from associated disease, and from traffic accidents and accident-​related natural causes.

studies; and (c) genome-​wide association studies (GWAS). Twin studies suggest that approximately 50% of the variation in SUDs is due to additive genetic factors (Agrawal & Lynskey, 2008; Enoch, 2012; Munn-​Chernoff & Baker, 2016). Thus, genetic and environmental factors appear equally important. This varies, however, depending on the particular substance. Genetic influences on alcohol addiction (50%) are not as strong as in cocaine or opiate addiction (60%–​70%) (Goldman et al., 2005). More recently, Hicks and colleagues (2013) reported that additive genetic factors explained 47% of the variation in alcohol dependence, 49% of the variation in drug dependence, and 41% of the variation in nicotine dependence; shared envifactors make up a nonsignificant CAUSES OF SUBSTANCE USE, ronmental 5%–​10% depending on substance, and nonABUSE, AND DEPENDENCE shared environmental influences explain the We now briefly review the genetic, environ- balance (41%–​48% of variation). mental, gene-​environment, psychological, and Prom-​ Wormley and colleagues (2017) social factors that increase vulnerability to reported that while substance initiation is sigSUDs. Among the strongest risk factors are nificantly influenced by shared and nonshared family history (genetic predisposition and early environmental influences, additive genetic childrearing practices), exposure to alcohol/​ factors are more likely to affect SUD progresdrugs that are used by relatives or peers (espe- sion (regular use and dependence). Although cially during adolescence), high-​risk environ- shared environmental factors remain influenments (high stress, few sources of healthy social tial in adolescence (when the developing brain support, easy access to alcohol/​drugs, permis- is highly plastic and sensitive to drug effects), sive attitudes toward use), and the presence of they no longer have much effect on substance mood, anxiety, and attention disorders in child- dependence in adulthood. In contrast to twin hood and adolescence (Volkow et al., 2016). studies, candidate gene association studies When comparing the prevalence of substance and GWAS have been unsuccessful in identiuse with the likelihood of developing an SUD, fying specific genes or combinations of genes only a small percentage of those who use alco- that increase the risk of developing SUDs or hol or drugs do so. Approximately 10% of those affecting their course. The exception is a polywho take addictive substances will develop an morphism of aldehyde dehydrogenase ALDH2 addiction, so other factors must be operative. allele (ALDH2*2), which affects alcohol metabAs we have argued in earlier chapters, risk olism in the liver resulting in unpleasant side factors for the development and maintenance effects that reduce alcohol intake and decrease of SUDs may provide clues on how religious risk of developing an AUD. The general conseninvolvement might impact vulnerability. sus, though, is that SUDs are polygenic in etiology, with multiple genes having small effects that add up to increased risk, especially as they Genetic interact with the environment (Prom-​Wormley Genetic influences are determined by (a) twin et al., 2017). studies involving monozygotic twins, dizygotic twins, and adopted twins, which proEN VIRON M EN TAL vide information on additive genetic, shared environmental, and nonshared environmen- Childhood abuse and neglect have long tal influences; (b) candidate gene association been linked to alcohol/​ drug use and the 170 •  M ental H ealth

development of SUDs (Felitti et al., 2019). Research has shown that nearly half (40%–​ 50%) of children who are maltreated in early childhood later experience substance use problems, especially in early adolescence (Dube et al., 2003). Because of the way the brain normally develops during adolescence, this promotes a tendency toward risky judgments, with choices particularly influenced by emotion. Childhood maltreatment has been shown to produce changes in the limbic system of the brain (amygdala, in particular) that further increase risk-​taking and substance use (Van Dam et al., 2014). Parenting style may also affect risk. An authoritative parenting style, one that is demanding but responsive to the individual child’s needs and showing love as the child grows older and becomes more independent, along with an open communication style and flexible application of rules, reduces the risk of later SUD. In contrast, an indulgent parenting style (affectionate with children, but making few demands or using punishment to correct behavior) and especially a neglectful parenting style (where parents are indifferent to the child’s behavior, setting no limits and failing to provide affection) have the opposite effect (Becoña et al., 2012). Cultural differences, though, may affect the impact of parenting style, in that an indulgent style in Spain, for example, may be more protective than an authoritative style (Becoña et al., 2012). With regard to AUD, environmental risk factors include parental alcohol dependence and parental divorce, which predict early first use of alcohol (Sartor et al., 2007). Early onset of drinking in adolescence, in turn, predicts development of AUD in adulthood. Family history of alcohol dependence (in addition to parental alcohol dependence), low parental monitoring, low self-​control, impulsivity, and peer alcohol use are among the strongest predictors of AUD (Connor et al., 2016). Environmental risk factors for other SUDs are similar to those of AUD. Developing an illicit drug use problem is predicted by parental drug use, and particularly marijuana use, poor parental adjustment, childhood abuse, substance-​ abusing peers, and alcohol use (Fergusson et al., 2008).

GEN E-​EN VIRON M EN T IN TERACTION S

Gene-​environment (G × E) interactions occur when genetic risk factors combine with or are affected by environmental risk factors to increase the risk of SUDs (Enoch, 2012). Such interactions are most evident for early environmental stressors, such as childhood sexual, physical, or emotional abuse; physical or emotional neglect; and parental divorce or death, family violence, parental mental illness, or economic adversity, especially when such stressors occur before age 5. What counts is the severity of the stressor, rather than the particular stressor itself, and the individual’s later access to alcohol or drugs. These effects appear independent of whether the parent has an SUD. Certain gene variants increase susceptibility of those with early life stress to alcohol or drug use disorders. This is particularly true for (a) the CRHR1 gene variant and childhood maltreatment in its effects on HPA reactivity during adulthood, and (b) the effects of the Met allele carrier of the BDNF Val66Met polymorphism and childhood maltreatment on later gray matter volume shrinkage. Animal models show that maternal separation has chronic effects on the mesolimbic dopamine pathway (reward pathways for experiencing pleasure from food, sex, or alcohol/​drugs), which may be increased among those with a certain genetic type. Not yet clear are the effects of G × E interactions during adolescence or adulthood, compared to those occurring before the age of 5 years. Although only a few studies show G × E effects on SUDs, many studies report such effects for mental disorders known to increase risk of SUDs (e.g., childhood conduct disorders, ADHD, antisocial behaviors). P SYCH OL OGICAL

As noted above, development of an SUD is increased in the presence of another psychiatric disorder, such as conduct disorder or ADHD during childhood/​adolescence and mood, anxiety, and personality disorders during adulthood (Najt et al., 2011). When both an SUD and a comorbid psychiatric disorder are present, compulsive substance use, severity of substance use, and treatment resistance are all

Substance Use and Substance Use Disorders • 171

more likely. For example, ADHD, conduct disorder, generalized anxiety disorder, and use of other substances (nicotine and cannabis) are strong predictors of later progression to alcohol use disorders (Sartor et al., 2007). Poor childhood and early adolescent adjustment are also known to predict increased likelihood of SUD (Fergusson et al., 2008). Lack of psychological coping skills necessary for dealing with stressors and urges can also precipitate SUD relapse and interfere with recovery, underscoring the importance of developing coping skills as an aspect of treatment (Botvin & Griffin, 2016). SOCIAL

Although early childhood environment was addressed above, social factors play a major role throughout the lifespan in the development and persistence of alcohol and drug use disorders. The Social Development Model helps to organize the various social factors that influence the development of SUDs (Catalano et al., 1996). This model is composed of four major pathways: (1) perception of opportunities for either prosocial or antisocial behavior; (2) involvement with prosocial or antisocial peers; (3) social skills that increase likelihood of involvement, recognition, and reward; and (4) perception of reward from involvement in various prosocial or antisocial groups. There is ample research showing that positive social environments, strong families, and involvement in prosocial peer groups play a critical role in protection against the development of SUDs. As noted above, family environment is crucial. Jones et al. (2016) note that: “because of their primacy in the developmental order, families have the greatest potential to influence further behavior as well as create a structure for future social interactions with peers and, later on, with romantic partners” (p. 723). In a study of 808 participants interviewed 12 times from age 10 to 33, these researchers found that that positive family functioning at age 10–​12 predicted a lower likelihood of early substance use, whereas family substance use and dysfunction led to a greater severity of substance abuse problems in a “cascading” manner. Finally, researchers found that “individual functioning” during adolescence in terms of mood and 172 •  M ental H ealth

anxiety problems, behavioral disinhibition, and poor engagement in work/​school or civic activities (community groups, volunteering) and physical activity predicted choice of negative social environments, thereby influencing future substance use. In an early review of this literature focusing on social support in the development of substance use problems in Hispanics, De La Rosa and White (2001) found that familial factors (family pride, family structure, family drug use, sanctions against drug use, parental involvement with children and control), peer influences (peer drug use, peer pressure to use drugs), involvement in religious social groups, and supervised after-​school and in-​home activities (vs. unsupervised activities with peers) had a powerful impact on substance use during childhood, adolescence, and adulthood. Peer support for those with SUDs through 12-​step programs is one of the most important factors in recovery reported by those experiencing alcohol and drug problems (Kelly et al., 2017). By surrounding the addict with a group of supportive peers and sponsors dedicated to helping the person maintain abstinence, such programs have repeatedly been shown to reduce the likelihood of substance use or relapse (Bassuk et al., 2016). One of the key factors in recovery is the replacement of the addict’s peer group of substance abusers (those who may be a source for obtaining alcohol/​drugs and encouraging their use) with a positive peer group made up of those who are abstinent or intent on maintaining abstinence through mutual support. We will say more about these mutual self-​help programs below when discussing clinical applications. Nevertheless, there is little doubt that social factors play an enormous role in the initiation, continuation, and recovery from SUDs.

TREATMENTS Current treatments for SUDs include medication-​ assisted treatments, professional counseling, recovery support services, and mutual self-​ help groups. Medication-​ assisted treatments include acamprosate, disulfiram, and naltrexone for alcohol dependence; methadone, buprenorphine, naltrexone, and the buprenorphine-​ naloxone combination

(Suboxone) for opioid dependence; and bupropion and varenicline for nicotine dependence. Addiction counseling includes individual or group cognitive behavioral therapy (CBT), motivational enhancement therapy, motivational incentives, relapse prevention therapy, and numerous other professional therapeutic approaches. Recovery support services include resources provided by recovery community centers, state or local recovery community organizations, college recovery programs, sober living environments, and so forth. Mutual self-​help groups include both faith-​based and secular recovery programs. Treatment usually involves a combination of medication-​ assisted treatments, professional counseling, and involvement in mutual self-​help groups. However, since 12-​step programs often require total abstinence, there may be conflict over use of highly effective medication-​assisted treatments in such programs, particularly for those with opioid use disorders (Monico et al., 2015). As noted above, even with all of the above resources available, approximately half of those with SUDs relapse. Thus, combined approaches are often essential (see clinical applications).

RELIGION, ALCOHOL, AND DRUG USE Case Vignette Manuel is a 19-​ year-​ old single never-​ married Hispanic male who works in an auto body repair shop in a large Northeastern urban city. He has had a rough childhood in that his dad was a heavy drinker and when intoxicated was abusive to his mom, himself and his siblings. After Manuel’s parents separated when he was 9 years old, his mother had to work full-​time to support the family, and often worked into the evening hours, when his oldest sister was responsible for watching over him and his siblings. When young, Manuel was small in stature and frequently was bullied at school. His mother was a devoutly religious person who took him and his siblings to church

every Sunday. They would pray as a family together every morning before leaving for school and every night after his mother returned from work. As Manuel moved into mid-​adolescence, he started to bulk up physically and joined the high school football team. He felt pressured by some of his peers on the team to get involved in parties after games where there was lots of alcohol and sometimes drug use. Nevertheless, the religious faith his mother had instilled in him while growing up prevented Manuel from giving in to the pressure. Instead, he would hang out with friends he had made at the church’s high school youth group, going to the gym with them on days when he didn’t have practice or games, and then going out for pizza afterward. Now, when his co-​workers at the car shop ask him to come party with them, he declines, saying that his religion doesn’t allow him to do that and instead goes to the gym or bowling alley to spend time with his young adult church friends.   

HOW RELIGION MIGHT INFLUENCE SUBSTANCE USE DISORDER Based on the above pathways by which SUD develops, how might religion affect the initiation, continuation, and recovery from alcohol or drug use? We speculate here on possible genetic, gene-​ environment, environmental, psychological, and social mechanisms.

Genetic Among those who are more religious, there is some evidence that genetic factors play a role in less use of illicit drugs during adolescence and young adulthood, the time when lifelong patterns of substance use often begin. Examining data from 2,537 young adults participating in Wave III of the National Longitudinal Study of Adolescent Health (Add Health), Dew and Koenig (2014) found that the SS and SL Substance Use and Substance Use Disorders • 173

genotypes of the serotonin transporter gene (5HTTLPR) were less common among those who were more religious, especially non-​Whites. Because SS/​SL genotypes are also less common among those who use illegal drugs (at least in that study), this could help to explain lower drug use among the more religious. However, there was no evidence in this study that genotype fully explained the inverse relationship between religiosity and drug use. Thus, both religiosity and genotype independently predicted illicit drug use. In a later analysis of data from Waves I through IV of the Add Health Study (9,422 adolescents age 12–​38), however, Dew et al. (2017) found that polymorphisms of the 5HTTLPR gene mediated the inverse relationship between religiosity (particularly frequency of prayer) and later substance abuse. Researchers concluded that religiosity may be related to lower rates of addiction in part through genetic mechanisms. Given the relatively few studies in this area, however, these conclusions need further study. G EN E -​E N V I RO N ME NT INT E RACT IONS

Although studies that examine G × E interactions are few (where environment =​religiosity), the evidence available suggests that religious involvement is more strongly inversely related to substance use among individuals with certain genotypes. Dew and colleagues (2017) reported that the following were found only among the 5,921 participants who were homozygous for the L allele of the serotonin transporter gene (but not in 3,030 who were carriers of the S allele): change in religious attendance over time predicted earlier age of cigarette smoking initiation, regular smoking, and degree of smoking; change in religious importance over time predicted age of smoking initiation, regular smoking, and age of initiation of alcohol use; low baseline religious importance predicted greater frequency and amount of alcohol use; change in frequency of prayer predicted increased smoking experimentation, regular smoking, earlier age at initiation of regular smoking, alcohol experimentation, and drug use; and low baseline prayer frequency predicted drug abuse. Likewise, among those heterozygous for the polymorphism 10/​ 10 genotype of the 174 •  M ental H ealth

dopamine transporter gene (DAT1) (but not in those homozygous for the 10-​repeat allele), change in religious importance predicted earlier age of smoking experimentation; lower religious importance at baseline or change over time predicted marijuana abuse; and change in prayer frequency predicted greater number of cigarettes smoking/​day. Similarly, among those with no 7-​repeat allele of the dopamine receptor subtype D4 (DRD4) (but not in those with at least one 7-​repeat allele), low baseline religious attendance and change in attendance predicted a greater degree of smoking among smokers; change in both attendance and importance predicted earlier age of marijuana first use; change in religious importance predicted any marijuana use; change in frequency of prayer predicted greater smoking experimentation, regular smoking, and earlier age of initiation of regular smoking; low baseline prayer predicted alcohol experimentation, drug abuse, and abuse of prescription medications. Finally, among those who were homozygous for the high expression alleles of the monoamine oxidase gene (MAOA) (but not in those with low expression alleles), low baseline religious attendance and change in attendance predicted a greater degree of cigarette use among regular smokers; change in attendance was associated with drug abuse; change in importance was associated with a greater frequency of alcohol use; low baseline importance was associated with marijuana abuse; low baseline prayer was associated with alcohol experimentation; and change in prayer over time was associated with earlier age of regular smoking and abuse of marijuana and other drugs. Thus, low baseline religious involvement or change in religious involvement (almost always a decrease) was associated with greater substance use only in those with certain gene polymorphisms. Other studies have reported similar interactions between genetic polymorphisms and religiosity in effects on alcohol use (Koopmans et al., 1999) and interactions between polymorphisms of the dopamine receptor gene and religiosity in predicting adolescent delinquency and antisocial behaviors, outcomes often associated with substance use (Beaver et al., 2009; Sasaki et al., 2011). However, candidate gene-​environment

interaction studies are often inadequately powered and have a poor history of replication, and so it is not clear that these associations will necessarily be confirmed in future studies. E N VI RO N M E NTAL

As noted above, well-​established risk factors for SUD are childhood maltreatment, low parental monitoring, a neglectful parenting style, maternal and paternal drug abuse, poor parental adjustment, parental divorce, early onset of drinking, and peer substance use. Every one of these risk factors have been shown to be inversely related to religious involvement (see Handbook appendices published in 2001, 2012, and current Appendix). Because sacred scriptures of many faith traditions emphasize the value of children (e.g., “Children are a heritage from the Lord, offspring a reward from him. Like arrows in the hands of a warrior are children born in one’s youth. Blessed is the man whose quiver is full of them”; Psalm 127:3–​5, NIV), parents are less likely to abuse or neglect them. Religious prohibitions against breaking the law increase parental monitoring of children and adolescents’ behavior; increase parental prohibition of experimentation with alcohol, drugs, or tobacco; and increase parental behaviors limiting access to such substances. Religious parents are also less likely to use or abuse alcohol, or take illicit drugs (see below). Parental divorce and single-​parent families are less common among the religious based on dozens of large systematic studies (Chapter 14). Religious parents may also be more likely to ensure child involvement in healthy peer groups and avoidance of antisocial, substance-​abusing friends. Thus, there are many environmental reasons why religiosity ought to be related to less substance use problems during both adolescence and adulthood. P SY C H O L O GI CAL

As noted above, mood, anxiety, and personality disorders during adulthood, as well as conduct disorder and attention deficit hyperactivity disorder (ADHD) during childhood/​adolescence, increase the likelihood of SUD, as does poor adjustment in childhood and early adolescence.

Lack of coping skills to deal with stressors and behavioral urges also appears influential in substance use initiation, continuation, and relapse. Religious involvement has been shown to reduce the risk of mood and anxiety disorders at all ages in many studies (see Chapters 5 and 8), and has been inversely associated with ADHD (Power & McKinney, 2014) and conduct disorder (Meltzer et al., 2011) in young adults. Finally, religion provides individuals at risk for SUD with coping resources and skills (through religious cognitions, prayer, inspirational scriptures, and role models) to deal with negative emotions and impulses that may lead to substance use or relapse (see Chapter 4). SOCIAL

Already discussed above are the influences on development that religious involvement has on the quality of parental care during early childhood and adolescence by promoting strong two-​parent families, increasing parental control and monitoring, limiting negative peer influences, reducing access to alcohol and drugs, and providing positive role models. Religious involvement affects virtually every factor that influences the development and persistence of SUDs based on the Social Development Model. This is done through perceptions of opportunities for prosocial behavior (high in religious families); involvement with prosocial peers (high in religious environments); adoption of social skills that increase the likelihood of involvement, recognition, and reward (emphasized in religious education); and perceptions of reward from involvement in various prosocial groups (encouraged by religious teachings such as love of neighbor and treating others as one wants to be treated). There is little question, as noted above, that one of the most important ways that religiosity could prevent SUD or assist in its recovery is by surrounding the vulnerable individual with a community of peers and friendship networks who do not use or abuse alcohol/​drugs. Perhaps the most difficult challenge facing those recovering from SUDs is replacing their social network of substance-​abusing peers with a prosocial peer group. Religious communities typically discourage or prohibit the use of Substance Use and Substance Use Disorders • 175

addictive substances by members, thus providing an alternative support system that may be difficult to find elsewhere (except perhaps in 12-​step programs, which are themselves religiously based—​see below).

and attended religious services at least weekly were over 4 times more likely to stop drinking heavily compared to women attending less than weekly (OR =​4.67, 95% CI =​1.03–​21.3). No similar effect, however, was found in men. In a 5-​ year prospective study, Haber and Jacob (2007) examined the interaction RESEARCH ON RELIGION, parent religious affiliation and parSUBSTANCE USE, AND SUDS between ent history of alcoholism in predicting alcohol Hundreds of scientific studies, using cross-​ use symptoms among 3,582 female adolessectional, prospective, and experimental cent offspring in Missouri. After controlling ­ designs, have now examined the relationship for other risk factors (except for adolescent between religiosity and alcohol/​drug use and alcohol use symptoms at baseline), religiously abuse. The first and second editions of the reared youth—​ assessed by parent religious Handbook systematically reviewed and sum- affiliation—​ experienced significantly fewer marized the research published prior to 2010. later alcohol dependence symptoms. Effects Those reviews indicated that 86% of 278 quan- were greater among Black than White adolestitative studies reported less alcohol use/​abuse cents. Researchers concluded that differences among the more religious, and for drug use/​ between “religious norms” regarding alcohol abuse, the figure was 84% of 185 studies. Of use and “social and cultural norms” of society all these studies, only 2 found more alcohol or were responsible for this finding. drug use/​abuse among the more religious. In Jackson and colleagues (2008) analyzed the present review of the research, which also data from an 8-​year prospective study of a ranincludes studies published since 2010, we focus dom national US sample of 32,087 youth age on large cohort studies, with emphasis on those 18–​26, examining trajectories of young adult that have controlled for baseline substance use, substance abuse across the follow-​up period. and randomized controlled trials (RCTs), which Religiosity was measured at baseline using a have examined alcohol/​drug use, abuse, and 2-​item scale that assessed religious attendance dependence. and importance of religion. Ten trajectories were formed involving combinations of chronic alcohol use, smoking, and marijuana use (i.e., Prospective Cohort Studies high use at baseline and throughout the 8-​year Reviewed below are longitudinal studies with follow-​up) and delayed alcohol, smoking, and sample sizes close to or greater than 1,000 that marijuana use (i.e., low at baseline, but increasassessed religiosity at baseline and followed ing toward the end of the follow-​up period). participants for 5 years or more. Studies are After controlling for other risk and protective presented first for alcohol and then for drugs. factors, religiosity was protective for every one Ten representative studies are reviewed for each of the substance abuse trajectories. class of substance, presented by year of publicaStevens-​Watkins and Rostosky (2010) anation (see Appendix for all high quality studies). lyzed data from a 6-​year prospective study of 1,599 African American male adolescents (age 12–​17) participating in the Add Health study, A LC O H O L U SE /​AB US E /​DE PE NDE NCE examining the effect of religiosity (assessed Strawbridge and colleagues (2001) prospec- by religious attendance, frequency of prayer, tively followed a random sample of 2,676 importance of religion) on young adult binge community-​dwelling adults in Alameda County, drinking (consuming 5 or more drinks in a California, from 1965 to 1994. Frequency of row). Although religiosity was inversely related religious attendance at baseline was examined to binge drinking during adolescence in cross-​ as a predictor of alcohol use during the 28-​year sectional analyses, when longitudinal analyses follow-​up. Among women in the sample (n =​ were controlled for age, family connectedness, 1,525), those who were heavy drinkers in 1965 and perceived close friends’ substance use, 176 •  M ental H ealth

adolescent religiosity did not significantly predict young adult binge drinking (B =​−0.05, SE =​0.04, although “control” variables may have been mediators). Haber et al. (2013) analyzed data from a 5-​year prospective study of 4,002 adolescent female twins (age 13–​19) and parents participating in the Missouri Adolescent Female Twin Study. Current and past religious affiliation were assessed and categorized as “differentiating” (i.e., affiliations that held alcohol norms that were different from societal norms—​ Baptists, for example), “accommodating” (e.g., Methodists, Lutherans), Catholic, or no affiliation. Also assessed were religious devotion, religious attendance, existential well-​ being, spiritual well-​being, self-​rated religiosity, and rules against alcohol use. Outcomes were time to initiation of first alcoholic drink, time to initiation of at-​risk drinking, and time from at-​risk drinking to alcohol dependence (AD). Cox proportional hazards models were used to analyze the data. Bivariate analyses revealed that almost all religious variables were related to better alcohol outcomes. In multivariate analyses that controlled for parental education, income, race, age, and risk factors for the development of AD (mental disorder, traumatic events, consistency of parental rules, arguments with parents, parental divorce), frequency of religious attendance, religious devotion, and differentiating affiliation all independently predicted greater time to first drink. Likewise, higher religious attendance and rules against alcohol use predicted greater time from first drink to at-​ risk drinking. However, only existential well-​being predicted time from at-​risk drinking to AD. In contrast, Catholic affiliation predicted less time to first drink, and both accommodating affiliation and Catholic affiliation accelerated onset of at-​risk use. Researchers concluded that after the onset of at-​risk drinking, only genetically based risk factors—​not religious affiliation—​appeared to influence development of AD. Note that this study, unlike several of the others above, used affiliation rather than service attendance as the religious variable under study. In a 5-​ year prospective study of 2,671 community-​ dwelling adults age 40 or older in Norway from 2003 to 2008, Nordfjaern

et al. (2018) examined the effects of religiosity on alcohol abstention and consumption. Religiosity was assessed by three variables measuring church membership and importance of religion. Regression analyses indicated that baseline religiosity predicted greater abstention and less consumption of alcohol, controlling for demographics and health characteristics, although baseline alcohol consumption was not included in models. Researchers concluded that religiosity was an important predictor of alcohol consumption and abstinence in the second half of life (age 40–​80). Chen and VanderWeele (2018) analyzed data from the Growing Up Today Study (GUTS), a longitudinal study of 5,681–​ 7,458 adolescents (average age 14.7 years at baseline in 1999) followed up for 8–​14 years (2007–​2013). Participants were the children of 116,430 US nurses participating in the Nurses’ Health Study II. Investigators examined the effects of religious service attendance and prayer/​meditation assessed at baseline on health outcomes, including binge drinking, marijuana use, other drug use, and prescription drug misuse across the follow-​up period. Controlled for in all analyses were sociodemographic characteristics, maternal health, and prior values of the alcohol and drug use outcomes when data were available. Those who attended religious services at least weekly in 1999 (compared to those who never attended) were less likely to use marijuana and other illicit drugs, and to misuse prescription drugs, although no effect was found on binge drinking (risk ratio [RR] =​0.97, 95% CI =​0.87–​ 1.07). Those who prayed or meditated at least once/​day or more (vs. never) used marijuana, other drugs, and misused prescription drugs less frequently, but again, there was no effect on binge drinking (RR =​0.91, 95% CI =​0.82–​1.01). Guo and Metcalfe (2019) analyzed data from a 10-​year prospective study of a US national random sample of 6,787 adolescents age 17–​21 years examining the effects of religious attendance on alcohol use. Controlled for in random-​ effects logistic regression analyses were emotional achievement, school enrollment status, weeks employed, marital status, parenthood status, arrest status, age, smoking, marijuana use, hard drug use, and other variables. Frequency of religious attendance independently predicted less

Substance Use and Substance Use Disorders • 177

alcohol use over time for within-​person effects (b =​−0.084, p < 0.001) and between-​person effects (b =​−0.287, p < 0.001), although these effects weakened with increasing age and non-​ White racial status. The findings were similar for marijuana and hard drug use (see below). Pawlikowski et al. (2019) examined data from three waves of a biennial longitudinal Polish household panel study (2009, 2011, 2015), which assessed a random sample of 6,400 individuals age 16 or older. Assessed was the effect of 2011 religious service attendance on endorsement of “drinking too much alcohol in last year” in 2015, controlling for physical, social, and emotional well-​being, and health behaviors including alcohol consumption in 2009 prior to the assessment of religious attendance in 2011 (to ensure that they were confounders, not mediators). Results indicated that frequency of religious attendance independently predicted less excessive drinking of alcohol for weekly attendees (OR =​0.50, 95% CI =​0.33–​0.75) compared to non-​attendees, and there was also a nonsignificant trend in the same direction for those who attended religious services more than weekly (OR =​0.66, 95% CI =​0.73–​1.19). Even more robust findings were reported for “smoking tobacco products every day” (see Chapter 17). Finally, Chen et al. (2020a) analyzed data on a sample of 9,862 young adults in the Growing Up Today Study (GUTS) with 3 to 6 years of follow-​ up; 68,376 middle-​ aged participants from the Nurses’ Health Study II (NHS-​II) with 12 years of follow-​up; and 13,770 older adults in the Health and Retirement Study (HRS) with 4 years of follow-​up. The study examined associations between at least weekly religious service attendance and subsequent heavy drinking, controlling for baseline drinking and also a rich set of social, demographic, economic, psychological and health-​related variables (as well as, in the GUTS and HRS samples, prior religious service attendance). In the meta-​analytic estimate combining these samples, at least weekly religious service attendance was associated with subsequently less heavy drinking overall (RR =​0.66, 95% CI =​0.59–​0.73), and in the GUTS data (RR =​0.66, 95% CI =​0.54–​0.81) and NHS-​II data (RR =​0.57, 95% CI =​0.50–​0.64), but not in the HRS data (RR =​1.31, 95% CI =​0.92–​1.86). 178 •  M ental H ealth

IL L ICIT D RUG USE/ A ​ BUSE/​ D EP EN D EN CE

We now review 10 high-​ quality large prospective studies of religious involvement and drug use. Hamil-​ Luker et al. (2004) examined the relationship between being “raised in a religious faith” (1 =​yes, 0 =​no) and cocaine use in the past year in a random national US sample of 2,791 adolescents age 15–​17 initially surveyed in 1979. Based on teenage delinquent or criminal activity in past year, latent class analysis was used to categorize participants into four groups: delinquents (n =​244; e.g., skipped school, drank, smoked and sold marijuana, got in fights), troublemakers (n =​398; e.g., drank, got in fights), partiers (n =​533; e.g., drank and smoked marijuana), and conformists (n =​1,354; e.g., infrequently engaged in delinquent-​like behaviors). Controlled for in all analyses were demographics, use of marijuana, family structure, attachments in school, and attachments in labor force (number of jobs, current employment), some of which could have been explanatory variables or mediators. Cluster analyses were used to identify characteristics of those following three trajectories of cocaine use over an 18-​year follow-​ up through 1998: young adult peak-​ users (23%; i.e., cocaine use surged between 1984 and 1988 when in early twenties), those who stopped using (19%; i.e., a steady decline in use of cocaine between 1984 and 1998), and low-​ risk or non-​users (60%). Among delinquents, those raised without a religious faith were significantly more likely to be in the young adult peak-​user trajectory group (b =​1.22, p < 0.05), whereas those raised with a religious faith were more likely to be in the low-​risk/​non-​user or decreasing cocaine use trajectory groups. Religious upbringing, however, was unrelated to cocaine use trajectory group in troublemakers, partiers, and conformists. T. L. Brown et al. (2004) analyzed data on 964 6th-​grade youth participating in the Drug Abuse Resistance Education project, a 10-​year prospective study following youth from age 10 to age 20, examining factors that impacted marijuana use over time. Baseline predictor variables included school factors, family relations,

peer pressure resistance, sensation seeking, expectancies for marijuana use, and church involvement (frequency and importance). The outcome was longitudinal trajectories of marijuana use stratified by Black and White race, with three different marijuana use trajectories (Groups 1–​3) identified for each race. Among Whites, Group 1 initiated marijuana use by 6th grade with a gradual increase through 10th grade and slight decrease between 10th grade and age 20 (n =​133); Group 2 initiated use by 9th grade with the sharp increase between 10th grade and age 20 (n =​487); and Group 3 did not use marijuana at any age (n =​428). Among Blacks, Group 1 initiated marijuana use by 6th grade, continued the same level of use until 10th grade and then decreased slightly (n =​18); Group 2 initiated use around 8th grade with a sharp increase in use by 10th grade (n =​74); and Group 3 began using between 10th grade and age 20 (n =​214). When groups were collapsed across race, church involvement was lowest in Group 1 (early onset of marijuana use) and highest in Group 3 (later onset or no use); differences were significant at p 75). The poor quality of the data collected among youth with significant cognitive impairment may have affected the association in this subgroup. As described in detail above, Guo and Metcalfe (2019) also examined the effects of youth and parental religious attendance on drug use in their 10-​year prospective study of 6,787 adolescents participating in the US National Longitudinal Survey of Youth, controlling for emotional achievement, school enrollment status, weeks employed, marital status, parenthood status, arrest status, age, smoking, marijuana use, hard drug use, and other variables. In the overall sample, random effects logistic regression analyses indicated that frequency of youth-​ reported religious attendance predicted both less marijuana use (b =​−0.126, p < 0.001) and less hard drug use (b =​−0.64, p < 0.01), independent of covariates,

for within-​person effects. Likewise, frequency of religious attendance also predicted less marijuana use (b =​−0.262, p < 0.001) and less hard drug use (b =​−0.182, p < 0.001) for between-​ person effects. Interestingly, no effect was seen for parental religious attendance. Interactions between youth-​reported religious attendance and age were not significant, indicating that inverse associations with drug use were present regardless of age. Interactions with gender and race/​ethnicity indicated that effects were stronger in females than in males and stronger in Whites than in non-​Whites. Crank and Teasdale (2019) analyzed data collected on 1,354 adolescents participating in the Pathways to Desistance study. As described earlier, this study involved juvenile offenders followed for 7 years post-​conviction. Desistance from substance use was the primary outcome variable, where substances included either marijuana or hard drugs. A single variable was used to assess religiosity: “I experience a close personal relationship to God.” Other independent variables assessed psychological strain (direct victimization or witnessing victimization), social bonds, social learning, and self-​control. Time-​variant controls included drug treatment and criminal offending. Multi-​ level growth curve modeling was used to conduct within-​ individual analyses to determine predictors of drug use outcome (dichotomized as 1 =​yes, 0 =​no). At baseline, 764 youth used marijuana and 373 used hard drugs. Multi-​level logistic regression indicated no overall effect of religiosity on desistance of marijuana or hard drug use over time, after important criminological predictors were included in the model (some being likely mediators). When analyses were stratified by gender, results indicated that among women, religiosity increased the likelihood of desistance from marijuana use by 26% (OR =​1.26, p < 0.05), although no effect was found in males. A similar pattern was found for hard drug use, but the findings did pass a p =​0.05 threshold. S. J. Jang (2019) analyzed data from the same Pathways to Desistance study involving adjudicated youth from juvenile and adult court systems in Arizona and Pennsylvania (n =​1,289), but followed for 10 years. The religiosity measure used in this report was

frequency of attendance at religious services (titled “objective religiosity”) and a 4-​item religiosity measure asking “How important has religion been in your life?”; “I experience God’s love and caring on a regular basis”; “I experience a close personal relationship with God”; and “Religion helps me to deal with my problems” (titled “subjective religiosity”). Marijuana use was the primary outcome variable, with frequency of use response options ranging from 1 =​“not at all” to 9 =​“every day.” Also measured were psychosocial correlates, including moral disengagement, legal cynicism, impulse control, suppression of aggression, time spent in the community (vs. in police or correctional custody), and sociodemographic characteristics (gender, race, age, social class, and family structure). Latent growth curve modeling was used to predict trajectories of change in marijuana use, controlling for time-​invariant sociodemographic variables and the time-​ varying covariate of exposure time. Results indicated that both subjective and objective religiosity were cross-​sectionally related to less marijuana use at baseline, although neither form of religiosity predicted desistance from marijuana use during follow-​up. Increases in both religious attendance and subjective religiosity, however, significantly predicted cessation or reduction of marijuana use over time (b =​−.368, p < 0.05, and b =​−.209, p < 0.05, respectively). Reduction in moral disengagement and legal cynicism, and increases in impulse control and suppression of aggression, were said to explain these effects. SUM M ARY

Nearly all large prospective cohort studies reviewed above examining the effect of religiosity on substance use, abuse, or dependence report that these behaviors are less frequent among the more religious. This was true either overall or for particular subgroups in the vast majority of the studies reviewed. Religious service attendance was the most common predictor of outcome. The consistency in these results provides powerful evidence that religious beliefs and practices serve to deter substance use that may lead to substance use disorders. The majority of these studies were among

Substance Use and Substance Use Disorders • 181

adolescents or young adults at a time when lifelong substance use patterns begin to develop, and therefore these findings have implications for the future productivity and health of these youth across their life spans.

were randomized to either SG plus treatment as usual (TAU) or to a TAU control group. TAU involved behavioral counseling and attendance at education groups. Participants in the SG group (n =​30) were “offered up to 12 sessions” of SG. Of those 30 participants, 3 did not attend any sessions, 5 attended only one session, 5 Randomized Controlled attended two sessions, and 17 attended more Trials (RCTs) than 2 sessions (designated as “treated”). The We now describe RCTs examining the impact of SG intervention was administered by three proreligious interventions on substance use prob- fessional spiritual directors, none of whom had lems. These studies are capable of determining experience working with substance-​dependent whether various aspects of religiosity are caus- people. Participants chose from 13 spiritual disally related to recovery from SUDs. We supple- ciplines to focus on during sessions and to pracment descriptions of individual studies here tice between sessions, with 12 of these based with systematic reviews and meta-​ analyses, on the work of Richard Foster (acceptance, given the large number of RCTs that have celebration, fasting, gratitude, guidance, medexamined religious-​based interventions such as itation, prayer, reconciliation, reflection, ser12-​step programs or Twelve-​Step Facilitation vice to others, solitude, worship). At baseline, (TSF) therapy. no significant differences on substance abuse Margolin et al. (2006) examined the effects (SA) measures were present between groups. of Buddhist-​based Spiritual Self–​Schema (SSS) At the 4-​month follow-​up (primary outcome), therapy in 72 methadone-​maintained addicts both groups experienced a large within-​group in Connecticut (age 21–​56). Participants were increase in percentage of days abstinent from randomized to either SSS (n =​38) or a wait-​ illicit drugs (F =​31.0, p < 0.001), with the effect listed standard care control group (n =​34). favoring the TAU only control group (F =​3.04, Participants in the intervention group received p < 0.08). The between-​group comparison of 8 weekly 60-​ minute individual therapist-​ led SG and TAU revealed no significant difference. sessions of SSS. In the intention-​to-​treat anal- The findings were similar for abstinence from ysis, results indicated no difference between other drugs and alcohol, with a large within-​ treatment groups. However, in the per-​protocol group gain in percent days abstinent, with both analysis, those in the SSS intervention group SG and TAU groups increasing by almost 50% experienced a significant increase in spiritual (F =​16.0, p < 0.001). Again, there was no signifpractices, expression of spiritual qualities, icant difference between SG and TAU groups. and motivation to prevent the development of Thus, SG had no benefit over usual care despite HIV infection, along with a decrease in HIV-​ more frequent social contact with SG therarisk behaviors (injecting drugs and/​or having pists. However, poor treatment compliance in unsafe sex). After controlling for pretreatment the SG group may have influenced the findings. HIV risk-​prevention behavior, demographics, Adekeye and Sheikh (2009) conducted an and addiction severity measures, completion RCT involving 30 young males with SUDs in of SSS therapy predicted post-​treatment HIV Zaria, Nigeria (average age 17.6, 70% Muslim). preventive behavior compared to controls SUDs included cigarettes, alcohol, cannabis, (OR =​8.89, 95% CI =​1.62–​48.93). codeine, and flunitrazepam. Participants were Miller et al. (2008) conducted an RCT exam- randomized to either (1) 15 sessions of cogining the efficacy of a 12-​session manual-​based nitive behavioral therapy (CBT) with “compoSpiritual Guidance (SG) intervention in 60 hos- nents of building self-​efficacy and religiosity” pitalized patients with severe addiction receiv- (the only description reported); or (2) 15 sesing polydrug detoxification (average age 39, sions of CBT without religiosity/​ self-​ efficacy 50% Hispanic). The intervention was initiated components. Outcomes measures included the after an average of 25 days of hospitalization Alcohol and Smoking Cessation Self-​ Efficacy and continued after discharge. Participants (ASE) scale, a 4-​item measure of alcohol and 182 •  M ental H ealth

smoking cessation self-​efficacy. Also measured were self-​ratings of “improved ability to stop drug use,” “improved positive thoughts to do without drugs,” and “improved ability to reject outside influences to use drugs.” Researchers compared change scores on the ASE measure from pre-​to post-​intervention in the intervention and control group using a t-​test, indicating better results in the intervention group compared to controls (13.6, SD =​8.03, vs. 1.0, SD =​0.75, respectively, t =​4.92, p < 0.05). Ratings of ability to stop drug use, have positive thoughts without drugs, and rejection of outside influences ranged from high to very high in the intervention group compared to low on all measures in the control group. While few details were reported on this RCT, which was of questionable quality, we summarize it here for the sake of completeness. Lambert et al. (2010) conducted two RCTs examining the effect of daily prayer (DP) on number of days having a drink containing alcohol. Participants in both studies were undergraduates at Florida State University who received extra credit for their involvement. In the first RCT, participants (n =​117, average age 19, 87% women; all involved in a romantic relationship) were randomized to one of four conditions: praying for others, undirected prayer, thinking about relationship topics daily, and paying attention to daily activities. Each group wrote in a diary what they experienced. For analysis, the two prayer groups were combined and compared to the two non-​prayer control groups combined. After 4 weeks, all participants completed the alcohol consumption outcome measure. In the second RCT (n =​115, average age 19, 82% women, none involved in a romantic relationship), participants followed the same protocol. In both RCTs, analysis of covariance indicated that those in the prayer conditions consumed significantly less alcohol than those in the control conditions (i.e., consumed more than 50% fewer drinks), controlling for initial prayer frequency, initial drinking scores, gender, and engagement in study activities. Khaledian et al. (2017) examined the effects of an Islamic-​ based spiritual therapy intervention on self-​ esteem and mental health in 40 adults attending a methadone therapy addiction treatment center in Ghorveh, Iran.

Participants were randomized to either the intervention group or a control group receiving standard care (TAU). The intervention consisted of nine 120-​minute sessions of spiritual therapy with emphasis on Islamic teachings (Komail prayer, worship, religious practices, reading the Qur’an, and listening to Qur’an recitation). Outcomes assessed were a 58-​item Self-​Esteem Inventory and the 28-​item General Health Questionnaire (GHQ-​ 28). Analysis of covariance was used to compare the mean pre-​to post-​intervention scores for the GHQ-​ 28 in experimental (35.8 to 27.2) and control groups (37.2 to 35.9). Results indicated a significant group effect favoring the intervention (F =​129.9, p =​0.001). The findings were similar for self-​esteem in terms of change from pre-​to post-​ intervention in the experimental (21.2 to 26.9) vs. the control group (22.1 to 21.9) (F =​199.6, p =​0.001). No information was provided on substance use outcomes. Again, few details were provided in this RCT of questionable quality. 12-​STEP P ROGRAM S

Numerous well-​conducted studies have examined the benefits of 12-​step programs using a prospective design (see Kelly et al., 2010). The fact that 12-​step programs are religiously based is clear from the principles outlined by the originators (Table 10.1). An early systematic review of RCTs examining these programs found that abstinence rates from alcohol among those who attended Alcoholics Anonymous (AA) were more than double compared to those who did not attend AA, with evidence for a dose-​ effect response (Kaskutas et al., 2009). RCTs have also found that Twelve-​Step Facilitation (TSF) therapy, which involves either 12–​ 15 professional individual and group counseling sessions to increase participation in 12-​step programs (Nowinski & Baker, 1992) or simple physician or peer referral of individuals to 12-​ step programs (Manning et al., 2012), increase 12-​step attendance and consequently improve SUD outcomes (Kaskutas et al., 2009; Donovan et al., 2013; Hai et al., 2019). This includes participants with SUDs and other comorbid mental illnesses (Bogenschutz et al., 2014; Tonigan et al., 2018). Substance Use and Substance Use Disorders • 183

Table 10.1  The 12 Steps

in 16 of the 20 studies, 11 of which examined TSF therapy. We have already described three 1. We admitted we were powerless over of the four RCTs examining non-​12-​step S/​ alcohol—​that our lives had become R interventions, except for a double-​blinded unmanageable. remote intercessory prayer study, which is itself 2. Came to believe that a Power greater than subject to a number of scientific, practical, and ourselves could restore us to sanity. theological objections (VanderWeele, 2017d). 3. Made a decision to turn our will and Among all 20 RCTs reviewed by Hai et al. our lives over to the care of God as we (2019), 4 studies compared S/​R interventions understood Him. to inactive controls, 14 used active controls, and 4. Made a searching and fearless moral 2 studies used both inactive and active controls. inventory of ourselves. The effect size (Cohen’s d) in studies using inac5. Admitted to God, ourselves, and to tive controls (i.e., no treatment) was moderate another human being the exact nature of in size overall but with a wide confidence interour wrongs. val (d =​0.54, 95% CI =​−0.32 to 1.39, i.e., not 6. Were entirely ready to have God remove statistically significant). However, when results all these defects of character. were stratified by outcome, for substance use 7. Humbly asked Him to remove our outcomes, the effect was small but with a someshortcomings. what narrower confidence interval excluding 8. Made a list of persons we had harmed, the null (d =​0.26, 95% CI =​0.13–​0.65, i.e., staand became willing to make amends to tistically significant), whereas for psychosocial-​ them all. spiritual outcomes, the effect estimate was large 9. Made direct amends to such people but again with a very wide confidence interval wherever possible, except when to do so that included the null (d =​0.79, 95% CI =​−1.18 would injure them or others. to 2.75, i.e., not statistically significant). 10. Continued to take personal inventory and For the 16 studies that used active controls when we were wrong promptly admitted (i.e., other proven interventions) the effect it. size overall was small with a confidence inter11. Sought through prayer and meditation val barely excluding the null (overall d =​0.18, to improve our conscious contact with 95% CI =​0.001–​0.358, i.e., significant). For God as we understood Him, praying only substance abuse outcomes, results were small for knowledge of His will for us and the with a confidence interval barely excluding the power to carry that out. null (d =​0.21, 95 CI =​0.019–​0.39), and for 12. Having had a spiritual awakening as the psychosocial-​spiritual outcomes, the estimate result of these steps, we tried to carry was smaller with a confidence that did include this message to alcoholics, and to practice the null (d =​0.14, 95% CI =​−0.10 to 0.39, i.e., these principles in all our affairs. not significant). Since the studies comparing S/​ Source: Alcoholics Anonymous, 4th ed. (2001), pp. 59–​60. R interventions to active controls were only 12-​ step programs, the effects could not be generalized to non-​12-​step interventions. Researchers There is also evidence from RCTs that non-​ concluded that there was evidence indicat12-​ step spiritual/​ religious interventions for ing that S/​R interventions were efficacious in SUDs are effective, although as reviewed above, helping those with substance use problems, these studies are few in number and often of although the efficacy of non-​12-​step programs poor quality. Hai et al. (2019) recently con- was inconclusive, calling for more studies ducted a meta-​analysis and systematic review examining the effects of these latter programs. of RCTs examining the efficacy of 12-​step and In the most recent Cochrane review of 27 non-​12-​step spiritual/​religious interventions studies involving 10,565 participants (21 RCTs for SUDs. They identified 20 studies involving and quasi-​ RCTs, 5 non-​ randomized trials, 1 3,700 participants. Spiritual/​ religious (S/​ R) economic study), Kelly et al. (2020) reported interventions involved 12-​step interventions that RCTs comparing manualized AA/​TSF with 184 •  M ental H ealth

other clinical interventions (e.g., CBT) found that AA/​TSF improved rates of 12-​month continuous abstinence significantly more than other treatments (RR =​1.21, 95% CI =​1.03–​ 1.42). Furthermore, in terms of cost, AA/​ TSF was also more cost-​effective than other treatments. The authors concluded: “There is high-​ quality evidence that manualized AA/​ TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence” (p. 2). In summary, 12-​step programs that explicitly use religion as a key aspect of treatment (e.g., Alcoholics Anonymous, 2001, pp. 59–​ 60) and TSF therapies appear to be effective in reducing substance use and increasing abstinence. Other religiously or spiritually integrated interventions for SUDs are few in number, of questionable quality, and their efficacy is promising but inconclusive.

Conclusions Evidence from RCTs supports the findings from prospective studies indicating that religious involvement may help to protect against the development of SUDs and speed recovery from them. Further research, however, is clearly needed.

OTHER ADDICTIONS We now describe (very briefly) research examining the relationship between religiosity and other addictions besides SUDs.

Addictions to Food Eating disorders in DSM-​ 5 include bulimia nervosa, binge eating disorder, and other or unspecified eating disorders having to do with eating too much. Chapter 19 on diet and weight also examines what happens when control over eating is lost (i.e., the obesity epidemic in the US). Note, however, that eating too little (e.g., anorexia nervous) also involves a type of addiction involving a preoccupation with food and body appearance, and so is included in this section. Disordered eating (whether too much or too little) appears to be increasing worldwide, particularly among young girls and women

(Gorrell et al., 2019). Religious involvement may play a role in the prevention or moderation of addictions to food. In a review of 22 studies on eating disorders, Akrawi and colleagues (2015) concluded that “. . . strong and internalized religious beliefs coupled with having a secure and satisfying relationship with God were associated with lower levels of disordered eating, psychopathology and body image concerns.” In contrast, greater levels of disordered eating were found among those with “a superficial faith coupled with a doubtful and anxious relationship with God” (p. 1). In our review of 12 of the higher-​quality studies (see Appendix), half of those reported inverse associations between religious involvement and eating disorder pathology, whereas the other half reported either no association or an association between religiosity and more eating disorder symptoms. With regard to the latter findings, for example, a study conducted in the United Kingdom found that a “spiritual view” of life was associated with more eating disorder symptoms. Likewise, in a study conducted in the United Arab Emirates, religious commitment was positively associated with more symptoms. In the only RCT that could be located, Richards and colleagues (2006) found that spiritual group therapy (based on Judeo-​ Christian principles) was significantly more effective than cognitive or emotional support group therapy in the treatment of 122 women hospitalized in the United States with eating disorder problems (Richards et al., 2006).

Gambling Disorder Although nearly 90% of the US population has gambled (more than three-​quarters within the past year), only a small percentage fulfill 4 or more of 9 criteria in the past 12 months specified in DSM-​5 for a gambling disorder (2.4% in 2011–​2013 compared to 2.0% in 1999–​2000) (Welte et al., 2015). However, when such a disorder is present, the consequences can be devastating for the individual and their family (Ashley & Boehlke, 2012). Although the relationship between religiosity and pathological gambling is complex, the majority of research (see Appendix) indicates an inverse relationship between religious involvement Substance Use and Substance Use Disorders • 185

and problem gambling, and in one of the latest studies, religiosity significantly predicted remission from the disorder and a more benign course (Bormann et al., 2019). Furthermore, there is evidence that the 12-​ step program Gambler’s Anonymous can be quite helpful, although further research is needed (Schuler et al., 2016).

Internet and Gaming Addictions Today, over 90% of children and teenagers in the United States play video games either on a console or via the Internet, and overall, spend a considerable amount of time on the Internet (Tsukayama, 2015). Internet gaming disorder (IGD) has been designated in DSM-​5 to be a condition requiring further research before assigning it an official status. The prevalence of IGD has been estimated to range from 1% to 28% depending on age and country where assessed, and when present, IGD has been associated with considerable psychological, social, and physical health consequences (Gentile et al., 2017; Mihara & Higuchi, 2017). Although not much research has examined the relationship between religiosity and gaming or Internet addictions, our review uncovered three studies that examined this issue, all finding an inverse relationship between religiosity and frequency of online or offline gaming or tendencies toward Internet addiction (Charlton et al., 2013; Braun et al., 2016; Malinakova et al. (2018b).

greatest in terms of opiate use disorders involving both illegal and prescription drugs, as well as for cocaine and methamphetamine use disorders, conditions that are now almost epidemic and increasing in frequency, especially in the United States. This increase seems to have occurred during a time of increasing secularization, where the internal controls provided by religion become less and less popular and thus less available, requiring more expensive forms of external control such as increasing law enforcement personnel and institutionalization in prisons and mental facilities. Research on the role that religiosity plays in the prevention, recovery, and treatment of other impulse control problems such as eating disorders, sex addiction, gambling disorders, and internet or gaming addiction is also needed, particularly RCTs testing religiously integrated interventions in these conditions.

CLINICAL APPLICATIONS In this section, we suggest clinical applications based on what is now known from the existing research.

The Spiritual History

As recommended in virtually every chapter of this book, clinicians and religious professionals are encouraged to take a detailed spiritual history from both the client and, after permission has been obtained, from the family. Besides obtaining a history of the client’s past RECOMMENDATIONS and present religious beliefs, practices, and FOR FUTURE RESEARCH level of religious commitment, negative experiMuch of the research reviewed above has ences with religion should also be explored and reported that religious involvement has pro- their role (if any) played in the client’s current tective effects on the development of substance substance use problems or addictive behaviors. use and other addictive disorders (eating, gam- Traumatic childhood experiences or histories bling, internet/​gaming). We also know a lot of abuse by clergy or other religious role modabout the effectiveness of certain religious-​ els must be identified. However, in addition to based interventions such as 12-​step programs. determining negative experiences with reliHowever, there is plenty of room and need for gion, professional helpers should also identify further prospective studies to determine how religious strengths and resources that may help and what types of religious involvement help to combat addictive disorders. Helpers should to prevent SUDs, as well as RCTs to deter- inquire about how much the client believes in mine those religious interventions (including and values the original scriptures of their faith 12-​step programs) that are most effective in tradition, since these may be utilized in therthe treatment of these conditions. The need is apy later on. 186 •  M ental H ealth

Simple Religious Interventions

inhalant, sedative, and benzodiazepine addictions. Twelve-​step Facilitation Therapy (TSF) For religious clients, or those considering them- programs for alcohol, opiate, and stimulant selves spiritual with religious leanings, we rec- addictions are also available. As noted earommend providing support for religious beliefs lier, TSF therapy increases the likelihood and coping behaviors, particularly if they are that a substance abuser will affiliate with and not contributing to the problem. Encouraging become actively involved in a 12-​ step proparticipation in a religious community may gram, increasing their chances of abstinence. help to provide a support group that is different There are also faith-​ based recovery services from the client’s former network of substance-​ and other religious mutual-​help groups (e.g., abusing peers. When appropriate, finding such Celebrate Recovery). Non-​faith-​based mutual-​ a community is one of the first priorities for help groups are also available for those who are those attempting to recover from an addiction, secular and not religious. These include SMART since this will help reduce access to addictive Recovery, Women for Sobriety (with a spirisubstances and cues that bring on cravings. tual emphasis), LifeRing Secular Recovery, and The client can also be encouraged to identify Secular Organizations for Sobriety. someone in their congregation willing to pray with them on a daily basis and to be available 24 hours a day to call when temptation to use Religiously Integrated addictive substances occurs. When appropri- Psychotherapy ate, the client might also be persuaded to seek Given the success of secular cognitive behavpastoral support on a regular basis from clergy. ioral therapy (CBT) (McHugh et al., 2010) and Recommendations are available on how to pro- acceptance and commitment therapy (ACT) vide pastoral care to congregants with alcohol (Lee et al., 2015) in the treatment of SUDs, the use problems (Weaver & Koenig 2009) and time is right for the development of religiously other addictions (Weaver et al., 2007). integrated forms of these therapies for those

Referral to 12-​Step or Similar Programs Twelve-​ step programs address the needs of an addicted individual for identity, integrity, an inner life, and interdependence within a larger social, moral, and spiritual context (Peteet, 1993). They are now widely available in the community for a range of addictive disorders, both for the client and for their spouse, family members, or friends. These include Alcoholics Anonymous (client) and Al-​Anon (family/​friends), Narcotics Anonymous (client) and Nar-​ Anon (family/​ friends), Cocaine Anonymous (client), Crystal Methamphetamine Anonymous (client), Marijuana Anonymous (client) and Mar-​Anon (family/​ friends), Smokers Anonymous (client), Caffeine Addicts Anonymous (client), Overeaters Anonymous (client), Sex Addicts Anonymous (client), Gamblers Anonymous (client) and Gam-​Anon (family/​friends), and Internet and Technology Addicts Anonymous (client), as well as 12-​ step programs for

suffering from addictions. To our knowledge, no such religiously integrated psychotherapies of this type have been developed or rigorously tested in randomized controlled trials.

Importance of a Combined Approach Given the multidimensional (genetic, neurobiological, social, and psychological) nature of SUDs as reviewed above, multi-​ pronged approaches to treatment are likely to be most successful. In addition, SUDs and other addictions seldom occur in isolation. Instead, they are often accompanied by other comorbid psychiatric disorders and sometimes physical health problems. When a person’s will and neurobiology have been hijacked by an addictive substance or behavior, combined approaches are often necessary in order to ensure a lasting recovery. These may include a combination of abstinence-​ based approaches, medication-​ assisted treatments, and, for those open to them, individual religiously or spiritually integrated psychotherapy (if available), and

Substance Use and Substance Use Disorders • 187

involvement in a faith-​based support group or 12-​step programs, together with active involvement in a religious community and daily support by a member of that community. Such combination approaches have yet to be developed or tested in randomized trials, yet based on what we now know from the systematic research reviewed above, such treatments are likely to have the most success.

gene-​ environment, psychological, and social risk factors. We then examined how religion might influence the development and course of SUDs based on these known risk factors. The heart of this chapter focused on research that has examined the relationship between religion and substance use, abuse, and disorder, as well as other addictive disorders, with an emphasis on the largest and best-​designed longitudinal studies and RCTs. We also made recommendations for future research and SUMMARY AND suggested a number of clinical applications CONCLUSIONS for mental health and religious professionals. In this chapter we reviewed the DSM-​ 5 In the next chapter, we examine personality definitions for substance use and other traits and disorders that often coexist with and addictive disorders, their prevalence in the pop- increase the severity of SUDs or complicate ulation, and known genetic, environmental, their treatment.

188 •  M ental H ealth

11 Personality Traits and Disorders Most of the shadows of this life are caused by our standing in our own sunshine. —​R alph Waldo Emerson

IN 1937, THE Harvard psychologist Gordon Allport defined personality as the “dynamic organization within the individual of those psychophysical systems that determine his unique adjustments to the environment” (Allport, 1937, p. 48). A more contemporary definition is that personality is an individual’s characteristic way of thinking, feeling, and behaving that makes him or her unique and different from other people, a set of psychological characteristics that are relatively stable across different environments, social settings, and time periods (Hampson, 2012). Related to personality is temperament. Temperament is different from personality in that temperament involves biologically based genetic predispositions responsible for individual differences in emotional responsivity that are evident soon after birth. Given a certain temperament, personality then forms slowly over time as the newborn, infant, and young child react and adapt to environmental

experiences. Personality is influenced by social learning, family environment, culture, and life events unique to the individual. Especially important is the “fit” between the infant/​ child’s needs and the ability of primary caregivers to meet those needs (Thomas & Chess, 1977). Character is different still from temperament or personality and is heavily dependent on learning, habits, and decision-​making. Character is revealed only in specific circumstances, and includes traits such as honesty, virtue, and kindness, which may slowly develop over a lifetime. Psychoanalysts have argued that personality is largely formed by the age of 3–​5, with the establishment of the ego and superego (James, 1950). More recent research indicates that further refinement of personality traits continues until about the age of 16, after which few changes occur, although character may not become similarly stable until age 30 or beyond (Allik et al., 2004; Barton-​Bellessa et al., 2015).

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0011

Unfortunately, the development of personality is not always healthy, depending on the extent to which basic needs are met by primary caregivers and on how well-​matched the person’s temperament is with the kind of nurturing environment provided by those caregivers during infancy and early childhood. Sometimes things do go awry. Personality “disorder” (PD) involves a way of thinking, feeling, and behaving that departs from the expectations of a person’s society and culture, which causes significant psychological distress or dysfunction in that individual’s occupational, social, or recreational functioning, and which persists over time (American Psychiatric Association, 2013). PDs are characterized by “pervasive, serious, and rigid self-​ destructive patterns in affect, cognition, interpersonal relations, and impulse control that impact psychological well-​being” (Budge et al., 2013). Simply put, people with PDs have difficulty interpreting interpersonal situations, and when combined with impulse-​ control problems and lack of empathy, this leads to relational conflicts at home, school, and work. For a long time, personality (and personality disorders) was felt to be lifelong and unchangeable (West & Graziano, 1989). However, results from recent research indicate that personality traits can change as a result of psychological interventions. Meta-​analyses of that research document a small to moderate effect size in terms of change (Cohen’s d =​0.37) (Roberts et al., 2017). The same is true for personality disorders, where the effect size is likewise small to moderate in terms of symptom improvement (d =​0.40) (Budge et al., 2013). Thus, while personality traits and disorders have long been considered stable and enduring, research indicates that change is possible. Might religious involvement be one of those factors that impact the development of personality and/​or the development and course of PDs? The answer to that question is the focus of the present chapter, in which we explore the relationships among religious involvement, personality traits, and PD. Personality traits will be described, personality disorders discussed, and then relationships with religiosity examined, focusing on the highest-​quality studies to date. 190 •  M ental H ealth

PERSONALITY TRAITS Personality traits or dispositions are prominent and characteristic features of an individual’s habitual way of behaving that are exhibited in a wide range of social and personal contexts (often present since early childhood, as noted above). The two most widely recognized contemporary models of personality traits are the Big Five Model (predominant in the field of psychology) and the Temperament and Character Trait Model (popular in the field of psychiatry). Personality traits described by the Big Five Model are neuroticism, extraversion, openness to experience, conscientiousness, and agreeableness (Norman, 1963; Costa & McCrae, 1992) (each is briefly described at the top of Table 11.1). Rather than emphasizing personality traits, the field of psychiatry focuses on biologically determined temperament and learned or acquired character traits. This model of personality traits was introduced by Robert Cloninger (1987) and can be measured using the Temperament and Character Inventory. In Cloninger’s model, the emphasis is on four temperament traits (harm avoidance, novelty seeking, reward dependence, persistence) and three character traits (cooperativeness, self-​directedness, self-​transcendence) (each is briefly described at the bottom of Table 11.1).

PERSONALITY DISORDERS The diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-​ 5) for personality disorder (PD) require impairments in personality functioning (related to self-​identity, self-​direction, intimacy in personal relationships, and empathy), along with the presence of one or more pathological personality traits of relatively severe intensity (manipulativeness, deceitfulness, callousness, hostility, irresponsibility, impulsivity, risk-​ taking) that are relatively stable over time and consistent across situations (American Psychiatric Association, 2013). The criteria insist that personality functioning and pathological traits cannot be considered normative for a particular developmental stage or social/​ cultural environment, nor can they be due to the direct physiological effects of a drug or

Table 11.1  Personality Traits Based on the Big Five and Temperament/​Character Trait models Big Five Modela Neuroticism: anxious, depressed, long-​standing tendencies toward being uptight or emotionally unstable Extraversion: sociable and talkative; thrives on making new social contacts; contrasts with introverts who score low on this scale and are more stimulated by thoughts and imagination Openness to Experience: intellectually curious, preference for variety, imaginative, aesthetically sensitive Conscientiousness: reliable, dependable, thorough, hard-​working, self-​disciplined, thinks carefully before acting, need for achievement Agreeableness: empathetic, considerate, friendly, generous, helpful to others; those scoring low on agreeableness tend to place self-​interest above the interests of others Temperament and Character Trait Modelb Harm avoidance: T; over-​responsive to environmental events, worries about future problems, prone to anxiety, fearfulness, easy fatiguability Novelty seeking: T; seeks novel and rewarding stimuli, impulsive, wastefulness, disorderly Reward dependence: T; wants to maintain ongoing behavior, sentimental, socially sensitive, attachment prone, dependent on approval and acceptance by others Persistence: T; determination to finish what one started and not give up Cooperativeness: C; tenderhearted, empathic, helpful, compassionate, principled Self-​directedness: C; responsible, purposeful, resourceful, self-​accepting, disciplined Self-​transcendence: C; self-​forgetting, acquiescent, enlightened, idealistic, spiritually accepting T =​temperament trait; C =​character trait. a Costa P. T. & McCrae, R. R. (1992). Normal personality assessment in clinical practice: the NEO Personality Inventory. Psychological Assessment, 4, 5–​13. b Cloninger, C. R. (1987). A systematic method for clinical description and classification of personality. Archives of General Psychiatry, 44, 573–​588.

medication or a physical health problem. PDs are categorized into three clusters: Cluster A (paranoid, schizoid, schizotypal), Cluster B (antisocial, borderline, histrionic, narcissistic), and Cluster C (avoidant, dependent, sensitive-​ compulsive) (see Table 11.2 for a brief description of each). Note that DSM-​5 has included (as a supplement to the main document) a proposed alternative model of diagnostic criteria that involves

a combined categorical-​dimensional approach requiring both self-​ interpersonal functional impairments and pathological personality traits in a more graded fashion, although the categorical model above remains the standard (South & DeYoung, 2013). This alternative model emphasizes recent observations that PDs are not purely categorical, but rather exist on a spectrum with various degrees of PD traits that span a range from normal to pathological. Personality Traits and Disorders • 191

Table 11.2  Personality Disorders Based on DSM-​5a and Overlap with Personality Traitsb Cluster A (the “odd” cluster) Paranoid: mistrust of others, jealous, suspicious, easily feels deceived or exploited by others, cold, secretive, responds angrily to perceived deceptions of others; overlaps with neuroticism, harm avoidance personality traits Schizoid: socially isolated, withdrawn, cold, lack of interest in others, preoccupied with fantasy; overlaps with harm avoidance Schizotypal: eccentric ideas, strange speech, odd behavior, unusual appearance, difficulty forming relationships; overlaps with openness to experiences, harm avoidance Cluster B (the “dramatic” cluster) Antisocial: socially irresponsible, disregards rules or social norms, deceitful, lacks empathy toward others; “sociopathy” is an earlier term used for this disorder, and a particular severe form is called “psychopathy,” characterized by superficial charm, manipulativeness, and callous aggression; overlaps with neuroticism, novelty seeking Borderline: love-​hate relationships, emotional instability, impulsive behaviors, poor unstable self-​ image, fear of rejection, intolerance of being alone; overlaps with neuroticism, harm avoidance, novelty seeking Histrionic: needs to be center of attention, inappropriate attention-​seeking social behavior, frequent mood swings; overlaps with extraversion, self-​transcendence Narcissistic: self-​centered, fragile self-​esteem, overt grandiosity, admiration-​seeking, feelings of entitlement, impaired empathy for others’ feelings; a “malignant” subtype exists characterized by grandiosity, manipulativeness, and callousness; overlaps with neuroticism, novelty seeking Cluster C (the “anxious” cluster) Avoidant: avoids interpersonal contact or intimacy, socially inhibited, hypersensitive to criticism or negative evaluation, rejection sensitivity, low self-​esteem, feelings of inadequacy; overlaps with neuroticism, harm avoidance Dependent: submissive, fearful of being alone, focuses on getting others to take care of them, need for excessive amount of advice or reassurance from others; overlaps with neuroticism, harm avoidance Obsessive-​compulsive: perfectionistic, rigid, preoccupied with details and orderliness, difficulty completing tasks, obstinate, need for control in relationships; overlaps with neuroticism, conscientiousness, harm avoidance a American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-​5®). Washington, DC: American Psychiatric Publishing b Based on data from Piedmont, R. (2009). Personality, spirituality, religiousness and the personality disorders. In Huguelet, P., & Koenig, H. G. (eds.), Religion and Spirituality in Psychiatry. New York, NY: Cambridge University Press (pp. 173–​189).

192 •  M ental H ealth

Although all PDs cause serious personal dysfunction and disruption of relationships, most experts agree that individuals with antisocial PD (also called “sociopathy”) and narcissistic PD are the most challenging to deal with and the most resistant to treatment, particularly those with the more severe forms, such as psychopathy and malignant narcissism. These individuals are often manipulative, callous, aggressive, lacking in empathy for others’ feelings, have little insight, a high threshold for anxiety or fear, and are rarely motivated to change. Individuals with other PDs (or less severe forms of antisocial and narcissistic PD) often experience distressing emotions from the way they behave and treat others, which may drive them to seek help. Individuals with the more genetically based Cluster A disorders may or may not have insight into how these conditions impact their relationships with others, nor feel the need for treatment.

PREVALENCE AND COST OF PERSONALITY DISORDERS The point prevalence of PDs in the United States and Western Europe based on community surveys ranges from 4% to 15%, whereas the prevalence in psychiatric settings approaches 50% (Tyrer et al., 2015). The worldwide prevalence of PDs in community samples from 13 countries (China, Nigeria, South Africa, Lebanon, Colombia, Mexico, US, Belgium, France, Germany, Italy, The Netherlands, Spain) has also been examined: the overall point prevalence for any PD (DSM-​IV criteria) was 6.1%, with the highest prevalence in Columbia (7.9%) and the United States (7.6%) and the lowest prevalence in Western European countries (2.4%) and Nigeria (2.7%) (Huang et al., 2009). The most common PD was the “odd” Cluster A (3.6%) and the least common was the “dramatic” Cluster B (1.5%), with the “anxious” Cluster C falling in between (2.7%). The overall point prevalence of 6.1% was actually low compared to that found in a systematic review of multiple studies that reported a median prevalence of 10.6% worldwide (Lenzenweger, 2008). The difference is likely due to different diagnostic criteria, populations, and methodologies.

Regardless of which estimate is more accurate, this means that PDs are one of the most common groups of psychiatric disorders in the world, especially in the United States. The cost of these disorders is enormous in terms of associated morbidity and mortality. Tyrer and colleagues (2015) reported that life expectancy at birth among those with PD in the United Kingdom is reduced by 19 years in women and 18 years in men. The increase in mortality is largely attributed to increased rates of suicide and homicide, although cardiovascular and respiratory diseases are widespread in those with PD, along with high rates of smoking, substance use, and depression/​ anxiety. Poor relationships with health professionals, as with all these individuals’ relationships, further contribute to morbidity by affecting the quality of care they receive. The annual economic cost of mental health treatments alone has been estimated at nearly $15,000 per person (Soeteman et al., 2008).

CAUSES OF PERSONALITY DISORDERS We now examine the genetic, environmental, and acquired physical/​neurobiological factors that impact the cause and/​or course of PDs, which will prompt consideration of how religiosity might impact this group of disorders. Since personality traits are not necessarily pathological, we focus here on PDs. As noted earlier, PDs primarily result from a combination of genetic predispositions and environmental influences such as experiences during infancy and childhood, interactions with peers during childhood and adolescence, and early life emotional, sexual, and physical traumas.

Genetic Factors “Quantitative genetics” involves twin and adoption studies that estimate the degree to which genetic and environmental factors affect the development of PDs. Twin studies provide estimates of additive genetic influences, shared environmental influences, and individual-​ ­specific environmental influences (which combined make up 100% of heredity). Personality Traits and Disorders • 193

Reichborn-​Kjennerud (2010) and South and DeYoung (2013) have summarized the findings in this area, emphasizing that estimates vary depending on how personality traits and PDs are assessed (via self-​report vs. structured psychiatric interviews). For normal personality traits, studies show that additive genetic influences account for approximately 30%–​ 60%. A relatively recent meta-​analysis summarizing the results of 134 studies examining the heritability of normal personality found an average effect size of 0.40, and concluded that 40% of personality was genetically transmitted, while 60% was due to environmental influences (Vukasović & Bratko, 2015). Genetic influences vary by PD cluster type, and estimates within clusters vary widely depending on the particular study, method, and population. For the odd Cluster A, heritability estimates range from 35% to 60%; schizotypal PD has the highest estimate of 61% and paranoid PD has the lowest at 28%, based on structured psychiatric interviews. For the dramatic Cluster B, studies using structured interviews found that heritability ranges from 35% to 69% for borderline PD, 31%–​63% for histrionic PD, and 24%–​ 77% for narcissistic PD, depending on whether the sample is a general community-​based one (lower estimates) or a clinical sample involving psychiatric patients (higher estimates). For antisocial PD, a meta-​analysis of 51 twin/​adoption studies found that genetic factors made up 41%, shared environmental factors 16%, and individual-​ specific environmental factors 43% (Rhee & Waldman, 2002). A more recent review confirms that about 50% of the total variance in antisocial behavior is due to genetic influences (Tuvblad & Beaver, 2013). With regard to the anxious Cluster C, rates of heritability reported from clinical samples vary from 28% for avoidant to 58% for dependent to 77% for obsessive-​compulsive PDs, whereas in general population surveys, genetic influences account for 35% in avoidant, 31% in dependent, and 27% in obsessive-​ compulsive PD (Reichborn-​ Kjennerud, 2010). There is general agreement that nonshared environmental factors unique to the individual make up the lion’s share of what is left over after genetic factors are accounted for. Besides twin and adoption studies, there are also molecular genetics studies that seek 194 •  M ental H ealth

to identify individual genes or combinations of genes that increase vulnerability to PD. Much of this work has targeted genes that code for neurotransmitters, particularly dopamine, serotonin, and norepinephrine, as well as other catecholamines. For Cluster A disorders, which have been linked to schizophrenia, researchers have found an association with polymorphisms of the dopamine 2 receptor (DRD2) and catechol-​O-​methyltransferase (COPT) genes, especially in schizotypal PD. For Cluster B disorders, characterized by impulsivity, aggression, and emotional instability, associations with polymorphisms of the serotonin transporter gene (5-​HTTLPR), serotonin receptor gene (5-​HT2A), monoamine oxidase A gene (MAOA), and tryptophan hydroxylase 1 and 2 genes (TPH1 and TPH2) have been found, especially in those with borderline and antisocial PD. For Cluster C disorders marked by anxiety-​related traits, polymorphisms of the 5-​HTTLPR, COMT, and dopamine D3 receptor (DRD3) genes have been identified, especially for avoidant and obsessive-​ compulsive PDs (Reichborn-​Kjennerud, 2010). Thus, there is little doubt that genetic factors (responsible for temperament) explain a substantial proportion of the variance in PDs, with the remainder being due to environmental factors and interactions between environment and genes, where genetic factors influence a person’s response to their environment. Specific genetic polymorphisms are unlikely to fully explain these disorders, but rather networks of many genes acting together in their influences.

Environmental Factors The effect that environmental and developmental factors have on PDs is cumulative over time. Most attention of late has focused on antisocial and borderline PDs (Cluster B). For example, in antisocial PD, the sequence begins with genetic vulnerability and ends with antisocial behavior, and is shaped by numerous intermediate environmental risk factors. After birth, there can be ineffective parenting and poor family management with financial and legal problems, residential instability, abusive parent-​child relationships, antisocial parental

role models, parental conflict and divorce, all of which increase the risk of child conduct problems. Conduct problems, in turn, can lead to failure in school and rejection by prosocial peers. Failure to integrate with prosocial peers then may lead to increased risk of alienation, depression, and involvement with deviant peers. Affiliation with deviant peers may in turn lead to substance use and delinquency, which can further lead to a consistent pattern of antisocial behavior and later crime, i.e., antisocial PD (Patterson et al., 1989; Hicks et al., 2012). The progressive development of other PDs is similar, although genetic vulnerability, parental role models, and particular stressors are different. The development of borderline PD begins with genetic vulnerability (stress reactivity, problems in emotional control), and is then influenced further by environmental factors beginning in infancy and early childhood. Parental psychopathology can lead to low parental affection and deficient nurturing, maternal hostility, or separation before age 5, and inconsistent childrearing, which then lead to dysfunctional parent-​ child relationships. This may be followed by child neglect and child maltreatment (emotional, physical, or sexual abuse), which causes self-​ image instability, boundary dissolution, unstable child attachment, and increased interpersonal hypersensitivity (Cohen et al., 2005; Bornovalova et al., 2006; Carlson et al., 2009). The result can be emotional instability, fear of abandonment, and inadequate ability to contain impulsive behaviors, with anger tantrums, demanding behaviors, and other behavioral problems, depressive and anxiety symptoms, and later, unstable interpersonal relationships, the hallmark signs of borderline PD (Chanen & Kaess, 2012). For PDs more generally, the sequence begins with genetic vulnerability, and once again, environmental risk factors shape the particular pathology. Those risk factors include poor family socioeconomic circumstances (poverty), poor parental role models, paternal sociopathy, parental conflict and divorce, parental illness, death or separation, resulting in single-​parent families (with inadequate supervision and mentoring of offspring). Adverse

childhood experiences (emotional, physical, sexual abuse) can further influence the process (Cohen et al., 2005; Tyrka et al., 2009). Gene-​ environment interactions are prominent features of all PDs.

Acquired Neurobiological and Physical Factors We have not yet discussed here the influences of physical trauma and neurobiological processes caused by non-​genetic factors on the brain in utero, during birth and infancy (including infections), or during accidents at any time in life that cause traumatic brain injury, since there is little systematic research on such etiologic factors (Koponen et al., 2002; Thomas et al., 2012). Although DSM-​5 specifically rules out conditions that are a “direct result of physical causes,” physical illnesses and traumas may indirectly interact with both genetic and environmental risk factors to increase vulnerability to PD. In fact, structural and functional alterations in the brain have been repeatedly documented among those with PD (Gunderson et al., 2018). Reduced gray matter volume has been found in the ventromedial prefrontal cortex and other brain regions that modulate impulse control and reactive aggression. Likewise, alterations have been found in the mesolimbic dopamine reward system, hypothalamic-​ ­pituitary-​adrenal axis reactivity, and amygdalar processing, resulting in either reduced emotional sensitivity (as in psychopathic forms of antisocial PD) or increased emotional reactivity (as in borderline PD). Furthermore, many of the neurobiological changes found in the brains of those with PD may be a result of the PD itself, since habitual patterns of pathological behavior, dysfunctional relationships, and negative life experiences may affect brain structure and function due to central nervous system plasticity (Cozolino, 2014; Luoni et al., 2015).

RELIGION, PERSONALITY, AND PERSONALITY DISORDER Based on what we know about the causes of PD, how might religious involvement affect the development and course of personality traits Personality Traits and Disorders • 195

and disorders, whose origins appear to involve a complex interaction between genetic, environmental, and acquired neurobiological factors, beginning in infancy and early childhood and continuing to influence personality across the life span? First, we present a case vignette and then hypothesize how religiosity might influence personality traits and disorders. Case Vignette José is a 24-​year-​old Hispanic immigrant from El Salvador. His childhood was a difficult one. After two divorces, his mother became pregnant with him out of wedlock. She had to return to work full-​time shortly after his birth to support him and his older brother. His mother had wanted to abort José, although this was not allowed in the Catholic region of El Salvador where they lived. While at work, she left José at home to be tended by his 8-​year-​old brother. When he was 2 years old, José’s mother married a man with an alcohol problem and two children of his own. Over the next few years, the only attention José received from his mother or stepfather was beatings during alcoholic rages or when he was severely disciplined for breaking their strict rules. At the age of 5, José’s parents left him in the care of his uncle when they immigrated to the United States. His uncle also drank heavily and repeatedly abused him, continuing the treatment he had received from his parents. At the age of 10, José escaped from his uncle’s home with the intention of reuniting with his parents in the United States. A child-​trafficker offered to take him to the United States if he would agree to perform sexual favors to pay for his passage. This began a difficult 2-​year-​long journey during which he was subject to periodic physical, mental, and sexual abuse. José would use alcohol, which was readily available, to numb his feelings. When he arrived at his parents’ home in the United States, they were not happy to see him, but allowed him

196 •  M ental H ealth

to stay with them for the next year. At the age of 13, he obtained a job working for a construction crew and after a year was able to save enough money to move out on his own. By age 16, he began supplementing his heavy alcohol use with cocaine whenever he could get it. For the next 8 years, José moved from job to job, often quitting because he felt disrespected. He also was in and out of jail for petty crimes to support his drug habit, although he escaped deportation. A handsome young man, who was superficially charming and manipulative, José participated in multiple sexual relationships with women, often at the same time. Lacking empathy, he cared little for these women or their feelings, telling them whatever he thought they wanted to hear. Most of the time, though, he simply felt dead inside. Periodically he suffered from bouts of suicidal depression and severe anxiety accompanied by flashbacks of earlier abuse. During one of these depressive spells, he reluctantly reached out to a co-​worker for help. His co-​ worker, a devout Christian, shared his beliefs with José and offered to pray with him daily before work. He also introduced him to the Bible. After several weeks, José had a conversion experience. He stopped his heavy drinking and drug use, and began regularly attending church services with his co-​worker.   

In 1982, George Vaillant and Eva Milofsky in the Department of Psychiatry at Harvard published an article in the Archives of General Psychiatry (the top biological psychiatry journal in the field) describing alcoholics whose lives were characterized by antisocial behaviors. They concluded the following: . . . it is important to appreciate that a major source of help in changing involuntary habits may come from increased religious involvement. Only recently have

investigators like Frank (1961), Bean (1975), and Mack (1981) begun to elucidate the nature of this process. Alcoholics and victims of other incurable habits feel defeated, bad, and helpless; invariably they suffer from impaired morale. For recovery, powerful new sources of self-​ esteem and hope must be discovered. Equally important is the fact that religious involvement facilitates deployment of the defense of reaction formation, wherein an individual abruptly rejects and hates what he once cherished and loved or vice versa. Reaction formations are essential to abstinence, and they are often stabilizing by surrendering commitments to one set of desires up to a “higher power” that dictates the exact opposite. (Vaillant & Milofsky, 1982, p. 132) Even more relevant to our case above, and prior to the 1982 article, Vaillant had written a piece titled “Sociopathy as a Human Process,” again published in the Archives of General Psychiatry, where he concluded: Finally, one-​to-​one therapeutic relationships are rarely adequate to change the sociopath. A therapist even five times a week—​ is not enough to satisfy an orphan. At the start of the recovery process, only the church, self-​help residential treatment, and addicting drugs provide relief for a sociopath’s pain; they all work 24 hours a day. . . . Only group membership or caring for others, or both, can eventually provide adults with parenting that they never received. . . . The psychopath needs to absorb more of other people than one person, no matter how loving, can ever provide. Sociopaths need to find groups to which they belong with pride. (Vaillant, 1975, p. 183) Might religious involvement indeed have the potential to affect personality, even the onset and course of PD? Examined below are hypothetical pathways by which religiosity might influence specific personality traits, as well as affect the onset and course of various PDs.

Personality Traits We focus here on the Big Five personality traits since these are widely acknowledged and studied within the mental health field and because some of these traits (high neuroticism, low conscientiousness, low agreeableness) may predispose to the development of PDs or protect against them (high extraversion, conscientiousness, agreeableness). Another reason for choosing the Five Factor Model (FFM) of personality traits is that more research has been done on religiosity and these aspects of personality than any other model of personality (e.g., Cloninger’s model). Bear in mind that these traits are considered normal, except at their extremes where they merge into pathological PDs. We have some preliminary perspectives here and summarize the actual empirical research further below. N EUROTICISM

Those who are more religious have a toolbox of coping resources (see previous chapters) that may facilitate better adaptation to stress, and consequently lead to lower levels of anxiety, depression, and emotional instability characteristic of neuroticism. Religious beliefs also discourage behaviors that lead to unstable emotions, such as substance use, delinquency/​crime, sexual promiscuity, divorce, and self-​centeredness, and in contrast, encourage tendencies that lead to emotional stability (forgiveness, altruism, honesty, dependability). Religiously engaged parents may also be less neurotic and less likely to create family environments that breed neurotic tendencies in infants and children (Chapter 14). EXTRAVERSION

Religiosity encourages sociability, getting together, and spending time with others while attending religious services and other religious gatherings. Most religious traditions emphasize prosocial behaviors and altruistic activities that may further increase social contacts, improve social skills, and lead to greater comfort in social settings. Religious parents may create more nurturing environments for infants and children, as well as expose them to Personality Traits and Disorders • 197

more social contacts and activities that could enhance extravert-​like tendencies (Chapter 14). O PE N N E SS TO E XPE RIE NCE

Religions typically endorse more conservative attitudes and traditional beliefs, while either overtly or more subtly discouraging “progressive” free-​thinking, open-​minded tendencies. Religious beliefs may also discourage trying out new behaviors that depart from religious norms, particularly behaviors that seek immediate rewards rather than religious forms of delayed gratification. C O N S C I E N TI O U SNE S S

Religious beliefs are likely to promote dependability, responsibility, self-​discipline, and hard work (e.g., “Protestant ethic”), and thus actively encourage and seek to instill conscientious traits both in children and adults. Religiosity may also promote family environments that reward conscientiousness and provide role models for children in this regard.

biologically determined and genetically based (being closely related to schizophrenia and other psychotic disorders). As a result, we might expect environmental factors (such as religion) to have less impact on these disorders. Relationships found between religiosity and PDs in this cluster might, in fact, may be due to the effect that these “odd” disorders have on religiosity than vice versa. For example, the paranoid or schizoid individual might be less drawn toward religious settings, particularly religious social gatherings, and the individual with schizotypal PD might actually be ostracized from such settings due to their strange thoughts and behaviors. Nevertheless, if religiosity of parents were to create a warm, caring, and accepting early family environment, this might help to neutralize tendencies in this direction. CL USTER B

The PDs that make up the “dramatic” cluster include conditions characterized by a pervasive and persistent disregard for moral standards, social norms, and the rights and feelings of others, as is typical in antisocial AG RE E A BL E N E SS PD (sociopathy and psychopathy); pervasive Religious beliefs may create social and cultural and persistent feelings of self-​ importance norms that promote sociability, friendliness, and grandiosity, need for admiration by generosity, empathy, altruism, and tendencies others, and lack of empathy for the feelings toward being helpful to others, while at the same of others, as found in narcissistic PD; a pertime discouraging argumentativeness, aggres- sistent need to be the center of attention siveness, or self-​ centered behaviors, though with labile emotions, as seen in histrionic tensions especially with other religious groups PD; and chronic problems with impulsivity, might be present. Again, religious parents may emotional lability, love-​ hate relationships, create home environments that reward and pro- poor self-​image and rejection sensitivity, the vide role models for agreeable, helpful, other-​ hallmark symptoms of borderline PD. All of person-​centered attitudes or behaviors during these disorders involve some form of extreme early childhood when such traits are developing. self-​ centeredness (usually developed as a survival mechanism). Given the impact that religious involvement may have on instilling Personality Disorders moral standards, a healthy self-​image, humilHow might religiosity impact the onset and ity, and a focus on the well-​being and rights course of PDs or pathological personality of others, religiosity might have its strongest traits? We discuss this by PD cluster type. influence on the development of these disorders. Again, given the impact of early infant and childhood experiences on the etiology of C LU S TE R A Cluster B disorders, the religiosity of parents As noted earlier, PDs of this type (paranoid, may have a strong impact on the development schizoid, schizotypal) are thought to be more of these PDs. 198 •  M ental H ealth

C L U S TE R C

results from large cross-​sectional studies and prospective cohort studies when available. Avoidant, dependent, and obsessive-​compulsive Some of these studies (European) have used PDs make up this category, known as the “anxthe Eysenck Personality Questionnaire (EPQ) ious” cluster. Characterized by low self-​esteem, to assess the personality traits of psychotifeelings of inadequacy, social inhibition (avoidcism, neuroticism, and extraversion. In cross-​ ant), fear of being alone, dependence on others sectional studies examining religiosity and (dependent), and perfectionism, rigidity, and personality traits, the primary aim of most need for control (obsessive-​compulsive), indiresearchers has not been to examine their viduals with these PDs may be driven to adopt relationship to each other. Because the focus religious beliefs and practices to help cope with is on predictors other than religiosity, investitheir PD symptoms. Thus, one might expect to gators have seldom controlled for confounders see a positive relationship between religiosity or other covariates. There are problems with and PD traits of this nature, especially in cross-​ prospective studies as well, which have largely sectional studies. Over time, though, religious focused on the impact of personality on religiosinvolvement may help to moderate these anxity, rather than on the impact of religiosity on ious traits, given religion’s potential impact personality (our primary interest). on increasing self-​esteem, encouraging socialization and the development of social skills, reducing excessive dependency on others (e.g., N EUROTICISM replacing this with dependence on God), and In an early meta-​ analytic review of cross-​ feeling less need for control (e.g., giving up consectional studies examining the relationship trol to God). between religiosity and FFM personality traits, Saroglou (2002) summarized the results from 13 small studies on religiosity and neuroticism SYSTEMATIC RESEARCH involving nearly 5,000 participants (mostly To what degree are the speculations above con- college students). A total of 26 effect sizes sistent with what systematic research has found were examined for religiosity (k samples =​8), regarding the relationship between religiosity, “open/​mature” progressive religion/​spiritualpersonality traits, and personality disorders? ity (k =​10), religious fundamentalism (k =​3), The focus of this section is on summarizing and extrinsic religiosity (k =​3). The average individual research studies that have exam- weighted effect size (r, sample size weighted) ined religion’s role in preventing, moderating, for religiosity overall was 0.00 (95% CI =​−0.03 or exacerbating pathological personality traits to 0.04, p =​ns), for “open/​mature” R/​S was and PDs. Unfortunately, few studies have been −0.09 (95% CI =​−.12 to −0.05, p =​0.0001), designed in a way that could determine this. We for religious fundamentalism was −0.12 (95% now review the best, highest-​quality studies to CI =​−0.22 to −0.03, p =​0.01), and for extrindate. Most of the existing research involves sic (vs. intrinsic) religiosity was 0.11 (95% cross-​sectional studies, especially those exam- CI =​ 0.05–​0.17, p =​0.01). ining religiosity and PD or PD traits. We begin Several more recent large cross-​ sectional by examining research on normal personality studies have examined the relationship traits and then turn to studies on PD, again between religiosity and neuroticism since 2010. reviewing these studies chronologically in each In the first such study, Francis (2013) examcategory from earliest to most recent (see the ined the relationship between religiosity and Appendix for full list of studies). neuroticism in a random sample of 33,982 high school students (grades 9 and 10) in the United Kingdom. Religiosity was assessed by frePersonality Traits quency of religious attendance (“explicit” reliWe examine here studies on normal personality giosity) and belief that one can be a Christian traits based on the FFM, usually measured using without going to church (“implicit” religiosity). the NEO Five Factor Inventory, summarizing Neuroticism was measured using the Junior Personality Traits and Disorders • 199

Eysenck Personality Questionnaire. Regression analyses indicated inverse relationships between both explicit and implicit religiousness and neuroticism (b =​−0.19, p < 0.001, for each, controlling for gender, age, other personality traits, Christian affiliation, belief in God, and the other forms of religiousness). A second study involved a web-​based sample of 1,047 community-​ dwelling adults (CDA) and 3,083 college students from across the United States, which examined the relationship between religiosity (religiousness, religious struggles) and neuroticism assessed using the FFM (Wilt et al., 2017). Religiousness was assessed using four items from the Religious Belief Salience Scale (Blain & Crocker) and religious/​ spiritual struggles (RSS) by the 26-​item Religious and Spiritual Struggles Scale (Exline). Results indicated that both current and past RSS were significantly and positively related to neuroticism in both CDA and college student samples (controlled analyses). In contrast, religiousness was significantly and inversely related to neuroticism in both samples (r =​−0.09, p < 0.01, and r =​−0.07, p < 0.001, respectively, uncontrolled analyses). Three prospective studies have examined the relationship between religiosity and neuroticism, although two of these focused instead on the impact of neuroticism on change in religiosity over time. McCullough and colleagues (2003) examined the impact of personality on religious development in a 19-​year prospective study of 492 gifted adolescents age 12–​18 (IQs of 135 or higher) who were participating in the Terman Longitudinal Study in California. Personality traits, categorized retrospectively into FFM traits, were assessed at baseline in 1922 and used to predict religiousness, assessed by a 4-​item scale in 1941. Religious upbringing was retrospectively assessed in 1941 and 1951, and the average score was used as a control variable (representing baseline religiousness). Not surprisingly, the strongest predictor of religiousness at age 31–​37 was religious upbringing (b =​0.41). Interestingly, religious upbringing for emotionally stable adolescents had a less positive effect on adult religiosity than it had for emotionally unstable adolescents. Neuroticism during adolescence 200 •  M ental H ealth

was unrelated to adult religiosity after controlling for religious upbringing. In a second report from the Terman Longitudinal Study, McCullough and colleagues (2005a) examined predictors of religious development from young adulthood (age 24–​40 in 1940) through age 80 in the intellectually gifted individuals above (final n =​399). Religiosity at the average age of 27 was assessed repeatedly up until age 80 using a single observer-​rated item that was determined by researchers’ reading of transcripts over this 53-​year period. Participants were then categorized into three groups based on changes in religiosity during that time span: low-​declining (41%), parabolic (increasing during childrearing young adulthood and then declining after age 50) (40%), and high and increasing religiosity (19%). Personality was assessed in 1940 using a 53-​item questionnaire and then, as in the earlier report, categorized retrospectively by the researchers into FFM traits. Predictors of participants in the “low-​ declining” group and “high-​ increasing” group were compared to those in the “parabolic” group. Neuroticism during young adulthood was unrelated to religious trajectory after controlling for baseline religiosity. In the only prospective study to our knowledge that has examined the possible impact of religiosity on neuroticism, Hui et al. (2018) followed 632 Chinese Protestant Christians over 6 waves of data collection (3 years) during which 188, called “apostates,” left their religious faith. A matched sample of 188 of the 444 who retained their Christian faith (“stayers”) was identified and compared to the 188 who had left. Personality traits, including neuroticism, were assessed using the FFM at baseline (Wave 1) and follow-​up (Wave 6). When degree of neuroticism (emotional instability) at baseline (Wave 1) was compared between the 188 who left the faith and the 188 matched individuals who stayed, a significant difference was found; those who left the faith scored higher on neuroticism (t =​2.54, p < 0.05). These results were confirmed in multivariate analyses (two-​way mixed design MANOVA). During the 3-​ year follow-​ up, while religiosity sharply declined over time from Wave 1 to 6 in the apostate group compared to those who retained their

Christian faith, change in neuroticism from Wave 1 to 6 did not differ between the two groups. Overall, then, of the studies identified in our systematic review (see Appendix), approximately half reported lower neuroticism among those who were more religious, and one found greater neuroticism (all cross-​sectional studies, except for the three prospective studies reviewed above).

review, about half found a positive association between religiosity and extraversion, and two found a negative association in Muslim college students (Agbaria & Bdier, 2019; Sultan et al., 2020), findings that are generally consistent with Saroglou’s earlier meta-​analysis. OP EN N ESS TO EXP ERIEN CE

For the trait of openness, Saroglou’s meta-​ analysis found that the average weighted effect size for religiosity overall was r =​−0.06 E XTRAV E RSI ON (CI =​−0.09 to −0.02, p =​0.01), for “open/​ For the trait of extraversion, Saroglou (2002)’s mature” R/​ S was 0.22 (CI =​0.18–​ 0.25, meta-​analysis described above reported that p =​0.0001), for religious fundamentalism was the average weighted effect size for overall −0.14 (CI =​−0.23 to −0.05, p =​0.0001), and for religiosity was r =​0.10 (95% CI =​0.07–​0.13, extrinsic (vs. intrinsic) religiosity was −0.09 p =​0.0001), for “open/​mature” R/​S was 0.15 (CI =​−0.15 to −0.03, p =​0.05). With regard (95% CI =​0.12–​0.19, p =​0.0001), for religious to more recent cross-​ sectional associations fundamentalism was 0.09 (95% CI =​0.00–​ between religiosity and openness, Browne et al. 0.18, p =​0.05), and for extrinsic religiosity (2014) surveyed a random sample of 1,093 CDA was 0.02 (95% CI =​−0.04 to 0.08, p =​ns). Wilt (average age 55) in Australia, examining the and colleagues’ (2017) study described earlier relationship between religiosity (affiliation, involving CDA and college students found that strength of religious beliefs, belief that knowlextraversion was significantly and positively edge comes from spiritual experiences) and correlated with religiosity in both samples openness (assessed by a 3-​item measure based (r =​0.14, p < 0.001, and r =​0.13, p < 0.001, on the FFM). Belief that knowledge comes respectively, uncontrolled analyses); no asso- from spiritual experiences (but not strength of ciation was found between religious/​spiritual religious faith) was positively correlated with struggles and extraversion. Likewise, in a study openness in both bivariate and multivariate of 8,594 Catholic clergy and pastoral staff in analyses, whereas religious affiliation was assoGermany, Kerksieck et al. (2017) found that ciated with significantly less openness. religious trust and daily spiritual experiences In a study of 1,530 CDA and college students were both positively correlated with extraver- in Poland and Iran (an aggregate of seven samsion (r =​0.10, p < 0.01, and r =​0.12, p < 0.01, ples), Aghababaei et al. (2015) found positive respectively, uncontrolled analyses). bivariate associations between intrinsic religiWith regard to prospective studies, both osity and openness assessed by the HEXACO studies of McCullough et al. (2003, 2005a) Personality Inventory, but this was not true for involving the Terman cohort of gifted individ- all samples (in only two of five Iranian samples uals found that extraversion did not predict were associations significant). In another study changes in religiosity during the 19-​to 53-​ of 228 Iranian college students, Afhami et al. year follow-​up periods. In the only identified (2017) reported that self-​rated religiosity and prospective study that examined the effect of religiosity assessed by the DUREL were related religiosity on extraversion over time, Hui and to significantly less openness (r =​−.25 and colleagues’ (2018) examination of Chinese r =​−.19, respectively, p < 0.01), and confirmed Christians above found no difference on extra- by at least one other study in Muslim college version at baseline between those who stayed students (Agbaria & Bdier, 2019). Wilt and colin the faith compared to those who left, nor leagues’ (2017) study of CDA and college studid the two groups differ on changes in extra- dents in the United States found that openness version during the 3-​year follow-​up. Overall, was unrelated to religiosity in the CDA sample then, of all studies identified in our systematic (r =​0.00) and weakly but positively related in Personality Traits and Disorders • 201

the college sample (r =​0.05, p < 0.05, uncontrolled analyses); however, current religious/​ spiritual struggles were more strongly related to openness in multivariate analyses (b =​0.22 to 0.24, p < 0.001). Studying clergy and pastoral staff in Germany, Kerksieck et al. (2017) found that religious trust and daily spiritual experiences were also both positively correlated with openness (r =​0.10, p < 0.01, and r =​0.16, p < 0.01, respectively, uncontrolled analyses). Concerning prospective studies, McCullough et al. (2003) found in uncontrolled analyses that openness during adolescence predicted significant increases in religiosity during the 19-​year follow-​up, although these effects did not persist in controlled analyses. In the only identified study to examine the effect of openness on religiosity, Hui and colleagues’ (2018) examination of Chinese Christians above found no difference in openness at baseline between those who stayed in the faith compared to those who left (apostates), nor did the two groups differ on changes in openness during the 3-​year follow-​up period. Overall, then, the findings vary widely with regard to associations between religiosity and openness to experience, but several studies reported negative associations (about one-​third of studies; see Appendix). C O N S C I E N TI O U SNE S S

For the trait of conscientiousness, Saroglou’s meta-​analysis found that the average weighted effect size reported for religiosity overall was 0.17 (CI =​0.13–​ 0.12, p =​0.0001), for “open/​mature” R/​S was 0.14 (CI =​0.11–​0.18, p =​0.0001), for religious fundamentalism was 0.09 (CI =​0.00–​0.18, p =​0.05), and for extrinsic (vs. intrinsic) religiosity was −0.04 (CI =​−0.10 to 0.03, p =​ns). Concerning the association between religiosity and conscientiousness in more recent cross-​ sectional studies, the findings are quite consistent. In Aghababaei et al.’s (2015) study of 1,530 CDA and college students in Iran and Poland, positive associations were found between intrinsic religiosity and conscientiousness assessed by the HEXACO Personality Inventory across all seven samples (r ranging from 0.17 to 0.28, uncontrolled). Likewise, Wilt et al. (2017) found that 202 •  M ental H ealth

conscientiousness was positively correlated with religiosity in both CDA (r =​0.16, p < 0.001) and college students (r =​0.17, p < 0.001) in uncontrolled analyses, whereas religious/​ spiritual struggles (the focus of the study) were negatively related to conscientiousness in controlled analyses. Kerksieck et al. (2017) also found a positive correlation between conscientiousness and both daily spiritual experiences (r =​0.13, p < 0.01) and religious trust (r =​0.18, p < 0.01) (uncontrolled). With regard to prospective studies, McCullough et al.’s (2003) 19-​year follow-​up of the intellectually gifted children in the Terman study found that conscientiousness was the only Big Five personality trait during adolescence that significantly predicted adult religiousness (greater religiousness) after controlling for religious upbringing (b =​0.14, p < 0.001). However, conscientiousness did not significantly predict increases in religiosity in the 53-​year follow-​up study of this cohort, which controlled for baseline religiosity (McCullough et al., 2005a). In the only identified prospective study examining the possible effects of religiosity on conscientiousness, Hui et al. (2018) found no difference at baseline between Chinese Christians who remained in the faith compared to those who left the faith, nor were there differences between these two groups on changes in conscientiousness over the 3-​year follow-​up. AGREEABL EN ESS

For the trait of agreeableness, Saroglou’s meta-​ analysis reported an average weighted effect size for religiosity overall of r =​0.20 (CI =​ 0.17–​0.24, p =​0.0001), for “open/​mature” R/​S of 0.15 (CI =​0.11–​0.18, p =​0.0001), for religious fundamentalism of 0.13 (CI =​0.04–​ 0.22, p =​0.01), and for extrinsic (vs. intrinsic) religiosity of −0.02 (CI =​−0.09 to 0.04, p =​ns). Concerning more recent cross-​sectional studies (see Appendix), almost all of those retrieved reported positive associations between religiosity and agreeableness, except for a negative correlation among Muslim college students in Palestine (Agbaria & Bdier, 2019). Aghababaei et al. (2015), Kerksieck et al. (2017), Afhami et al. (2017), Wilt et al. (2017), Carlson et al. (2019), Sultan et al. (2020), Entringer et al.

(2020), and Lace et al. (2020) reported that those who were more religious scored higher on agreeableness, consistent with the earlier Saroglou review. With regard to longitudinal studies, McCullough et al. (2003) found that agreeableness during adolescence predicted significant increases in religiosity during the 19-​year follow-​up, although the effect lost significance when controlling for covariates. However, in McCullough et al.’s (2005a) report on their 53-​ year follow-​ up of this cohort, agreeableness during young adulthood (average age 27) was the only Big Five personality trait that distinguished the parabolic group from the low-​declining group (agreeableness lower, b =​−0.035, p < 0.05) and the high-​increasing group (agreeableness higher, b =​ +​0.066, p < 0.05), controlling for religious upbringing, baseline religiosity, and sociodemographic characteristics. However, in the only identified prospective study examining the effects of religiosity on agreeableness, Hui et al. (2018) found no difference at baseline between Chinese Christians who remained in the faith compared to apostates, nor were there differences between these two groups on changes in agreeableness over the 3-​year follow-​up.

E (dominance, aggressiveness, hostility, rebelliousness) and higher on factor G (responsibility, strong superego, concern over moral standards and strength of character). Analyses of change in Cattell 16-​PF scores from Wave 1 to Wave 4 for the entire sample found no significant differences between religious and non-​ religious copers. However, when stratified by gender, male religious copers showed a decline over time in factor Q3 (i.e., they became less concerned over social image and less compulsive or ambitious; F =​7.74, p =​0.001), and female religious copers experienced a decline in factor Q4 (i.e., they became more relaxed, tranquil, and composed; F =​3.92, p < 0.03). Although this was a prospective study, religious coping (Wave 5) was assessed 2–​4 years after changes in personality were measured (Waves 1–​4), making it impossible to determine if religious coping preceded those changes. Nevertheless, these findings suggest that religiosity may assist in the maturing of personality traits over time, even after age 55.

Personality Disorders We now examine research on religiosity and the three major PD clusters, focusing on specific disorders where such research exists. In all these studies, only PD traits have been examined.

C H A N GE S I N PE RS ONALIT Y

As noted earlier, there is considerable controversy over whether personality can change, and in particular, whether religiosity can influence personality—​ especially after the age of 30. Nevertheless, we are aware of a study conducted over 30 years ago that addressed this issue. Koenig and colleagues (1990) followed 100 adults age 55–​80 over 6 years as part of the Duke Longitudinal II Study of Aging. Sixteen personality traits on the Cattell 16-​ PF were assessed at baseline (Wave 1) and 6 years later at follow-​up (Wave 4). Two to four years after Wave 4, religious coping was assessed in terms of how participants coped with the worst event in their life, the worst event in the past 10 years, and the worst aspects of their present situation (Wave 5). Compared to those not using religion as a coping behavior, those who used religion to cope consistently across all three events scored significantly lower at Wave 4 on factor

CL USTER A

Very little research exists on religiosity and the odd PDs (paranoid, schizoid, schizotypal), and what does exist is cross-​sectional. Breslin et al. (2015b) examined the relationship between religiosity and schizotypal traits in a sample of 371 CDA in Ireland. Religiosity was measured by a 16-​item multidimensional measure of prayer (frequency and type). Schizotypal traits were assessed by the Schizotypal Personality Scale. Controlling for age and gender, results indicated that “magical thinking” was positively associated with prayer. However, bivariate correlations revealed that prayer was also significantly associated with less paranoid ideation. To what extent the measure of schizotypal traits used here was loaded with items assessing normative prayer-​ type experiences or religious beliefs is not clear (only the abstract was available for review). Personality Traits and Disorders • 203

Horton et al. (2016a) examined the relationship between spiritual well-​being and the presence of PD traits in 252 patients receiving treatment for substance abuse at a residential treatment facility in southeastern Florida. The Millon Clinical Multiaxial Inventory (MCMI) was used to identify PD traits using DSM-​IV-​TR criteria. Participants were divided into two groups, a clinical or subclinical group (those scoring at or above a cutoff of 75 on the MCMI) and a no PD traits group (those scoring below the cutoff). Paranoid, schizoid, and schizotypal traits were examined (present in 7.5%, 22.6%, and 2.0%, respectively). Spiritual well-​being was assessed by the Spiritual Well-​ Being Scale (Palouzian & Ellison), which includes a 10-​item religious well-​being (RWB) and a 10-​item existential well-​ being (EWB) subscale. Since the EWB subscale is simply a measure of psychological well-​being, only the relationship with RWB is relevant here. In bivariate analyses, RWB was unrelated to paranoid, schizoid, or schizotypal PD traits. In a separate report, Horton and colleagues (2016b) examined the relationship between spiritual well-​ being and the presence of PD traits in 305 patients receiving substance abuse treatment (expanded sample from Horton et al., 2016a, above). In this report, a score at or above a cutoff of 85 on the MCMI was used to designate the clinical group and a nonclinical group (those scoring below the cutoff). Schizoid PD was the only Cluster A disorder examined. Again, RWB was not associated with schizoid PD traits in bivariate analyses. In a cross-​sectional study of 1,194 college students at the University of Alberta, Canada, Crespi et al. (2019) examined the relationship between “spirituality” and schizotypal traits. Spirituality was measured by the Hardt Spirituality Questionnaire that assesses belief in God, search for meaning, mindfulness, and sense of security. Thus, of these dimensions, the only non-​contaminated measure of religiosity was the 4-​item “belief in God” subscale, which was further clarified as “any God, and having a relationship with them involving trust, love, faith and friendship.” Schizotypal traits were assessed using the Schizotypal Personality Questionnaire-​ Brief (SPQ-​ B; Callaway) that assesses ideas of reference, magical thinking, and unusual perceptions. Results indicated 204 •  M ental H ealth

that scores on the belief in God subscale were positively correlated with the 4-​item magical thinking subscale of the SPQ-​B (partial r =​0.15, p < 0.0001), but not with other subscales, similar to the Breslin study above. The questions on the magical thinking subscale were: “Do you believe in telepathy (mind-​reading)?”; “Do you believe in clairvoyance (psychic forces, fortune telling)?”; “Have you had experiences with astrology, seeing the future, UFOs, ESP, or a sixth sense?”; and “Have you ever felt that you are communicating with another person telepathically (by mind-​reading)?” In a study of 189 college students in East Germany, Hanel et al. (2019) examined the cross-​sectional relationship between religiosity and “schizotypy” (SZ; a latent personality trait that increases risk of schizophrenia and schizotypal PD). Religiosity was measured by the 15-​item Centrality of Religiosity Scale (Huber) that assesses beliefs, experiences, public practices, private practices, and intellectual interest. SZ was assessed by the Oxford-​Liverpool Inventory of Feelings and Experiences (Mason), which measures four dimensions: unusual experiences, cognitive disorganization, introverted anhedonia, and impulsive nonconformity. Results indicated that overall religiosity was unrelated to overall SZ or any of its dimensions, with the single exception of impulsive nonconformity. Religiosity was inversely related to that dimension (partial r =​−0.15, p < 0.05, controlling for age, gender, and social desirability). This was especially true for frequency of public religious practice. Carvalho et al. (2020) also reported in a study of 751 CDA in Brazil that general religiosity and attachment to God were related to significantly fewer schizotypal personality traits, except for greater paranormality (general religiosity) and eccentric style (un-​anxious attachment to God). CL USTER B

Considerably more research on religiosity exists for the dramatic cluster (antisocial, borderline, narcissistic, histrionic), but again, most of that research is cross-​sectional. One of two exceptions is a 30-​to 40-​year prospective study of 117 CDA in Berkeley, California. In that study, Wink and colleagues

(2003) examined religiousness (rated on a 1–​5 scale based on involvement in institutionalized religion or tradition-​centered religious beliefs and practices) and spirituality (rated on a 1–​5 scale based on Eastern spiritual practices such as meditation, shamanistic journeying, contemplative prayer, etc.). R/​S was assessed at baseline when participants were in their thirties, and it was then examined as a predictor of narcissism (degree to which individual showed need for power and attention, dis-​esteem for others, willfulness, risk-​seeking) assessed when participants were in their sixties and seventies (but not at baseline). No association was found between religiosity or spirituality and narcissism after controlling for gender, social class, cohort, and either spirituality or religiosity in analyses (b =​−0.11, p =​ns, and b =​0.02, p =​ns, respectively). Hafizi et al. (2014) examined the cross-​ sectional relationship between religiosity and borderline PD traits in 429 medical students in Iran (95% Shia Muslim). Religiosity was assessed using the 5-​ item DUREL, which measures organizational (ORA), non-​ organizational (NORA), and intrinsic religiosity (IR). Borderline PD traits were determined using the self-​report version of the Structured Clinical Interview for DSM-​ IV Borderline Personality Disorder (SCID-​II BPD). Bivariate analyses indicated that overall religiosity (r =​−0.18, p < 0.01) and each of the religiosity subscales (ORA, r =​−0.12; NORA, r =​−0.17; IR, r =​−0.18) were inversely related to overall BPD traits (all p < 0.01). In particular, religiosity was associated with less anger, less instability of mood, less feelings of emptiness, and less self-​ harm behaviors. In Horton and colleagues’ report (2016a) on 252 patients with substance abuse problems discussed earlier, no association was found between RWB and borderline, histrionic, or antisocial PD traits. However, RWB was positively associated with narcissistic PD traits in their expanded sample of 305 (Horton et al., 2016b). Although regression analyses were conducted, the report was not clear on whether other variables were controlled for. Good et al. (2017) conducted a 1-​ year prospective study of 1,132 first-​year college students at a Canadian university examining

the effects of spirituality/​religiosity (S/​R) on non-​ suicidal self-​ injury (including “cutting” behaviors that are common in those with borderline PD). A 6-​item measure of S/​R was administered at T1 and T2: two items assessing frequency of organizational religious activities (ORA), two items measuring frequency of reading S/​R books and frequency of prayer (NORA), and two items assessing S/​R questioning and doubt (SRQD). Non-​suicidal self-​injury was measured using the Inventory of Statements about Self-​ Injury (ISAS) at both T1 and T2. Covariates included T1 age, gender, Canadian birth, and depressive symptoms. Auto-​regressive cross-​lag path analysis was used to analyze the data. Results indicated that T1 SRQD positively predicted T2 ISAS scores, and T1 ISAS scores positively predicted T2 SRQD. No effect was found for ORA or NORA on non-​suicidal self-​injury. Nadal et al. (2018) examined the association between R/​S and antisocial behavior (as a proxy for antisocial PD traits) in 9,495 college students attending multiple universities across the United States. Religiosity was assessed using the 10-​item Religious Commitment Inventory (Worthington), whereas spirituality was measured by the Spiritual Assessment Inventory (Hall & Edwards). Participants were categorized into four groups: religious and spiritual (RAS), spiritual but not religious (SBNR), religious but not spiritual (RBNS), and neither religious nor spiritual (NRNS). In addition, latent profile analysis was used to separate participants into high R/​S, moderate R/​S, and low R/​ S. Antisocial behaviors were assessed using the Antisocial Behavior Questionnaire. Controlling for gender, results indicated that antisocial behavior was significantly lower among the RAS group compared to the SBNR and RBNS groups, but surprisingly, significantly higher than in the NRNS group (p =​0.03). There was no difference in antisocial behaviors between the high R/​S and low R/​S groups, and antisocial behaviors were highest in the moderate R/​ S group. These findings contrast with studies of delinquency and crime (see Chapter 13), which consistently find these behaviors less common among the more religious. Buzdar et al. (2019) surveyed 618 Muslim college students in Pakistan to examine the Personality Traits and Disorders • 205

relationship between religiosity and narcissistic PD (NPD). Religiosity was assessed by the Religious Orientation Scale (Gorsuch & McPherson; intrinsic religiosity [IR], extrinsic religiosity-​ personal [ER-​ P], and extrinsic religiosity-​ social [ER-​ S]) and by the Quest Religious Orientation (QRO) scale (Batson; readiness to face existential questions, religious doubts, openness to change). NPD traits were determined using the Narcissistic Personality Inventory, which assesses exhibitionism, entitlement, exploitive tendencies, vanity, self-​ sufficiency, and superiority. Results indicated that high scores on IR and ER-​P were associated with significantly more NPD traits, whereas high scores on the “openness to change” subscale of the Quest scale were associated with lower NPD trait scores (all p < 0.001). Daghigh et al. (2019) also reported significantly more narcissistic PD traits in religious Muslim college students in Iran. Since hostility/​ aggression is a key aspect of antisocial PD, we briefly review two high-​ quality cross-​sectional studies that have examined R/​S –​hostility/​aggression relationships and one RCT of a spiritual intervention. Salas-​ Wright et al. (2014b) surveyed a random US national sample of 90,202 adolescents (average age 14.6 years) examining the relationship between religiosity and engaging in physical violence, including individual fighting, group fighting, and attacking others. Religiosity was assessed by religious attendance, religious group participation, and importance and influence of religious beliefs. All religious measures were significantly associated with less violence (OR ranging from 0.71 to 0.91, adjusting for age, race, family income, education, substance use, depression, anxiety, and risk taking). In the second study, Salas-​ Wright et al. (2015) surveyed two national random samples of young US adults age 18–​25 examining relationships between religiosity and antisocial behavior, including violent attacks on others, theft, and selling drugs (n =​19,312 in Survey 1, and n =​2,721 in Survey 2). Participants in both surveys were categorized using latent profile analysis into four groups depending on religious involvement (disengaged public/​private religiosity, low public/​private, moderate public/​ private, and public/​ private devoted). 206 •  M ental H ealth

Multinomial logistic regression was used to examine correlates of antisocial behavior. In Survey 1, compared to those who were disengaged, those with devoted public/​private religious involvement were 65% less likely to be involved in theft (OR =​0.35, 95% CI =​0.24–​ 0.51), 70% less likely to sell drugs (OR =​0.30, 95% CI =​0.22–​0.41), and 48% less likely to participate in a physical attack on someone (OR =​0.52, 95% CI =​0.37–​0.72). Similar findings, though somewhat weaker, were reported in the second survey, with OR of 0.66, 0.52, and 0.27, respectively. Finally, Bormann et al. (2006) conducted an RCT examining the efficacy of spiritual-​based mantra repetition (e.g., “Lord have mercy”; “Om mani padme hum”) on trait anger and other mental health outcomes in 93 HIV-​ positive medical patients (San Diego) randomized to either the mantra intervention or an attention control group (group interaction, videos, etc.). Results indicated a significant between-​ group comparison (group by time interaction F =​2.74, p =​0.05), favoring the spiritual mantra group. Thus, focusing on and repeating a spiritual phrase caused a greater reduction in trait anger compared to involvement in social group and educational activities. CL USTER C

There are only a few studies on the relationship between religiosity and “anxious” PD traits (avoidant, dependent, obsessive-​ compulsive), and they are all cross-​sectional. In the study by Horton and colleagues (2016a, 2016b) reviewed above, no association was found between RWB and avoidant or dependent PD traits among 252–​305 inpatients in a residential substance abuse treatment program. In a study of 377 psychiatric outpatients with obsessive-​compulsive disorder in The Netherlands, Van der Hooft and colleagues (2018) examined the relationship between religious involvement (religious affiliation, commitment, attendance) and (1) obsessive-​ compulsive (OC) symptom severity assessed by the Y-​BOCS, and (2) OC cognitions assessed by the Interpretation of Intrusions Inventory. After controlling for age, anxiety, and depression, no associations were found between any

measure of religiosity and any measure of OC symptom severity—​except that OC cognitions were significantly elevated in Catholics compared to Protestants and those with no religious affiliation. In contrast, Ghafoor et al. (2018) found that degree of religious activity assessed by a 19-​ item scale was inversely related to OCD personality symptoms in 200 psychiatric patients with OCD in Pakistan (r =​−0.20, p = 0.002, no controls). Inozu et al. (2020), however, reported that a 2-​item measure of religious commitment was associated with significantly more OCD symptoms in 273 Muslim college students in Turkey.

Summary Overall, given the few prospective studies examining religiosity’s effects on personality traits and the complete absence of prospective studies examining the effects of religiosity on actual PD, it is difficult to determine whether religiosity affects the development or course of personality traits or PD. With regard to personality traits based on the FFM, cross-​sectional studies indicate that those who are more religious tend to score lower on neuroticism, higher on extraversion, higher or lower on openness, higher on conscientiousness, and higher on agreeableness, although reports are not always consistent (except with agreeableness and conscientiousness). Prospective studies suggest that agreeableness (and perhaps conscientiousness) may predict increases in religiosity over time. However, since few longitudinal studies have examined the effect of religiosity on personality traits over time, little can be said about whether religiosity actually influences the development of personality. To our knowledge, as noted above, no studies have examined the relationship between religiosity and PD diagnosed using DSM or ICD criteria. With regard to Cluster A “odd” PD traits, there appears to be little association with religiosity, except that paranoid ideation and impulsive nonconformity may be less common and magical thinking more common among the more religious. Concerning Cluster B “dramatic” PD traits, a 30-​to 40-​year longitudinal study reported no association between

religiosity and narcissism, although two cross-​ sectional studies (one in Turkey and one in Iran) found more narcissistic PD traits in religious Muslim college students. In a one-​year longitudinal study of college students, researchers found no association between religiosity and non-​ suicidal self-​ injurious behaviors (characteristic of borderline PD), except that spiritual/​ religious questioning and doubt predicted more such behaviors. The remaining cross-​sectional studies found less borderline PD traits in religious medical students, less hostility/​aggression and antisocial behaviors in religious adolescents and young adults, and a significant reduction in trait anger in an RCT examining a spiritual intervention. A final cross-​sectional study found no association between religiosity and histrionic, borderline, or antisocial PD traits in those with substance abuse disorders. Regarding Cluster C “anxious” traits, no relationship has been found with avoidant, dependent, or obsessive-​compulsive PD traits in three cross-​sectional studies, except that obsessive-​ compulsive cognitions were more common in Catholics than Protestants or non-​ religious OCD outpatients in the Netherlands. However, one study of psychiatric patients in Pakistan found fewer OCD symptoms in those who were more religiously active, whereas another study of Muslim college students in Turkey reported significant more such symptoms in those who were religious. Thus, the most reliable pattern of research results has been that religious involvement is inversely related to antisocial behavior, positively related to consciousness, and positively related to agreeableness, although even those findings are not entirely consistent. It is clear that more research is needed on the effects of religiosity on both personality traits and especially on PDs before any conclusions can be drawn.

PROMOTING VIRTUES One way that religion may help to form healthy personality traits and prevent the development of disordered personality is the impact it has on character, i.e., promoting virtues that may be viewed as the opposite of negative personality traits. These virtues include a disposition Personality Traits and Disorders • 207

toward gratitude, forgiveness, altruism, compassion (empathy), and humility. There is recent research showing a relationship between religiosity and many of these virtues (Carlisle & Tsang, 2013; Krause & Hayward, 2015). Our systematic review through 2018 (see Appendix) indicated that a majority of studies found religiosity to be positively related to each of the following virtues: self-​discipline (4 out of 5 studies), cooperativeness (3 of 3), altruism/​ generosity (19 of 22), compassion (3 of 4), forgiveness (7 of 10), and gratitude (2 of 2). See Davis et al. (2013) for a comprehensive summary of research on religiosity and forgiveness, and Shariff et al. (2016) for a meta-​analysis on prosociality. Not only might religion’s encouragement and instillation of positive virtues help to ward off personality pathology, but this may also help to explain how religiosity affects mental health and well-​being more generally (e.g., Sharma & Singh, 2019; see also Chapter 16).

RECOMMENDATIONS FOR FUTURE RESEARCH Given the severity of many personality disorders, their often lifelong duration and resistance to conventional treatments, and the tremendous suffering they cause for the afflicted person and everyone around them, there is an urgent need for more research on how individual religiosity and parental religiosity affect the onset and course of PDs across the life span. This, of course, will require prospective studies with long-​ term follow-​ up, which are expensive and difficult to carry out. Prospective studies will be needed to work out the directionality of potential effects of religion on PDs, and of PDs on religious involvement. Many of the cross-​sectional studies above found little association between religiosity and PDs. However, such patterns are consistent both with, for example, (1) there being little effect of either on the other, but also potentially consistent with (2) religiosity being protective for PDs, but those with specific PDs being drawn into religion/​spirituality, or possibly other patterns of causal effects as well. Once again, good prospective data with control for baseline outcomes will be needed to examine these potentially bidirectional relationships. 208 •  M ental H ealth

Besides Buddhist-​based mindfulness meditation interventions (now treated as secular interventions by mental health professionals), we are aware of no religious/​spiritually integrated interventions for PD or PD traits that have been developed or tested in RCTs. This is despite what Harvard psychiatrist George Vaillant said almost 50 years ago (see above). Again, such intervention studies are expensive, and support for such studies by national funding bodies is scarce to nonexistent. Until more funding is available, the most practical studies in the near future will involve qualitative studies, small prospective cohort studies, studies that incorporate religious variables into existing larger cohort studies, and small single-​ group experimental studies to gather pilot data that may justify support for larger RCTs.

CLINICAL APPLICATIONS Treatment is challenging since those with PDs often have comorbid psychiatric disorders (substance use problems, depression, anxiety, and sometimes coexisting other PDs). In addition, these individuals may not be suffering enough to motivate them to seek treatment—​ particularly those with antisocial or narcis­ sistic PD, and to a lesser extent, persons with Cluster A disorders. Finally, clients with PD may attempt to deceive or manipulate the mental healthcare provider and fail to comply with treatment recommendations. Despite these barriers, there are currently a number of conventional treatments being used to address the concerns of those with PD. Psychosocial approaches (over medication) are the primary treatments recommended for PDs, given that the core problem is difficulty with personal and social relationships (Bateman et al., 2015). Evidence-​based psychotherapeutic interventions include cognitive therapy, dialectical behavior therapy, mentalization-​based therapy, transference-​ focused psychotherapy, schema-​ focused psychotherapy, problem-​ solving, psychoeducation, and social skills training. Recall that a meta-​analysis of RCTs of interventions in PD reported a small to moderate improvement in symptoms (d =​0.40) (Budge et al., 2013). Such secular treatments, then, are at least partially effective. Unfortunately, this

applies only to those who meet the strict inclusion/​exclusion criteria required to participate in such trials and are healthy enough to comply with and complete the intervention. Those individuals may look very different from the clients who show up at a therapist’s office. Psychopharmacological interventions have also been recommended for the treatment of specific symptoms such as affective instability, cognitive-​ perceptual problems, and psychotic symptoms, as well as for comorbid conditions such as depression, anxiety, and substance use disorders (Bateman et al., 2015). One study found that 92% of patients with emotionally unstable PD in the United Kingdom Mental Health Services received psychotropic medication (Paton et al., 2015). Despite only modest success with existing therapies, there are good reasons to suspect that treatment may be at least somewhat effective in relieving symptoms for all but the most resistant PDs (e.g., intractable psychopathy or malignant narcissism). So, how might religious approaches to treatment further extend the help that clinicians can provide?

The Spiritual History As recommended throughout this volume, mental health and religious professionals should always take a spiritual history from both the client and family members, if the client consents. Does he or she have any religious or spiritual beliefs? How important are these to her or him? If no belief, were such beliefs ever important? Is the client currently involved and active in a faith tradition? If not, has this ever been the case? What was the religious environment in which the person grew up, if any? Does the client know of anyone who has been helped or hurt by religion? Has the client ever been mentally, sexually, or physically traumatized by religious leaders or pastoral staff? If yes, how has this affected their attitude toward religion now? Is the client currently experiencing any religious struggles (anger at God, feeling abandoned by God or abandoned by their faith community, feeling that God doesn’t care, feeling unloved by God, confused in their understanding of the Divine, etc.)? There are no “right” or “wrong” answers here—​just the client’s experiences. The goal is to determine how religion

might be related to the cause of PD or might be utilized as a resource during treatment.

Simple Religious Interventions These may, or may not, be helpful, depending on the particular type of PD. For example, the person with a severe antisocial PD, especially psychopathic subtype, may not be anxious or feel a need for support (due to reduced biological sensitivity to anxiety or fear). Instead, as noted above, they may try to manipulate and deceive the care provider in order to achieve their own self-​centered goals (e.g., for housing or drugs). Those with other PDs, such as borderline, histrionic, dependent, avoidant, or ­ obsessive-​ compulsive, may be more open to religious support, pastoral care, or a recommendation that encourages involvement in a faith community. However, therapeutic limits often need to be set and adhered to, as some patients (such as those with borderline PD or serious self-​image problems) may easily cross social boundaries, thereby involving care providers in their dependent or love-​hate relationship patterns.

Religiously Integrated Therapies Although to our knowledge, no evidence-​based religiously/​spiritually integrated therapies for PD currently exist, mental health professionals are beginning to explore such treatments. Piedmont (2009) emphasized that religion and spirituality (R/​S) have therapeutic value in the management of borderline, narcissistic, antisocial, and schizotypal PDs, stressing that the anti-​narcissistic aspects of R/​S help to bring out greater honesty and intimacy that will help clients relate better to themselves and others (despite some research to the contrary—​see above). Similarly, Goodman and Manierre (2008) discuss the role that a spiritually oriented form of psychoanalytic group therapy can play in the treatment of individuals with borderline PD. They qualitatively describe the use of this approach in nine female psychiatric inpatients, emphasizing two patterns of God representation in these patients: (1) a “punitive, judgmental, rigid God,” which generally corresponds to images of their parents; and (2) a “depersonified, inanimate, abstract God,” Personality Traits and Disorders • 209

which represents an idealization to compensate for detached parental figures (especially in borderline patients with narcissistic features). While women in that study with punitive God images were able to recreate these representations toward a more benign or benevolent image of God, those with depersonified images of God had much more difficulty with this transition. Such discussions provide an important background for the future development of religiously/​ spiritually integrated interventions specifically for PDs of this type. Contemplative practices for the treatment of PD have also been explored. Dialectical behavior therapy (DBT) currently includes Buddhist-​based mindfulness as a major component when treating patients with borderline and other PDs, as do many other psychotherapeutic approaches. While anxious to incorporate Buddhist-​based mindfulness, those who conduct DBT and conventional psychological treatments for PD typically ignore other contemplative practices rooted in other faith traditions. These include Christian-​ based mindfulness (Ford & Garzon, 2017), Hindu mantra repetition (Bormann et al., 2006), Christian centering prayer (Ferguson, 2010; Keating & Osborne, 2008), Hindu transcendental meditation, Jewish meditation (as practiced by Kabbalists and Hasidic rabbis), and Islamic meditation (such as Salat, Dhikr, or Sufi meditative approaches) (Holthouser & Bui, 2016). Admittedly, these contemplative practices have not been extensively tested in RCTs, which may help to partly explain their infrequent use (in contrast to Buddhist-​based mindfulness). However, in this age of “patient-​ centered” care, choosing therapies that are consistent with a client’s own faith tradition ought to be considered.

Combined Approaches Given the complexity and long-​standing nature of PDs, the best results will require a combined approach, one that includes evidence-​ based psychotherapy (with patient-​ centered spiritual components incorporated), pastoral care, religious community support (as Vaillant suggested for sociopathy), and medication directed at specific symptoms of emotional instability. 210 •  M ental H ealth

This comprehensive treatment of religious patients with PD would ideally include collaboration among psychiatrists, psychotherapists, and pastoral care providers to address all aspects of these life-​destroying disorders that often result from genetic predispositions, early dysfunctional family environments, and neurobiological changes in the brain—​features that make PDs so difficult to treat.

SUMMARY AND CONCLUSIONS In this chapter we defined personality more generally, described personality traits (focusing on the Five Factor Model), and reviewed the diagnostic criteria for DSM-​5 personality disorders. We then explored the prevalence, cost, and causes of PDs, focusing on genetic, environmental, and acquired neurobiological and physical influences. A case of a young man with antisocial PD was then presented to illustrate the role that religion can play in modifying the course of the disorder. Next, we hypothesized how individual religious involvement (and that of parents during infancy and early childhood) might impact the development of personality traits and the development and course of PDs. The heart of this chapter, as in all chapters throughout this volume, involved reviewing systematic research on the relationship between religiosity, personality traits, and PDs. Research on both the impact of personality on religion and the impact of religion on personality was examined. We found that most of that research has been cross-​sectional, with very few prospective studies, and to our knowledge, only one RCT (and that was for trait anger and not in those with PD). We concluded that the research on religiosity and personality is still in its infancy, and emphasized the need for future prospective studies to determine the impact of religiosity on PD, as well as for more efforts to develop and test religiously integrated interventions. Finally, we discussed secular treatments for PD and suggested ways to integrate the client’s religious or spiritual beliefs into those treatments. In a later chapter (Chapter 13), we focus on the role that religiosity can play in the social and societal consequences of PD, particularly antisocial PD, i.e., delinquency and criminal activity.

12 Psychological Well-​Being and Positive Emotions But the fruit of the Spirit is love, joy, peace, forbearance, kindness, goodness, faithfulness, gentleness and self-​control. —​Galatians 5:22–​23

RATHER THAN FOCUSING on psychopathology and mental disorder, this chapter instead examines the impact that religiosity has on generating positive emotions, particularly feelings of well-​being, life satisfaction, happiness, meaning and purpose in life, optimism, hope, gratitude, and self-​esteem. Other than the highs experienced during the manic phase of bipolar disorder, positive emotions often reflect mental health resiliency. An overall sense of psychological well-​being, perceiving life as having meaning and purpose, having an optimistic view of the future, being hopeful that good things are ahead, being thankful for what one has, and having a positive view of oneself may affect how well a person copes with change, loss, or other traumatic stress. Such positive emotions may help to protect against the development of depression, anxiety, or other emotional disorder, or speed their resolution. Religious involvement may be

particularly important in generating emotions like these that sustain individuals through difficult times. Psychological well-​being exists on a continuum from low well-​being (where feelings of oppression, sadness, and hopelessness predominate) to states of high well-​being (where genuine happiness or joy is present and sustained). Rather than simply avoiding pain, humans strive to experience pleasure, completeness, and meaning. In his book The Pursuit of Happiness, David Myers (1993) notes Aristotle’s (384–​322 bce) comment that happiness is the “supreme good” and that “all else is merely a means to its attainment” (p. 19). Likewise, American psychologist William James (1890) wrote that “how to gain, how to keep, how to recover happiness is in fact for most men at all times the secret motive of all they do” (p. 19). Similarly, life-​satisfaction expert Edward Diener (Diener, 2000; Diener et al., 2006) has concluded that

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0012

subjective well-​ being is the most powerful motivator in life and more important than the drive for material success. The experience of positive emotions for many, then, is a necessary part of life to be obtained by whatever means possible. Today, there is an entire branch of psychology—​positive psychology—​that focuses on fostering well-​being, happiness, and other positive emotional states. There are now hundreds of studies documenting the relationship between positive emotions and both mental and physical health (Lopez et al., 2018). In this chapter, we begin by describing the predictors of psychological well-​ being (subjective well-​ being, satisfaction with life, happiness).

an aspect of temperament—​has been shown to be affected by genetic influences. The set-​ point theory claims that people are born with their own individual “set point” for well-​being or happiness, which may increase or decrease depending on circumstances, but eventually returns to its biologically determined level (Lykken & Tellegen, 1996; Lucas et al., 2007). While there is now evidence against a strict interpretation of set-​point theory (Diener et al., 2009), it nevertheless correctly identifies a tendency for people to sometimes return to genetically influenced baselines. Twin studies have reported that up to 72% of well-​being is hereditary (Keyes et al., 2010). However, several meta-​ analyses of genetic studies have found that psychological well-​ being has an average heritability estimate in the range of PREDICTORS OF 30%–​ 40%, which indicates that while some WELL-​B EING of the individual differences in psychological What are the causes of psychological well-​ well-​being may be attributed to genetic effects being? What are the characteristics of those (about one-​third), that leaves a lot to be deterwho are happiest and most satisfied with their mined by other factors (Diener et al., 2018). lives? According to an early review by W. Wilson Thus, 60%–​70% of the variation in well-​being (1967), persons with the most advantages have may be due to environmental factors, as well the highest well-​being and greatest happiness. as to individual attitudes, behaviors, and deciIn other words, the “happy person emerges sions that people make. as a young, healthy, well-​educated, well-​paid, extroverted, optimistic, worry-​free, religious, Satisfaction of Goals married person with high self-​esteem, high job morale, modest aspirations, of either sex and This theory posits that well-​being is determined of a wide range of intelligence” (p. 294). Others by the extent to which people have achieved suggest that happiness has more to do with or are achieving the goals that are important being satisfied with what one has than it does to them. This view is also consistent with the with the amount that one has. What else have “resource theory” of psychological well-​being, we learned about the factors that influence which holds that fulfilling basic needs (such as well-​being? food and shelter) and psychological needs (such Edward Diener, a psychologist whose work as independence and control over one’s life), on factors contributing to psychological well-​ which depend heavily on income, is the key to being and life satisfaction has spanned over well-​being and happiness. Nevertheless, while 35 years, divides the three theories on causes studies also show that income is associated with of psychological well-​being into genetic influ- positive life evaluation up to about $75,000 per ences, satisfaction of goals, and mental state year in the United States, there appear to be (Diener et al., 2018). only small increases in positive emotions with incomes above this level (Kahneman & Deaton, 2010). Likewise, in a survey of more than 1.7 Genetic Factors million individuals worldwide, the annual As noted in Chapter 11, genetic factors play income threshold above which there was little a major role in determining a person’s basic increase in emotional well-​being and positive temperament. Not surprisingly, then, psycho- life evaluation was around $60,000–​75,000 to logical well-​being—​which some consider to be $95,000 (Jebb et al., 2018). 212 •  M ental H ealth

The satisfaction of goals theory argues that psychological well-​being and life satisfaction depend on the extent to which people have enough physical/​material, cognitive, spiritual, and relational resources to meet their most valued life goals. Thus, those who perceive they have few needs (such as a poor Amish family, for example) may more easily meet valued life goals (and be happy) than very wealthy individuals who have high expectations for a luxurious lifestyle that might be difficult to meet (and therefore may be less happy).

happier than the old (Diener, 1984). More recent research, however, has found that this is not always the case, or at least that age effects on well-​being are more complex. Depending on the specific birth cohort and geographical location, cultural setting, length of follow-​up, and characteristics controlled for, the relationship between age and well-​being might be linear and positive, linear and negative, U-​shaped, inverted U-​shaped, or the two might be completely unrelated (Ulloa et al., 2013). For example, in a group of individuals born and raised around World War II in a devastated country in Europe, they might find that life has gotten Mental State a lot better since then, resulting in a linear The mental state theory of psychological well-​ positive association between age and well-​ being holds that happiness is dependent on being (possibly due to increases in resources cognitive processes, i.e., reference points, stan- or perhaps downward comparisons). In condards of comparison, and ways that people trast, a person who has a lifelong chronic illattend to specific events. Concerning reference ness that has gradually worsened and affected points, a person may compare their situation their employment and ability to function indeto others’ situations and conclude that they are pendently is likely to experience a decline in worse or better off (known as “upward compar- well-​being with increasing age. ison” or “downward comparison”) with conseIn general, though, research seems to sugquent effects on happiness (Hsee & Zhang, gest a U-​ shaped relationship between well-​ 2010). Concerning attention to specific events, being and age, with the lowest well-​ being and the memory and interpretation of those experienced during middle age (Clark, 2019). events, the person who focuses on and savors In a study of 2,000,000 persons from nearly positive events is likely to be happier than the 80 countries, Blanchflower and Oswald (2008) person who ruminates about negative events found that life satisfaction was lowest in the (Kahneman et al., 1999). mid-​to late forties (in the US, age 45). They speculated that this is a time in life when many people realize that they will never achieve the Other Factors lofty goals and aspirations they had during Well-​being and happiness are likely explained their youth (the infamous “mid-​life crisis”). by a combination of genetics, goal satisfaction, Consequently, they struggle and eventuand mental state, but also by other factors ally settle for “life being as good as it gets.” that we describe below (many of which may However, the U-​shaped curve may depend parbe included under or at least affected by the tially on the factors that are being controlled above). for in the analysis of their data. Variables such as education, income, and marital status change over the life course and may effectively AG E mediate the relationship between life satisfacRecall that Wilson (1967) emphasized first tion and age (Glenn, 2009; Hellevik, 2017). that it is young people who have the greatest Recent US analyses suggest the left part of the well-​being. Youth is a prime time in life when “U” may be flatter, and younger people may not health, beauty, and strength are at their peak; be doing so well today (Glenn, 2009; Thomas when fear, worry, and caution may be of little et al., 2016). concern; and when future possibilities seem Greater well-​being in later life could also be limitless and life has no end. Indeed, many explained by happier people surviving longer early studies reported that the young were than those who are unhappy (Diener & Chan, Psychological Well-Being and Positive Emotions • 213

2011). Alternatively, social comparisons may increase in later life (i.e., seeing one’s peers get sick or disabled), enhancing life satisfaction over appreciation for good health. Interestingly, Blanchflower and Oswald made no mention of religion as a contributor to well-​being, despite the well-​known observation that religion peaks in later life (when factors that decrease well-​ being, such as physical disability and income needs, also peak).

explain the high rates of unhappiness in the United States when the unemployment rate reached 8.7% in March 2009 and was hovering near 10% in January through May 2010. By 2019, increases in national rates of happiness were at least partly due to an improving economy and reduction in unemployment rate to 3.6% (US Bureau of Labor Statistics, 2019; McCarthy, 2019). In a review of 104 studies with 437 effect sizes, McKee-​ Ryan and colleagues (2005) found that unemployed individuals had lower life satisfaction than those who EDU CATI O N were employed (d =​0.48). Among those who Education has long been linked to greater well-​ were unemployed, the centrality of work in life, being, although the effect is relatively small and the availability of coping resources, cognitive due more to the higher occupational status and appraisals of their situation, and coping strathigher income of those with more education egies were more strongly related to well-​being (Witter et al., 1984). In a recent meta-​analysis than were human capital (education, ability, of 47 studies involving a total of 38,946 par- occupational status) or other demographic ticipants, Bücker and colleagues (2018) found characteristics. Recent studies confirm the that the average correlation between academic strong correlation between employment and achievement and subjective well-​ being was well-​being (Ohtake, 2012; Sameem & Buryi, small to medium in magnitude (r =​0.164, 95% 2019), as well as longitudinal studies (McKee-​ CI =​0.113–​0.216, equivalent to a Cohen’s d of Ryan et al., 2005; Lucas et al., 2004). 0.33), which was stable across demographic characteristics, domains of well-​ being, and GEN D ER measures of academic achievement. Given the relatively weak findings, the authors con- In contrast to that found for depression, where cluded: “low-​achieving students do not neces- the likelihood of depression is nearly twice sarily report low well-​being, and high-​achieving as great in women compared to men, gender students do not automatically experience high differences in subjective well-​being are much levels of well-​being.” However, an important smaller. Early research suggested that there issue with research on the association between was an interaction with age. Diener (1984) education and well-​being is that many of these found that while younger women were happier studies have used cross-​ sectional data. This than younger men, this association reversed is problematic because, as with age, many of in later life. This finding was confirmed by the analyses have controlled for some of the Inglehart (2002) in a sample of 146,000 plausible mechanisms between education respondents from 65 countries assessed in and well-​being, such as employment, income, the cross-​sectional World Values Surveys conand marital status, since education tends to ducted between 1981 and 1997. For those enhance each of these. Longitudinal analyses age 18–​24, 24% of the men and 28% of the that take this temporal ordering into account women described themselves as very happy, suggest that greater education improves hap- whereas in the over 65 age group, 20% of the piness and life satisfaction through these path- women and 25% of men described themselves ways (Cunado & de Gracia, 2012; Powdthavee as very happy. The crossover occurred around et al., 2015). age 45–​54. More recently, Batz and Tay (2018) note that in a meta-​ analysis involving 281 samples including over a million individuals, EMP L OY ME N T after accounting for publication bias, men Well-​ being and happiness are strongly cor- experienced significantly higher levels of life related with employment status. This helps to satisfaction than women, although the effect 214 •  M ental H ealth

size was very small (d =​0.03). Examining “positive affect” more generally, Zuckerman and colleagues (2017) found no difference between men and women in a study that involved an international representative sample of 455,104 adults; however, they did find that women had higher levels of “negative affect” compared to men (consistent with findings for depression). E TH N I C I TY

Once the confounders of education, income, and urban residence are controlled, race exerts a small but significant effect on well-​being, one that is at least partly dependent on age and gender. African Americans in general have lower well-​being than White Caucasian Americans. Using data from the General Social Survey (GSS) for the period 1972 to 1996, Hughes and Thomas (1998) found that quality of life was worse for African Americans. In almost every year of that study, African Americans had lower life satisfaction, lower happiness, lower marital happiness, greater anomie, less trust, and worse health. There is evidence, however, that this trend may reverse in later life, when older African Americans tend to be happier (and much more religious) than older Whites (Campbell et al., 1976). More recent research suggests that the gap between Blacks and Whites at all ages in the United States is narrowing. Analyzing data from the GSS between 1972 and 2014, Iceland and Ludwig-​ Dehm (2019) found that the “very happy” gap was 6% in the 2012–​2014 period, compared to 15% in the 1972–​1976 period. This decline in the happiness gap was found to be due to increases in income and likelihood of being married among Blacks, as well as improved educational attainment, decreased poverty, increased life expectancy, and improvements in residential segregation and neighborhood economic conditions, as racial inequality has begun to narrow in recent years. Furthermore, church attendance also appears to narrow the happiness gap between US Blacks and Whites, in that Blacks are more likely to attend religious services than Whites, and as we will see below, frequency of religious attendance is strongly correlated with psychological well-​being.

M ARITAL STATUS

It has long been known that married persons report greater happiness than the never married, divorced, or separated (Andrews & Withey, 1976). More relevant than marital status by itself, however, are family and marital satisfaction, which have been strongly correlated with well-​ being in many studies (Diener, 1984). Reverse causation, however, may also be a factor in that happier people may also be more likely to attract marriage partners (Lyubomirsky et al., 2005). However, even longitudinal studies, controlling for baseline happiness, suggest an effect of marriage on well-​being (Stutzer & Frey, 2006; Uecker, 2012; Marks & Lambert, 1998). When examined over time, people are usually happiest during the year before marriage and then shortly after marriage, although after several years of marriage, they may drop back to their pre-​marital baseline happiness level (Lucas et al., 2003). Recent research suggests that marriage may help to ease the mid-​life dip in life satisfaction. Furthermore, the relationship between marriage and life satisfaction is about twice as large for those who indicate their spouse is also their best friend (Grover & Helliwell, 2019). Having children is not associated with greater well-​ being, despite the expectations of those without children, particularly when household income, education, religiosity, and health status are controlled. Instead, the happiness of couples having children depends more on finances, marital quality, and sleep disturbances caused by the children (Deaton & Stone, 2014), though further longitudinal research is needed to determine how children affect happiness over time, especially in later life. The effect of children on well-​being may also vary considerably across countries and cultural contexts. SOCIAL SUP P ORT

Both longitudinal and intervention studies demonstrate that frequency of social contacts is associated with greater well-​being. An early meta-​analysis by Okun and colleagues (1984) of 115 studies found that social activity predicts about 2%–​4% of the variance in well-​being

Psychological Well-Being and Positive Emotions • 215

(after other covariates are controlled) (Mancini & Orthner, 1980). Researchers also noted that some social contacts (with friends) are associated with greater well-​being, whereas other social contacts (with relatives) may be less so, due in part to the more complex and sometimes ambivalent nature of these relationships (also see Litwin, 2001). Recent meta-​analyses confirm the link between social support and well-​being, both overall (Song & Fan, 2013), in children and adolescents (Chu et al., 2010), across the life span (Siedlecki et al., 2014), and in countries outside the United States (Yalcin, 2015). In a review of 86 studies with a total sample size of 32,948 participants, Song and Fan (2013) found that social support was positively correlated with subjective well-​being, satisfaction with life, positive affect, and negative affect, with r ranging from −0.23 (d = –0.47) for negative affect to 0.36 (d = 0.77) for well-​being. Likewise, in a review of 246 studies in children and adolescents, Chu et al. (2010) found a positive association between social support and well-​being, increasing in strength with age; this was true especially when support was provided by teachers and school personnel. In a review of 35 studies conducted in Turkey involving 14,564 participants, Yalcin (2015) found an average effect size of r =​0.36 (d =​0.77) between social support and well-​being. Thus, social support has been related to greater well-​being in all ages and in many locations throughout the world, especially when that support comes from diverse sources, including both family and unrelated friends (as might be found within a religious community). PHY S I CA L H E A LT H

A recent review of the relationship between physical health and well-​being found a consistent association between medical illness, physical disability, and poorer perceptions of well-​ being (Steptoe, 2019). People who are physically ill or disabled report less happiness, lower life satisfaction, less positive affect, more negative affect, and more depression. The causal arrow, however, appears to go in both directions, in that physical health problems lead to lower levels of well-​being, and lower levels of well-​being lead to more physical illness 216 •  M ental H ealth

and greater disability (see below). In a systematic review and meta-​ analysis of 29 studies with sample sizes ranging from 69 to 350,000, Ngamaba and colleagues (2017) reported a pool effect size of r =​0.35 (95% CI =​0.31–​0.39), indicating a substantial relationship between health status and well-​being. The association was stronger when well-​being was operationalized as life satisfaction (r =​0.37, d =​0.80) as compared to happiness (r =​0.31, d =​0.65) and was stronger in developing (r =​0.42, d =​0.93) compared to developed countries (r =​0.34, d =​0.72). The relationship between health and well-​being was moderate to large in size, and did not vary much when examined within samples of persons with chronic medical illness or those from the general population.

Impact of Well-​Being on Health Not only do many factors affect psychological well-​being, but well-​being also impacts many aspects of health, including physical health and longevity (Diener et al., 2017; Trudel-​Fitzgerald et al., 2019), as well the quality of social relationships, work performance, and resilience in many other areas of life (De Neve et al., 2013). Indeed, there is growing research showing that those who are happier live longer, and there is evidence that this relationship is causal in nature, based on longitudinal studies, experimental studies, and randomized controlled trials (see Diener & Chan, 2011, for a review). Interestingly, an early study of Catholic sisters found that those in the happiest quartile measured at the time of entry into the convent had a 2.5 times lower mortality than those in the lowest quartile (Danner et al., 2001). Positive emotions also affect the likelihood of successful physical rehabilitation following injury or illness and speed recovery more generally. In a meta-​analysis of 17 studies examining the impact of positive emotions (well-​being, life satisfaction, etc.) on rehabilitation, Lamers and colleagues (2012) reported a statistically significant average 14% increase in recovery and survival in physically ill patients. Successful recovery following injury, surgery, stroke, or other medical conditions often depends on having meaning and purpose in life, being optimistic, and retaining hope with regard to the

future, which give people a reason to engage in the hard work of rehabilitation (Stewart & Yuen, 2011).

RELIGION AND POSITIVE EMOTIONS Religious involvement is related to many of the predictors of well-​being described above, including satisfaction with goal attainment, focus on positive events, likelihood of obtaining an education and meaningful employment, likelihood of a stable and satisfying marriage, acquiring a supportive social network, and maintaining good physical health (see Section VI). Before theorizing further on how religious involvement might impact psychological well-​ being and other positive emotional states, we present a case vignette.

Case Vignette Lamar is a divorced 45-​ year-​ old male postal worker who lives alone in a downtown apartment located in a large US city. He works at a local post office that is always short-​staffed, with long lines of impatient and often rude customers. Despite his work situation, Lamar maintains a positive attitude toward the postal employees he works with and the people he serves at the counter. Things weren’t always that way. After separating from his wife five years ago, Lamar was angry, depressed, and would frequently visit bars at night to drink and drown out his grief over the loss of his family. He almost lost his job at the post office when staying out late and arriving late for work the next morning due to the aftereffects of drinking the night before. His emotional tolerance was at an all-​time low, which made him irritable toward customers. Lamar was reprimanded more than once by his superiors after mouthing off to customers, who often complained about his harsh tone and curt service. Lamar was unhappy with his job and hated his life. One day,

in desperation, he attended a religious revival at a local Pentecostal church, which he had gone to on rare occasions in the past. Something happened there that changed his outlook. The preacher said something that made him realize his life had meaning and God had a purpose for it, even the negative experiences he was having now. Lamar responded to the altar call and gave his life to Jesus, after which he felt a peace and sense of motivation that he had not experienced before, even before his life had fallen apart. Lamar then and there decided to change. He began to pray and read the Bible before work, attend religious services on Sundays and Wednesday nights, and stopped going to bars and drinking. With newfound purpose, he began to view his work at the post office as a “mission field.” Lamar decided that he would treat every customer with respect, no matter how unpleasant they were, and the same applied to his co-​workers. As people began to respond in like manner to his positive attitude and behavior, he began to feel better and better about himself. The changes in Lamar persisted. After several months, he became one of the most well-​liked personnel at the post office, and customers would frequently leave positive comments about his service on the feedback form. Lamar liked himself and the person he had become. He was certain it was because of his newfound relationship with God, and he was immensely grateful for that.   

How might religion have increased Lamar’s happiness, well-​ being, and satisfaction with life? For him, religious beliefs provided structure and meaning, helped him feel better about himself and his future, helped to motivate him to care more for others (as he believed he had been cared for my God), and provided healthier ways to cope with stress and loss. As noted in the previous chapter, religion encourages people to forgive one another and prompts them to Psychological Well-Being and Positive Emotions • 217

engage in religious and other community activities that benefit others. The latter, in turn, expands their social network with prosocial peers and provides opportunities for service (volunteer activities) that may further enhance self-​esteem, reduce loneliness, and bond people together with a common goal. For some, religion may fill a void in life that nothing else can. The French mathematician, physicist, and theologian Blaise Pascal, put it this way in 425 ce: What else does this craving, and this helplessness, proclaim but that there was once in man a true happiness, of which all that now remains is the empty print and trace? This he tries in vain to fill with everything around him, seeking in things that are not there the help he cannot find in those that are, though none can help, since this infinite abyss can be filled only with an infinite and immutable object; in other words, by God himself. (Pascal, 1966, p. 75)

RESEARCH ON RELIGION AND POSITIVE EMOTIONS To what extent does quantitative research back up the speculations above? We now review studies that have examined the relationship between religiosity, psychological well-​ being, life satisfaction, happiness, and other positive emotions (purpose and meaning, optimism, hope, gratitude, and self-​esteem).

Psychological Well-​being In our systematic review of quantitative research published prior to 2010 (Koenig et al., 2012, Appendix), we identified 326 studies that examined the association between religiosity and subjective well-​being, happiness, or life satisfaction. Of those, 79% (256 studies) reported significant positive associations, 1% (3 studies) indicated negative associations, and 20% reported no association or mixed findings (positive and negative effects, depending on religious characteristic). Among the 120 highest-​ quality studies (based on sampling method, sample size, research design, statistical controls), 82% reported positive associations 218 •  M ental H ealth

and 1% (1 of 120 studies) reported lower well-​ being among the more religious. Most studies were cross-​sectional in design, thus contributing very little evidence for causal inference. However, 16 studies were prospective and 8 (50%) reported that greater religiosity at baseline predicted higher well-​being at follow-​up. There were also 5 experimental studies, all of which produced a significant increase in well-​ being based on within-​group comparisons of before and after a religious or spiritual (R/​S) intervention. Finally, there were nine RCTs, of which about half reported that an R/​S intervention significantly increased psychological well-​being compared to a wait-​listed or active control condition. What about more recent research? P ROSP ECTIVE STUD IES

There have been many high-​quality prospective studies with samples over 1,000 published since 2010. We have chosen 12 of those to review below, along with 3 RCTs examining the efficacy of R/​S interventions. Lim and Putnam (2010) analyzed data from a 1-​year prospective study of a random national US sample of 1,915 community dwelling adults. Religious involvement was assessed by frequency of religious attendance, private/​ subjective religious activity, number of friends in the congregation, and religious identity (importance of religion to one’s sense of self). Life satisfaction was measured by single question asking how satisfied participants were as a whole with life on a 0–​10 scale. Analysis of covariance was used to control for baseline life satisfaction, overall social involvement, civic involvement, and number of close friends. Results indicated that frequency of religious attendance significantly improved life satisfaction in the fully controlled model (b =​0.112, p < 0.001). This effect was explained by number of friends in the congregation and by religious identity. Furthermore, after controlling for T1 life satisfaction and T1 religious attendance (b =​0.150, p < 0.001), increases in religious attendance between T1 (2006) and T2 (2007) predicted T2 life satisfaction (b =​0.151, p < 0.01), an effect explained by number of fiends in the congregation. The

authors concluded: “Our findings suggest that religious people are more satisfied with their lives because they regularly attend religious services and build social networks in their congregations” (p. 914). We next summarize a smaller study (in contrast to large long-​term prospective cohorts), but one which uses more frequent measurements to examine the effects of daily spiritual experiences (DSE) on daily perceptions of psychological well-​being over a 2-​week time period. Kashdan and Nezlek (2012) conducted this study using a daily diary of spiritual experiences and positive emotions in 87 Virginia college students. DSE were measured by two questions: “Today, the spiritual part of my life was very important to me” and “Today, my personal relationship with a power greater than myself was important to me.” As a measure of trait spirituality, investigators also had participants complete a 22-​item spiritual involvement and beliefs scale. Daily measures of psychological well-​being were assessed in terms of self-​ esteem, meaning in life, and positive affect. The data were analyzed using a series of multilevel models, using lagged analyses to determine whether DSE predicted future well-​ being or vice versa. Results indicated that DSE predicted greater meaning in life, self-​esteem, and positive affect. For those with higher trait spirituality, researchers found that greater negative affect and lower positive affect on one day predicted greater DSE on the next day. The authors concluded that DSE increased well-​ being, whereas low well-​being increased DSE, suggesting bidirectional effects. Bradshaw and colleagues (2014) analyzed data from a 3-​year prospective study of a random national US sample of 1,024 community-​ dwelling adults age 66 or older to examine the effects of listening to religious music on life satisfaction. Religious music was assessed by frequency of (a) listening to religious music outside of church and (b) listening to gospel music. Frequency of religious attendance and private prayer were also asked about. Life satisfaction was measured by a 4-​item index. After controlling for T1 life satisfaction and numerous other sociodemographic, religious, and health characteristics, listening to religious music outside of church (but not gospel

music) predicted T2 life satisfaction (b =​0.019, SE =​0.008, p < 0.05). Lechner and Leopold (2015) analyzed data from a prospective study of a national random sample of 5,446 community-​ dwelling adults in Germany who transitioned to unemployment during a 22-​year follow-​up (out of a total sample of 20,806). The purpose was to examine the buffering effect of religious attendance (assessed by single question) on the negative effects of unemployment on life satisfaction during a 3-​year follow-​up after unemployment began. In the overall study, participants were surveyed yearly from 1990 to 2012. Life satisfaction was measured by a single question asked during all waves of data collection. Religious attendance was assessed 1 year prior to transition to initial unemployment (64.3%) or at the time of initial transition to unemployment (35.7%). Participants were then followed up with two later waves of data collection, allowing for a maximum of three consecutive years spent in registered unemployment. Controlled for in fixed effects regression models were time-​ varying covariates (marital status, historical period) and time-​ constant covariates (age at transition to unemployment, migration background, region of Germany). Results indicated that life satisfaction decreased more slowly during the first year of employment for those attending religious services weekly or more often (b =​0.359, p < 0.01), as did life satisfaction during the second year of unemployment (b =​0.467, p < 0.05) and the third year of unemployment (b =​0.631, p < 0.01). Researchers concluded: “These results suggest that religious attendance on a weekly basis can mitigate the psychological impact of unemployment” (p. 166). Again, in a departure from our reviewing large prospective studies, we consider a study that examined the effects of religiosity on positive affect (a proxy for psychological well-​being) among cancer patients in Greece. Kaliampos and Roussi (2017) followed 86 Greek cancer patients for an average of 7 months, assessing religious beliefs and religious coping at baseline (T1) and positive affect at baseline and follow-​ up (T2). All participants were newly diagnosed with cancer and undergoing adjuvant chemotherapy at baseline. Religious coping was

Psychological Well-Being and Positive Emotions • 219

assessed by a 2-​item subscale of the COPE, and positive affect was measured by the Profile of Mood States (POMS). After controlling for T1 positive affect, T1 psychological distress, gender, family history of cancer, religious beliefs, and other coping behaviors (acceptance, planning, positive interpretation, mental disengagement, denial, seeking social support), T1 religious coping predicted significantly higher T2 positive affect (b =​0.36, p < 0.05). Jung (2018) analyzed data from a random national US sample of 1,635 middle-​ aged community-​ dwelling adults, examining the buffering effect of R/​S on positive and negative affect. Religiosity was assessed by frequency of religious attendance and a 4-​item measure of religious importance; spirituality was assessed by a 2-​item index asking about the salience/​ importance of spirituality. The impact of childhood adversity (assessed by a 14-​item measure) on positive and negative affect (each assessed by 6-​item measures) was the primary study aim. Positive and negative affect were assessed at baseline in 1995 (T1) and again on follow-​up 10 years later (T2). Controlled for in regression analyses were age, gender, race, marital status, educational level, and household income, along with T1 positive and negative affect. Results indicated no direct relationship between T1 measures of religiosity or spirituality and 2 positive or negative affect. However, evidence for interaction was found between T1 spirituality and childhood abuse (b =​0.020, SE =​0.009, p < 0.05) on positive affect and between T1 religious importance and childhood abuse on positive affect (b =​0.019, SE =​0.009, p < 0.05). At high levels of religious or spiritual importance, no relationship was found between childhood abuse and positive affect, whereas among those with moderate or low religious or spiritual importance there was a moderately strong inverse relationship (p < 0.01) between childhood abuse and positive affect. Thus, both religiosity and spirituality buffered the negative effects of childhood adversity on positive affect over time. Kent and colleagues (2018) analyzed data from a random US national sample of 1,024 community-​ dwelling adults over age 65 to examine the effect on life satisfaction and other indicators of psychological well-​ being 220 •  M ental H ealth

of (a) feeling forgiven by God (single item); (b) transactional forgiveness from God (3-​ item scale, e.g., “In order to be forgiven by God, I must . . .); and (c) attachment to God (6-​ item scale). Satisfaction with life was assessed by a 3-​item scale at T1 (2001) and T2 (2004). Controlled for in regression models were age, gender, marital status, income, education, prayer frequency, religious service attendance, and religious affiliation, as well as T1 life satisfaction. Results indicated no direct relationship between any religious variable and life satisfaction. However, a significant positive interaction emerged between secure attachment to God and both forgiveness from God (b =​0.230, p 0.50). These findings provided evidence toward causal inference for daily spiritual experiences affecting meaning in life, but not vice versa. Davis and Kiang (2016) surveyed 180 Asian American high school students who were followed for up to 4 years, examining the effects of religious participation (2-​item measure) and religious identify (8-​item measure) on mental health outcomes, including positive affect. Both religious participation (b =​0.10, p =​0.02) and religious identity (b =​0.26, p < 0.001) were associated with the presence of meaning in life using hierarchical linear modeling controlling for gender and US-​born status. However, it appeared that baseline meaning in life was not controlled for in these analyses. In the Chen and VanderWeele (2018) study described above, which included 5,681–​7,458 adolescents (average age 15) followed for 8–​ 14 years, attendance at religious services at least once per week (vs. never) predicted a greater “sense of mission in life” on follow-​up (b =​0.28, p < 0.0019), as did praying at least once per day (vs. never) (b =​0.43, p < 0.0019). Analyses were controlled for multiple measures of baseline psychological well-​ being, mental health, physical health, and other character strengths (frequency of volunteering, forgiveness of others, etc.), using generalized estimating equations. Finally, in the Chen et al. (2020a) study above, which followed 92,008 young, middle-​ aged, and older US adults for 3–​12 years, greater frequency of religious attendance at baseline predicted greater purpose in life in the overall sample, after multiple controls and Bonferroni correction of p-​values (b =​0.25, p < 0.002). With regard to RCTs, in a study of 132 persons with chronic medical illness and major depressive disorder (MDD) recruited in North Carolina and California, religious cognitive behavioral therapy (RCBT) was equally effective as secular CBT for increasing PIL (assessed by Ryff’s 20-​item Purpose in Life Scale) during the 3-​ month trial and 3-​ month follow-​ up period (Daher et al., 2016). However, RCBT was more effective than secular CBT on increasing PIL among those who were highly religious at baseline (group by time interaction B =​5.87,

Psychological Well-Being and Positive Emotions • 223

SE =​2.57, p =​0.026, dc =​0.64, indicating a moderate to large effect size).

disagreement with the statements: “I’m optimistic about my future”; “I always look at the bright side of things”; and “In uncertain times, I usually expect the best.” Controlled for in S U M MA RY regression analyses were age, gender, marital There is strong evidence from observational status, race, education, and Wave 1 optimism. studies that religious involvement is both asso- Results indicated that Wave 1 religious doubt ciated with greater purpose/​ meaning in life significantly predicted a reduction in optimism and predicts increases in purpose/​meaning in between Wave I and Wave 2 (b =​−0.09, p < life over time. The evidence from experimental 0.05), especially in older adults with less edustudies is less consistent, but a nonrandomized cation (8th grade education or less; b =​−0.23, controlled trial and an RCT indicated that reli- p < 0.001). gious interventions increase PIL, particularly An RCT examined the effects of a prayer in those who are highly religious, providing intervention using a cross-​over design in 63 further evidence toward causal inference sug- depressed/​ anxious patients randomized to gesting that the direction of effect is from reli- either the intervention (6 weekly prayer sesgiosity to purpose/​meaning in life. sions) or a wait-​list control group; those in the wait-​list control group were later crossed over to receive the intervention (Boelens et al., 2009). Optimism A significant increase in optimism (assessed by Our systematic review identified 32 studies the 10-​item Life Orientation Test) was found published prior to 2010, of which 26 (81%) from baseline (T1) to the end of intervention reported significant positive relationships (T2) and 1-​month follow-​up (T3) in the prayer between R/​S and optimism. Of the 11 highest-​ group; no change in optimism occurred in the quality studies, 8 (73%) reported this associ- wait-​ list control group. When controls were ation. All studies were cross-​sectional except crossed over and received the intervention, a three prospective studies and one RCT. All significant increase in optimism from the time three prospective studies reported that base- of cross-​over to the end of intervention and 1-​ line religiosity predicted increased optimism month follow-​up was also found. on follow-​ up (or religious doubt predicted Since 2010, there have been three reports lower optimism). The single RCT reported that from a single prospective study of older adults, a prayer intervention significantly increased as well as at least one RCT. McFarland (2010) optimism among depressed/​anxious primary analyzed data from two waves (2001–​2004) care patients compared to a wait-​ list con- of a US national sample of adults age 66 or trol group. older (same sample as the Krause, 2006d study In one of the earlier prospective studies, above) to examine the impact of religiosity on Krause (2006d) analyzed data from a US nation- mental health outcomes, of which optimism wide longitudinal survey of 852 adults age 66 was one. Religiosity was assessed by a 3-​item or older to examine the effect of religious doubt index of organizational religiosity (attending on optimism. Religious doubt at Wave 1 (2001) religious services, Sunday school/​Bible study was assessed using a 5-​item scale developed by groups, prayer groups) and 3-​item index of non-​ the investigator, and optimism was measured at organizational religiosity (read the Bible, pray Wave 1 and Wave 2 (2004) by three indicators by self, watch religious services on TV or radio). based on a standard scale (Scheier and Carver). Optimism was measured with the 3-​item index Religious doubt was determined by questions described above. Analyses were controlled for such as: “How often do you have doubts about age, race, education, marital status, functional your religious or spiritual beliefs?”; “How often limitations, and Wave 1 optimism, and were do you doubt that God is directly involved in dichotomized by gender. Among men (n =​305), your daily life?”; and “How often do you doubt high organizational religiosity at Wave 1 sigwhether your prayers make a difference in your nificantly and positively predicted greater optilife?” Optimism was measured by agreement or mism three years later at Wave 2 (b =​0.317, 224 •  M ental H ealth

SE =​0.126, p < 0.001), although no effect on optimism was found in women (n =​496). Non-​ organizational religiosity was not related to optimism in either men or women. Krause and Hayward (2014b) examined the effects of listening to religious music on hope/​ optimism in a US national sample of adults age 66 or older followed from 2001 (Wave 1) to 2004 (Wave 2), utilizing the same sample as McFarland (2010) and Krause (2006d). Religious involvement at Wave 1 was assessed by (a) frequency of church attendance, (b) role of faith in connectedness with others, and (c) listening to religious music, using a 4-​item index developed by the authors (“Religious music . . . lifts me up emotionally, . . . gives me great joy, . . . helps strengthen and renew my faith, . . . makes me feel closer to God”). What the investigators called “hope” was assessed at Wave 1 and 2 using the 3-​item optimism index described in the Krause (2006d) study above. Structural equation modeling was used to examine relationships, controlling for demographics, faith-​ related connectedness with others, and Wave 1 hope/​optimism. Results indicated that Wave 1 religious attendance significantly predicted Wave 2 hope/​optimism (b =​0.125, p < 0.001). While listening to religious music at Wave 1 predicted Wave 2 hope/​ optimism, it lost significance when controlling for Wave 1 hope/​ optimism and religious attendance. Kent and colleagues (2018), again using the same sample of older adults above, examined the effect of attachment to God and being forgiven by God on changes in optimism from 2001 to 2004. Attachment to God was assessed by a 6-​ item index (Bradshaw and Kent). Forgiveness by God was assessed by an item assessing being forgiven by God (“I believe God forgives me for the things I’ve done wrong”) and three items measuring transactional forgiveness, i.e., whether individuals must change their behavior to receive forgiveness from God. Optimism was again assessed by the 3-​item index described above. Regression analyses controlled for Wave 1 optimism, as well as age, gender, race, marital status, education, income, religious attendance, prayer, and religious affiliation. Results indicated that a secure attachment to God predicted a significant increase

in optimism during the 3-​ year follow-​ up (b =​0.118, p < 0.05), although being forgiven by God and transactional forgiveness did not. In an RCT, Koenig and colleagues (2015e) randomized 132 persons age 18–​ 85 with chronic medical illness and major depressive disorder to either a 12-​week RCBT intervention or to a secular CBT intervention. Optimism was assessed by the 10-​item Life Orientation Test-​R at baseline, following the intervention, and at the 3-​ month follow-​ up. Both RCBT and secular CBT significantly increased optimism during the study period to a similar degree (group by time interaction B =​−0.75, SE =​0.57, t =​−1.33, p =​0.185), although the trend slightly favored RCBT (Cohen’s d =​0.23). Baseline religiosity also predicted an increase in optimism over time, independent of treatment group (B =​0.07, SE =​0.02, p < 0.0001). SUM M ARY

Prior to 2010, over 80% of studies found a positive relationship between religiosity and optimism. Since then, all three prospective studies reported a positive effect of baseline religiosity on optimism at follow-​up, and one RCT found a significant effect of a 6-​week prayer intervention on increasing optimism in primary care patients with depression/​ anxiety. Since 2010, three reports from a single prospective study of older US adults found that religious measures at baseline predicted increases in optimism over the 3-​ year follow-​ up. A second RCT found that religious and secular CBT interventions increased optimism to a similar extent during the intervention, although baseline religiosity predicted a significantly greater increase in optimism both during and after the intervention period, independent of treatment group. As with its relationship to meaning and purpose in life, religious involvement is both cross-​sectionally associated with optimism and appears to increase optimism over time, at least in older adults.

Hope While hope and optimism may appear similar, there are also important distinctions. Based on three studies that examined the differences

Psychological Well-Being and Positive Emotions • 225

between hope and optimism, Bruininks and Malle (2005) concluded: “. . . hope is distinct from optimism by being an emotion, representing more important but less likely outcomes, and by affording less personal control. . . . When people do have a high degree of control, they may no longer need to be just hopeful but can be optimistic because the outcome is now attainable” (p. 327). Hope differs from optimism in that it does not necessarily expect or presume that the future will be good, but rather focuses on the possibility that it may be good, characteristically in difficult or challenging circumstances. In our systematic review of quantitative studies published prior to 2010, 40 quantitative studies were identified, of which 29 (73%) reported significant positive relationships between religiosity and hope (Koenig et al., 2012). Of the 6 highest-​quality studies, 3 (50%) reported a positive association. All studies were cross-​sectional except for 1 prospective study and 2 clinical trials. The prospective study found no effect for T1 religious coping or religious well-​being on T2 hopelessness after controlling for T1 hopelessness, although a significant inverse cross-​sectional association was present at T1 between religious coping and hopelessness. In the first RCT, both a religious and the secular forgiveness intervention increased hope to a similar degree in 149 divorced women. In the second RCT involving 166 cardiac patients, no effect on hope was found for pastoral care visits compared to an untreated control group. Since 2010, there have been at least three prospective studies and one nonrandomized controlled trial, which we now review. Opsahl and colleagues (2019) prospectively followed 23,864 adults age 50 or over in 10 European countries in 2004–​2005 (T1). Data on participants were collected every 2 years through 2015 (T2–​T6). Religiosity was assessed by frequency of religious attendance, frequency of prayer, and religious education (“Have you been religiously educated by your parents?”). Responses to those three items were also categorized into highly religious, religious during crisis only, and nonreligious. Hope was assessed by a single question: “What are your hopes for the future?” Responses were coded so that “no hopes for the 226 •  M ental H ealth

future” was the primary dependent variable. The data were analyzed using logistic regression models that utilized robust standard errors for cluster analyses for repeated measures, and adjusted for European region, gender, age, education, marital status, employment, and long-​ term illness. Results indicated that frequency of prayer predicted a lower likelihood of having no hopes for the future (OR =​0.89, 95% CI =​0.81–​ 0.99). Frequent attendance at religious services also predicted a lower likelihood of hopelessness (OR =​0.74, 95% CI =​0.67–​0.83), although religious education did not (OR =​0.97, 95% CI =​0.87–​1.09). Those categorized as highly religious (compared to all other participants) were 27% less likely to report no hopes for the future (OR =​0.73, 95% CI =​0.65–​0.83). In the Chen et al. (2020a) study above, which followed 92,008 young, middle-​ aged, and older US adults for 3–​12 years, greater frequency of religious attendance at baseline predicted greater hope in a meta-​analytic estimate across all samples, after multiple controls and Bonferroni correction of p-​values (b =​0.07, p < 0.002). The estimates were similar in the three different age samples, but the effect size was not large enough to detect independently in the sample of older adults alone (Long et al., 2020a). In the only clinical trial, Nedderman and colleagues (2010) conducted a nonrandomized controlled trial involving 39 female prisoners at a maximum-​security state prison in Gatesville, Texas. The earliest volunteers for the study were nonrandomly assigned to the intervention group (n =​20), whereas later volunteers were assigned to a wait-​list control group (n =​19). The intervention was a 12-​week psychoeducational group based on Christian spirituality that focused on increasing hope through educational and cognitive-​behavioral methods. The 12-​item Herth Hope Scale (HHS) was used to measure hope and consisted of three subscales: inner sense of temporality in future (HHS1); inner positive readiness and expectancy (HHS2); and interconnectedness with self and others (HHS3). A series of t-​ tests for independent samples was conducted to examine differences between group mean change scores (positive change scores indicating increases in hope). For the effect on

overall HHS score, there was a trend favoring the intervention group (t =​1.89, p =​0.067). Increases in hope were particularly strong for HHS1 (inner sense of temporality in future) (t =​2.83, p =​0.007). Lack of statistical power in this small sample may have contributed to the borderline overall effect. S U M M A RY

Religiosity is associated with greater hope in about half of cross-​sectional studies, and there is some evidence from prospective studies that religiosity increases hope over time. Religious interventions appear to increase hope compared to control groups, although the effects thus far have been modest in nature.

Gratitude One of the best ways to boost positive emotions is to be thankful. The old saying, “He enjoys much who is thankful for little” (Thomas Secker) says it all. Those who are more grateful not only experience more positive emotions and greater well-​being (Wood et al., 2010), but also are more likely to be prosocial (Ma et al., 2017) and to experience better physical health more generally (Jans-​Beken et al., 2019). Our systematic review prior to 2010 identified five studies examining religiosity and gratitude; we add to that an additional report that was missed. Of these six studies, all six (100%) found that religiosity was associated with greater gratitude, including three longitudinal studies (two in one report). Krause (2009e) analyzed data from a 2-​year prospective study of a US national sample of 818 adults age 65 or older followed from 2005 (T1) to 2007 (T2). Gratitude was assessed at T1 and T2 by a 3-​item index developed by the author based on other gratitude measures. Religiosity was assessed by frequency of religious attendance, private prayer, and a 2-​item measure of God-​ mediated control. After controlling for age, gender, education, marital status, and T1 gratitude, frequency of church attendance significantly predicted T2 gratitude scores (b =​0.193, p < 0.001). Although frequency of prayer did not predict gratitude independent of church attendance in this study, God-​mediated

control both independently predicted gratitude (b =​0.107, p < 0.01) and explained 23% of the effect of church attendance on gratitude. In the study missed in our 2010 systematic review, Lambert and colleagues (2009) reported results from four studies examining the prayer-​ gratitude relationship in samples acquired from colleges in the Southeast United States—​a cross-​sectional study, two longitudinal studies, and an RCT. In the first study of 674 undergraduates, frequency of prayer (3-​item index) was positively associated with gratitude (6-​item Gratitude Questionnaire by McCullough) (b =​0.19, p < 0.01). In the second study, 780 undergraduates were assessed at baseline (T1) and 6 weeks later (T2), finding that T1 prayer frequency predicted greater T2 gratitude (same measures), controlling for T1 gratitude and frequency of religious attendance (b =​0.09, p < 0.05); furthermore, cross-​lagged analyses revealed that while T1 prayer significantly predicted T2 gratitude, T1 gratitude did not predict T2 prayer. These results were then replicated in a second longitudinal study of 832 undergraduates (including the cross-​ lagged findings). In the fourth study, an RCT, 104 undergraduates were randomized to either prayer or control conditions; those in the prayer condition who were assigned to pray every day scored significantly higher on gratitude than those in the control condition on follow-​up. Based on these four studies, researchers concluded: “Together, these studies provide evidence that prayer increases gratitude” (p. 139). More recently, Schnitker and colleagues (2014) conducted a single group experimental study involving 45 Western European adolescents, average age 16, who attended a Young Life summer camp. Young Life is an evangelistic Christian youth organization that provides a summer camp that involves religious teaching and religious activities specifically intended to lead youth to a faith commitment or recommitment. Participants were assessed at baseline before attending the camp (T1), immediately following the camp (T2), and 1 year later (T3). R/​S measures assessed at baseline were the 10-​ item Religious Commitment Scale (Worthington) and the 8-​ item Spiritual Transcendence Index (Seidlitz). Also assessed was whether youth made a commitment/​

Psychological Well-Being and Positive Emotions • 227

recommitment to their Christian faith at T2, and also, level of Young Life participation during the year of follow-​up using a 3-​item index assessed at T3. Gratitude was one of several outcome measures administered at each assessment (6-​item Gratitude Questionnaire), along with a 6-​item measure of patience and a 12-​item measure of responsible attitudes and performance (both assessed using standard scales). Gratitude, patience, and responsible attitudes/​performance were then combined to form a measure of “moral sociability.” Within-​ group analysis from baseline to follow-​up indicated no change in religious commitment, but a significant overall decline in spiritual transcendence and an overall decline in moral sociability from T1 to T3. In regression models that controlled for both T1 moral sociability and T3 Young Life participation, increases in religious commitment (b =​0.27, p < 0.05) and increases in spiritual transcendence (b =​0.34, p < 0.01) from T1 to T3 predicted greater T3 moral sociability. T2 commitment/​recommitment to their Christian faith resulting from summer camp involvement, however, did not significantly predict T3 moral sociability (b =​0.08, p > 0.05). S U M MA RY

Religious involvement is cross-​sectionally associated with gratitude, and greater religiosity or increases in religiosity predict increases in gratitude over time. There is also modest evidence from experimental studies that religious interventions increase gratitude over time. There is some question, however, about what mediates the relationship between religiosity and gratitude. Rosmarin and colleagues (2011c) reported in a cross-​sectional study that the relationship found between religious commitment and gratitude (r =​0.45, p < 0.0001) was fully mediated by gratitude toward God, consistent with the explanation that religiosity increases gratitude primarily through gratefulness to God.

Self-​esteem Our systematic review of studies published prior to 2010 identified 69 studies examining the relationship between R/​S and self-​esteem (Koenig et al., 2012). Of those, 42 (61%) 228 •  M ental H ealth

reported a significant positive association between R/​ S and self-​ esteem, whereas two (3%) reported a significant inverse relationship. Of the 25 methodologically most rigorous studies, 17 (68%) reported greater self-​esteem among the more R/​S. All studies were cross-​ sectional except for six prospective studies and one experimental study. Half of the prospective studies indicated that R/​S predicted an increase in self-​esteem over time, and half found no effect. The one experimental study reported an increase in self-​esteem following a religious seminar in 24 college students. With regard to more recent research conducted since 2010, we focus on five large prospective studies and a single RCT. In the McFarland (2010) study above, a 3-​year prospective study of 894 community-​ dwelling older US adults, the effects of organizational and non-​ organizational religiosity on self-​ esteem over time were examined. Self-​esteem was assessed by a 3-​item measure developed by Krause: “I feel I am a person of worth, or at least on equal playing with others”; “I feel I have a number of good qualities”; and “I take a positive attitude toward myself.” Regression analyses were stratified by gender and controlled for age, race, education, marital status, and health, as well as T1 self-​esteem. Results in women (n =​558) indicated no significant effect of either organizational religiosity or non-​organizational religiosity on self-​esteem. However, in men (n =​336), organizational religiosity predicted significantly greater T2 self-​ esteem three years later (b =​0.216, p < 0.01). Likewise, Bradshaw and colleagues (2015), utilizing the same sample and statistical approach, later reported that greater frequency of listening to religious music at T1 predicted significantly increased T2 self-​ esteem (b =​0.015, SE =​0.007, p < 0.05). Among those younger in age, Bert (2011) followed 110 adolescent mothers and their teenage offspring over a 14-​year period postpartum. Maternal religiosity was assessed prenatally (T1) and when children were ages 3 (T2), 5 (T3), and 8 (T4) by frequency of church attendance, frequency of contact with church members and church leaders, and physical and emotional support received from the church community. These were combined and averaged

over T1–​T4 to form a religiosity scale titled “early maternal religiosity.” Maternal self-​ esteem was assessed using the 25-​item Self-​ Esteem Inventory (SEI; Coopersmith), whereas child self-​esteem was assessed using the 25-​ item SEI School Form-​ Ages 8–​ 15. Maternal and child/​adolescent self-​esteem were assessed only at T5. Regression analyses controlled for socioeconomic status and maternal intelligence (IQ), but not baseline self-​esteem. Results indicated that early maternal religiosity (T1–​T4) predicted greater maternal self-​esteem at T5 (b =​0.22, p < 0.05). The effect on child/​adolescent self-​esteem at T5 did not reach statistical significance (b =​0.12, p > 0.10). Krause and Hayward (2014c) analyzed data from a 2-​year prospective US nationwide survey of 1,011 adults age 65 or older. This report focused on assessments at Wave 4 in 2002–​ 2003 (T1), Wave 5 in 2005 (T2), and Wave 6 in 2007 (T3). Religiosity was measured by frequency of church attendance (single item) and God-​mediated control (3-​item measure developed by Krause) at T2. God-​mediated control at T2 was assessed by the statements: “I rely on God to help me control my life”; “I can succeed with God’s help”; and “All things are possible when I work together with God.” Self-​esteem at T2 and T3 was assessed using the same 3-​ item index developed by Krause described in McFarland (2010). T1 interests in life were examined using a 3-​item scale developed by the author (i.e., “My life is full of things that interest me”; “I enjoy learning new things”; and “I am often busy doing something interesting”). Structural equation modeling was used to examine the data, controlling for age, gender, education, marital status, T1 interests, and T2 self-​esteem. Results indicated that T2 religious attendance and God-​mediated control had no direct effect on self-​esteem at T3. However, when indirect effects of church attendance and God-​mediated control through T1 interests in life on self-​esteem were examined, the total effect of church attendance and God-​mediated control on T3 self-​esteem became statistically significant (b =​1.39, p < 0.001, and b =​0.154, p < 0.001, respectively). Kent and colleagues (2018) analyzed data from the McFarland (2010) older adult sample above, examining the effects of T1 (2001)

religious attendance, prayer, religious affiliation, attachment to God, and forgiveness by God on self-​esteem at T2 (2004), controlling for T1 self-​esteem, age, gender, race, marital status, education, other religious variables, and income. Results indicated no effect of religious attendance, prayer, attachment to God, or being forgiven by God on T2 self-​esteem. However, there was a significant interaction between having a secure attachment to God and being forgiven by God (b =​0.147, p < 0.05), such that among those with a secure attachment to God, feeling forgiven by God predicted greater self-​esteem at T2. This was also true for God attachment and transactional forgiveness (i.e., being forgiven by God, but only if changing behavior), such that among those with a secure attachment to God, transactional forgiveness predicted increased T2 self-​esteem (b =​0.101, p < 0.05). Thus, the influences of being forgiven by God (whether under the condition of changing behavior or not) on self-​esteem appears to be dependent on having a secure attachment to God. In their analysis of data from the Growing Up Today Study involving 5,681–​ 7,458 US adolescents (average age 15) followed for 8–​ 14 years, Chen and VanderWeele (2018) also found effects of religiosity on self-​esteem in this age group. Frequency of religious attendance (once/​week or more vs. never) at baseline in 1999 (T1) had a marginal effect on later self-​ esteem in 2007–​2013 (T2) after controlling for other indicators of psychological well-​ being, character strengths, physical health, mental health, and health behaviors, and Bonferroni correction of p-​values (b =​0.07, 95% CI=​−0.00–​ 0.14, p > 0.05). However, frequency of prayer or meditation (once per day or more vs. never) at T1 significantly predicted increased self-​esteem at T2 (b =​0.08, 95% CI =​0.00–​0.15, p < 0.05). With regard to RCTs examining the effects of a religious intervention on self-​ esteem, Ysseldyk et al. (2016) conducted two such studies to examine how immersion in religious spaces influences self-​esteem among Christians and atheists. In the first study, 97 participants (average age 28) were recruited at three outdoor locations in a British city (a cathedral, castle, and shopping district). Half were atheist (n =​49), and half were Christian (n =​48).

Psychological Well-Being and Positive Emotions • 229

Participants were then randomly assigned to one of two conditions: (1) immersion (“take a moment to consider your external surroundings, that is, the buildings or landmarks around you”); or (2) non-​immersion (focus on “your internal feelings, that is, the thoughts or emotions within you”). Participants were then asked to complete a questionnaire after considering their internal feelings, thoughts, and emotions. The questionnaire assessed three dimensions of state self-​esteem (appearance, social, and performance) (Heatherton & Polivy). Results indicated a significant interaction between group and immersion at the cathedral only (not at the castle or the shopping district): among atheists at the cathedral, social self-​ esteem was higher when they focused inwardly (non-​ immersion), whereas in Christians, social self-​ esteem was higher when they focused outward at the cathedral. In the second study, 124 women, average age 19.6 years, were recruited on the campus of a Canadian university. Equal numbers of Christians and atheists were randomly assigned to one of three “virtual locations” that involved watching an online video of a cathedral, mosque, or museum. Half of the participants viewed their video through virtual reality goggles while being actively encouraged to imagine themselves in the place. Following the video, participants responded to a questionnaire that assessed self-​esteem using the three dimensions of state self-​esteem used in the first study (appearance, social, performance). Results from this study indicated that Christians consistently reported higher social self-​ esteem than atheists after watching the cathedral video, although they experienced less social self-​esteem after viewing the mosque video; otherwise, there was no interaction between group and virtual location. Researchers concluded: “These results suggest that immersion in spaces that reflect one’s own religious beliefs and identity has positive consequences for . . . well-​being [self-​esteem]” (p. 14). S U M MA RY

Prior to 2010, our systematic review found that nearly two-​ thirds of studies (mostly cross-​ sectional) reported greater self-​ esteem 230 •  M ental H ealth

among those who were more religious; in half of six prospective studies, religiosity predicted greater future self-​esteem or increases in self-​ esteem. A single experimental study also found that self-​esteem increased following a religious intervention (seminar). Since 2010, all six prospective studies reviewed here found a positive effect of religiosity on future self-​esteem, particularly among older adults, but also in other subgroups as well (adolescent mothers and adolescents through young adulthood). In the last intervention study, researchers found that self-​esteem was dependent on context for atheist and Christian young adults.

CONCLUSIONS FROM THE RESEARCH Most studies, both cross-​ sectional and prospective, find a significant positive association between religiosity and well-​ being, meaning and purpose in life, and gratitude. The majority of studies also find a positive effect of religiosity on optimism, hope, and self-​ esteem. These studies are primarily from the United States, but a few have also been conducted in European and other countries. RCTs and experimental studies further support the findings from these observational studies. In earlier chapters, religious involvement was found to be associated with less psychiatric disorder for some conditions and to predict a faster remission of symptoms. Based on the review above, religiosity even more consistently is related to and predicts increases in positive emotions, as do religious interventions.

RECOMMENDATIONS FOR FUTURE RESEARCH As usual, we encourage researchers to carry out new prospective studies or analyze data from existing prospective studies and publish the findings in peer-​review journals. There are now so many cross-​sectional studies examining the relationship between religiosity and well-​being, particularly from the United States, that further studies of this kind are generally no longer needed. Previous research has firmly established a positive cross-​ sectional correlation between religious involvement, psychological

well-​being, and a variety of other positive emotions. However, the question of causality remains, and conducting more cross-​sectional studies cannot answer that question. Cross-​sectional studies might still be beneficial, or preferably longitudinal studies whenever possible, to examine associations between religiosity and positive emotions in different religions outside of Christianity, particularly in Eastern religions. Studies are also needed in Far Eastern and Middle Eastern countries, as well as in Eastern European countries and Russia, areas where the relationship between religiosity and well-​ being remains unclear. Large prospective studies, in turn, are needed in the United States and every region throughout the world and in every religion. Of particular interest is whether the findings vary by religion, culture, and geographical location, and if the associations identified indicate causal inference. Multidimensional measures of religiosity should be used in these studies, although each dimension of religiosity should be examined separately in its effects on positive emotions (e.g., organizational religiosity, non-​ organizational religiosity, intrinsic religiosity, religious attachment, religious forgiveness, religious giving, etc.). Randomized controlled trials are also needed but are expensive (as are prospective studies). However, they have a low priority for government funding organizations such as the US National Institutes of Health and similar funding bodies in other countries. Of greater priority to these organizations is identifying effective treatments for mental disorders which impair functioning and adversely affect health in other ways that cause people to use costly health services. Most persons do not usually seek treatment for low levels of happiness or decreased well-​being, as long as it does not affect their ability to function. Thus, government agencies do not wish to spend their scarce resources on developing interventions to increase positive emotions. We disagree with this policy. The reason is because greater well-​being, more purpose and meaning in life, greater hope and optimism, more gratitude, and greater self-​esteem are all indicators of emotional resilience and reserve. When major life stressors do occur, those who regularly

experience positive emotions are more able to weather these storms and not allow stressors to cause mental disorder or affect their functioning (Tugade & Fredrickson, 2004; Kobau et al., 2011; Layous et al., 2014). Moreover, many of these interventions can effectively be carried out without cost or at very low costs and could be widely distributed with government effort (VanderWeele, 2020a). While interventions to increase positive emotions are not a high priority for government funding, some treatments have been developed to increase positive emotions or improve emotion regulation in order to treat or ward off mental disorder in high-​risk subgroups of the population (Quoidbach et al., 2015; Moskowitz et al., 2017, 2019). Secular interventions to increase positive emotions have been shown to increase positive emotions (see reviews above). This begs the question of why there are so few well-​designed RCTs examining the effects of religious interventions on psychological well-​being, life satisfaction, happiness, purpose and meaning in life, hope and optimism, gratitude, or self-​esteem. Given a number of well-​designed prospective studies showing that religiosity increases positive emotions over time, it would seem time to develop religious interventions to accomplish this goal. Again, lack of funding is a major barrier that needs to be overcome. Private rather than government sources of funding support may be needed to develop and test religious interventions for increasing positive emotions (at least for conducting pilot work in this regard). Another approach might be to include positive emotions and broader well-​being assessments as outcome measures in all spiritually or religiously integrated treatments for mental disorder (for which funding support may be easier to obtain). For example, see the RCT reviewed in this chapter on the effects that religiously integrated cognitive behavioral therapy (RCBT vs. secular CBT) has on purpose in life (Daher et al., 2016) and optimism (Koenig et al., 2015e), a study (funded by the John Templeton Foundation) whose primary aim was to examine the effects of RCBT on depressive symptoms in major depression. Incorporating broader happiness and well-​ being assessments into both medical and mental health interventions, both religious and

Psychological Well-Being and Positive Emotions • 231

secular (VanderWeele et al., 2019), and into large longitudinal cohort studies (VanderWeele et al., 2020d) could go a long way in advancing research on our understanding of the determinants of well-​being and the role of religion.

CLINICAL APPLICATIONS As noted above, people without mental disorder are unlikely to seek treatment for decreased positive emotions (e.g., lack of happiness, purpose or meaning in life, optimism), except when these are present during the course of a mental disorder or during a crisis such as a life-​ threatening illness. In this case, clinicians will have an opportunity to screen for positive emotions and make efforts to increase them utilizing patients’ core values and beliefs, which may in turn help to resolve the mental disorder or crisis. Similarly, individuals who are unhappy in their job or marriage may often seek out counselors and/​or religious professionals to help them feel better in these situations.

Spiritual History All clinical interventions (including those by religious professionals) should begin by taking a history from the client and members of their family, asking about their experience of positive emotions and their spiritual background and resources. In general, however, clinicians rarely ask about life satisfaction, level of happiness, purpose and meaning in life, optimism or hope, or feelings of gratitude. Again, the focus is usually on pathology, not on emotional strengths that provide resiliency. Given the research reviewed above, clinicians should ask clients about positive emotions like those discussed in this chapter and consider asking about and supporting clients’ religious involvement in order to enhance those emotions and thereby increasing their resiliency. Of course, this must be done using a client-​centered approach, and religion should never be prescribed to clients, particularly to those who are not religious to begin with. Clergy are most likely to be in close contact with the general population that may include individuals who are experiencing low positive emotions but not mental disorder. Thus, it is also important for clergy to ask about 232 •  M ental H ealth

positive emotions during pastoral care sessions with members of their congregation and provide guidance from their sacred scriptures on how to increase these emotions.

Religious Education Clinicians, particularly mental health professionals, should consider educating clients about the need to experience positive emotions (as a way of increasing resiliency) and the role that their religious resources may play in this regard. However, given that there is relatively little research demonstrating that increasing religious involvement results in increased positive emotions, a sensitive and cautious approach must be taken in this regard. Nevertheless, there is some research (as discussed above) showing that religious interventions can increase life satisfaction and well-​ being (Muslim-​ based interventions in Iran), as well as increase purpose and meaning in life, optimism, and hope (Christian-​based interventions in the US and Europe), particularly in those who are religious. Education by religious professionals is particularly important, since clergy have first access to a large segment of the population in many countries. Sermons and religious education classes could focus on the benefits that religious belief and practice have on well-​being, happiness, and other positive emotions. This is perhaps best done by emphasizing positive religious scriptures, of which there are many. For example, there are biblical verses that emphasize thinking about positive things (Philippians 4:8), focusing on the well-​ being of others (Matthew 5:44; 22:39), and finding purpose and meaning in life (Romans 8:28).

Simple Religious Interventions Simple religious interventions may be tried by mental health and religious professionals to increase well-​ being through emphasis on religious practices (meditation or scripture study), seeking support from or giving support to other members of their congregation, becoming more involved in religious community activities, or engaging in religious helping or volunteering. As noted above, when mental

health professionals do this, it must be client-​ centered, and only with explicit permission from the client (and in clients who are already religious). Clinicians may also refer individuals to pastoral care providers, chaplains, or other trained religious professionals to help them enhance positive emotions through spiritual direction.

SUMMARY AND CONCLUSIONS This chapter has examined the relationship between religiosity and positive emotions such as psychological well-​ being, happiness, life satisfaction, purpose in life, optimism, hope, gratitude, and positive feelings about the self. Positive emotions are among the most powerful motivations for all that humans do. Most people make achieving happiness a central goal in life, whether that be done consciously or unconsciously. In this chapter, we first examined predictors of psychological well-​ being, examining various psychological theories of well-​ being that involve genetic influences, satisfaction of goals, and cognitive processes having to do with reference points in comparison to others. We then reviewed the impact of age, education, employment, gender, ethnicity, marital status, social support, and physical

health on well-​being and life satisfaction. Next, the impact of well-​being on health more generally was explored, including its effects on social relationships, work performance, and psychological resilience, as well as on physical health and longevity. With this background in mind, we then brought religion into the picture by presenting a case vignette of a troubled individual who found hope and peace through religious conversion. We next theorized how and why religion might impact psychological well-​being. This was followed by a review of research examining this relationship. Early studies were first reviewed, and then more recent studies. Examined were studies on the relationship between religiosity and psychological well-​being, purpose and meaning in life, optimism, hope, gratitude, and self-​ esteem. We focused on prospective studies and RCTs in an attempt to gain insight into causal inference. We concluded the chapter by providing recommendations for future research and describing clinical applications for mental health and religious professionals. Although much further research is needed, the published studies thus far indicate that religious beliefs and practices can be powerful sources of positive emotions for many people, providing resiliency when facing the trials in life that all experience.

Psychological Well-Being and Positive Emotions • 233

SECTION III Social Health IN THIS SECTION we examine the relationship between religion and indicators of social health, including the topics of delinquency and crime, marital and family stability, and social support. As with mental health, the effects of religiosity are largely “proximal” and “direct”

on social health (although in some cases may be mediated by mental health and perhaps even behavioral health). Again, this contrasts with how religion influences physical health, acting entirely “indirectly” through mental, social, and behavioral health.

13 Delinquency and Crime Thou shalt not steal. . . . Thou shalt not covet thy neighbor’s house, thou shalt not covet thy neighbor’s wife, nor his manservant, nor his maidservant, nor his ox, nor his ass, nor any thing that is thy neighbor’s. —​Exodus 20:15,17

IN 1948, J. Edgar Hoover stated flatly, “In practically all homes where juvenile delinquency is bred there is an absence of adequate religious training for children . . . most of them have never been inside a church” (Hoover, 1948, pp. 33–​35). There is an old saying that likewise expresses this: When religion is unable to restrain from the “inside out,” then government will have to restrain from the “outside in.” We begin this chapter by defining the terms crime and delinquency, and then move on to examine the prevalence, consequences, and costs of delinquency and crime. We explore factors thought to be etiological in the development and course of delinquent and criminal activity, including genetic, biological, environmental, psychological, and social factors, along with gene-​ environment interactions. We present a case vignette and then speculate on how religious involvement might impact delinquency and crime, based on their known

causes. Research is then reviewed on religiosity and crime, gaps in the research discussed, and recommendations made for future study. The chapter ends with recommendations on treatment and prevention for health and religious professionals.

DEFINITIONS When individuals cannot control (or decide not to control) their self-​centeredness based on common moral standards and individual conscience—​and those behaviors infringe on the rights of others—​ then governing bodies must step in to establish laws to maintain social order. Laws are meant to regulate activities viewed as injurious to the general population or to the state, including those that cause injury or loss to people. Crime is defined as the breaking of laws with prescribed punishments that a governing authority has established.

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0013

Delinquency is problem behavior engaged in by young persons that is either against the basic principles of society, or is harmful to society, or violates the law. Legally, juvenile delinquency involves law-​ breaking behaviors committed by individuals below the age of 18. Problem behaviors tend to start at relatively early ages, particularly in boys around age 9 or 10, and are often characterized by the onset of stubborn behavior and minor covert antisocial acts such as lying or shoplifting. These behaviors tend to be followed by acts of more outward defiance, minor aggression, and property damage (Huizinga, 1994). In time, more serious forms of delinquency may ensue, such as violent behavior (e.g., fighting, assault, etc.) and chronic forms of resistance to authority figures, including truancy, underage drinking, drug use, and running away from home.

PREVALENCE, COSTS, AND CONSEQUENCES Juvenile Delinquency According to the US Department of Justice’s Office of Juvenile Justice and Delinquency Program, the highest juvenile arrest rate for all offences in US residents age 10–​17 over a span of 37 years (1980–​2017) was 8,476 per 100,000 in 1996, a rate that has been steadily declining, with the most recent count at 2,408 per 100,000 in 2017 (OJJDP, 2019a). The most common arrests were for simple assault, ­larceny-​theft, and drug abuse violations. Racial minority youth were responsible for approximately half of all juvenile arrests for murder and robbery, 44% of burglary, and 43% of l­arceny-​ theft (OJJDP, 2019b). While the juvenile arrest rate for property crimes and aggravated assault has declined between 2012 and 2017, murder rates have increased annually since 2012. Violent crimes such as murder and robbery peak at age 17–​18 (for all ages) and rates per person are higher among Black youth than White youth (OJJDP, 2019c). Of the 809,700 juvenile arrests made in 2017, 71% were male, 28% were under age 15, 62% were White, 35% Black, 2% Native American, and 1% Asian. The female share of juvenile arrests grew from 18% in 1980 to 29% in 2017. The highest rates of 238 •  S ocial H ealth

juvenile arrests for aggravated assault in 2017 occurred in Nevada and Louisiana, for larceny-​ theft in Louisiana and South Dakota, for drug abuse in South and North Dakota, and for weapons charges in Illinois and Rhode Island (OJJDP, 2019b). Estimates of the yearly economic cost of youth incarceration in 2011 (not including the costs to victims or maintenance of a police force) ranged from $8 billion to $21 billion (Justice Policy Institute, 2014). The value of saving one 14-​year-​old high-​risk juvenile from a life of crime has been estimated to range from $2.6 million to $5.3 million (Cohen & Piquero, 2009). The consequences of juvenile delinquency, however, go far beyond financial considerations. Those consequences include school dropout, reduced life chances for employment, substance abuse problems, maltreatment of the offender’s children, adult crime and incarceration, chronic illness due to injury, and early death (Colman et al., 2009; Brezina et al., 2009; Stoddard-​Dare et al., 2014). For example, one longitudinal study of 499 female juvenile delinquents found that by age 28, nearly two-​thirds had been investigated by child protective services for acts of child maltreatment (Colman et al., 2010). Likewise, in a 7-​year prospective study of 1,829 juvenile youth offenders age 10–​ 18 in Chicago, Teplin et al. (2005) found that the standardized mortality ratio (SMR) was 806 per 100,000, which is more than four times that of the general population; 90.1% of deaths were due to homicide, 5.4% to law enforcement interventions (being shot by police), 1.1% to suicide, and 1.3% to motor vehicle accidents.

Adult Crime There were 10,554,985 arrests made in 2017 (3.25% of the population; Department of Justice, 2019). Of those, 518,617 were for violent crime (murder, manslaughter, rape, robbery, aggravated assault); 1,249,757 were for property crimes (burglary, larceny-​ theft, arson), 1,632,921 were for drug abuse, and 990,678 for driving under the influence. These figures include juvenile arrests of offenders under age 18. Whites (who made up 76.7% of the general population in 2017) accounted for 68.9% of all persons arrested, Black or African

Americans (13.3% of general population) accounted for 27.2%, and other races accounted for 3.9%. The violent crime 2-​year arrest rate increased by 0.8% from 2016 to 2017, whereas property crime arrests decreased by 6.7%. The arrest rate for adults decreased by 0.5% and for juveniles decreased by 4.5%. Overall, the crime rate for all offences has decreased from 14.2 million in 1990 to 10.6 million in 2017 (US Bureau of Justice Statistics, 2019). The economic cost of crime in the United States is enormous. In 2012, the Department of Justice reported that federal, state, and local governments spent more than $280 billion on police protection, the court system, and prisons (WatchBlog, 2017). The overall costs of crime, however, range from $690 billion to $3.4 trillion, including tangible costs (e.g., the anticipation of crime, direct consequences of crime, response to crime) and the intangible costs (e.g., avoidance behavior due to fear of crime, victims’ and offenders’ pain and suffering, victims’/​offenders’ families’ pain and suffering, future social costs of crime, offenders’ lost opportunity due to incarceration instead of working, overdeterrence costs to innocent accused individuals, costs to avoid false accusations, costs to ensure equal treatment of offenders). These figures probably underestimate the true economic cost given that it is difficult to determine how much crime actually occurs. Not included in the estimates above are costs due to undetected embezzlement, identity theft, scams, and other cyber-​related crime, or premature deaths from illegal drug use or deaths due to driving while intoxicated.

DETERMINANTS OF DELINQUENCY AND CRIME Many factors are responsible for delinquent behaviors during youth and criminal activities during adulthood. Discussed here are genetic, biological, environmental, social, psychological, individual decision-​making factors, and gene-​ environment interactions. After reviewing these hypothesized causal factors, we will turn to ways that religious involvement—​either of the individual or their parental caretakers—​ might influence these pathways.

Genetic In 1964, Eysenck reported a high concordance in criminal behavior among identical twins compared to that in fraternal twins (77% vs. 12%, respectively), concluding that “beyond any question, heredity plays an important, a possibly vital part, in predisposing a given individual to crime.” Research since then has estimated that up to 60% of antisocial and criminal behavior is heritable, i.e., due to genetic factors, whereas between 10% and 50% is due to shared and nonshared environmental factors (Fox, 2017). Specific candidate genes or genetic polymorphisms that increase the risk of criminal behavior are less well established, although progress is being made here as well. For example, Caspi and colleagues found that a polymorphism of the monoamine oxidase A (MAOA) gene associated with a lower production of MAOA neurotransmitter was associated with an increased risk of violent behavior during adulthood, especially in the setting of childhood abuse. In their sample of 1,037 children assessed at ages 3, 5, 7, 9, 11, 13, 15, 18, 21, and 26 years, they found that while only 12% had both the low MAOA-​producing polymorphism and a history of childhood abuse, these individuals committed 44% of the violent crime in this cohort, and if both these risk factors were present, 85% engaged in some form of antisocial or criminal behavior (Caspi et al., 2002; Kim-​Cohen et al., 2006). Likewise, serotonin transporter (5HTT), dopamine transporter (DAT1), and dopamine receptor (DRD2, DRD4) gene polymorphisms are also reported to play a role in delinquent and criminal behaviors (Barnes et al., 2013).

Biological Hormonal and neurobiological factors may also increase risk of criminal and antisocial behavior (see also Chapter 11). Higher testosterone levels may help to explain the difference in criminal behavior between men and women (Eme, 2007). Exposure to certain chemicals or toxins, such as lead, has also been associated with juvenile delinquency and criminal behavior (Wright et al., 2008). Exposure in utero to maternal cigarette smoking and/​ or alcohol increases Delinquency and Crime • 239

the risk of later criminal or antisocial behavior (Pratt et al., 2006; Brown et al., 2015). A recent research priority in the mental health field has been understanding how fetal exposure leads to the development of psychopathology, including the effects of maternal depression (Robinson et al., 2019; Craven, 2020). Traumatic brain injury (often from automobile accidents or fighting) may also have this effect by impairing impulse control, increasing aggressive behavior, and adversely affecting decision-​making (Kuin et al., 2019). Both structural and functional deficiencies in brain regions known to regulate behavior and impulse control have been implicated in criminal and antisocial behavior; these include the prefrontal, orbitofrontal, and superior frontal cortex, along with the amygdala and other areas of the limbic system (Reddy et al., 2018). There is evidence that damage to the right frontotemporal cortex, as occurs in frontotemporal dementia, may be associated with a loss of moral behavior (Roberts et al., 2019). Whether such deficits are the cause or the result (neuroplasticity leading to behavior-​induced structural brain changes) of repeated criminal activity or antisocial behavior remains unknown.

manner, has been repeatedly shown to prevent delinquency. McCord found that “competent” mothers who protected their child against criminal influences were self-​ confident, provided leadership, were nonviolent and affectionate in their discipline, together with high family expectations from both parents, decreased risk of juvenile delinquency (even in deteriorated neighborhoods) (McCord, 1991). Fathers’ influences become increasingly important as the child matures, especially in the way that fathers interact with their wives (high mutual esteem, non-​aggressive, non-​undermining), providing role models for healthy social behavior. Assortative mating, i.e., the likelihood that someone with a criminal history will marry someone else with a criminal history, can elevate both environmental and genetic risk. For example, a longitudinal study of 87,026 children at ages 5 and 11 and their parents in Australia found that 70% of offending mothers married a partner with an offending history (Tzoumakis et al., 2019). Children of parents with a history of criminal activity in this study scored significantly lower on social competence, emotional maturity, language development, cognitive development, communication, general knowledge, physical health, and psychologEnvironmental ical well-​being using standard measures (even Although genetic and biological influences may after controlling for child gender, age, English be difficult to separate from environmental/​ as a second language, socioeconomic status, developmental factors, research indicates that and maternal age at birth). Researchers indiapproximately half (50%) of those in state cated that these factors contribute to underprison have at least one other family member performance, exclusion from prosocial groups, arrested for criminal activity (Eriksson et al., school dropout, and involvement with antiso2016). Not surprisingly, numerous environ- cial peers, often leading to substance abuse and mental and developmental factors have been eventually criminal activity. reported to predict criminality, violence, gang Prominent among environmental influences membership, and victimization of others. are neighborhood characteristics in poverty-​ Childhood abuse has already been mentioned. stricken areas that expose young adults to In addition, maternal attachment problems drugs, crime, violence, and gangs, where sur(lack of maternal affection), divorce or sepa- vival of the fittest becomes the rule of life. ration of parents, lack of childhood supervi- Failure to play by such rules may result in sion (due to parental absence in single-​parent exclusion, social isolation, and increased risk of homes, lack of resources, etc.), criminal behav- being a victim of others’ antisocial acts. ior of parents (as role models), alcoholic and/​or abusive parents, and lack of healthy family valSocial ues have long been theorized as factors contributing to delinquency and adult crime (McCord, Non-​ family social factors that increase risk 1991). Discipline that is restrictive and consis- of delinquency and adult crime include social tent, but not harsh, applied in an affectionate interactions with law-​ breaking peers during 240 •  S ocial H ealth

youth, and then later, with other criminals during adulthood. Relationships of this type often develop during excessive free time among unsupervised youth, or during incarceration in juvenile detention facilities or prison. Such relationships may continue after release back into the community, helping to form gangs and criminal networks. A life of criminal behavior is perpetuated by problems finding employment and difficulties identifying a prosocial peer group that will accept and include them (Miller, 2010; Hirschi, 2017). Indeed, finding a prosocial peer group that will accept, include, and support them can be a real challenge for those with a criminal past.

Psychological Risk of delinquent or criminal behavior is further increased by the presence of mental disorder, which itself has genetic, biological, and environmental causes. Mental health problems such as psychotic illness, mood disorder, attention deficit and hyperactivity disorder, or personality disorder, all increase this risk (Ogloff et al., 2015; Hodgins & Klein, 2019). Among incarcerated juveniles, two-​ thirds of males and three-​quarters of females meet criteria for at least one mental disorder, not to mention substance use disorders (Underwood & Washington, 2016). Lack of psychological resources for coping with stress and poor social support from prosocial peers, particularly during periods of economic downturn, have also been shown to play a role in law-​breaking behavior (Agnew, 2015; Logan-​Greene et al., 2017).

Individual Decision-​Making In addition to genetic, biological, environmental, social, and psychological influences, there is also a role for individual beliefs, attitudes, and decision-​making in the development of antisocial behavior patterns during youth and adulthood (Tibbetts & Gibson, 2002). Walsh and Ellis (1999) summarized the primary determinants of crime obtained from a survey of criminologists; impulsiveness, poor discipline practices, lack of supervision, and unstable family life were the primary causes

mentioned, all helping to form patterns of poor decision-​ making. In addition, Gottfredson and Hirschi (1990) emphasized that low self-​ control was one of the most important factors underlying criminal activity. While genetic and biological influences often drive impulsiveness and low self-​­ control, there is no doubt that individual decision-​making based on moral beliefs and values also plays a role (Tarry & Emler, 2007; Van Gelder & De Vries, 2012).

Gene-​Environment Interactions As noted earlier, the combination of childhood abuse, other environmental risk factors, and the presence of certain genetic polymorphisms increases risk of violence and criminal behavior (Caspi et al., 2002; Barnes et al., 2013). Given the right genetic makeup (impulsivity, reduced neurobiological control), experiences during childhood (abuse, neglect, poor attachment, low parental support), and environmental circumstances (low education, poverty, negative peer influences, low prosocial support), almost anyone can become a juvenile delinquent or criminal (Chhangur et al., 2015; Fragkaki et al., 2019; Barnes et al., 2019; Ling et al., 2019). The question we now raise is whether religion is an environmental factor that can help moderate the effects of high-​risk genes and adverse developmental experiences in fostering delinquent or criminal behavior.

RELIGION AND DELINQUENCY/​C RIME Given the above causes for juvenile delinquency and adult crime, what role does religious involvement play as a factor in preventing or exacerbating antisocial behavior? We begin with a case.

Case Vignette Howard is a 17-​year-​old male who is living at home in a poverty-​stricken area of Chicago. When he was about 5, his mother and father split up, the result of

Delinquency and Crime • 241

his father’s heavy alcohol use and physical abuse of his mother. After that, Howard’s mother had to work full-​time to support herself and him (an only child) since her ex-​husband was unwilling to provide alimony or child support. Because of her lack of education and work experience, his mother was forced to go from job to job, often working evening shifts. As a result, she was seldom at home when her son returned from school. Howard had a hard time at school due to poor social skills, a learning disability, and a volatile temper that got him into fights with other kids when they made fun of him. As Howard grew older, he began to skip school and hang out with older kids in the neighborhood. Teachers at school where overwhelmed with other problem children, and after attempting to contact his mother once or twice, simply gave up trying. Howard’s absence from school was only intermittent, and compared to the other kids, he was relatively quiet and not disruptive during class. When his mother arrived home in the evening and asked about his day, he would lie to her when he skipped school. Howard felt guilty about doing that, since he knew that his mother cared deeply for him and had taught him right from wrong. However, the draw toward older delinquent peers in the neighborhood was just too strong. Howard’s mother was a religious person. He would often find her reading her Bible and sometimes praying on her knees, which she said was for him. Howard’s problems continued after entering high school and began to escalate. During the middle of freshman year, he and a friend were expelled for breaking into a teacher’s office and stealing the teacher’s laptop computer. His mother was beside herself about her son’s behavior, but couldn’t seem to control him. Out of school, Howard got a job at a local grocery store stocking shelves and cleaning up. After work, he and his friends in the neighborhood would drink

242 •  S ocial H ealth

alcohol and use drugs, when they could get them, to get high. As her frustration with her son’s behavior grew, Howard’s mother decided in desperation to start attending a local church. She forced Howard (now age 15) to attend with her and eventually enrolled him in a youth group at the church. Although he was initially very resistant, his mother insisted that he accompany her and participate in the church youth group. She forced him to attend youth group activities after church and sometimes during the week in the evenings. Physically strong and talented, Howard found that he enjoyed playing basketball and other sports with the teens in his youth group, who began to look up to him. Feeling accepted made him feel good. Howard also started to pay attention in Sunday school classes and found that he enjoyed the Bible stories. He noticed that the struggles of biblical figures were often like those he was dealing with. As he grappled with problems at work and with other challenges in his life, including threats from his previous antisocial peer group, Howard started to pray on his own. As time passed, his faith in God grew. Along with that came a desire to make something of his life. Eventually, Howard decided to return to high school, a different one than the one from which he was expelled. His mother was thankful that things were beginning to change for her son.   

RELIGION’S IMPACT ON DELINQUENCY/​C RIME Is Howard’s experience that unusual? Might religious involvement impact juvenile delinquency and/​or adult crime? In this section, we consider how religion might impact the development or course of antisocial behavior, based on what we know about the causes of delinquency/​crime reviewed above.

Genetic As noted in previous chapters, there is evidence from animal studies that a nurturing parent can influence the genetic structure of an offspring’s DNA (through methylation), changes that may be transmitted from one generation to another, affecting stress reactivity during adulthood (Meaney & Szyf, 2005). The possibility that this may occur also in humans is a topic of current research and discussion (Champagne & Curley, 2009; Uher & Weaver, 2014; Beach et al., 2015). If religiosity increases maternal bonding and attachment, then it is at least theoretically possible for religion to affect the genome (including genetic factors that increase risk of delinquency or crime).

family life, child neglect or abuse, poor maternal attachment, low expectations, deficient family values and moral standards). Religious individuals may also be less likely to choose partners and spouses with a history of criminal activity, since this may not be consistent with their values, thus helping to eliminate the assortative mating effect on children mentioned earlier (reducing both genetic and environmental risk).

Social

As noted above, one of the strongest risk factors for antisocial behavior is peer-​group influences. Peer pressures contribute not only to the onset of delinquency and crime, but also to maintaining such behavior since it may be difficult to find psychological and practical supBiological port elsewhere once a pattern of such behavReligiosity of parents may influence the like- iors is established. Religious communities, lihood of intrauterine exposure to substances however, have an obligation to support those (alcohol, drugs, nicotine, stress hormones) in need. “Love thy neighbor” means including that may adversely affect the growth of brain and assisting “the stranger” (or in this case, regions, such as the frontal cortex and lim- the troubled youth or released inmate) by, for bic system, known to be altered in those with example, offering help to find employment antisocial tendencies (impulsivity, lack of con- and/​ or befriending the person. Surrounding trol). If religiosity reduces the likelihood of the juvenile or criminal offender with a prosoalcohol use, drug use, cigarette smoking, and cial support group and offering ways for these decreases stress hormone levels during preg- individuals to give back to society is one way to nancy (see Chapters 10, 17, 25), then it may transform such lives. Besides helping to rehamoderate these pathologic neurobiological bilitate those with former antisocial lifestyles, changes. Likewise, if religiosity reduces risk-​ religious social support can also help to pretaking behaviors that result in traumatic brain vent the onset of delinquency/​crime by providinjury (from fights, automobile accidents, etc.) ing prosocial peers and role models that guide or from brain changes with aging that affective youth toward a life of contribution rather than cognitive function, then it may indirectly influ- crime. ence risk of delinquent or criminal behavior.

Environmental There are many ways that religious involvement could affect environmental factors known to increase risk of antisocial behavior during youth and adulthood. If religiosity of parents is related to closer family ties, greater marital stability, and closer monitoring of child and adolescent activity (see Chapter 14), then it may affect some of the strongest determinants of later delinquency and crime (e.g., poor disciplinary practices, lack of supervision, unstable

Psychological Religious teachings can help to form positive character traits and values during youth, as well as provide coping resources for dealing with life’s challenges. Religious education seeks to instill honesty, dependability, self-​ control, humility, forgiveness, gratitude, and altruism—​­ ­ characteristic traits that are the opposite of those exhibited by juvenile delinquents and adult criminals (Reisig et al., 2012). Such behaviors are also essential for leading a happy, productive, and successful life, and Delinquency and Crime • 243

for the formation of healthy relationships. Religion also provides healthy coping behaviors and resources to help deal with stressful life changes and loss, serving to counteract other coping options such as turning to alcohol, drugs, risky sex, or behaviors that have long-​ term negative consequences. Religious coping includes praying for strength and endurance, finding guidance and reassurance in Scripture or other inspirational literature, and helping others through volunteering or prosocial activities. These behaviors help to address emotional distress without negative consequences. Religious involvement may also help prevent depression, anxiety, and other psychiatric disorders that may cause or complicate the treatment of delinquent or criminal behaviors.

data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), finding that those with the high risk A1 allele of the DRD2 gene (known to be associated with delinquency) were at increased risk of delinquency only if they had few religious beliefs, but not if they were more religious. This was true in both cross-​ sectional and longitudinal analyses. Likewise, Koopmans et al. (1999) reported that religiosity moderated genetic influences on alcohol use initiation. In that study, among women without a religious upbringing, genetic influences accounted for 40% of the variance in alcohol use initiation, compared to 0% in those raised within a religious family.

Individual Decision-​Making

Thus, there are many ways that religious involvement might help to reduce juvenile delinquency and prevent adult crime. Religiosity targets the primary causes of antisocial behaviors, particularly biological, environmental, social, and psychological factors, and affects the decisions individuals make that lead to either a life of harming others or one of helping.

Finally, the moral and ethical standards promoted by religion help to guide day-​to-​day decisions that reduce stress and improve quality of life. All major world religions encourage love of others, compassion, empathy, and putting the needs of others first, rather than behaviors such as stealing, cheating, lying, acting greedily, fighting, and engaging in other antisocial activities that hurt others and ultimately hurt the person engaging in them. Prosocial, other-​ focused decisions at work and play that put others first (vs. self-​centered choices) help to build positive relationships that breed success on the job and build friendship networks both inside and outside of work. The same applies to relationships within the family, as individuals relate to their spouse and children, which will affect the next generation and their risk of delinquent and criminal behavior.

Gene-​Environment Interactions We turn again to the question of whether religiosity might buffer or moderate the effect of genetic risk on delinquency/​crime. By providing healthy family experiences during childhood and prosocial environments during adolescence and adulthood, religious involvement could help to neutralize tendencies toward impulsiveness, self-​ centeredness, and risk-​ taking. For example, Beaver and colleagues (2009) analyzed 244 •  S ocial H ealth

SUM M ARY

RESEARCH ON RELIGION AND DELINQUENCY/​C RIME To what extent are the speculations above supported by existing research? Is religiosity related to less juvenile delinquency and adult crime, as we hypothesize above? Does religious involvement help to prevent the onset of antisocial behaviors or help individuals stop engaging in such activities? In reviewing the research, we focus on the 10 highest-​quality longitudinal studies, most with at least 1,000 participants (see Appendix for all studies). Many, but not all, of these reports come from a single prospective study, the US National Longitudinal Study of Adolescent Health (Add Health), a high-​quality study with long-​term follow-​up that included several measures assessing baseline religious involvement of both adolescents and parents. Unfortunately, no randomized controlled trials (RCTs) testing religious interventions could be found. However, several single group experimental studies have examined religious interventions, and those will be summarized. As

usual, studies are reviewed in order of year of publication. Johnson et al. (2001) used three waves of longitudinal data on a sample of 1,725 adolescents age 11–​ 17 in the National Youth Survey (NYS) to examine longitudinal associations between religiosity and delinquency. Religiosity was assessed by religious service attendance, importance of religion, time spent in religious activities, and importance of involvement in community religious activities. Delinquency was assessed by a measure assessing whether the youth had destroyed property, stolen something, and hit or threatened to hit someone. The investigators fit a latent variable structural equation model (where both religiosity and delinquency were treated as latent variables, based on their indicators) to estimate associations between religiosity at Wave 3 and delinquency at Waves 4 and 5 with control for Wave 3 delinquency. The models additionally controlled for respondent’s age, race, place of residence, family income, and background of family disruption. The estimates from the structural equation model suggested evidence for effects of religiosity on subsequent delinquency and some evidence also for direct effects on delinquency, even when controlling for subsequent beliefs concerning whether it is wrong for someone to engage in delinquent acts, which may be a mediator. Regnerus (2003a) analyzed data from a random sample of 9,401 adolescents participating in the Add Health study over a 1-​year follow-​ up. The purpose of this report was to examine religious context influences on self-​ reported delinquent behavior. Wave I (1995) individual, county-​level, and school-​level measures of general religiousness and conservative Protestant affiliation and homogeneity were examined as the primary predictors. On the individual level, conservative Protestantism was measured by adolescent self-​assessed “born-​again” Christian status, whereas general religiousness was assessed by frequency of church/​religious attendance. At the school level, religiosity was determined by proportion of weekly church attenders and proportion of self-​ identified “born-​again” Christians. At the county level, religious involvement was assessed by the proportion of religious adherents and conservative

Protestants. Delinquency was measured at Waves I (1995) and II (1996) by an index of theft and minor delinquent acts engaged in during the past year. Control variables were intactness of biological family, race, family satisfaction, family economic status, school attachment, intergenerational closure, autonomy from parents, and importantly, Wave I report of theft and delinquency. Multi-​level regression models were used to analyze the data. Individual religious service attendance was inversely related to both theft and delinquency. There was also a nonsignificant trend in that direction for those who were born-​again Christians. School-​ level and county-​level effects were similar. The researcher concluded that individual-​level religious effects were the strongest, but conservative Protestant homogeneity at both the county and school level was also associated with lower theft and delinquency. Furthermore, religious homogeneity interacted with individual-​ level measures of conservative Protestantism to further reduce the incidence of theft and delinquency (especially theft). In a second report from the Add Health study, Regnerus (2003b) analyzed 12-​month follow-​up data from 1995 to 1996 on 11,046 adolescents in grades 7–​ 12 to examine the effects of adolescent and parent religiosity on delinquency. Parent religiosity was measured by frequency of religious attendance, conservative Protestant affiliation (vs. other affiliation), and the importance of religiosity. Adolescent religiosity was assessed in a similar manner. Serious delinquency (painting graffiti on or otherwise damaging another’s property, stealing something from a home/​building, shoplifting, stealing something worth < $50, stealing something > $50, threatening to use or using a weapon against someone, taking part in group fighting, selling marijuana/​drugs) was assessed at both Wave I and Wave II. Structural equation modeling was used to analyze the data, controlling for adolescent autonomy and family satisfaction (with Wave I delinquency in the model). Multi-​ group path analyses were conducted based on generation, gender, and age group. Results indicated that religiosity of both parent and child decreased serious forms of delinquency. In the intergenerational model, parental religiosity protected girls more than Delinquency and Crime • 245

boys from delinquency. In boys, greater parental religiosity indirectly reduced delinquency through effects on autonomy and family satisfaction. Conservative Protestant affiliation of parents (but only if this was true for both parents) was consistently related to less adolescent delinquency in girls and boys. In their third report from the Add Health study, Regnerus and Elder (2003c) examined the influence of religious involvement on vulnerability to committing delinquent acts among “low-​risk” adolescents in grades 7–​12 during the same 1-​year follow-​up period (n =​7,767). Logistic regression analyses were used to examine the effect of Wave I church attendance, change in attendance, importance of religion, and change in importance of religion on self-​reported delinquency during the previous 12 months. Results indicated that while frequency and change of church attendance were unrelated to delinquency reports at Wave II, both importance of religion and change in importance were significantly related, reducing the likelihood of such occurrence (OR =​0.66 and OR =​0.74, respectively, both p < 0.001). These effects weakened very little when adding more delinquency and academic risk factors (i.e., family satisfaction, positive self-​ image, level of personal autonomy, child temper, intergenerational closure, and school attachment, but apparently not baseline delinquency) to the models (OR =​0.71 and OR =​0.76, respectively, both p < 0.001). Researchers concluded that a lower importance of religion, as well as a reduction in importance of religion, helped to identify low-​risk youth vulnerable to future delinquent behavior. Using data from the Add Health study again, Pearce and Haynie (2004) examined whether religious mothers have adolescent children who are less likely to be delinquent. In this study, religiosity of mothers and adolescents were examined as predictors of delinquent behavior during a 1-​ year follow-​ up from 1995 to 1996 (similar to Regnerus’s studies). Maternal and child religiosity were assessed at Wave I (religious attendance and importance averaged together). Delinquency was assessed by an index of 14 delinquent behaviors reported at Wave I and Wave II. Binomial regression models were used to estimate the effect of maternal 246 •  S ocial H ealth

and child religiosity on Wave II adolescent delinquency, controlling for religious affiliation, race/​ethnicity, age, gender, education of parent, two-​parent household, region of United States, and Wave I delinquency. Results indicated that maternal religiosity predicted a lower likelihood of adolescent delinquency (b =​−0.09, SE =​0.03, p < 0.01). When analyses were repeated for child religiosity, a similar effect was found (b =​−0.06, SE =​0.03, p < 0.01). When both maternal and child religiosity were included in the model, the effect of maternal religiosity persisted (b =​−0.06, p < 0.01), but not child religiosity (b =​−0.04, SE =​0.03, p =​ns). When a “maternal religiosity by child religiosity” interaction was included in the model, there was evidence for interaction (b =​−0.07, SE =​0.02, p < 0.001). Further analysis indicated that the lowest delinquency occurred when both mother and child had high religiosity. This study also examined the mechanism by which the maternal-​child relationship might influence delinquency. Frequency of child arguing with mother, degree to which mother trusted child, and family protective factors (how much the adolescent felt parents cared about him/​her, how much the adolescent felt understood by parents, and how much fun the adolescent had with family, how much attention the adolescent felt was paid to him/​her by family) were entered into the model. Results indicated that frequency of arguments predicted increased delinquency, whereas mother trusting child and family protective factors reduced delinquency. Controlling for these factors, however, did little to reduce the effect of combined high maternal and high child religiosity (the interaction) on preventing delinquency (b =​−0.05, SE =​0.02, p < 0.001). Researchers concluded that these factors did little to explain the protective effect of maternal-​child religiosity on delinquency. Fauth and colleagues (2007) analyzed data from 1,315 children age 9–​ 12 participating in the Project on Human Development in Chicago Neighborhoods to examine the relationship between after-​school activities and delinquency outcomes. Participants and their parents were surveyed in 1995–​1996 (Wave I), 1998–​1999 (Wave II), and 2000–​2001 (Wave III). At Wave II, students were asked if they

engaged in five different activities after school during the school year: sports or cheerleading, performing arts, student government, community-​ based groups, or church groups. Frequency of participation in the past year was asked in Wave II and frequency of participation in the past month was asked in Wave III. Youth delinquency during the past year was assessed at each wave (Waves I–​III) by a self-​report measure asking about engagement in 15 different delinquent behaviors, ranging from attacking someone with a weapon to stealing to engaging in gang fighting. Also assessed (assuming at baseline, although not specified) were youth characteristics (age, gender, race/​ ethnicity), maternal and family characteristics (education, marital status, income), neighborhood characteristics, and youth anxiety/​depression and substance use, all of which were controlled for using three-​level hierarchical regression. Results indicated no relationship between participation in church groups and delinquent activities in any of the analyses, although some of the control variables may have been mediators depending on when they were measured. Glanville et al. (2008) analyzed follow-​up data from the Add Health study involving 15,197 adolescents in grades 7–​ 12 assessed initially in 1994–​1995 (Wave I), one year later (1996, Wave II), and 7 years later (2001–​2002, Wave III). Outcomes of interest here were adolescent Wave III school dropout (which served as a proxy for delinquency), grade point average (GPA; from transcript during year after Wave I), and school attachment (Wave II). Frequency of religious attendance and involvement in church youth activities were combined as the measure of religious involvement assessed at Wave I, the primary predictor variable. Wave I variables controlled for in regression analyses were parental education, family income, family composition/​ type, race, gender, age, urban/​ rural residents, family satisfaction, self-​image, bad temper, vocabulary score, ever held back a grade, GPA at Wave I, participant truancy at Wave I, friends’ truancy at Wave I, and school attachment at Wave I. Cross-​sectional analyses at Wave I indicated that religious involvement was inversely related to friends’ truancy (b =​−0.016, p < 0.001), and positively related to friends’ grades (b =​0.012, p < 0.001), sports

participation (b =​0.008, p < 0.05), participation in other activities (b =​0.017, p < 0.001), and intergenerational closure (number of child’s friends’ parents that child’s parent spoke to within past 4 weeks) (b =​0.091, p < 0.001). After controlling for Wave I variables above, Wave I religious involvement predicted lower Wave III school dropout (b =​−0.046, p < 0.001), higher Wave II GPA (controlling for Wave 1 GPA; b =​0.019, p < 0.001), and greater Wave II school attachment (controlling for Wave I school attachment; b =​0.013, p < 0.001). Researchers concluded that religious attendance reduces school dropout by promoting “higher intergenerational closure, friendship networks with higher educational resources and norms, and extracurricular participation” (p. 105) (i.e., factors likely to reduce risk of juvenile delinquency and adult crime). Miller and Vuolo (2018) analyzed 12-​year follow-​up data from the Add Health study that included information from Waves II (1996), III (2001–​2002), and IV (2007–​2008, during young adulthood age 24–​32). A total of 13,796 participants provided data from all three waves. Religious importance, weekly attendance, and daily prayer were assessed at Waves II through IV; religious belief (“I employ my religious or spiritual beliefs as a basis for how to act and live on a daily basis”) was measured at Wave III only. “Secular” delinquency/​crime (secular DC) was assessed at Waves II through IV using an index of self-​reported delinquent/​criminal behaviors in the past 12 months (as described earlier); “ascetic” delinquency/​crime (ascetic DC) was measured by marijuana use in the past 30 days at Waves II–​IV. Multiple sociodemographic and risk factors for delinquent/​criminal activities were controlled for using cross-​lagged structural equation modeling, which sought to differentiate the “religion-​FIRST” effect from the “DC-​FIRST” effect. Analyses were stratified by secular DC and ascetic DC. Results indicated that Wave II religious importance significantly predicted a decline in Wave III secular DC, while Wave II secular DC had no effect on Wave III importance of religion, supporting a “religion-​FIRST” effect. While neither Wave II nor Wave III religious attendance predicted future secular DC at Wave III or Wave IV, Wave II secular DC predicted a Delinquency and Crime • 247

significant decrease in Wave III attendance (and Wave III secular DC also predicted a significant decrease in Wave IV attendance), supporting a “DC-​FIRST” effect. No evidence was found for effects of daily prayer or employment of religious belief on future secular DC, or vice versa. Wave II religious importance predicted a significant decrease in Wave III ascetic DC (marijuana use), while Wave II ascetic DC did not affect Wave III importance, favoring a “religion-​ FIRST” effect. Effects of religious attendance on future ascetic DC, however, were bidirectional in nature—​Wave III attendance predicted lower Wave IV ascetic DC, and Wave II and III ascetic DC predicted lower Wave III and IV attendance, respectively. Wave III employment of religion in daily life also predicted a significant decrease in Wave IV ascetic DC, but Wave II ascetic DC did not predict Wave III employment of religion, favoring a “religion-​FIRST” effect. No evidence was found for effects of daily prayer on future ascetic DC or for ascetic DC on future prayer. Thus, while delinquency/​ crime may impact religious attendance, it appears that religious importance and employment of religion in daily life influence delinquency/​crime. In a 7-​year prospective study of 1,354 adolescents, Guo (2021) used group-​based trajectory and growth-​curve models to examine the impact of religiosity on criminal behavior over time, controlling for covariates. Participants, age 14–​18, had been adjudicated guilty of serious crimes (Pathways to Desistance Study) in Maricopa County (Phoenix), Arizona, and Philadelphia County, Pennsylvania. Religiosity was assessed at baseline by religious attendance and religious importance, while spirituality was measured by the questions (a) “I experience God’s love and caring on a regular basis”; (b) “I experience a close personal relationship to God”; and (c) “Religion helps me to deal with my problems.” Criminal behavior over time was measured by aggressive offending, income-​ related offending, self-​reported offending, and official arrest (crime trajectories that included baseline criminal behavior). Results indicated that more religious adolescent offenders had a lower likelihood of engaging in future crime (based on crime trajectories) than nonreligious offenders for all dimensions of religiosity assessed. Increases in religiosity over time 248 •  S ocial H ealth

further attenuated the risk of criminal behavior, while decreases in religiosity increased that risk. These findings persisted after confounding variables were controlled. The researcher concluded, “A small range of gains and losses in religiosity may increase the risk of recidivism, while maintaining high religiosity over time may result in a smaller growth change in recidivism” (p. 1614). These findings are consistent with Guo and Metcalfe (2019)’s report from a 10-​year prospective study of 6,787 youth from age 17–​21 to 27–​31 involved in the US National Longitudinal Survey of Youth, which found that increases in religious attendance predicted decreased risk of all forms of substance use (alcohol use, marijuana use, and hard drug use). Finally, in a prospective study that examined the effects of religiosity on crime during adulthood, Stansfield and colleagues (2019) conducted an 8-​year longitudinal study of 571 offenders (83% White) incarcerated for at least 1 year in prisons of the Oregon Department of Corrections. The purpose was to examine the impact of religiosity/​spirituality on recidivism, i.e., the likelihood of being re-​incarcerated after release from prison. At baseline, participants were asked to self-​categorize themselves as: (1) both spiritual and religious, (2) spiritual but not religious, (3) religious but not spiritual, or (4) neither religious nor spiritual. Participants were also asked their current religious affiliation and if they grew up in a religious family setting. Participants were also asked if they attended a humanist, spiritual, and religious (HSR) services program at any time during their imprisonment (80% led by religious/​ spiritual volunteers or chaplains). Finally, religious orientation was assessed using the 20-​item Age Universal Religious Orientation Scale (Gorsuch), which measures intrinsic and extrinsic religiosity. Regression models controlled for all religious variables, severity of infraction, recidivism risk, time served, type of offense, gender, and race. Results indicated that those who said they were spiritual but not religious were over twice as likely to be re-​ incarcerated during the follow-​up period compared to those were both spiritual and religious. In addition, those who attended the monthly HSR program were significantly less likely to be re-​incarcerated (OR =​0.94, p < 0.05). Finally,

those scoring higher on intrinsic religiosity were less likely to be imprisoned again after release (OR =​0.95, p < 0.01). The difference in re-​incarceration rates between those indicating they were “spiritual but not religious” and those who were “both spiritual and religious” was explained by participation in the HSR program (19% of the total effect) and by level of intrinsic religiosity (37% of the total effect). Given these results, researchers emphasized the importance of “ensuring support for persons in prison in the process of making meaning, in addition to supporting the work of prison chaplains and religious volunteers in prison” (p. 337). See also the 10-​year follow-​up of this cohort that examined the effects of involvement in the HSR program above, with similar positive results but only in those with a history of prior sexual offense (Stansfield et al., 2020). All studies reviewed above were conducted in the United States. Although numerous cross-​ sectional studies of religiosity and delinquency/​ crime have been conducted in other countries, we are aware of only three prospective studies of this type conducted to date (Tomaszewska et al., 2018, in Poland; Schuster et al., 2019, in Chile and Turkey; and Bhutta et al., 2019, in Pakistan), which reported no effect, mixed findings, or a positive effect, respectively (see Appendix). Of the 11 relatively high-​quality cross-​ sectional studies performed in other countries listed in the Appendix, 9 reported a significant inverse relationship between religiosity and some component of delinquency/​ crime or a buffering effect of religiosity on the relationship between affiliation with delinquent peers and perpetration of serious physical violence.

Religious Interventions To our knowledge, as noted above, no RCTs have examined whether religious interventions reduce delinquency/​crime. However, there are several studies that have examined the effect of such interventions on recidivism or drug abuse. The Stansfield et al. (2019) study above suggests that participation in an HSR program during incarceration predicted a lower likelihood of recidivism over an 8-​year follow-​up after release. Several early studies of similar

design and of variable quality have likewise reported positive results. Catherine Hess (1977) from the National Institute on Drug Abuse reported outcomes from Teen Challenge (TC), a Christian-​based program for troubled youth with a history of delinquency and/​or drug and alcohol abuse. Back then, TC maintained 4,500 inpatient beds in the United States and Puerto Rico, with 86 centers for males age 18 or over, 37 centers for females age 18 or over, 13 centers for females age 12–​17, and 11 centers for males age 12–​ 17. Over 8,000 people entered TC residential programs in 2001 and 2,901 completed them. An abstract of the study by Hess indicates that investigators collected follow-​up data on TC program participants to determine program effectiveness, dropout rates, and success in the community after completion of the program. Of TC graduates in 1968, 88% of former abusers were abstaining from the use of marijuana in 1974, and 95% of former abusers were abstaining from heroin use. Concerning adult criminal behavior, Johnson and colleagues (1997) followed prison inmates at four New York State prisons for one year to determine if participation in a Prison Fellowship (PF) program impacted inmates’ recidivism rates. PF is a nonprofit religious program for prisoners that provides opportunities for group Bible study, spiritual development seminars, and life-​plan seminars. Investigators selected 201 former inmates who were PF program participants (mean age 32) and matched them to 201 inmates who did not participate in PF. Results indicated that both groups were similar on initial adjustment to prison, with each committing similar amounts and types of institutional infractions. While no difference was found on recidivism rates between groups at the 1-​year follow-​up, the level of PF participation in Bible study groups significantly predicted recidivism rates. PF inmates in the high participation category (10 or more Bible studies completed) were significantly less likely than non-​PF inmates to be arrested during the follow-​up period (14% vs. 41%, p < 0.05). Johnson (2004) continued to follow PF and non-​ PF prisoners for an additional 7 years (total 8-​ year follow-​ up), incorporating new approaches to measuring PF participation, Delinquency and Crime • 249

expanding measures of recidivism, and using survival analysis to analyze the data. The new approach to measuring PF participation involved lowering the number of Bible studies attended from 10 to 5 in order to qualify for “high attendance,” thus increasing cell size for analysis from 22 to 44 for high-​attending participants. Johnson also expanded the recidivism outcome measure to include number of times arrested, percent arrested, and mean and median years to arrest. High participation predicted a longer median time to re-​arrest (average 18 months longer), with the most pronounced effect occurring between baseline and the 2-​year follow-​up (27% vs. 46%, p < 0.05); differences became smaller and nonsignificant after 3 years. Survival analysis suggested that the risk of re-​arrest (controlling for five other predictors of arrest) for high attendees vs. low attendees was 49% lower at 2 years (p < 0.05) and 41% lower at 3 years (p < 0.05). Concerning re-​incarceration, high participation predicted lower rates of re-​incarceration at 2-​year (9% vs. 18%) and at 3-​year follow-​ups (14% vs. 26%), although these results achieved only borderline significance (p =​0.06), possibly due to low power. As with re-​arrests, the effect diminished to nonsignificance after 3 years of follow-​up (through year 8). Thus, the effect of attending Bible studies during prison had its maximum effect on recidivism during the first 2–​3 years after release. Johnson and Larson (2008) reported on a more intensive prisoner program titled the InnerChange Freedom Initiative (IFI) initiated at a state prison in Richmond, Texas. This Christian-​ based program consisted of three phases. Phase I lasted 12 months and included biblical education as well as tutoring, substance abuse prevention, and life skills training; support designed to increase one’s personal faith; support to improve relations with family members and crime victims; mentoring; and community Bible study. Phase II lasted 6–​12 months and sought to continue the educational, work, and support group aspects of the program, but included community service work at off-​site locations such as Habitat for Humanity. Phase III was an aftercare component of the program that lasted for an additional 6–​12 months and was designed 250 •  S ocial H ealth

to assist IFI participants when re-​ entering society by helping with housing, employment, mentorship, and making connections with local church communities. A total of 177 prisoners were enrolled in the program between 1997 and 1999. Comparing those who completed the program (n =​75) with those who did not (n =​102), completers were less likely to be arrested (16% vs. 42%, p < 0.0005) and less likely to be incarcerated (8% vs. 34%, p < 0.0001) during an 18-​month follow-​up.

Summary Prospective studies are becoming increasingly sophisticated in attempts to explain the inverse relationship between religiosity and delinquency/​crime over time. That there is an inverse relationship is rarely disputed. In the second edition of the Handbook, we found that of 104 studies published prior to 2010 (mostly cross-​sectional), 82 (79%) reported an inverse relationship between religiosity and crime. In our review of the 10 highest-​quality prospective studies above, we also found that greater religiosity predicted less delinquency/​crime in 9 of those studies (90%). Religiosity of both parent and child likely affects future child antisocial behavior; however, it is also likely that delinquent and criminal behavior adversely affects religious involvement (i.e., reverse-​causation), especially for religious attendance. Several religious programs have been developed to reduce delinquent behaviors (drug abuse) among youth and recidivism rates among adult prisoners, and the preliminary results are promising. However, rigorous RCTs of such programs are lacking.

RECOMMENDATIONS FOR FUTURE RESEARCH More longitudinal studies with long-​ term follow-​up are needed to examine the impact of religious community involvement on prevention of delinquency/​crime and on change in antisocial behaviors over time, especially in other countries and in minority populations where religiosity and the religious community are especially important and rates of antisocial behaviors are disproportionately high.

Concerning the latter, in fact, Agnew (2016) questions why minor offenses and serious crime are not even higher in African Americans despite rampant poverty, discrimination, drug use, and other environmental risk factors. While he emphasizes the important role that religion plays in prevention for this racial group, there is little prospective research to support this. Also greatly needed is more research on the effects of parental religiosity (measured prior to birth of the child) and religious upbringing (during early and later childhood) on juvenile delinquency and later adult crime. Since many of the known determinants of antisocial behaviors are related to early family relationships and attachment to caregivers, this is a natural area on which to focus. Such research will likely also require long-​term prospective studies (informed by qualitative work) and eventually RCTs. Several programs designed to help troubled youth and adult prisoners have already been developed, but as yet have not been subject to rigorous evaluation. Given the effectiveness of secular cognitive-​behavioral approaches (see below), religiously integrated therapy holds great promise for those who are religious. As noted in Chapter 3, both long-​term prospective studies and RCTs are expensive and difficult to carry out, especially if done well. Such research, however, is particularly challenging in juvenile delinquents or adult criminals, given the frequent presence of psychiatric comorbidity, substance use problems, and lack of cooperation. This leads to high dropout rates and losses to follow-​up, which can seriously affect the quality of findings. However, given the cost of juvenile delinquency and adult criminal activity due to the need to maintain a police force, prisons, and legal systems to ensure public safety, along with the widespread availability of religious institutions and religious education programs, such research is desperately needed, and government funding for such studies should be highly cost-​effective.

CLINICAL APPLICATIONS As noted above, persons who engage in antisocial activities, whether young or old, frequently suffer from comorbid psychiatric problems and

substance use disorders, as well as physical health problems often resulting from delinquent or criminal activities. Such problems are likely to bring such individuals into contact with health professionals, either voluntarily or involuntarily through court-​ ordered treatment. How can medical, social service, mental health, criminal justice system, and religious professionals take advantage of what is already known about the causes of juvenile delinquency and adult crime and the role that religion might play in mitigating these behaviors? We divide our suggestions for clinical application, as in earlier chapters, into initial assessment, simple religious interventions, religiously integrated psychotherapy, and referral to religious-​based programs.

Assessment Given the potential impact of religiosity and religious resources on both the development and course of delinquent and criminal behaviors, as well as on the mental health problems that may contribute to and complicate treatment, the first step for health professionals trying to help these individuals is to take a spiritual history to identify religious resources that may help in recovery efforts. While juvenile delinquents and adult criminals tend to be less religious than the general population, this does not mean that they are not religious at all or have no religious resources available to them in the form of family members, friends, or a religious community. These resources, then, need to be identified and the receptiveness of the client to utilizing such resources determined. Clinicians must also be able to distinguish juvenile delinquents and adult criminals who are already somewhat religious (and may benefit from religious interventions) from those who are not, although this is often difficult to determine. An important complication in trying to make such assessments has to do with psychiatric comorbidity, and we will describe several such challenges below. On one end of the spectrum, there are those with strong psychopathic or malignant narcissistic traits who feel fine, are not motivated to seek help, and may use religion in order to further their self-​centered goals. The prevalence Delinquency and Crime • 251

of psychopathy in the general prison population is about 15%–​ 25% (Boduszek et al., 2019). Psychopathy, as noted in Chapter 11, is a more neurobiologically based syndrome of “emotional hyporeactivity” characterized by fearlessness, impulsivity, superficial charm, manipulativeness, dominance, cruelty, and lack of empathy or care about the rights and feelings of others. These individuals feel no need to change; it is the other person who is always the problem. The true psychopath has been characterized (theoretically) as having no conscience or moral standards (Hare, 1993). Inmates with narcissistic personality disorder are much less common than those with psychopathy, are more likely to be incarcerated for white-​collar crimes such as fraud and forgery, and tend to cause disruption in prison through threats of violence and physical assault (Coid et al., 2009; Davison & Janca, 2012). Psychologist Eric Fromm, who coined the term “malignant narcissism,” described these individuals as “the quintessence of evil” (Fromm, 1964), a concept that psychiatrist Scott Peck later elaborated in People of the Lie (Peck, 1983). However, most juvenile delinquents and adult criminals are not psychopaths or malignant narcissists. Delinquents or criminals with antisocial personality disorder make up slightly more than half of all prisoners (Boduszek et al., 2019), and those with a non-​psychopathic subtype are more likely to have alcohol and drug abuse problems and mood disorders, which may drive them to seek help to change. Those without antisocial personality disorder (25%–​35%) may have a different personality disorder that causes emotional distress or an Axis I psychiatric disorder such as depression, anxiety, or other distressing disorder, one that makes them quite eager for help. Thus, there is a wide range of troubled youth and adult criminals in terms of willingness to receive treatment, sincerity in doing so, and cooperativeness. To some degree, this is even true for psychopaths and narcissists. Many individuals who commit delinquent or criminal acts do so out of desperation. They feel excluded or ostracized by peers, lack social or work skills, may engage in criminal activity to support family or loved ones, or suffer from addictions, impulse control problems, or cognitive/​ psychiatric disorders over which they 252 •  S ocial H ealth

have little control. These are individuals with a conscience who may feel extremely guilty and ashamed for what they have done, and are plagued by moral injuries about which they are only dimly aware (see Chapter 8). The goal of assessment is to uncover such issues and to determine religious resources that may assist in recovery and healing. As noted above, religions offer help in dealing with moral failure (through confession, experiencing forgiveness, and giving back), provide supportive prosocial peers as alternative communities, and encourage individuals to engage in the world in more positive, healthy ways.

Simple Religious Interventions There is little research documenting the effectiveness of simple religious interventions such as supporting religious beliefs, encouraging prayer, or suggesting that the person meditate on religious scriptures, read inspirational literature, or take part in a religious community. However, such support and encouragement by clinicians or religious professionals may be helpful to those who are religious and receptive (or have family members or friends who are). For example, Stansfield and colleagues (2017) found in a prospective study that religious support had strong effects on both post-​release employment and substance use that were in a prosocial direction. Qualitative studies likewise document the importance of religious belief and support in the transformation process of young and adult offenders (Schroeder & Frana, 2009).

Religiously Integrated Psychotherapy For those who are motivated, cognitive behavioral therapy (CBT) has been shown to be effective in reducing recidivism rates in high-​risk offenders, particularly when focused on anger control and interpersonal problem-​ solving (Landenberger & Lipsey, 2005; Clark, 2010). Although religiously integrated CBT for the treatment of juvenile or adult offenders currently exists, the development and testing of such therapeutic approaches should be a high priority (see above). Given that early life and adult trauma are often the cause of later

delinquent and criminal behaviors, religiously a lifelong history of crime or early death. Of integrated trauma-​focused CBT may be particu- course, the prevention of delinquency during larly effective in cases where spiritual struggles youth and criminal behavior during adulthood or other symptoms of moral injury are present must likewise be a high priority. The teaching (Partridge & Walker, 2015; Harris et al, 2018). of moral and ethical principles both within the Religious-​ based educational and cognitive-​ public school system and the religious combehavioral approaches directed at parents of munity (with an emphasis on the education of delinquent youth are also needed (particularly future parents) is crucial in this regard. parents with criminal histories) to prevent transmission of such behaviors across generations.

Referral The helping professional should be aware of specialized religious (and secular) programs in their local area for troubled youth or adult offenders. Religiously based 12-​step programs that focus on the spiritual virtues of “love and service” have been shown in single-​group experimental studies to reduce relapse into substance abuse and criminal offending among young persons (Kelly et al., 2011a; Lee et al., 2017). The benefits of youth programs such as Teen Challenge for juvenile offenders have already been described (Hess, 1977; Bicknese, 1999). Secular programs such as Boys Town and Girls Town also emphasize the moral and spiritual development of young offenders (Davis & Daly, 2003) and the evidence base for their effectiveness is growing (Larzelere et al., 2004). For adult offenders, as discussed above, programs such as Prison Fellowship (Johnson, 2004) and InnerChange Freedom Initiative (Johnson & Larson, 2008) have shown benefits in terms of reducing recidivism rates.

Combined Approaches As with treatments for personality disorder, given the extensive comorbidity associated with delinquent and criminal behavior (psychiatric, social, physical, religious and moral), a combined approach is almost always required to help these individuals. Mental health and medical professionals, social workers, criminal justice experts, and religious professionals must all work together to develop an effective treatment plan that can be applied both during confinement and after release back into the community. Anything less is likely to be ineffective, result in reincarceration, and lead to

SUMMARY AND CONCLUSIONS

This chapter focused on the impact of religion on juvenile delinquency and adult crime. We first defined these terms and then discussed the prevalence, costs, and lifelong consequences of antisocial behaviors of this type. We next examined the known causes of delinquency and crime, including genetic, biological, environmental, social, psychological, and individual determinants, as well as gene-​ environment interactions. This background was intended to provide a better understanding of the importance of such causal factors and provide clues on how religious involvement might influence them. We then presented a case vignette describing a delinquent young person and how the religious faith of his mother led to eventual transformation and recovery. We next speculated on how religious involvement might help to prevent the development of delinquency/​crime or assist in their treatment, focusing on known determinants. Following that, we summarized research that has examined the relationship between religion and delinquency or crime, focusing on large longitudinal studies. We also examined religious-​based programs designed for juvenile delinquents and adult criminals and reviewed their effectiveness based on the limited research available. Recommendations for future research were then made, emphasizing the importance of longitudinal studies and RCTs and the challenges involved in conducting such studies. Finally, suggestions for clinical application by health and religious professionals were provided, informed by the available research evidence and common sense. In the next chapter, we examine the role that religion plays in what often serves as the basis for both personality and future behavior—​marital and family health and stability. Delinquency and Crime • 253

14 Marital and Family Stability . . . husbands ought to love their wives as their own bodies. He who loves his wife loves himself. —​Ephesians 5:28

AS NOTED IN Chapters 10, 11, and 13, family problems and marital instability are often the source of future substance use problems, personality disorders, and delinquent and criminal behavior during youth and adulthood. They are also frequently the cause for lack of social and practical support, particularly in later life when such care and support is especially needed. There are few endeavors as important for the future of our nations, cultures, and human civilization as ensuring the health of marriages and families. This chapter is about the role that religion plays in marital health and family stability. When a couple are married, they often repeat a set of wedding vows. One of the oldest standard wedding vows is found in the Book of Common Prayer, which in 1662 was endorsed by Thomas Cranmer, Archbishop of Canterbury (Lippo, 2018). Those vows read: “I, _​_​_​_​_​, take thee, _​_​_​_​_​, to be my wedded Husband/​Wife, to have

and to hold from this day forward, for better for worse, for richer or poorer, in sickness and in health, to love, cherish, and to obey, till death us do part, according to God’s holy ordinance.” This vow, made before God and the couples’ family and friends, indicates their intention to seek a life together and raise a family. The content of these vows and the place in which they are often made (i.e., a place of worship) emphasize the role that religion plays in helping to form and maintain the marital bond.

DIVORCE The likelihood that a first marriage will end up in divorce in the United States increased, depending on the couple’s education, from about 20% in 1960 to 45%–​55% in 2016. Divorce is lowest among those with either less than high school or those with college and above, and is highest among individuals in the middle (Hendi, 2019).

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0014

The expected duration of first marriage has decreased from 34.5 years in 1960 to 25.6 years in 2010, an almost 9-​year decline. Divorce rates are climbing around the world, with the highest rates found in developed countries such as Russia, Denmark, Finland, Sweden, and former Communist countries, which are also some of the least religious countries (World Population Review, 2019). In the four decades between 1970 and 2008, the annual divorce rate more than doubled globally, from 2.6 to 5.5 divorces per 1,000 married individuals (DePaulo, 2019). For the past 20 years in the United States, however, according to the latest statistics from the US Centers for Disease Control (CDC, 2017b), both marriage rates and divorce rates in the United States have been declining. In the year 2000, the marriage rate per 1,000 was 8.2; by 2017, the marriage rate had declined to 6.9 per 1,000, indicating an 11% drop. The number of divorces and annulments per 1,000 was 4.0 in the year 2000, compared to 2.9 per 1,000 in the year 2017 (a 28% decrease). In 2017, there were 2,236,496 marriages and 787,251 divorces or annulments. The decreasing rate of divorce is thought to be due to changing attitudes and behaviors toward marriage among younger persons (millennials and Gen Xers), who are now increasingly choosing to marry at a later age after they have completed their education, established their careers, and stabilized their finances (Cohen, 2017; Lascala, 2019). Another reason for the decreasing marriage and divorce rate may be the increasing rate of cohabitation (living with an unmarried partner). The high divorce rate may moreover be one reason that is driving cohabitation, i.e., single young people or those who have been married wanting to be sure they are compatible with their partners before committing to a long-​lasting marital relationship (Perelli‐Harris et al., 2017), or avoiding marriage altogether for fear of making a commitment and then subsequently having a divorce. Among US adults age 18–​24, the cohabitation rate increased from 0.1% in 1968 to 9.4% in 2018; in contrast, the rate of living with a marriage partner decreased from 39.2% in 1968 to 7.3% in 2018 (Gurrentz, 2018). Thus, cohabitation in this age group is now more likely than living with a spouse. When couples who cohabitate split up, this is

not counted in divorce rates, helping to explain the decrease in divorce (which may simply be an indicator of increasing cohabitation without marriage). However, premarital cohabitation before marriage has been shown to increase risk of divorce and marital distress (Jose et al., 2010), especially among those who have cohabitated with another individual before marriage or have cohabitated before making a mutual commitment to marriage (Manning & Cohen, 2012). While those cohabitating with individuals they do not eventually marry have lower marital dissolution rates during the first year of marriage, they experience significantly higher divorce rates after 5 years of marriage compared to those who do not cohabitate (Rosenfeld & Roesler, 2019a). Thus, marriage is becoming less common in young adults today than in prior generations, but those who do marry may experience more stable marriages. The question of whether future marriages will be more or less stable over time, given the increasing rates of cohabitation and premarital sex, is an important one for progressive societies and cultures.

Predictors of Divorce Classic predictors of divorce, which have changed little over the past decades, include younger age at marriage, education at the high school level only, poverty and socioeconomic strain (lower paying jobs, lower status jobs, poorer working conditions), higher education among women, greater workplace (vs. home) involvement, unstable families of origin (divorce of parents), race (African American, due to cultural factors, stigma, and racial discrimination), and inter-​ racial marriage (Teachman, 2002; Rosenfeld & Roesler, 2019b). This led Rosenfeld and Roesler (2019b) to conclude that being married appears to be becoming a more privileged status in the United States. Couples with less education, a history of childhood poverty and disadvantage, and less stable families of origin appear to be at greatest risk for divorce. In addition, as noted above, cohabitation prior to marriage is another a risk factor, as well having premarital sex. While premarital sex with one’s eventual spouse does not increase divorce risk, premarital sex with prior Marital and Family Stability • 255

partners not leading to marriage does increase the risk (Kahn & London, 1991; Teachman, 2003). Likewise, the total number of prior sexual partners is associated in marriage with lower levels of sexual quality, communication, and relationship stability (Busby et al., 2013). Positive attitudes toward the moral acceptability of premarital sex are also cross-​nationally associated with lower marriage and higher divorce rates (Barber, 2018).

The Consequences Divorce has many health consequences for both the couple and their children. T HE C O U P L E

Early research documented the negative effects of divorce. Verbrugge (1979) reported an increased risk of acute and chronic medical problems and disability in both men and women following divorce. In terms of mental health, men experience an increased risk of suicide, psychiatric hospital admission, and being a victim of violence, whereas women experience an increased risk of depression and need for medical services (Bloom et al., 1978; Amato, 2000). Other longitudinal studies suggest that divorce is subsequently associated with poorer mental health outcomes (Marks & Lambert, 1998; Wilcox, 2011; Aseltine & Kessler, 1993) and physical health outcomes (Lillard & Panis, 1996; Kaplan & Kronick, 2006; Shor et al., 2012), even after controlling for baseline health. Additional recent research suggests that these negative consequences may depend on gender and time course (Leopold, 2018): men experience more short-​term reductions in psychological well-​ being, whereas women have more long-​term effects related to the loss of household income, increased risk of poverty, and stress of single parenting. Both genders suffer from medium-​term negative consequences with respect to economic well-​being; mental and physical health problems; stress related to moving, homeownership, re-​partnering, social reintegration with new friends; and loneliness. Leopold concluded that while men experience more negative consequences in the short term, women have more in the long term. 256 •  S ocial H ealth

CH IL D REN

The consequences of divorce for children are even more devastating and long-​lasting than for adults. These include a decline in academic achievement (based on standardized achievement tests, grades, and teachers’ ratings), conduct (increased opposition-​defiance behaviors, aggression, juvenile delinquency), psychological adjustment (increased depression, anxiety, reduction in well-​being), difficulties with self-​concept (decreased self-​esteem, perceived competence, impairments in sense of control), reduction in social adjustment (increased loneliness, impairment of friendships), and poorer child-​parent relationships (Amato & Keith, 1991; Zill et al., 1993; Amato, 2001; Wilcox, 2011; Sands et al., 2017). Recent research confirms that family structure is crucial to the health and well-​being of children, in that children living with and raised by married, biological parents have the advantage. These children have better physical health, emotional health, and school performance compared to those from single-​parent or divorced families (Anderson, 2014).

MARITAL SATISFACTION Just because a couple remains married for many decades does not necessarily mean that the marriage is a healthy and happy one. What predicts marital satisfaction? As usual, in reviewing predictors of marital satisfaction, we keep in mind how religious involvement might influence these factors.

Similarities in Background People often choose a partner based on similar interests and background, but certainly not always. There is some evidence for the old adage that “opposites attract,” at least initially (Clore & Bryne, 1974), and that complementarity on psychological factors such as need for affiliation and control is associated with greater marital quality and duration (Tracey et al., 2001). However, most research supports the “birds of a feather flock together” cliché (i.e., congruency of interests) as a stronger predictor of marital harmony (Cottrell et al., 2007; Gonzaga et al.,

2007). Indeed, research has repeatedly found that similarity between romantic partners in terms of socioeconomic status, educational level, age, ethnicity, physical attractiveness, intelligence, psychological attitudes, and ethics and values predicts higher levels of marital satisfaction and a lower likelihood of separation or divorce (Shiota & Levenson, 2007). In contrast, considerable research shows that couples with complementary (or different) backgrounds, while initially attracted to one another, are more likely to encounter marital stress and end up in divorce (Berscheid & Regan, 2005; Glomb & Welsh, 2005).

Personality Style Likewise, couples in marriages where one partner feels the other partner is lower than desired on the personality traits of agreeableness, emotional stability, and intellectual openness experience less marital and sexual satisfaction (Botwin et al., 1997). Malouff et al. (2010) also found that intimate relationships were most satisfying if both partners demonstrated low neuroticism, high agreeableness, high conscientiousness, and high extraversion (but interestingly, not high openness). However, this too is not always true. When studying 12-​year trajectories of marital satisfaction from middle age to later middle age in couples married for 20–​40 years, Shiota and Levenson (2007) found that greater similarity in overall personality predicted worse marital satisfaction over time. This was especially the case for similarity between spouses on conscientiousness and extraversion. Furthermore, some of the latest research suggests that couple similarity in personality is not as strong a predictor of marital satisfaction as similarity in age, spirituality, and growth orientation (George et al., 2015). The presence of psychopathic personality traits, not surprisingly, has been consistently related to lower marital satisfaction, poorer romantic relationship quality, and lack of marital commitment (Weiss et al., 2018). Those with psychopathic traits (callous, aggressive, antagonistic, disinhibited, superficially charming) desire less intimacy in relationships and are more likely to cheat on their partners. As noted in the last chapter, Weiss and colleagues

(2018) found that selective mating results in persons with psychopathic traits choosing marital partners with psychopathic traits. Cross-​ sectionally, psychopathic traits were associated with more negative affect and less positive affect when addressing areas of tension in the relationship. Longitudinal analyses examining 4-​year marital trajectories of those with psychopathic traits predicted lower initial and less sustained marital satisfaction over time and increased 10-​year divorce rates.

Conflict and Commitment Also, not unexpectedly, marital conflict (i.e., negativity, difficulty relating, disagreements over sex, finances, childrearing, etc.) predicts lower marital satisfaction and increased divorce risk. Stanley et al. (2002) found that withdrawal during conflict by one or the other partner, rather than working through problems together, was associated with poorer relationship quality. The specific area most frequently argued about differed depending on whether the marriage was a first one or a remarriage. In first marriages, money was the most common source of conflict, whereas in remarriages, couples argued most about children. Conflict over money leading to negative communication, however, was shown to be one of the strongest predictors of relationship quality regardless of whether the marriage was a first one or remarriage. More important to men with regard to conflict was the frequency of negative interactions, whereas women were more concerned about lack of positive connections in the relationship. Greater commitment to the marriage was found to be associated with less monitoring of each other, not feeling trapped, and greater satisfaction.

Infidelity In the United States, approximately 22%–​25% of men and 11%–​ 13% of women will have an extramarital affair during their lifetime (Labrecque & Whisman, 2017). Infidelity has long been known to be a strong predictor of marital unhappiness and dissolution, both within and outside the United States (Betzig, 1989; Zare, 2011). Longitudinal research Marital and Family Stability • 257

documents the impact that extramarital sex has on marital stability, especially when this occurs with a close personal friend (Amato & Rogers, 1997; Labrecque & Whisman, 2020). While some have questioned whether infidelity is a predictor or a consequence of marital unhappiness, the research suggests that the direction of effect is primarily as a predictor (Previti & Amato, 2004).

Substance Use Alcohol and drug abuse/​dependence in either husband or wife are known to adversely affect the marital relationship (Gigy & Kelly, 1993; Holden & Rollins, 2019). As noted in Chapter 10, the parents’ substance abuse often serves as a role model for children and their own eventual use of substances, as well as increasing the availability of such substances to children (Velleman & Templeton, 2016). Substance use problems in parents are frequently associated with emotional and physical abuse of spouse and of children, which often quickly leads to marital conflict, separation, and divorce (Fischel-​Wolovick, 2018).

Other Predictors Other predictors of poor marital satisfaction include spouse workload, use of pornography, partner attachment insecurity, and inability to forgive and quickly repair the relationship following conflict. Higher workloads (too many demands, feeling very busy) experienced by one or both spouses predict decreasing marital satisfaction and poorer child-​parent relationships over time (Lavner & Clark, 2017). Pornography use predicts lower marital satisfaction and stability, increased likelihood of infidelity, lower sexual satisfaction (for men, in particular), and problems with self-​image and capacity for intimacy (for women, in particular). The impact of pornography on marital satisfaction is particularly damaging if one member of the couple is devoutly religious (Perry, 2016). Attachment security involves feeling that one’s partner is accessible and responsive, whereas attachment insecurity results from the consistent experience of being disconnected from one’s partner. Sandberg et al. (2017) found that secure attachment predicted marital satisfaction for both men 258 •  S ocial H ealth

and women, with higher levels of secure attachment and higher levels of attachment behaviors related to better marital quality. Finally, couples’ ability to forgive one another (Fincham et al., 2004; Fincham, 2015) and more quickly “repair” the relationship after conflict (Gottman et al., 2015; Gottman & Silver, 2015) strongly predicts marital satisfaction and stability.

FAMILY STABILITY AND FUNCTIONING Marital stability, satisfaction, and harmony serve as the foundation for family health. As noted above and in previous chapters, the family environment has an enormous influence on child, adolescent, and eventual adult mental, social, occupational, behavioral, and physical health. What do we know about other factors besides marital quality that affect family stability and functioning? By “family” here, we mean parent(s), children, grandparents, and other close relatives who live with or significantly interact with these individuals.

Mental Health The presence of a mental disorder such as depression or significant anxiety in the husband or wife is known to strain family functioning. Herr and colleagues (2007) found that both currently and formerly depressed married partners experienced poorer family functioning and parent-​youth relationships compared to nondepressed and never depressed individuals. This effect was particularly strong for women with depression. Postpartum depression in either mother or father can likewise adversely affect the family environment for the infant and other children (Letourneau et al., 2013; Ramchandani et al., 2011). Acute and chronic psychotic disorders can also cause havoc in the family environment (Koutra et al., 2014). As noted above, parental substance abuse has devastating effects on family stability and the future health of children (Johnson, 2002; Doherty & Allen, 1994). The family is also adversely affected when mental illness occurs in one or more children, which disrupts relationships between all family members (Richardson et al., 2013).

Physical Health Medical problems in either parents or children increase family stress and dysfunction (Pedersen & Revenson, 2005; Zhang, 2018). Families with an ill parent are often financially stressed given the reduction in income from job loss, medical bills, adverse effects on ability to perform household duties, and emotional distress from difficulty coping with the illness. Families with an ill child likewise experience severe stressors that disrupt the family, including the marital relationship (Martin et al., 2012).

Household Composition In the 30 richest countries in the world, 7%–​21% of children live in single-​parent families (United Nations Children Fund, 2007). The number of children living in two-​parent households in the United States decreased from 88% in 1960 to 69% in 2016 (US Census, 2016) and then to 68% in 2017 (65% if the 3% of children living with no parents are included) (Livingston, 2018). This means that over one-​third of children in America are growing up in no-​parent or single-​ parent households (two-​thirds with their mother alone). From 1960 to 2016, the percentage of children living only with their mother increased from 8% to 23% (almost a 3-​fold increase) and children living only with their father increased from 1% to 4% (a 4-​fold increase) (US Census, 2016). According to the American Academy of Pediatricians, “The message is clear: fathers do not parent like mothers, nor are they a replacement for mothers when they are not at home; they [each] provide a unique, dynamic, and important contribution to their families and children” (Yogman et al., 2016, p. e9). Research has consistently shown that children in two biological parent households have better mental and physical health compared to children living in single-​mother or grandparent-​only families. Although these differences are partially due to socioeconomic and demographic differences (decreased income as a result of divorce, or difficulty obtaining a well-​paying job for women), the findings persist even after controlling for these factors (Bramlett & Blumberg, 2007). Children in

single-​parent households are more likely to suffer from delinquent behaviors and emotional distress not only from resource deprivation, but also from less intense and consistent monitoring (Amato & Keith 1991; Teel et al., 2016). Such children are also more likely to have sleep problems (Troxel et al., 2014), psychosomatic illnesses (Moncrief et al., 2014), and to suffer from victimization (maltreatment, assault, peer victimization, property crime, witnessing family violence, exposure to community violence) (Turner et al., 2013). Children of mothers in unstable relationships are over eight times more likely to experience emotional or behavioral problems compared to children of mothers who have a strong relationship with their partners (Hannighofer et al., 2017). While some children may do better after their parents’ divorce, particularly in high-​conflict volatile marriages, even this is somewhat controversial (Amato et al., 1995; Hanson, 1999). Not only do children in single-​ parent families have worse mental health, the parent in these families is also more likely to suffer from mood and anxiety disorders (Wade et al., 2011; Jacoby et al., 2017).

Domestic Violence Interparental violence is known to adversely affect family functioning, particularly the mental health of children (Bayarri Fernandez et al., 2011; Telman et al., 2016). Such violence is often fueled by alcohol and drug use, and most often—​ though not always—​ perpetrated by the male parent (Capezza et al., 2015). Married women are less likely to experience physical abuse, compared to single or cohabitating women (Wilcox & Wilson, 2014). Domestic violence often serves as a role model for children, who often later engage in spouse abuse themselves as adults (Corvo & Carpenter, 2000).

Protective Factors Factors that contribute to family resiliency, i.e., the ability of families to withstand external stressors that might otherwise break them apart, provide important clues on family strengths that may counteract instability. What are the characteristics of strong families that stay together Marital and Family Stability • 259

in the face of events that might otherwise lead to family distress and dysfunction? Benzies and Mychasuk (2009) described these strengths, which they divide into individual, family, and community factors. These family resiliency factors are consistent with the negative effects that mental and physical health problems, household composition, and domestic violence issues discussed above have on family stability. Individual personal factors include (1) an internal locus of control (believing that one is in control of one’s own destiny, has the power to change their situation, and create their own circumstances, i.e., effectively adapt to crises and take charge when necessary); (2) emotional regulation (ability to control actions and emotional responses, delay gratification, control impulses, think clearly in stressful circumstances); (3) healthy belief systems (beliefs that provide a positive outlook on life, a sense of purpose and meaning, optimism about the future); (4) self-​efficacy (belief that one has the strength and ability to reach specific goals); (5) effective coping skills (possess resources to meet taxing or stressful demands); (6) education, skill, and training that provide more options for effectively dealing with problems (i.e., stable employment, adequate income, safe living conditions); (7) family physical health (members attend to diet, exercise, weight control); and (8) temperament (parents and children who have “easier” personality styles, i.e., agreeable, conscientious). Family level factors include (1) family structure (smaller families with less economic stress, older more mature mothers vs. adolescent mothers, and two-​parent families); (2) intimate partner marital stability (high-​quality communication, secure and loving, mutual support); (3) family cohesion (warm, cooperative family interactions); (4) supportive parent-​ child relationships (secure parent-​child attachment, warm and nurturing maternal-​ child interactions); (4) stimulating environments (emphasis on learning activities, developing cognitive and problem-​solving skills); (5) social support (emotional and tangible support from friends and extended family); (6) family of origin influences (good role models for intergenerational transfer of positive character traits); and

260 •  S ocial H ealth

(7) stable, adequate income and housing (as with individual person factors). Community factors include (1) community involvement (increased social networks, neighborhood involvement, after-​school enrichment programs); (2) peer acceptance (support from healthy relationships with prosocial peers); (3) supportive mentors from outside the family (teachers, coaches, clergy); (4) safe neighborhoods (low crime, drug use, violence, poverty); (4) accessible high-​quality childcare and school environments; and (5) availability of high-​ quality healthcare.

Summary Divorce is commonplace and increasing around the world. Rates are especially high in developed countries such as the United States with increasingly progressive attitudes toward marriage, cohabitation, premarital, and extramarital sex. Many factors that often overlap and interact with one another adversely affect marital stability and satisfaction. These include marrying at a younger age, education level, economic stress and poverty, unstable families of origin (parental divorce), cohabitation, premarital sex and number of prior partners, infidelity, poor commitment to the marriage, differences in background and personality leading to marital conflict, high workload, pornography use, difficulty forgiving, and struggles repairing the relationship after conflict. Mental health problems, substance abuse, acute and chronic medical illness, single parenthood, and domestic violence all contribute to family instability. Divorce, marital conflict, and family instability affect the health of both parents and children, setting the stage for intergenerational transmission of family and mental health problems. What role might religion play in breaking this vicious cycle?

Case Vignette John and Sally on the surface appeared to be the perfect couple, a physician and a nurse, whose relationship formed during mature adulthood. John was 33 and had been married previously (widowed);

Sally was 29 and never married. They fell in love and after 18 months of dating, they tied the knot. However, there were early signs that did not bode well for the couple. Although they had many different likes and interests, those differences were largely ignored during the courtship. John and Sally were both from good, stable families (with no history of divorce), but their family backgrounds were markedly different. John came from a family whose members often argued and fought with one another, and then quickly made up. The emphasis was on accomplishment, saving money, strict discipline, and excelling in school and work. Sally came from a family that emphasized family activities and having fun, with less concern about spending and following rules. The couple also had personality differences. John was introverted and intense, committed to his work and being productive, while Sally was more relaxed and extroverted, focused on relationships with friends and family. Indeed, these differences before the marriage had attracted them to each other. After the marriage, however, those differences became sore spots and sources of conflict. This resulted in frequent arguments over money, sex, how they spent their time, and later, how to raise their children. There were disagreements on little things too, i.e., what TV programs to watch, what foods to eat, eating habits, exercise, choice of friends, sleep schedules, i.e., just about everything. Anger and resentment began to set in. As the arguments increased in frequency, John began to withdraw into his work and Sally retreated into her children and family of origin. While neither seriously considered divorce, pondering the “death do you part” clause in their vows was not an uncommon thought. From the beginning of their relationship, however, the couple had one thing in common that never changed: their religious faith. Both were firmly committed

to the teachings of their Christian religion and shared common morals and values. This, in fact, was one of the most important characteristics that had brought them together in the first place. Marriage for them was a lifelong commitment. Neither of their parents had divorced, and both Sally and John believed that divorce was not an option. Given these strong beliefs, both felt trapped in the marriage. Since there was no way “out,” they decided early on to seek marital counseling to help resolve their many differences. That counseling would continue for the next three decades, as they sought help to improve their marriage. The advice from counselors was consistent: they needed to change themselves, not each other. It was not an easy experience for either John or Sally, or the counselors, several of whom actually “fired” this couple, deciding they could not help this treatment-​resistant marriage. However, as John and Sally sought to apply what they learned in counseling and matured in their religious faith, things slowly began to change. Although they had always attended religious services together, they began to pray daily together. After arguments, John would take the initiative to apologize and repair the relationship, while Sally worked hard to be responsive, making every attempt to forgive current and past hurts that had built up. Increasingly, over time they came to accept each other’s differences, and learned to calmly discuss hurts rather than hold on to them. These efforts were driven by their religious faith, not their feelings. However, the feelings eventually followed as old wounds began to heal.   

RELIGIOUS TEACHINGS ON MARRIAGE AND DIVORCE Marriage is identified as one of the Seven Sacraments in the Roman Catholic Church. In Marital and Family Stability • 261

the Vatican II documents, the purpose of marriage was described as: The matrimonial covenant, by which a man and a woman establish between themselves a partnership of the whole of life, is by its nature ordered toward the good of the spouses and the procreation and education of offspring; this covenant between baptized persons has been raised by Christ the Lord to the dignity of a sacrament. . . . God who created man out of love also calls him to love the fundamental and innate vocation of every human being. For man is created in the image and likeness of God who is himself love. Since God created him man and woman, their mutual love becomes an image of the absolute and unfailing love with which God loves man. It is good, very good, in the Creator’s eyes, and this love which God blesses is intended to be fruitful and to be realized in the common work of watching over creation: “and God blessed them, and God said to them: ‘Be fruitful and multiply, and fill the earth and subdue it.’ ” (CCC, 1993a, 1601, 1604) In Catholicism, with rare exceptions, divorce is considered morally wrong: “The matrimonial union of man and woman is indissoluble: God himself has determined it ‘what therefore God has joined together, let no man put asunder’ ” (CCC, 1993a, 1614). Depending on denomination, Protestant faith traditions vary in their teachings on divorce, but all view marriage as holy. Divorce is not considered as serious a sin among most Protestants as it is in Catholicism, but no Protestant denomination encourages divorce. Marriage is viewed as a lifelong commitment and sacred relationship, except in cases of infidelity, based on Matthew 5:31–​32 and Matthew 19:2–​6. Although divorce rates are surprisingly high among conservative Protestants, a group that

strongly advocates for the sanctity of marriage, there are reasons for that high divorce rate. Nonreligious factors that explain much of this pattern are lower education, earlier age of marriage, earlier age of parenthood, and lower income (Glass & Levchak, 2014). Conservative Protestants are also less likely to cohabitate in unmarried partnerships compared to non-​ conservative Protestants (Braithwaite et al., 2013). Since divorce rates do not apply to those who cohabitate, as noted above, the breakups of cohabitating partners reduce the divorce rate in non-​conservative Protestants, thus giving the impression that divorce rates in conservative Protestants are higher. Moreover, as will become clearer in our discussion of research studies below, it is perhaps principally religious service attendance rather than denominational affiliation that is more strongly associated with lower divorce. Islam likewise emphasizes the sacred nature of marriage and the lifelong commitment when a man and woman decide to marry. In a Muslim wedding, the couple does not usually recite wedding vows, but rather listens to the imam. However, some do choose to say the traditional vows. In that case, the bride says: “I, _​_​_​_​_​_​, offer you myself in marriage and in accordance with the instructions of the Holy Qur’an and the Holy Prophet, peace and blessing be upon him. I pledge, in honesty and with sincerity, to be for you an obedient and faithful wife. The groom responds with the statement: “I pledge, in honesty and sincerity, to be for you a faithful and helpful husband” (Bradley, 2017). The Qur’an stresses the importance of marriage and its function (4:24; 4:129; 5:5; 24:32–​33). Divorce is discouraged and adultery is prohibited (17:32). Marriage requires that spouses be devoted and faithful to one another: “Husbands should take good care of their wives, with [the bounties] God has given to some more than others and with what they spend out of their own money. Righteous wives are devout and guard what God would have them guard in their husbands’ absence” (4:34).1 Although polygamy is allowed in Islam, it can only occur under

1. All quotations from the Qur’an are from the translation by M. A. S. Abdel Haleem, The Qur’an, Oxford World’s Classics (New York, NY: Oxford University Press, 2004).

262 •  S ocial H ealth

specific circumstances and is seldom practiced today (5% or less in the Arab world; Ozkan et al., 2006). Judaism also discourages divorce but has long allowed it in situations of constant bitterness and strife between spouses, and for other reasons as well. According to Judaism 101 (Rich, 1996), it may initially seem that divorce is commonplace: “Under Jewish law, a man can divorce a woman for any reason or no reason. The Talmud specifically says that a man can divorce a woman because she spoiled his dinner or simply because he finds another woman more attractive, and the woman’s consent to the divorce is not required. In fact, Jewish law requires divorce in some circumstances: when the wife commits a sexual transgression, a man must divorce her, even if he is inclined to forgive her.” In fact, the divorce process in Judaism is complex and exacting, one that makes it difficult based on Jewish law. Nevertheless, the result is that Jews tend to have more positive attitudes toward divorce than many other religious faiths (Adamczyk, 2013). Early Hindu beliefs concerning the treatment of women favored the male in this ancient patriarchal society (as did most other world religions), increasing the possibility of marital conflict or sexual coercion. For example, the Brhadaranyaka Upanishad says: When she has changed her clothes at the end of her menstrual period, therefore, one should approach that splendid woman and invite her to have sex. Should she refuse to consent, he should bribe her. If she still refuses, he should beat her with a stick or with his fists and overpower her, saying: “I take away the splendor from you with my virility and splendor.” (6:4:6–​7) There is evidence that such demeaning views of women continue to influence the treatment of women within marriage in countries such as Nepal (Puri et al., 2011) and India, where domestic violence is reported by 40% of married women (Kalokhe et al., 2015). These findings, however, contrast with the importance of the family in Hinduism, where sexual relations outside of marriage are less common than in

almost any other religious group (Adamczyk & Hayes, 2012). According to the Taittiriya Samhita (part of the Yajurveda), fidelity between husband and wife is considered the highest dharma (Divine law), and according to the Mahabharata epic poem, cherishing one’s wife is virtually synonymous with paying homage to the goddess of prosperity (Sharma et al., 2013). Buddhism has no clear rules regarding divorce and marriage. In fact, Buddhist religious practice may be considered a spiritual alternative to marriage (Schak, 2008). If married, couples have the freedom to separate if they consistently disagree and are unhappy together, since Buddhists believe that a good life involves harmony between partners. According to the Buddhist scholar, Sri Dhammananda (2005), “if a husband and wife really cannot live together, instead of leading a miserable life and harboring more jealousy, anger and hatred, they should have the liberty to separate and live peacefully.” In Buddhism, marriage is considered a secular, not a sacramental act, although many Buddhists may seek a blessing from the monk at their local temple after the marriage ceremony. In general, Buddhism discourages divorce based on the third step in the Eightfold Path, Right Action. Buddhism prescribes compassion, kindness toward others, and proscribes other actions such as cheating, stealing, dishonesty, and sexual misconduct. The endorsement of “prosocial” behaviors and avoidance of antisocial ones serves to promote marital harmony. The emphasis on right action should lower the likelihood of many situations that often lead to divorce: being fired from work, imprisoned, cheating on one’s spouse, or abusing one’s spouse. Indeed, Buddhists—​ like Hindus—​ may in practice have more negative attitudes toward divorce than many other religious faiths (Adamczyk, 2013).

RELIGIOUS TEACHINGS ON THE FAMILY All religious traditions emphasize the importance of the family. Catholic and Protestant Christians alike view the health of the

Marital and Family Stability • 263

family as foundational for a healthy society. The Catechism of the Catholic Church states: “The Christian family constitutes a specific revelation and realization of ecclesial communion, and for this reason it can and should be called a domestic church.” It is a community of faith, hope, and charity; it assumes singular importance in the Church, as is evident in the New Testament. The Christian family is a communion of persons, a sign and image of the communion of the Father and the Son in the Holy Spirit. In the procreation and education of children it reflects the Father’s work of creation. It is called to partake of the prayer and sacrifice of Christ. Daily prayer and the reading of the Word of God strengthen it in charity. The Christian family has an evangelizing and missionary task. The relationships within the family bring an affinity of feelings, affections and interests, arising above all from the members’ respect for one another. The family is a privileged community called to achieve a “sharing of thought and common deliberation by the spouses as well as their eager cooperation as parents in the children’s upbringing.” (CCC, 1993b, 2204–​2206) Protestant Christians likewise view the family as a sacred institution based on New Testament teachings (Ephesians 5:21–​ 23; Colossians 3:18–​ 21; 1 Peter 3:1–​ 7). Protestants, like Catholics, view the family as an example of the church itself at a local level, as expressed, for example, in the New Testament scripture: Submit to one another out of reverence for Christ. . . . Husbands, love your wives, just as Christ loved the church and gave himself up for her to make her holy, cleansing her by the washing with water through the word, and to present her to himself as a radiant church, without stain or wrinkle or any other blemish, but holy and blameless. In this same way,

husbands ought to love their wives as their own bodies. He who loves his wife loves himself. (Ephesians 5:21, 25–​28)2 The New Testament also does not mince words when referring to the responsibility of family members toward one another: “Anyone who does not provide for their relatives, and especially for their own household, has denied the faith and is worse than an unbeliever” (1 Tim 5:8). In a departure from Catholic teachings on celibacy, Protestant traditions have encouraged the clergy to marry and have families in order to contribute more fully to society (e.g., Martin Luther was married). Emphasis is also placed on the value and importance of children, as for example in the Gospel of Matthew: At that time the disciples came to Jesus and asked, “Who, then, is the greatest in the kingdom of heaven?” He called a little child to him, and placed the child among them. And he said: “Truly I tell you, unless you change and become like little children, you will never enter the kingdom of heaven. Therefore, whoever takes the lowly position of this child is the greatest in the kingdom of heaven. And whoever welcomes one such child in my name welcomes me. If anyone causes one of these little ones—​those who believe in me—​to stumble, it would be better for them to have a large millstone hung around their neck and to be drowned in the depths of the sea. . . . See that you do not despise one of these little ones. For I tell you that their angels in heaven always see the face of my Father in heaven. (Matthew 18:1–​ 6, 10) Judaism likewise stresses the importance of having children. Of the 613 commandments in the Torah, the first commandment of the first book of the Torah instructs, “Be fruitful, and multiply” (Bereshit 1:28). The attitude toward children and the attitude of children toward their parents are emphasized:

2. All quotations are from the New International Version (NIV) of the Holy Bible (1973, Biblica)

264 •  S ocial H ealth

Lo, children are a heritage of HaShem; the fruit of the womb is a reward. As arrows in the hand of a mighty man, so are the children of one’s youth. Happy is the man that hath his quiver full of them. . . . (Tehilim 127:3–​5)3 Honour thy father and thy mother, that thy days may be long upon the land which HaShem thy G-​d giveth thee. (Shemot 20:12) [this is the only commandment which promises long life to those who obey it] Like Jews, Muslims prioritize family and kin relationships above all others. The Qur’an reinforces this in many places: . . . Worship none but God; be good to your parents and kinfolk, to orphans and the poor; speak good words to all people. . . . (2:83) They ask you [Prophet] what they should give. Say, whatever you give should be for parents, close relatives, orphans, the needy, and travelers. God is well aware of whatever good you do. (2:215) Worship God; join nothing to him. Be good to your parents, to relatives to orphans, to needy, to neighbors near and far, to travelers in need, and to your slaves. (4:36) Islam also stresses the responsibilities of children to their parents. Children are responsible for respecting and supporting their parents, especially elderly parents. This is considered a religious obligation and a good deed to be rewarded both here and in the next life: . . . be kind to your parents. If either or both of them reach old age with you, say no word that shows impatience with them, and do not be harsh with them, but speak to them respectfully and lower your wing in humility towards them in

kindness and say “Lord, have mercy on them, just as they cared for me when I was little.” (17:23–​24) We have commanded man to be good to his parents . . . “Lord, help me to be truly grateful for Your favors to me and to my parents. . . .” (46:15) Hindus, Buddhists and those from other Eastern religious traditions have long stressed the importance of the family unit. Hindus emphasize the integration of religious beliefs into all of life, especially the family and community. For example, when an individual has an emotional problem in Indian societies, it is the family that is often the focus of treatment, not the individual, since the problem is identified as due to strife within the family, which is consistent with long-​held beliefs by Indians concerning the person, family, caste system, and society, with the family being central (Sax, 2014). Unlike Westerners who treasure their independence and self-​sufficiency, Hindus are instead heavily dependent on relationships within the family as part of South Asian culture. Buddhism is not known as a family-​centered religion, since the principle of moksha (non-​ attachment to and withdrawal from the world) may foster disengagement from family in pursuit of Enlightenment and liberation from the endless cycle of human births and deaths. However, family relationships are important based on the fourth step of the Eightfold Path, which emphasizes speaking softly, gently, affectionately, and avoiding lying or gossiping, which applies to family members. In the Sigalovada Sutta, the Buddha teaches that both the husband and wife should treat each other respectfully, with the wife managing the home and family, and the husband sharing authority with his wife (BBC, 2019). The Buddha also taught that children must pay their debts to parents by supporting and respecting them, which is considered first among all meritorious deeds (Xing, 2016). Many Buddhists and members of other Chinese religions also endorse the worship of family members who have died,

3. All quotations are from the Jewish Bible (Jewish Bible Society, 1997, Benyamin Pilant).

Marital and Family Stability • 265

underscoring the importance of family in this religion. Ancestral worship remains a common practice in some countries today; for example, over 75% of Buddhists in China say that they have venerated ancestral spirits at gravesites and two-​ thirds indicate they believe in the power of ancestors (Koenig, 2017f, pp. 36, 40).

RELIGION’S EFFECT ON MARITAL AND FAMILY STABILITY Based on what is known about (a) factors that influence marital and family stability, and (b) religious teachings based on the holy Scriptures of the five major world religions, we now theorize how religious beliefs might affect the marital relationship and family health.

Marriage and Divorce Given widespread religious beliefs about the sanctity of marriage and discouragement of divorce except in extreme circumstances, one might expect divorce to be less common among the more religious, especially if both members of the couple ascribe to such beliefs. Furthermore, because many religions discourage premarital sex, cohabitation before marriage, and infidelity (primary predictors of divorce), one might expect divorce rates to be lower among the more devoutly religious (particularly among Catholics, conservative Protestants, and Muslims, where prohibitions are strongest). However, some religions may encourage marriage at a young age and early pregnancy, which are known risk factors for divorce. Religious involvement tends to be more common among those with lower education, lower income, and among ethnic minorities, which are also risk factors for divorce (Paul, 2010). Marital satisfaction may be greater or lower among those who are more religious. On the one hand, spouses who have common religious beliefs may experience greater marital satisfaction due to common ethical and moral values. They may be more likely to come from religious families that provide good role models in terms of marital commitment and communication. Psychopathic tendencies may be less likely in the more religious, reducing self-​centeredness. 266 •  S ocial H ealth

Religious teachings emphasizing humility, empathy for one another, and forgiveness might lead to more rapid repair of relationship breaches, thereby enhancing marital satisfaction. Given religious prohibitions against infidelity and pornography use, religious couples may experience more secure attachment, thereby enhancing emotional and sexual intimacy. Likewise, religious beliefs that discourage excessive alcohol intake and drug use may reduce the likelihood of domestic violence that can destroy marital harmony. On the other hand, religious beliefs stressing the lifelong commitment of marriage may bind the individual to a loveless and unhappy marriage. Differing religious beliefs between couples may give rise to conflict, including arguments over in which tradition children should be raised. Conservative religious beliefs may also lead to the domination of one spouse over the other (“wives submit to your husbands”), and in some cases, these beliefs may inappropriately be used to justify spousal abuse. Religious beliefs may thus reduce marital happiness and satisfaction. Financial stressors may also be more common among religious persons, as noted above, since religious involvement is more common among ethnic minorities and those of lower socioeconomic status (as Karl Marx said, religion is the “opiate of the masses”). This too may adversely affect communication and lead to conflict and arguments over money that reduce marital happiness, thus confounding the relationship between religiosity and marital satisfaction.

Family Stability Given religious teachings emphasizing the importance of family, those who are more religious may place a higher value on family relationships, pay more attention to family members, spend more time on family activities, and make greater efforts to forgive one another for hurts (as religious scriptures strongly emphasize). Emotional disorders (depression, anxiety, substance use) may be less common among religious parents, making them more available to each other and to their children (see Chapters 4–​10). When serious mental health problems do occur, religious resources may help

family members cope better with them (Pearce et al., 2016). Physical health problems may also be fewer among religious family members as more attention is paid to diet, exercise, and health-​ maintenance activities (see Chapters 17–30). Personality traits such as agreeableness and conscientiousness, which are known to be associated with religiosity (see Chapter 11), have also been associated with greater family stability, as noted above. Religious teachings encourage discipline and seek to instill moral values that enhance character and respect for others, which may decrease conflict within and outside the home. Likewise, religious beliefs that stress the importance and value of children may promote warm, nurturing parental behaviors toward children, helping to improve child-​parent relationships and attachments. Having two biological parents in the home, as most religions promote, may also assist in the mentoring and monitoring of children as they grow older, leading to less adolescent substance use/​ abuse, teenage pregnancies, and involvement with antisocial peers, behaviors that may derail education and thereby adversely affect future job opportunities. Religious involvement may also increase social support by expanding social networks available to buffer family stressors. Engagement in religious activities as a family may also provide opportunities for participation in prosocial activities (e.g., through religious volunteering), which could lead to other healthy relationships that provide emotional and instrument support when needed. Thus, many of the individual, family, and community factors described by Benzies and Mychasuk (2009) above are supported by sacred religious scriptures containing wisdom about family relationships that has filtered down through thousands of years. Devout religiosity, though, does not always lead to greater family harmony, just as it does not always lead to greater marital stability. Religious beliefs may foster rigid thinking, over-​ monitoring, excessive restrictions, and harsh discipline of family members who fail to meet the high moral standards that their faith tradition insists on, leading to resentments, arguments, and impaired parent-​child relationships. Religion may also split families apart if a child or spouse decides to convert to a different

religion, or suddenly becomes more religious and demands similar changes from others. The personalities and past experiences of parents and children can often influence the impact of religion on family stability. In the next section, we review research on the relationship between religiosity and marital and family health.

RESEARCH ON MARITAL AND FAMILY STABILITY In the previous two editions of the Handbook, we systematically reviewed quantitative research examining the relationship between religiosity and marital stability. A total of 79 studies were identified, of which 68 (86%) found less divorce, greater marital satisfaction, less spouse abuse, and greater likelihood of an intact family with two biological parents in the home among those who were more religious. No studies (0%) found significantly lower marital stability. However, 67 of those 79 studies were cross-​ sectional and could therefore demonstrate associations only. Of the 12 prospective studies, three-​quarters reported significant positive relationships, with religious involvement at one point in time predicting greater marital or family stability at a future time point. We summarize here quantitative research published both before and since 2010, focusing on the highest-​quality prospective studies and randomized controlled trials (RCTs). The exception is when discussing family stability and domestic violence, where few prospective studies exist on these important topics. In those areas, several high-​quality cross-​sectional studies are examined, with the hope that future prospective studies will be conducted in these areas. As in previous chapters, we describe studies in order of study design and year of publication.

Prospective (and Cross-​ Sectional) Studies As noted above, prospective studies assess religiosity at one time point and examine its impact on marital or family functioning at some future time, thus providing information that may be relevant to causal inference. Preferably, these Marital and Family Stability • 267

studies control for baseline functioning as well, allowing researchers to determine if religiosity predicts changes in marital/​family functioning over time. We discuss (1) 10 prospective studies examining the impact of religiosity on marital instability (divorce) or on known risk factors for marital instability; (2) three cross-​sectional and two prospective studies examining religiosity’s impact on family functioning and the value of children; (3) three prospective studies examining child abuse; and (4) two large cross-​ sectional studies and one prospective study examining domestic violence.

and self-​reported health. Those who attended religious services weekly or more were 57% more likely to have a stable marriage during follow-​up compared to those who attended less frequently (OR =​1.57, 95% CI =​1.00–​2.45, p < 0.05). This effect was particularly strong among women (OR =​1.78, 95% CI =​1.05–​3.01). Wilcox and Wolfinger (2007) analyzed data from a 1-​year prospective study of 3,069 unmarried new parents in 20 large US cities who participated in the Fragile Families in Child Well-​Being Study. The primary outcome was likelihood of marriage subsequent to non-​marital birth. Follow-​ up interviews were conducted with parents 12–​30 months after birth (average MA RI TA L I N S TAB ILIT Y 15 months). Frequency of religious attendance Measures of marital instability focus on either was the only measure of religiosity (other than divorce or on risk factors for future divorce such religious denomination), and this was examined as dedication to the marriage, out-​of-​wedlock separately for mothers and fathers. Adjusted in births (non-​marital parity), and premarital sex. analyses were parent age, number of children, Call and Heaton (1997) employed a multi- cohabitation status, race, education, religious dimensional specification of religiosity with affiliation, parent homogeneity on religious panel data from the National Survey of Families affiliation, relationship quality, domestic vioand Households (n =​4,587 married couples). lence, sexual infidelity, and time to marriage. They used event-​ history models to examine Data were analyzed using log-​logistic parametthe religion–​marital stability relationship. They ric event history models. Results indicated that report that no single dimension of religios- conservative Black Protestants (respondents ity adequately described the effect of religious indicating a Pentecostal, Church of God, or experience on marital stability, but that the fre- other sectarian affiliation) were more likely to quency of religious attendance had the greatest marry soon after non-​marital birth compared to positive impact on marital stability. When both those with no religious affiliation (OR =​2.36, p spouses attended church regularly, the couple < 0.05). Likewise, frequency of religious attenhad the lowest risk of divorce. Spouse differ- dance for both mother and father predicted ences in church attendance increased the risk of a greater likelihood of marriage for all particidissolution. However, when controlled for social pants (OR =​1.55 for mothers and OR =​1.67 for and demographic factors, the effect of religious fathers, both p < 0.01). These findings weakened attendance only persisted for the wife’s atten- only slightly when controlling for relationship dance (B =​−0.093, p < 0.05). They also provided quality, presence of domestic violence, conflict evidence that the wife’s religious beliefs con- over fidelity, and other relationship beliefs and cerning marital commitment and non-​marital behaviors. sex are more important to the stability of the Brown and colleagues (2008) prospectively marriage than the husband’s beliefs. followed 373 systematically identified couStrawbridge et al. (2001) analyzed data ples (199 Black and 174 White Americans) in from a 28-​ year prospective study of 2,676 Michigan over a 7-​year period. Couples were participants in Alameda County, California, eligible if they were of the same race and if the examining the effects of religious attendance wife was less than 35 years old. Interviews were at baseline on marital stability during follow-​ conducted 4–​9 months after marriage (T1) and up. “Stable marriage” was defined as becoming then during the third (T2) and seventh years married after baseline (1965) and not divorcing (T3) after marriage. Religiosity was assessed or separating by 1994. Controlled for in mul- during the first and third years after marriage tivariate analyses were age, gender, education, (T1 and T2), and was measured by subjective 268 •  S ocial H ealth

religious participation, religious service attendance, and homogeneity of religious attendance (i.e., whether both attended together). Divorce status of all 373 couples was determined over the 7-​year period using extensive tracking methods. Cox proportional hazards regression was used to examine predictors of time to divorce or censorship. Analyses were performed separately in wives and husbands. In wives, controlling for race, education, and income, the likelihood of divorce was reduced by 42% in those attending religious services frequently (HR =​0.58, p < 0.01); this effect was significantly greater in White American wives than in Black American wives (interaction B =​0.49, p < 0.05). In husbands, no relationship was found between religiosity and divorce, regardless of race. Uecker (2008) analyzed data on married young adults (first marriage) participating in the National Longitudinal Study of Adolescent Health (Add Health Study) with 7-​year follow-​ up from 1994–​1995 (Wave I) to 2001–​2002 (Wave III). Of the full sample of 10,199 participants age 15 or older at Wave I, a total of 2,079 were married during the 7-​ year follow-​ up, which served as the final sample for this analysis. Wave I frequency of religious attendance, importance of religion, and religious denomination were assessed, along with whether the person had taken a formal abstinence pledge (“Have you taken a public or written pledge to remain a virgin until marriage?”). The primary aim of the study was to examine the effects of religion, religiosity, and abstinence pledging on likelihood of having premarital sex (assessed at Wave III and known to be a predictor of future marital stability; see above and a review by Larson & Holman, 1994). Multinomial logit models were used to examine the data. Among these married participants, 89% had engaged in premarital sex (22% with future spouse, 67% with someone else). The average age of first sex was 16.9 years (range 10–​26). Only 3% of the religiously unaffiliated waited until marriage to have sex, compared to 16% of conservative Protestants and 43% of Mormons. Overall, 11.1% of adolescents reported having made an abstinence pledge at Wave I. Conservative Protestants (19.9%) and Mormons (15.6%) were more likely to have made an abstinence

pledge compared to 4.2% of those with no religious affiliation. Of those who had made an abstinence pledge, 72% ended up having premarital sex, compared to 92% who had not made the pledge. In the same study, those who attended religious services at least weekly or indicated that religion was very important to them were eight times more likely to abstain from sex before marriage compared to those who never attended or those who said religion was not important. Multivariate analyses indicated that risk-​ taking, a planful personality, thrill seeking, and ability to maintain self-​control had virtually no effect on the influence of these religious variables. Parent religiosity and high school religiosity explained only a small part of the effect of religious attendance and abstinence pledging on not having premarital sex. Likewise, a small proportion of the religious attendance effect was explained by differential exposure (drinking, age at marriage, number of romantic partners). Social control variables (guilt, gain respect from peers) also partially mediated the religious attendance and abstinence pledge relationships with not having premarital sex. The final model, which included all variables, indicated that religious attendance, importance of religion, and abstinence pledge during adolescence all significantly predicted not having premarital sex (vs. having premarital sex “with someone other than their spouse”). Religious and pledge variables did not predict being abstinent before marriage vs. having premarital sex “with future spouse only.” Several more recent studies have likewise found a lower likelihood of premarital sex and cohabitation before marriage among the more religious (Hayward, 2019; Hardy & Willoughby, 2017; Dilmghani et al., 2018c; Kogan & Weissman, 2020). Lyons and Smith (2014) analyzed data on a random sample of 7,367 adolescent females participating in the Add Health Study (above) to examine the impact of religiosity on non-​ marital parity (having a baby out of wedlock) during a 14-​year follow-​up. Participants were followed from Wave I (1994–​1995) to Wave IV (2008); participants were on average age 24–​32 at Wave IV. Religious variables assessed were religious affiliation, intrinsic religiosity Marital and Family Stability • 269

(measured by importance of religion, frequency of prayer, belief that the sacred scriptures are a work of God and completely without mistake), and social religiosity (frequency of religious attendance in the past 12 months, and participation in youth group or Bible classes in the past 12 months). Also assessed were family structure (two married biological parents in the home), socioeconomic status, and urban versus rural residence. Hazard regression modeling was used to analyze the data controlling for race, religious affiliation, family structure, SES, and urban residence, with the primary outcome being time to live birth out of wedlock or censoring. Results indicated that 32% of the overall sample had a birth out of wedlock (52% of Blacks, 34% of Hispanics, 24% of Whites). Bivariate analyses indicated that compared to those with no religious affiliation, mainline Protestants were 36% less likely (HR =​0.64, p < 0.001) to give birth, Catholics were 38% less likely (HR =​0.62, p < 0.001), and those with other religions were 46% less likely (HR =​0.54) (p < 0.001). Likewise, greater importance of religion, greater frequency of prayer, literal interpretation of Scripture, greater frequency of religious attendance, and greater youth group participation (i.e., all measures of religiosity) were associated with a lower likelihood of non-​marital parity. Multivariate analyses, adjusting for covariates including indicators of religiosity, demonstrated a reversal from a lower to greater likelihood of mainline Protestants having a birth out of wedlock (HR =​1.71, p < 0.05), a similar trend in Catholics to do likewise (HR =​1.59, p < 0.10), and emergence of a greater likelihood of Evangelical Protestants having non-​marital parity (HR =​2.33, p < 0.001). However, frequency of prayer was associated with a significantly lower likelihood of giving birth out of wedlock (HR =​0.90, p < 0.01), and frequency of religious attendance predicted a marginally lower likelihood of non-​marital parity as well (HR =​0.94, p < 0.10). When examined by race, frequency of prayer was related to a lower likelihood of non-​ marital parity in Whites (HR =​0.89, p < 0.05), Blacks (HR =​0.80, p < 0.001), and other races (HR =​0.26, p < 0.05, but not in Hispanics. Likewise, frequency of religious attendance was associated with a lower 270 •  S ocial H ealth

likelihood of non-​marital parity among Whites (HR =​0.88, p < 0.05), but not among Blacks or Hispanics. Among Blacks, any religious affiliation was associated with a greater likelihood of having a child out of wedlock, compared to those with no religious affiliation. There is evidence from both within and outside the United States that non-​marital parity is a risk factor for future marital instability (Teachman, 2002; Jasilioniene, 2007). Tuttle and colleagues (2015) examined the effects of religiosity on marital infidelity and subsequent divorce in 763 US adults married for at least 12 years, collected during the Marital Instability over the Life Course Study. Religiosity was assessed in 1988 (T1) and 1992 (T2) by frequency of religious attendance alone and with spouse, frequency of religious activities outside of regular services, influence of religiosity on life, frequency of prayer, frequency of Bible reading, and frequency of watching religious broadcast on television. Marital infidelity was assessed between 1988 and 1992. Divorce was assessed between 1992 and 1997 (T3). Structural equation modeling was used to analyze the data. Control variables included gender, race, age, years married, and years of education. Results indicated that T1 religiosity was inversely related to marital infidelity between T1 and T2 (B =​−0.22, p < 0.01) and perceived marital instability at T2 (B =​−0.06, p < 0.001), and was positively related to marital happiness at T2 (B =​0.48, p < 0.01). However, after controlling for T1 marital happiness, T1 and T2 marital instability, and T2 religiosity, T1 religiosity predicted an increased likelihood of divorce between T2 and T3 (HR =​2.03, p < 0.05). In contrast, T2 religiosity in that model predicted a greater than 50% lower likelihood of divorce between T2 and T3, controlling for T1 religiosity (HR =​0.47, p < 0.05). Researchers concluded that religiosity indirectly reduces the likelihood of subsequent divorce by increasing marital happiness. Interestingly, marital infidelity between T1 and T2 had no influence on T2 marital stability or divorce between T2 and T3. In a 4-​year prospective study of 331 married couples, Rose and colleagues (2018) examined the mediating effects of spousal forgiveness and partner’s perceptions of spousal forgiveness

on the relationship between religiosity (10-​ item Santa Clara Strength of Religious Faith Questionnaire) and marital satisfaction (6-​item Norton Quality Marriage Index). Participants were assessed initially in 2007 (T1) and yearly after that until 2010 (T4). Longitudinal structural equation modeling was used to analyze the data, controlling for income, relationship length, family size, and forgiveness and marital satisfaction at T1. Results indicated that husbands’ religiosity at T1 was associated with increases in wives’ marital satisfaction at T4, independent of wives’ or husbands’ forgivingness at T3. Wives’ religiosity at T1, however, predicted lower levels of wives’ perceptions of husbands’ forgiveness at T3, which led to decreases in both wives’ and husbands’ marital satisfaction at T4. In a 14-​year prospective study, among the longest and most rigorously analyzed to date, Li and colleagues (2018a) examined the effects of religious attendance on divorce and remarriage in 96,113 female nurses followed through 2010. Religious affiliation was also assessed. Religious attendance in 1992 and 1996 was modeled in four categories ranging from “never” to “more than once a week.” Likelihood of divorce over the 14-​year follow-​up (1996–​2010) was determined among 66,444 women who were married, while the likelihood of remarriage was assessed in divorced (n =​7,311), separated (n =​986), and widowed (n =​21,372) women. Marital status was determined in 1996. Cox proportional hazards regression and multivariate logistic regression were used to analyze the data, controlling for husband’s education, median family income, geographic region, unemployment status, religious attendance in 1992, prior divorce history, alcohol consumption, healthy eating, physical functioning, depression, physical exercise, medical conditions, menopause status, postmenopausal hormone use, physical exam, smoking status, and body mass index. Results indicated that more than once/​week religious attendance in 1996 predicted a 42% lower risk of divorce (HR =​0.58, 95% CI =​0.44–​0.74) and a 47% lower risk of divorce or separation (HR =​0.53, 95% CI =​0.42–​0.67). Among those who were divorced, separated, or widowed in 1996, there was no effect of religious attendance on remarriage in divorced or separated women;

however, among widowed women, those who attended religious services more than once/​ week were over twice as likely to remarry by 2010 (HR =​2.06, 95% CI =​1.52–​2.80). Valerie King and colleagues (2019) analyzed data from Waves I (1994–​1995) and III (2001–​ 2002) of the Add Health Study that included 2,085 adolescents living with their married biological mothers and stepfathers at Wave I. Predictors of likelihood of separation of the mother and stepfather by Wave III were examined in multivariate models. Adolescents’ report of religious activity with parents (attendance at religious services or other activities) was assessed at Wave I. Responses were categorized as religious activities with both mother and stepfather, with one parent only, or with neither parent. Control variables included adolescent age, gender, race, years in the stepfamily, number of siblings (biological, half-​siblings, step-​siblings), family income, and maternal education. Also assessed were possible mediators including stepfather-​adolescent closeness, adolescent closeness with mother, quality of mother-​ stepfather relationship, adolescent’s feeling of family belonging, shared nonreligious activities with parents, and frequency of family dinners. Results indicated that among adolescents who were religiously active with both parents at Wave I, the likelihood of mother and stepfather separating by Wave III was significantly lower (B =​-​ 0.58, SE =​0.27, p < 0.05). Controlling for shared nonreligious activities and frequency of family dinners did not alter this relationship. This effect was at least partly explained by quality of the mother-​stepfather relationship, which reduced the effect to a trend level (B =​-​0.53, SE =​0.29, p =​0.07). Researchers concluded that attending religious services or church-​related events with both parents predicted future stepfamily marital stability, an effect that was present above and beyond that of engaging in other types of nonreligious shared activities. FAM ILY F UN CTION IN G

Family functioning has been assessed in a variety of ways, including positive parenting, positive marital and romantic interactions, child attachment security, family cohesion, child-​ parent disclosure, strength of family ties, value Marital and Family Stability • 271

of children as a burden or joy, and other indicators. We include here three high-​quality cross-​ sectional studies and two prospective studies. In the first cross-​ sectional study, Goeke-​ Morey and colleagues (2013) identified a random sample of 695 mother-​ child dyads in Belfast, Northern Ireland, to assess the association between maternal religiosity and child/​family functioning. Maternal religiosity was assessed with 9 questions: importance of religion, frequency of church attendance, and a 7-​ item Attitude Toward Christianity Scale (Francis). Parent-​ child attachment was measured using the 15-​ item Parent Attachment Security Scale (Davies); family cohesion by the Family Environment Scale (Moos); maternal behavioral control by a 5-​item index (Kerr); and children’s disclosure by a measure of how often children disclosed information to parents (Stattin). Family risk factors included family conflict, mother’s psychological distress, and child’s adjustment problems, all using standard scales. Controlled for were child age and gender, and mother’s religious affiliation. Results indicated that maternal religiosity was positively and significantly related to greater mother-​child attachment security (p < 0.001), family cohesion (p < 0.001), and child disclosure (p < 0.001), and was inversely (negatively) related to family conflict (p < 0.001), mother psychological distress (p < 0.05), and child adjustment problems (p < 0.001), although there was no relationship found with maternal behavioral control. Maternal religiosity also moderated the effects of family cohesion, maternal behavioral control, family conflict, maternal distress, and child adjustment problems on mother-​child attachment security (all at statistically significant levels and in a positive direction). The researchers concluded that mothers’ religiosity consistently predicted positive processes and stronger relationships in families. In a second cross-​sectional study, this time examining adult child–​parent relationships in later life, Valerie King and colleagues (2013) analyzed data from a random sample of 9,002 community-​dwelling adults with at least one living parent who participated in the first wave of the National Survey of Families and Households (1987–​1988). Six measures of adult 272 •  S ocial H ealth

child–​parent ties were examined: providing care in the past year to an ill or disabled parent; providing assistance to parents in terms of housework, transportation, or home/​ car repairs; relationship quality with father; relationship quality with mother; frequency of contact with fathers; and frequency of contact with mothers. Religiosity was assessed by two items, frequency of religious attendance and whether there had been a change in religion from childhood (i.e., congruence of child-​ parent religion). Control and mediating variables included adult child filial norms, age, gender, race, current employment status, marital status, number of living siblings, and presence of children in household, whereas parent characteristics included health, distance from child household, living status of parents, and whether parents were still married to each other. Regression models were used to control for covariates and to identify mediators. Results indicated that adult child religious attendance was positively related to caring for parents, assisting parents, quality of relationship with fathers and mothers, and amount of contact with fathers and mothers. These relationships persisted after controlling for both child and parent characteristics; the only exception was providing care to parents, which lost statistical significance after adjusting for controls. If the adult child changed religions from childhood (i.e., incongruency between child and parent religion), then this was inversely related to quality of relationship with fathers, quality of relationship with mothers, and frequency of contact with mothers. These findings are consistent with the baseline cross-​sectional findings of King and colleagues’ (2019) longitudinal study of adolescents in stepfamilies above, who reported that frequently attending religious services or other church-​related events with both parents was associated with significantly greater stepfather-​ adolescent closeness, mother-​ adolescent closeness, mother-​ stepfather relationship, and adolescent’s feeling of family belonging. In the last cross-​sectional study, Stier and Kaplan (2020) analyzed a random sample of approximately 30,000 adults in 24 countries (largely European, but including Chile, Iceland, Israel, Japan, South Korea, and the United States). The purpose was to examine correlates

of perceiving children as either a burden (costly, interfering with work or personal freedoms) or a joy (source of joy and happiness, social support, social standing). Religiosity was assessed by frequency of attendance at religious services at the individual level and average attendance at the country level. The data were analyzed using hierarchical linear modeling that examined individual-​and country-​level characteristics, controlling for gender, education, work status, marital status, and age at the individual level, and unemployment rate, weeks paid parental leave, and percentage of children in day care at the country level. Results indicated an inverse relationship between religiosity and negative perceptions of children at the individual (B =​−0.60, p < 0.05) and country (B =​−0.14, p < 0.05) levels. Religiosity was also positively related to positive perceptions of children as providing joy and happiness (B =​0.026, p < 0.05), social standing (B =​0.044, p < 0.05), and social support (B =​0.043, p < 0.05) at the individual level. Researchers noted that these findings were consistent with past research showing that greater religiosity was associated with traditional family values (Liefbroer & Rijken, 2019) and positive attitudes toward children and marriage (Jones & Brayfield, 1997; Gubernskaya, 2010; Yucel, 2015). Among prospective studies, Spilman and colleagues (2013) analyzed data from a 20-​year longitudinal study of 451 adolescent youth in two-​ parent families across two generations, following youth from adolescence to young adulthood when many had their own families (Family Transition Project). Adolescents in the 7th grade (G2; average age 16.5, assessed initially in 1991) and their parents (G1, assessed initially in 1989) were recruited from eight rural Iowa counties and followed through 2007. Religiosity in G1 and G2 was measured using a scale assessing (a) importance of religious or spiritual beliefs in day-​to-​day life, (b) importance of being a religious person, and (c) frequency of church attendance (assessed in 1991 for G1 parents and in 1991, 1992, 1994, and 1997 for G2 adolescents). Marital interactions for G1 parents were assessed in 1991, 1992, and 1994 (during G2 adolescence), whereas romantic relationship interactions for G2 adolescents were assessed in 1995–​2007. Marital

and romantic interactions assessed were quality of communication (positive expression, clear, appropriate), prosocial (helpfulness, sensitivity), hostility (angry, critical), antisocial (self-​centered, defiant, lack of constraint), and angry coercion (threatening or blaming behaviors). Positive parenting (based on videotaped parent-​child discussions of family rules, problems, etc.) was assessed for G1 parents in 1991–​1994 (during G2 adolescence) and for G2 adolescents in 1997–​2006 (who had children of their own by that the time). Controls were gender, G1 income, G1 education, G1 religious affiliation, and G2 personality (agreeableness and conscientiousness). Structural equation modeling was used to examine relationships. Results indicated that G1 parent religiosity in 1991 was associated with G2 youth religiosity during adolescence (1991–​1994), which in turn predicted youth religiosity during transition to adulthood (1997; average age 22.5). G1 religiosity in 1991 also predicted G1 positive marital interactions in 1991–​1994 (during G2 adolescence) and was positively associated with G1 positive parenting during 1991–​1994. G1 positive parenting during G2 adolescence (1991–​ 1994) and G2 youth religiosity in 1991–​1994 during adolescence, in turn, predicted both G2 positive romantic relationship interactions during transition to adulthood (1995–​ 2007) and G2 positive parenting during transition to adulthood (1995–​2007). Researchers concluded that religiosity serves as a personal resource that is uniquely and positively predictive of quality family relationships, which is transmitted across generations. Silverstein and colleagues (2019) analyzed data collected on 220 adolescents participating in the Longitudinal Study of Generations. Participants were initially assessed in 1971 and followed up at least once in 1997 (average age 43), 2000, 2005, or 2016. The question posed by researchers was whether adolescents who participated in religious activities with their mothers in 1971 would be more or less likely to assist their older mothers once adolescents reached adulthood (between 1997 and 2016). Religiosity was assessed by a single question in 1971 that asked about the extent to which adolescents participated in religious activities with their mothers. Response options were Marital and Family Stability • 273

trichotomized for analysis into none (50%), intermittently (i.e., about once a year or several times a year; 21%), and regularly (every other month, about once a month, about once a week, several times a week, or every day; 29%). Assistance provided to mothers was the primary outcome variable and was based on how often participants assisted mothers in (1) household chores, (2) transportation or shopping, (3) help if she were sick, (4) provision of personal care, (5) discussion of important life decisions, or (6) provision of information and advice (summed to produce a single outcome variable assessed at each wave). Time-​ varying covariates included child gender, child age, child self-​rated health, number of living siblings, child’s self-​rated religiosity in midlife, and maternal factors, such as age, functional impairment, and widowhood status (as indicators of maternal vulnerability). Time-​ varying covariates tested as possible mediators included emotional closeness with mothers, geographic distance, and children’s norm of eldercare responsibility (tested for each of the six outcomes above). Sociodemographic factors (assessed in 1971) controlled for in analyses included child gender, child marital status, parental education, family income, and participation in shared nonreligious activities. Data were analyzed using multilevel modeling with random effects. Results indicated that compared to adult children not engaged in religious activities with mothers, those who participated in “intermittent” religious activities were more likely to provide assistance to mothers (B =​1.80, SE =​0.84, p < 0.05) and those who participated in “regular” religious activities with mothers tended to be more likely to provide such assistance (B =​1.44, SE =​0.76, p < 0.06). These effects were especially strong for widowed mothers. Emotional closeness and geographic distance mediated these effects, especially for widowed mothers. In contrast, intermittent and regular participation in nonreligious activities with mothers during adolescence had no effect on amount of assistance given. Researchers concluded that religious activities with mothers during adolescence produce benefits at a point in the family life cycle when intergenerational solidarity becomes especially important. 274 •  S ocial H ealth

CH IL D ABUSE

Three relatively high-​quality prospective studies have examined the effect of religiosity on child abuse, one examining maternal abuse risk, the second examining the effects of punishing children by physical means, and the third measuring retrospective accounts of physical abuse, sexual abuse, and neglect during childhood. Bert (2011) analyzed data from an ongoing longitudinal study of adolescent parenting on child development from pre-​birth to age 14 years, following the children of a sample of 110 mothers. At the time of childbirth, mothers’ average age was 17.1 years (range 14–​19 years). Mothers were African American (67%), White American (27%), or Hispanic American (7%). Mothers were interviewed prior to their children’s birth (T1) and when children were ages 3 (T2), 5 (T3), and 8 years (T4); children were interviewed at age of 14 (T5). Early maternal religiosity was assessed at T1 by frequency of church attendance, closeness to the church community, and physical and emotional support received from the church; at T2–​T4, mothers were also asked about frequency of contact with church members and church leaders. Scores were summed over each time measurement and ranged from 0 to 16. Child abuse was assessed at T5 by the Child Abuse Potential Inventory (CAPI; Milner), a measure which assesses rigidity (of the mother’s expectation for a child’s behavior) and unhappiness (mother’s feeling of being alone in the world and feeling worthless and misunderstood by others). Controlled for in hierarchical regression analyses were T5 maternal IQ and T5 maternal social position (occupational and educational status). Regression analyses revealed that early maternal religiosity predicted lower child abuse potential on the CAPI (b =​−0.19, p < 0.05) and predicted greater maternal self-​ esteem (B =​0.22, p < 0.05), as well as a tendency toward less child depression at age 14 (B =​−0.17, p < 0.10) and fewer childhood externalizing behaviors (B =​−0.21, p < 0.05). CAPI scores at baseline, however, were not measured or controlled for in these analyses. Ellison and colleagues (2011b) analyzed longitudinal data obtained from 456 children participating in the US National Survey of

Families and Households to examine whether corporal punishment of children age 2–​4 years at baseline (T1) increased antisocial behavior and emotional problems over a 5-​year period (T2), and whether the religion of the mother moderated this effect. Outcomes included antisocial behaviors such as extent to which child (1) cheats or tells lies, (2) bullies or is cruel or mean to others, (3) does not feel sorry when misbehaving, (4) is disobedient at school, (5) has trouble getting along with teachers, (6) feels or complains that no one loves him/​ her, (7) has sudden changes in mood, (8) feels worthless or inferior, (9) is unhappy, sad, or depressed, and (10) is withdrawn or doesn’t get involved with others. Corporal punishment involved spanking or slapping the child during the week prior to the interview. Religion of the mother was measured by affiliation and beliefs about the Bible. Affiliation was dichotomized as conservative Protestant vs. other. Beliefs about the Bible were determined by how much the mother agreed with two statements: “The Bible is God’s Word and everything happened or will happen exactly as it says,” and “The Bible has the answer to all important human problems.” Answers were summed to create an index of conservative religious views. Controlled for in all analyses were T1 child antisocial behavior and emotional distress, positive maternal behaviors, maternal depression, maternal sociodemographic characteristics (including conservative religious affiliation and beliefs), and child age and gender. Results indicated that corporal punishment at T1 had no effect on child antisocial behaviors at T2, although when analyses were controlled for T2 corporal punishment, T1 corporal punishment predicted significantly fewer child antisocial behaviors at T2 (b =​−0.14, SE =​0.06, p < 0.05). However, children receiving corporal punishment at both T1 and T2 had elevated levels of T2 antisocial behavior (b =​0.49, SE =​0.22, p < 0.05) (perhaps the reason why they were being punished). Regarding child emotional distress, corporal punishment at baseline (T1) had no effect on child emotional distress at T2, whether T2 corporal punishment was controlled for or not. However, corporal punishment at both T1 and T2 was associated with greater child emotional distress at T2 (b =​1.11,

SE =​0.28, p < 0.05). With regard to maternal religious affiliation, results indicated that the negative effects of corporal punishment at T1 or T2 on child antisocial behaviors at T2 were significantly less among conservative Protestant mothers, and the same was true for T1 corporal punishment on T2 emotional problems. Substituting conservative beliefs about the Bible, however, for conservative Protestant affiliation did not replicate these results. Researchers concluded that it was conservative Protestant communities and traditions—​ not specific doctrinal tenets—​that reduced the negative effect of spanking on child outcomes. Watts (2017) analyzed data from a 7-​year prospective study of 9,002 adolescents in grades 7–​12 (Add Health cohort) examining the effects of baseline characteristics (T1) on child abuse and neglect (retrospectively assessed at T3). Characteristics assessed at T1 included religiosity (frequency of prayer, importance of religion religious attendance participation in religious youth activities). Perceptions of childhood abuse or neglect were assessed at T3 when participants were age 18–​24. Regression models indicated that T1 religiosity in females predicted fewer reports of physical abuse (B =​−0.50, SE 0.16, p < 0.01), sexual abuse (B =​−0.75, SE =​0.36, p < 0.05), and neglect (B =​−0.556, SE =​0.27, p < 0.05) during adolescence. No effect was found in males. D OM ESTIC VIOL EN CE

We now review two high-​quality cross-​sectional studies and one prospective study that have examined the relationship between religiosity and domestic violence. Ellison and Anderson (2001b) examined the cross-​sectional relationship between religious involvement and domestic violence using data from the National Survey of Families and Households (Wave I; NSFH-​ I), a random national sample of 13,017 Americans. They focused on a sub-​ sample of respondents who were married to or cohabiting with a person of the opposite sex at the time of the interview (n =​6,800). Religious involvement was measured by religious attendance. Respondents were asked whether arguments with their spouse ever “became physical.” This Marital and Family Stability • 275

was followed by a question asking how many fights resulted in the person hitting, shoving, or throwing things at their partner. Men attending religious services weekly or more were 61% (b =​−0.93, p < 0.01) less likely than non-​attendees to self-​report domestic violence; when partner-​reported abuse was examined, this effect remained significant but diminished to 49% (b =​−0.67, p < 0.05) controlling for race, age, income, spouse’s contribution to income, education, education difference, cohabitation, and unemployment. The associations were similar in women attending religious services at least weekly (vs. non-​attendees) for self-​ reported and partner-​ reported domestic violence, although slightly weaker (but still statistically significant). The associations also persisted after controlling for measures of social integration, social support, alcohol abuse, drug abuse, low self-​esteem, and depression. Ellison and colleagues (2007), again analyzing NSFH-​I data, examined the relationship between ethnicity, religious involvement, and domestic violence in 6,800 adults married to or cohabiting with a member of the opposite sex at the time of the interview. Domestic violence was measured as in the Ellison and Anderson (2001b) study above by both self-​report and report by partner. In women, after controlling for age, education, employment status, marital status, cohabitation status, and race/​ethnicity, frequency of religious attendance was related to a small decrease in the likelihood of being a victim of domestic violence (OR =​0.95, p < 0.10); compared to women never attending religious services, those who attended several times a week were roughly 40% less likely to be a victim of such violence. In men, frequency of religious attendance was related to a lower likelihood of perpetrating domestic violence (OR =​0.91, p < 0.001); compared to non-​attendees, men attending religious services several times a week were 72% less likely to abuse their partner. The effect was present in White American men (OR =​0.94, p < 0.05), although it was somewhat stronger in African American men (OR =​0.91, p < 0.10) and Hispanic men (OR =​0.83, p < 0.05). The estimated ethnic/​ racial differences in domestic violence among non-​attending men compared to those attending several times per week were substantial for African Americans 276 •  S ocial H ealth

(OR =​3.53, p < 0.01) and Hispanic American men (OR =​2.21, p < 0.10). Researchers concluded that religious involvement, specifically religious attendance, protects against domestic violence and that this protective effect is stronger for African American men and women and for Latino men—​ethnic groups known to be at high risk for domestic violence. In the only prospective study, Katerndahl and colleagues (2015) examined the effects of religiosity on the consequences of domestic violence among 200 women with a recent history of husband-​to-​wife physical abuse in Texas. Since all participants had experienced domestic violence, religiosity as a predictor of the likelihood or severity of such violence was not examined. Participants were followed up for 12 weeks, completing daily assessments of severity of violence. Assessed at baseline (T1) were three religious characteristics: visits to a religious/​spiritual counselor (clergy, folk healer, spiritualist), degree of religious coping (4-​item subscale of the COPE [Carver]), and severity of “spiritual” symptoms (lack of purpose, harmony, self-​confidence). Stepwise linear regression was used to examine outcomes at 12 weeks (T2), which were level of hope, support, psychological symptoms, positive coping and appraisal, readiness for change, functional status, use of medical services, and leaving the relationship. Controlled for in analyses were baseline demographics, along with childhood, marital, and violence variables (duration, daily severity, and dynamics of violence). Results indicated that visits to religious/​ spiritual counselors was associated with less positive appraisal and more symptoms/​ dysfunction, but also with greater readiness for change. Negative spiritual symptoms at T1, not surprisingly, were uniformly related to worse T2 outcomes. T1 religious coping predicted a greater likelihood of staying in the relationship (T2), which may or may not have been a positive outcome. T1 outcomes were not controlled for in analyses examining T2 outcomes.

Randomized Controlled Trials (RCTs) RCTs can determine whether a religious intervention is more (or less) effective in relieving

marital/​family distress when compared to no treatment or a control intervention. We review two relatively high-​quality trials focusing on satisfaction during marriage and on forgiveness of an ex-​spouse. Laurenceau and colleagues (2004) conducted an RCT to examine the efficacy of a premarital intervention program on enhancing relationship satisfaction during marriage. A total of 217 newly engaged couples from 57 religious organizations in the Denver, Colorado, area participated in the study. Random assignment was at the religious organization level. Religious organizations were randomly assigned to one of three types of premarital counseling: (1) a premarital program (Prevention and Relationship Enhancement Program or PREP) delivered by university clinicians (U-​PREP) (n =​85 couples); (2) PREP delivered by religious organization clergy, preferably from the couple’s home church (RO-​PREP) (n =​81 couples); or (3) a naturally occurring marriage preparation control group (NO-​PREP) (n =​51 couples). The PREP intervention was administered in a 3-​session format, i.e., one weekend day followed by two weeknight sessions (total of 12 hours). The goal was to decrease identified risk factors for marital distress and increase protective factors for marital functioning. Outcomes were assessed using the 15-​item Marital Adjustment Test, a standard measure of marital satisfaction, and by the Interaction Dynamics Coding System, an observer-​rated system for assessing problem-​ solving communication skills that produces global positive communication and global negative communication scores. At baseline, 2.5 months post-​intervention, and 14.0 months post-​ intervention, participants completed scales on marital satisfaction, positive communication, and negative communication. Results indicated that RO-​PREP, i.e., PREP delivered by clergy and lay leaders, was more effective than either U-​PREP or NO-​PREP in reducing negative communication and increasing or maintaining positive communication across all assessment periods. RO-​PREP couples showed greater declines in wife negative communication compared to U-​PREP or NO-​ PREP couples (although husbands showed no difference across treatments on this outcome). In contrast, NO-​ PREP couples experienced

significant declines in both husband and wife positive communications, compared to RO-​ PREP couples. Likewise, U-​PREP couples experienced significant declines in husband positive communication over time when compared to RO-​ PREP couples. Investigators concluded that religious leaders using PREP strategies in premarital counseling had significantly better results than university clinicians or regular premarital counseling. Rye and colleagues (2005) examined the effectiveness of religious and secular versions of an 8-​session, 90-​minute forgiveness group intervention for divorced persons. A total of 192 persons (mean age 45) were randomized to a secular forgiveness condition, a religious forgiveness condition, or a no-​ intervention condition. Both secular and religious versions were similar in that they consisted of a variety of activities, discussion topics, and homework assignments designed to help individuals forgive their ex-​spouse. In the religious intervention, participants were encouraged to draw on their religious beliefs while working toward forgiveness. Prayer was also used to enhance forgiveness, as participants were given time for silent prayer and two homework assignments related to prayer. Participants in the no-​ intervention control group were given a list of free or low-​cost community resources where they could obtain individual or group support to cope with divorce. Outcome measures were a 15-​item self-​rated forgiveness scale, a 17-​item observer-​rated forgiveness scale, and a 10-​item forgiveness knowledge scale. Participants were assessed at baseline, immediately post-​ intervention, and 6 weeks after the intervention. Hierarchical linear modeling was used to analyze growth trajectories across the three assessment points in the 149 subjects who completed the study. Results indicated that participants in both the secular and religious forgiveness conditions experienced significantly greater increases in forgiveness and forgiveness understanding compared to the no-​intervention control group. However, there was no significant difference between secular and religious forgiveness interventions. Investigators concluded that many clients use religious strategies when forgiving, even when not explicitly encouraged during therapy, and Marital and Family Stability • 277

adolescence predicted future assistance provided to mothers, especially after widowhood, due to increased adult child-​mother emotional closeness and shorter geographic distance (likely due in part to emotional closeness), all suggesting that such religious activities increased intergenerational solidarity. SUMMARY OF THE Supporting these findings on family stabilRESEARCH ity, prospective studies examining child abuse Based on 10 high-​quality prospective studies found that (1) maternal religiosity predicted described above, religious involvement by mar- a lower potential for child abuse; (2) maternal ital partners protected against future divorce or affiliation with conservative Protestant faith against risk factors for divorce in 8 of those 10 traditions reduced the negative effects of corstudies, including the largest and best-​designed poral punishment on future antisocial behavstudy conducted to date, which found nearly a iors or emotional problems in their children; 50% reduction in the likelihood of divorce/sep- and (3) greater religiosity during adolescence aration. Greater religiosity also reduces factors predicted a lower likelihood of childhood abuse that increase risk of divorce, including poor and neglect as perceived by those adolescents dedication to the relationship, non-​ marital during young adulthood. Similarly, domestic violence was found birth, avoidance of marriage after non-​marital birth, cohabitating before marriage, and having (based on two reports of cross-​sectional analsex before marriage with persons other than a yses of data from a single study) to be less future spouse. These findings provide evidence common among those who attended religious for a positive effect of religiosity on marital sta- services more frequently, both in terms of being bility over time. a victim of domestic violence and in terms of The findings are similar for family function- perpetrating domestic violence, especially in ing. One cross-​sectional study found positive ethnic minority men. However, one prospecassociations between maternal religiosity and tive study also found that use of religious copmultiple indicators of family stability (mother-​ ing predicted a greater likelihood that women child attachment security, family cohesion, of abuse would stay in the relationship (which child disclosure, child adjustment problems). is of course not always a good thing). Another cross-​sectional study found that adult Finally, a randomized clinical trial found child religiosity was associated with a greater that marriage preparation provided by clergy likelihood of assisting parents, quality of rela- was superior to either that provided by unitionship with father and mother, and amount versity clinicians or traditional premarital of contact with fathers and mothers. A third counseling in reducing negative communicacross-​sectional study found that religiosity was tions and increasing or maintaining positive associated with perceiving children as a source communications over time once couples were of joy and happiness, rather than as a burden. married. Similarly, a randomized trial among A prospective study found that parent religi- divorced persons suggested that both a stanosity while raising adolescents was associated dard secular forgiveness intervention and a with positive marital interactions, which pre- religious forgiveness intervention achieved dicted positive parenting; positive parenting, similar benefits in terms of forgiving an ex-​ in turn, predicted future young adult child reli- spouse, compared to a no-​intervention congiosity; and both of these, in turn, predicted trol group. the adult child’s positive romantic interactions Overall, then, religious involvement appears and positive parenting themselves (indicating to be associated with greater marital and family intergenerational transfer of positive partner stability, less child abuse and domestic violence, interactions and positive parenting). Another and may be useful in preparing couples for marprospective study of adolescents found that riage, and if divorce does occur, it may also help religious activities with mothers during with forgiving an ex-​ spouse. These research that while the study found no evidence that the religious intervention was superior to the secular intervention, religious clients may appreciate therapy that helps them draw on their faith to enhance forgiveness.

278 •  S ocial H ealth

findings are consistent with the speculations above regarding how religious involvement positively affects marital and family stability.

RECOMMENDATIONS FOR FUTURE RESEARCH Further research is needed to better understand the relationship between religious involvement and marital stability and satisfaction, family stability, and the occurrence of child abuse and domestic violence. While many cross-​sectional studies show that those who are more religiously active experience greater marital satisfaction, little is known about how this relationship comes about or changes over time. Do persons with early marital difficulties who stay together because of religious beliefs experience greater marital harmony and satisfaction later in life, or do these individuals suffer silently (or not so silently) for decades in a marriage from which they cannot escape? How exactly does the religiosity of one or both members of the marital dyad affect the marital relationship and relationships with children, including adult children, over the life span? Long-​term prospective studies are needed to answer these questions. Likewise, how effective are religious interventions in both enhancing marital stability (preventing divorce) and improving marital satisfaction and couple well-​being? How might religious devoutness affect the risk of domestic violence over time, particularly in highly conservative or fundamentalist religious groups? To our knowledge, there have been no RCTs examining the effectiveness of religiously integrated therapies in the treatment of marital discord/​disharmony. This is true even though marital counseling is one of the most common activities of pastors and clergy, and many marital therapists likewise use religious principles in their counseling practices. Both professions do so largely based on case reports, individual testimonies of effectiveness, and findings from observational studies, rather than from RCTs that support such integration. While there are a number of longitudinal research studies, many of these, as seen above, are relatively small and often are based on convenience samples. While the existing evidence

on marital stability is not insubstantial, in many of these studies there is considerable statistical uncertainty. The field would benefit from more large longitudinal designs. This is especially true for studies of the role of religion on family functioning, sexual abuse, and domestic violence, where some of our reporting had to rely on cross-​sectional studies. As emphasized in previous chapters, well done prospective studies and RCTs are expensive and difficult to carry out, and there is almost no funding available for such research (other than perhaps private funding). Adding religious variables to existing long-​term observational studies, i.e., studies designed for some other purpose, may help to reduce the cost of conducting studies from scratch focused specifically on religiosity’s effects (as much as that might be preferred). Funding for high-​quality RCTs that examine the efficacy of religiously integrated interventions to enhance marital stability, on the other hand, may require a change in national policies toward the support of such research.

CLINICAL APPLICATIONS Despite weaknesses in the current evidence base, the research findings summarized above justify making several tentative suggestions with regard to clinical applications. Healthcare professionals might consider recommending that couples in a long-​term relationship, marital or otherwise, who positively self-​identify as religious, engage in religious activities together (e.g., attending religious services together, praying together, seeking guidance from the holy Scriptures on how to treat one another). Such recommendations must be made cautiously depending on the couple and their religious inclinations, and therefore as always must be client-​centered. Encouraging religious activity together will likely be most successful in couples who are religious to some degree, have been religiously active in the past, or are currently engaged in such activities together. The old adage, “The family that prays together stays together,” may indeed be true based on what the evidence suggests thus far. Religious professionals who provide pastoral support for couples either before or Marital and Family Stability • 279

after marriage should be aware of objective research that finds engaging in religious practices together benefits the marriage. Given the importance of marriage and the family in most religious traditions, clergy probably do not need research in order to support such interventions with members of their congregation. Nevertheless, being aware of the research findings may be encouraging when conducting pastoral interventions, as well as helpful in sermon preparation, given the value that the public places on scientific research. That research demonstrates the effect of marital and family stability on the mental, social, and physical health of all family members (Slatcher & Schoebi, 2017; Margelisch et al., 2017; Hanson et al., 2019). The above research also underscores the importance of preparing couples prior to marriage for what will take place during marriage. Such preparation may be done by secular therapists, but more likely will involve community clergy or pastoral counselors. The objective is to counsel couples in a psychologically informed way about what challenges to anticipate when getting married. We recommend the Prepare & Enrich program, which has some research to back its effectiveness (Olson, 2017). Despite the importance of marital and family stability, clergy should be cautious when counseling couples where child abuse or domestic violence may be taking place. Given the impact of such behaviors on the couple and family, clergy should refer such clients for professional counseling early on (and in some cases, contact child and adult protective service agencies as necessary). While there is much to say about encouraging couples to make every effort to fulfill their marriage vows of lifelong commitment, when the safety of one member of the couple (or a child) is at stake, intervention is a priority and may include separation of the involved members temporarily, if not permanently in some instances. Among health professionals seeing children or couples with young children, consideration should be given to encouraging religious activities with parents, at young ages perhaps regardless of whether the child wants this or not. The instilling of ethical principles, moral values, and prosocial character traits is an important 280 •  S ocial H ealth

part of childrearing, which will have benefits not only for the future mental, social, and physical health of the child, but also for society more generally and later relationships when those children are adults. Religious involvement during youth may help in this regard, as could religious education before, during, or after religious services, or during religious youth group activities. Religious professionals, in turn, should ensure that high-​quality education programs are available to young members of their congregation. Religious education of parents, through sermons and adult education programs, that emphasizes the importance of child and adolescent religious involvement may also be important and is supported by existing research. For religious clients with marital or family problems, healthcare providers should consider referral to religious professionals—​particularly licensed professional religious counselors or pastoral counselors with experience and skill in handling these issues. Although there is much need for evidence-​ based religious therapies, there is probably enough evidence to support the use of religious resources in therapy to enhance marital stability, improve relationships with children, and support healthy interactions with other family members, even when a more conventional form of secular therapy is being conducted.

SUMMARY AND CONCLUSIONS The development of personality characteristics, good mental health and physical health during adulthood, future social relationships, prosocial values, and risk of delinquency during youth and crime during adulthood are heavily influenced by the environment in which a person is raised. We have focused here on the impact of religiosity on marital and family stability. The chapter opened with a discussion of increasing divorce rates in the United States and around the world. We examined predictors of divorce (cohabitation, premarital sex, non-​marital parity, socioeconomic factors, unstable parents of origin) and the health consequences of divorce on adults and children. We then reviewed characteristics that bring couples together

(differences, similarities, personality style) and described factors that affect marital satisfaction (conflict, commitment, fidelity, substance use, workload, pornography use, attachment security, forgiveness, and relationship repair). Next, predictors of family stability and functioning were examined, including mental disorder, medical illness, household composition, and domestic violence, followed by protective factors at the individual, family, and community level that promote family resiliency. With this background, we then presented a case vignette of a couple with marital conflict based on dissimilarities in background, personality, and goals, and the role that religion played in helping them work through their difficulties. This was followed by a review of the teachings

of the major religious faiths on marriage, divorce, and the importance of family and children. Based on those teachings, we speculated on what effect religious involvement might have on marital and family stability. The heart of this chapter involved a review of quantitative, systematic research that has examined the effects of religiosity on likelihood of divorce, quality of the marital relationship, family stability, child abuse, and domestic violence, focusing on the best observational studies and RCTs. We then closed out the chapter with recommendations for future research and clinical application. In the next chapter, we examine religious involvement as a source of more general support, which is also a key social determinant of health.

Marital and Family Stability • 281

15 Social Support Thou shalt love thy neighbor as thyself. —​Leviticus 19:18

THIS CHAPTER EXAMINES the relationship between religiosity and social support, and more broadly, with other social constructs related to health. After discussing various social determinants of health, we explore how social support and related constructs (loneliness, forgiveness, social capital, altruism) affect mental, behavioral, and physical health. We then present a case that illustrates the role that religion can play in bolstering social support after loss and theorize why religious involvement might be particularly important in doing so, based on the teachings in religious scriptures of the major world religions concerning care for others. This is followed by a review of the research examining the relationship between religiosity and social support, loneliness, forgiveness, and social capital (along with altruism and volunteering). We conclude the chapter with recommendations for future research and suggestions for clinical application.

SOCIAL DETERMINANTS OF HEALTH Social determinants of health (SDH) have been defined as conditions in the human and physical environments in which people “are born, grow, work, live, and age” that affect their health, functioning, and quality-​of-​life (World Health Organization, 2011). Table 15.1 lists the SDH as described in Healthy People 2020 (2019). Somewhat remarkably, religious participation is not on the list, though clearly, as argued throughout this book, religion can powerfully affect health. Thus, researchers have argued that religion should be understood as a social determinant of health (Idler, 2014; VanderWeele & Chen, 2020a). The various SDH presented in Table 15.1 may be particularly important during adolescence, when the entire trajectory of an individual’s life is often set. Research indicates

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0015

Table 15.1  Social Determinants of Health Availability of resources to meet daily needs (e.g., safe housing and local food markets) Access to educational, economic, and job opportunities Access to healthcare services Quality of education and job training Availability of community-​based resources in support of community living and opportunities for recreational and leisure-​ time activities Transportation options Public safety Social support Social norms and attitudes (e.g., discrimination, racism, and distrust of government) Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community) Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it) Residential segregation Language/​literacy Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media) Culture Source: Healthy People 2020 (2019).

that while adolescent health is influenced by structural factors such as national wealth, income inequality, and access to education, other social determinants that strongly influence future health include membership in safe and supportive families, access to safe and supportive schools, and exposure to positive prosocial peers that foster the development of healthy habits and capacity to make moral and ethical choices (Viner et al., 2012). Researchers emphasize that it is important to address SDH early by improving youth’s family and peer relationships, and by identifying and addressing risk and protective factors in the social environment (particularly supportive relationships).

SDH, as currently understood, are influenced by the distribution of money, power, and resources at the societal level, and specifically by what governments and political systems can provide to citizens to enhance their health in terms of redistribution of resources. However, we focus here not on what the government can do, but rather on what religiosity and religious organizations provide to members at the individual level, which then in turn influences health at the individual, community, and eventually societal level. Religion may do this by helping to form individual beliefs and attitudes regarding how to treat people (family, friends, co-​workers, or individuals encountered in public settings at restaurants, stores, gas stations, on the road, or elsewhere) and what one’s responsibilities are toward ensuring the well-​ being of others. Religious behaviors in this regard include loving one’s neighbor, wherever the neighbor is encountered, forgiving the neighbor when a wrong has been committed, supporting the neighbor when emotionally distressed, giving money to those in need (for religious reasons), and volunteering to provided services or otherwise meet the needs of the less privileged (again, for religious reasons). Thus, our emphasis here is somewhat different from that of the current literature on SDH, in that we instead stress the availability of social support, behaviors such as forgiveness that help to maintain relationships, and volunteer and community activities that increase social capital and the health of the community (factors that may indirectly influence many of the other determinants of health in Table 15.1). However, before examining the role that religion plays in enhancing social support by improving individual relationships through forgiveness and by increasing social responsibility through religious giving and volunteerism, let us examine research on the impact that social factors more generally have on mental and physical health.

SOCIAL FACTORS AND HEALTH Some research indicates that SDH may be responsible for up to 45%–​60% of the variation in health status (Donkin et al., 2017). Social

Social Support • 283

environments influence the development of both chronic physical diseases (obesity, diabetes, heart disease, cancer) and emotional disorders (depression, anxiety, substance use disorders, suicide), conditions that increase disability and impair quality of life (Cockerham et al., 2017; Compton & Shim, 2015). As understanding of the impact of social factors on health has increased, this has given rise to an entirely new field of study called “social epidemiology” (Berkman et al., 2014). Women, those who are more educated, and older persons are more likely to benefit from the impact of social factors on health (Haslam et al., 2018).

Social Integration and Support In a classic review of data from five large prospective studies, House and colleagues (1988) found that lack of social relationships was a major risk factor for the development of health problems. Those who were less socially integrated in these studies were less physically and psychologically healthy and were more likely to die sooner. The researchers concluded that lack of social relationships had a negative impact on health, one that was comparable to smoking, obesity, physical inactivity, and high blood pressure. Recent and more comprehensive reviews of the literature have confirmed these findings (Holt-​Lunstad et al., 2010; Holt-​Lunstad et al., 2015; Jetten et al., 2012). For example, Holt-​Lunstad and colleagues (2010) conducted a meta-​ analysis that included 148 studies (total n =​308,849) where the average follow-​up time was 7.5 years. Both social integration (i.e., measures of social networks, marital status, network size, and social participation) and social support (i.e., measures of loneliness and perceived support from others) were examined as outcome variables. Those with adequate social relationships were 50% more likely to survive during follow-​up compared to those with poor or insufficient social relationships. As House et al. (1988) had found, this reduction in mortality was comparable to results from meta-​analytic reviews of smoking cessation and other well-​established risk factors for mortality (obesity, physical inactivity). The results remained stable when controlling for a wide range of demographic 284 •  S ocial H ealth

factors including age, gender, baseline health status, length of follow-​up, and cause of death. Likewise, in a meta-​analytic review of 70 independent prospective studies including 48,673 participants with an average 7-​year follow-​up, Holt-​ Lunstad and colleagues (2015) found that the weighted average effect sizes for social isolation, loneliness, and living alone corresponded to an increased mortality risk of 29%, 26%, and 32%, respectively. The findings persisted after controlling for size of social networks and multiple other factors, including depression. In comprehensive review of research on social support and recovery from mental illness or emotional disorder, Tew and colleagues (2012) emphasized the importance of interpersonal relationships, social capital, and social inclusion. Both the size of the social network and the degree to which the social network was supportive turned out to be strong predictors of mental health outcome. They found that living with a partner or as part of a family helped the person with mental illness to maintain a broader network of social capital. In contrast, those living alone were at greater risk of social isolation and persistent mental health problems. Thus, social integration and social support, particularly high-​quality support, predict better mental and physical health over time across a wide range of prospective studies, even after controlling for factors that might confound this relationship. ETIOL OGICAL FACTORS

Numerous factors—​ genetic, developmental, and individual factors (attitudes, beliefs, behaviors)—​influence perceptions of need for social support and its availability. Early studies found that genetic factors contribute at least partly to a person’s motivation and ability to create and maintain a social network. In a Swedish study of 424 twins age 50 or above, Bergeman et al. (1990) found that while genetic factors contributed to the perceived adequacy of their social support network, they had little effect on the quantity of support available. In a younger sample, Kendler (1997) administered a social support inventory at two points in time, separated by 5 years, to 1,898 white female same-​sex twin

pairs age 26–​63 in the Virginia Twins Registry, identifying six aspects of social support that were stable across the 5-​year follow-​up: relative problems, friend problems, relative support, confidants, friend support, and social integration. Genetic factors had a substantial influence on all six aspects, with heritability of the stable component of social support ranging from 43% to 75%. Familial-​environment factors contributed only to relative problems and relative support in this study. Thus, genetic factors are known to influence many aspects of sociability. This may be in part due to inherited personality tendencies (see Chapter 11) such as extraversion, agreeableness, openness, and other prosocial traits that affect the amount and quality of social contacts. Likewise, developmental factors (experiences during early childhood) and family role models (sociability of parents and relatives) also influence the development of future social relationships (Pallini et al., 2014). Attitudes, beliefs, and behaviors developed during youth and modified during adulthood based on life experiences will influence the quality and extent of available social support. Individuals who are outgoing, kind, generous, honest, responsible, dependable, humble, and other-​ centered (prosocial attitudes and behaviors) more easily attract people to themselves, form relationships, and maintain those relationships over time. Thus, genetic factors, early developmental experiences, and learned prosocial attitudes and behaviors all contribute to a person’s perceptions of need for social support and attitude/​behaviors that determine whether social networks will be available to them for support during times of need.

Forgiveness One of the most important factors influencing the quality and durability of close interpersonal relationships, and one that is crucial for maintaining family and non-​ family support networks, is forgiveness. The ability to forgive a friend or partner after one has been hurt or wronged is essential for healthy, long-​term supportive relationships, and consequently affects both mental and physical health (Toussaint et al., 2015b; VanderWeele, 2018). Forgiveness

itself might be understood as replacing ill will toward the offender with goodwill. Understood in this way, forgiveness is different from excusing, or forbearing, or not demanding justice. One can forgive and still pursue a just outcome. Forgiveness represents an alternative to rumination, resentment, and suppression, and in this way facilitates positive emotional regulation. Research has shown that forgiveness is associated with lower levels of depression, anxiety, hostility, substance use (smoking, alcohol and drug use), more positive emotions, greater life satisfaction, higher social support, and fewer self-​ reported health symptoms (Toussaint et al., 2015b). Both prospective cohort studies and randomized clinical trials of forgiveness interventions provide evidence for a causal link between forgiveness and health. In a meta-​analytic review of 54 forgiveness intervention studies involving 2,323 participants, researchers found a moderate to large average effect size (Becker’s Δ+​ =​0.56, 95% CI =​0.43–​ 0.68) on increasing forgiveness, resulting in a decrease in depression, anxiety, and hopelessness (Wade et al., 2014). The important role that forgiveness plays in couple and marital satisfaction is no longer questioned (Aalgaard et al., 2016), and is a well-​ recognized and essential skill for maintaining long-​term close relationships. Although the influence of forgiveness on physical health is not as clear as on mental health, evidence of this type pertaining to both older and younger populations is growing. For example, Toussaint et al. (2012) found that conditional forgiveness, i.e., the belief that apologies, assurances, and compensation are required before forgiving someone was associated with increased mortality (independent of demographic and health factors) among 1,232 adults age 66 or over. Likewise, in a study of 148 college students, greater lifetime stress exposure and lower levels of forgiveness independently predicted worse physical health (Toussaint et al., 2016). Finally, in a meta-​analysis of 128 correlational studies involving 58,531 participants that examined the effects of forgiving others on physical health, Lee and Enright (2019) identified a mean effect size of r =​0.14 (p < 0.001), indicating a small positive relationship across all studies between forgiveness and Social Support • 285

better physical health. However, evidence from longitudinal studies for an effect of forgiveness on physical health is not as clear (Long et al., 2020b).

Social Capital

overall and the health of the individuals who make up those communities.

RELIGION AND SOCIAL SUPPORT

We now turn to the role that religious involveAlthough social capital has many definitions, ment can play in enhancing social support, we use Robert Putnam’s (2000) explana- behaviors that maintain that support (forgivetion. Social capital describes the presence of ness), and social capital. social networks in a community that facilitate cooperation and mutually supportive (trusting) relationships, which serve as a valuable Case Vignette means of combating social disorders inherMichelle is a 39-​year-​old mother of two ent in modern societies, such as crime, delinyoung children age 9 and 11. She lives quency, substance use, and poverty. Social with her family in a small Midwestern capital is measured by degree of community US town. Michelle was raised in a reliparticipation, volunteerism, social trust, recgious family and is now a devoutly reliiprocity, and membership in civic, political, gious Jew herself, after straying away or social justice organizations. Social capital, from her faith during and shortly after then, involves social interactions at a level college. Since a transformative religious above individual social relationships and is experience renewed her faith during often thought of as an indicator of community her mid-​twenties, she has been actively health (Kawachi, 1999). involved in her synagogue’s children’s Social capital has been shown to affect “capaministry, in community volunteer activbility” development and community empowities sponsored by the synagogue, and erment (Ansari et al., 2012), as well as to be in parent-​teacher activities at the local protective on the individual level against delinschool. Her husband, a police officer, was quent behavior and antisocial attitudes (Dufur recently fatally shot during a traffic stop et al., 2019), crime (Buonanno et al., 2009), when confronting a man who had robbed and poverty (Abdul-​Hakim et al., 2010). Social a local convenience store. Michelle was capital has also been shown to enhance mendevastated by the loss of her husband, tal health during adulthood (Ehsan & Silva, who was her closest friend and the father 2015), especially following natural disasters/​ of her children. Michelle could barely wartime conflicts (Noel et al., 2018). For examfunction during the weeks following her ple, Noel et al. (2018) in a review of 15 studies husband’s death. Soon after the funeral, in post–​natural disaster contexts and conflict-​ members of her synagogue took turns affected settings found that social capital was regularly checking on her, listening to inversely associated with post-​traumatic stress Michelle express her sorrow and difficuldisorder, anxiety, and depression, and posities, bringing her meals, giving her time tively associated with psychological well-​being. away from the kids, and helping with the Links between social capital and better physical chores around the house and yard. This health of community members have also been continued for nearly two months until it shown. A meta-​analysis of 145 studies examwas clear that Michelle was back on her ining the relationship between social capital feet and able to function again. Over the and physical health found that 88% of studies next year, with continued support by reported at least partial support for a protecfriends at her synagogue, Michelle gradtive effect for social capital on health (Rodgers ually returned to involvement in her synet al., 2019). Thus, social capital at the commuagogue and community activities.    nity level—​like social support at the individual level—​affects both the health of communities 286 •  S ocial H ealth

IMPACT OF RELIGION ON SOCIAL SUPPORT

the companion by your side, the way-​farer (ye meet)” (4:36). According to a famous Hadith, the Prophet Muhammad is reported to have How might religion impact social support? We said: “ ‘A believer to another believer is like a first theorize on how religious involvement building whose different parts support each might influence social support, relationship-​ other.’ The Prophet then clasped his hands with maintenance activities (forgiveness), and social the fingers interlaced while saying that” (Sahih capital, and then review the empirical research. Bukhari, vol. 8, book 73, no. 55). Elsewhere, the Prophet is reported to have said: “The believers in their mutual kindness, compassion and Social Support sympathy are just like one body. When one of All major world religions encourage care for the limbs suffers, the whole body responds to others within the religious community and it with wakefulness and fever” (Sahih Bukhari, often outside of it as well. Christian, Jewish, vol. 8, book 73, no. 40). and Muslim teachings all emphasize love of Hindu and Buddhist teachings are similar neighbor. Christian beliefs extend that teach- concerning support to others in the commuing of “love your neighbor as self” (Matthew nity, although meeting together for religious 22:39) to include even the love of one’s ene- services is not emphasized as much as in the mies (Matthew 5:44); in fact, the very identity Western traditions of Judaism, Christianity, of followers of Jesus Christ is based on their and Islam. Although there is usually no “con“love for one another” (John 13:35). Emphasis gregation” of members associated with a Hindu is also placed on meeting regularly as a group temple, meeting together as a group occurs together, thus providing opportunity for the during collective rituals that may take a varidevelopment of supportive social relations ety of forms. This may involve monthly par(Hebrews 10:25). For Catholic Christians, ticipation at the Temple or at annual feasts. attending religious services once per week is an According to Whitehouse and Lanman (2014), obligation (CCC, 2003). “imagistic” rituals lead to fusion as a religious The same is true in Judaism, where attending group and willingness to sacrifice for other synagogue services on Shabbat (the sabbath) is Hindus in the community, whereas “doctrinal” encouraged. “Love your neighbor as yourself” rituals foster a shared group identity that pro(Matthew 22:39) has its origins in the Torah motes trust and cooperation. These rituals lead (Vayikra [Leviticus] 19:18). Judaism empha- to a strengthening of in-​group ties (without sizes love and care for the foreigner or non-​Jew sacrificing relationships with those outside the (Devarim [Deuteronomy] 10:18–​ 19; Shemot Hindu community), producing both bonding [Exodus] 22:20). The community (Kehilla) is within the group and bridging to others outvery important in Judaism. Jewish people call side the group. Power (2017) has reported that themselves Am Yisrael (“the people of Israel”)—​ Hindus who partake in collective religious ritunot Dat Yisrael (“the religion of Israel”). Helping als have a higher probability of having supportand supporting one another are evidenced in ive relationships than those who do not. the United States by the fact that every Jewish Buddhists likewise emphasize the imporcommunity has charitable organizations within tance of community (the Sangha). When it, designed to help poor members of the com- conversion to Buddhism occurs, the devomunity. Participation in the religious commu- tee must state publicly that “I take refuge in nity is not an option in Judaism, but is rather a the Buddha. I take refuge in the Dhamma. religious obligation (mitzvah). I take refuge in the Sangha,” emphasizing Likewise, Muslims emphasize the impor- commitment to the community of believers tance of community involvement, support, (Dhammayut Order, 2013; see also Carter & and care for each other based on the Qur’an Palihawadana, 2000). Furthermore, three of and Hadith. The Qur’an says, “do good—​ to the eight principles described in the Eightfold parents, orphans, those in need, neighbors Path to enlightenment—​the heart of Buddhist who are near, neighbors who are strangers; teachings—​ emphasize “right speech,” “right Social Support • 287

conduct,” and “right effort.” Applying these Buddhist principles to the treatment of others, whether inside or outside the Buddhist faith, should lead to supportive relationships.

Forgiveness Forgiveness is strongly emphasized within Christianity. In this faith tradition, it is taught that if a person does not forgive (and forgive repeatedly), then he or she will not be forgiven (Luke 6:37; Matthew 6:14–​15, and 18:21–​22), as specified in the Lord’s Prayer (Matthew 6:12). Likewise, the Torah strictly forbids the taking of revenge or the bearing of grudges (Vayikra [Leviticus] 19:18). The Torah also commands, “Thou shalt not hate thy brother in thy heart” (19:17). Similarly, the Qur’an emphasizes the need to forgive and the need to be forgiven by God: “Believers, even among your spouses and your children you have some enemies—​beware of them—​but if you overlook their offenses, forgive them, pardon them, then God is all forgiving, all merciful” (64:14); and “Whatever misfortune befalls you [people], it is because of what your own hands have done—​God forgives much.” As in Christianity, God’s forgiveness is predicated on forgiving others: “. . . let them pardon and forgive. Do you not wish that God should forgive you?” (24:22). The Qur’an promises that it is God who will reward the person who forgives: “Let harm be requited by an equal harm, though anyone who forgives and puts things right will have his reward from God himself” (42:40). According to the Hindu Dharma (cosmic law or order), forgiveness is considered one of the 10 cardinal virtues (along with courage, temperance, non-​ covetousness, inner purity, control of senses, reflective prudence, wisdom, truthfulness, freedom from anger) (Tiwari, 1998). The Dharma emphasizes that one must also seek forgiveness if one has wronged someone else. The great Hindu epic Mahābhārata (in which the Bhagavad Gita is contained), says: “Those who are forgiving have one flaw; there is no second flaw in them. And that flaw is that ordinary men consider the forgiving as weak. But, this must really be considered a flaw because forgiveness is indeed the greatest strength. Indeed, forgiveness is a virtue of 288 •  S ocial H ealth

the weak and an adornment of the powerful” (5.33.47–​48). In Buddhism, the second principle of the Eightfold Path is “right intention,” which emphasizes loving kindness (metta) and compassion (karuna), under which forgiveness falls. There are many statements in the Dhammapada that emphasize the need to forgive and release hatred (verses 4, 265, 291, 320, 390; Carter & Palihawadana, 2008). Thus, all major religious traditions emphasize the need to forgive others to attain a state of emotional and spiritual peace. See Rye et al. (2000) for further discussion of the understanding of forgiveness in the major world religions.

Social Capital As noted above, social capital involves community participation, volunteerism, social trust, reciprocity, and membership in civic, political, or social justice organizations. All major world religions endorse community participation; volunteering time or giving money for the benefit of others; acts of altruism; doing good to others (not only reciprocity, but even doing good to enemies and foreigners); and involvement in community organizations that promote moral and ethical values to ensure justice for all.

Other Social Determinants of Health Religion’s influences on social support, behaviors such as forgiveness that help to maintain relationships, and community activities that increase social capital may also impact many of the other SDH described earlier. Religion does so by encouraging prosocial norms and attitudes that lead to a reduction in alcohol/​drug addiction, delinquency, crime, and social disorder; counters discrimination, racism, and social status inequalities by emphasizing the equal value and rights of all persons; contributes to the formation of attitudes toward premarital sex, cohabitation, marital commitments, and the value of children that enhance family health; encourages moral values that reduce teenage pregnancy, HIV-​infection, alcohol/​drug addiction, and delinquency (thereby increasing the likelihood of acquiring an education and obtaining a high-​quality job that enables people to afford safe living environments and to

gain access to healthcare); and emphasizes the responsibility that individuals have toward one another, thereby supporting community-​based resources that care for the poor and homeless, as well as providing healthy recreational and leisure-​time activities that contribute to community health. Thus, by emphasizing and instilling prosocial values and behaviors, religion addresses many of the SDH in a way that avoids external forces that depend on ever-​ changing government and political systems.

Summary There is every reason, based on the core teachings of Christianity, Judaism, Islam, Hinduism, and Buddhism, to expect that religious involvement and religiosity might be related to greater social support, increased forgiveness (fostering supportive relationships), and greater social capital (involvement and concern with the health of the community), as well as to many of the other SDH. We now turn to what systematic quantitative research has found.

RESEARCH ON RELIGION AND SOCIAL SUPPORT We focus here on the highest-​ quality large prospective studies, making reference to meta-​analyses when they are available. We are particularly interested in evidence for a causal relationship between religiosity and SDH, focusing on social support, forgiveness, and social capital. Unfortunately, to our knowledge, there are no randomized controlled trials (RCTs) examining the effect of religious interventions on social support or social capital; however, several RCTs have examined the effects of forgiveness interventions, and at least two have examined religious forgiveness interventions, which we will review.

Social Support Based on our systematic review of quantitative research published prior to 2010, 74 studies were identified that had examined the relationship between religiosity and social support (Koenig et al., 2012). Of those, 61 (82%) found significant positive associations, and none of

the 74 studies reported significant negative associations. For example, in a 28-​year prospective study of 2,676 community-​dwelling adults in Alameda, California, Strawbridge and colleagues (2001) found that among those who saw fewer than three friends or relatives per month in 1965, attending religious services at least weekly at that time predicted a 62% increase in likelihood of seeing three or more friends/​ relatives per month by 1997 (OR =​ 1.62, 95% CI =​1.13–​2.31). Likewise, in a 3-​year prospective study of 854 community-​dwelling older adults (national US sample), Krause and Bastida (2009) found that frequency of religious attendance at Wave 1 predicted significantly greater emotional support at Wave II (β =​ 0.145, p < 0.001), controlling for Wave I emotional support. Prospective studies published since 2010 examining the effects of religious involvement on social support (social network size, social integration, perceptions of support quality, loneliness) have reported similar findings. Semplonius et al. (2015) conducted a 3-​year prospective study of 1,132 college students in Ontario, Canada, finding that greater involvement in religious activities at baseline predicted less difficulty with emotional regulation over time, controlling for baseline emotion regulation. Emotion regulation, in turn, predicted more social ties over time, controlling for previous social ties. Thus, while religious activity was not directly related to increases in social ties over time, it significantly increased social ties indirectly, acting through improved emotional regulation (b =​0.007, p =​0.004). Thompson et al. (2017) followed 218 African American women with breast cancer over a 2-​ year period, finding that religious/​spiritual (R/​ S) beliefs (assessed by the 15-​item Systems of Belief Inventory) were positively correlated at baseline with social support (assessed by the 19-​item Medical Outcomes Study Social Support Survey) in cross-​ sectional analyses (β =​0.31, p < 0.05). However, R/​S beliefs did not predict increases in social support over time, after controlling for age, employment status, education, household income, marital status, medical comorbidity, cancer stage, cancer treatment, insurance status, general health, and depressive symptoms, using growth curve Social Support • 289

modeling. Statistical power, though, may have been an issue since no variables (including depressive symptoms) predicted changes in social support over time. Orr and colleagues (2019) analyzed four waves of data collected during the Irish Longitudinal Study on Aging (ILSA) to examine the impact of religiosity on social support and depressive symptoms. The ILSA involved a nationally representative sample of 3,737 women and 3,022 men over age 50 in Ireland who were followed from 2009 (T1) to 2016 (T4). Religiosity was assessed at baseline (T1) and at each of the three follow-​ups (T2–​T4) by frequency of religious attendance and importance of religion in life (single items). Social support was measured by social connectivity (count of close relatives and friends) at all four waves. Latent growth curve models were used to analyze change in social connectivity over time, controlling for age, education, self-​ reported health, and marital status, stratifying analyses by gender. Results indicated that while religious attendance and importance of religiosity were cross-​sectionally related to social connectivity at T1, neither T1 attendance nor T1 importance predicted the slope of increasing social connectedness between 2009 and 2016. Similarly, neither changes in attendance nor changes in religious importance were related to increases in social connectedness over time. This was true for both genders. In a 17-​year follow-​up of a random sample of 2,479 Hispanic adults aged 65 or older living in the Southwest United States, Hill et al. (2019) used growth mixture modeling and multivariate multinomial logistic regression to predict the effects of religious attendance on social support trajectories from 1993 to 2010. Compared to those who never attended religious services, individuals attending services at any frequency were less likely to follow a low social support trajectory over time. Results were independent of age, gender, immigrant status, language proficiency, education, income, religious affiliation, marital status, living arrangements, contact with family/​ friends, secular group memberships, self-​esteem, smoking, heavy drinking, depression, cognitive functioning, and physical mobility. Researchers concluded: “. . . religious attendance and social support trajectories of 290 •  S ocial H ealth

older Mexican Americans is primarily driven by processes related to social integration, not selection [due to personality, health status, or health behavior]” (p. 403). Finally, Chen et al. (2020a) analyzed data from 92,008 US community-​dwelling adults participating in three prospective cohort studies consisting of young, middle-​aged, and older adults. Follow-​up time was 3 to 12 years, depending on the cohort. In these outcome-​wide analyses, attendance at religious services at baseline predicted an increase in social integration over time in middle and older cohorts combined (β =​0.26, 95% CI =​0.24–​0.28, p < 0.002, with Bonferroni correction, n =​81,146), independent of multiple physical health, health behavior, psychological distress, and psychosocial well-​being covariates. Importantly, the social integration variable used as the outcome was defined in terms of variables such as frequency of contact with friends and family and participation in nonreligious community groups, excluding religious groups. This is important because religious service attendance itself is a form of social support, so the estimate in this study corresponds to the effect of service attendance on subsequent forms of social integration other than attendance at religious services.

Loneliness In our systematic review conducted before 2010, we identified seven studies (all cross-​ sectional), of which four found inverse relationships between religiosity and loneliness and two found no association (Koenig et al., 2012). In the minority was one study that found greater loneliness among 240 cancer patients, caregivers, and volunteers in Israel who were more likely to use religion to cope. However, because all of these studies were cross-​sectional, it was not possible to determine, for example, whether religious participation decreases loneliness or whether lonely people cease religious participation; likewise, it is not possible to determine whether greater religious coping caused participants to be lonelier, or whether loneliness caused them to turn to religion to cope with their loneliness. At least five high-​quality prospective studies since 2010 have examined the relationship

between religiosity on loneliness over time. In a prospective study of 1,191 Israeli older adults age 75–​94, Cohen-​Mansfield and colleagues (2016) examined change in religious identity between 1989/​1992 (T1) and 1993/​ 1996 (T2, average 3.5 years later) and change in religiousness (retrospectively assessed over the past 20 years at T1) on change in loneliness. Loneliness was assessed with a single question asking about whether the person had felt lonely within the past month, although it is unclear whether this question was asked at T1 or at T2, or both. Results indicated that those who reported becoming more religious during the previous 20 years were more likely to have lower levels of loneliness (MANCOVA =​5.09, p < 0.01, controlling for age, gender, and education). However, those whose religious identity (orthodox/​ultra-​orthodox, traditional, secular) “changed” from T1 to T2 scored higher on loneliness (F for MANOVA =​4.00, p < 0.05); unfortunately, no breakdown was provided on whether the change was from secular to religious or from religious to secular. Given that no information was provided on when loneliness was assessed (or whether change in loneliness was measured), the effect of religious change on change in loneliness could not be determined. Much clearer are the results from a 6-​year prospective study of a national random sample of 6,403 persons age 16 years or older of Polish citizens (Pawlikowski et al., 2019). In an analysis of three waves of the biennial Polish household panel study (2009, 2011, 2015), researchers examined the effect of 2011 religious service attendance on loneliness in 2015 (assessed by a single question: “Do you feel lonely?”), controlling for physical, social, behavioral, and emotional well-​being (including loneliness) in 2009 prior to the assessment of religious attendance in 2011. Results indicated that compared to those who never attended religious services, those who attended to any extent in 2011 were less likely to report being lonely in 2015: a 23% reduction in loneliness was found for those attending services 1–​ 3 times per month (OR =​0.77, 95% CI =​0.62–​ 0.96), a 42% reduction for those attending weekly (OR =​0.58, 95% CI =​0.46–​0.73), and a 35% reduction for those attending more than weekly (OR =​0.65, 95% CI =​0.48–​0.89). The

findings persisted even after controlling for many possible social and psychological confounders and mediators of religion’s effect on loneliness, including level of civic engagement, participation in social life, satisfaction with leisure time, satisfaction with friendship relationships, trust of others, baseline health conditions, physical well-​being, health behaviors, and emotional well-​being (including satisfaction with life, depressive symptoms, worry, sleep, and energy level). In the Chen et al. (2020a) study above, frequency of religious attendance (once/​week or more vs. never) predicted significantly less loneliness in all three cohorts examined, with an overall weighted b =​−0.06 (95% CI =​−0.08 to −0.04, p < 0.002) with Bonferroni correction. In a 1-​year follow-​up of 564 Muslim adolescents in Indonesia, French et al. (2020) found that positive religious coping at T1 predicted a significant reduction in loneliness at T2, independent of T1 loneliness, gender, father education, and mother education (b =​−0.07, p < 0.05). Finally, K. Long et al. (2020a), in a 7-​year prospective study of a US national sample of 54,703 nurses, found that both religiously-​ motivated self-​ forgiveness and divine forgiveness predicted a significant decline in loneliness, independent of multiple covariates in outcome-​wide analyses.

Forgiveness As noted above, forgiving one another for hurts, disappointments, or betrayals is essential for healthy close interpersonal relationships, relationships that are often the most reliable sources of social support during times of need. In addition to forgiving and receiving forgiveness from one another, the willingness and ability to forgive oneself for past transgressions, as well as forgiving God and receiving forgiveness from God, are other aspects of forgiveness that are likely to impact health and well-​being. Is there any objective evidence that greater religiosity increases the capacity to forgive? Our systematic reviews of studies published prior to 2010 identified 39 studies (1 prior to 2000 and 38 between 2000 and 2010) that examined the relationship between religiosity and forgiveness; of those, 32 (82%) reported Social Support • 291

significant positive associations with religiosity, 5 found no association, and 2 reported mixed results (both positive and negative associations). All were cross-​ sectional except for 2 prospective studies, 2 experimental studies, and 2 RCTs. In the first prospective study, Tsang et al. (2005) surveyed 60 college students experiencing serious interpersonal transgressions within 2 months prior to the study (T1). Religiosity was assessed by the 9-​ item Allport Intrinsic Religiosity Scale, whereas revenge was measured by the Transgression-​ Related Interpersonal Motivations Inventory. Participants were re-​interviewed 2 months later (T2), when decreases in revenge were considered evidence of forgiveness. T1 intrinsic religiosity was significantly and inversely related to both T1 and T2 revenge scores and marginally predicted a reduction in revenge over time (change score) (r =​−0.22, p < 0.10, no controls). Krause (2010a) prospectively followed 696 adults age 66 or older for a 3-​ year period, examining the effects of religious involvement on self-​forgiveness. Religious involvement was assessed by frequency of religious attendance, private prayer, and church-​based religious support (i.e., emotional support from fellow church members and satisfaction with that support). Self-​forgiveness was measured by a single question: “I forgive myself for things I have done wrong,” which was assessed at baseline (T1) and 3 years later (T2). Regression analyses controlled for age, sex, education, marital status, and race, and T1 self-​forgiveness. Results indicated that only T1 emotional support from church members (“How satisfied are you with the emotional support you’ve received from the people in your church?”) predicted T2 self-​ forgiveness (b =​0.154, p < 0.001). Chen and VanderWeele (2018) analyzed data from the Growing Up Today Study (GUTS), where 5,681–​7,458 adolescents (average age 14.7 years) were followed from baseline (1999, T1) until 8–​14 years later (2007–​2013, T2). Investigators examined the effects of T1 religious service attendance and prayer/​meditation on T2 character strengths, including forgiveness of others. Analyses controlled for sociodemographic characteristics, psychological well-​being, mental health, maternal mental health, other character strengths, physical 292 •  S ocial H ealth

health, and health behaviors, and p-​values were adjusted using the conservative Bonferroni correction. Attending religious services at least weekly at T1 (compared to never attending) predicted a greater likelihood of forgiving others at T2 (b =​0.69, 95% CI =​0.61–​0.77, p < 0.0019). Likewise, praying or meditating once or more/​day at T1 predicted a greater likelihood of forgiving others at T2 (b =​0.83, 95% CI =​ 0.75–​0.91, p < 0.0019). The findings above are consistent with a meta-​analytic review by Davis and colleagues (2013) involving (1) 64 studies examining the relationship between religiosity/​spirituality (R/​ S) and “trait” forgiveness (n =​99,177); 50 studies examining “state” forgiveness (n =​8,932); and (3) 23 studies examining self-​forgiveness (n =​4,000). Results indicated that the average correlation between R/​S and trait forgiveness was r =​0.29 (95% CI =​0.26–​0.32); between R/​S and state forgiveness was r =​0.15 (95% CI =​0.10–​0.19); and between R/​S and self-​ forgiveness was r =​0.12 (95% CI =​0.06–​0.19). Researchers concluded: “These findings are consistent with prior reviews that have suggested a moderate relationship between R/​S and trait forgiveness and a smaller (perhaps inconsistent) relationship between R/​S and state forgiveness” (p. 238). However, this meta-​analysis included numerous cross-​ sectional studies, making evidence for causal inference and direction of causation unclear. At least two RCTs of a religious (vs. secular) forgiveness intervention by the same research group have also been reported. Rye and Pargament (2002) randomized 58 Christian female psychology students (mean age 18) to one of three groups: a secular forgiveness intervention (n =​20), a religious forgiveness intervention (n =​19), and a non-​ intervention comparison group (n =​19). The intervention was administered in a group format for a total of 90 minutes per week on 6 consecutive weeks. Forgiveness was assessed a 16-​item Forgiveness Scale based on the Enright Forgiveness Inventory, a 10-​item Forgiveness Likelihood Scale based on hypothetical situations, and a 10-​item Forgiveness Knowledge Scale. Participants were assessed at 1-​ week pre-​intervention, 1-​week post-​intervention, and 6-​ week follow-​ up. Time by condition

analyses demonstrated that, compared to the to detect differences between two successful nontreated control group, both religiously inte- interventions. grated and secular interventions significantly increased forgiveness on two of the three scales Social Capital (Forgiveness Scale and Forgiveness Concept Scale). No difference was found between sec- In our systematic review of studies published ular and religious forgiveness interventions. prior to 2010, we identified 14 studies that However, investigators reported that many examined the relationship between religiosparticipants in the secular condition reported ity and social capital (defined as community using religiously based forgiveness strategies participation; volunteerism; membership in (despite not being encouraged by group lead- ­community-​based, civic, or political/​social-​ ers), and noted that for many individuals, for- justice organizations; social trust; and/​or recgiveness is inherently religious. iprocity). Of those studies, 11 (79%) reported In the second study, Rye and colleagues significant positive relationships between (2005) conducted an RCT examining the effects religiosity and social capital. All were cross-​ of religious vs. secular interventions with the sectional studies, except for one prospective goal of increasing forgiveness toward an ex-​ study. Glanville and colleagues (2008) analyzed spouse. A total of 149 Midwestern divorced data from 12,258 participants in the National individuals (median age 45) were randomized Longitudinal Study of Adolescent Health to to one of three groups: a secular forgiveness examine the effect of religious involvement intervention, a religious forgiveness interven- on educational attainment and social capition, or a no-​intervention control. Secular and tal over a 7-​year period from 1994 (Wave I) religious interventions involved eight weekly to 1995 (Wave II) to 2001–​2002 (Wave III). group sessions lasting 90 minutes each. Both Religious involvement (Wave I) was assessed by religious and secular interventions involved frequency of religious attendance and participrocessing of negative feelings, learning about pation in religious youth activities. Social capforgiveness, and moving closer toward forgive- ital was assessed by intergenerational closure ness. In the religious intervention sessions (by asking parents the number of their child’s (conducted from a Christian perspective), friends’ parents they had talked to in the previparticipants were actively encouraged to draw ous month), friends’ grade point average (GPA), on their religious beliefs and sources of reli- friends’ truancy, involvement in sports extragious support, discussed scripture passages curricular activities, and involvement in other during the sessions, and were given homework extracurricular activities. Structural equation assignments related to prayer. Forgiveness was modeling was used in all analyses to control assessed by a 15-​item Forgiveness Scale, 17-​ for self-​image, bad temper, family satisfaction, item Observer Forgiveness Scale (completed household composition, adolescents’ grades, by an adult friend or family member), and 10-​ verbal ability (vocabulary score), ever being item Forgiveness Concept Scale. Participants held back in school, parents’ education, family were assessed at pre-​ intervention, post-​ income, race, ethnicity, sex, age, urbanicity, and intervention, and 6-​week follow-​up. Results Wave I GPA, truancy, and school attachment. indicated that compared to the nontreated Results of cross-​sectional analyses indicated control group, both religious and secular for- that at Wave I religious involvement was cross-​ giveness interventions significantly increased sectionally associated with higher intergenerscores on both the Forgiveness Scale and the ational closure (b =​0.091, p < 0.001), friends’ Forgiveness Concept Scale (but not Observer grades (b =​0.012, p < 0.001), lower friends’ Forgiveness Scale). No differences, however, truancy (b =​−0.016, p < 0.001), greater sports were found between secular and religious participation (b =​0.008, p < 0.05), and greater interventions on any of the three forgive- participation in other activities (b =​0.017, p < ness outcome measures. One should note, 0.001). Controlling for the earlier mentioned however, that in both of these trials, the covariates and, in addition, Wave I social capisample sizes were small, making it difficult tal variables (intergenerational closure, friends’ Social Support • 293

grades, friends’ truancy, sports participation, and other school participation), religious involvement predicted higher participant GPA at wave II (b =​0.019, p < 0.001), lower school dropout through Wave III (b =​−0.046, p < 0.001), and higher school attachment at Wave II (b =​0.013, p < 0.001). Thus, greater religious involvement at baseline was associated with higher measures of social capital, and both religiosity and social capital predicted better educational outcomes over the next 7 years. However, the impact of religious involvement on changes in social capital over time was not examined. Since 2010, at least five additional high-​ quality studies have been identified, all cross-​ sectional except for one prospective study. The cross-​sectional studies all reported significant positive correlations between religiosity and greater social capital. The single prospective study, however, did not find that religiosity predicted an increase in social capital over time. The single prospective study by Pawlikowski et al. (2019) discussed earlier involved a 6-​year longitudinal study of a national random sample of 6,403 persons age 16 years or older in Poland that included three waves of the Polish household panel study in 2009 (T1), 2011 (T2), and 2015 (T3). Researchers examined the effect of T2 religious service attendance on T3 general trust, an indicator of social capital (“Generally, do you believe that you can trust most people?”), while controlling for T1 physical, social, behavioral, and emotional well-​ being prior to the assessment of religious attendance at T2. The analyses gave a point estimate that attending religious services either weekly or more than weekly at T2 was associated an increase in likelihood of trusting people at T3, but the confidence interval was relatively wide and included the null (OR =​1.24, 95% CI =​0.95–​1.63, and 1.17, 95% CI =​0.83–​1.66, respectively), after controlling for indicators of happiness, life satisfaction, loneliness, depression, energy level, etc.

Altruism and Volunteerism Since altruism, generosity, and frequency of volunteering in a community are characteristic of social capital, we briefly review the findings 294 •  S ocial H ealth

relating religiosity to these behaviors. Prior to 2010, seven high-​quality studies examined the relationship with religiosity; all seven studies were cross-​sectional and reported significant positive relationships (see Appendix of this Handbook). Since 2010, at least 21 studies have examined the association, of which 16 found positive relationships (see Appendix). Among those 21 studies, 6 were prospective in design; all 6 reported that greater religiosity or spirituality at baseline, or increases of religiosity over time, predicted more altruism, generosity, or volunteering. For example, Krause (2015b) conducted a 3-​year prospective study of 1,154 US adults over age 50 examining the effect of religious involvement at baseline on volunteering. Results indicated that frequency of religious service attendance predicted an increase in volunteering over time, independent of sociodemographic confounders and baseline volunteering (b =​0.140, p < 0.001). In another example, Chen and VanderWeele (2018) followed 5,689–​7448 US adolescents (average age 15) for 14 years into young adulthood, examining the effects of religious upbringing (frequency of religious attendance and frequency of prayer or meditation during adolescence) on a wide range of outcomes, including frequency of volunteering. In these outcome-​wide analyses that included Bonferroni correction of p-​ values and controls for multiple confounders, researchers found that frequency of prayer/​ meditation at baseline predicted a significant increase in frequency of volunteering over time (b =​0.36, 95% CI =​0.29–​0.43, p < 0.002), as did baseline frequency of religious attendance (b =​0.28, 95% CI =​0.21–​0.35, p < 0.002). Finally, Neugebauer et al. (2020) analyzed data from a 5-​year prospective study of 230 community-​dwelling adults in New York City at high and low risk for major depressive disorder (MDD), examining the effects of importance of R/​S on altruism over time. Altruism was assessed by a 15-​item measure of compassion, social love, and human engagement. Analyses were controlled for age, gender, generation, depressive symptoms, negative life events, religious denomination, and frequency of religious attendance. Results indicated that those indicating at baseline that R/​S was highly important were more than twice as likely to engage in

altruistic activities at follow-​up (OR =​2.52, 95% CI =​ 1.15–​5.49, p =​0.02); effects were particularly strong in the group at high risk for MDD (OR =​4.69, 95% CI =​1.39–​15.84, p =​0.01).

Summary In the research published both prior to 2010 and since then, most studies report that religiosity is associated with greater social support (or with less loneliness) and predicts future increases in support (or reductions in loneliness) over time. This is consistent with the religious teachings of all major faith traditions that encourage love, care, and support for others, whether those others are within or outside the religious community. Religious community gatherings increase the number of social contacts and thus the potential for developing supportive relationships. Likewise, most studies examining the relationship between religiosity and forgiveness report a positive relationship, and religious interventions increase forgiveness to a similar degree as secular interventions (bearing in mind that participants in secular interventions may utilize religion to help them to forgive, whether instructed to or not). Greater forgiveness is likely to result in close social relationships that persist over time. Finally, in most studies, religiosity or spirituality is related to greater social capital (community involvement), greater altruism, generosity, and volunteerism, and predicts increases in these activities over time. Thus, religiosity in general (there are exceptions) appears to foster greater social support, greater social capital, and better relationship dynamics (as also found in Chapter 14). See Appendix for past and more recent studies.

RECOMMENDATIONS FOR FUTURE RESEARCH As always, there is a need for prospective cohort studies where religiosity is measured at multiple time points, along with outcome measures assessing social support and related social indicators of health, also at multiple time points. There have been only a few recent longitudinal studies with the specific aim of

examining the effects of religious involvement on social support over time, and more are needed. This is particularly true for studies that utilize high-​quality methods, as described in Chapter 3, that are capable of providing evidence for causal inference. Does greater religiosity increase social support over time, or does social support increase religious involvement over time? Important as well will be for researchers to study how different aspects of religion and spirituality affect social support. It may be, as some of the evidence above suggests, that religious service attendance has stronger effects on social support than religious beliefs or private practices, but further evidence on such questions is needed. Another important consideration, particularly for studies examining the effect of religious service attendance on social support, is that social support outcomes are defined independently of religious participation itself. As noted above, religious service attendance can itself be a form of social support and is often included in measures of social integration (Berkman & Syme, 1979; Berkman et al., 2014). Thus, if the purpose of a study is to examine how religious service attendance affects other forms of social support that are not distinctively religious, it is important that social support outcome measures do not include religious service attendance itself (Chen et al., 2020a). Personality factors also likely influence this relationship and should be routinely controlled for, as well as studied in their own right. Those with more extroverted and socially oriented personalities may find themselves more comfortable in religious community settings, compared to those who are introverted and more socially shy. Thus, these factors need consideration when conducting observational research (cross-​ sectional and prospective cohort studies). RCTs also are in short supply and greatly needed to determine if religious interventions that specifically target social support are effective, particularly compared with secular interventions that seek to do likewise. One question is whether religious interventions that provide religious rationales for seeking social support, forgiving others, or engaging in volunteer and other community activities are more effective Social Support • 295

than secular interventions. However, even if not, such religious interventions may nevertheless be helpful in ensuring greater outreach and use within religious communities themselves. Given the impact that social support, stable interpersonal relationships, and engagement in prosocial activities have on individual and community health, such intervention studies could provide clues on how to increase health and resiliency, both on the individual level and on the community level, thereby affecting public health more generally.

CLINICAL APPLICATIONS The provision of social and emotional support is a key aspect in all psychological interventions. Listening, reflecting back what is heard in a kind and respectful manner, and seeking to understand can provide great comfort to a person experiencing emotional turmoil. Most of those who are not seeking formal counseling depend on emotional and instrumental support from relatives and friends to cope with the daily challenges and stresses that are part of normal life. When taking a mental or physical health history, clinicians must evaluate how much social support a patient is currently receiving from family and friends, identify if there is conflict in these relationships, screen for loneliness, and educate him or her about the importance of such support for optimal mental and physical health. However, individuals will vary in their need for social interaction and support, which should be assessed and considered when developing a treatment plan (extroverts will in general need more, introverts less). The same objective level of social interaction can lead to different levels of subjective social connection or different levels of loneliness, depending on social needs. Based on the research reviewed in this chapter, religious forms of social support may be especially helpful and satisfying for many. If the patient is lacking in social support and open to seeking more, clinicians may consider encouraging them to join a religious congregation and/​ or engage in religious community activities to expand their social network. Religious organizations are readily available 296 •  S ocial H ealth

in every community, and as noted above, they promote religious beliefs that encourage support and care for one another. Initially attending with a family member or close friend may help to break the ice in terms of meeting others and establishing connections. Congregations vary in the degree to which members support one another, especially in terms of supporting new members, requiring that the patient shop around to identify a friendly and warm religious community that meets their social needs. Of course, any suggestions in this regard should be done in a patient-​centered manner, asking whether he or she has ever been affiliated with a religious group and about past experiences in this regard (which may be positive or negative). When prior experiences with religious communities have been negative, clinicians may help by clarifying whether this resulted from the nature of the community, from the expectations that the individual brought to it, or from a combination of both. Clinicians may also encourage patients who are socially isolated or lonely to find others with similar social needs and then provide support to them. Social contact can be initiated by efforts to be friendly and outgoing, asking how others are doing, and listening attentively. Most individuals will readily talk about themselves and their own challenges and needs. Not only may such efforts relieve one’s own loneliness, but they may also help to relieve depression or grief. This is particularly true for older adults. As persons age, they are increasingly likely to lose close friends and family members to sickness or death, and it may be difficult finding new friends and forming satisfying social contacts. Rather than waiting for others to initiate social contact, older adults should be encouraged to take the offensive (in a non-​offensive manner, of course) to establish new relationships. If religion is important to the person, whether young or old, there are many sacred scriptures that encourage reaching out to others in need and providing care and support to them (as described earlier). These scriptures can help to motivate religious individuals to reach out to others in a kind, caring, and helpful manner. Simple religious interventions may also be implemented to increase social support beyond encouraging membership in a religious

congregation. Attending religious services may be insufficient to establish social contacts and expand one’s social network. Clinicians may encourage clients to attend religious group activities outside of regular services, join a religious home group, attend a prayer or Bible study group, participate in religious education classes, or engage in religious volunteering. Religious volunteering with other members of a congregation is one of the quickest ways to establish relationships, since having a common goal and engaging in a prosocial activity together often helps to increase social bonds.

SUMMARY AND CONCLUSIONS In this chapter we have examined the relationship between religious involvement and social determinants of health with a focus on social support, forgiveness, social capital, and altruism. We first discussed SDH as they are currently understood (which emphasize the redistribution of money, power, and resources at the societal level by government and political systems). We have focused here, however, on what religiosity and participation in the religious community can provide at the individual level, especially in terms of access to social support, learning to give and receive forgiveness, as well as engaging in volunteer and other community civic activities that enhance social capital at the community level.

We examined genetic and developmental factors that influence the need for social support and the skills necessary to acquire it. We then explored the effects that social support, forgiveness, and social capital have on mental and physical health. The effect of religiosity on social support was then introduced by a case vignette that illustrated the impact that support from the religious community can have on a person’s ability to cope following traumatic loss. We next theorized how religion might impact (a) social support, (b) the ability to forgive others to maintain social relationships, and (c) the promotion of activities that build social capital, based on what is taught in the sacred scriptures of Christianity, Judaism, Islam, Hinduism, and Buddhism, and we speculated on the direct and indirect effects that religion may have on other SDH as well. The core of this chapter, however, involved a review of quantitative research that has systematically examined religiosity and its associations with or impact on social support, loneliness, forgiveness, social capital, and altruism, where we focused on prospective studies and, when available, experimental studies and RCTs. We concluded this chapter by making recommendations for future research and providing suggestions for clinical application. In the next chapter, we examine in greater detail the potential mechanisms relating religious participation to mental and social health.

Social Support • 297

SECTION IV Explanatory Mechanisms: Mental and Social Health IN THIS SECTION we include a single comprehensive chapter that examines how religious involvement may impact mental and

social health, acting through psychological, characterological, and communal mechanisms.

16 Understanding the Religion, Mental, and Social Health Relationship Science and religion are not at odds. Science is simply too young to understand. —​Dan Brown

R E L I G I O U S I N V O LV E M E N T H A S the potential to positively influence virtually every area of life, especially the psychological and social dimensions. It does so across the life span, beginning even before birth. While the potential is there, it does not always do so. Religion can also adversely affect mental health and well-​being at every life stage, so this too must be considered. Based on the research reviewed in the previous 15 chapters, however, it is clear that the majority of studies find that those who are more religious tend to be mentally and socially healthier. In this chapter, we explore how religion might impact mental health and well-​being, i.e., discuss the mechanisms by which religion has this effect. Those pathways are genetic, prenatal, environmental, psychological, social, behavioral, biological, and potentially unique to each individual. We will not comment on what some take to be supernatural pathways, as such questions are arguably beyond the bounds of the naturalistic

methods of science. The effects of religion and mental health are also bidirectional in nature, i.e., religion not only affects mental health, but also is affected by mental health. Before examining how religion might influence mental health, we briefly explore how mental health affects religion, since this may help to understand both the positive and the negative relationships that have been reported.

EFFECT OF MENTAL HEALTH ON RELIGION People who are mentally distressed, particularly those who are mentally ill, depressed, or demoralized, may be less able or less willing to engage in religious activities. For example, the depressed person often suffers from social withdrawal, feels tired, and has trouble concentrating, all of which will affect their ability to attend religious services, engage in prayer or meditation, read religious scriptures, or

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0016

participate in rituals and other religious practices. Depressive symptoms often include negative thoughts, doubts, and exaggerated feelings of guilt, which can adversely affect religious beliefs and attitudes. The emotional pain caused by depression may cause religious struggles including, for those from monotheistic traditions, feelings of being punished by God, doubts about God, or questions about God’s intentions and care. Similarly, a person with a substance use disorder may be overwhelmed by their addiction, leaving little time or energy for religious involvement. Likewise, their behavior may arouse feelings of guilt or shame, causing them to avoid attending religious services, praying, or reading religious scriptures. On the other hand, those who are happy, extraverted, and socially oriented may be more likely to engage in community religious activities. Similarly, those who by nature are more responsible, altruistic, forgiving, grateful, or have other temperamental dispositions influenced by genetic or developmental factors, may feel quite comfortable in religious environments that reinforce these positive traits. Such dynamics may help to explain the inverse relationships often found between religiosity and emotional and social disorders (rather than indicating that religion is having beneficial effects on these conditions). Other mental disorders may have the opposite effect. For example, those suffering from anxiety may be propelled by their symptoms to engage in religious activity in order to cope. Anxiety is a powerful motivator for religious beliefs and religious behaviors that the individual believes will help to relieve their distress. These possibilities are reflected in old adages such as “when you have nowhere to go, go to your knees” and “there are no atheists in foxholes.” Religion may be sought after to reduce discomfort or distress, just like medication or psychological counseling. Similarly, people with certain mental disorders or pathological tendencies may feel quite comfortable in religious settings, such as those with obsessive-​ compulsive disorder (OCD). An individual who prays or performs religious rituals repeatedly and compulsively may be admired as particularly devout and faithful by others in religious settings. Dynamics like these will lead

to a positive relationship between religiosity and mental distress or disorder, especially in cross-​sectional or short-​term prospective studies, potentially leading some to conclude that religion worsens these conditions (as Sigmund Freud argued). Indeed, the relationship between religion and mental health and well-​being is a complex one. At any one point in time, that relationship is due to multiple influences and bidirectional effects. Close attention to design and sample characteristics will be necessary to understand the many factors that ultimately explain the relationship between religiosity and mental health as reported in a study. In the rest of this chapter, we examine how religion might affect mental health in a causal manner, either positively or negatively. However, before examining theoretical causal pathways, we first review what is known from thousands of scientific studies about the primary determinants of mental health. These determinants may provide clues on how religion could have an influence.

DETERMINANTS OF MENTAL HEALTH Although many determinants of mental health have been discussed in earlier chapters, we summarize them here. Those determinants include genetic, prenatal, environmental, psychological, social, behavioral, biological, and individual-​level factors, as well as interactions between them.

Genetic Genetic factors play a major role in mental health, but questions remain as to the extent and in what manner. Most experts agree that genetic factors are not deterministic, but rather depend on environmental and individual-​level factors that contribute to a complex interaction of biological, psychological, and social influences that then result in a person’s state of mental health. For example, as discussed in Chapter 5, depression is one of the most common, disabling, and costly psychiatric disorders in the United States and around the world. Monozygotic twin studies (which examine

302 •  E x planator y M echanisms : M ental and S ocial H ealth

individuals with the same genetic code) indicate that the average correlation between identical twins on depressive disorder varies by age, with a correlation of 0.60 for those age 0–​11 years, 0.50 for age 12–​17, 0.39 for age 18–​64, and 0.34 for age 65 plus (Polderman et al., 2015). The overall heritability for depression hovers around 40%, and this estimate has not changed much in the past 20 years (Sullivan et al., 2000). Nevertheless, genome-​wide association studies (GWAS) have for some time failed to identify a single genetic variant or combination of variants responsible for depression (Dunn et al., 2014). Although some progress has been made recently (Wray et al., 2018), replication of GWAS findings has been difficult. The challenges may not be surprising, given that non-​genetic factors influence and interact with the large pool of genes likely responsible for depression in any one individual. However, the difficulty may also reflect the challenges in precisely defining the phenotype (observable characteristics of an individual resulting from the interaction of its genotype with the environment) and adequately characterizing depression. For other mental disorders, correlations in monozygotic twins likewise decrease with age, perhaps due to the accumulation of environmental influences over time (Polderman et al., 2015). For behavioral disorders, the correlation drops from 0.67–​0.77 at age 0–​17 years down to 0.50 for those over age 65; for anxiety disorders, the correlation decreases from 0.62 at age 0–​11 to 0.41 at age 18–​65; and for temperament/​personality, it decreases from 0.61 at age 0–​11 to 0.36 among those age 65 or older. Heritability estimates for schizophrenia and bipolar disorder are somewhat higher (see Chapters 6 and 9). The inheritance of mental health tendencies in general (including psychiatric disorders and psychological well-​being) is estimated to be around 49% (Polderman et al., 2015). Thus, genetic factors account for about 50% of a person’s mental state, indicating substantial influences from other factors.

Prenatal Genetic factors provide the raw material for later mental health. However, recent research

Table 16.1  Prenatal Factors Adversely Affecting Mental and Physical Health Later in Life Maternal smoking Maternal secondhand smoke (inhaled from partner smoking) Maternal alcohol use Paternal alcohol use (preconception) Maternal nonprescription illicit drug use Poor maternal diet Maternal depression or anxiety (affecting placental blood flow) Chronic maternal stress (affecting placental blood flow and slower central nervous system development) Stress in marital relationship affecting the mother Domestic abuse affecting the mother Maternal conflict about the pregnancy Infections during pregnancy (due to decreased immune function from stress or alcohol/​ drug use) Low social support

suggests that as the fetal brain develops in the womb, it is affected by many factors (Day et al., 2016) (Table 16.1). These factors can later impact mental health and psychological resiliency. The intrauterine period is a critical one for neural development when the foundations of language, cognition, and emotional regulation are formed (Klengel & Binder, 2015). Maternal stress during pregnancy has been associated with premature birth, decreased fetal heart rate–​ movement coupling (i.e., slower central nervous system development), and birth complications (Walsh et al., 2019). Maternal anxiety, depression, and stress appear to reduce placental blood flow, which may at least partly explain the adverse effects on fetal growth and development (Arabin & Baschat, 2017). Furthermore, exposing the developing fetal brain to high levels of circulating cortisol (released from the mother when stressed) alters the fetus’s stress response system after birth (Palma-​ Gudiel et al., 2015). Mothers who are stressed are also more likely to use substances such as alcohol, drugs, or nicotine, which adversely affect fetal brain development

Religion, Mental, and Social Health Relationship • 303

(Ross et al., 2015). In contrast, high levels of social support have been found to differentiate physiologically healthy pregnant women from those experiencing psychological stress (Walsh et al., 2019).

Early Childhood Environment Early environmental influences occur during the time immediately after birth, and during infancy and early childhood. After birth, the infant’s brain continues to develop rapidly, as it is now influenced by the care provided by primary caregivers. As noted in earlier chapters, a mismatch between infant temperament and caregiver nurturing can adversely affect the child’s later responses to stress (Thomas & Chase, 1977; see Chapter 11 as well). A stressed or otherwise preoccupied caregiver (due to an unwanted pregnancy, marital difficulties, other children, job responsibilities, substance abuse, etc.) may not be able to meet the infant’s basic need for nurturance and care during this vulnerable period. If not met, this will have a lasting impact on the child’s ability to form attachments, especially a sense of trust, which will then adversely affect later relationships and then ability to self-​regulate emotions. The end result may be difficulty acquiring and maintaining supportive social relationships necessary for buffering future life stressors (Beeghly et al., 2016).

Later Childhood Environment During later childhood (age 3 through adolescence), environmental factors continue to play an important role in later mental health and resiliency. Risk factors during this period include lack of healthy role models, inadequate monitoring of behavior, failure to instill ethical and moral values, and lack of exposure to prosocial peer groups (Blum et al., 1998). Teenage pregnancy, alcohol or drug use, and delinquent or antisocial behaviors may derail education and future job opportunities, leading to poverty, inability to afford mental healthcare, exposure to antisocial peer groups and unsafe neighborhood environments, increased risk of adult incarceration, and other situations that adversely affect mental health.

Adult Environment Environmental influences during adulthood continue to impact mental health. Traumatic events such as divorce or separation, incarceration, auto accidents due to reckless driving or substance use, accidents due to high-​risk behaviors, psychological and physical stress due to robbery, assault, or rape, and other negative life events increase risk of mental disorder and emotional problems.

Gene-​Environment Interactions As noted above, genetic factors may make one more or less vulnerable to the effect of certain traumas or environmental circumstances. Conversely, however, environmental influences can also potentially alter the effects of genetic factors. We briefly review the physical structure of genes, as this is relevant to gene-​environment interactions. In the human, there are 46 chromosomes in the cell nucleus that make up the genetic material that is passed on from generation to generation. Each chromosome contains genes composed of DNA nucleotide sequences that determine the cell type and function. DNA is stored as a code made up of four nucleotides (adenine, guanine, cytosine, and thymine), and during transcription produces messenger RNA (mRNA), which then guides the formation of cell proteins. Chromatin, which is composed of DNA and protein, is the material that makes up the chromosome. The protein part of the chromatin consists of “histones” that package and order the DNA nucleotide sequences in the chromosome. There are at least three different ways that the environment can influence the activity of genes (called epigenetic effects) without altering the DNA sequence of nucleotides (Al Aboud & Jialal, 2018). These are through (1) DNA methylation, (2) histone modification, and (3) non-​ coding RNA effects, each of which is involved in the turning on or off of genes. During DNA methylation, a methyl group is added to one of the four DNA nucleotides (cytosine, in particular). If that DNA nucleotide is located in the promotor region of the gene, this will turn off the gene (i.e., the transcription of the DNA into mRNA will not take place or will occur

304 •  E x planator y M echanisms : M ental and S ocial H ealth

at a much slower pace). Histone modification occurs when the histone protein is modified by acetylation, trimethylation, phosphorylation, or other mechanisms. Histone modification can lead to either an increase in gene transcriptional activation (by acetylation) or a reduction in transcriptional activation (by trimethylation). The third epigenetic pathway involves changes in non-​coding RNA (ncRNA), which is a functional RNA molecule that is transcribed from DNA but is not translated into proteins. These ncRNAs regulate gene expression or silence genes at the transcription and post-​ transcription levels. The environment, including maternal nurturing activities during critical periods of prenatal development (feelings and thoughts about the fetus) and during the early postnatal period of infancy (feelings, thoughts, and behaviors toward the infant) may affect gene structure by the process of methylation, which will affect later adaptive responses to psychological stressors (Denhardt, 2018). These changes in gene structure are then passed down from parent to child and then later from the child to their offspring, influencing stress-​reactivity of future generations (“the sins of the father . . .”; see quotes from early biblical and Greek times; Bartlett & Kaplan, 2002). Epigenetic effects may also occur after infancy, although less is known about such effects. Chronic stress during G1 (Generation 1) adolescence and adulthood has been shown in animal models to have epigenetic effects resulting in G2 (Generation 2, offspring of G1) deficits in social behavior and increased anxiety, deficits that are also passed on to their own G3 (Generation 3, offspring of G2) (Saavedra-​Rodriguez & Feig, 2013).

Psychological Positive thoughts and cognitions are recognized as essential for good mental health and resiliency (Scheier & Carver, 1993; Macleod & Moore, 2000; Carl et al., 2013). Indeed, this is the basis for cognitive therapy. Healthy coping behaviors in response to life stressors are likewise crucial for the maintenance of good mental health. These include humor, seeking support from others, problem-​solving, adjusting expectations, reappraising the stressor in a positive

light, accepting responsibility, and exercising self-​control (Chapter 4). Unhealthy or maladaptive coping behaviors include denial, dissociation, sensitization, anxious avoidance, escape (substance use), self-​blame, and behavioral disengagement. Family members, teachers, and peers who encourage and model healthy coping skills will help to support the development of healthy cognitions and behaviors.

Social Having a broad social network (including large extended family and friendship networks), particularly one that is readily available and supportive, enhances mental health and increases well-​being. This is especially true for prosocial support networks that contribute positively to the individual and to the community. As noted in Chapter 15, greater social support has been related in hundreds of studies to better mental health and more successful adaptation to life events that involve painful loss or unwanted change (see Thoits, 2011, and Holt-​ Lunstad et al., 2015, for reviews).

Behavioral Some behaviors are good not only for physical health, but also for mental health and well-​ being. These include regular exercise (White et al., 2017), a healthy diet (Tarelho et al., 2016), control of weight (Kolotkin & Andersen, 2017), adequate sleep (Freeman et al., 2017), safe driving habits (e.g., wearing seat belts) (Vaughn et al., 2012), safe sexual practices, low to moderate consumption of alcohol, avoidance of addicting drugs (Jane-​Llopis et al., 2006), cigarette smoking (Fluharty et al., 2016), vaping (Grant et al., 2019), and excessive caffeine intake (Wang et al., 2015). Although genetic, developmental, and environmental factors have a strong influence on health behaviors, individual decision-​ making and self-​ control also affect the adoption and maintenance of healthy habits (see below).

Biological Biological factors that influence mental health include chronic physical illness, physical pain,

Religion, Mental, and Social Health Relationship • 305

cardiovascular disease, disabling stroke, traumatic brain injury, progressive neurological and cognitive disorders (multiple sclerosis, Parkinson’s disease, dementia), and immune or inflammatory disorders. Physical illness can cause changes in functioning at any age that adversely affect independence, mobility, schoolwork or job, socioeconomic status, ability to participate in recreational activities, peer and family relationships, and may negatively impact brain regions that affect mood (Secinti et al., 2017; Doherty & Gaughran, 2014; Matheson et al., 2014). Biological influences on mental health often increase during later life, although when they occur during young or middle adulthood, such changes can be particularly devastating.

Individual Individual-​level factors include the decisions that people make that influence their mental health, including (1) those having to do with the treatment of friends, family members, and peers at school and work (e.g., whether to be patient, forgive others vs. seek revenge, be generous with time and money, help others, be honest and dependable); (2) decisions on how to respond to negative life events (e.g., to withdraw, deny, or suppress with drugs/​ alcohol, vs. confront, accept, reframe); (3) decisions on whether to seek healthcare when needed and comply with prescribed treatments; and (4) decisions about the use of time and money (Baron & Brown, 2012; Melnyk et al., 2006, 2013). The choices that people make have the potential to influence their mental health and well-​being, as well as affect the availability of resources (psychological, social, physical, and financial) when needed. C HARAC TE R, MORALS , AND V I RTU E S

Related to individual decision-​ making, and overlapping with psychological and behavioral factors that affect mental health, are habits or character traits that result from repeated personal choices over time. These habits/​traits, when positive and healthy, are often called “virtues.” The so-​called cardinal virtues, which

are sometimes thought to lay the foundation for all moral virtues, are prudence (practical wisdom), justice (giving to others what is their due), temperance (moderation, self-​ control), and fortitude (courage) (Pieper, 1990). These are sometimes supplemented in Christian traditions by the so-​called theological virtues of faith, hope, and charity (love). Other virtues (often subsumed under the cardinal virtues above) include humility, responsibility, patience, truthfulness, honor (respect for others), loyalty, friendliness (sociability), kindness (concern for others’ well-​being), and gratitude. Virtues are character traits that often attract people to one another and promote positive social relationships.

Interactions There is usually no single factor that accounts for a person’s mental health. As emphasized above, there is a complex interaction between genetic, prenatal, environmental, psychological, social, behavioral, biological, and individual-​level factors that determine a person’s well-​being, mental health, and resiliency. The effect of individual-​ level factors should not be underestimated, as the decisions and choices that a person makes can substantially impact their mental health and social relationships, regardless of any other factors that may be present.

HOW RELIGION AFFECTS MENTAL HEALTH Religious involvement has the potential to influence (or be influenced by) each of the determinants of mental health discussed above (see Figure 16.1). We now examine how religion might affect mental health through genetic, prenatal, developmental, environmental, psychological, social, behavioral, biological, and individual-​level pathways.

Genetic and Gene-​Environment Interactions As noted above, mental health problems often have genetic roots. Religious beliefs and practices, perhaps through the evolutionary

306 •  E x planator y M echanisms : M ental and S ocial H ealth

Religious Involvement (attendance, prayer, scripture study, volunteering, religious education, religious devotion, coping)

Prenatal Environment

Maternal Stress & Substance Use

Early Child Environment

Caregiver Nurturing & Support

Later Child Environment

Train/Model Morals & Values; Monitoring

Adult Environment

Trauma, Losses, Negative Life Events

Psychological

Positive Cognitions, Healthy Coping

Social

Support, Prosocial Peers, Volunteer

Mental & Social Health

Healthy Lifestyle

Behavioral

(exercise, diet, weight, no smoking, alcohol/drugs)

Individual/ Personal

Prosocial Choices, Healthy Decisions, Virtues/Character

Genetic Influences

Gene x Environment Interactions

FIGURE 16.1.  Theoretical model describing pathways by which religion may affect mental and social health.

selection of certain genes or perhaps through epigenetic influences, due to their adaptive nature may reduce vulnerability to mental disorders or affect the set point for emotional well-​being (see Chapter 12). There is some—​though limited—​evidence that religion may exert its effects through the presence of genetic polymorphisms that reduce risk of mental disorder. As noted in Chapter 10, this evidence is largely confined to substance use disorders (Dew et al., 2017; Beaver et al., 2009; Sasaki et al., 2011). As reviewed in Chapter 10, Dew and Koenig (2014) found that the SS and SL polymorphisms of the serotonin transporter gene (5HTTLPR) were less common in those who were more religious, especially among non-​Whites. Because SS/​SL genotypes are also less common among those who use illegal drugs, this could help to explain the lower drug use found in religious persons. Of course, this could also confound associations

between religious participation and genotype. Religiosity has also been shown to moderate the relationship between genetic risk and drug use, such that the effects of genetic risk are weaker among those who are more religious (Meyers et al., 2019). Despite these preliminary findings, there is a great need to further examine the influence of religion through genetic mechanisms both on substance use disorders as well as on other psychiatric disorders. Although largely speculative at this time, since there is little research that has examined this possibility, religious influences (as an environmental exposure) may impact gene structure and function through (1) devotional religious activities and healthy lifestyles of parents during pregnancy, (2) nurturing of the infant during the early postnatal period, and (3) perhaps the nurturing received during later childhood, adolescence, or adulthood through positive experiences of God’s love (for

Religion, Mental, and Social Health Relationship • 307

monotheists) or care received from members of a closely knit faith community. Several studies have reported intriguing results related to the modulation of gene expression through Buddhist meditation (Kaliman et al., 2014), Muslim religious interventions (Akbari et al., 2016), and Christian spiritual beliefs (Simons et al., 2019). What remains unclear is whether the epigenetic effects of religious involvement on gene expression can be transmitted from parents to children and future generations.

Prenatal Given numerous studies reporting that religious involvement can help to buffer stressful life events (see Appendix), improve coping (Chapter 4), reduce depression and anxiety (Chapters 5 and 8), decrease alcohol and drug use (Chapter 10), increase marital and family stability (Chapter 14), and increase social support (Chapter 15), there is a strong argument for maternal religiosity playing a role in enhancing the biochemical environment in which the fetal brain and nervous system develop during pregnancy (see Clements & Cyphers, 2020, for a summary of religiosity and substance use during pregnancy). This is likely to be an important pathway by which maternal religiosity could influence the mental health of offspring, even before birth. In fact, there is evidence for a positive effect of maternal religiosity on offspring depression and suicide from an intergenerational study of those at high and low risk for depression (Miller et al., 1997; Jacobs et al., 2012; Svob et al., 2018). There is also evidence of a positive effect of parental religiosity on offspring substance abuse (Miller et al., 2001) and adolescent sexual behavior (Landor et al., 2011). The challenge is determining whether the positive effects of parental religiosity on offspring mental health occur before or after birth, or both (see “Recommendations for Future Research” below). However, a recent randomized controlled trial (RCT) has provided evidence in this regard. Gilani and colleagues (2019) randomized 84 primiparous women (first pregnancy; gestational age 20–​28 weeks) in Shiraz, Iran, who scored average or weak on religious knowledge/​ attitude to either (1) a

religious intervention or (2) a control group. Those in the intervention group attended six 90-​ minute sessions of religious education held once/​ week (which taught Islamic religious principles based on the Qur’an), while the control group received routine pregnancy care. Head circumference at birth, motor skills, minor motor skills, major motor skills, and language skills at 1 and 3 months post-​birth were the primary outcomes. At baseline, there were no differences in age at pregnancy or education level between the two groups. Results indicated a significant between-​group difference in head circumference, favoring the religious intervention group (34.6 vs. 33.0, p =​0.026). Likewise, religious knowledge before delivery in the intervention group was significantly related to infants’ gross motor skills and major motor skills at 1 month of age and to language skills, major motor skills, and fine motor skills at 3 months of age (p < 0.05 for each).

Early Environment Parental religiosity could also have an impact during infancy and early childhood, when a sense of basic trust is established, the capacity for stable attachment develops, and personality begins to form (Chapter 14). Because religiosity may influence the occurrence of life stressors, coping behaviors, alcohol/​drug use and abuse, and family stability (including the desire to have children and the value placed on them), a child growing up in a religious family may have a better chance of having these emotional needs met. Being wanted (vs. being a burden due to overwhelmed parents with other problems and priorities; Stier & Kaplan, 2020), having mentally stable non-​substance-​abusing parents, and being surrounded by a supportive community may increase the infant/​young child’s chances of mental health later in life.

Later Childhood Environment Religious influences may have their greatest potential for impact during later childhood and adolescence, a time when rapid learning occurs and habits develop. Religious education (beginning during preschool or before in the home) seeks to instill moral and ethical values that will

308 •  E x planator y M echanisms : M ental and S ocial H ealth

affect the quality of social relationships and the health behaviors of these young people for the rest of their lives. This is especially important during the time when peer influences are particularly strong, such as during middle school and high school, when temptations to engage in thrill-​seeking are strong and experience is lacking. Emphasis on living by moral standards (as demonstrated by the moral behaviors of parents and religious educators) will help children and adolescents make decisions that will be good for them and for those around them. Frequent contact with a prosocial peer group, such as might be provided by religious education classes or a faith community youth group, may help to reinforce such moral standards and ethical values. Having two parents in the home to monitor youth activities is another positive influence that is more likely in religious families (see Chapter 14). As reviewed in Chapters 10 and 13, most systematic research shows that religious youth are less likely to use drugs and alcohol, less likely to engage in risky sexual activity resulting in a teenage pregnancy or sexually transmitted disease, less likely to participate in delinquent activity, and more likely to do well in school and complete their education. This makes for healthier, happier, and more socially responsible children, adolescents, and future adults (Bartkowski et al., 2008; Chen & VanderWeele, 2018). The positive effects of religiosity on mental health outcomes include those experienced by children of teenage mothers (Carothers et al., 2005; Bert, 2011).

and social support (Chapter 15) will also help religious persons weather the storms caused by negative life events. With fewer life stressors, less adversity to confront, and more social support come better mental health and greater well-​being.

Psychological Religious beliefs may enhance mental health by increasing positive thoughts and promoting healthy coping behaviors. In 1952, Norman Vincent Peale—​a well-​known clergyman during the twentieth century—​published The Power of Positive Thinking (Peale, 1952). The book was on the New York Times’ bestsellers list for 186 straight weeks, during which over 5 million copies were sold worldwide. Peale wrote the book based on the teachings of his Christian religious faith, with 4 of the 10 principles being explicitly religious. The core of positive thinking involves optimism and hope, both of which have been strongly related to religiosity (Chapter 12). As noted above, religious beliefs also emphasize healthy coping behaviors such as active coping, planning, positive reframing, seeking emotional and instrumental support, and acceptance, and in contrast, discourage negative coping behaviors such as denial, substance use, or behavioral disengagement (Chapter 4). Responses to stressful life circumstances affect mental health and well-​being in both the short and long term.

Social

Helping and supporting others is encouraged by virtually every major world religion Religiosity also affects experiences related to (Coward, 1986). Involvement in religious commental health during adulthood. Negative munity activities is not only associated with life events are less common among those who larger support networks and more social conare more religious—​ less divorce/​ separation tacts (Chapter 15), but also with a higher qual(Chapter 14), less criminal and antisocial activ- ity of support that endures long after social ity resulting in incarceration (Chapter 13), exchange is no longer possible. Social exchange fewer automobile accidents (Chliaoutakis et al., theory posits that human relationships are 2005; Nabipour et al., 2015; Tabrizi et al., 2017), based on the marketplace philosophy of maxless job loss due to underperformance (Osman-​ imizing profits and minimizing losses, i.e., “if Gani et al., 2013; Darto et al., 2015; Zahrah you scratch my back then I will scratch your et al., 2016), and fewer physical health problems back, but if you can no longer scratch my back, I and less disability (see Section VI). The strong will stop scratching your back” (Kim, 2016). The relationship between religious involvement reason why the social exchange principle does

Adult Environment

Religion, Mental, and Social Health Relationship • 309

not always apply to highly religious individuals is that they have other motivations for providing care and support to others, besides social exchange. Religious commandments encourage individuals to love one another (even to love one’s enemy), whether it is easy or difficult, whether the person returns the support or not, because of divine—​not human—​rewards. Thus, the “profits” from loving and supporting one’s neighbor for the religious person are more likely to outweigh the “losses” (effort or difficulty) because of promised divine rewards. For example, when people become physically ill or disabled (particularly in later life) and are no longer able to return social support to others, support from the religious community often persists. The most common source of social support for those age 65 or older, besides that received from family members, is from their religious community (Koenig et al., 1988b; Walls & Zarit, 1991; Krause et al., 2009c). While some cross-​ sectional studies have reported that the effects of religion on mental health are completely due to social interactions and support (Stavrova et al., 2013; Hovey et al., 2014), this is not the case in other studies. Both cross-​ sectional and prospective studies have found that social factors explain only a fraction of the effect of religiosity on mental health outcomes (Koenig, 2007a; Steffen et al., 2017; VanderWeele, 2017b; Lorenz et al., 2019).

Behavioral Religious involvement can also influence mental health by its effects on health behaviors. More than 80% of chronic medical illness could be avoided by implementing healthy lifestyle recommendations, i.e., regular exercise, healthy diet (Mediterranean), weight control, not smoking cigarettes or vaping, and developing emotional resiliency (Ford et al., 2009; Hyman et al., 2009; Bodai & Tuso, 2015; Bodai et al., 2018). Chronic medical illnesses include heart disease, diabetes, stroke, and cancer, which account for more than two-​thirds of all deaths worldwide (Bauer et al., 2014). Risky sexual activity, excessive alcohol use, and sleeping less than 7–​8 hours/​night contribute further to the risk of developing chronic medical illness (Liu et al., 2016). In the United States, more than

50% of the population has at least one chronic illness (Bauer et al., 2014), and 86% of all US health expenditures are due to treating chronic illness (NACDD, 2018). Religious involvement has been associated with better coping and greater emotional resiliency, less alcohol and drug use, less cigarette smoking, increased exercise, better diet, and less risky sexual activity (see Chapters 4, 5, 8, 10, 12, 17–​19, and Appendix). Thus, by promoting emotional resilience and encouraging healthy behaviors, religiosity could indirectly have a positive impact on mental health.

Biological Chronic medical illness, in turn, is associated with increased disability, greater dependency on others, and reduced financial resources, all of which are strong risk factors for poor mental health, reduced quality of life, and decreased well-​being (Cadman et al., 1987; Ormel et al., 1994; de Ridder et al., 2008). Many studies find that religious involvement is related to less heart disease (Chapter 20) and lower blood pressure (Chapter 21); less cerebrovascular disease (Chapter 22), dementia (Chapter 23), and cancer (Chapter 26); and reduced physical disability (Chapter 28). Religiosity is also related to less inflammation and better immune and endocrine function (Chapters 24 and 25), which will help to prevent both acute and chronic disease. Therefore, if religious involvement reduces chronic illness and improves physiological systems that lessen susceptibility to disease, it ought to enhance mental health and improve quality of life.

Individual Decisions and Choices As noted earlier, decisions that people make on a daily, hourly, and moment-​ to-​ moment basis result in the development of habits. Prosocial, other-​oriented habits influence the quality of relationships, availability of social support, productivity at school and work, and ultimately mental health. While individuals are not responsible for their genes, prenatal influences, or the quality of their early childhood nurturing, they are accountable for their later decisions and life choices. Early religious

310 •  E x planator y M echanisms : M ental and S ocial H ealth

education (whether obtained during or after religious services, attending religious schools, or at home) can help to instill moral values that help young people develop a habit of prosocial decision-​making (Havighurst, 1956; Maton & Wells, 1995; Halstead & Taylor, 2000; Huda et al., 2017). Religious schools are often more effective in doing so than public or secular schools (Moran & Jennings, 1983; Guttman, 1984; Tritter, 1992; Hofmann-​Towfigh, 2007). As a result, religious education has been associated with better mental health (Tavares et al., 2004; Eskin, 2004), although more research is needed (see below). By emphasizing the formation of good habits, religion may promote the development of positive character traits and virtues. Religiosity has been associated with a wide range of virtues in different populations (Krause & Hayward, 2015; Schnitker & Emmons, 2017; Sharma & Singh, 2019) and even in health professionals (Shepherd et al., 2018). Virtuous behaviors are not only strongly influenced by religion (Luna et al., 2017), but may even be viewed as having a transcendent or spiritual dimension. Positive psychology has documented the mental health benefits of virtuous behaviors such as forgiveness, gratitude, generosity, and altruism (Compton & Hoffman, 2019). Other virtues, as noted above, include equanimity, humility, patience, and accountability. Virtuous behaviors and attitudes do not usually come naturally but rather are “taught and caught,” based on early education and modeling that encourage repeated virtuous decisions and choices. Thus, the instilling of moral standards and values through religious education leads to virtuous choices, which have mental health consequences.

Interactions Mental health (and mental disorder) is the final result of genetic, prenatal, environmental, epigenetic, psychological, social, behavioral, biological, and person-​level decision-​making, all acting individually and together in a complex web of causation. Religion’s direct and indirect effects on each of these factors individually and in concert help to explain the overall influence of religion on mental health. In turn, each of

these factors also affect religiosity and religious involvement (through reverse causation), adding further to the complexity. This makes it difficult to track the exact mechanisms by which religion impacts mental health and the magnitude of that impact. Figure 16.1 summarizes the pathways by which religion may affect mental health and well-​being, although it fails to do justice to the many interactions that ultimately explain how religion increases (or decreases) well-​being or influences mental disorders. Although the causal direction of the effects in this model generally goes from left to right, bidirectional arrows are included to indicate the possibility of effects in the reverse direction as well, along with effects of the various domains and mechanisms on each other. Further research will be needed in order to refine this model and perhaps adapt it for specific religious traditions in different populations, since different belief systems and cultural factors almost certainly influence these relationships.

RECOMMENDATIONS FOR FUTURE RESEARCH Long-​term prospective studies are needed to evaluate the various aspects of, and relative effect sizes related to, the theoretical model illustrated in Figure 16.1. A single study to test the overall model would be difficult because of the length of follow-​up and the cost. If such a study were attempted, parent religiosity would need to be assessed prior to conception, during pregnancy, immediately after birth, and then periodically during infancy, and childhood. Religiosity and mental health outcomes would need to be assessed during adolescence (or whenever the child or adolescent is capable of providing accurate responses of their own to questionnaires), the later teen years, and then in young adulthood, middle age, and later life. Although such a study would be difficult since it would likely require a follow-​up period of 80 or more years, which would be enormously expensive and require multiple generations of researchers, there have been attempts on a more limited scale to empirically assess all aspects of the theoretical model explaining

Religion, Mental, and Social Health Relationship • 311

how religion affects health published in prior editions of this Handbook (e.g., see Kudel et al., 2011). Furthermore, multi-​generational studies on religion and mental health spanning 40 years and including three generations of participants have been reported in the literature and are currently ongoing (Svob et al., 2019). Rather than attempting to verify the entire model in a single study, however, more limited prospective studies and RCTs designed to examine specific pathways illustrated in Figure 16.1 might be more practical. Such an approach is also more feasible in terms of time and cost. Based on the results of future studies, as noted earlier, this model will need to be modified and expanded to refine our understanding of how religion (and especially specific aspects of religion) affects mental health and well-​being in different religions and cultures. Further longitudinal research is also needed to examine the impact of religious education on mental health outcomes over time. Of the studies that we could locate that have examined such effects, all are cross-​sectional in design. In order to examine such effects, participants would need to be assessed prior to their exposure to religious education (in grade school or high school), following completion of their religious education, and then periodically during young adulthood, middle age, and later life, with a control group for comparison. Besides assessing religiosity and mental health, we also recommend the measurement of moral virtues and ethical behavior, since these are likely to be important pathways by which religion ultimately influences mental health. Multiple assessments over time in longitudinal studies are needed to determine the role played by reverse causation in the relationships found between religion and mental health. As noted at the beginning of this chapter, reverse causation is especially likely to be present in those with depression or substance use disorders, where positive effects might be influenced by the effects of the mental disorder on religious activity. Reverse causation is also likely to be present among those with anxiety disorders, but possibly in the opposite direction, where the relationship between religiosity and anxiety could be due to the motivating effects of anxiety on religious activity in an attempt to relieve symptoms.

Finally, studies of gene expression following religious interventions are needed to determine whether religious experiences can impact mental health through gene-​ environment interactions. Despite being theoretically plausible and holding promise based on the results above, few if any high-​ quality intervention studies of this type have been conducted. Needed also are studies of gene expression among persons engaged in normal religious activity (e.g., attending worship services, private prayer, religious volunteering, listening to or singing religious music), across different religions and levels of religious devotion (e.g., levels of attachment to God).

CLINICAL APPLICATIONS The theoretical mechanisms described above by which religion could impact mental health may provide mental health and religious professionals with clues on areas to explore when taking a spiritual history and developing a treatment plan. In most instances, religion should be viewed as a resource, not a liability (although, as noted earlier, there are clear exceptions). Figure 16.1 will provide professionals with information about mechanisms that could help them untangle the complex relationship between a person’s religious beliefs and practices and their mental health. Such an understanding of the multiple pathways by which religion can affect mental health and by which mental health can affect religion will provide direction not only in terms of treatment, but also in terms of having compassion toward clients who are caught up in a complex web that involves their parents and their own past and present religious beliefs/​experiences and mental health problems. The complexity illustrated in Figure 16.1 also underscores the need for collaboration between mental health, religious, and medical professionals, all of whom play an important role in helping clients with mental health issues. No single health or religious professional can address all issues likely present, requiring a multidisciplinary team approach with close collaboration and communication between helping professionals. Mental health professionals should take the initiative to

312 •  E x planator y M echanisms : M ental and S ocial H ealth

partner with clergy/​chaplains and faith communities when treating religious individuals with mental health problems. Religious professionals, in turn, will need to take the initiative in screening, referring, and coordinating the care that members of their congregation may need. Helping professionals on such multidisciplinary teams should recognize the limits of their expertise, deferring to more specialized colleagues for some issues, as well as ensuring that all interventions are client-​centered. This includes seeking permission from clients to include other professionals in their treatment or to involve their faith community. Finally, given that the virtues (e.g., chastity, temperance, charity, diligence, patience, kindness, humility) and related attitudes/​ behaviors (accountability, generosity, respect for others, friendliness, truthfulness, being forgiving, being grateful) play an important role in the pathway that leads from religiosity to mental health, helping professionals should consider emphasizing these virtues when providing mental healthcare, spiritual direction, and religious education. When treating those with mental health problems, however, this must be done in a gentle and sensitive manner, without inducing guilt or shame, which may already be exaggerated as part of the mental disorder.

SUMMARY AND CONCLUSIONS In this chapter, we have explored how religion, religiosity, and religious commitment might

impact mental health and well-​ being. We began by discussing how mental health might impact religious beliefs and activities (reverse causation). The complex and bidirectional nature of these effects has been emphasized throughout the chapter. We examined well-​ established determinants of mental health, focusing on genetic, prenatal, environment, psychological, social, behavioral, biological, and finally, person-​level factors related to individual decisions and personal choices, and the interactions between each of these factors. After reviewing these predictors of mental health, we then focused on how religion might theoretically impact mental health and well-​ being through those pathways (Figure 16.1). We emphasized both the direct effects that religion may have on mental health through healthy coping behaviors and the indirect effects that religiosity may have on mental health acting (a) through the determinants of mental health mentioned earlier and (b) through the effects that these mental health determinants have on one another, resulting in a complex web of causal pathways from religiosity to mental health and well-​being. Finally, recommendations for future research were provided, along with suggestions for application by clinicians and religious professionals. This chapter concludes Sections III and IV on religion and mental and social health. In Section V to follow, we examine the impact of religiosity on health behaviors (cigarette smoking, exercise, and diet/​weight), perhaps some of the most important pathways by which religious beliefs affect physical health.

Religion, Mental, and Social Health Relationship • 313

SECTION V Health Behaviors IN THIS SECTION we examine the relationship with and impact of religion on health behaviors, specifically cigarette smoking, exercise, diet, and weight. As with mental and social health, the effects of religiosity are likely “proximal” and “direct” on these health behaviors (in contrast to how religion influences physical health, which is “indirect,” acting through mental, social, and behavioral health). The importance of examining health behaviors should be clear. Based on a recent study of 8,721 adults participating in the US National Health and Nutrition Examination Survey (NHANES) 2009–​2016 (Araújo et al.,

2019), only 12% of Americans (95% CI =​ 11%–​14%) were reported to be “metabolically healthy” as indicated by the following: a waist circumference of < 102 for men and < 88 cm for women; a fasting blood glucose < 100 mg/​dL; a hemoglobin A1c < 5.7%; systolic blood pressure < 120, diastolic blood pressure < 80 mmHg; triglycerides < 150 mg/​dL; high-​density lipoprotein (HDL) cholesterol of > 40 in men and > 50 mg/​dL in women, and not taking any related medication. Religious involvement is related to many of these metabolic parameters, most of the time through health behaviors.

17 Cigarette Smoking Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times. —​Mark Twain

IN THIS FIRST chapter on religiosity and health behaviors, we examine the relationship between religious involvement and cigarette smoking. Health behaviors have an enormous impact on mental and physical health and overall survival. More than 80% of chronic health conditions could be eliminated by adopting a healthy lifestyle that involves healthy eating, regular exercise, maintaining a healthy weight, preserving emotional resilience, and in particular, avoidance of cigarette smoking (Pasupathi et al., 2009; Cunningham et al., 2015; Carter et al., 2015). Without question, cigarette smoking is the health behavior with the greatest overall impact on health.

Addiction to Nicotine The addiction to nicotine resulting from chronic cigarette smoking is extremely difficult to break. Most people do not realize that nicotine is among the most addictive of all drugs and in the

same class as heroin, cocaine, and barbiturates (Schilling, 2019; Drazen et al., 2019). Although more than 70% of smokers want to quit, fewer than 10% are able to do so without medical support (NCHS, 2012; Rigotti, 2012). Nearly 80% of those who attempt to quit return to smoking within 30 days of quitting (most within one day of quitting), and each year, only 3% of smokers quit successfully (Benowitz, 2010; Hughes et al., 2014). The addiction to cigarettes begins early, and among adult smokers in the United States, more than half began to smoke before the age of 18 years (Ali et al., 2020). While approximately two-​thirds of young people in the United States try cigarettes, only 20%–​25% of those adopt the habit of daily smoking as adults (Johnston et al., 2007).

Prevalence and Predictors In 2012, there were over 1 billion smokers worldwide (928 million men and 207 million

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0017

women) (World Health Organization, 2014). Cigarette smoking in the United States is at an all-​time low, with current prevalence based on 2016 data being 17.1% (95% CI =​15.6%–​ 18.5%) (down from 42% in 1964), though prevalence varies across states from 8.8% in Utah to 24.8% in West Virginia (Hu et al., 2019). For use of smokeless tobacco (chewing tobacco, snuff, or dip), the prevalence is 4.0% (95% CI =​ 3.3%–​4.7%), ranging from 1.3% in the District of Columbia to 7.8% in Arkansas. For electronic cigarette (e-​cigarette) use, the current prevalence is 4.7% (95% CI =​3.9%–​5.5%), ranging from 2.4% in the District of Columbia to 6.7% in Oklahoma, with an overall lifetime prevalence of 22.1% (95% CI =​20.4%–​23.7%). In 2015, a systematic review of the literature reported that the predictors of smoking initiation among young persons were earlier age or school grade, lower socioeconomic status, poor academic performance, sensation seeking or rebelliousness, having family members or friends who smoke, and exposure to seeing people smoking in films (Wellman et al., 2016). In contrast, having high self-​esteem and greater parental monitoring or child supervision predicted a lower likelihood of smoking initiation. People with mental health problems are at particularly high risk for cigarette smoking. One recent study of a nationally representative sample of 5,592 US adults found that nearly 70% of 1,376 persons with severe mental illness (SMI) had a lifetime history of cigarette smoking and 48% currently smoked (compared to 41% and 21%, respectively, of those without SMI in that study) (Kalkhoran et al., 2019). Cigarette smoking is also associated with other dangerous behaviors, such as drugs use, fighting, carrying weapons, attempted suicide, and high-​ risk sexual behaviors. In 2019, the US Centers for Disease Control (CDC) reported that 53% of high school students (8.0 million) and 24.3% of middle school students (2.9 million) reported having ever tried a tobacco product (Wang et al., 2019). Nearly one-​ third of high school students (31.2%) reported a past 30-​day use of cigarettes, e-​cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, or bidis (4.7 million), and 12.5% of middle school students did likewise (1.5 million). Of all tobacco products, e-​ cigarettes were the most commonly used by 318 •  H ealth B ehaviors

high school students (27.5% or 4.1 million) and middle school students (10.5% or 1.2 million), followed in order by cigars, cigarettes, smokeless tobacco, hookahs, and pipe tobacco.

Health Consequences Cigarette smoking is a leading cause of preventable death in the United States and worldwide (Benowitz, 2010; ACS, 2019). Cigarette smoke contains a mixture of harmful chemicals, including cyanide, benzene, formaldehyde, methanol, acetylene, ammonia, and even small amounts of radioactive materials (depending on the type of soil in which tobacco plants are grown), as well as gases such as nitrogen oxide and carbon monoxide. Worldwide, cigarette smoking between 2005 and 2010 has been estimated to be responsible for 20% of the total mortality of adults age 40–​79 (24% in men and 12% in women) (Renteria et al., 2016). The likelihood that a lifelong smoker will die prematurely as a result of cigarette smoking is approximately 50%, with an average loss of at least 10 years of life (Doll et al., 2004; Benowtiz, 2010; DHHS, 2014). Cigarette smoking harms virtually every organ in the body and is responsible for nearly 500,000 deaths every year in the United States (DHHS, 2014). The most common causes of death from cigarette smoking in the United States are respiratory-​ related events (pneumonia, chronic bronchitis, etc.), cardiovascular disease, lung cancer, and malignancies other than lung cancer (Labaki et al., 2019). More specifically, compared to nonsmokers, smokers are more likely to die from laryngeal cancer (13 to 26 times), lung cancer (14 to 19 times), chronic obstructive pulmonary disease (11 to 18 times), aortic aneurysms (8 times), urinary bladder cancer (4 to 6 times), and lip or oral cavity cancer (4 times) (Lariscy et al., 2018). Cigarette smoking causes about 80% of lung cancers (especially small cell type) and 30% of all cancers (ACS, 2019). About 3% of lung cancers are due to secondhand smoke. The use of smokeless tobacco, while not as harmful to health as cigarette smoking, increases the risk of cancers of the upper aerodigestive tract, particularly the oral cavity, esophagus, and pancreas, and increases risk of cardiovascular disease (Pakhale et al., 2016).

Furthermore, many smokeless tobacco products available worldwide (such as slaked lime or khaini, and ingredients such as betel quid) are associated with serious and often fatal diseases due in part to increased levels of cancer-​causing nitrosamines, which may be 100 times higher in some international products compared those available in the United States (e.g., “Toombak”) (Idris et al., 1994; IARC, 2007). E-​cigarette use also has health consequences. E-​cigarettes are battery-​powered devices introduced in 2006 that deliver nicotine via aerosol by heating a liquid solution that contains propylene glycol and/​ or glycerin, nicotine, and flavors. E-​ cigarette use has been associated with increased heart rate, increased cough and wheezing, acute arterial endothelial dysfunction, myocardial and coronary vascular contractility, insulin sensitivity, and oxidative stress; in some cases, e-​cigarette aerosols can affect adolescent brain development and cause DNA damage, resulting in a future increased risk of cancer (Helen & Eaton, 2018; Thorndike, 2019). A recent alert from the CDC indicated that an outbreak of e-​cigarette or vaping product use has resulted in numerous reports of rehospitalization or death from lung injury (Mikosz et al., 2020). Although e-​cigarettes may be less harmful than smoking combustible cigarettes, they have the same risk of nicotine dependence as cigarette smoking and have biological effects (as noted above) that could adversely affect health outcomes, especially when started at a young age. This is particularly true for pregnant women who use e-​cigarettes, which may have adverse effects on the fetus (Murthy, 2017). Furthermore, e-​cigarettes can serve as a gateway that increases the risk of later switching to combustible cigarette smoking (Thorndike, 2019).

RELIGION AND CIGARETTE SMOKING Case Vignette Aaron is a 16-​year-​old high school student who is an average student, socially outgoing, and has a number of close friends at school who live in his neighborhood and with whom he occasionally

spends time on weekends and after school. His parents are quite religious and closely monitor his activities with friends. Aaron attends weekly synagogue, celebrates Jewish holy days, and participates regularly in Jewish social events with his parents and two younger sisters. He takes the bus to and from high school. One day, after he and two schoolmates get off the bus after school, one of them pulls out a cigarette and begins to smoke. Aaron and his other friend are surprised and ask the friend when he began to smoke. His friend tells him that he began about 6 months ago but until now has kept it a secret. The friend offers Aaron a cigarette, which Aaron somewhat reluctantly takes and tries a few puffs on, which cause a coughing fit when he inhales like his friend. He also feels a bit dizzy and strange headed. However, he doesn’t want to seem like a sissy, so he continues to smoke about a third of the cigarette before telling his friend he’s had enough. Once they split up, Aaron begins to feel guilty about what he has done as he walks home. His parents don’t smoke, nor do any friends in his synagogue’s youth group. When Aaron gets home, his mother greets him and asks him how his day went. As they talk, his mother notices a smoky smell on Aaron’s clothes. She asks him about it. He tries to change the subject, but she persists. Eventually, Aaron sheepishly confesses. When his father arrives home from work, both parents meet with Aaron to discuss the events of the day. They quietly ask him why he agreed to try smoking and what the experience was like for him. Aaron’s father explains the health risks of smoking and the potential for addiction. Aaron feels ashamed and tells his parents that he really didn’t like the experience and will not do it again. His parents both hug him and the matter is resolved. The next time his friend offers him a cigarette, Aaron politely refuses.   

Cigarette Smoking • 319

HOW RELIGION MIGHT IMPACT SMOKING

to which it is exposed (including cigarette smoking). In the Pali Canon (the most sacred scripture Theoretically, there are a number of ways that of Buddhism), the third step on the Eightfold religious involvement might impact the initi- Path involves “right action,” which proscribes ation of cigarette smoking or other nicotine-​ any actions that might harm a sentient being containing products, as well as affect the (Bodhi, 2010). Smoking would be viewed in likelihood of quitting. These include (1) reli- Buddhism as inflicting harm on a sentient gious beliefs that emphasize respect for the being, the person smoking. Thus, because physical body and avoidance of addicting sub- smoking harms the physical body as one dimenstances; (2) prosocial, law-​abiding peer group sion of the person, this behavior would be disinfluences that discourage underage smoking; couraged. The principle of non-​ attachment, (3) absence of smoking parental role models which is central to Buddhist belief, would also and lack of access to cigarettes; (4) careful par- apply here in terms of addiction to cigarettes ent monitoring and education that discourage or other nicotine-​containing products. The secsmoking; and (5) alternative methods of coping ond of the Four Noble Truths states that the with psychological or social stressors that may cause of suffering is “craving,” and to eliminate otherwise lead to smoking. suffering, craving (including the craving for cigarettes) must be done away with (Koenig, 2017f, p 15). Respect for the Physical Body While most major religious traditions (with certain exceptions, such as Latter Day Saints and Seventh Day Adventists) do not have specific teachings against cigarette smoking, they do discourage habits that harm the body. In Christianity, for example, the physical body is considered the “temple of the Holy Spirit” and believers are encouraged to glorify God with their bodies (1 Corinthians 6:19–​20). In Islam, based on teachings in the Qur’an and Sunnah, the physical body is considered a trust from God and is to be respected and cared for (Alahmad & Dekkers, 2012). The same is true in Judaism, where the Torah says that humans are created in the image and likeness of G-​d (Bereshit [Genesis] 1:26–​27) and should treat their bodies as such. In Hinduism, the physical body is referred to in Sanskrit as deham, where de means “to protect” and aham means “the individual Self” (Atman). Thus, deham (the physical body) protects the Self, and also assists in the Self’s continuation upon earth as a baddha, or bound soul (Jayaram, 2019). While the immortal and imperishable Self is distinguished from the perishable and physical body, the physical body is also compared to a temple of God where the chief deity is housed and worshipped. Thus, the body must be cared for in order to minimize dangers and vulnerabilities 320 •  H ealth B ehaviors

Peer Group Influences Federal law says that no one can purchase cigarettes in the United States before the age of 21 (this age was raised from 18 to 21 on December 20, 2019). Youth who are part of a religious community are more likely to be law-​abiding and prosocial (Chapter 13). Thus, a young person involved in such a community is likely to be surrounded by peers who do not smoke. Peer pressure to smoke, then, may be less among religious youth, resulting in a lower likelihood of these youth initiating smoking in their teen years.

Parental Role Models If parents do not smoke cigarettes, then children are less likely to smoke (see above). Not only do parents serve as role models, but if they do not smoke, their children and adolescents will have less access to cigarettes, especially since they are unable to purchase them. The only access these youth will have to cigarettes is from peers at school or in the neighborhood.

Parental Monitoring Religious parents are more likely to monitor their children’s activities (Chapters 13 and

14) and more likely to educate them about the dangers of smoking and the use of other nicotine-​containing products. Parents in religious households who regularly check on and monitor their youngster’s activities (as in the case vignette above) are more likely to identify attempts to start smoking, confront them about the activity, administer disincentives, and thereby prevent smoking initiation. Two-​ parent households are also more common among religious families, resulting in a greater capacity to monitor. A single parent who works all day to support a family will be limited in their ability to check on their youths’ activities during the day and after school.

Alternative Coping Strategy Religious involvement may also provide an alternative way of coping with psychological or social stressors that may cause some individuals to start or continue to smoke as a stress reliever. Religion provides coping behaviors such as praying, meditating, reading religious scriptures or other inspirational materials, and giving and receiving support from members of a religious community, all of which may reduce stress levels. If stress is lower, then reasons to smoke will be fewer. Based on the considerations above, there is reason to think that cigarette smoking should be less common among those who are more religious, whether children, adolescents, or adults. However, we will now examine what the systematic empirical research has found in this regard.

RESEARCH ON RELIGION AND SMOKING Given the pervasive negative effects of cigarette smoking and other nicotine-​containing products on mental and physical health, religious involvement has an enormous potential to impact health through this one behavior alone. In this section, we briefly review the research results prior to 2010, and then selectively summarize the largest and best-​designed prospective cohort studies examining the influence of religiosity on the initiation and cessation of cigarette smoking.

Early Research In the second edition of the Handbook, our systematic review identified 137 quantitative studies examining the relationship between religiosity and cigarette smoking published prior to 2010. Of those, 124 (91%) found that religiosity was inversely related to smoking in cross-​ sectional studies or predicted a lower likelihood of smoking initiation or greater likelihood of smoking cessation in prospective studies. Of the 17 prospective cohort studies with follow-​ups ranging from 1 to 29 years, 12 (71%) reported that religiosity at baseline predicted a lower likelihood of future cigarette smoking or a greater likelihood of quitting, and 5 studies (29%) found no effect (2 of the 5 on smoking cessation). In one of the largest and longest prospective studies to date, a 29-​year follow-​up of a random sample of 2,676 adults in Alameda County, California, conducted from 1965 to 1994, Strawbridge and colleagues (2001) found that those who attended religious services at least weekly in 1965 were 78% more likely to quit cigarette smoking by 1994 compared to those attending less than weekly (OR =​1.78, 95% CI =​1.22–​2.61), an effect that was especially strong in women.

Recent Research Since 2010, there have been at least 15 additional prospective studies, with all 15 reporting at least some evidence for less use of cigarette or other nicotine-​containing product in those who were more religious at baseline, though in a few cases the results are not definitive. We now briefly review some of those studies below in order of year of publication (see Appendix for full list). Hodge and colleagues (2011) conducted a 2-​ year prospective study of 804 Latino students (average age 11) from low income, inner-​city neighborhoods living in the Southwest United States. The purpose was to examine the effects of religious affiliation, religious attendance, and importance of religiosity on the students’ use of alcohol, cigarettes, marijuana, and inhalants. Results indicated that youth who said religion was very important at T1 were 22% less likely to report lifetime use of cigarettes at T2, Cigarette Smoking • 321

controlling for demographics and other indicators of religious involvement (OR =​0.78, 95% CI =​ 0.63–​0.96). In a 10-​year prospective study of a national random sample of 4,496 middle-​age US adults (average age 48 at baseline), Bailey et al. (2015) examined the effects of religiosity on tobacco smoking. Religiosity was assessed by frequency of religious attendance, importance of religiosity, importance of spirituality, religious/​ spiritual comfort seeking, and religious/​spiritual decision-​ making. Four categories were created for each religious variable, based on scores obtained at baseline and follow-​up: high-​ high, high-​low, low-​high, and low-​low. Logistic regression analyses controlled for age, gender, race/​ethnicity, income, and education. Results indicated that those with high-​high religious attendance were significantly less likely than those with low-​low attendance to be a persistent smoker (OR =​0.30, 95% CI =​0.22–​0.41, p < 0.001) or an ex-​smoker (OR =​0.51, 95% CI =​ 0.34–​0.76, p < 0.001). Those who were high-​high on religious importance were also significantly less likely than those with low-​low religious importance to be a persistent smoker (OR =​0.61, 95% CI =​0.47–​0.79, p < 0.001) or an ex-​smoker (OR =​0.66, 95% CI =​0.47–​0.93, p < 0.05). Similarly, those who were high-​high on spiritual importance, religious/​spiritual comfort seeking, or religious/​ spiritual decision-​ making were all significantly less likely to be a persistent smoker. Religious involvement, however, was not associated with smoking cessation among smokers at baseline; and in fact, with regard to attempts at cessation that were unsuccessful, those with high-​high religious attendance (compared to low-​low) were 90% more likely to have made an unsuccessful attempt between baseline and follow-​up (OR =​ 1.90, 95% CI =​1.00–​3.58, p < 0.05), which may be due to more attempts (ultimately unsuccessful) to stop smoking among those with high-​ high religious attendance compared to those with low-​low attendance. Chen and VanderWeele (2018) followed 5,681–​7,458 adolescents (average age of 14.7) from baseline (T1) to 8–​14 years later (T2). The effects of T1 religious attendance and prayer/​ meditation on T2 cigarette smoking were examined. Controlling for age, race, sex, 322 •  H ealth B ehaviors

geographical region, prior health status or health behaviors, mother’s age, race, marital status, socioeconomic status, mental health, depression, health behaviors (including prior smoking) and psychological well-​being (with Bonferroni correction), attending religious services at least weekly or more at T1 (vs. never) predicted a 15% lower risk of cigarette smoking at T2 (risk ratio [RR] =​0.85, 95% CI =​0.76–​ 0.96, p < 0.0019). Likewise, T1 praying/​meditating once per day or more at T1 (vs. never praying/​meditating) predicted an 11% lower likelihood of cigarette smoking at T2 (RR =​ 0.89, 95% CI =​0.78–​1.00, p < 0.05). J. L. Lee et al. (2019) followed a community sample of 674 adolescents (53% African Americans and 47% Puerto Ricans) attending schools in Harlem, New York City, from an average age of 14 to an average age of 36 years in this 22-​year prospective study. Adolescent risk and protective factors were examined for use of alcohol, tobacco, and cannabis. Family church attendance at T1 was assessed with a 3-​item index: “How often: (a) do you attend religious services, (b) does your mother attend religious services, and (c) does your father attend religious services?” Multivariate growth mixture models were used to identify six trajectories of substance use, which served as the primary outcomes: (1) increasing alcohol use, increasing tobacco use, moderate cannabis use (IAITMC); (2) moderate alcohol use, low tobacco use, low cannabis use (MALTLC); (3) moderate alcohol use, high tobacco use, high cannabis use (MAHTHC); (4) increasing alcohol use, increasing tobacco use, and increasing cannabis use (IAITIC; worst trajectory); (5) increasing alcohol use, low tobacco use, increasing cannabis use (IALTIC); and (6) low alcohol use, no tobacco use, and no cannabis use (LANTNC; best trajectory). Predictors of trajectory were analyzed using multinomial logistic regression. Results indicated that family church attendance at age 14 predicted a lower likelihood of being in the IAITIC group (worst trajectory, which included increasing tobacco use) compared to the LANTNC group (best trajectory, which included no tobacco use) (adjusted OR =​0.75, 95% CI =​0.60–​0.92, p < 0.01). Researchers concluded that “family church attendance may act as a protective

factor against deviance such as substance use in adolescence” (p. 7). In a 2-​year prospective study of 327 medical students in Brazil, Moutinho and colleagues (2019) examined the effects of religiosity on alcohol use, cigarette smoking, and drug use. Religiosity was assessed by the 5-​item DUREL (organizational, non-​ organizational, intrinsic religiosity), substance use by the Alcohol, Smoking and Substance Involvement Screen­ ing Test (ASSIST), and mental health by the 21-​item Depression Anxiety and Stress Scale (DASS). Data were collected every 6 months, resulting in four waves over the 2 years. Stepwise regression was used to control for undergraduate semester, gender, age, income, race, religious measures, and mental health scales. The highest incidence among all substances used during the 2-​year follow-​up was tobacco (cigarettes, chewing tobacco, cigars, etc.). Results indicated that non-​organizational religiosity predicted a significant decline in tobacco use over time, independent of baseline tobacco use (B =​−0.27, SE 0.08, p =​0.001). Martin et al. (2019) conducted a 4-​year prospective study of 53,650 current female smokers in the United Kingdom (average age 58.3) from 2001 to 2005. The purpose was to examine baseline factors in 2001 that predicted cessation of smoking by the 2005 follow-​up. Among possible predictors were social activities, one of which was participation in a “religious group” (7.7% of the sample). Other social activities included volunteer work, adult education, art/​ craft group, dancing group, sports club, yoga, music/​singing group, and bingo. Logistic regression was used to identify independent predictors of smoking cessation between baseline and the 4-​year follow-​up. Among possible predictors were marital status, economic deprivation, education, and type of social participation. Results indicated that 31% had stopped smoking during the 4-​year interval. Although participation in a religious group in unadjusted analyses predicted a 16% increased likelihood of smoking cessation (OR =​1.16, 95% CI =​ 1.06–​1.26), this effect was reduced to nonsignificance (OR =​1.05, 95% CI =​0.96–​1.15) after controlling for age, age of smoking initiation, average number of cigarettes smoked per day, time between surveys, and self-​rated health.

Pawlikowski et al. (2019) analyzed data from three waves of a biennial longitudinal Polish household panel study, which initially assessed a random sample of 26,243 individuals age 16 or older in 2009 (T1). They examined the effect of 2011 (T2) religious service attendance on health behaviors and well-​being in 2015 (T3), controlling for T1 demographics, financial situation, civic engagement, health conditions, alcohol use, physical activity, emotional well-​ being, and prior smoking in 2009 before the assessment of religious attendance in 2011. Although numerous health behaviors were assessed in that study, the outcome variable of interest in this chapter is “smoking tobacco products every day.” A total of 6,468 persons participated in all three follow-​ups. Compared to those not attending religious services, those attending religious services 1–​3 times/​month at T2 experienced a 32% reduction in smoking by T3 (OR =​0.68, 95% CI =​0.54–​0.85); those attending 4 times per month experienced a 43% reduction (OR =​0.57, 95% CI =​ 0.44–​0.74); and attending more than 4 times per month predicted a 66% reduction (OR =​ 0.44, 95% CI =​0.31–​0.64). Importantly, these findings demonstrated a “gradient in effect” for frequency of religious attendance in predicting a reduction in smoking, providing evidence for causality. C. Zhang and colleagues (2019) examined the effects that trajectories of religious service attendance from age 14 to 43 had on nicotine dependence by age 43. A random sample of 543 mothers and their children living in Albany and Saratoga Counties in upstate New York were enrolled in this longitudinal study from 1975 (T1) to 2012–​2013 (T8). Children were assessed in 1983 (T2, average age 14) through 2012–​2013 (T8, average age 43). Religious service attendance was assessed from T2 to T8 in children by the question: “How often do you go to church or temple to attend religious services?” with response options from “never” to “once a week or more.” Nicotine dependence (DSM-​IV) was assessed at T8 using the UM-​ CIDI nicotine dependence structured interview. Six trajectories of religious service attendance were identified using growth mixture modeling: (1) non-​ attendance at all time points (13%); (2) weekly/non-decreasing attendance Cigarette Smoking • 323

(11%); (3) weekly/​occasional decreasing attendance (32%); (4) occasional/​ non-​ decreasing attendance (12%); (5) occasional stable (20%); and (6) weekly stable (12%). Controlled for in all analyses using multivariate logistic regression were gender, T8 age, T2 family income, T2 highest parental education, T2 maternal religious service attendance, T2 mother cigarette smoking, T2 mother hard liquor use, T2 child cigarette smoking, and T2 hard liquor use. Results indicated that those in the weekly stable group (#6) had the lowest prevalence of nicotine dependence at T8 (8.1% vs. 20.7–​37.3% for all other trajectories, p < 0.01). Logistic regression analyses indicated that those in the non-​ attendance group were over three times more likely to have a nicotine dependence disorder at T8 compared to those in the weekly stable group (adjusted OR =​3.35, 95% CI =​1.00–​11.19, p < 0.05). Those in the trajectory involving weekly attendance at age 14 transitioning to no attendance group after age 25 were more than four times as likely to have a nicotine dependence disorder at age 43 (adjusted OR =​4.06, 95% CI =​1.25–​13.22). In the four most recent prospective studies that followed a combined sample of nearly 100,000 community-​dwelling adults and children for 3 to 14 years, all four reported a significant decline in tobacco use over time for those with some form of religious participation or identity (Y. Chen et al., 2020a; Sartor et al., 2020; Upenieks et al., 2020; Ross et al., 2020) (see Appendix). S U M MA RY

As summarized in greater detail in the Appendix tables, more than 90% of cross-​sectional studies (of 120 conducted prior to 2010 and 40 high-​quality studies from 2010 to 2019) found that greater religiosity was inversely related to cigarette smoking. Likewise, in over 75% of 17 prospective studies conducted prior to 2010 and in 100% of 15 retrospective or prospective cohort studies from 2010 to 2020, greater religiosity predicted a lower likelihood of cigarette smoking over time (either no smoking initiation or smoking cessation). Among those who do smoke, religious persons may be more likely to attempt to quit smoking, although at least 324 •  H ealth B ehaviors

one study found that it may take considerable effort by these individuals to do so (Bailey et al., 2015). Although prospective studies are not capable of definitively establishing causality, they can provide some evidence for it. Thus far, most of that evidence points toward the conclusion that religious involvement prevents the onset of cigarette smoking and increases the likelihood of quitting. To our knowledge, no randomized controlled trial (RCT) has yet examined the effects of a religious intervention on cigarette smoking cessation among those who smoke.

RECOMMENDATIONS FOR FUTURE RESEARCH More cross-​sectional studies demonstrating an inverse relationship between religiosity and cigarette smoking are probably not needed, given the evidence that has already accumulated. Numerous high-​ quality prospective cohort studies have now also been done. However, the vast majority (over 80%) of prospective studies have been conducted in the United States. Relatively few such studies have been conducted in other countries (e.g., Sperber et al., 2001, in Israel; Hoving et al., 2007, in Europe; Benjamins et al., 2008, in Mexico; Yong et al., 2009, in Malaysia/​Thailand; Ahrenfeldt et al., 2018, in Europe; Moutinho et al., 2019, in Brazil; Pawlikowski et al., 2019, in Poland; and Martin et al., 2019, in the United Kingdom). The findings appear to be strongest in more religious countries such as the United States, Brazil, Mexico, and Poland, but weaker in more secular world regions (although often present in those area as well). More longitudinal research, then, could be done in countries outside the United States, especially in regions of the world with high rates of smoking such as Russia, Eastern Europe (e.g., Serbia, Croatia, Latvia), Southern Europe (e.g., Greece), the Middle East (e.g., Jordan, Lebanon), Indonesia, and some Micronesian countries (e.g., Kiribati and Nauru, where nearly half of the population smokes). Such studies should begin during childhood, prior to when cigarette smoking often begins, and follow participants up through young adulthood and middle age (after which smoking initiation

seldom occurs). Careful attention to family and peer smoking behaviors will be necessary (and controlled for), given their strong impact on smoking initiation. Religion may be particularly helpful in preventing smoking initiation, although it may also help individuals to quit if their faith provides a resource to help them keep trying. While much of the evidence above may seem fairly strong, further attention could be given to methodological procedures and appropriate analysis of longitudinal data. For example, two studies described above considered trajectories of religious participation (Bailey et al., 2015; Zhang et al., 2019). In settings in which the prior outcomes (e.g., smoking) do not affect subsequent exposure (e.g., religiosity), such approaches can be valid. But when there is the possibility of feedback over time, then using trajectories in a naïve way can result in substantial biases (Robins et al., 2000; VanderWeele et al., 2016a). In the case of smoking and religious participation, it is quite possible that those who begin smoking are more likely to subsequently withdraw from a religious community due to potentially feeling they are not conforming to social and/​or religious norms, and this feedback can introduce bias into analyses of trajectories. Alternative methods for causal inference are available to handle such time-​ varying exposures and trajectories in the face of feedback (Robins et al., 2000; VanderWeele et al., 2016a), but these methods were not used in the studies considered above, which might thus be biased. More work could be done on examining the potential effects of trajectories of religious service attendance with appropriate methods that handle feedback. Similar considerations arise when thinking about smoking as either a potential mediator or a potential confounder of the effects of religiosity on other health outcomes such as mortality. Some analyses adjust for smoking behavior when examining the relationship between religiosity and physical health outcomes, on the grounds that it may be a confounder since it could affect whether someone participates in religious services. Other analyses do not adjust for smoking behavior on the grounds that it may be a mediator for the effects of religious service attendance on mortality, since religious

service attendance can affect smoking, which then alters mortality risk. It can thus be confusing to discern how to proceed. In actuality, smoking behavior may be both a confounder and a mediator for the effects of religious service attendance on subsequent health, with prior levels of smoking (temporally preceding the service attendance exposure) being a confounder, but with subsequent levels of smoking being a mediator. When trying to estimate the overall effect of religious service attendance on subsequent health, it is thus appropriate and important to adjust for prior levels of smoking, but important not to adjust for subsequent levels of smoking (VanderWeele, 2015). This once again highlights the importance of using longitudinal data with multiple waves of data. One cannot distinguish between confounders and mediators with cross-​sectional data, but with longitudinal data one can do so by using the available data at different time points. Although longitudinal studies are expensive, the cost of cigarette smoking and use of other nicotine-​containing products on public health and healthcare expenditures is enormous. In the United States alone (where the rate of cigarette smoking is relatively low at 17% compared to the rate in Russia, for example, at 41%), the healthcare cost of cigarette smoking has been estimated at $300 billion per year (Xu et al., 2015). In one region of Russia that makes up only 14% of the total Russian landmass, the Krasnoyarsk region (krai) where 46% of the population smokes cigarettes, the economic cost of cigarette smoking due to premature mortality has been estimated at almost $700 million, a significant fraction of the gross domestic product of the region (Artyukhov et al., 2016). As noted above, RCTs of religious interventions in smoking could help to establish valuable tools to assist with smoking cessation efforts. A number of smokers might be open to such interventions. One study conducted in the Northwest United States (the least religious region of the country) found that among 105 smokers, 88% indicated they had spiritual resources, i.e., spiritual practices or belief in a Higher Power. Of those, 78% reported that spiritual resources might help them to quit, and 77% said they were open to having their Cigarette Smoking • 325

providers encourage use of spiritual resources when quitting (Gonzales et al., 2007). Ideally, an RCT might enroll religious patients with a chronic habit of daily smoking (individuals likely to have the most difficulty quitting). These individuals could be randomized to receive either a standard smoking cessation intervention (of which there are many; see T. J. Brown et al., 2016, and Akanbi et al., 2019) or a religiously integrated version of a standard smoking cessation intervention. This religiously integrated version might be developed for use across a range of faith traditions (Christian, Jewish, Muslim, Hindu, Buddhist), although it could also be religion-​specific, taking advantage of specific core religious beliefs and practices of each tradition to help motivate quitting. Such a study would be relatively simple and would not be prohibitively costly. Given the demonstrated success of motivational interviewing in smoking cessation (Lindson et al., 2019), the development of religious interventions could be informed by its principles. Those principles involve exploring with clients the reasons why they may feel unsure about quitting and helping them to discover ways to increase their willingness to quit, instead of telling the person why and how this should be done, thus allowing participants to choose to their own strategies for smoking cessation, thereby increasing their confidence in doing so. At least one spiritually oriented program for smoking cessation is now available, Nicotine Anonymous (see below), although to our knowledge no research has been done to demonstrate its effectiveness in helping people quit. Testing the benefits of spiritual/​ religious programs such as Nicotine Anonymous should be a high priority for future research (Glasser, 2010).

CLINICAL APPLICATIONS Whether the provider is a health professional or religious professional, consideration should be given to encouraging religious individuals who smoke to use their religious resources to help them cut down or quit smoking (using a person/​patient/​client-​centered approach, as usual). Such encouragement should not be done until after taking a thorough spiritual history, 326 •  H ealth B ehaviors

including questions about their cultural traditions. The same applies to use of other nicotine-​ containing products, such as cigars, smokeless tobacco, and e-​cigarettes. Patient or client education on the impact of smoking on health, and the benefits that implementing religious resources may have in quitting, is essential before making recommendations. Based on our review of the research above, cigarette smoking is the most common preventable cause of death in the world, and religious involvement has consistently been shown to be associated with less cigarette smoking and a greater likelihood of quitting. Religious practices that are particularly helpful in reducing smoking include personal prayer or meditation, reading religious scriptures, reciting religious scriptures (for Muslims especially), use of religion to cope with stress (rather than smoking a cigarette), and involvement in a faith community where the majority of participants are nonsmokers (reducing the social pressure to smoke). As noted above, religiously integrated smoking cessation interventions need to be developed and tested in religious clients who smoke, perhaps based on the principles of motivational interviewing. Once these become available, clinicians and religious professionals will need to refer religious clients to professionals trained in these interventions. Until then, the peer-​ support group Nicotine Anonymous, as mentioned earlier, is based on the 12 steps of Alcoholics Anonymous (8 of 12 steps being explicitly religious in nature; see Chapter 10). Nicotine Anonymous has been around since 1982, and a brief history and summary of the program’s underlying principles is available (Anonymous, 2005). Today there are more than 500 Nicotine Anonymous groups meeting worldwide, and clients may go to the following website to locate a group near them: https://​nicot​ ine-​anonym​ous.org/​. Participation in Nicotine Anonymous groups is possible via the Internet or by telephone, and there are email and pen pal programs that are also available (https://​nicot​ ine-​anonym​ous.org/​pen-​and-​email-​pals.html). Smoker’s Anonymous (operated by Recovery, a subsidiary of American Addiction Centers) specifically relies on spiritual principles to help individuals beat their addiction to cigarettes or

other nicotine-​ containing products (https://​ www.recov​ery.org/​supp​ort-​g ro​ups/​smok​ers-​ anonym​ous/​). Again, little systematic research exists on the benefits of Nicotine Anonymous (Martin et al., 1997) or other spiritually based programs (Knight, 2004). However, if the effects are similar to those of other 12-​step programs such as Alcoholics Anonymous, then benefits could be considerable.

SUMMARY AND CONCLUSIONS This chapter has examined the relationship between religious involvement and cigarette smoking. We first discussed the strength of nicotine addiction, placing it in the same category as addiction to heroin, cocaine, and barbiturates. We then presented information on the prevalence and predictors of cigarette smoking, finding that it was the most prevalent of all addictive disorders in the United States and around the world. Among the strongest predictors of cigarette smoking are low socioeconomic status, having family members or friends who smoke, and having a severe mental illness. We next examined the effects of cigarette smoking and nicotine-​ containing products on physical health, finding that it was a leading cause of preventable death in the United States and worldwide. In the heart of the chapter, we examined the relationship between religion and cigarette smoking, beginning first with a case vignette of a young person whose religious faith and family helped him to resist peer pressure to smoke.

Next, we explored how religious involvement might theoretically impact cigarette smoking through religious teachings that emphasize respect for the physical body, positive peer group influences, positive parent role models, greater parental monitoring, and provision of an alternative coping resource for dealing with stress. We then reviewed empirical research on religion and smoking, first summarizing the results of studies published prior to 2010 and then reviewing several prospective studies examining the effect of religiosity on smoking initiation and cessation. Similar to the results of many studies on alcohol or illicit drug use, the research demonstrates that religiosity is strongly and inversely related to cigarette smoking in over 90% of cross-​sectional studies and predicts less initiation or cessation of smoking in about 85% of prospective studies. Recommendations for future research were provided, with an emphasis on the development and testing of religiously integrated interventions to help religious individuals stop smoking. Finally, applications to clinical practice were suggested, including encouraging clients to use their religious resources to help cut down on or quit smoking, educating clients about the harm to health that smoking causes, stressing the role that religion can play in helping to stop smoking, and referring religious nicotine-​addicted clients to Nicotine Anonymous or similar spiritually oriented peer self-​help groups. In the next chapter we examine another important health behavior, physical exercise, and its relationship to religious involvement.

Cigarette Smoking • 327

18 Exercise Those who think they have not time for bodily exercise will sooner or later have to find time for illness. —​Edward Stanley

IS RELIGIOUS INVOLVEMENT associated with physical activity (PA)? Answering that question is the subject of this chapter. We begin by providing recommendations regarding levels of PA, describe the health benefits of regular PA at the individual level, and then examine the costs of lack of PA at the societal level. We then turn to examine the role of religious participation in PA.

throughout the week (Physical Activity Guide­ lines Advisory Committee, 2018, p. 8). “Aerobic” PA is the type that causes shortness of breath and increases heart rate. Aerobic PA can involve walking, running, dancing, gardening, hiking, swimming, cycling, physical work, household chores, sports, or other planned physical exercise. Similar to the Guidelines for Americans above, the World Health Organization (WHO, 2019) recommends 150 minutes or more/​ RECOMMENDED LEVELS OF week of moderate-​intensity aerobic PA or at PHYSICAL ACTIVITY least 75 minutes/​week of vigorous-​intensity The 2018 Physical Activity Guidelines for aerobic PA, or an equivalent combination Americans recommends that “adults should of ­ moderate-​and vigorous-​ intensity activdo at least 150 minutes (2 hours and 30 min- ity. PA should be performed in bouts of at utes) to 300 minutes (5 hours) a week of least 10 minutes in duration. For additional moderate-​intensity, or 75 minutes (1 hour and health benefits, WHO recommends moderate-​ 15 minutes) to 150 minutes (2 hours and 30 intensity aerobic PA for up to 300 minutes/​ minutes) a week of vigorous-​intensity aerobic week or vigorous-​intensity aerobic PA for up PA, or an equivalent combination of moderate-​ to 150 minutes/​week, or an equivalent comand vigorous-​ intensity aerobic activity” spread bination of moderate-​and vigorous-​intensity

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0018

activity. On top of that, muscle-​strengthening exercises involving major muscle groups is recommended on 2 or more days/​week. In order to determine the exact amount of energy expended, which is often done for research purposes, investigators will often multiply a person’s estimated metabolic equivalent of task (MET; amount of oxygen consumed at rest, sitting quietly in a chair, or 3.5 ml of oxygen/​kg/​ minute) by the number of hours spent in various types of PA during the week, and then sum across all activities to obtain a person’s overall PA energy expenditure in MET hours (METh) per week. Moderate-​intensity PA involves expending 3.0 to less than 6.0 METs (e.g., walking briskly [2.5 to 4 mph], raking leaves off the yard, or playing doubles tennis). Vigorous-​intensity aerobic PA requires 6.0 or more METs (e.g., jogging, running, carrying heavy loads upstairs, or shoveling snow). The minimum recommended energy expended on PA per week is 7.5 METh.

BENEFITS OF PHYSICAL ACTIVITY TO THE INDIVIDUAL Lack of PA has been called “[t]‌he biggest public health problem of the 21st-​century” (Blair, 2009, p. 1). Many studies have demonstrated the health benefits of regular PA, including gains to both mental and physical health. With regard to mental health, a 2015 meta-​analysis of 92 studies involving 4,310 participants found a medium effect size for reducing depression (d =​−0.50) and anxiety (d =​−0.38) in community populations, causing researchers to conclude: “These findings represent a comprehensive body of high-​quality evidence that physical activity reduces depression and anxiety in non-​clinical populations” (Rebar et al, 2015, p. 366). Young persons also experience psychological benefits from exercise. In a meta-​analysis of results from 162 studies involving 204,171 school-​ aged children and youth from 31 countries, PA was associated with better psychological, social, and cognitive health (Poitras et al., 2016). The physical health benefits of regular PA are indisputable. In a study of 661,137 men and women (median age, 62 years) participating in prospective cohort studies in the United States and Europe (with 116,686 deaths reported during

follow-​up), investigators found a dose-​response relationship between exercise and reduced mortality risk (Arem et al., 2015). Compared to those with no leisure-​time PA, participants performing any amount of PA below the recommended 7.5 METh/​week (but more than none) experienced a 20% lower mortality risk (HR =​0.80, 95% CI =​0.78–​0.82). This mortality benefit increased to a 31% lower risk at 7.5 to 15 METh/​week (i.e., 20–​40 minutes of moderate or 10–​20 vigorous PA/​day; HR =​0.69, 95% CI =​0.67–​0.70). The mortality risk was 37% lower at 15–​22.5 METh/​ week (i.e., 40–​60 minutes of moderate PA or 30 minutes of vigorous PA/​day; HR =​0.63, 95% CI =​ 0.62–​0.65). At 5 times the minimum recommendation, the mortality risk was 39% lower (HR =​ 0.61, 95% CI =​0.59–​0.78). No further benefit to mortality risk was found from exercising more than 5 times the minimum recommendation (greater than 37.5 METh/​week, i.e., more than 100 minutes of moderate PA/​day or 50 minutes of vigorous PA/​ day). Interestingly, this study found a similar dose-​response risk reduction for death due to cancer as it did for death due to cardiovascular disease, although risk reduction was greater for death from cardiovascular disease. Besides increasing survival, regular PA predicts a lower likelihood of developing many serious health problems, including cardiovascular disease (Ford & Caspersen, 2012), non-​insulin-​ dependent diabetes mellitus (Zanuso et al., 2010), fractures from osteoporosis (Nikander et al., 2010), risk of developing and dying from colon cancer (Je et al., 2013), risk of developing breast cancer (Friedenreich, 2010), and risk of developing a range of obesity-​related diseases (Slentz et al., 2009; Reilly et al., 2019). Likewise, in a systematic review of 15 prospective studies, each involving at least 5 years of follow-​up and including a total of 288,724 participants, Reiner and colleagues (2013) found that PA had a positive long-​term influence on weight reduction, coronary heart disease, adult onset diabetes mellitus, and dementia/​Alzheimer’s disease.

COSTS OF PHYSICAL INACTIVITY AT THE SOCIETAL LEVEL The United States has one of the highest adult physical inactivity rates in the world at 40% Exercise • 329

of the population (WHO, 2018b). In fact, the only countries exceeding that 40% are in South America (e.g., Brazil, Columbia, Argentina), the Middle East (e.g., Saudi Arabia, Iraq, United Arab Emirates), and some European countries (e.g., Portugal, Italy, Germany). Carlson and colleagues (2015) estimated the excess healthcare expenditures in the United States due to inadequate PA (i.e., less than moderate-​intensity PA of 20 minutes/​day). Estimates were based on data from the National Health Interview Survey (2004–​2010) and the Medical Expendi­ ture Panel Survey (2006–​2011). Expenditures included the direct costs of all services: inpatient, outpatient, emergency room, office-​ based, dental, vision, home health, prescription drug, and other health services. Results indicated that 11.1% of the total US healthcare expenditures (95% CI =​7.3–​14.9) were due to inadequate PA, i.e., approximately $131 billion per year (95% CI =​$91–​$172 billion). In a systematic review of 40 studies in 12 different countries, Ding and colleagues (2017) reported that the average estimated healthcare costs due to physical inactivity (again, in most cases defined as less than 20 minutes/​day of moderate-​intensity PA) ranged from 0.3% of national healthcare expenditures (Czech Republic and England) to 4.6% (New Zealand). However, only one of these 40 studies included all costs: direct healthcare costs, indirect costs of productivity losses, costs of home-​ based services (domestic and childcare), and costs of leisure-​based opportunities. This review did not include the Carlson et al. (2015) study above. Thus, at least in the United States, physical inactivity is responsible for nearly one-​tenth of all healthcare expenditures, not counting the indirect costs from loss of productivity.

RISK FACTORS FOR PHYSICAL INACTIVITY Lee and Ellingson (2018) classified risk factors for physical inactivity into individual and environmental categories. Such risk factors may provide clues on how religious involvement can influence PA. The “individual” category included socioeconomic, psychological, and health factors. Socioeconomic risk factors were female gender, 330 •  H ealth B ehaviors

older age, Black/​ Hispanic race, low income, low education, and low social/​cultural norms for PA. Psychological risk factors included low self-​efficacy, depression, low perceived enjoyment of exercise, low knowledge/​beliefs about the benefits of exercise, and low comparison with others. Health risk factors included obesity, chronic diseases such as diabetes, cancer, or stroke, functional limitations due to musculoskeletal problems, physical injuries, and low physical fitness. The environmental category included household, occupational/​ school, leisure time, and transportation risk factors. Household factors were having a washing machine, dishwasher, cleaning robot, motorized lawnmower, short distances to grocery and supermarkets, and no garden or backyard. Occupational/​school factors included having a sedentary job (such as work seated at a computer), labor-​saving robots at work, presence of elevators (i.e., no stairs to climb), absence of employee fitness programs, lack of physical exercise in schools, and small school playgrounds. Leisure-​time risk factors were time spent watching TV, engagement in social media, or participation in sedentary gaming activities. Also included in this category were having sedentary parents and friends, living in unsafe neighborhoods, cold weather, and absence of pet ownership. Finally, transportation risk factors included having a car, inability to walk or ride a bicycle to destinations, no streetlights, availability of inexpensive gas, short commuting distances, convenient transportation systems, and non-​rural living (i.e., factors that make it less necessary to be physically active). Data on risk factors for physical inactivity are also available in a variety of international contexts. For example, in a study of 17,928 undergraduate students in 23 low-​ , middle-​ and high-​income countries, Pengpid and colleagues (2015) found that the prevalence of physical inactivity among students was 41.4%, ranging from 22.0% in Kyrgyzstan to 80.6% in Pakistan. Physical inactivity in this study was defined as less than 30 minutes of moderate-​ intensity activity 5 days/​week or less than 20 minutes of vigorous activity 3 days/​week, or a combination. Risk factors for physical inactivity were older age (22–​30 years), low or lower

middle-​income countries, skipping breakfast, and lack of social support. When analyses were stratified by gender, risk factors for physical inactivity in men were being overweight or obese, eating a diet high in fat or cholesterol, and low personal control. In women, eating a diet low in fiber and low personal mastery were also associated with physical inactivity. Thus, being a university student appears to be a risk factor for physical inactivity, depending on country, based on the amount of time spent in the sedentary activity of studying and preparing for classes. Young adulthood is often a time when lifelong habits of PA develop. Saudi Arabia is one of the most religious countries in the world, but it also has one of the world’s highest levels of physical inactivity at 53.1% (WHO, 2018b) and obesity at 35.4% (WPR, 2019). Assiri and colleagues (2015) reported risk factors for physical inactivity among 400 male Saudis, nearly two-​ thirds (65%) of whom were in the low PA group. Participants were consecutive adult patients seen in primary healthcare centers in Abha, Saudi Arabia. Risk factors for inactivity included younger (15–​29) and older age (45–​69), obesity, lower education level, lower monthly income, employment status (unemployed, retired, student, or private-​ sector work), and marital status (unmarried), consistent with Lee and Ellingson’s (2018) review of socioeconomic risk factors above. Likewise, in a systematic review of 65 studies examining risk factors for physical inactivity in Saudi Arabia, Al-Hazzaa (2018) found that female gender, high screen time, reported “lack of time,” no suitable place to exercise, lack of social support, low self-​efficacy, bad weather, and culture or tradition were all contributory. In Saudi culture, being obese or overweight is often viewed as a sign of prosperity, success, and high social status, which may limit motivation to exercise.

RELIGION AND PHYSICAL ACTIVITY Case Vignette Deepa is a 20-​year-​old college student who comes from an orthodox Hindu

family that migrated from India to the United States about 30 years ago. She is taking pre-​med classes and plans to enroll in medical school after college. Both of her parents are physicians. Her classes are difficult, and she spends many hours every day preparing for classes, most of the time sitting in front of her computer. Deepa notices that she has gained about 10 pounds in the past 2 months. As a devout follower of Hinduism, Deepa strives to achieve balance in her life, using self-​control, meditation, yoga, and healthy dietary practices. However, she has allowed her daily Hatha yoga practices (one of the six recognized systems of orthodox Hinduism that involves physical poses and breathing exercises) to lapse over the past semester due to her heavy course load. Her daily running, done for years as a form of spiritual self-​ control and endurance training, has also suffered. With the stress of upcoming exams, she has also found herself eating more junk food and snacks, which she thinks is the cause of her weight gain. Deepa feels bad about the weight gain and is determined to get back to her usual religious/​spiritual practices. In order to make her religious faith a priority, she decides to reserve 60 minutes each day for yoga exercises, meditation, and running, and to change her diet, in order to demonstrate self-​ control. Soon, Deepa finds that she has lost the 10 pounds that she gained and also notices that she is more focused in class and when doing homework.   

HOW RELIGION MIGHT IMPACT PHYSICAL EXERCISE As in previous chapters, we speculate on how religious involvement might impact PA. We first examine religious beliefs as documented in the holy scriptures of Christianity, Islam, Judaism, Hinduism, and Buddhism, teachings that refer directly or indirectly to PA, and then discuss Exercise • 331

how religiosity might affect (or be affected by) individual and environmental factors known to influence PA.

Religious Teachings As noted in the previous chapter on cigarette smoking, Christians believe that the physical body is the “temple of the Holy Spirit” and are obligated to care for it as they would care for God’s temple or dwelling place (1 Corinthians 6:19–​20). Numerous other New Testament scriptures emphasize the importance of maintaining the health of the physical body, including: If anyone destroys God’s temple [by failing to care for it], God will destroy him. For God’s temple is holy, and you are that temple. (1 Corinthians 3:17) For you were bought with a price. So glorify God in your body. (1 Corinthians 6:20) But I discipline my body and keep it under control, lest after preaching to others I myself should be disqualified. (1 Corinthians 9:27) I appeal to you therefore, brothers, by the mercies of God, to present your bodies as a living sacrifice, holy and acceptable to God, which is your spiritual worship. (Romans 12:1) Thus, in Christianity, caring for the physical body, training the physical body, and making the physical body a living sacrifice are all ways to glorify God. The same is true in Judaism. Jewish physician and religious scholar Moses Maimonides said in the Mishneh Torah, “Exercise refers to both strong and weak movements, providing it is movement that is vigorous and affects breathing, increasing it” (cited in Address, 2018). Likewise, the Torah directs followers to take good care of their bodies (“Take ye therefore good heed unto yourselves” (Devarim [Deuteronomy] 4:15). Rabbi Israel Meir Kagan (a nineteenth–​twentieth century Jewish theologian) wrote, “The entire Torah is dependent 332 •  H ealth B ehaviors

upon the mitzvah of taking care of your [physical] body” (Kaufman, 2018). In making the case for PA from a Jewish perspective, Kahan (2002) notes that Talmudic scholar Rabbi Yochanan advised that one-​third of the day should be spent walking (equivalent to 27 miles). The attention to physical health is perhaps why the practice of medicine is so revered in this faith tradition and often is chosen as a lifelong profession (Hart, 2007). For example, in the United States where 3% of the general population is Jewish, 18% of physicians are Jewish (Stern et al., 2011). Islam also encourages PA and sport. The Qur’an and Hadith emphasize the need to always be in good physical shape in case of war or to advance Islamic causes, where physical agility and endurance will be required. Abu Huraira reported the Prophet Muhammad said: “A strong believer is better and is more lovable to Allah than a weak believer . . .” (Sahih Muslim 2664). Likewise, the second caliph, Umar Ibn Khattab, instructed followers to “[t]‌each your children swimming and archery, and tell them to jump on the horse’s back” (Al-​Qaradawi, 1992, p. 296). In a Hadith reported by Al Tabarani, narrated by Hazrat Ibn Umar, the Prophet Muhammad is reported to have said: “Any action without remembrance of Allah is either diversion or heedlessness excepting four acts: Walking from target to target (during archery practice), training a horse, playing with one’s family, and learning to swim” (Al-​Qaradawi, 1999, p. 332). The Prophet himself would competitively run with his wife Aisha, setting an example for his companions: “Aisha said: I raced with the Prophet and beat him in the race. Later, when I had put on some weight, we raced again and he won” (Al Qaradawi, 1992, p. 293). While Islam encourages PA and sport in both men and women, some interpretations of Islamic teachings may discourage such activity, especially among women (Walseth & Fasting, 2003). Comprehensive reviews that summarize the strong emphasis placed by Islam on exercise and PA are available elsewhere (Walseth & Fasting, 2003; Kahan, 2003; Kasule, 2008). The practice of yoga has often been viewed by those in the West as a Hindu form of physical exercise, but it is much more than that.

Yoga was never intended to be only a physical exercise, but rather a spiritual practice to foster self-​ discipline, focus, and single-​ mindedness (Shastri, 2012). Another more intense form of PA in Hinduism, intended to produce both physical and spiritual health, is the Dhanur Veda, or Vedic martial arts. The Vedic martial arts are thought to be one of the oldest forms of structured PA intended to foster self-​ discipline, physical endurance, and spiritual growth. The Vedas (i.e., the original Hindu scriptures) contain many verses that describe ancient Hindu kings and their exploits in these martial arts involving vigorous PA and intense training. Hindu warriors such as Arjuna and Rama harnessed forces of nature by combining martial arts, including archery, with mantras and meditation. The classical Hindu text, the Caraka Samhita, describes the Indian medical system, Ayurveda (Sharma & Dash, 2008). This text emphasizes that good health is the result of diet, sleep, rest, and especially, PA and regular exercise: “Physical exercise brings about lightness, ability to work, stability, resistance to discomfort, and alleviation of impurities (dosas)” (Sharma & Dash, 2008, pp. 152–​153). The Caraka Samhita is also thought to be one of the world’s oldest texts recommending exercise for many different medical problems, including excess phlegm, anorexia nervosa, drowsiness, excessive sleep, timidity, laziness, sweet taste in the mouth, excessive salivation, diarrhea, loss of strength, hardening of the arteries, obesity, improved digestion, goiter, urticaria, and pallor (Sharma & Dash, 2008, pp. 370–​371). However, it also warns against exercising too much (see Mondal, 2013). Admittedly, pictures and statues of the Buddha today do not depict him (or his followers) as physically fit. However, physical exercise was strongly encouraged by the Buddha. The Cankama Sutta indicates that the Buddha said: “Monks, there are these five benefits of walking up and down. What five? One is fit for long journeys; one is fit for striving; one has little disease; that which is eaten, drunk, chewed, tasted, goes through proper digestion; the composure attained by walking up and down is long-​lasting. These, monks, are the five benefits of walking up and down” (Aggacitta & Kumara,

2013). In the Dhammapada, the Buddha describes his devotee as “One who wears rags from a dust heap, Lean, having veins [visibly] spread over body, meditating alone in the force, that one I call a brahmana” (Dhammapada 395; Carter & Palihawadana, 2000, p. 67). Thus, a characteristic of a brahmana (a seeker of the truth and follower of the Buddha) is physical fitness (i.e., “lean, having veins [visibly] spread over body”). Indeed, the Buddha would often take early morning walks. In the Pali Canon, there is the phrase janghavihara, which means a walk taken for exercise, a constitutional walk taken for the purpose of health (Thera, 2017, p. 54). Thus, it is clear that the core teachings of the five major religious traditions stress the importance of exercise to maintain physical fitness, since one must have good physical health in order to live a long and healthy life, one characterized by service to others as an active member of a faith community. The sick, disabled, or deconditioned person will not be able to serve others or God in the same way as a healthy and fit individual. Nevertheless, the emphasis placed on PA and the physical body today, in practice, may vary across different religious traditions. The amount of PA required for participating in religious practices may be different. Some faith traditions emphasize religious activities that are more sedentary (e.g., private prayer, contemplation, meditation, or scripture reading), whereas others promote attending religious services outside the home or active forms of worship, which may require some PA. For example, Muslims bow, kneel, and stand as part of the five required daily prayers, which may be done alone or as part of a group at the mosque. Likewise, evangelical Christians wave their arms, stand, or even dance during worship services. Similarly, Catholics kneel, sit, and stand repeatedly during the celebration of the Mass. Attending group religious services with others outside the home often requires showering, getting dressed, driving to place of worship, parking, walking from parking lot to sanctuary, walking back to parking area after the service, and perhaps going out with friends after the services, which may include more walking, all of which may involve at least some degree of PA. Exercise • 333

As noted earlier, cultural and social norms can impact an individual’s level of PA and religion’s role in shaping PA. For example, one study found that persons living in Muslim countries had higher rates of physical inactivity compared to non-​ Muslim countries, due largely to inactivity among Arabs, especially Arab females (Kahan, 2015). This finding is consistent with a report from the World Health Organization (WHO, 2018b) and has been confirmed by a systematic review of the literature (Sharara et al., 2018). Another study of 12,137 college students in Hong Kong, Korea, Malaysia, Singapore, and Taiwan, in contrast, found that Muslims had the lowest levels of sedentary activity compared to other religious groups in Hong Kong, Korea, Malaysia, and in Taiwan, but the highest level of physical inactivity in Singapore. Likewise, in a study of PA levels among 686 adults in Ghana (assessed by the WHO Global Physical Activity Questionnaire-​ 2), PA was highest for those affiliated with traditional African religions, lowest in Christians, and Muslims fell somewhere in between these two groups (Asiamah, 2016). Thus, geographical region and cultural influences (which may or may not have anything to do with level of religiosity) may impact the relationship between religion and PA level. Religious pilgrimages might also serve to promote PA. Pilgrimages often involve a lot of walking, and sometimes running. For example, the Hajj in Islam must be made at least once during a Muslim’s lifetime if he or she is physically able and can afford it (Qur’an 2:196). The Hajj, one of the five pillars of Islam, takes place during the twelfth month of the Islamic lunar calendar, when nearly two million Muslims from around the world come together in Mecca, Saudi Arabia. The Hajj should be distinguished from the Umrah (the “lesser pilgrimage” to Mecca), which can be performed at any time, involves fewer rituals, and may take place over only a few hours. The Hajj is a deeply religious time when pilgrims focus on their relationship with God. There is also plenty of physical exercise during the five or six days of the Hajj, when many sacred rituals are performed. These include the Tawaf, which involves walking seven times counterclockwise around the Kaaba (a building at the center of the Great 334 •  H ealth B ehaviors

Mosque of Mecca), followed by the Sa’ay, which consists of running or walking seven times between the hills of Safa and Marwah located near the Kaaba. Likewise, Catholics also often go on pilgrimages, such as the Camino de Santiago, where pilgrims visit the shrine of the apostle Saint James the Great in the Cathedral of Santiago de Compostela in Galicia, northwestern Spain. Most pilgrims walk one of several routes, although some bicycle or even travel by horseback or donkey (as those in medieval times did). There are many different routes to take in northern Spain and from all over Europe (UNESCO, 2020). Many Catholics take this pilgrimage as a spiritual retreat to produce spiritual growth and form a deeper connection with God. There is also a religious pilgrimage in Hinduism called the Kumbh Mela, which takes place every 12 years (and the half-​ Kumbh, every 6 years), when pilgrims bathe in the place where the Ganges and Yamuna rivers cross in northern India (Frayer & Khan, 2019). For the 2019 event, attended by an estimated 15 million devotees, nearly 200 miles of new roads were built for pilgrims to travel on. Many pilgrims walk to this holy place, where they squat in the river next to each other while chanting mantras. They sleep at the river’s edge in a vast city of tents, where temperatures often drop toward freezing during the night, all for spiritual purposes.

Risk Factors for Physical Inactivity Recall the following risk factors at the individual level that increase the likelihood of physical inactivity: female gender, older age, Black/​ Hispanic race, low income, low education, low cultural/​social norms for PA, low self-​efficacy, depression, low perceived enjoyment of exercise, low knowledge/​beliefs about the benefits of exercise, less likelihood of comparing oneself to others, obesity, chronic disease, and physical functional limitations. Risk factors at the environmental level included having a washing machine, dishwasher, cleaning robot, motorized lawnmower, short distances to grocery and supermarkets, no garden/​backyard, having a sedentary job, labor-​saving robots at

work, elevators, absence of employee fitness programs, reduced physical exercise in schools, small school playgrounds, much time spent on watching TV, social media, inactive gaming activities, as well as sedentary parents and friends, unsafe neighborhoods, cold weather, not having pets, having a car to drive, being unable to walk or ride a bicycle to destinations, no streetlights, inexpensive gas, short commuting distances, convenient transportation systems, and non-​rural living. With these risk factors in mind, religious individuals may be at greater or lower risk of physical inactivity. Religiosity is known to be associated with female gender, older age, Black race/​ ethnicity, lower income, lower socioeconomic class, less education, and greater weight (Chapter 19), which would need to be controlled for as potential confounders for assessing the effects of religious participation on PA. With less income and lower education comes (1) a lower likelihood of attending schools with physical exercise programs, (2) a greater likelihood of living in unsafe neighborhoods or urban settings, and (3) less access to healthy fruits/​vegetables and more access to affordable high-​calorie and low-​ nutrition foods, which increase weight, thereby making PA more difficult. In contrast, religiosity may also be related to fewer risk factors for physical inactivity. Those who are more religious may have higher self-​esteem (Chapter 15), less depression (Chapter 5), fewer functional limitations (Chapter 28), and a greater likelihood of living in rural environments, which may be associated with longer distances to grocery stores and supermarkets, longer commuting distances, and less convenient transportation systems, all requiring the person to walk or bicycle to work, a store, or social/​recreational activities. Rural residence may also be associated with large gardens (access to vegetables), large play areas, more pets, physically active jobs (farm work), and less time spent in sedentary activities such as watching TV, involvement in social media, or playing video games. Of course, religion itself can also shape decisions on many of these factors and so ideally, to ensure that the variables being controlled for are confounders and not mediators, researchers should measure and control for these variables prior to the religious participation assessment.

Thus, religiosity may be associated with either more or fewer individual and environmental risk factors for physical inactivity, some of which have little or nothing to do with religiosity and yet must be considered when examining the relationship between religiosity and PA. Differing religious beliefs, cultural settings, and risk factors (both positive and negative) are likely to affect this relationship, underscoring the complexity of conducting research on religion and PA and the interpretation of the results from such studies.

RELIGIOSITY AND PHYSICAL ACTIVITY We now review research that has sought to quantitatively examine the relationship bet­ ween religiosity and PA. We first summarize the results from a systematic review of the literature conducted prior to 2010 contained in the second edition of the Handbook (Koenig et al., 2012), and then review more recently published high-​ quality studies since 2010 (see Appendix for complete list and findings). Again, as in previous chapters, emphasis is placed on prospective studies and randomized controlled trials (RCTs) that may provide evidence for causal inference.

Early Research Prior to 2010, a total of 37 studies were systematically identified on religiosity and PA. Of those, 25 (68%) reported a positive relationship between religiosity and greater PA, 6 (16%) indicated a negative relationship with PA, and 6 studies (16%) found no association. Nearly all studies were cross-​sectional (36 of 37). The only prospective study was by Strawbridge and colleagues (2001) who followed a random sample of 2,676 adults in Alameda County, California, from 1965 to 1994, assessing religious attendance at baseline as a predictor of change in exercise (swimming, taking long walks, doing physical exercises, or taking part in active sports) during the 29-​year follow-​up. At baseline, physical exercise was unrelated to religious attendance; 39% of weekly attendees indicated they were physically active compared to 42% of those attending less than weekly. For those Exercise • 335

not physically active in 1965, however, persons who attended religious services at least weekly at that time were over 50% more likely to become physically active in 1994 compared to those attending services less often (OR =​1.54, 95% CI =​1.22–​1.94), controlling for baseline age, gender, education, and self-​rated health. Effects were particularly strong in women, who were nearly 75% more likely to start exercising (OR =​1.74, 95% CI =​1.30–​2.32).

religious (OR =​1.06, 95% CI =​0.98–​ 1.16). Researchers concluded that religiosity was associated with better health habits and predicted an increase in these habits, including regular exercise, over time. P ROSP ECTIVE COH ORT STUD IES

Kim and VanderWeele (2018) examined mediators of the effects of religious attendance on mortality in 5,200 US adults age 50 or over. Religious attendance in 2008 was examined as Recent Research a risk factor for mortality from 2010 to 2014, Since 2010, there have been at least one ret- controlling for a number of potential conrospective cohort study, 9 prospective studies founders in 2006, including prior frequency of (two examining the same sample), 2 single-​ attendance, age, gender, marital status, race, group experimental studies, and 3 RCTs exam- education, insurance status, total wealth, smokining religious interventions to increase PA. We ing, frequency of exercise, alcohol use, BMI, summarize the best of these studies below (see health conditions, social integration, social Appendix for full list). participation, living situation, contact with children, family and friends, and physical functioning. Assessed in 2010 as possible mediators R ET RO S P E C TI VE COHORT S T UDY of the attendance-​mortality relationship were Kobayashi and colleagues (2015) analyzed data life satisfaction, optimism, mastery, positive collected from a retrospective cohort study affect, purpose in life, depressive symptoms, involving 36,965 individuals (average age 47) cynical hostility, hopelessness, loneliness, negwho had annual health checkups at St. Luke’s ative affect, anxiety, trait anger, state anger, International Hospital in Japan from 2005 to alcohol consumption, smoking, BMI, social fac2010. The purpose was to examine cross-​sectional tors (living with a spouse, having contact with and longitudinal relationships between religi- children and other family members, or contact osity and a range of cardiovascular (CV) risk with friends), sense of control, financial strain, factors, including physical exercise. Religiosity physical functioning, and exercise. Higher reliwas assessed at baseline with a single ques- gious attendance predicted a significantly lower tion: “Are you religious?” (not religious at all, risk of mortality during follow-​up. When medislightly religious, somewhat religious, reli- ators of this effect were examined, the second gious). Controlled for in analyses were age, gen- strongest 2010 explanatory factor was greater der, marital status, occupation, body mass index exercise among those who attended more fre(BMI), and other health habits. Overall, 63% of quently in 2008, explaining 5.4% of the overparticipants indicated they were slightly or not all survival effect, p < 0.001, surpassed only by at all religious, 28% said they were somewhat more contact with friends at 10.7%. Since exerreligious, and 10% reported they were religious. cise in 2010 explained a significant part of the Cross-​sectional multivariate analyses in 2005 effect of 2008 religious attendance on 2010–​ indicated that religious individuals were more 2014 mortality, this indicates 2008 religious likely to exercise regularly (OR =​1.25, 95% CI attendance positively influenced 2010 exercise 1.14–​1.37). In retrospective longitudinal anal- (even after controlling for 2006 exercise and yses (using generalized estimating equations religious attendance). adjusting for time), being somewhat religious Ahrenfeldt and colleagues (2018) analyzed at baseline (vs. not religious at all) predicted a data from a longitudinal study of 23,864 pergreater likelihood of engaging in regular phys- sons ages 50+​who participated in the Survey ical exercise (OR =​1.07, 95% CI =​1.01–​1.14); of Health, Aging, and Retirement in Europe a similar trend was found for those who were (SHARE). Participants were initially assessed in 336 •  H ealth B ehaviors

2004–​2005 (Wave 1) and followed up every two years in 2006–​2007 (Wave 2), 2009 (Wave 3), 2011 (Wave 4), 2013 (Wave 5), and 2015 (Wave 6). European countries included were Denmark, Sweden, Italy, Spain, Austria, Belgium, Germany, Switzerland, and the Netherlands. Of the 16,263 who reported they belonged to a religion, 27% indicated Protestant, 45% Catholic, 13% Orthodox, Muslim, or other, and 14% none. Three measures of religiosity were administered at Wave 1: (1) “Thinking about the present, about how often do you pray?” (assessed only in those who said they belonged to a religion); (2) “[Have you] taken part in a religious organization (church, synagogue, mosque, etc.) within the past month?” (asked of the entire sample, of whom 12% indicated they had); and (3) “Have you been educated religiously by your parents?” (74.0% of those belonging to a religion). Degree of religiousness was categorized into three groups: (1) more religious (praying, taking part in a religious organization, and being religiously educated); (2) less religious (praying, but not taking part in a religious organization or religiously educated); and (3) nonreligious (not praying, taking part in religious activities, or religiously educated). Lifestyle variables included two questions on PA: “How often do you engage in activities that require a moderate level of energy such as gardening, cleaning the car, or doing a walk?”; and “How often do you engage in vigorous physical activity such as sports, heavy housework, or a job that involves physical labor?” Physical inactivity was defined by the response “hardly ever or never” to the first question, whereas no vigorous physical activity was defined as the same response to the second question. Included in analyses were all participants in Wave 1 with at least one follow-​up at Waves 2, 4, 5, or 6. Logistic regression and mixed effects models examined the effects of religiosity on physical inactivity outcomes, adjusting for European region, gender, age, education, marital status, and employment status, and corrected for multiple testing using the Holm-​Bonferroni method. Longitudinal analyses suggested that Wave 1 prayer marginally predicted a lower likelihood of future physical inactivity and no vigorous activity (ORs approximately 0.90, with 95% CIs just below 1.0), whereas participation in a

religious organization strongly predicted less physical inactivity and no vigorous activity (ORs approaching 0.60, with small CIs). Religious education did not significantly predict either of the two physical inactivity outcomes. Compared to less religious and nonreligious groups, those who were more religious at Wave 1 were particularly less likely to be physically inactive or engaged in no vigorous physical activity in future waves (ORs at 0.60 or lower with small CIs). There were also significant differences between the more religious and the less religious in the same direction, but not between the less religious and the nonreligious. When analyses were stratified by religious affiliation, effects were strongest in the “other affiliations” group (82.6% of whom were Orthodox Christian, 1.9% Jewish, 2.4% Muslims, 13.1% other). J. Zhang and colleagues (2019) analyzed data from a 12-​month prospective study of 595 African American homosexual males in Philadelphia, Pennsylvania, examining the impact of religiosity (among other predictors) on PA level. Baseline religiosity was assessed with a 3-​item index made up of frequency of religious attendance, reading the Bible or other religious works, and listening to religious radio stations. PA was assessed by number of days in the past week spent in vigorous-​intensity aerobic activities for at least 20 minutes, moderate-​ intensity aerobic activities for at least 30 minutes, and strength-​building activities. Also assessed and controlled for in GEE (generalized estimating equation) models were education, income, depression, childhood sexual abuse, alcohol dependency, drug dependency, intimate partner violence, unemployment, connection to the gay community, Black pride, optimism, and social network diversity. The primary outcome was PA averaged over the 6-​and 12-​month follow-​up assessments. Results indicated weak associations between religiosity and increased future PA (b =​0.08, 95% CI =​−0.07 to 0.22) in the final model, but the confidence interval included 0. Pawlikowski et al. (2019) analyzed data from three waves of a biennial longitudinal Polish household panel study, which initially included a random sample of 26,243 participants ages 16 or older in 2009 (Wave 1). Researchers examined the effect of 2011 (Wave 2) religious Exercise • 337

attendance on health behaviors and well-​being in 2015 (Wave 3), controlling for Wave 1 demographics, financial situation, civic engagement, health conditions, cigarette smoking, excessive alcohol use, and emotional well-​being in 2009 prior to the assessment of religious attendance in 2011. Among the numerous health behaviors that were assessed, the study also examined “practicing sport or other physical activity” (yes vs. no) as an outcome. A total of 6,383 persons participated in all three follow-​up waves. In this group, attending religious services more than 4 times per month in Wave 2 predicted a 32% increase in the likelihood of practicing a sport or engagement in other PA at Wave 3 (OR =​1.318, 95% CI =​1.003–​1.732). In a 3-​to 12-​year prospective study involving three cohorts of young, middle-​aged, and older community-​dwelling older adults (n =​92,008), Y. Chen et al. (2020a) examined the effects of frequency of religious attendance on health in an outcome-​ wide analysis that included “frequency of physical activity.” After controlling for demographics, family history, socioeconomic status, prior attendance at religious services, prior health status, health behaviors, social interaction, and other factors including volunteering and registering to vote, and after applying Bonferroni correction to p-​values, results did not provide evidence for an effect of religious attendance on frequency of PA. Likewise, in a 7-​ year prospective study that examined the effects of religiously motivated self and divine forgiveness on frequency of PA in the middle-​ aged cohort included in the Chen et al. study above, which involved 51,661 nurses in the Nurses’ Health Study, Long et al. (2020b) did not find evidence for an effect on frequency of PA. Finally, in a 10-​year prospective study of 1,596 community-​dwelling Danish older adults participating in the Survey of Health, Aging, and Retirement in Europe (SHARE) study, Herold et al. (2020) examined the effects of religiosity on PA, using repeated measures logistic regression models to adjust for age, gender, study wave, education, and marital status. Religiosity at baseline was assessed by three questions asking about attendance at religious services, praying, and having received a religious education by parents. Based on responses, participants were categorized into four groups: nonreligious, 338 •  H ealth B ehaviors

religious only in childhood, religious only in adulthood, and persistently religious. PA was assessed by engagement in “activities requiring a moderate level of energy” and “sports and activities that are vigorous.” Results indicated that being religiously educated predicted a 37% lower likelihood of not engaging in moderate PA (OR =​0.63, 95% CI =​0.43–​0.82) and a 23% lower likelihood of not engaging in vigorous physical activity (OR =​0.77, 95% CI =​0.63–​0.95). Praying was also associated with a 19% lower likelihood of engaging in no vigorous physical activity (OR =​ 0.81, 95% CI =​0.65–​1.00). No effect was found for attending religious services. When outcome was assessed with an unhealthy lifestyle index (which included no moderate or vigorous PA, as well as current smoking, alcohol consumption, and high body weight), compared to those in the nonreligious group, being in the persistently religious group predicted a significantly lower likelihood of an unhealthy lifestyle (b =​−0.24, 95% CI =​−0.29 to −0.09). SIN GL E-​GROUP EXP ERIM EN TAL STUDY

Kahan and Nicaise (2012) administered a faith-​ based intervention to 45 American Muslim students attending an Islamic day school in San Diego, California. Participants were 16 Somali, 12 Arab, 9 South Asian, 3 Persian, and 2 with mixed ethnicities. The average age of participants was 12 years, and the majority (60%) were female. A faith-​based intervention called Virtual Umra (VU), which involved a religious version of the Sport Play and Active Recreation for Kids (SPARK) intervention, was implemented. SPARK uses Map Challenges to take students on virtual trips to various destinations by walking to them, thereby increasing their PA. The goal was to “virtually” walk to Mecca within 8 weeks (250,000 steps), i.e., make a virtual Islamic pilgrimage through steps walked at school. Steps during school were recorded via a pedometer. Each participant was given a travelogue, passport, and Google map of the route with 15 sacred destinations and a page to record their steps. Analyses were stratified by gender and by required physical education (PE) days vs. non-​PE days. Results indicated that the

VU intervention significantly increased steps walked for boys (but not girls) and only on PE days. Researchers concluded that the intervention resulted in a modest increase in steps walked and encouraged future research on faith-​based interventions to focus on increasing PA in female Muslim students. Martinez and colleagues (2013) conducted a single group experimental study of a promotora faith-​based intervention carried out over 6 months in 143 church-​going Latina females (average BMI =​33, obese range) living in San Diego. The promotora intervention involved training community health leaders to lead walking groups of church-​going Latina women in order to increase PA. The average age of participants was 43 years, 82% were Mexican-​born, and all were recruited from a single church. Participants engaged in 60-​ minute walking routes in the morning and evening, starting and ending at the church. During these walks, the promotora intervention leaders encouraged participants through the use of faith-​ based messages and prayer. Examples of faith-​based messages were “The body is the temple of the living God and you have to take care of your temple” and “Beloved, I pray that in all respects you may prosper and be in good health, just as your soul prospers.” Participants were also encouraged to interact with each other during weekly aerobic exercises to build community cohesion (thought to be important in motivating women to continue PA after the intervention). PA was assessed using the self-​reported Global Physical Activity Questionnaire that measures the frequency and duration of moderate and vigorous leisure time physical activity (LTPA) (e.g., “During the last 7 days, on how many days did you do moderate [or vigorous] physical activities during your leisure time for at least 10 minutes?” LTPA was determined by adding up the minutes per week spent in moderate to vigorous LTPA. Results indicated a significant increase in LTPA from baseline to 3 months (b =​0.24, p < 0.05) and from 3 months to 6 months (b =​0.24, p < 0.05), with an average increase of 53 minutes of LTPA from baseline to 6-​month follow-​up. Researchers concluded that the faith-​based promotora intervention was successful in increasing LTPA in church-​going Mexican American women.

RAN D OM IZED CON TROL L ED TRIAL S ( RCTS)

Duru et al. (2010) randomized 62 older sedentary African American women to either a faith-​ based intervention (“Sisters in Motion”) or to a control group. Sedentary participants age 60 or over were recruited from three churches in the Los Angeles area (Catholic, African Methodist Episcopal, Seventh-​Day Adventist). The intervention group participated in eight 90-​minute meetings on two days each week for eight weeks. Each meeting included 45-​minutes of a faith-​ based curriculum (lectures and discussion) and 45 minutes of PA. After the initial 8 weeks, participants engaged in a 2-​day session each month for 6 months. Control group participants met for 90 minutes on 2 days/​week, with 45 minutes spent on lectures and discussions (e.g., on topics such as advanced directives, memory loss, identity theft) and 45 minutes spent on PA (same duration of time as the intervention group). The only difference between groups was the faith-​ based curriculum in the intervention group. The faith-​based curriculum included three components: (1) scripture reading (with discussion of how the scriptures related to PA) and group prayer; (2) goal setting and reinforcement; and (3) a pedometer competition (small teams competing to see who walked more). The primary outcome was steps walked (based on pedometer readings) at 6 months following the intervention. At baseline, there were no differences between intervention and control groups on PA levels or other measures. At 6-​month follow-​up, those receiving the faith-​ based intervention walked an average of 7,457 steps/​week more than the control group (p =​0.02). Researchers concluded that the faith-​based intervention led to an increase in walking compared to the control condition. Webb and Bopp (2017) conducted an RCT to examine the efficacy of a web-​based Christian intervention designed to increase PA in 45 Christian clergy (60% male, average age 48). Participants were randomized to either the Walking in Faith intervention (n =​24) or to a wait-​list control group (n =​20). Those receiving the intervention engaged in a 12-​session web-​ based program based on biblical scriptures that focused on the following topics: (1)

Exercise • 339

benefits of PA and risks of sedentary activity (1 John 2:6); (2) the value of an active lifestyle (Matthew 25:31–​46; 1 Peter 4:10); (3) identifying and overcoming barriers (Matthew 6:34); (4) goal-​setting, self-​monitoring, and rewards (2 Corinthians 5:9–​10); (5) seeking and providing social support (Ephesians 4:49); (6) PA and stress management (2 Timothy 2:24); (7) modeling health behaviors for others (Matthew 5:14–​15); (8) dealing with potential setbacks (John 16:33); (9) basic nutrition for an active lifestyle (Genesis 1:29); (10) promoting health in all its dimensions (Luke 21:34); (11) review of key information learned (Romans 12:1); and (12) long-​ term maintenance of PA (1 Corinthians 15:58). The wait-​list control group participated only in baseline and outcome assessment at 3 months. PA outcomes were assessed by accelerometer and self-​reported PA. Accelerometers are considered the standard measure for objectively assessing PA and are more accurate than pedometers. Participants all wore an accelerometer for 7 days at baseline and 7 days at the 3-​month follow-​up. They also completed the self-​rated Communities Healthy Activities Model Program for Seniors (CHAMPS) evaluation at baseline and follow-​ up. CHAMPS assesses energy expenditure in terms of METs. Also assessed using standard measures were self-​efficacy for exercise and outcome expectations for exercise. Intervention and control groups were similar at baseline on demographics and all PA measures. Results indicated no difference between the two groups on self-​reported PA based on the CHAMPS questionnaire at follow-up. However, on objective PA assessment measured by the accelerometer, those in the intervention group reduced their sedentary time significantly more than controls, decreasing from 4,167 to 3,880 minutes/​week of sedentary time compared to the control group, which increased their sedentary time from 3,912 to 4,048 minutes/​week (p < 0.05). Likewise, time spent in moderate PA as assessed by the accelerometer also increased more in the intervention group compared to the control group (from 1,291 to 1,468 minutes/​week vs. from 1,235 to 1,151 minutes/​week, respectively, p < 0.05). The intervention group also increased significantly 340 •  H ealth B ehaviors

more than the control group on self-​efficacy in terms of sticking to PA and on self-​evaluation of outcome expectations for PA. Researchers concluded that a religiously tailored web-​based Walking in Faith intervention has potential to influence objectively assessed PA and attitudes toward PA in clergy. Finally, Arredondo and colleagues (2017) randomized 16 Catholic churches in San Diego County (California) to either a 2-​year faith-​ based PA intervention or to a cancer screening attention-​ control condition, examining the effects on self-​ reported and accelerometer-​ measured PA during the first 12 months of the study. A total of 436 women age 18–​65 who attended church at least 4 times/​month and lived within 15 minutes of church were recruited for the study. The PA intervention involved individual, interpersonal, organizational, and environmental components. On the individual level was attendance at PA classes (2 walking groups, 2 cardio-​ dance classes, and 2 strength-​training classes) organized by trained church volunteers. Before each class, participants prayed as a group together (the faith-​based aspect of the intervention). After the class, participants were given a handout sheet with physical goals followed by a short discussion on how to accomplish these goals (which also may have included faith-​ based elements). On the interpersonal level, volunteers provided participants with a 30-​ minute motivational interview and social support to encourage PA and overcome barriers. On the organizational level, extensive advertising was done to alert church members about the classes. Finally, on the environmental level, advocacy efforts were directed at local governments to make the church grounds and surrounding neighborhood more conducive to walking. The primary outcome was accelerometer-​measured PA. Accelerometers were worn for 12 hours/​day for 7 days at baseline and again for the same amount of time at the 12-​month follow-​up. Participants also completed the World Health Organization’s Global Physical Activities questionnaire, which assesses self-​reported moderate to vigorous physical activity (MVPA). Compared to the control condition, those in the intervention group increased PA

significantly when assessed by the accelerometer (increasing MVPA by 22 minutes/​week, d =​0.25, indicating a small effect) and by self-​ report (increasing MVPA by 40 minutes/​week, Cohen’s d =​0.38, a moderate effect). Compared to the control group, those in the intervention group were also 66% more likely to meet the 2008 WHO Physical Activity Guidelines (> 150 minutes/​week of moderate or 75 minutes/​ week of vigorous PA). Body mass index (BMI) also decreased in the intervention group by an average of 0.5 points compared to controls (d =​0.23, a small effect). Researchers concluded that this faith-​ based intervention increased moderate to vigorous PA and decreased BMI.

Summary Religious scriptures in all five major religious traditions emphasize care for the physical body. In research published prior to 2010, more than two-​thirds of the 37 quantitative studies examining the relationship between religiosity and PA reported significant positive results. Although most of the studies were cross-​sectional, the only prospective study also found that religious involvement predicted an increase in PA over time. Since 2010, the majority of high-​ quality retrospective longitudinal and prospective cohort studies found that religiosity predicted an increase in PA over time. Likewise, all single group experimental studies and RCTs (5 out of 5) reported that a faith-​based religious intervention resulted in an increase in PA. Based on these findings, we conclude that in the majority of studies, religious involvement is cross-​sectionally related to greater PA, predicts an increase in PA over time, and religious interventions increase PA, all pointing toward a causal relationship from religiosity to greater PA. Thus, in concordance with what one might expect from religious scriptures encouraging care for the physical body, numerous research studies indicate that religiosity does have a positive effect on PA. Reverse causation, however, is always possible in that regular PA probably increases the likelihood that a person will be able to engage in religious practices (and, correspondingly, those unable to engage in PA may be unable to participate).

RECOMMENDATIONS FOR FUTURE RESEARCH Given the impact that PA and exercise have on mental health, physical health, and longevity, future research should continue to examine the effects that religiosity may have on PA, particularly carefully conducted prospective studies and RCTs. The mechanism by which religiosity affects PA also needs to be clarified. As noted in previous chapters, private and public funding for such studies is limited. However, since there are many planned and currently funded prospective studies examining the impact of exercise on health, we recommend including measures of religiosity at both the startup of new studies or at the time of follow-​up assessments in large ongoing prospective studies. These studies will help to further determine whether religiosity predicts changes in PA over time and the causal nature of these effects. Further observational research, both cross-​sectional and prospective, in non-​Western countries is also needed since there currently exists little research published in religions other than Christianity or in geographical regions outside the United States or Europe (e.g., the Middle East, northern Euro-​ Asian countries, southern Asia, and the Far East). Such research is especially important in countries where physical inactivity and obesity are prevalent. While many of the studies suggested an effect of religious participation on PA, not all did, and further study could attempt to examine moderators across contexts for the effect of religious participation on PA. The same recommendations apply to single-​ group experimental studies and RCTs. Religious interventions such as the Virtual Umrah in Muslims serve as a model in this regard (see above). RCTs that include a fair comparison group are needed to ensure that results from single-​group experimental studies are not due to social attention or simply the passage of time. In addition, the experimental studies and RCTs completed thus far often include a combination of interventions, some of which are faith-​based and some of which are not. Sorting out whether it is the religious component that is responsible for the increase in PA, or whether benefits are due primarily to non-​religious elements, would be of interest in future studies. Exercise • 341

This would require careful selection of populations so that administering either intervention type during randomization would be appropriate for all participants.

CLINICAL APPLICATIONS Given the benefits of PA and exercise to health, clinicians in all medical specialties and mental health professions will want to encourage clients to engage in some form of regular PA, particularly at a level that meets the WHO’s minimal requirements (see above). Enough is known now from the research reviewed above to encourage clinicians to inquire about clients’ religious beliefs (i.e., take a spiritual history) with the purpose of identifying religious beliefs that may help to motivate them to engage in PA. This could be enhanced by clinicians learning about the religious teachings in various faith traditions that emphasize the need to exercise and stay physically active (a few of which have been described in this chapter). Healthcare providers could potentially ask patients if they are aware of any religious teachings in their faith tradition that emphasize care for the physical body. Such questions will need to be asked in a sensitive manner so as not to induce excessive guilt over this personal matter (although some amount of motivating may be appropriate). This would perhaps not be done until a more thorough spiritual history has been taken and a therapeutic relationship formed with the patient. If clients are not aware of such religious teachings, then the clinician may mention what he or she knows about religious beliefs regarding PA from the client’s faith tradition, and then ask them to provide more information after looking into this further (perhaps as homework to complete and report back on during the next visit). For the nonreligious person, other strategies can be employed to increase PA. We also encourage religious professionals to emphasize the importance of caring for the physical body and engaging in regular PA. This can be done in sermons or teachings, during religious education classes, and in religious newsletters. In the Christian tradition, preserving the temple (body) in which God dwells

342 •  H ealth B ehaviors

can be emphasized, since that temple is not the person’s own to do with whatever they please (1 Corinthians 6:19). In addition, religious professionals may consider including programs in their congregations (as described above) that have been shown to increase PA. Religious persons may also be encouraged to engage in solitary activities, such as reading religious scriptures or inspirational books or watching religious television, while walking on a treadmill (which often have a rack for books), or listening to religious sermons, scripture, or music while walking or running (via head-phones). Doing so can take the person’s mind off the discomfort often experienced with vigorous PA and help to make both exercise and private religious activities regular habits. Greater PA within a faith community can enhance the community’s life by promoting physical health; by staying healthy, more community members can work, contribute financially, and engage in volunteer activities that support the congregation. For example, a group or individual program that has both spiritual and physical health benefits is “prayer walking.” As a group program, this requires identifying someone in the congregation to organize church members to walk together in the neighborhood several days per week, praying or worshiping as they walk. This might also help attract new members when those in the neighborhood start asking what the group is doing and why. A two-​page guide on how to organize such an activity is readily available (Hawthorne, 2001), as well as a book to help with motivation (Hawthorne & Kendrick, 1993).

SUMMARY AND CONCLUSIONS In this chapter, we first examined the health benefits of physical activity to the individual and the cost of physical inactivity to society. We then examined individual and environmental factors which increase the risk of physical inactivity, describing Saudi Arabia as an example of a deeply religious country that has one of the highest physical inactivity and obesity rates in the world, due in part to

historical and cultural influences. Next, a case vignette of a young Hindu college student was described, illustrating the dilemma that faces many devoutly religious students who may fall away from physically active religious practices because of the sedentary activity of studying. We then speculated on how religious involvement might impact physical exercise, first examining religious teachings on PA from the five major world religions, and then exploring how religiosity might impact both individual and environmental risk factors for physical inactivity. In the heart of the chapter, we focused on quantitative research that has examined the relationship between religiosity and PA. We first discussed a systematic review of research prior to 2010, which revealed that more than two-​thirds of studies found a positive relationship between religiosity and PA, though almost all of these were cross-​sectional. We then summarized more recent high-​quality

retrospective longitudinal and prospective cohort studies published since 2010 that examined religiosity’s impact on PA over time. The results of single-​ group experimental studies and RCTs were also reviewed, studies that have examined the impact of faith-​based interventions on increasing PA. Many of the more recent studies are methodologically stronger and provide evidence for an effect of religious participation on PA. This is a topic in which the quality of the studies concerning religious participation has improved substantially over the past decade. Progress is clearly being made in the field. Finally, we made recommendations for future research and for clinical practice that are relevant to both health professionals and religious professionals. In the next chapter, we examine the relationship between religiosity, diet, and weight, which like PA and exercise, have an enormous impact on both mental and physical health.

Exercise • 343

19 Diet and Weight Eat of what is lawful and wholesome on the earth. . . . O children of Adam, take your adornment at every masjid, and eat and drink, but be not excessive. Indeed, He likes not those who commit excess. —​Qur’an 2:168, 7:31

MOST MAJOR WORLD religions, especially Islam, Judaism, Buddhism, and Hinduism, have specific prescriptions and proscriptions regarding the foods that are allowed. Few religions, however, have beliefs about how much to eat (except to avoid gluttony and excess) or teachings that discourage overeating to avoid weight gain. This chapter examines the relationship between religiosity, consuming a healthy diet, and weight. We first focus on diet and then on weight.

BENEFITS OF A HEALTHY DIET A healthful diet has long been considered an essential component of health, especially cardiovascular health, metabolic health, and cancer prevention.

Cardiovascular Disease and Stroke Prospective studies have demonstrated a relationship between diet and cardiovascular or cerebrovascular disease (CVD). For example, in a prospective study of 84,129 women in the US Nurses’ Health Study, Stampfer and colleagues (2000) found that those who ate a diet high in cereal fiber, omega-​3 fatty acids, folate, and polyunsaturated fat, and low in trans-​fat, saturated fat, and sugar, were substantially less likely to have a heart attack during the next 14 years. Similar findings were reported in the Health Professionals Follow-​up Study that involved 51,529 men examined over 16 years, which found that those who ate a diet low in trans-​fat and saturated fat, low in red meat, high in fruits and vegetables (legumes, tofu, soy products), and high in cereal fiber, were also significantly less likely to develop coronary heart disease (CHD) (Chiuve et al., 2006).

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0019

Recently, evidence for the health benefits of diet comes from research on the Mediterranean diet (Jospe et al., 2020). Ranked the best overall diet in 2020 by US News & World Report (2020), this diet involves eating plenty of fruits and vegetables (except potatoes), whole-​grain cereals and legumes, a low to moderate intake of fish and poultry, low consumption of red meat and dairy products, and moderate alcohol intake (1–​2 drinks/​day, particularly wine with meals) (Hu, 2003; Mitrou et al., 2007; American Heart Association, 2019). In a systematic review of 11 prospective studies and randomized control trials (RCTs), Grosso et al. (2017) found that those who strictly adhered to a Mediterranean diet experienced a nearly 30% reduction in incidence of CHD (RR =​0.72, 95% CI =​0.60–​0.86), a 33% reduction in myocardial infarction (RR =​0.67, 95% CI =​0.54–​0.83), and nearly a 25% reduction in stroke (RR =​0.76, 95% CI =​0.60–​0.96). With regard to components of the Mediterranean diet that are thought to be most beneficial, pooled results from numerous RCTs indicate that consumption of olive oil, whole fruits, raw vegetables, legumes (e.g., beans, peas, lentils), and nuts (e.g., soy, carob, peanuts, particularly dry-​ roasted and unsalted) explained 40% of the reduced risk of CVD (Grosso et al., 2017). Consumption of a Mediterranean diet has been shown to reduce the risk not only of CVD, but also of developing breast cancer, colorectal cancer, diabetes, obesity, asthma, erectile dysfunction, and cognitive decline (Widmer et al., 2015). Adherence to this diet rivals the effects of more established treatments for CVD, including aspirin, beta-​blockers, angiotensin-​converting enzyme inhibitors, and exercise. Another diet recommended by the National Heart, Lung, and Blood Institute and American Heart Association is the Dietary Approaches to Stop Hypertension, or the DASH diet, ranked second best overall by US News & World Report, following the Mediterranean diet (DHHS, 2006; American Heart Association, 2019a; US News & World Report, 2020). The DASH diet is similar to the Mediterranean diet in emphasizing whole grains, fresh fruits, and raw vegetables, although it allows more protein from sources such as low-​fat dairy and cuts of meat

and poultry. However, it minimizes intake of fat, sweets, and salt (no more than 1.5 grams of sodium intake per day, i.e., approximately 2/​3 teaspoon salt, including salt in food and added salt).

Metabolic Disease Metabolic syndrome (MetS) is a condition characterized by dyslipidemia (increased serum cholesterol and triglyceride), insulin resistance, type 2 diabetes, impaired glucose tolerance, hypertension, and central obesity. MetS is known to increase the risk of CVD (Grundy, 2016). In a review and meta-​analysis of observational studies, Rodriguez-​ Monteforte and colleagues (2017) concluded that a prudent/​ healthy diet similar to the Mediterranean diet is associated with a lower prevalence of MetS, whereas an unhealthy Western diet, high in meat, processed meat and poultry, refined grains, fast foods, snacks, sweets, desserts, soda, and sweetened drinks, is associated with an increased risk. Likewise, a review by Shab-​ Bidhar et al. (2018) found that a prudent/​ healthy diet decreased the likelihood of MetS by 11% (OR =​0·89, 95% CI =​0.84–​0.94, p =​0.002), whereas an unhealthy Western diet increased risk by 16% (OR =​1.16, 95% CI =​1.11–​1.22, p < 0.001). Thus, there is little doubt that diet affects the likelihood of developing MetS. We now discuss the impact of diet on two important components of MetS, serum cholesterol and diabetes mellitus, given their link with developing CVD. D IET AN D SERUM CH OL ESTEROL

The adverse effects of high serum cholesterol are well known, as are the benefits of lowering cholesterol (Silverman et al., 2016). Total cholesterol is determined by adding high density lipoproteins (HDL; good cholesterol), low density lipoproteins (LDL; bad cholesterol), and 20% of the triglyceride (fat) level in blood. The prevalence of high total cholesterol (240 mg/​dl or above) in US adults is 12.4%, with the highest rates found in those age 40–​59 years (17.1%) (Carroll et al., 2017). The prevalence of low HDL (less than 40 mg/​dl) is 20.1% overall, with the highest prevalence found again in men Diet and Weight • 345

age 40–​59 years (31.9%). “High” LDL is defined as 100 mg/​dL or higher for individuals at high risk for coronary heart disease, above 130 mg/​ dL for those at intermediate risk, and above 160 mg/​dL for those at low risk. The prevalence of high LDL in the United States based on data collected during the 2005–​2008 NHANES study (latest available data) was 33.5% (CDC, 2011). The optimum level of total cholesterol is 200 mg/​dl or less, of HDL cholesterol is 60 or above, and of LDL cholesterol is less than 100. The cholesterol ratio is the total cholesterol divided by HDL cholesterol, and the optimal ratio is between 3.5 and 1.0. Cholesterol levels are determined by diet (eating cholesterol-​ containing foods), exercise, and heredity (genetics). High cholesterol-​ containing foods, for example, are cheese, egg yolks, beef, pork, poultry, and shrimp. Careful attention to diet, weight reduction, exercise, and avoidance of cigarette smoking can reduce cholesterol levels. In order to lower cholesterol, the 2015–​2020 Dietary Guidelines for Americans (2015) recommend decreasing the consumption of saturated and trans-​fats and refined carbohydrates such as sugar; increasing the intake of fish high in omega-​3 fatty acids, whole grains, fruits, vegetables; and using heart-​healthy vegetable oils, especially olive oil and canola oil. Diet alone can reduce LDL cholesterol levels by as much as 35% in just two weeks. Such a diet consists of low-​saturated-​fat and low-​ cholesterol-​ containing foods where less than 7% of total calories are obtained from saturated fat and cholesterol intake is less than 200 mg per day. Foods low in saturated fat are the following: fat-​free or 1% dairy products, lean meats, fish, skinless poultry, whole grain foods, and uncooked fruits and vegetables.

diabetes), in addition to improving the course of the illness among those who already have it (Maiorino et al., 2017). CAN CER

As noted above for the Mediterranean diet, the foods that one eats can influence the risk of developing cancer (Norat et al., 2015). Between 30% and 40% of all cancers may be prevented by attention to diet and lifestyle, especially breast, colorectal, prostate, and lung cancers (Divisi et al., 2006). A diet rich in selenium and omega-​3 fatty acids may help to prevent prostate cancer, whereas a diet rich in animal fats may increase risk of breast cancer. The primary way that adherence to the Mediterranean and DASH diets prevents cancer, especially endometrial cancer, post-​menopausal breast cancer, and hepatocellular cancer, is by their preven­ tion of obesity (Kerr et al., 2017). Obesity increases cancer risk because it causes a state of chronic low-​grade inflammation in the body. In addition, adipose tissue is responsible for synthesis of aromatase, the rate-​limiting enzyme that converts androgens to estrogens, which increase risk of post-​menopausal breast cancer. A diet high in processed foods has also been shown to increase cancer risk overall, especially breast cancer (Fiolet et al., 2018). Pancreatic, gastrointestinal, hematologic, and genitourinary cancers have been linked with diets high in sugar (Makarem et al., 2018). Red meat and meats with a high concentration of nitrates and nitrites have long been associated with risk of developing colorectal cancer (Rossi et al., 2019).

IMPORTANCE OF BODY WEIGHT

Next, we examine ways that weight is measured, review the prevalence of weight probControl of type I and type II diabetes is highly lems, and discuss the health consequences of dependent on diet. A systematic review of 24 being overweight. Body mass index (BMI) is studies by Sleiman and colleagues (2015) found considered the standard measure of weight that adherence to the Mediterranean diet in proportion to height. BMI is obtained by can significantly reduce HbA1c, 2-​hour post-​ dividing one’s weight in kilograms by the prandial glucose, fasting glucose, and insulin square of one’s height in meters (kg/​ m2). resistance. There is even evidence that a healthy Alternatively, multiplying weight in pounds diet can reduce the risk of developing diabe- times 703 and dividing the product by height in tes (at least type II diabetes, or adult-​onset inches squared also gives the equivalent BMI. DI E T A N D D I A B E T E S

346 •  H ealth B ehaviors

Underweight is defined as a BMI < 18.5, normal weight as 18.5–​24.9, overweight as 25.0–​29.9, and obesity as 30 or greater, although these cutoffs may vary depending on country (China and Japan define overweight as a BMI of 24 or higher and obesity as 28 or higher; in India, overweight is defined as a BMI of 23 or higher and obesity as 27 or higher). Several other ways of measuring weight include waist-​to-​hip ratio (WTHR), waist circumference (WC), and waist-​ height ratio (WHR).

Prevalence The number of obese people in the United States is increasing rapidly. According to the National Health and Nutrition Examination Survey (NHANES), the prevalence of obesity increased from 33.7% in adults age 20 or older in 2007–​2008 to 39.6% in 2015–​2016 (Hales et al., 2018). Among youth age 2–​19 years, the prevalence increased from 16.8% to 18.5% during this period. Note that in 1980, the prevalence of obesity among adults was 13.4% and among children was 5% (Office of the Surgeon General, 2010). Thus, the obesity rate among adults increased from 1980 to 2015–​2016 by 196% and in youth by 270%. As a result, the prevalence of type II diabetes in adults has nearly tripled since 1980 (to now, nearly 1 in every 10 Americans) (Office of the Surgeon General, 2010; Bullard et al., 2018). The highest rates of obesity are found among African American and Hispanic American adults. Between 1999 and 2016, obesity rates increased from 39.6% to 47.3% among African Americans age 20 or older and from 31.2% to 47.2% in Hispanic Americans (American Heart Association, 2019b). During the same time period, obesity rates in children/​young adults age 2–​19 years increased from 19.5% to 22.5% in African Americans and from 19.3% to 26.1% in Hispanic-​ Americans. Consumption of an unhealthy Western diet (as described above) is the main reason for such trends. With regard to obesity worldwide, the prevalence has nearly doubled in the past 35 years, with approximately one-​third of the world’s population now overweight or obese (Arroyo-​ Johnson et al., 2016; Chooi et al., 2019). In 2014, 11% of men and 15% of women were

obese based on WHO criteria. Furthermore, 42 million children under age 5 years were overweight in 2013. Abarca-​Gomez and colleagues (2017) provide the latest figures based on pooled data from 2,416 separate studies involving 128.9 million participants, including 31.5 million young people age 5–​19 years. In 1975, the mean age-​standardized BMI among children and adolescents age 5–​19 years was 17.2 for girls and 16.8 for boys. By 2016, this had increased to 18.6 in girls and 18.5 in boys (with obesity rates in girls increasing from 0.7% in 1975 to 5.6% in 2016, and in boys, from 0.9% to 7.8%). The approximate figures for average age-​standardized BMI in women age 20 or over increased from 22.4 in 1975 to 25.0 in 2016 (see Figure 1 in Abarca-​Gomez et al., 2017), and for men, from 22.0 to 24.8 in 2016 (Figure 2, Abarca-​Gomez et al., 2017). Among women, obesity rates were highest in Egypt, South America, the Middle East, the United States, and South Africa. Among men, rates were highest in the United States, Canada, Mexico, the Middle East, Australia, Argentina, and Chile (see Figure 7.1 in the Appendix of Abarca-​ Gomez et al., 2017). In general, Americans and Europeans have the highest rates of obesity, with more than 50% of the population being overweight or obese, which is likely due to increased access to food and the financial ability to purchase it (Chooi et al., 2019).

Health Consequences Research studies estimate that being overweight or obese at age 35–​44 increases the risk of diabetes mellitus by over 200%, ischemic heart disease by 66%, hypertensive heart disease by 115%, ischemic stroke by 86%, and hemorrhagic stroke by 154% (Singh et al., 2013). Likewise, other studies estimate that excessive weight increases risk of cancers of the colon and rectum by 30%, gastric cardia by 80%, liver by 80%, gallbladder by 30%, pancreas by 50%, kidney by 80%, esophagus by 380%, and uterus by 610% (Lauby-​Secretan et al., 2016). Being overweight also increases stress on weight-​bearing joints, resulting in musculoskeletal disorders, especially osteoarthritis of the knee and hip (Anandacoomarasamy et al., 2008). Furthermore, those who are Diet and Weight • 347

obese in midlife have a 104% increased risk of Alzheimer’s disease and a 64% risk for any dementia compared to those of normal weight (Anstey et al., 2011). Obesity is also commonly associated with psychiatric disorders (Rajan & Menon, 2017), and weight gain is a common side effect of psychiatric medications (Alonso-​ Pedrero et al., 2019). By some estimates, in 2014, being overweight contributed to 320,000 deaths in the United States, and in 2015, being overweight contributed to 4 million deaths globally (GBD 2015 Obesity Collaborators, 2017). While there remains some debate with regard to the effect of being just overweight (but not obese) on mortality risk, being obese seems clearly detrimental (Kodama et al., 2009; Flegal et al., 2013).

Types of Fat Adipose tissue may be located either under the skin (i.e., subcutaneous) or surrounding the viscera (abdominal organs). Subcutaneous fat is less worrisome than visceral fat (or brown fat) since the latter has immunologic, neuroendocrine, and metabolic effects, increasing inflammation throughout the body and increasing the risk of metabolic syndrome (Tchernof & Després, 2013). As a result, there are metabolically unhealthy individuals with a low BMI (but increased visceral fat), and metabolically healthy people with a high BMI (low levels of visceral fat). Thus, it is particularly important to determine the amount of fat surrounding a person’s abdominal organs, i.e., visceral fat. Early reports indicated that a high WTHR (waist-​to-​hip ratio), characteristic of those with “apple”-​shaped bodies, had higher amounts of visceral fat, whereas those with a low WTHR, characteristic of those with “pear”-​shaped bodies with a higher proportion of fat on their hips, had lower visceral fat and thus lower metabolic risk (Seidell et al., 1990). More recently, waist circumference (WC) assessed at the midline between the lowest rib and iliac crest has been reported to be the best predictor of visceral fat in both men and women (W. Shi et al., 2017). Waist-​ height ratio (WHR) is another good measure of visceral fat (Swainson et al., 2017). Adipose tissue (fat) produces leptin, which suppresses appetite. However, with increasing 348 •  H ealth B ehaviors

weight and accumulation of fat, the body develops resistance to leptin, thereby increasing hunger (Klok et al., 2007). Thus, as fat deposits increase, leptin resistance increases and hunger increases, creating a vicious cycle.

Financial Cost The health consequences of obesity have enormous cost, with estimates of $147 billion/​ year in the United States in 2008 dollars, with an increased annual cost of $1,429/​year for an obese person compared to an individual of normal weight (Finkelstein et al., 2009). More recent estimates of healthcare costs in 2014 were $1,901/​year for an obese person compared to a person of normal weight, resulting in an annual excess cost of $149.4 billion for the country as a whole (Kim & Basu, 2016). In Europe, the total additional direct and indirect healthcare costs of being overweight or obese was estimated at €117 to €1,873 per person per year, approximating 0.47%–​0.61% of gross domestic product, i.e., the monetary value of all goods and services produced in a country per year (von Lengerke & Krauth, 2011).

Predictors of Obesity Childhood obesity is a strong predictor of adult obesity (Simmonds et al., 2016). More than half of obese children go on to become obese adolescents, and approximately 80% of obese adolescents go on to become obese adults. Determinants of childhood obesity include risk factors at the individual level (increased food intake, physical inactivity, availability of easy transportation, electronic and televised forms of sedentary entertainment), genetic level (basal metabolic rate and lipostatic set points), social level (parent and peer obesity), psychological level (stress, depression, low self-​ esteem), behavioral level (electronic media use), and socioeconomic level (poverty, inability to afford nutritious foods), all acting within the context of family factors (low parental education, poor parental nurturing, home food environment, shared family meals, eating patterns of mothers) and community environmental factors (proximity to fast food outlets, supermarkets, farmers markets, access

to outdoor play areas, level of neighborhood crime) (Campbell, 2016). However, 70% of all obese adults were not obese as children or adolescents, and 80% of obese individuals over age 30 were not obese as adolescents, so obesity during childhood or adolescence is not the only risk factor (Simmonds et al., 2016). Obesity rates are generally higher in women than in men, with differences greatest between age 50 and 65 (Chooi et al., 2019). Rates of obesity increase with age, again peaking between age 50 and 65 and slightly declining after age 65. Self-​control/​self-​restraint is also a factor that cuts across all risk factors for obesity in both childhood and adulthood, within and outside the United States (Elfhag & Morey, 2008; Pearson et al., 2018; Mackenbach et al., 2019).

RELIGION, DIET, AND WEIGHT As noted earlier, many world religions have beliefs about diet, which have consequences for weight and health. We begin with a case, and then review what different religions have to say about diet and eating behaviors. Case Vignette Tom, a 64-​ year-​ old businessman, has been a lifelong member of the Seventh Day Adventist (SDA) church, in which he has been active and raised his family. His religious faith is important to him and has guided his choices concerning diet and lifestyle. Since childhood, Tom has been largely a vegetarian and has avoided meat products (as did his parents, who were also SDA). However, he will occasionally eat eggs and milk products like cheese. Tom rarely drinks alcohol (although is not a teetotaler), has never smoked, and does not drink caffeinated beverages. His blood pressure is in the normal range and his total cholesterol level is at a high normal level (220 mg/​dl). His weight has been creeping up in recent years, so Tom has started an exercise program that involves walking

briskly for 30 minutes every morning before work. He walks with a neighbor (another member of his church), and they often pray aloud when walking, which helps the time go by more quickly. Tom likes it when people say that he looks younger than his age.   

Religious traditions that encourage members to adhere to a specific diet are Seventh Day Adventists and Latter Day Saints in the Christian tradition, Orthodox Jews, Muslims (especially around the month of Ramadan), and to a lesser extent, Buddhists and Hindus. Members of the Seventh Day Adventist church, a conservative Christian denomination, abstain from alcohol, tobacco, and drinks that contain caffeine. They also avoid biblically proscribed meats (in the Hebrew Scriptures) such as pork, and some are complete vegetarians. SDAs also frequently avoid hot spices and highly refined foods. SDA diets tend to be high in folate, thiamin, vitamin C, and vitamin A; low in total fat, saturated fatty acids, and cholesterol; and high in dietary fiber. Likewise, Latter Day Saints abstain from alcohol, cigarette smoking, caffeinated beverages, and any habit-​ forming drugs. They often make their own bread from whole grains, prepare their own canned products, and avoid refined and highly processed foods. Latter Day Saints typically do not abstain from meat, however, and their meat consumption is actually rather high. Not surprisingly, then, SDAs and Latter Day Saints live an average of 4 years longer than the general population (Berkel & deWaard, 1983; Jarvis, 1977; Fraser et al., 2020). Many Protestants and Catholics fast or give up certain foods during religious holidays (e.g., Advent preceding Christmas, and Lent preceding Easter). The Catholic Church also encourages members to eat fish on Fridays (i.e., abstain from warm-​blooded flesh meat) as a penance to commemorate the day that Jesus was crucified. Fish is allowed because the drawing of a fish in the dirt was one way that early Christians let each other know they were Christian at a time when it was dangerous to Diet and Weight • 349

be one (Koenig, 2017g). Likewise, Jesus cooked fish for his apostles after his resurrection; most of those apostles were fishermen; and Jesus’s followers were often referred to as “fishers of men” for establishing God’s kingdom on earth (Matthew 4:19). The Bible emphasizes meeting together both for worship and for meals (Acts 2:42, 46). Indeed, at the Last Supper before Jesus’s crucifixion, he broke bread with his disciples and encouraged them to repeat this practice after his death (Luke 22:19). Protestant Christians who closely follow the Bible, especially Baptists and other evangelical Christian groups, emphasize meeting together at the church or in small groups at people’s homes, where potluck meals are the norm. The foods brought to these potlucks are usually rich in calories, fat, and sweet desserts, which may affect weight among members of this faith group. However, the Bible also discourages gluttony: “ ‘I have the right to do anything,’ you say—​but not everything is beneficial. ‘I have the right to do anything’—​but I will not be mastered by anything” (1 Corinthians 6:12); “Do you not know that your bodies are temples of the Holy Spirit, who is in you, whom you have received from God? You are not your own; you were bought at a price. Therefore, honor God with your bodies” (1 Corinthians 6:19–​20); and “Do not, for the sake of food, destroy the work of God” (Romans 14:20). Proverbs 23:2 is even more explicit: “put a knife to your throat if you are given to gluttony.” Orthodox Jews follow the Mosaic code that emphasizes avoidance of pork and adherence to a kosher diet (Vayikra [Leviticus] 11:1–​47; Devarim [Deuteronomy] 14:3–​ 21). Kosher foods are beef, deer, goat, lamb, chicken, duck, goose, and turkey (if slaughtered humanely and prepared in accordance with Jewish law, although these meats cannot be combined with dairy). Pork, however, is forbidden. Fish with fins and scales (e.g., salmon, tuna, carp, and herring), but not catfish or shellfish (without fins and scales), are allowed and may be consumed with dairy products since fish is not considered meat in this tradition. Eggs of all kinds and vegetables of all kinds are allowed. A kosher diet is generally a healthy diet. In Islam, there are specific meats and other foods that are considered either “halal” (allowed) 350 •  H ealth B ehaviors

or “haram” (not allowed) (Gagne, 2020). Halal food is food prepared according to Islamic law as specified in the Qur’an and Sunnah. As in Judaism, the particular way that an animal or poultry is slaughtered is important. In Islam, the appropriate way of slaughtering (dhabiha) a living and healthy animal (required) is by cutting through the jugular vein, carotid artery, and windpipe, and then draining all blood from the carcass. Haram (forbidden) foods include pork, blood, and meat that has not been prepared by the dhabiha method (Regenstein et al., 2003). The Qur’an says: “He has forbidden you only these things: carrion, blood, pig’s meat, and animals over which any name other than God’s has been invoked” (16:115). Halal (allowed) foods include certified meats, halal deli meats, seafood, nuts, legumes, eggs, peanut butter, and tofu, but not pork and pork products such as ham, sausage, or bacon, non-​certified meats and poultry, and any other product prepared with alcohol or animal fats. Halal foods include cereal products, rice, and pasta, except those containing haram ingredients such as alcohol, animal fats, or vanilla extract. All fruits, fruit juices, and vegetables, whether frozen, canned, raw, boiled, buttered, or cooked in vegetable oil, are allowed, except those containing haram ingredients such as alcohol, animal fats, gelatin, or bacon. Milk, yogurt, cheese, and ice cream made with bacterial culture are also permitted, except for cheese, yogurt, and ice cream made with animal rennet, vanilla extract, gelatin, pepsin, or lipase, which are haram. Fasting is also an important practice in Islam, not only during the month of Ramadan but at other times as well. During Ramadan, no food or liquid may be consumed from sunrise (Sahur) to sunset (Iftar). Dima-​Cozma and Cozma (2012) found that Muslims eat a greater variety of foods during Ramadan than during the rest of the year, and there is an increase in consumption of sugary foods and drinks during this time. On average, however, Muslims tend to lose about 3–​8 pounds during Ramadan. In addition, devout Muslims may fast three days per month or even two days per week, although excessive fasting is discouraged (Ali, 1990). The Qur’an also emphasizes that people should not overeat: “eat and drink [as We have permitted]

but do not be extravagant [eat excessively]: God does not like extravagant people” (7:31). The Buddha explains the benefits of mindful eating in the Donapaka Sutta: “When a person is constantly mindful, and knows when enough food has been taken, all their afflictions become more slender—​they age more gradually, protecting their lives” (Olendzki, 2013). Likewise, Buddhist beliefs emphasize self-​control in the Five Moral Precepts, which include not killing or harming any living creature, not stealing, not engaging in sexual misconduct, not lying, and not consuming intoxicants such as alcohol, tobacco, or mind-​altering drugs (Hua, 2003). In general, Buddhism prohibits eating any and all meat, because it results from the killing of living creatures, thus violating the First Moral Precept, and because meat is considered an intoxicant to the body, thus violating the Fifth Moral Precept. Thus, many Buddhists (and some Hindus) follow a modern vegetarian diet that is high in carbohydrates, has a high polyunsaturated to saturated fatty acid ratio, and has a moderate overall fat content. Rice and soybeans are the primary sources of protein in the diet. Permitted foods in Buddhism that frequently make up the Buddhist’s diet include boiled or stir-​fried noodles, raw or cooked vegetables, seaweed, rice, soy sauce, sesame oil (which contains no sodium, as soy sauce does), occasionally fish, and herbal tea made from various tea plants. Consequently, blood concentrations of cholesterol, glucose, and uric acid are often lower in Buddhists compared to those found in other religious groups. Many Hindus are lacto-​vegetarian (i.e., they avoid eating meat and eggs). However, some may eat lamb, chicken or fish. Beef is generally avoided because the cow is considered holy. Products from the cow (dairy), however, are allowed. Hindus believe that the mind and body can be trained to resist and overcome cravings or harmful behaviors such as food addiction among those who are overweight or obese. The Bhagavad Gita states: “It is true that the mind is restless and difficult to control. But it can be conquered . . . through regular practice and detachment. Those who lack self-​control will find it difficult to progress in meditation; but those who are self-​ controlled, striving

earnestly through the right means, will attain the goal” (6:34–​35).

HOW RELIGION MIGHT AFFECT DIET AND WEIGHT Many of the world’s great religions, then, encourage (and even prescribe) a healthy diet and self-​control that may help with keeping weight down and avoiding obesity. However, religious beliefs and commitments may also encourage some of the key predictors of obesity, as described above.

Diet On the one hand, diet is a matter of personal choice and involves having the “will” to eat healthy food. Religious beliefs may help increase the will (self-​control) and motivation to eat in a way that maximizes the health of the physical body. On the other hand, choice of foods depends on having financial resources to obtain those foods. Fresh fruits and vegetables are usually not that expensive but may be difficult to access, and healthy meats and fish tend to be quite costly. Those who are more religious, in a number of contexts, tend to have lower incomes and therefore may not be able to afford high-​quality protein foods or have access to fresh fruits and vegetables. There are also social and cultural factors that influence diet. For example, in the United States, ethnic/​ racial groups such as African Americans and Hispanic Americans are more religious than White Caucasian-​ Americans, and also tend to have lower incomes and ethnic traditions that favor consumption of high-​ calorie, high-​fat foods, resulting in less healthy diets. Such diets tend to be passed down in families, as certain tastes develop from family traditions involving food and food preparation. Social, cultural, and family pressures, then, may reduce the likelihood of eating nutrition-​rich foods by those who are more religious. Socioeconomic factors may also influence food consumption in other ways. Financial resources are necessary to obtain regular dental care, and this may confound the relationship between religiosity and diet, since some racial/​ ethnic minorities may not be able to afford Diet and Weight • 351

high-​quality dental care, resulting in dental conditions, perhaps especially in older ages, that make eating fresh fruits (e.g., apples), raw vegetables (e.g., carrots, celery, broccoli, cauliflower, or lettuce), or nuts more difficult, resulting in a lower consumption of these healthy foods and increased intake of soft high-​calorie cooked or processed foods. Thus, many factors related to socioeconomic status and ethnic background must be considered when examining the relationship between religiosity and diet.

Weight With regard to weight, the primary predictors of obesity, as noted earlier, are obesity in childhood; unhealthy diet and poor nutrition; physical inactivity; availability of easy transportation to school, work, and grocery stores; time spent on sedentary electronic and televised forms of entertainment; genetic factors such as basal metabolic rate set point; social and cultural influences; psychological stress, depression, and low self-​esteem; poverty and inability to afford nutritious foods; low parental education, unhealthy home food environment, poor eating habits of parents as role models, parent obesity, and low parental psychological nurturing; greater proximity to fast food outlets, residence in non-​rural settings, poor access to outdoor play areas, and high-​crime neighborhoods; and demographic factors such as female gender and middle/​older age. As with diet, self-​ control also plays a major factor in the development and maintenance of obesity. On the one hand, religiosity has been associated with greater self-​ control, rural living (greater distances to school, work, and grocery stores, greater access to outdoor play areas, less neighborhood crime, greater access to fresh vegetables), greater physical activity (Chapter 18), less depression (Chapter 5), higher self-​esteem (Chapter 12), and greater parental nurturing (Chapter 14; Chen et al., 2019a). On the other hand, religiosity has also been associated with ethnic/​ racial background (African American or Hispanic American) and low socioeconomic status, factors known to be associated with high rates of obesity. Religiosity is also greater in women and those who are older, both groups with an increased risk of being overweight. In 352 •  H ealth B ehaviors

addition, religiosity has also been associated with conservative traditions and cultural practices, which may breed social attitudes that promote obesity (viewing it, as in Saudi Arabia, as a sign of prosperity and success). Note, however, that many of these factors that are associated with religiosity and diet/​weight are not necessarily on the pathway from religiosity to diet/​weight, but rather may be confounding the relationship between religion and diet/​ weight. Based on what is known about factors that influence weight, then, it could be difficult to predict how religiosity might be related to being overweight or obese.

RESEARCH ON RELIGIOSITY AND DIET Can systematic research help to answer the question of whether and how religiosity affects diet and weight? We begin with diet. First reviewed are research findings from studies published prior to 2010 (Koenig et al., 2012), followed by a selective review of high-​quality studies published more recently, with a focus on prospective studies, experimental studies, and RCTs when available. However, since prospective studies and clinical trials examining the effects of religiosity on diet are relatively few, we also present high-​quality cross-​sectional studies that have examined the relationship between religiosity and diet, though the results of these must be interpreted with additional caution.

Early Research In our systematic review conducted prior to 2010, we identified 22 studies that examined the relationship between religiosity and diet (or the effects of a religious intervention on diet). Of those, 14 (64%) found that greater religiosity was associated with a healthier diet (13 significantly so, 1 reporting a trend in that direction); one study (5%) reported that religiosity was associated with a worse diet; and the remainder (31%) found no association or mixed findings depending on how they measured religiosity. Not included among those 22 studies were several research reports indicating that the diet of Seventh Day Adventists was better than that of non-​Adventists (less meat consumption, lower

cholesterol-​containing foods, etc.). Among the 22 studies examining religiosity, 19 were cross-​ sectional, 1 was prospective, and 2 were RCTs. The one prospective study assessed fruit and vegetable intake at the beginning and end of the seventh grade among 3,878 middle-​schoolers in Minnesota, finding that a self-​reported 6-​item measure of “influence of spiritual or religious beliefs on decision-​ making” at baseline predicted greater fruit and vegetable consumption (using general linear mixed modeling) (Lytle et al., 2003). The first RCT was a randomized trial of the Eating for a Healthy Life (EHL) intervention, where religious organizations (ROs) were the units of recruitment and randomization. The faith-​based elements of the EHL involved motivational messages and church-​related social activities (Bowen et al., 2009). Results indicated that participants in intervention ROs reported significantly healthier dietary behaviors compared to ROs not receiving this intervention. The second RCT involved (1) an Internet-​ delivered secular program, Guide to Health (GTH), to decrease dietary fat and increase fruits and vegetable (F&V) intake; (2) a GTH+​ program that involved church-​based support; and (3) a wait-​list control condition (Winett et al., 2007). Fourteen churches were randomly assigned to each of these three intervention arms, with a total of 1,071 persons participating. At the 5 churches assigned to the GTH+​ arm, prompts and reminders were provided from the pulpit and in church bulletins, and the names of those who had reached nutrition goals were placed on posters displayed at the church, in church bulletins, and in church newsletters. Nutrition outcomes using standard measures were assessed at baseline, 7 months from baseline, and 16 months from baseline. Results indicated that compared to the control group, both GTC only and GTC+​groups significantly increased fiber and F&V intake and decreased fat intake, but there was no difference between the two active treatments. Thus, GTC+​with church supports was not more helpful in improving nutrition than GTC only.

Recent Research Since 2010, a number of cross-​sectional studies, at least two prospective studies, and at

least one single-​ group experimental study have been published examining the impact of religiosity on diet. We now review three high-​ quality cross-​sectional studies, along with the two prospective studies and the experimental study (for a full list of studies and results, see Appendix). CROSS-​SECTION AL STUD IES

Salmoirago-​ Blotcher et al. (2011) analyzed data from a sample of 57,182 postmenopausal women enrolled in the US Women’s Health Initiative, examining the relationship between frequency of religious attendance and, among other outcomes, total fiber intake, saturated fat consumption, and total calorie intake. The mean age of participants was 62.0 years, 83% were White/​non-​Hispanic, and 65% were married. Logistic regression was used to examine the relationship between religious attendance and dietary behaviors, controlling for age, race/​ ethnicity, marital status, family income, education, general health score, physical functioning, and health insurance status. Results indicated no relationship between religious attendance and saturated fat intake, adjusting for total caloric intake. However, compared to those not attending religious services in the past month, fiber intake increased significantly in a dose-​response manner with increasing religious attendance such that total fiber intake was 8% higher in those attending less than once per week, 16% higher in those attending once/​week, and 31% higher among those attending religious services more than once/​ week (adjusted OR =​1.31, 95% CI =​1.23–​1.39). Likewise, compared to those never attending services, total calorie intake was significantly lower among those attending less than once/​ week but more than never (4% lower), once/​ week (9% lower), and more than once/​week (6% lower) (adjusted OR =​0.94, 95% CI =​0.89–​ 0.99). Thus, more frequent religious attendance was associated with both greater fiber intake and lower calorie consumption. Michaelson and colleagues (2014) analyzed data from a random sample of 26,078 adolescents age 11–​ 15 in Canada, examining the relationship between participation in church/​religious groups and dietary behaviors Diet and Weight • 353

(frequent breakfast skipping, infrequent vegetable eating, infrequent fruit consumption). Controlled for in regression models were gender, grade level, urban-​rural geographical location, family structure, material wealth (SES), and meals eaten as a family. Results indicated that youth who participated in church/​ religious groups were 22% less likely to frequently skip breakfast (adjusted OR =​0.78, 95% CI =​ 0.71–​ 0.86), 27% less likely to infrequently eat vegetables (adjusted OR =​0.73, 95% CI =​ 0.65–​0.83), and 19% less likely to infrequently consume fruits (adjusted OR =​0.81, 95% CI =​ 0.71–​0.92). In a study examining the effects of religiosity on mortality among 36,613 community-​ dwelling African American women in the United States (age 50–​79; 44% average BMI over 30), VanderWeele et al. (2017a) examined the relationship between religiosity and dietary behaviors at baseline. Since dietary behaviors were not the primary outcome, only unadjusted cross-​sectional analyses concerning diet were presented in the baseline descriptive statistics. Religiosity was assessed by frequency of religious attendance (several times/​ week vs. one time/​month or less), frequency of prayer (several times/​day vs. rarely/​never), degree to which religion was used in coping (very involved vs. not involved), and degree to which a participant considered himself or herself a religious or spiritual person (very vs. not/​ slightly). The primary dietary outcome was having a DASH dietary pattern. As noted above, the DASH diet is similar to the Mediterranean diet in emphasizing whole grains and grain products, fruits, and vegetables, while allowing more protein sources from low-​fat dairy and lean cuts of meat and poultry, but very little fat, sweets, or salt. Analyses revealed no relationship between any religious measure and high DASH dietary score (fifth quintile), except among Black women who prayed several times/​ day, who were significantly less likely than those who prayed less often to score in the high range (18% vs. 22%, p < 0.05). PRO S P E C TI VE ST UDIE S

Although the following study does not examine the impact of religiosity on diet, it does 354 •  H ealth B ehaviors

examine the effects of religiosity on health as a result of fasting. In this 20-​year prospective study, Kunto and Mandemakers (2019) examined the impact of Ramadan fasting during pregnancy on later child stature (height) and body mass, tracking children from early childhood to late adolescence (age 19). This study, the Indonesian Family Life Survey, involved 9,771 Indonesian mothers who gave birth to 21,723 children. Muslim mothers who prayed at least five times a day were categorized as religious Muslims (n =​7,054); mothers who did not practice the Islamic five daily prayers were classified as less-​religious Muslims (n =​1884); and mothers who were not Muslim were also included in the study (n =​833). Analyses were performed using cluster-​robust mother fixed-​ effects models with multiple controls. Results indicated reduced stature during late adolescence (age 15–​19) for children of “religious” Muslim mothers who performed Ramadan fasting during the first trimester of pregnancy (compared to non-​exposed siblings). In addition, religious Muslim mothers’ children exposed to Ramadan fasting during the third trimester of pregnancy experienced lower body mass than unexposed siblings. In contrast (and curiously), children of “less religious” Muslim mothers exposed to prenatal fasting experienced positive effects on body mass, effects that peaked during early adolescence (10–​14 years of age). Children of “non-​Muslim” mothers exposed to prenatal fasting experienced negative effects on stature, but only during early childhood (age 0–​4 years) and were able to catch up by late adolescence. Researchers concluded: “Raising societal awareness that pregnant Muslim women have the right not to observe the Ramadan fast should be top of the agenda for policymakers” (pp. 37–​38). In the second prospective study, Long et al. (2020b) followed 51,661 US nurses over a 7-​year period in the Nurses’ Health Study-​II, examining the effects of religiously motivated self-​forgiveness and divine forgiveness on diet quality (among other outcomes). After controlling for numerous covariates and using Bonferroni correction to adjust p-​values for multiple outcome comparisons, no effect of either self-​forgiveness or divine forgiveness on diet quality was found.

E XP E RI ME N TAL S T UDY

Hermstad and colleagues (2018) conducted a single-​ group experimental study examining the effects of a 1-​year program to change church social environment and church physical environment to support healthy eating. The program was implemented at six churches in southern Georgia (US) and outcomes were assessed at baseline and follow-​up among 258 church members who completed all assessments (82% female, 84% African American). The program involved efforts to improve the physical environment (more healthy foods and beverages offered, less unhealthy foods and beverages offered, healthy food options identified, support for nutritional opportunities including establishment of community gardens, farmers markets, etc.) and to improve the social environment (social support for healthy eating; changing social norms; change in knowledge, attitudes, and beliefs; and increase in self-​ efficacy). Measures administered at baseline and 1-​year follow-​up were (1) Church Social Support for Healthy Eating, (2) Church Social Norms Related to Healthy and Unhealthy Eating, and (3) Healthy and Unhealthy Foods Consumed scales. Within-​church analyses were conducted using generalized estimating equations (GEE) to examine outcomes, controlling for demographic covariates. Results indicated significant improvements in all three socioenvironmental aspects of healthy eating for three of the six churches. Although the presentation of methods and results in this study were difficult to follow, the authors concluded that “. . . socioenvironmental characteristics are essential to multilevel interventions and merit consideration in designing policy and environmental change interventions.” Whether there was anything distinctively religious about the intervention, besides being held in churches, was not clear.

Summary Recent research, particularly cross-​ sectional studies, confirms reports from earlier research indicating that greater religiosity is positively related to consuming a healthier diet in many of studies thus far published. However, this

is not a uniform finding, especially in prospective studies, and so prior results must be interpreted with caution, and certain religious practices (such as strict fasting during pregnancy) may also potentially have negative health outcomes. More prospective studies are needed, as are RCTs that are explicit in their description of the faith-​based component of the intervention. In the single-​group experimental study and two RCTs reviewed above, the faith-​based component was not made clear and had to be assumed. The finding that secular programs held in churches improve nutrition among participants, while interesting, says little or nothing about whether a religious component of the intervention was responsible for the improvement in eating habits.

RESEARCH ON RELIGIOSITY AND WEIGHT Considerably more (and better-​ quality) re­ search has been conducted on the relationship between religiosity and weight compared to that on the relationship between religiosity and diet. There have been numerous prospective studies in large samples, as well as several experimental studies and RCTs, making dependence on cross-​ sectional research less necessary.

Early Research In our systematic review of studies published prior to the year 2010, we identified 40 quantitative studies, 5 of which were denominational comparisons. The 5 denominational studies reported that Seventh Day Adventists, Buddhists, and Amish weighed less than comparison groups; Latter Day Saints weighed more than non-Latter Day Saints; and in the only denominational prospective study, religious affiliation (Catholics, others, none) did not predict increases in BMI over 6 years. Of the remaining 35 studies, 6 (17%) reported that religiosity was associated with lower weight (or less underweight), 12 (35%) found a positive association with greater weight, 15 (43%) reported no association, and 2 reported mixed results. Of the 6 prospective studies, none reported that religiosity predicted heavier weight, 2 Diet and Weight • 355

reported lower weight, 3 reported no effect, and 1 reported mixed findings (see Appendix for study details). Of the 2 prospective studies reporting lower weight, a study from Greece found that those fasting for religious reasons lost more weight than those who did not fast (not surprisingly), and the other study in Israeli men found that having an exclusively religious education or describing oneself as very religious predicted lower body weight (although based on the study’s description, it is not clear if these results were cross-​ sectional or prospective). Neither study was of high quality. In contrast, an 8-​year prospective study of a national random sample of 3,617 US adults found that frequent religious attendance predicted a lower likelihood of developing obesity in women (but not men), whereas frequency of “reading religious books” and “watching or listening to religious programs on TV or radio” (more sedentary activities) predicted a greater likelihood of obesity in women (but not men) (Cline & Ferraro, 2006). There were also two single-​group experimental studies, one examining a church-​based weight-​loss program and the other examining the effects of Ramadan fasting in Israel, both reporting reduced weight from these interventions. There was also an RCT that was initially missed in our earlier review. This trial involved 31 obese African American breast cancer survivors who were randomized to either spiritual counseling or a control group that received standard dietician counseling only (Djuric et al., 2009). Spiritual counseling was delivered by telephone using an 8-​step framework, 4 of which were explicitly religious in referring to a Higher Power. Participants engaged in daily meditation or prayer, inspirational readings, and journaling. Average weight loss from baseline to 6 months was 1.5% of baseline weight in the spiritual counseling arm (n =​12) and 2.5% in the dietician-​only arm (n =​12), though with no significant difference between groups, which is perhaps not surprising given the very small sample size. By the 18-​month follow-​up, weight loss was 1.5% in the spiritual arm (n =​ 11) and 1.9% in the dietician-​only arm (i.e., those in the dietician arm gained back 0.7% of body weight, with no further weight change in the spiritual counseling arm). When one 356 •  H ealth B ehaviors

participant in the spiritual counseling arm who gained 42 pounds from baseline to 6 months and continued to gain weight more slowly up to 18 months was excluded, reduction in weight for those in the spiritual counseling arm at 18 months was 3.2% of baseline weight (n =​10). Based on this small RCT, spiritual counseling performed similarly well to standard counseling from a dietician.

Recent Research The quality of research published since 2010 is considerably higher than that reported prior to that time. Here, we review results from a retrospective cohort study, 10 high-​quality prospective cohort studies, and 3 RCTs. RETROSP ECTIVE COH ORT STUDY

Kobayashi and colleagues (2015) analyzed data from 36,965 individuals (average age 47) who had annual health checkups at St. Luke’s International Hospital in Japan between 2005 and 2010. Among several goals of the study was to examine the effects of religiosity on becoming overweight or obese from baseline in 2005 to follow-​up in 2010. Religiosity was assessed at baseline with a single question: “Are you religious?” Controlled for in analyses were age, gender, marital status, occupation, health habits, and baseline BMI. Overall, 63% of participants were slightly or not at all religious, 28% were somewhat religious, and 10% were religious. Cross-​sectional multivariate analyses in 2005 indicated that religious individuals were more likely to be overweight or obese (OR =​ 1.33, 95% CI =​1.20–​1.47), an association that was present in both men and women. In longitudinal analyses (using generalized estimating equations adjusted for time), however, being religious at baseline did not predict a greater likelihood of becoming overweight or obese during the 5-​year follow-​up (adjusted OR =​ 0.99, 95% CI =​0.89–​1.11). P ROSP ECTIVE COH ORT STUD IES

Hill et al. (2017b) analyzed data from the Mexican Health and Aging Study, which collected baseline data collected in 2001 (T1;

n =​15,186) and follow-​up data in 2003 (T2) and 2012 (T3). A total of 2,089 participants in Mexico from T1 were selected for anthropometric analyses at T3, and of those, 772 were community-​dwelling adults age 50 or over (the final sample for analysis). Religious participation (frequency of attendance) was assessed in 2003 and categorized as never, once in a while, or at least weekly. An attendance change score between T2 and T3 was also calculated (positive numbers indicating that participation increased between waves). Weight was assessed at T3 as BMI and WTHR (waste-​to-​hip ratio). Controlled for in analyses were age, gender, education, marital status, household income, and self-​rated health. Results indicated that attendance at religious services at least once in a while (vs. never) at T2 predicted significantly lower WTHR (indicative of lower visceral fat) at T3 (b =​−0.03, p < 0.01), and a similar trend was found for attending services once/​week or more (b =​−0.02, p < 0.10). “Change” in attendance from T2 to T3, however, did not predict T3 WTHR, and neither attendance measure predicted T3 BMI. Chen and VanderWeele (2018) followed 5,681–​7,458 US adolescents average age 14.7 years at baseline (T1) for 8–​14 years (T2). The effects of T1 religious attendance and prayer/​ meditation on T2 overweight/​ obesity were examined along with other lifestyle outcomes. Controlling for age, race, sex, geographical region, prior health status, other health behaviors, mother’s age, race, marital status, socioeconomic status, mental health, depression, and psychological well-​being (with Bonferroni correction), neither frequency of attending religious services nor prayer/​meditation was related to being overweight or obese at baseline (T1), nor did either of these indicators of religiosity predict future weight status over time (T2). Ahrenfeldt and colleagues (2018) analyzed data from a longitudinal study of 23,864 persons age 50 or over participating in the Survey of Health, Aging, and Retirement in Europe (SHARE). Participants were initially assessed in 2004–​2005 (T1) and followed up in 2006–​2007 (T2), 2011 (T4), 2013 (T5), and 2015 (T6). European countries included were Denmark, Sweden, Italy, Spain, Austria, Belgium,

Germany, Switzerland, and the Netherlands. Of the 16,263 (68%) who reported they belonged to a religion, 27% indicated Protestant, 45% Catholic, and 27% Orthodox Christian, Muslim, or other. Three questions assessing religiosity were administered at T1: (1) “Thinking about the present, about how often do you pray?” (assessed only in those who said they belonged to a religion); (2) “[Have you] taken part in a religious organization (church, synagogue, mosque, etc.)” within the past month (asked of the entire sample, of whom 12% indicated they had); and (3) “Have you been educated religiously by your parents?” (74.0% of those belonging to a religion). Degree of religiousness was categorized into three groups: (1) more religious (praying, participating in a religious organization, and religiously educated); (2) less religious (praying, but not participating in a religious organization or religiously educated); and (3) nonreligious (not praying, participating in a religious organization, or religiously educated). Lifestyle variables included an assessment of BMI (> 25 or overweight) at each wave. Included in analyses were all participants at T1 with at least one follow-​up at T2, T4, T5, or T6. Logistic regression and mixed effects models examined the effects of religiosity on becoming overweight, adjusting for European region, gender, age, education, marital status, and employment status, and corrected for multiple testing using the Holm-​Bonferroni method. Longitudinal analyses indicated that T1 prayer did not significantly predict being overweight; the 95% confidence intervals (CI) for the odds ratio (OR) in both cross-​ sectional and longitudinal analyses included 1.0. Participation in a religious organization was marginally associated with being overweight in the cross-​sectional analysis at T1, but not in prospective analysis. While not associated with weight status in cross-​sectional analyses, being religiously educated did significantly predict a lower likelihood of being overweight in the future (approximately 15% lower, with 95% CIs not including 1.0). Being “more religious” overall was positively associated with being overweight in cross-​sectional analyses at baseline (OR close to 1.0), but again did not predict future weight status over time. Among those affiliated with Orthodox Christian, Muslim, Diet and Weight • 357

Jewish, or other traditions, participation in a religious organization predicted a higher likelihood of becoming overweight in the future (OR =​1.37, 95% CI =​1.12–​1.68), although this effect was not found in Protestants, Catholics, or those with no affiliation. Whitehead and Bergeman (2020) assessed the effects of daily religious coping (measured by a 9-​item scale) on metabolic health over a 56-​ day period in 267 older adults living in Indiana (US). A daily diary was used to record religious coping, negative affect, and perceived stress. Multilevel modeling was used to examine the effects of religious coping acting through negative affect and perceived stress on metabolic health, including BMI and WTHR (although it is not clear when exactly the weight measures were obtained). A composite measure of the obesity outcome was also created by summing BMI, WTHR, and HgA1c (hemoglobin A1c, a measure of average blood glucose). Controlling for age, gender, income, and education, daily religious coping was found to reduce the effect of daily stress on negative affect. Correlational analyses revealed that the more that daily religious coping reduced daily negative affect, the lower the WTHR (partial r =​0.18, p =​0.05). A similar trend in that direction was found for the composite obesity measure (partial r =​0.17, p =​0.06). In an attempt to explain how frequent religious attendance decreased mortality in 5,200 US adults aged 50 or over, Kim and VanderWeele (2018) measured BMI as a possible mediator. In the main analysis, religious attendance in 2008 (T2) was examined as a risk factor of mortality between 2010 (T3) and 2014 (T4). Controlled for in analyses were 2006 (T1) religious attendance, age, gender, marital status, race, education, insurance status, total wealth, smoking, frequency of exercise, alcohol use, BMI, health conditions, social integration, social participation, living situation, contact with children, family and friends, and physical functioning. Assessed in 2010 (T3) as potential mediators of the attendance-​mortality effect were demographics, social factors, mental health, physical functioning, and health behaviors and states, including BMI. As noted in the previous chapter, higher T2 religious attendance predicted a significantly lower risk of mortality during 358 •  H ealth B ehaviors

follow-​up between T3 and T4. When mediators of this effect were examined, T3 BMI approached significance as a negative mediator, explaining −2.34% of the effect of religious attendance on mortality (p =​0.078). Since T3 BMI may have explained part of the effect of T2 attendance on mortality between T3 and T4, T2 religious attendance was a predictor of higher T3 BMI, at least at a trend level (after controlling for BMI and religious attendance at T1). Chen et al. (2019b) examined the effect of earlier parenting style on maintaining a healthy weight in midlife among 3,929 Americans assessed over a 10-​year follow-​up. Included in this analysis was baseline family religiousness as a possible predictor of future weight. The average age of participants in 1995 (T1) was 47 years. Family religiousness at T1 was assessed retrospectively by a single question: “How important was religion in your home when you were growing up?”, with response options being not very important, somewhat important, and very important. Change in BMI from 1995 (T1) to 2004 (T2) was the primary outcome. Multivariate analyses (generalized estimating equations) controlled for parenting style, demographics, and both childhood and adult characteristics. Results indicated that growing up in a family where religion was very important did not significantly predict change in BMI over time (b =​−0.11, 95% CI =​−0.27 to 0.05). Spence and colleagues (2020) examined the effects of religious attendance on risk of hypertension among 44,281 non-​hypertensive women participating in the Nurses’ Health Study-​II. Religious attendance was assessed in 2001 (T1) as a predictor of the development of hypertension between 2001 and 2013 (T3) (the primary outcome in this report). Results indicated that women who attended religious services more often at T1 were less likely to develop hypertension during this 12-​ year follow-​up from T1 to T3. BMI assessed in 2003 (T2) was examined as a mediator of this effect, along with demographics, perceived stress, abuse during childhood, social-​emotional support, self-​reported chronic illnesses, and other lifestyle factors (cigarette smoking, alcohol consumption, physical activity, diet). Results indicated that the strongest (and only) significant mediator of the effects of T1 religious

attendance on incident hypertension between T1 and T3 was T2 BMI, explaining 11.5% of the effect (p < 0.001). This finding suggested that T1 religious attendance must have significantly predicted lower BMI at T2, which in turn predicted lower risk of hypertension during follow-​up from T1 to T3. Three additional large prospective studies have also recently examined the effects of religious involvement on future weight, two examining frequency of attendance at religious services and one examining religiously motivated forgiveness. Both studies examining frequency of religious attendance reported no effect on weight over 7–​12 years of follow-​up (Suh et al., 2019; Chen et al., 2020a). The study examining religiously motivated forgiveness (Long et al., 2020a) found that while self-​ forgiveness did not predict a greater likelihood of being overweight/​obese at follow-​up, divine forgiveness (always/​almost always feeling forgiven by God vs. never/​seldom) did marginally predict a 6% greater likelihood of being overweight/​obese (RR =​1.06, 95% CI =​1.00–​1.11).

motivation. The primary outcome measure was BMI at baseline, 16 weeks post-​treatment, and 6 months post-​ treatment. Results indicated that there were no baseline differences in age, BMI, gender, or religious characteristics between the two groups except that average weight (but not BMI) was significantly lower in the Catholic-​tailored group than in the control group. Outcomes at 16 weeks post-​treatment indicated no between-​ group differences in weight loss, percent weight loss, attendance at sessions, or self-​monitoring; however, there was a significant difference in treatment satisfaction favoring the Catholic-​tailored group (p =​0.007). By 6 months post-​treatment, the percent of weight gained back was slightly lower in the Catholic-​tailored group (0.9%) compared to the standard group (2.3%). Although the difference was not statistically significant (p =​0.17), the continued benefits in the Catholic-​tailored intervention may have been due to greater treatment satisfaction (above). Nam (2013a) conducted a clinical trial examining the effects of an obesity-​reduction intervention in 48 rural African American women in South Carolina. Participants were RA N D O MI ZE D CONT ROLLE D nonrandomly assigned to either a spiritual TRI A L S ( RC TS) group or a nonspiritual control group. This Krukowski and colleagues (2010) examined quasi-​experimental design is known as a non-​ the effects of a 16-​week group weight-​control equivalent groups design, in which subjects are program in 34 overweight Catholics who not randomly assigned to treatment groups. were randomized to receive either a Catholic-​ The study took place in two churches, one tailored weight-​control program (n =​17) or a church where a spiritual version of the Life standard program (n =​17). Participants were Project weight-​loss program was administered recruited from a single Catholic Church in Little (n =​31), while in the other church, the standard Rock, Arkansas. The Catholic-​tailored program Life Project weight-​loss program was impleincluded all components of the standard pro- mented (n =​17). In both groups the curriculum gram (calorie and fat goals, graded physical emphasized the benefits of exercise, maintainactivity recommendations, self-​ monitoring, ing cardiovascular fitness, the food pyramid, problem-​ solving, and goal setting), but also portion sizes, understanding food labeling, included Catholic faith-​based elements (teach- avoiding fast foods, keeping food records, and ings from the Bible and the Catechism of the so forth. Participants in both groups received Catholic Church) in the lesson materials, self-​ the standard curriculum, i.e., a total of ten 1-​ monitoring journals, and counselor feedback. hour education sessions held once a week over The Catholic-​tailored program started the group approximately 3 months. The spiritual group each week with prayer and inclusion of Catholic also received sessions on New Testament scriptexts and references to Catholic traditions tures related to health and meditation, which (seven sacraments, Catholic saints as role mod- were designed to augment the baseline curels). Participants in the Catholic-​tailored group riculum by connecting healthy behavior with were encouraged to say the Rosary or pray when religious faith. The average weight and BMI of engaging in physical activity to help maintain participants were compared before and after Diet and Weight • 359

the intervention program within each group. In addition, a change-​score model was used to compare the spiritual and nonspiritual groups directly using regression techniques. Results indicated that the average weight decreased in the spiritual group from 214.4 to 210.8 pounds (loss of 3.6 lbs., p < 0.01) compared to 171.6 to 170.8 pounds (a loss of 0.8 lbs., p =​ns) in the standard group. BMI decreased from 37.4 to 36.2 in the spiritual group (p < 0.01) compared to 29.7 to 29.0 in the standard group (p < 0.05). Change score analysis indicated that the spiritual group lost significantly more weight than the standard group (t =​2.3, p =​0.018) and also tended to decrease their BMI more than the standard group (t =​1.8, p =​0.08). What is remarkable here, as in other studies of faith-​ based and secular interventions, is the small amount of weight reduction over 3 months despite two fairly intense interventions, thus underscoring the difficulty that people encounter when trying to lose weight. Finally, Gainey and colleagues (2016) examined the effects of a Buddhist walking meditation intervention on weight, glycemic control, and vascular function in 23 patients with type II diabetes. Participants were randomized to either a Buddhist-​ based walking meditation exercise (n =​12) or to a traditional walking exercise (n =​11). The exercise program involved walking on a treadmill at 50%–​ 70% maximum heart rate for 30 minutes each session (with a 10-​minute warm up and a 10-​minute cool down) for a total of 50 minutes. This was done three times per week over 12 weeks. The only difference between groups was that in the Buddhist group, participants said “Budd” and “Dha” with each step as their foot contacted the floor to practice mindfulness while walking. Results indicated no significant change in BMI or body fat in either group during the intervention (although blood pressure, HgA1c, cortisol, and brachial artery stiffness all improved significantly in the Buddhist meditation group alone). Note, however, that the sample size in the study was very small.

Summary Early studies (mostly cross-​sectional) indicated that that greater religiosity was associated with 360 •  H ealth B ehaviors

greater weight or higher BMI (35%), associated with lower weight or BMI (17%), or was unrelated (43%). Of six prospective studies, however, none found that religiosity predicted an increase in weight over time, two found that religious behaviors predicted a reduction in weight (at least short-​term), and one study (arguably the best one of them all) reported mixed findings—​less obesity among those who attended religious services more frequently and greater obesity among those engaged in sedentary religious activities more often such as reading religious scriptures or watching religious TV. More recent research, particularly longitudinal studies, indicates that greater religiosity in a number of studies predicts either a reduction in weight/​BMI over time or has no impact. Based on the results from 11 high-​ quality cohort studies, 4 reported that greater religiosity predicted low weight/​ BMI or less obesity over time, 5 found no association, 1 reported marginally greater obesity/​ overweight, and 1 reported mixed results. The latter study found a significantly lower likelihood of being overweight among persons in Europe who were religiously educated (vs. not), although religious participation predicted an increased likelihood of being overweight in a small subgroup of participants affiliated with Orthodox Christian, Muslim, Jewish, or other non-​Christian affiliations (this was not true, however, for Catholics or Protestants, who made up nearly three-​quarters of the sample). Although a larger proportion of cross-​sectional studies suggest associations between religiosity and greater rather than lesser weight, these associations may, as noted earlier, be confounded by income or race. The majority of prospective studies, however, both earlier and recent, do tend to find that religiosity or religious activity predicts either a reduction in weight/​BMI or has no effect. However, the effects, if any, seem to be small compared to the effects of religiosity on many other health outcomes. Religious participation may increase weight through certain pathways (e.g., potlucks or unhealthy foods) and decrease it through other pathways (e.g., exercise; see Chapter 18). Thus, it is perhaps not surprising that most effect estimates on average seem to be small or negligible. Single-​group experimental studies,

and both randomized and nonrandomized clinical trials of faith-​based interventions, reported either no effect of the religious/​spiritual intervention or a reduction in weight/​BMI (a weight reduction that was often quite small, given the intensity of these interventions). These findings are not surprising, given the complexity of the relationship between religion and body weight and the many factors affecting it.

into young adulthood and midlife, when changes in eating patterns often occur and weight increases due to the slowing of metabolic rate. Collecting information on parental religiosity and the religious home environment will also be important. Further qualitative work may be needed in order to inform the design of such studies. Given the poor long-​term results from existing weight-​ loss programs (both faith-​ based and secular), new interventions are needed RECOMMENDATIONS FOR that utilize participants’ religious resources to FUTURE RESEARCH improve diet and food choices, increase physiImproving diet, reducing calorie intake, exer- cal activity, and reduce body weight if needed. cising, and losing weight all depend on self-​ Such interventions must be rigorously tested control, willpower, and context. Religious in well-​designed controlled clinical trials. While commitment has the potential to provide all of single-​ group experimental studies provide these, although that remains to be definitively helpful information for use in designing RCTs, established empirically. Given the scope of the having a control group is essential, particuproblem, particularly the problem of unhealthy larly a control group that receives equal social eating and obesity among members of many attention and exposure to high-​quality secular religious organizations, and the potential for programming. While single-​group experimenapplying religious teachings to improve diet tal studies (before-​after design) are easier to and reduce obesity in religious settings, further conduct and less expensive, interpreting the research could be of benefit. More information findings from such studies—​even when diet is necessary to improve our understanding of improves or weight reduction occurs—​is difhow religion impacts health (and is impacted ficult due to possible selection effects (only by health) through diet and weight control. the most motivated people may agree to parProspective studies are needed for the latter, ticipate in such studies), social attention and while RCTs are needed to determine the efficacy interaction, or simply the passage of time. of interventions that utilize this information. Furthermore, long-​ term follow-​ up is needed Once again, cross-​sectional studies are less to determine whether changes in dietary pracimportant in providing new information unless tices persist, weight loss continues, or weight is conducted in non-​Christian religions and in gained back. different geographical locations outside of the Researchers should also bear in mind that West, where less is known about the relation- participant religiosity itself may impact the ship among religion, diet, and weight. In gen- success achieved by secular treatments, includeral, prospective cohort studies remain a high ing weight-​loss programs, special diets, propriority, since they are capable of identifying fessional counseling, behavioral treatments, the many pathways by which religion could weight-​loss medications, and bariatric surgery, impact diet and weight, while controlling for although this has not yet been established. This confounders such as race/​ethnicity, age, gen- possibility, however, could be determined by der, socioeconomic status, and various social including sensitive measures of religiosity at and cultural traditions related to dietary prac- baseline in new studies (or during later waves tices and attitudes toward food consumption. of existing studies) to examine whether the Sensitive multidimensional measures of religi- treatment effectiveness depends on the religiosity should be included in such studies, with osity of participants, i.e., if religiosity moderdata collection beginning in early childhood ates treatment effects. Doing so would be much (interviewing parents), continuing through less expensive than trying to fund a prospective adolescence when dietary and physical activity study devoted entirely to studying the effects patterns are often established, and extending of religiosity on diet or weight. Diet and Weight • 361

Prospective studies and RCTs examining the effects of religiosity on diet or weight should be a high priority in the United States, where 40% of the adult population is obese, at least 50% are church members (Jones, 2019), and 62% attend religious services at least once per month (Pew Research Center, 2019d). Establishing the effectiveness of faith-​ based interventions in religious communities and then widely implementing them in churches and other religious communities could be a smart way to address the obesity epidemic that has affected at least half the country’s population. Research of this type is particularly important for changing food choices and physical activity levels among members of minority populations who must deal with stresses of economic deprivation and discrimination that drive eating habits. Religion is widespread among African Americans, 59% of whom indicate that religion is very important in their lives and 33% of whom attend religious services at least weekly (Mohamed et al., 2021). Yet nearly 50% of this minority group struggles with obesity and its negative health consequences. Prospective studies and clinical trials testing religiously integrated interventions are also needed in religious countries other than the United States, particularly those in the Middle East, some parts of Africa, and Mexico, Central and South America, where eating habits are often poor and obesity widespread. Research has shown that obese adults who eat less fat, exercise more, use prescription weight-​ loss medications, and participate in commercial weight-​loss programs (i.e., tackling the problem through a multi-​pronged approach) are more likely to lose weight and keep it off (Nicklas et al., 2012). For religious persons, utilizing participants’ religious resources to increase motivation and compliance, as well as increasing engagement in a faith-​based self-​ help groups such as Overeaters Anonymous (OA), might be particularly effective. Thus, religious beliefs, teachings, and religious activities should be integrated into multifaceted programs for the treatment of religious clients and then tested in RCTs to establish efficacy. As reviewed above, faith-​based interventions taking a single approach with only modest faith-​ based modifications seldom produce much of a lasting impact. Likewise, simply implementing 362 •  H ealth B ehaviors

a secular diet or weight-​loss program in a church with minimal utilization of religious resources has also not yielded much benefit. Another strategy is to take an existing secular program with demonstrated effectiveness (e.g., Weight Watchers, Jenny Craig, or Nutrisystem) and adapt it to the unique social and cultural issues faced by participants that impact food choices, while integrating religious beliefs and practices into the program to justify and motivate long-​term behavior change (similar to the approach taken by Djuric and colleagues (2009). Many faith-​based elements are already included in OA; however, to our knowledge, not a single prospective study or RCT has yet examined the efficacy of this program. Such research may also help to identify ways to improve the results achieved by this and other faith-​based programs.

CLINICAL APPLICATIONS There are many clinical applications of the existing research relevant for both health professionals and clergy. The first step is for clinicians and clergy to educate the patient or church member on the importance of eating a healthy diet and controlling weight. This may not be the most comfortable subject for clinician, clergy, or client, but must be done when individuals ask for help to deal with problems of excess weight or obesity that are interfering with their health or well-​being. Although neither weight nor diet is generally considered to be a central aim or end of religion, many religious teachings—​as noted above—​do take the health of the body seriously. Once the seriousness of the matter has been established, the helping professional should take a spiritual history to identify if the person is religious or spiritual, the degree to which it is important in their life, and the types of religious beliefs and practices to which she or he subscribes. The clinician or religious professional may then brainstorm with the religious client about what their religion has to say about eating a healthy diet, maintaining their physical health, or controlling weight. The clinician may decide to do some research in this regard and/​or assign the patient to do likewise and then report on what has been learned at the next visit. Again, this

approach must be centered on the client and the client’s religious faith. Religious professionals, particularly community clergy, should be aware of successful diet and weight-​loss programs that have been utilized in religious congregations, particularly those with a faith-​based component. Having members of a congregation eat healthy foods (such as those included in the Mediterranean diet described above), exercise regularly, and maintain an ideal body weight will result in a congregation that is healthier, happier, and more capable of serving others (rather than being one that needs to be visited in the hospital). Clergy can also make recommendations (either from the pulpit, during adult education classes, or when coordinating potluck dinners) on food choices that will improve health and maintain the temple of the Holy Spirit for doing good works. Clergy and staff can be guided by the 2015–​ 2020 Dietary Guidelines for Americans (that apply to non-​Americans as well). These guidelines, together with clinical experience, suggest that better health and lower weight result from eating a variety of vegetables (preferably raw and from a variety of subgroups such as green leafy vegetables, broccoli, cauliflower, carrots, tomatoes), legumes (beans and peas), whole fresh fruits (apples, oranges, etc.), fat-​free or low-​fat dairy products (milk, yogurt, cheese), non-​ dairy substitutes (low-​ calorie soy or almond milk), plenty of beverages that are low in calories and high in electrolytes, whole grain breads and cereals, high-​fiber foods, a variety of protein sources (seafood, grilled lean meats and poultry, eggs, nuts, seeds, soy products), less processed foods, limited added sugar (no more than 10% of calories/​day from sugar), limited salt intake (no more than ½ tablespoon/​day), and minimal trans-​fats and saturated fats (i.e., reduce all oils when cooking except for unsaturated fats such as olive oil or canola oil) (Table 19.1). If weight loss is desired, then reducing calorie intake by 500 per day will result in a 1-​ pound weight loss per week, which is safe and sustainable over the long term, but must be combined with regular exercise. Helping professionals should also recognize that success rates for those attempting to lose weight on their own are dismal, with between

2% and 20% of obese individuals achieving long-​ term weight reduction (Strunkard et al., 1959; Wing & Phelan, 2005). Even formal weight-​loss programs have high dropout rates and only rarely enable participants to achieve a normal weight, with the overwhelming majority of those initially losing 5%–​10% of body weight regaining it back one year later (Rothblum, 2018). Nevertheless, there are also a number of secular and spiritual programs that clinicians and clergy may recommend, and some individuals may benefit greatly from them. Table 19.1 provides a list of weight-​loss strategies. We recommend that clinicians utilize clients’ religious beliefs and practices to improve motivation and increase self-​control in order to maximize success rates. Again, one of the two most popular self-​ help programs is Overeaters Anonymous (OA) (2020), a worldwide program based on the 12-​ steps of Alcoholics Anonymous (Tsai & Wadden, 2005). Recall from Chapter 10 that 8 of these 12 steps are explicitly religious in nature. For overweight or obese individuals, excessive food consumption is just like any other addiction that takes control over a person’s life (whether that addiction involves excessive alcohol use, illicit drugs, sex, or pornography). One difference for eating addictions, though, is that one cannot completely stop eating. Thus, “abstinence” is defined as refraining from addictive-​like excessive eating behaviors. Temperate and sensible eating habits must be learned and adhered to over time as a permanent lifestyle change, which often requires recognition of loss of control, surrender of the problem to a Higher Power, and support from others (as well as supporting others with food addictions). In OA, members typically construct a plan with their healthcare provider and participate in local OA groups in person or online on a weekly or more frequent basis. There is no cost to members. Some individuals, however, particularly those with eating disorders, may have a difficult time because, as some experts (Wasson, 2003) note, OA rules may be perceived as overly rigid. For those who are not religious, the other major self-​help program is Take Off Pounds Sensibly (TOPS), a secular approach that focuses on a low-​calorie exchange diet and provides a curriculum on diet, physical activity, Diet and Weight • 363

Table 19.1  Strategies for Losing Weight and Healthy Eating 1. Aerobic exercise, 20–​30 minutes/​day up to 50–​60 minutes/​day (see Chapter 18) 2. Seven to eight hours of sleep per night (inadequate sleep increases appetite) 3. Diet, adopting a long-​term approach (based on 2015–​2020 Dietary Guidelines for Americans) -​vegetables (leafy, broccoli, carrots, cauliflower, squash, legumes, nuts) (preferably raw) -​whole fruits (fresh apples, oranges, grapes, berries) -​whole grains, complex carbohydrates, high fiber -​fat-​free dairy (milk, yogurt, cheese) and non-​dairy beverages (fortified soy, almond) -​variety of protein-​rich foods (seafood, lean meats, poultry, eggs, legumes, nuts, seeds, soy) -​unsaturated fats and oils (olive oil is the best); avoid saturated and trans fats -​avoid added sugars (< 10% of calories/​day), salt (2,500 mg or less/​day) -​drink plenty of fluids (zero calorie or low-​calorie drinks with electrolytes, e.g., Gatorade Zero) 4. Religious and secular self-​help groups (if having trouble sticking to a diet) -​Overeaters Anonymous (in-​person and online groups) -​Take Off Pounds Sensibly (in-​person and online groups) 5. Religious and secular weight-​loss programs -​The Daniel Plan (based on the Book of Daniel in the Hebrew Bible) -​The Maker’s Diet (aka The Bible Diet) -​Weight Watchers -​Jenny Craig 6. Psychotherapy/​counseling for weight loss (inpatient and outpatient programs) -​behavioral therapy and cognitive-​behavioral therapy -​interpersonal therapy -​ body-​oriented therapy -​cognitive reframing -​hypnosis (least effective) -​spiritual counseling (in person or by telephone) 7. Medications (only effective if food intake is reduced and physical activity increased) -​phentermine (brand name Lomaira) -​phentermine +​topiramate combo (brand name Qsymia) (most effective, ↑ side effects) -​combination naltrexone and bupropion (brand name Contravel) (safe and effective) -​orlistat (brand name Alli) (available over the counter) (least effective, ↓ side effects) 8. Bariatric surgery (for severe obesity, combined with reduced food intake and increased exercise) -​gastric bypass (reduces stomach size and bypasses part of small intestine) -​sleeve gastrectomy -​adjustable gastric band -​biliopancreatic diversion with duodenal switch

and behavior modification (TOPS, 2020). Like OA, TOPS uses group support and weekly weigh-​ins to achieve weight loss. Membership costs are $32/​year plus $5/​year for local chapter dues. Both OA and TOPS are nonprofits organized and led by volunteers. A systematic review of non-​ medical commercial weight-​ loss programs identified only five that had

364 •  H ealth B ehaviors

been subject to objective research: eDiets. com, Health Management Resources, TOPS, OPTIFAST, and Weight Watchers (Tsai & Wadden, 2005). Three clinical trials examined the efficacy of the largest of these programs, Weight Watchers, demonstrating an average of 3.2% weight loss after 2 years. A single multisite randomized trial of TOPS involving 234

participants demonstrated that the 12-​week program resulted in a 1.6% decline in weight after one year and a 67% attrition rate (Tsai and Wadden indicated in 2005 that the TOPS website reported an average 5.8-​pound weight loss/​ year per member). Among “medically-​ supervised” weight-​loss programs, those who complete treatment lose approximately 15%–​ 25% of their initial weight, although Tsai and Wadden note that these programs are associated with high cost, high attrition rates, and a high likelihood of gaining back 50% or more of lost weight in one or two years. No studies examining the effectiveness of OA were identified in that review, nor, as noted above, were we able to identify any studies of OA in our review. A more recent discussion of OA also provided little information on the effectiveness of OA based on systematic objective research (Rodriguez-​ Martin & Gallego-​ Arjiz, 2018). Clearly, given its potential for impact, there is a great need for researchers to examine average weight loss and attrition rates for this program. There are also numerous professional counseling and behavioral programs designed to help persons change their diets or lose weight. These may be provided either on an outpatient or inpatient basis. Spiritual counseling by telephone is another possibility (see Djuric et al., 2009, above). Medications and bariatric surgery are other options (Table 19.1). The latter, however, are only effective in the long term if combined with reduced food intake and physical exercise. Although further research to establish efficacy is needed, there is enough known already to encourage clinicians to integrate clients’ religious beliefs/​ practices into psychological, behavioral, pharmacological, and surgical treatments, thereby taking advantage of religious resources to achieve greater success in modifying diet, increasing exercise, and reducing weight. Much of this chapter has focused on diet and losing weight. However, dieting may be a problem for those with eating disorders (e.g., anorexia nervosa, bulimia nervosa, binge eating disorder), resulting in severe undernutrition, leading in some cases to starvation and death.

Thus, both healthcare professionals and clergy need to be alert for problems of this type, especially when making recommendations about food choices and weight loss. Interestingly, at least one RCT has shown that spiritual group therapy is effective in the treatment of eating disorders (Richards et al., 2006).

SUMMARY AND CONCLUSIONS Obesity is reaching epidemic proportions in the United States and around the world and has serious adverse health consequences. If Americans do not collectively adopt healthier eating habits, it has been estimated that nearly half of the population will be obese in the next 10 years (48.9%, 95% CI =​47.7–​50.1; Ward et  al., 2019). Poor eating habits, unhealthy diets, excessive calorie intake, and lack of physical activity are the primary reasons for this growing problem. While genetic, economic, social, and cultural factors all play a role, also important are lack of knowledge, easy access to high-​calorie poor-​nutrition foods, and lack of self-​control. The relationship between religiosity, diet, and weight is a complex one, although systematic research—​particularly prospective studies—​suggests that religiosity can play a role in improving diet, controlling weight, and reducing obesity. Both religious beliefs about the body as sacred and proscriptions against excesses and gluttony directly address the need for self-​control with regard to eating behaviors. Unfortunately, religious interventions have thus far shown little impact on reducing weight in faith-​based settings, although many of these interventions simply involve secular weight-​ control programs administered in religious settings, rather than truly integrating religious beliefs and practices into the interventions themselves. Much further research is needed to determine how religious resources can be utilized in creating interventions to improve diet, reduce calorie intake, increase exercise, and stop the obesity epidemic that is raising the costs of healthcare and causing much unnecessary morbidity and mortality, especially in minority populations.

Diet and Weight • 365

SECTION VI Physical Health IN THIS SECTION we examine the relationship with and impact of religion on physical health. Unlike previous sections, the effects of religion on physical health is “indirect,” acting largely through mental, social, and behavioral pathways (see Chapter 31). Thus, the relationship with physical health is more “distal” (rather than “proximal” as with the effects of religion on mental, social, and behavioral health). This makes it more difficult to show the effects that religiosity has on physical health. Readers should bear this in mind when evaluating the research discussed

in the forthcoming chapters, since the impact of religiosity on physical health outcomes is predictably weaker than effects on psychological, social, and behavioral health, dimensions of health on which religion has a more proximal or “direct” effect. Nevertheless, as will be discussed in Chapter 27, the cumulative effects of religiosity on all-​cause mortality risks will make clear that there are a number of relevant pathways by which religiosity ultimately affects physical health, even if it is more difficult to discern exactly what those pathways are.

20 Heart Disease Thou hast made us for thyself, O Lord, and our heart is restless until it finds its rest in thee. —​Augustine of Hippo

THE “HEART” IN ancient times was often considered the “seat of the emotions,” consistent with Aristotle’s belief that the heart was the center of the human body, the seat of the soul and the emotions (French, 1978). In this chapter we examine the relationship between religiosity and heart disease, where heart disease includes coronary heart disease (CHD, i.e., myocardial infarction, angina, acute coronary syndrome), congestive heart failure, cardiomyopathy (viral or alcoholic), valvular heart disease, rheumatic heart disease, infective endocarditis, congenital heart disease, cardiac arrhythmias, and other conduction disturbances of the heart. We are interested here in the impact that devout religious involvement has on the development and course of heart disease, CHD in particular. We also explore the possibility that religious interventions may be useful in preventing or treating heart disease. First, however, we examine the prevalence, the health consequences, and the direct and

indirect financial costs of heart disease, and then go on to examine risk factors that increase its likelihood.

PREVALENCE Approximately 8.0% of the US population age 20 or over (approximately 19.2 million adults) had CHD in 2012 (Yoon et al., 2016). Each year at least 660,000 Americans will have a new coronary event, either a first hospitalization for myocardial infarction (MI) or death due to CHD, and 305,000 will have a recurrent MI (Mozaffarian et al., 2016). The average age at first MI in men is 65.1 years, whereas this occurs about 7 years later in women (age 72.0). In the United States, there are between 650,000 and 1.3 million persons living with congenital heart disease, approximately 5.3 million with atrial fibrillation, and 6.2 million with cardiomyopathy or heart failure (Benjamins et al., 2019).

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0020

Worldwide, there were an estimated 422.7 million cases of cardiovascular disease (CVD) in 2015 (Roth et al., 2017), which includes peripheral artery disease, CHD, cerebrovascular disease, abnormal heart rhythms, hypertensive heart disease, cardiomyopathy, rheumatic heart disease, congenital heart disease, endocarditis, valvular heart disease, aortic aneurysms, thromboembolic disease, and venous thrombosis. Broken down by numbers, this involves 155 million cases of peripheral artery disease, 42.4 million cases of cerebrovascular disease, 33.3 million cases of atrial fibrillation, 6.1 million cases of hypertensive heart disease, 2.5 million cases of cardiomyopathy and myocarditis, and 115,700 cases of endocarditis. The second most common CVD (after peripheral artery disease) in 2015 was CHD. There were 110.6 million persons living with CHD and 7.29 million new cases of acute MI (Roth et al., 2017). Eastern Europe had the highest estimated prevalence of CHD at 4,140 cases per 100,000.

HEALTH CONSEQUENCES In the United States, death from heart disease in 2017 numbered 647,457 (23% of all deaths), making it the most common cause of mortality in both men and women (just ahead of cancer deaths at 599,108) (Heron, 2019). Worldwide, of the 17.9 million people who died from CVDs in 2015 (the most common cause of death making up 31% of all global deaths), 8.9 million people (50%) died from CHD (Roth et al., 2017 World Health Organization, 2018). The highest age-​standardized CHD death rates in 2015 were in Central Asia (336/​100,000) and Eastern Europe (326/​ 100,000), whereas the lowest rates were in high-​income Asia-​Pacific countries (45/​100,000) and Western Europe (80/​100,000), with North America ranked in between at 106/​100,000. Not only is CHD the most common cause of death in the United States and worldwide, it also is the number one cause of disability-​adjusted life years (DALYs). DALYs combines years of life lost due to CHD and years of life lived with disability due to CHD. The age-​ standardized DALYs rate worldwide due to CHD in 2015 was 2,453 per 100,000, far exceeding that from 370 •  P h y sical H ealth

other CVDs such as hypertensive heart disease (262/​100,000), rheumatic heart disease (147/​ 100,000), cardiomyopathy and myocarditis (130/​100,000), atrial fibrillation (71/​100,000), and endocarditis (32/​100,000) (Kassebaum et al., 2016). CHD is the most common cause of DALY in those age 45 or older (ahead of stroke, the second most common cause). The bottom line is that CHD takes more lives and causes more disability than any other medical condition in the United States and around the world.

HEALTHCARE COSTS The direct annual medical costs of CVDs in the United States are projected to increase from $396 billion in 2012 to $918 billion in 2030 (based on 2012 dollars; Mozaffarian et al., 2016). These costs are due to acute hospitalization (61%), medications (16%), physician care (11%), and nursing home care (7%). Indirect costs as a result of lost productivity due to the illness are estimated to increase from $183 billion in 2012 to $290 billion in 2030. Thus, overall costs (direct and indirect) are predicted to increase from $579 billion in 2012 to $1.2 trillion in 2030 (again in 2012 dollars). With regard to CHD, the total projected costs from 2015 to 2030 are estimated to rise from $182 billion in 2015 to $322 billion in 2030 (Mozaffarian et al., 2016, p. e352). Costs depend largely on how adherent patients are to their medication regimens, how seriously they engage in cardiac rehabilitation programs, and the degree to which they make required lifestyle changes (Bitton et al., 2013). Although direct and indirect costs of CVDs, and CHD in particular, outside of the United States are difficult to find, Srivastava and Mohanty (2013) reported that in India, the total costs of hospitalization (which makes up the largest proportion of total direct cost) in 2004 was $10.2 billion ($1,523/​person), with projected costs of $11.7 billion in 2010, $14.4 billion in 2016, and $16.6 billion in 2020. For CHD, a review of cost estimates in low-​and middle-​ income countries found several estimates in excess of $5,000 per episode, with an average monthly cost of CHD treatment ranging between $300 and $1,000 (Gheorghe et al., 2018).

HEART DISEASE RISK FACTORS

Table 20.1  Risk Factors for Heart Disease

We now review risk factors for heart disease, CHD in particular. More space is spent here discussing heart disease risk factors than risk factors for other medical conditions in future chapters because of its importance. As noted earlier, CHD is the most disabling of all health conditions and the most common cause of death in the United States and worldwide. Table 20.1 lists factors known to affect the development and course of CHD and heart disease more generally. Many of these risk factors lie on the hypothesized causal pathway between religiosity and heart disease, being influenced by religiosity or affecting cardiac risk among individuals who are more religious (thereby confounding the relationship). Modifiable and non-​modifiable risk factor categories discussed below include demographic, socioeconomic, genetic, biological, environmental, cultural, social, psychological, and behavioral. Among risk factors for CHD, only a few characteristics (age, gender, race/​ethnicity) and genetic factors (family history) are not modifiable.

Demographic Older age (including hormonal influences with menopause)† Male gender† Minority race/​ethnicity (especially for African Americans)†

Demographic Factors Increasing age has been associated with increased risk of CHD, a risk that markedly increases after the age of 45. Among women, this is partly due to hormonal changes (Kassebaum et al., 2016). Reductions in estrogen and testosterone during menopause increase risk of developing CHD (Bajelan et al., 2019). Male gender is a risk factor in that women develop CHD approximately 7–​10 years later than men, although the difference between genders is decreasing (Maas & Appelman, 2010). Based on longitudinal data collected in the National Health and Nutrition Examination Surveys (NHANES), men were more than three times as likely as women among those age 35–​54 to report having a myocardial infarction (2.5% vs 0.7%) during the 1988–​ 1994 NHANES. However, by the 1999–​2004 NHANES that gap had decreased to 2.0% vs. 1.1% (Towfighi et al., 2009). The higher risk of CHD in men is likely due to differences in physiological, psychological, and behavioral risk factors between the

Socioeconomic Low education, low income, poverty*† Unemployment* Genetic Family history of coronary heart disease (or other cardiac problems) Epigenetic influences during infancy (also see environmental below)* Biological Metabolic risk (high blood sugar, blood pressure, total cholesterol, adiposity)* Inflammation (low grade systemic inflammation)* Environmental In-​utero parental use of alcohol/​drugs* Pre-​and postnatal parental stress and emotional illness* Unsafe neighborhood environment† Environmental toxins and air pollution† Poor access to medical care (availability, affordability, acceptability)* Poor adherence to treatment* Cultural Traditions fostering high-​risk diets, being overweight, physical inactivity*† Social Marital status (divorce)* Low social support, loneliness, social isolation* Small social networks, lacking in diversity* Low (community) social capital* Psychological High early life stress* Stressful life events during adulthood (acute and chronic)* Depression, anxiety, severe trauma* Pessimism * Personality (type A, hostile/​aggressive; type D, socially inhibited, negative, pessimistic)* (continued) Heart Disease • 371

Table 20.1  Continued Behavioral Cigarette smoking (including use of smokeless tobacco)* Poor diet (few vegetables and fruits, high saturated fats, high sugar, high processed foods)* Being overweight or obese*† Physical inactivity, lack of regular exercise* Alcohol or drug use* Inadequate sleep* Poor dental care* * Risk factors on which religious involvement may have a positive influence † Risk factors that may be associated with religiosity and confound the relationship

sexes (Khamis et al., 2016). The decreasing gap between sexes may be due to men becoming more aware of their need to reduce smoking, moderate alcohol intake, and reduce workplace stress, whereas women have become more involved in leadership positions and other high-​stress occupations. Race/​ethnicity also influences the risk of CHD. In the United States, the Black-​W hite ratio of heart disease deaths increased from 1.04 in 1968 to 1.21 in 2015 (higher in Blacks). Most of that increase came during the 1970s and 1980s up through 2005, with modest decreases since then (Van Dyke et al., 2018). In-​hospital mortality rates among Black male coronary artery bypass graft (CABG) patients are 35% higher than in White males (Becker & Granzotti, 2019). Sudden cardiac death is also one-​third more likely among Blacks than Whites in the United States, with income being the strongest mediator of this effect (Zhao et al., 2019).

Socioeconomic Factors Lower levels of education, greater financial difficulties, and unemployment have all been strongly linked with CHD (Galobardes et al., 2006). This effect is likely due to the influence of lower socioeconomic status (SES) on major risk factors for CHD (Reddy et al., 2002). The effect of education is particularly striking and true for both genders, but especially 372 •  P h y sical H ealth

for women, where the risk of CHD has been found to be more than one-​ third higher (34%) in the lowest compared to the highest education group, even after adjustment for other risk factors (Backholer et al., 2017). Unemployment, both immediately after job loss and increasing with length of unemployment, has also been shown to increase risk of CHD (Ardito et al., 2017).

Genetic Factors Family history has long been known to increase risk of CHD based on results from the Framingham Heart Study (Myers et al., 1990; Pohjola-​ Sintonen et al., 1998). Vaidya and colleagues (2007) reported that if a sibling—​ brother or sister—​has a myocardial infarction or angina (chest pain) from blocked coronary arteries, the chances that a healthy brother will have this problem in the next 10 years increases by 20%. For a healthy sister, the risk increases by 7%. The younger the sibling’s age when CHD develops, the greater the brother or sister’s risk is for developing CHD. Genetic factors are also thought to increase risk of congenital heart disease (Zaidi & Brueckner, 2017), as well as cardiac valve defects (Andreassi & Della Corte, 2016). While genetic factors are often thought to be non-​modifiable, more recent research has found that a positive behavioral lifestyle may interact with genetics to affect risk, particularly in those with high genetic risk for CHD (Khera et al., 2016). Epigenetic modifications have been identified that influence the development of not only CHD, but also CVD more generally (Muka et al., 2016).

Biological Factors Metabolic syndrome, i.e., the combination of increased blood pressure, high blood sugar, increased visceral adiposity, and abnormal cholesterol or triglyceride levels, has been shown to affect the development of CHD, nearly doubling risk of disease (Mottillo et al., 2010). High blood pressure and high total cholesterol are the greatest culprits. Increased systemic inflammation (as reflected by high levels of C-​ reactive protein and pro-​ inflammatory cytokines, which are also increased with depression

and psychological stress) has been implicated in the pathogenesis of atherosclerosis more generally and CHD in particular (Wirtz & von Känel, 2017).

Environmental Factors Environmental risk factors begin with parental use of alcohol/​drugs, parental stress, and parental emotional illness during the prenatal period affecting the fetus. Maternal behavior with regard to diet during pregnancy has long been known to influence the development of CHD (and death) in their children as adults (Osmond et al., 1993). Even during the preconception period, heavy alcohol use by fathers may increase risk of fetal alcohol syndrome (FAS) and negative cardiac effects in those with this syndrome (Abel, 2004). The fact that alcohol use by mothers at any time during pregnancy increases risk of FAS is well-​established, increasing the risk of congenital heart defects by 50% (Loser & Majewski, 1977). FAS is also linked to other cardiovascular abnormalities and aberrant vascular function known to cause CHD during adulthood, as repeatedly shown in animal models (Parkington et al., 2010; Ninh et al., 2019; Moritz et al., 2019). Adverse fetal exposures during pregnancy may also lead to developmental changes that lead to cardiovascular system dysfunction when the child reaches adulthood (Gluckman et al., 2008). Besides alcohol and drugs, one of those exposures is maternal psychological distress, as hypothesized many years ago (Ferreira, 1965), which can affect the development of CHD directly or indirectly through adult child behaviors that increase risk (Vehmeijer et al., 2019). The mechanism by which this occurs is likely through dysregulation of the maternal hypothalamic-​ pituitary-​ adrenal (HPA) axis, resulting in higher fetal brain exposure to cortisol, which then adversely affects the child’s stress response system during adulthood (Harris & Seckl, 2011). This change has been shown to increase blood pressure and systemic vascular resistance, thereby leading to the development of CHD (Rondo et al., 2010). Other environmental risk factors include neighborhood safety, environmental toxins and

air pollution, and availability of high-​quality medical care. These may either directly or indirectly affect the development of CHD. Unsafe neighborhoods, i.e., high-​ crime areas where access to outdoor physical activity is limited and access to drugs/​alcohol and poor-​nutrition foods is increased, may adversely affect diet and weight, indirectly affecting CHD through these risk factors (see below). Environmental toxins include exposure to arsenic, lead, and cadmium, which are known to affect the heart (Chowdhury et al., 2018). Air pollution in large urban environments may directly affect CHD risk (Rajagopalan et al., 2018). These environmental exposures are often a result of socioeconomic circumstances that force individuals to work and live in inner-​city environments where such exposures are more common. Work environments, particularly highly stressful occupations that lead to job strain and poor effort-​reward balance, also impact the development of atherosclerosis and CHD (Theorell et al., 2016; Sara et al., 2018). Not surprisingly, individuals with poor access to high-​ quality medical care are also at elevated risk for CHD and other heart conditions (Schroder et al., 2016).

Cultural Factors As noted in Chapter 19, traditions regarding diet, choice of foods, and preferred weight that are rooted in culture may affect risk of CHD, especially in developing countries. As noted in Chapter 19, being overweight is not considered a problem by everyone. In some cultures, being overweight or obese may be viewed as beautiful, fertile, and prosperous, particularly among people who are struggling to find enough food to survive (Mokhtar et al, 2001). Furthermore, women in some highly religious Arab countries may have limited access to sports and physical activities, and multiple pregnancies may be encouraged, all leading to increased weight and resulting increased risk of CHD (Badran & Laher, 2011). Cultural factors may even affect what a person considers to be a disease or illness. While Western definitions emphasize dysfunction of organs or body systems, non-​ Western conceptions of illness may have more to do with sociocultural views of disease and Heart Disease • 373

how a particular society reacts to it (Benson et al., 2010).

Social Factors Social support and integration have a strong influence on the development and course of CHD (Havranek et al., 2015; Chang et al., 2017). For example, in a systematic review of 35 studies involving over 1 million participants, Manfredini and colleagues (2017) found that most studies reported better CHD outcomes for married persons due to lower risk factors and better health status overall, with single men having the worst prognosis. Those with low social support, particularly individuals who report being lonely, are likewise at high risk for developing and dying from CHD. In a systematic review and meta-​analysis involving 148 studies (308,849 participants), Holt-​ Lunstad and colleagues (2010) found that overall survival increased by 50% in participants with stronger social relationships (OR =​1.50, 95% CI =​1.42–​1.59). In a more recent review of 16 longitudinal studies with follow-​ups ranging from 3 to 21 years where 4,628 CHD events occurred during follow-​up, poor social relationships were associated with a 29% increased incidence of CHD (RR =​1.29, 95% CI =​1.04–​1.59) (Valtorta et al., 2016). Social connections (assessed by social network size, social integration, marital status, and social support quality) have been shown to affect lifestyle (physical activity, nutrition, sleep, smoking, risk-​taking behaviors), mental health (stress, depression, resilience, meaning/​ purpose, hopefulness), and medical adherence (taking medication, following diet, instituting lifestyle change) (Holt-​Lunstad et al., 2010). Each of these, in turn, influences biomarkers such as systemic inflammation, blood pressure, gene expression, neuroendocrine functioning, and adiposity—​major risk factors for CHD. At the community level, high “social capital” has also been linked to lower rates of CHD. Social capital refers to level of community participation in formal as well as informal social networks and activities through volunteering, a shared sense of identity, shared understandings, shared norms, shared values, trust, and

374 •  P h y sical H ealth

reciprocity. For example, in a 2-​year prospective study of 1,358,932 men and 1,446,747 women in Sweden age 45–​74, Sundquist and colleagues (2006) found that higher social capital was associated with lower risk of CHD in both men and women beyond individual-​level risk factors. In neighborhoods with low social capital, the incidence of CHD was 19% higher in men and 29% higher in women (OR =​1.19, 95% CI =​1.14–​1.24, and OR =​1.29, 95% CI =​ 1.21–​ 1.38, respectively), after adjusting for age, country of birth, education, marital status, and housing tenure.

Psychological Factors Many studies have found a link between psychological factors and the development and course of CHD. These include early life stress during childhood, stressful life events during adulthood, depression, anxiety, severe trauma, and personality type. For example, depression is more common in those with CHD, and the risk of CHD is more common among those who are depressed. The prevalence of major depression (MDD) in those with CVD is 15%–​ 20%, which is up to 3–​4 times higher than in the general population at 4%–​5% and similar to that in patients with cancer or end-​stage renal disease (Huffman et al., 2013). Based on results from six published meta-​analyses, the risk of MDD in those with CHD is increased by 30% to 90% (Carney & Freedland, 2017). Risk of developing or dying from CHD is also increased among those with depression, particularly among women. For example, an 18-​year prospective study of 890 women in Southeastern Australia found that the risk of experiencing one or more cardiac events during follow-​up among those with depressive disorder was over twice that of women who were not depressed after adjusting for anxiety (OR =​2.39, 95% CI =​1.19–​4.82) (O’Neil et al., 2016). The risk increased further in that study as other covariates were controlled. After adjusting analyses for typical CHD predictors, the risk increased to over 3-​fold (OR =​3.22, 95% CI =​1.45–​6.93) and increased slightly more after adjusting for atypical risk factors (OR =​3.28, 95% CI =​1.36–​7.90).

Knowledge about the mechanisms by which depression increases CHD risk has been growing rapidly with recent research. Depression has been linked to increased systemic inflammation (e.g., elevated levels of C-​reactive protein and interleukin-​6) (Huffman et al., 2013), which in turn has been associated with the development and progression of CHD (Hohensinner et al., 2011). Similarly, depression has been associated with dysfunction of the internal lining of coronary arteries (endothelium), leading to increased risk of vasoconstriction and myocardial ischemia (van Dooren et al., 2016). Depression also interferes with platelet functioning, leading to increased likelihood of aggregation and clotting in coronary arteries (Huffman et al., 2013), increasing the risk of myocardial infarction. However, the greatest effect of depression on CHD outcomes is due to the lack of motivation and loss of interest. The latter interferes with the ability to comply with lifestyle modifications and medical treatments, which are crucial to successful cardiac rehabilitation after a CHD event (Whooley ­ et al., 2008). The prevalence of anxiety disorders is also higher in those with CHD compared to the general population, especially generalized anxiety disorder (8.0% in those with CHD, compared to 3.1% in the general population), panic disorder (6.8% vs. 2.7%), and agoraphobia (3.6% vs. 0.8%) (Tully et al., 2016). Likewise, the risk of developing CHD also increases among those with anxiety. In a meta-​analysis of 20 studies with varying follow-​up periods ranging from 2 to 21 years examining those with anxiety (i.e., panic, phobia, post-​traumatic stress, any anxiety or worry), Roest and colleagues (2010) found a 26% increased risk of incident CHD and a 48% increased risk of cardiac mortality. The increased risk is thought to be due to the effects of anxiety on blood pressure, smoking, medication adherence, inflammation, and heart rate variability. Again, however, the increased physiological effects of anxiety interacting with lifestyle risk factors are thought to far outweigh all other influences. General outlook on life, particularly pessimism, has been associated with an increased risk of death from CHD. For example, in an 11-​ year prospective study of 2,815 adults over age

50 in Finland, the adjusted risk of death from CHD was over twice as high among those in the highest quartile of pessimism compared to those in the lowest quartile (OR =​2.17, 95% CI =​1.21–​ 3.89) (Pänkäläinen et al., 2016). Likewise, the toxic effects of anger (related in part to difficulty forgiving and letting go of past hurts) have also been identified as an independent risk factor for CHD and CVD more generally (Suls, 2018). Personality type may also play a role in this regard, as research has shown that the hostile, aggressive Type A (Chen et al., 2019) and the distressed Type D (characterized by social inhibition and negative affect) (Kupper & Denollet, 2018; Lin et al., 2018) are strong predictors of CHD risk and mortality. The anger associated with Type A personality has been strongly linked with low scores on the personality trait of agreeableness, reflecting a cynical, self-​centered, mistrustful orientation toward others. In contrast, agreeableness (Gidron, 2004; Costa et al., 2013), conscientiousness (Jokela et al., 2014), self-​regulation (Kubzansky et al., 2011), and optimism (Tindle et al., 2009) all predict lower risk of CHD. For example, Tindle and colleagues (2009) followed 97,253 postmenopausal women free of heart disease for 8 years, examining the effects of optimism and cynical hostility on risk of CHD (myocardial infarction, angina) and CHD mortality. Women who scored in the top quartile of optimism (vs. lowest quartile) had a 16% decrease in myocardial infarction incidence (HR =​0.84, 95% CI =​ 0.73–​0.96), a 14% decrease in all-​cause mortality (HR =​0.86, 95% CI =​0.79–​0.93), and a 30% decrease in CHD mortality (HR =​0.70, 95% CI =​0.55–​0.90). Women who scored in the top quartile of cynical hostility (vs. lowest quartile) had a 13% increase in risk of MI (HR =​ 1.13, 95% CI =​0.98–​1.30), a 16% increase in all-​cause mortality (HR =​1.16, 95% CI =​1.07–​ 1.27), and a 25% increase in CHD-​related mortality (HR =​1.25, 95% CI =​0.98–​1.60). A meta-​ analysis of longitudinal studies examining associations between purpose in life and cardiovascular events found a 17% reduction in cardiovascular events over time (adjusted pooled relative risk =​0.83 [CI =​ 0.75–​0.92], p =​0.001) for those with a high sense of purpose in life (Cohen et al., Heart Disease • 375

2016). In light of the existing evidence, the American Heart Association in 2021 released a scientific consensus statement on the importance of psychological health and well-​being for cardiovascular health (Levine et al., 2021).

As noted in Chapter 19, the diet most commonly recommended by health professionals in 2020 was the Mediterranean diet (US News & World Report, 2020). Research shows that this diet, characterized by consumption of olive oil, whole fruits, raw vegetables, and legumes (e.g., beans, peas, lentils), low or moderate intake of Behavioral fish and poultry, and low consumption of red By far the strongest predictors of CHD risk (and meat and dairy products, has been associated prognosis among those with CHD) are behav- with decreased body inflammation (Smidowicz ioral: cigarette smoking, poor diet, being over- & Regula, 2015) and reduced risk of CVD and weight or obese, physical inactivity, physical CHD, especially when supplemented with extra-​ illnesses influenced by health behaviors (dia- virgin olive oil and/​or nuts (e.g., soy, carob, dry-​ betes, pre-​diabetes, high blood pressure, high roasted or unsalted peanuts) (Estruch et al., total cholesterol), and compliance with CHD 2018; Rosato et al., 2019). treatment. Healthy heart behaviors include A poor-​quality diet also increases the risk moderate alcohol use, avoidance of non-​ of being overweight or obese due to overconprescription illicit drugs, obtaining adequate sumption of calories. High BMI in children, sleep, and getting regular dental care to avoid adolescents, and adults predicts increased risk periodontitis and teeth decay. Those who are of CHD with a dose-​ response effect (Baker physically active and engaged in healthy heart et  al., 2007; Tirosh et al., 2011; Gary et al., behaviors are at least half as likely to expe- 2011; Twig et al., 2016). For example, in an 80-​ rience a cardiovascular event, die from CVD, year follow-​up of 18,955 men in the Harvard or die from any cause (Lacombe et al., 2019). Alumni Study, those who were obese in early Similarly, among those who already have CHD, adulthood had nearly twice the risk of future engagement in healthy heart behaviors reduces death from CHD (HR =​1.83, 95% CI =​1.21–​ the risk of recurrent CHD events and cardiac 2.76), with evidence for a linear trend across death (Lavie et al., 2016). BMI categories (p for trend < 0.01) (Gary et al., In a meta-​analysis of 141 prospective cohort 2011). Similarly, men who were overweight studies, the risk of developing CHD among men or obese in middle age were at 25% and 60% was increased by 48% (pooled relative risk [RR] increased risk, respectively, of dying from CHD. =​1.48) in those who smoked one cigarette per Along with a poor diet, inadequate physiday and was increased by 104% (RR =​2.04) in cal exercise is a major contributor to increased those who smoked one pack (20 cigarettes) per weight. Physical activity, exercise training, and day (Hackshaw et al., 2018). After adjustment cardiorespiratory fitness have all been shown for multiple confounders, the risk of developing to reduce risk of CHD (Lavie et al., 2019). In CHD increased further to 74% (RR =​1.74) and contrast, physical inactivity predicts increased 127% (RR =​2.27), respectively. Among women, risk of CHD in a dose-​response fashion. For after adjusting for other risk factors, smoking example, in a meta-​ analysis of 33 studies, one cigarette per day increased risk of CHD by Sattelmair and colleagues found that those who 119% (RR =​2.19) and among those smoking engaged in 150 minutes of moderate-​intensity one pack/​day the risk was increased by 295% leisure-​time physical activity had a 14% lower (RR =​3.95). A similar risk has been associated risk of CHD (RR =​0.86, 95% CI =​0.77–​0.96), with smokeless tobacco as well, especially for whereas those who engaged in 300 minutes those living in the European region and among per week had a 20% lower risk (RR =​0.80, 95% users of snus/​snuff (Gupta et al., 2018). CI =​0.74–​0.88). Physical activity appears to Consumption of a poor-​ quality diet (i.e., interact with BMI such that among those with high-​calorie, processed foods, saturated fats, high BMI who are physically active, risk of CHD added sugar, low amounts of uncooked vegeta- is low compared to those with high BMI who bles and fresh fruit) is a strong risk factor for are physically inactive (Arsenault et al., 2010; the development of atherosclerosis and CHD. Koolhaas et al., 2017). 376 •  P h y sical H ealth

Although many have asserted that drinking alcohol-​containing beverages, particularly red wine, is cardioprotective, the evidence supporting this claim is not established and is still debated (Vogel, 2019). Alcohol use appears to be more protective if consumed with meals and in moderation (i.e., 2 drinks or less per day), but it is not clear that alcohol reduces CHD risk in the first place, as concerns still remain about confounding. With higher intake, acute alcohol intoxication has been associated with decreased left ventricular function and proarrhythmic effects, paroxysmal atrial fibrillation in particular, and drinking 3 or more drinks per day increases the risk of both systolic and diastolic hypertension (a major risk factor for CHD). Furthermore, research indicates that heavy alcohol use (more than 14 drinks/​week for women and 21 drinks/​week in men) and heavy episodic/​binge drinking are associated with increased mortality (Toma et al., 2017). Given that alcohol is the third most common cause of preventable death in the United States, in addition to the risk of dependence, adverse effects, and abuse, drinking alcohol in whatever form or amount simply in order to prevent CHD is not recommended (Vogel, 2019). See also the environmental effects of alcohol use during pregnancy and preconception described above. Use of illicit drugs, including marijuana, has also been associated with an increased risk of CVD more generally and CHD in particular. Smoking marijuana has similar effects as smoking cigarettes on pulmonary function and the acceleration of cardiovascular aging (Reece et al., 2016). Likewise, cocaine use has been associated with subclinical coronary atherosclerosis (Lai et al., 2016) and predicts noncalcified coronary artery plaque progression (Sandfort et al., 2017). Methamphetamine use has also been associated with cardiomyopathy, even among young persons (Yeo et al., 2007). Finally, opioid use (heroin, oxycontin, etc.) has been associated with increased risk of myocardial infarction and CHD (Carman et al., 2011; Li et al., 2013). Inadequate sleep and poor dental care also increase the risk of CHD. In a meta-​analysis of 22 independent reports involving 517,440 participants experiencing 17,841 incident cases of CHD, Wang and colleagues (2016) found a

U-​shaped relationship between sleep duration and CHD risk, with the lowest risk occurring at a sleep duration of 7–​8 hours/​night, and either less or more sleep associated with increased risk. In a meta-​analysis of prospective studies, Cappuccio et al. (2011) found that self-​reported short sleep is associated with a 48% increased risk of incident CHD. Furthermore, among those who have an MI or unstable angina, more than 50% of these individuals sleep less than 7 hours/​night during the month following the event and consequently experience a more than 50% increased risk of recurrent CHD events or death within a year after the event (Alcántara et al., 2014). Perhaps surprisingly, poor dental care is another risk factor for developing CHD. Chronic periodontitis has been shown to independently increase the risk of developing atherosclerotic vascular disease, including that in the coronary arteries. At least five meta-​analyses have reported that chronic periodontitis is associated with an increased risk of developing CHD (Dietrich et al., 2017). Likewise, there is evidence that teeth loss is associated with CHD risk and death. Those with only 0 to 10 teeth are at a 34% increased risk compared to those with 25 to 32 teeth (RR =​1.34, 95% CI =​1.10–​ 1.63) (Humphrey et al., 2008). The mechanism by which periodontal disease increases risk of CHD has been thought to be due to increased body inflammation (based on increased levels of C-​reactive protein) and adverse effects on coronary artery endothelial function. Periodontal treatment, in turn, results in reduction of C-​reactive protein levels and improvement of endothelial function (Dietrich et al., 2017). Even when access to high-​quality medical care is not a problem, poor adherence to prescribed medical treatments, cardiac rehabilitation, and lifestyle changes increases the risk of poor CHD outcomes (Ho et al., 2009). Among those who engage in cardiac rehabilitation programs that involve making lifestyle changes, 50% discontinue participation within the first 12 months (Burke et al., 1997).

Summary Heart disease is a condition responsible for more than one-​third of all deaths among those Heart Disease • 377

age 35 or older in the United States and is, in fact, the most common cause of death and disability in both developed and underdeveloped countries throughout the world. Half of all men and one-​third of all women will have some level of CHD when they reach middle age. Many factors—​both modifiable and non-​ modifiable—​ increase the risk of developing CHD. While gender, age (including hormonal changes with menopause), race/​ethnicity, and family history cannot be altered, many other risk factors can be: socioeconomic conditions, genetic-​ environment (epigenetic) influences during infancy and/​or early childhood, metabolic factors (diabetes, hypertension, and cholesterol influenced by diet and physical activity), systemic inflammation, environmental risks (including in-​utero influences as a result of parent health behaviors and mental health), cultural influences, and especially, psychological, social, and behavioral factors (cigarette smoking, physical inactivity, poor diet, overweight, alcohol/​drug use, inadequate sleep, poor dental care, and poor compliance with recommended treatments). We have taken up considerable space to document the effects of CHD risk factors because almost every one of these factors may be directly or indirectly influenced by religious involvement.

RELIGIOSITY AND HEART DISEASE Case Vignette While shoveling snow from his driveway, Bob experienced a crushing pain in the left side of his chest that radiated into his arm and neck. He immediately stopped and went inside the house. The pain continued and he started to feel weak and short of breath. His wife called 911 and paramedics took him to the hospital. After performing an electrocardiogram and an emergent coronary angiogram, the doctor told Bob that he had experienced a heart attack due to a narrowing of the large artery that supplies blood to the left side of his heart.

378 •  P h y sical H ealth

The doctor recommended immediate coronary artery bypass graft (CABG) surgery, to which Bob agreed. While recovering in the hospital after surgery, Bob was initially anxious and then began feeling depressed. His father had died of a heart attack shortly after he had turned 60. At age 57, Bob wondered what this meant for him. Would he follow in his father’s footsteps? What about his job and family responsibilities? Why had God allowed this to happen to him? He had been a hard worker, faithful husband, and devoted father. He thought, what have I done to deserve this? Bob’s pastor came by for a visit and they talked for a while. Bob shared that he didn’t think he deserved this and wondered whether God was punishing him for something. The pastor asked Bob to look around at other patients in the 8-​bed ward. He asked Bob if God was punishing all those patients by causing them to have medical problems that put them in the hospital. Bob got the point. Rather than be angry with God, the pastor suggested that he turn to God for help in dealing with his situation. After the pastor left, Bob thought about that conversation. Bob then said a prayer and asked God for help. He felt a little better, though not much. For the next few days, he began to pray regularly, started reading his Bible again, and began accepting offers of support from friends at church. Slowly, he found his spirits improving. Maybe God did have a plan for his life. If so, he could handle whatever might come, since if this was part of God’s plan, then God would be with him and give him the strength to carry on. With this return of hope, Bob felt more motivated to get involved in the rehabilitation plan that his doctor had prescribed for him. Life would be very different from here on out. He would have to stop smoking, ease up on his alcohol intake, lose about 30 pounds, and start an exercise program. Bob would also have to find a

less stressful position at work, and begin taking regular vacations, something he had not done for years. Work and family had been his entire life. After spending two weeks in cardiac rehab, Bob was discharged home. After two months, he was back at work (but in a less stressful position). Bob began attending church more regularly and even started volunteering a few hours on weekends at the church’s food kitchen. He didn’t know how many years he had left, but he wanted them to count for something. Maybe this heart attack had been part of God’s plan after all.   

HOW RELIGION MIGHT IMPACT HEART DISEASE Based on what is known about factors that increase risk of heart disease, how might religious involvement at least theoretically affect the development and course of CHD (the most common form of heart disease)?

Demographic Religious involvement does not impact a person’s age, sex, or race/​ethnicity, though there are associations with these. In fact, those who are older, female, and members of minority groups (African American in particular) are more likely to be highly religious. Thus, these factors must be considered and controlled for when examining the relationship between religiosity and heart disease. These factors are all related to both CHD and religiosity and therefore may affect results when examining the relationship between the two.

Socioeconomic Care must also be taken to control for SES, since those with lower education, lower incomes, and lower SES also tend to be more religious. Karl Marx described religion as the “opium of the people,” one that calmed the masses of poor people. However, religious involvement,

particularly during youth, may impact both the ability to complete one’s education and to later obtain a good job, thereby helping individuals to get out of poverty. If a young person does not use drugs or alcohol, become engaged in delinquent activities, get pregnant out of wedlock (or get someone else pregnant) during their teen years, then they will have a better chance of completing their education. Likewise, religiosity is positively related to academic performance among young persons and to employment later in life (e.g., see Mohanty, 2010; Stansfield et al., 2017). We describe this research in Chapters 13 and 14 (also, see Appendix). Thus, socioeconomic circumstances are modifiable by religious involvement in a way that may impact CHD risk.

Family History and Epigenetics There is research showing that religiosity may influence parental warmth during early childhood (Chen et al., 2019a; see also Chapter 14). Although religiosity may not affect a person’s family history of CHD, maternal nurturing during early infancy may cause epigenetic changes that influence stress reactivity later in life (changes that are then genetically transmitted from generation to generation) (see Chapter 16). A healthier stress response will lead to less psychological distress and lower risk of CHD, as reviewed earlier.

Biological Metabolic risk factors (high blood sugar, hypertension, high cholesterol, increased adiposity) are largely driven by health behaviors such as diet, weight, and physical activity. As noted in Chapters 18 and 19, religious persons tend to be more physically active and may consume a healthier diet, which is likely to affect blood sugar, blood pressure, and cholesterol levels. Being overweight or obese, though, may be a problem for many religious persons (a relationship potentially confounded by race/​ethnicity), which could adversely affect CHD risk. With regard to body inflammation, which is a major part of the mechanism leading to atherosclerotic coronary artery disease, religiosity has been associated with lower levels of C-​reactive Heart Disease • 379

protein and pro-​inflammatory cytokines such as interleukin-​6 (see Chapter 24), which should reduce the risk of developing CHD. Thus, greater religiosity may increase or decrease biological risk factors that lead to heart disease.

Environment Environment begins in the womb during early development (and even before conception, as noted for paternal substance use above). Thus, effects of parental religiosity may influence fetal developmental during pregnancy, impacting later CHD risk. For example, religiosity is a strong predictor of lower levels of alcohol and drug use (Chapter 10). If a mother (or father during the preconception period) is less likely to use or abuse alcohol, then the negative effects of this substance on fetal brain growth (and development of fetal alcohol syndrome) will be less and therefore the child will be at lower risk of developing congenital heart disease, cardiac defects, and other heart diseases (including CHD) during adulthood. Religious involvement is also related to greater marital and family stability (Chapter 14), which is likely to reduce maternal stress levels both during and after pregnancy, thereby making parents more available to infants to meet their basic need for love and support, which will affect future mental health and risk of developing CHD. Religious involvement may be greater in neighborhoods with high crime rates, drug use, greater poverty levels, and fewer resources to ensure a clean environment free of toxins and air pollution. This may be particularly true in inner cities where there are often high concentrations of ethnic minorities, who are much more likely to be religious (at least in the US). In this case, environmental risk factors related to unsafe neighborhood characteristics may increase the likelihood of CHD among more religious individuals living in these neighborhoods. As with low SES, this is a factor that must be considered and controlled for in studies of religiosity and CHD. Since religiosity is often related to lower SES status, religious individuals may have less access to the high-​quality medical care necessary for the prevention and treatment of CHD. On the one hand, worse socioeconomic 380 •  P h y sical H ealth

circumstances, along with discrimination against ethnic minorities who are more religious, may lower access to high-​quality medical care due to availability and affordability for those living in inner-​city and rural environments. On the other hand, if religiosity increases the likelihood of obtaining an education and gainful employment, this could lead to better health insurance and greater access to medical care. Religiosity is also often related to better compliance with medical treatments (see Appendix), and if so, this would also help in the prevention and treatment of heart disease.

Cultural In general, those who are more religious tend to be more conservative and more likely to hold on to cultural and family traditions. Such traditions can affect diet, weight, and physical activity levels. As noted earlier, those living in highly religious countries in the Middle East may consume high-​calorie, unhealthy foods that have traditionally been part of a diet passed down from generation to generation in these communities. This may also apply to customs such as the number of pregnancies and childrearing, particularly among religious women who may feel that they should stay home and have babies. Such traditions may increase risk of being overweight and physically inactive, increasing risk of CHD and poor outcomes. However, there are some culture-​based religious traditions involving cleanliness and self-​ care more generally that may actually decrease CHD risk (Litman et al., 2019).

Social Social pathways are among the most likely mechanisms by which religiosity (particularly social religious involvement) could impact the risk of heart disease. As noted in Chapter 15, there is substantial evidence that religious involvement increases both the quality of support and the amount of support, enhances social integration, and reduces loneliness, each known to be strongly related to the development and course of CHD. Those who are more religious are more likely to be married, less likely to divorce, less likely to be socially

isolated, and more likely to have a diverse and broad social network consisting of family and non-​family friends. Community religious involvement is also related to greater social capital (see Appendix), since those who are more religious tend to volunteer and become involved in prosocial community activities and organizations. Activities of this sort may give a sense of meaning and purpose to their lives that is protective against CHD.

Psychological Greater religiosity has been associated with better coping with stress (Chapter 4), less depression (Chapter 5), less anxiety (in many studies) (Chapter 8), greater meaning and purpose, greater optimism, and greater overall well-​being (Chapter 12). Religious involvement is also related to (and predicts) less pessimism, less anger and aggression, and positive personality traits such as agreeableness and conscientiousness (Chapter 11). As noted above, these are psychological states and traits related to a lower risk of CHD and better cardiac outcomes. Stressful life events during adulthood (divorce, incarceration, accidents, job loss) should also be less common among those who are more religious because they are more likely to “follow the rules,” to be responsible, and to be conscientious. Individuals who are raised in religious families are also less likely to experience stress during early childhood because these families are more stable and relationships with parents may be better (as children are often highly valued in religious families; see Chapter 14).

Behavioral Religiosity has been related to less cigarette smoking and cessation of cigarette smoking (Chapter 17), better diet (more generally and especially for some religious groups), greater physical activity (Chapter 18), less alcohol and drug use (Chapter 10), better sleep in about half of studies (e.g., Ahrenfeldt et al., 2018, and see Appendix), lower rates of periodontitis (Merchant et al., 2003; Zini et al., 2012a) and fewer dental caries (Zini et al., 2012b), and greater attention to cleanliness and overall self-​care (Litman et al., 2019). Thus, there

are multiple behavioral pathways by which religious involvement may reduce CHD risk. Some of those pathways, however, may involve bidirectional effects. For example, those who smoke cigarettes or abuse alcohol/​drugs may be less welcome in religious settings, and those who are more physically active may be more able to attend religious services. Prospective studies, then, are important in order to identify whether religious involvement actually causes an increase in health behaviors that are good for the heart (see Chapters 17–​19).

Summary Although the relationship between religiosity and CHD is a complex one (Figure 20.1), in which religiosity acts indirectly on heart disease through multiple psychological, social, and behavioral pathways and is affected by numerous confounding influences, the logic described above would favor the hypothesis that religiosity has positive effects on the prevention of CHD and the improvement of health outcomes among those with CHD.

RESEARCH ON RELIGION AND HEART DISEASE We now test the hypothesis above by reviewing research that has examined the relationship between religiosity and heart disease, CHD in particular. As noted above, there are numerous factors that confound the relationship between religiosity and CHD, and bidirectional effects may also influence such relationships, adding a further layer of complexity to the study of religion’s effect on heart disease. Fortunately, a number of high-​ quality prospective studies have examined the effects of religiosity on heart disease, and there have been several randomized controlled trials (RCTs) of religious interventions. As in prior chapters, the research is presented by date of the research (prior to and after 2010), study design, and year of publication.

Early Research In our 2010 review of studies examining the relationship between religiosity and heart Heart Disease • 381

Demographic Older age Gender Minority race/ethnic

+

Socioeconomic Low education Low income Unemployment

+ or –

Religiosity

– or NA + or – + or – + or – –

+

Genetic Pos family history Neg epigenetic effects

Metabolic risk Inflammation

+

Environmental Neg parental influences (in-utero, postnatal) Unsafe neighborhood Poor access/compliance

+

Cultural Positive traditions Negative traditions Social

– –

+

Biological

Marital instability Poor social support Loneliness Psychological Early/later stress Depression/anxiety Neg person traits

+ or –

+

Coronary Heart Disease

+

+

+

Behavioral Smoking Physical inactivity Poor diet

FIGURE 20.1.  Pathways by which religiosity may impact coronary heart disease.

disease (e.g., CHD, acute coronary syndrome, myocardial infarction), 24 quantitative studies were identified (14 cross-​sectional, 6 prospective, and 4 clinical trials). Of those 24, 14 (56%) found less heart disease in those who were more religious or reported a positive effect of a religious or spiritual intervention. Of the 14 cross-​sectional studies, 10 reported inverse relationships between religiosity and heart disease, 3 found no association, and 1 reported mixed results. Of the six prospective studies, one found that religiosity (assessed by attendance at synagogue, self-​definition as Orthodox, and having a religious education) predicted significantly lower death rates from CHD during a 23-​year follow-​up period in 10,059 middle-​ aged Israeli men, findings that were independent of blood pressure, diabetes, cholesterol, smoking, weight, and baseline heart disease (Goldbourt et al., 1993). A second prospective 382 •  P h y sical H ealth

study, however, found that while infrequent (< weekly) attendance at religious services predicted a 21% increase in death from circulatory diseases overall (HR =​1.21, 95% CI  =​1.06–​ 1.37, net of baseline sociodemographic characteristics, physical health, social connections, and health behaviors), infrequent attendance did not predict mortality from ischemic heart disease (HR =​1.03, 95% CI =​0.81–​1.32) during a 31-​ year follow-​ up of 6,545 community-​ dwelling adults in Northern California (Oman et al., 2002). A third prospective study involved an 8-​year follow-​up of 93,676 participants in the US Women’s Health Initiative, reporting significantly more CHD events during follow-​up in uncontrolled analyses and greater CHD mortality in those saying they received a great deal of strength/​ comfort from religion (although the latter effect was reduced to nonsignificance when those with a history of MI or stroke at

baseline were excluded) (Schnall et al., 2010). Of the three remaining prospective studies, one found no effect of religiosity on CHD outcomes in 503 post-​MI patients followed for 18 months (Blumenthal et al., 2007), one found no effect of religious attendance on CVD mortality in 28,369 male health professionals followed for 10 years (Eng et al., 2002), and the final study in 62 post-​MI patients followed for 6 months reported that frequent religious attendance predicted faster functional recovery, whereas greater self-​rated religiosity predicted slower recovery (Martin & Levy, 2006). Of the four experimental studies or clinical trials, three reported positive effects of a religious or spiritual intervention and one found no effect. The 2010 review also identified nine studies examining the effects of religiosity on cardiovascular reactivity (CVR, including brachial artery vasoreactivity, cardiac output, peripheral resistance), all of which were experimental studies or RCTs. Four of the nine indicated significant positive effects of religiosity on CVR, one indicated a trend in that direction, one found that religiosity had negative effects on CVR, one reported no association, and two indicated mixed findings (e.g., positive effects in men, negative effects in women). Our review located an additional four studies that examined religiosity’s effect on heart rate variability (HRV)—​one cross-​sectional and three experimental studies or RCTs (all involving yoga or transcendental meditation [TM] interventions). Higher HRV is associated with better cardiac functioning. The cross-​sectional study reported a positive association between religiosity and HRV. Of the three experimental studies, a clinical trial of a yoga intervention reported a positive effect on HRV, whereas a clinical trial involving TM reported a trend in that direction, and one TM study found no effect. The 2010 review also uncovered five studies that examined the impact of religiosity on outcomes following cardiac surgery, including four prospective studies and one clinical trial. Three of four prospective studies reported reduced postoperative complications or greater survival following cardiac surgery among those who were more religious (Oxman et al., 1995; Contrada et al., 2004; Ai et al., 2009a), whereas

one study found no effect on length of hospital stay (Contrada et al., 2008). The RCT found no effect of prayer on cardiac outcomes (Ikedo et al., 2007). Finally, two studies examined general cardiovascular functions, one finding that repeating the rosary prayer in Latin or repeating yoga mantras significantly increased the arterial baroreflex, a healthy finding (Bernardi et al., 2001). The second study found no cross-​ sectional associations between “spiritual feelings” or frequency of religious attendance and indicators of subclinical atherosclerosis (coronary artery calcium, left ventricular mass, or ankle brachial index), although those who attended religious services daily had greater carotid intima-​ media thickness compared to those who never attended (see Chapter 22) (Feinstein et al., 2010). Thus, the results from these early studies are inconsistent, with the majority of cross-​ sectional studies finding less CHD or better cardiovascular functions in the more religious, and the majority of interventions studies also reporting positive effects. However, the findings from prospective studies were mixed.

Recent Research Since 2010, at least nine additional prospective studies have examined the effects of religiosity on CHD, three experimental studies have explored the effects of religiosity on CVR, three clinical trial or experimental studies have focused on heart rate variability, and four prospective studies and two RCTs have examined effects of religiosity or a religious intervention on general cardiovascular functions (pulse rate, endothelium-​ dependent vasodilation, vascular activity). We review several of the higher-​ quality studies below (see Appendix for all studies).

Prospective Studies Salmoirago-​ Blotcher and colleagues (2013) examined the impact of private religious activities (PRA) on future adverse cardiovascular events (CVEs) using data from the Women’s Health Initiative (WHI). Of the 161,808 women age 50–​ 79 recruited between 1994 and 1998, 93,676 women were unwilling or Heart Disease • 383

ineligible to participate in WHI clinical trials and were therefore enrolled in this prospective study. Those who completed follow-​up in 2005 and had no self-​reported CVEs through 2005 were recruited into an extension of the study with follow-​ up through 2010 (n =​43,708). PRA were assessed 5 years after baseline in 2003 and CVEs were recorded during an average 7-​year follow-​up. CVEs included nonfatal angina, myocardial infarction, congestive heart failure, coronary and carotid revascularization procedures, stroke, transient ischemic attack, peripheral arterial disease, and any fatal CVE. Results indicated that those engaged in daily PRA experienced a 16% increased risk of new CVEs compared to those who never engaged in private religious activities (HR =​1.16, 95% CI 1.02–​1.30), controlling for demographics, lifestyle, risk factors, and psychosocial characteristics. Researchers admitted that this small increase in CV risk was probably due to the mobilization of spiritual resources to cope with aging and illness. Floud et al. (2016) conducted a 9-​year prospective study of a national random sample of 735,159 female community-​ dwelling adults, average age 60 (without prior heart disease, stroke, or cancer) in the United Kingdom. During follow-​up there were a total of 30,756 cases of first CHD events (hospitalization or death). Social participation at baseline was examined as a predictor, assessed by participation in 11 social activities, including whether or not participants belonged to a religious group (18%). Cox proportional hazards regression models were used to predict the incidence of a CHD event, first controlling for age and region of residence (Model 1), and then controlling for socioeconomic deprivation, education, marital status, smoking, alcohol intake, BMI, physical activity, self-​ rated health, happiness, hypertension, and diabetes (assessed at baseline; Model 2), with 99% CIs used because of the large number of predictors. The analysis was repeated excluding the first 4 years of follow-​up to ensure the removal of unhealthy individuals at baseline. The findings indicated that belonging to a religious group was associated with a 14% lower likelihood of having a CHD event, after

384 •  P h y sical H ealth

controlling for age and region (RR =​0.86, 99% CI =​0.83–​0.90). However, when other covariates were controlled (some of which may have been mediators), the risk of experiencing a new CHD event among those belonging to a religious group reversed from being protective to increasing the risk by 5% (RR =​1.05, 99% CI =​1.01–​1.10). When the first 4 years of follow-​up were excluded, the risk decreased to nonsignificance (RR =​1.04, 99% CI =​0.99–​ 1.10). Among those not participating in a religious group at baseline who changed to belonging to one 4 years later, the likelihood of being a current smoker decreased by 31% (from 6.8% to 4.7%), suggesting that not smoking may have explained some of the initial protective effect. Note that participation in any of the 11 social activities (vs. none) was associated with a lower risk of CHD event when only age and region were controlled (RR =​0.83, 99% CI =​0.81–​0.86); however, as with belonging to a religion, the RR reversed from lower to higher risk when controlling for all covariates (RR =​1.06, 99% CI =​1.02–​1.09). The authors noted that controlling for education, self-​rated health, smoking, and physical activity were likely to reduce the positive effects of social participation on risk, switching it from lower to greater risk. This suggests, perhaps, that some of these covariates were also mediators for belonging to a religious group (e.g., smoking); nevertheless, the authors categorized them all as confounders—​despite their assessment at baseline, which meant that they could be either confounders or mediators. The authors concluded that “social participation has little or no direct effect on CHD risk” (in contrast to what many other studies had found). Li and associates (2016b) at the T.H. Chan Harvard School of Public Health examined the effects of 1996 religious attendance on mortality from CVD and other causes among 74,534 women followed for 18 years from 1996 to 2012 in the Nurses’ Health Study-​II. There were 13,537 deaths that occurred during the 1,104,175 person-​years of follow-​up. Religious attendance in 1992 was controlled for as a covariate, and those diagnosed with CVD before 1996 were excluded. In addition to 1992

religious attendance, many other demographic, socioeconomic, and social, mental, behavioral, and physical health variables were also controlled for. Mediators assessed after the 1996 religious attendance exposure included depressive symptoms, smoking, alcohol consumption, diet quality, number of close friends, having someone close to talk to, optimism, and phobic anxiety. Compared to women who never attended religious services, mortality from CVD among women attending more than once/​ week (after adjusting for covariates) was 27% lower (HR =​0.73, 95% CI, 0.62–​0.85). There was also a significant trend in effects such that CVD mortality during follow-​ up decreased in a dose-dependent manner as frequency of religious attendance increased (p for trend < 0.001). Frequent religious attendance also predicted lower all-​cause mortality during follow-​ up (Chapter 27); mediation analysis indicated that these effects were due to lower depressive symptoms (11% of the mortality reduction), reduced cigarette smoking (22%), greater optimism (9%), greater social integration (23%), and other causes (35% unexplained). For CHD mortality, frequent religious attendance (> once/​week) predicted a 43% reduction in mortality based on age-​adjusted analyses (HR =​0.57, 95% CI =​0.45–​0.74, p < 0.0001). However, when analyses were additionally controlled for other correlates—​including alcohol consumption, physical exercise, multivitamin use, hypertension, hypercholesterolemia, type II diabetes, depression, menopausal status, postmenopausal hormone use, physical exam in past 2 years, healthy eating score, smoking status, pack years smoked, BMI, husband education, physical functioning, living situation, family medium income, family history of heart disease, use a blood pressure medication, personal history of diabetes, parental MI before age 60, social integration, and religious service attendance in 1992—​the association between frequent religious attendance and CHD mortality weakened considerably (HR =​0.81, 95% CI =​ 0.60–​1.09). Likewise, in age-​adjusted models, frequent religious attendance (more than once/​ week) predicted a 28% reduction in the incidence of nonfatal myocardial infarction (MI) (HR =​0.72, 95% CI =​0.62–​0.84, p < 0.0001)

and 48% reduction in fatal MI (HR =​0.52, 95% CI =​ 0.39–​0.67, p < 0.0001). In fully adjusted models, the associations for nonfatal MI (HR =​ 0.95, 95% CI 0.78–​1.14) and fatal MI (HR  =​ 0.72, 95% CI =​0.53–​0.99, p =​0.007) again weakened somewhat. The authors noted that this was the first report on religious attendance and mortality that included repeated measures of religious attendance, accounted for reverse causation, and controlled for time-​dependent confounders using proportional hazard and marginal structural models. Eilat-​Adar and Goldbourt (2019) reanalyzed data collected from 10,232 male civil servants and municipal employees age 40–​65 in 1965 who participated in the Israeli Ischemic Heart Disease study that followed these men through 1988, examining baseline predictors of mortality during follow-​up (see Goldbourt et al., 1993). Religiosity was assessed in 1965 on a 1–​5 scale, where 1 =​nonbelievers/​agnostics (n =​1,747), 2 =​ secular (n =​1,528), 3 =​traditional (n =​1,782), 4 =​ religious (n =​1,528), and 5 =​Haredim (most religious) (n =​2,103). Of the 9,245 participants on whom follow-​up data were complete, 1,098 died from CHD. Baseline religiosity predicted a significant reduction in CHD mortality, adjusting for age, cigarette smoking, systolic blood pressure, diabetes, SES, BMI, and cholesterol. Compared to agnostics and nonbelievers, Haredim (strict Orthodox believers who adhere to the Jewish traditions) were 33% less likely to die from CHD during the 23-​year follow-​up (OR =​0.67, 95% CI =​0.53–​0.85). Wen and colleagues (2019) followed 82,510 low-​income American adults age 40–​79 in the Southeast US (65% African American) for an average of 10.3 years from 2002 through 2015, examining the effects of religious attendance, self-​ rated spirituality, and self-​ rated importance of religion as predictors of survival using Cox regression modeling adjusting for age, gender, race, marital status, education, income, insurance coverage, enrollment source, BMI, chronic diseases at baseline (comorbidity index, hypertension, diabetes, heart attack, high cholesterol, stroke, chronic obstructive pulmonary disease, cancer), rural-​urban status, and neighborhood deprivation. There were 4,473 CVD deaths during follow-​up. No religious or

Heart Disease • 385

spiritual variables predicted survival in the knowledge, skills, and confidence in self-​care Cox proportional hazards regression models during initial hospitalization (called “activaindependent of the covariates above (although, tion,” which was low in 58% of these patients), again, some of those covariates may have been they found significant associations with relimediators of the effect). Interestingly, social giosity (Abu et al., 2019c). After adjusting for support and depressive symptoms (known age, gender, race/​ ethnicity, education, perpsychosocial predictors of survival) also had ceived stress, anxiety, quality-​of-​life, cognitive no association with either all-​cause or CVD impairment, health literacy, smoking, alcohol mortality. use, length of hospitalization, other medical Abu et al. (2019b) examined the effects of comorbidities, and in-​hospital treatment pracreligious practices on survival among 2,068 tices, patients who indicated that they received hospitalized patients admitted for acute coro- a great deal of strength and comfort from relinary syndrome (ACS; 55% diagnosed with non-​ gion were over twice as likely to report they ST segment elevation MI, 30% with unstable were “activated” (i.e., actively involved in self-​ angina, and 15% with ST-​segment elevation care and self-​management behaviors despite MI) in Massachusetts and Georgia. The average challenges) (OR =​2.02, 95% CI =​1.44–​2.84). age of participants was 61 years at baseline, Furthermore, those who indicated they were and 81% were non-​Hispanic White. Religious receiving intercessory prayer from others were measures assessed at baseline were strength nearly 50% more likely to be activated (OR =​ and comfort received from religion (85% yes), 1.48, 95% CI =​1.07–​2.05). However, patients frequency of prayer for own health (61%), and more involved in praying for their own health frequency of intercessory prayer by others for (petitionary prayer) were 28% less likely to be one’s health (89%). Participants were followed activated (OR =​0.72, 95% CI =​0.61–​0.99). for 2 years post-​discharge, and survival status Thus, being less engaged in self-​care and self-​ was determined by review of medical records management behaviors may have explained and death certificates (6% dying during follow-​ why those involved in higher levels of petiup). Cox proportional hazards models were tionary prayer were more likely to die during used to determine predictors of survival, con- follow-​up. It does not, however, explain why trolling for age, gender, race/​ethnicity, length receiving strength/​ comfort from religion or of hospitalization, type of ACS, receipt of reper- intercessory prayer from others (both of which fusion therapy, GRACE-​risk score, symptoms were associated with more self-​care and self-​ of depression, anxiety, and physical quality-​of-​ management behaviors) had no impact on life. Results indicated that in unadjusted mod- survival—​at least after control for covariates, els, those who indicated they were praying for some of which may have been mediators or their health (petitionary prayer) were 81% more explanatory variables. likely to die during follow-​up (HR =​1.81, 95% Ahrenfeldt et al. (2019) analyzed data from CI =​1.11–​2.95). This risk was reduced to 64% a 11-​year prospective study of 23,864 particiafter controlling for age, gender, and race/​eth- pants age 50 or over in the Survey of Health, nicity (HR =​1.64, 95% CI =​1.01–​2.66), and was Aging, and Retirement in Europe (SHARE). further reduced after adjusting for type of ACS, Participants were followed from 2004/​ 2005 receipt of reperfusion therapy, length of index to 2015 during 6 waves of data collection. hospitalization, comorbidities on admission, Religious involvement was assessed at baseline and GRACE-​risk score (HR =​1.50, 95% CI =​ by (1) frequency of prayer (“Thinking about 0.93–​2.42). In all cases the confidence intervals the present, about how often do you pray?” were quite wide. No association with mortality dichotomized for analysis into praying vs. not was found for strength/​comfort from religion praying); (2) religious participation (“Have you or intercessory prayer from others. done any of these activities in the last month: Interestingly, when researchers cross-​ taken part in a religious organization, i.e., sectionally examined the relationship between church, synagogue, mosque, etc.?” (yes vs. no); religious variables above and patients’ and (3) “Have you been educated religiously

386 •  P h y sical H ealth

by your parents?” (yes vs. no). Responses were summed and categorized into three groups: “more religious” (participants who prayed, took part in a religious organization, and were religiously educated), “less religious” (those who prayed, but did not take part in a religious organization nor were religiously educated), and the “nonreligious” (those who did not pray, did not take part in a religious organization, and did not have religious education). Logistic regression models were used to control for European region, gender, age at interview, education, marital status, and employment. Cross-​sectional results in 2004/​2005 indicated that those who took part in a religious organization (vs. not) were over 25% less likely to report having been told they had a heart attack (HA) (OR =​0.74, 95% CI =​0.60–​0.90); however, no effect was found on self-​reported HA in longitudinal analyses. Praying (vs. not) was not associated with HA in cross-​sectional analyses, but predicted a 27% increased risk in longitudinal analyses (OR =​1.27, 95% CI =​ 1.10–​1.48). Religious education had no effect on HA in either cross-​sectional or longitudinal analyses. When religious categories were compared, no effect on reported HA was found for being “more religious” vs. all others, or being “more religious” vs. “less religious,” in either cross-​sectional or longitudinal analyses. However, being “less religious” compared to “nonreligious” predicted an increased risk of future HA in longitudinal analyses (OR =​1.49, 95% CI =​1.13–​1.98). In a prospective study that followed 92,008 young, middle-​aged, and elderly US participants for between 3 and 12 years, Chen et al. (2020a) examined the effects of religious attendance at baseline on a wide range of future health outcomes, including a self-​reported diagnosis of CHD. Controlled for at baseline were age, gender, race/​ ethnicity, marital status, geographic region, household income, depression, weight, cigarette smoking, and heavy drinking, with Bonferroni correction of p-​values. Meta-​ analytic results across all three cohorts indicated no association of attendance at religious services on risk with subsequent self-​reported heart disease (RR =​0.93, 95% CI =​0.80–​1.07, p =​0.235).

Two prospective studies have also examined the effects of religiosity on general cardiovascular functions, specifically pulse or heart rate. The relationship between religiosity and heart rate is an important one given the relationship between higher heart rate and increased risk of CHD mortality (Dankner et al., 2003). Hill and colleagues (2017b) analyzed data from 772 community-​dwelling adults in Mexico age 50 or over to examine the effects of frequency of religious attendance (assessed in 2003 and 2012) on a variety of biological functions including heart rate (assessed only in 2012). Analyses were controlled for age, gender, education, marital status, household income, and self-​ rated health (but not base heart rate). Results indicated that both baseline frequency of religious attendance (once/​week or more) and an increase in attendance during the 9-​year follow-​ up (2012–​2003) significantly predicted a lower heart rate on follow-​up (b =​−5.92, p < 0.001, and b =​−1.26, p < 0.05, respectively). These findings were replicated in a 4-​year prospective study by Suh and colleagues (2019), who examined the impact of religious attendance on biological risk in a US national random sample of 2,912 adults age 50 or over. These researchers also found that weekly religious attendance in 2006 (baseline) predicted a significantly lower heart rate in 2010 (follow-​up) (b =​−0.77, p < 0.05, controlling for age, gender, marital status, employment, race/​ethnicity, education, household wealth, financial debt, and heart rate at baseline in 2006). Concerning effects on clinical course following cardiac surgery, four of five prospective studies have found that greater religiosity at baseline predicted better surgical outcomes (less morbidity, mortality) (Oxman et al., 1995; Contrada et al., 2004; Ai et al., 2009a; Bagheri et al., 2019), and one found no effect (Contrada et al., 2008).

Experimental Studies With regard to religiosity and CVR, at least three experimental studies have examined the effects of religiosity on this cardiovascular outcome. Greater CVR in response to a psychological stressor has been associated with the

Heart Disease • 387

development of CVD (including CHD) and with recurrent CVD events (Chida & Hamer, 2008). Masters and Knestel (2011) enrolled 177 community-​ dwelling adults age 40–​ 70 years in an experimental study involving two CVR manipulations. These manipulations involved a cognitive stressor (mental arithmetic) and an interpersonal stressor (confrontational role play). Intrinsic, extrinsic, pro-​ religious, and nonreligious participants were identified using the 14-​ item Gorsuch and McPherson IR-​Revised scale. Results indicated that CVR (i.e., blood pressure and heart rate change in response to experimental stress) was lowest in the pro-​ religious group compared to the other four groups. Two earlier studies by this research group had found that those scoring high on intrinsic religiosity experienced lower CVR compared to those scoring high on extrinsic religiosity (Masters et al., 2004, 2005). Later, Masters and colleagues (2020) reported that devotional prayer and intrinsic religiosity decreased CVR in response to an experimental stressor among 85 Christian college students. In a study that examined the moderating effects of religiosity on coping style and CVR, Ayazi et al. (2018) found that when 74 Black men underwent an experimental stressor (anger recall task), John Henryism (JH; propensity to be a high striver, or actively cope with the stressors in life) was associated with increased CVR only among those with low education and low levels of non-​ organizational religious activity (NORA, i.e., prayer, Scripture reading). This effect was not present in those with high NORA. However, for Black men with low education and low JH, CVR was higher during anger recall in those with high NORA, but not in those with low NORA. Heart rate variability (HRV) is another cardiovascular function known to be associated with prognosis in CHD. Reduced HRV is known to predict poorer CHD outcomes (Wennerblom et al., 2000). In an experimental study that examined the effects of Buddhist chanting on HRV in 21 Buddhist chanters, Gao et al. (2019) found that HRV was significantly increased during periods of Buddhist chanting (compared to nonchanting periods of rest).

388 •  P h y sical H ealth

Clinical Trials At least four clinical trials (with a control group) have examined the effects of religious interventions on a range of cardiovascular functions. In the first of these, Kurita and colleagues (2011) examined the effects of “spiritual activation” on HRV in 59 nursing home patients in Japan with subclinical CVD, cerebrovascular disease, or pulmonary disease. Participants were assigned to either a spiritual activation group who received weekly 30-​ minute sermons by chaplains over the next 20 months (n =​33) or to a control group (n =​26) who received no intervention (there was no evidence for random assignment). Average age of patients was 85–​87. Five experienced licensed chaplains delivered 30-​minute liturgies, including singing a hymn after a sermon. The content of sermons came from the Bible. HRV was determined using an ambulatory ECG Holter monitor. Clinical characteristics did not differ significantly between the two groups at baseline. Following the 20-​month intervention, the two groups were compared. Results indicated that the high-​frequency domain of HRV was significantly more frequent in the intervention group compared to the control group (190 vs. 92, p < 0.05), and the low-​frequency domain of HRV was significantly less frequent (1.4 vs. 2.2, p < 0 .05). Likewise, the PNN50 (ratio of successive RR-​interval differences greater than 50%) was significantly higher in the intervention group compared to the control group (10.5 vs. 3.6, p < 0.05). Researchers concluded that spiritual activation (accomplished by listening to chaplains’ sermons and religious hymn-​ singing) can modify vagal control of heart rate (HRV) in a healthy direction. Similarly, Amjadian et al. (2020) examined the effects of an Islamic religious intervention on HRV during rehabilitation among 60 patients who had undergone coronary artery bypass graft (CABG) surgery in Iran. Participants were randomly assigned to either the religious intervention, a breathing relaxation group, or a usual care control group. Those receiving the Islamic religious intervention experienced a significant increase in HRV compared to changes in the control group,

although the HRV increase was still greater in the breathing relaxation group than in the religious intervention group. Prakhinkit and colleagues (2014) examined the effects of Buddhist walking meditation (BWM) on arterial structure and function among 45 community-​ dwelling older adults age 60–​90 with mild to moderate depression in Bangkok, Thailand. Although religious affiliation was not provided, 94% of the population of Bangkok is Buddhist. Participants were randomly assigned to either (1) the intervention group (BWM), (2) a traditional walking exercise group (TWE), or (3) a sedentary control group. Those in the two walking groups performed exercise training for 20 minutes 3 times/​week during Phase 1 (weeks 1–​6), and in Phase 2 increased the length and intensity of their exercise training to 30 minutes 3 times/​ week (weeks 7–​12). Those in the BWM group engaged in an aerobic walking exercise that incorporated Buddhist meditations. While walking, participants in the BWM group were instructed to practice mindfulness as they rhythmically swung both arms voicing “Budd” with arm swing up and “Dha” with arm swing down. Arterial structure and function of the brachial artery were assessed with ultrasound equipment using arterial occlusion techniques. Significant pre-​ post within-​ group differences were found for resting brachial diameter, peak radial diameter, flow-​mediated dilation, time to peak diameter, time to peak dilation, and peak shear rate in the BWM group. Furthermore, significant differences were found between the BWM and TWE groups on resting brachial diameter and peak brachial diameter, favoring the BWM group. Researchers concluded that BWM was more effective in improving vascular function compared to TWE. In a second RCT examining the effects of BWM on vascular function, Gainey and colleagues (2016) randomized 23 patients with type II diabetes in Bangkok, Thailand, to either the BWM group (n =​12) or TWE group (n =​ 11). The exercise program involved walking on a treadmill at 50%–​70% maximum heart rate for 30 minutes (with a 10-​minute warm up and a 10-​minute cool down) for a total of 50 minutes performed 3 times/​week over 12

weeks. Again, the only difference between groups was that the BWM group voiced “Budd” and “Dha” while setting each foot on the floor as they engaged in mindfulness meditation. Among multiple outcomes assessed were vascular activity and arterial stiffness, measured by transcutaneous Doppler transducers: basal brachial artery diameter, peak brachial diameter, flow-​mediated endothelial-​dependent vasodilation, brachial artery pulse wave velocity, and ankle-​brachial index. Results indicated that flow-​mediated endothelium-​dependent vasodilation improved significantly in both groups, although a significant improvement in brachial artery pulse wave velocity (an indicator of arterial stiffness) was found only in the BWM group. Otherwise, there were no significant within-​group changes on the other three indicators of vascular function in the BWM or TWE group, nor were there any between-​group differences on any of the five measures above. With regard to the effects of a religious intervention on outcomes from cardiac surgery, an RCT in 78 patients undergoing open-​ heart surgery found that listening to prayer by headphones during surgery (vs. relaxation techniques or a placebo condition) had no effect on clinical outcomes (duration of intubation, length of ICU stay, length of hospital stay, or use of morphine after surgery) (Ikedo et al. (2007).

Summary Both early and more recent research on religiosity, CHD, and CVD risk factors report a wide range of findings depending on study design (see Appendix for a list of all studies). With regard to CHD, of 8 high-​quality cross-​sectional studies, 5 reported less CHD among those who were more religious, with the remaining studies finding either no association, mixed results, or more CHD. Of 15 prospective studies (after adjustment for multiple covariates, including possible mediators), only 2 reported that religiosity predicted better CHD outcomes (both from the same sample in the Israeli Ischemic Heart Disease study), while 8 found no effect, 2 reported mixed results, and 3 reported worse outcomes. Thus, the majority of prospective

Heart Disease • 389

studies have found that religiosity has little or no effect on CHD once confounders (and possibly potential mediators) are controlled, although several studies had initially found positive effects in less rigorously adjusted analyses. Three high-​quality studies, however, have also reported negative effects of religiosity on CHD risk. With regard to experimental studies or clinical trials, three of four reported that religious or spiritual interventions had beneficial effects, whereas one study on the Ramadan fast found no effect. Not included here are studies of double-​ blinded distant intercessory prayer (not scientifically credible) or the Relaxation Response (not a religious/​spiritual intervention). The findings are similarly wide-​ranging for other cardiac and cardiovascular outcomes. With regard to CVR, of six experimental studies or clinical trials that examined the effects of religiosity, three studies by Masters et al. reported that those scoring high on intrinsic religiosity (IR) experienced lower CVR than those high on extrinsic religiosity (ER), or that those high on both IR and ER (pro-​religious) experienced lower CVR than those scoring high on IR or ER. A recent experimental study by Masters et al. in Christian college students found that CVR was lower in those engaging in devotional prayer or scoring high on IR. Finally, an early RCT reported no effect of transcendental meditation on brachial artery reactivity (BAR) in medical patients with stable CHD. With regard to HRV, five studies examined either the relationship between religiosity and HRV or the effects of a religious/​spiritual intervention on this outcome. The cross-​ sectional study found a positive association with greater religiosity and greater HRV in a random sample of 229 older adults from ethnic minority groups in Chicago. Of the four intervention studies, the one single-​group experimental study found that Buddhist chanting increased HRV, and of the three RCTs, one found a trend for transcendental meditation to increase HRV, one found that Christian chaplain sermons increased HRV in nursing home patients, and one found mixed effects on HRV for an Islamic religious intervention in CABG patients undergoing rehabilitation. Among studies of miscellaneous cardiovascular functions, the first of two cross-​sectional 390 •  P h y sical H ealth

studies reported no association between religiosity/​ spirituality and coronary artery calcium, common carotid intima-​media thickness, left ventricular mass, or ankle brachial index, whereas the second study found significantly increased palpitations in those who engaged in prayer for healing. In two prospective studies, both reported a lower heart rate among those attending religious services more frequently. Two RCTs examining the effects of Buddhist walking meditation on vascular function also reported positive effects. Finally, four of five prospective studies of cardiac surgery patients found that religiosity at baseline predicted lower morbidity/​ mortality during or after hospitalization, and one clinical trial of prayer by headphone found no effect. Thus, the diversity of findings on the relationship between religiosity, CHD, and biological CHD risk factors indicates promising results but underscores the need for further research before any definitive conclusions can be drawn.

RECOMMENDATIONS FOR FUTURE RESEARCH Given the mixed findings above (positive, negative, and no effects), even in high-​quality studies, further research is needed as to why results are different across studies and whether there might be moderators of the effects of religious involvement or religious interventions on the development or course of heart disease. The inconsistency of results is surprising, since as reviewed earlier, there is a solid rationale for expecting that religious involvement ought to reduce CHD risk based on research demonstrating effects on known CHD risk factors (Figure 20.1). Failure to clearly specify whether covariates controlled for in analyses are either confounders or mediating variables may be one reason for these diverse findings. This is particularly important because studies have often reported significant protective effects of religiosity on CHD, which then diminish or completely disappear after controlling for covariates, which may often be mediators of a protective effect. It is also possible that confounding by SES or race/​ethnicity is still a factor in some of these studies.

However, it may also be that there are countervailing detrimental pathways concerning contexts in which religious service attendance leads to poorer diet or greater weight. Finally, it is also possible that the effects of religious service attendance vary by context or setting. Further research could investigate these various possibilities. Several large prospective studies examining the development and course of heart disorders are currently ongoing, and some of those studies include measures of religiosity (e.g., NHANES, the Nurses’ Health Study, Black Women’s Health Study, and so forth). While several reports from these studies have already been summarized above, as follow-​up increases and participants age increases, the effects of religious involvement may become more evident. Other large ongoing prospective studies examining CHD and CVD that have not included religious variables would benefit from incorporating them in future waves of data collection, particularly religious attendance. Religious attendance, as noted in Chapter 2, often comprises a package of psychological, social, and behavioral influences that may impact cardiac outcomes. Large long-​term prospective studies designed to specifically examine the effects of religiosity on the development of heart disease from childhood onward would be ideal; however, it is unlikely that such studies will be carried out in the near future, given the cost, technical challenges, and general lack of interest by government and private funding bodies. However, prospective studies of persons at high risk for CHD (perhaps after acute myocardial infarction or acute coronary syndrome) may produce important findings without long-​term follow-​up. Likewise, religious interventions are needed in high-​ risk individuals that target mental health, social integration, and behavioral change. Such studies need not be inordinately expensive, and results may provide evidence to support larger studies needed for widespread adoption. The need for such interventions is underscored by the fact that, as noted earlier, heart disease is the most common cause of death and disabling medical condition, and the costliest of all human diseases in both developed and underdeveloped countries worldwide.

Since religious involvement is also widespread in almost every country, and if religious interventions are found to help prevent or improve the course of CHD and/​or other CVDs, then they could have considerable impact. This includes effective educational interventions at the religious community level.

CLINICAL APPLICATIONS What might clinicians and religious professionals do now to utilize the potential benefits of religious belief and practice (1) in maintaining a healthy heart and cardiovascular system among those without existing disease, and (2) in utilizing religious interventions to help prevent future cardiac events in those with existing heart problems? Below we discuss several of these, including taking a spiritual history (as always), supporting and utilizing clients’ religious beliefs and practices, implementing religious interventions to address cardiac risk factors, and educating religious communities about what they can do to help reduce heart disease.

Taking a Spiritual History Clinicians and religious professionals must first identify the religious resources that individuals have, and that is done by taking a spiritual history. As underscored numerous times in this volume, the spiritual history must be client-​centered. The goals are to learn about the person’s past and current religious involvement, including past and current religious affiliation or denomination (and reasons for switching, if this has occurred), past and present positive and negative experiences with religion, current level of religious involvement as indicated by frequency of private religious practices, and involvement in the religious community. Importance of religion in life overall and impact on lifestyle choices should also be determined.

Support Religious Resources In general, there is little evidence that religious involvement is harmful to one’s heart (although possible given the results from some Heart Disease • 391

prospective studies). There is also considerable evidence and rationale to suggest that religious resources may be helpful, unless of course they are used to justify anger, hatred, or aggression toward others. Religious beliefs, based on what is taught in the core scriptures of a person’s faith tradition, often promote stress-​ reduction, social involvement, and heart-​ healthy behaviors. Beliefs like these should be supported. As always, both clinicians and clergy should provide support in a sensitive, gentle, and person-​centered manner.

Religious Interventions Targeting Risk Factors For those who are religious, particularly if deeply religious, the person’s beliefs may be utilized to help motivate lifestyle modifications that promote a healthy body and heart, the physical foundation of God’s temple. These include recommendations about changing diet (e.g., adoption and adherence to a Mediterranean diet), engaging in regular exercise, achieving an ideal body weight, cessation of smoking, moderation of alcohol intake, reducing one’s stress level, and engaging in social and volunteer prosocial activities. There are many verses within the sacred scriptures of the five major world religions that address this topic (Table 20.2). The “heart” in these scriptures often refers to the emotions (or in Buddhism, the “seat of consciousness”), rather than to an internal organ. However, the impact that emotions and thoughts have on coronary artery blood flow, cardiac rhythm disturbances, and other cardiac functions acting through the autonomic nervous system (as described above) makes these verses quite relevant. When devout religious believers meditate on these scriptures, this may help to relieve cardiac disturbances caused by sympathetic nervous system overactivity due to life stressors. Religiously integrated psychotherapies can also be utilized to treat depression, anxiety, and other negative emotional states that increase the risk of developing CHD or affect the course of disease. Previously described interventions for depression (Chapter 5) and anxiety (Chapter 7) in religious clients have

392 •  P h y sical H ealth

been shown to be at least as effective as secular approaches, if not more so in religious individuals. Referral to clergy for pastoral care, to pastoral counselors for therapy, or to licensed religious counselors for support and guidance are other options. Encouraging those with substance use disorders and heart problems to join mutual support peer groups such as Alcoholics Anonymous or Narcotics Anonymous may also be helpful, given the benefits that participants often derive from such programs (Chapter 10). For religious clients experiencing high stress due to job or family situations, particularly those with a strong family or personal history of CHD, simple religious interventions may be suggested. These include devotional prayer, meditating on heart-​healthy scriptures (Table 20.2), getting involved or more involved in a religious community, volunteering for religious reasons, or attending a scripture study or prayer support group. Listening to tape-​ recorded calming and inspiring religious scriptures using headphones prior to heart surgery or cardiac procedures may also help in some cases. Admittedly, further research is needed to establish the efficacy and safety of such recommendations, although the likelihood of harm is probably small.

Educating Religious Communities Clergy should consider educating members of their congregation during sermons and adult education classes about religious, psychological, social, and behavioral ways of preventing CHD or improving its course. This may be done by encouraging the adoption of a healthy lifestyle such as by following a heart-​healthy Mediterranean diet, reducing weight, engaging in regular exercise, stopping smoking, and moderating drinking, as mentioned earlier. Some religious congregations have parish nurses who engage in disease-​prevention and health-​promotion efforts that can help members adopt such lifestyle changes. Clergy are also ideally positioned to emphasize the benefits that religious involvement may have in preventing or improving CHD. This may help motivate congregants to engage in supportive

Table 20.2  Religious Scriptures That Support Heart Health Jewish Biblea A merry heart is a good medicine; but a broken spirit drieth the bones. (Mishlei 17:22) Hope deferred maketh the heart sick; but desire fulfilled is a tree of life. (Mishlei 13:12) Care in the heart of a man boweth it down; but a good word maketh it glad. (Mishlei 12:25) Above all that thou guardest keep thy heart; for out of it are the issues of life. (Mishlei 4:23) Happy are they that keep His testimonies, that seek Him with the whole heart. (Tehilim 119:2) A new heart also will I give you, and a new spirit will I put within you; and I will take away the stony heart out of your flesh, and I will give you a heart of flesh. (Yechezchial 36:26) New Testament Bibleb Blessed are the pure in heart, for they will see God. (Matthew 5:8) Jesus replied: “Love the Lord your God with all your heart and with all your soul and with all your mind.” (Matthew 22:37) And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus. (Philippians 4:7) Be careful, or your hearts will be weighed down with carousing, drunkenness and the anxieties of life, and that day will close on you suddenly like a trap. (Luke 21:34) Peace I leave with you; my peace I give you. I do not give to you as the world gives. Do not let your hearts be troubled and do not be afraid. (John 14:27) Let the peace of Christ rule in your hearts, since as members of one body you were called to peace. And be thankful. (Colossians 3:15) The Qur’anc And God ordained this only as a glad tiding, and that your hearts should thereby be set at rest—​ since no succor can come from any save God: verily, God is almighty, wise! (Qur’an 8:10) If God finds any good in your hearts, He will give you something better than all that has been taken from you, and will forgive you your sins: for God is much forgiving, a dispenser of grace. (Qur’an 8:70) For, God does not grace with His guidance people who [deliberately] do wrong: the building which they have built will never cease to be a source of deep disquiet in their hearts until their hearts crumble to pieces. (Qur’an 9:109–​110) It [the Qur’an] has been revealed] in this manner so that We might strengthen thy heart thereby—​for We have so arranged its component parts that they form one consistent whole. (Qur’an 25:32–​33) O my dear son! Be constant in prayer, and enjoin the doing of what is right and forbid the doing of what is wrong, and bear in patience whatever (ill] may befall thee: this, behold, is something to set one’s heart upon! (Qur’an 31:17) But withal, if one is patient in adversity and forgives—​this, behold, is indeed something to set one’s heart upon! (Qur’an 42:43) (continued)

Heart Disease • 393

Table 20.2  Continued The Bhagavad Gitad When a man abandoneth, O Partha, all the desires of the heart, and is satisfied in the SELF by the SELF, then is he called stable in mind. (2:55) In that Peace the extinction of all pains ariseth for him; for of him whose heart is peaceful the Reason soon attaineth equilibrium. (2:65) All the gates [sense organs] closed, the mind confined in the heart, the life-​breath fixed in his own head, concentrated by yoga. (8:12) Even if the most sinful worship Me [Lord Krishna, the Supreme God], with undivided heart, he too must be accounted righteous, for he hath rightly resolved. (9:30) Be not bewildered, be thou not afraid, Because thou hast beheld this awful Form [as Lord Krishna reveals himself as the Supreme God]; cast fear away, and let thy heart rejoice; behold again Mine own familiar shape. (11:49) The Lord [the Supreme God] dwelleth in the hearts of all beings, O Arjuna, by His illusive power, causing all beings to revolve, as though mounted on a potter’s wheel. (18:61) The Buddha’s Teachings (from the Pali Canon)e Surely at all times happily doth rest the Arahant [one who has achieved Nirvana] in whom all fire’s extinct. Who cleaveth not too sensuous desires, cool all his being, rid of all the germs that bring new life, all cumbrances cut out, subdued the pain and pining of the heart, calm and serene he resteth happily for in his mind he hath attained to Peace. (Samyutta Nikaya, Kindred Sayings, Part 1, p. 273, cited on p. 123) [The Buddha advises His disciples thus:] . . . Unsullied shall our minds remain, neither shall evil words escape our lips. Kind and compassionate ever shall we abide with hearts harboring no ill-​ will. (cited on p. 248) All living beings have actions (Kamma) as their own, their inheritance, their congenital cause, their kinsman, their refuge. It is Kamma that differentiates beings into low and high states. . . . If a person is jealous, envies the gains of others, marks of respect and honour shown to others, stores jealousy in his heart, he, as a result of his jealousy, when born amongst mankind, will be powerless. If a person is not jealous, does not envy the gains of others, marks of respect and honour shown to others, stores not jealousy in his heart, he, as a result of his absence of jealousy, when born amongst mankind, will be powerful. (Majjhima Nikaya, Cullakammavibhanga Sutta, No. 135, cited on pp. 256–​258) There are these five corruptions of the heart [sensual desires, ill-​will, sloth and torpor, restlessness and worry, and doubts], tainted by which the heart is neither soft, nor pliable, nor gleaming, nor easily broken up, nor perfectly composed for the distraction of the corruptions. (Samyutta Nikaya, cited on p. 427) Thus should you train yourselves: Unsullied shall our hearts remain. No evil words shall escape our lips. Kind and compassionate with loving heart, harboring no ill-​will shall we abide, enfolding, even these bandits with thoughts of lovingkindness [the Buddha’s response to his disciples when they were threatened by robbers]. (Kakcupama Sutta, cited on p. 480) If bandits sever your limbs with a two-​handed saw, and if you entertain hate in your heart, you will not be a follower of my teaching. . . . As an elephant in the battlefield withstands arrows shot from a bow, even so I endure abuse; verily most people are undisciplined. (cited on p. 499)

394 •  P h y sical H ealth

Table 20.2  Continued All verses quoted from the Jewish Publication Society Bible. Retrieved on 1-​31-​2020 from http://​www.bres​lov.com/​bible/​. All verses quoted from the New International Version (NIV) of the Holy Bible. Grand Rapids, MI: Zondervan, 1978. c All verses quoted from the Qur’an translation by Muhammad Asad in The Message of the Koran (retrieved on 7-​27-​2022 from http://​ www.muham​mad-​asad.com/​Mess​age-​of-​Quran.pdf. d All verses quoted from: Besant, A., & Das, B. (1905). The Bhagavad Gita. London: Theosophical Publishing Society. Retrieved on 1-​31-​ 2020 from https://​www.vive​kana​nda.net/​PDFBo​oks/​bha​gava​dgit​awit​h00l​ondi​ala.pdf. e Buddha’s sayings are from: Mahathera, V. N. (1998). The Buddha and His Teachings. Tullera, Australia: Buddha Dharma Education Association. Retrieved on 1-​31-​2020 from https://​www.buddha​net.net/​pdf_​f​i le/​bud​dha-​teachi​ngsu​r w6.pdf. a

b

religious community activities, read and live by religious scriptures, or participate in regular prayer or meditation to reduce psychological stress. Clergy can also encourage congregants to see their medical professional to optimize cholesterol levels, reduce blood pressure, and control other risk factors, as well as to learn about early symptoms of heart disease. Clergy can emphasize the importance of complying with suggested medical or surgical treatments, considering such compliance as a religious practice itself. Clergy can also encourage members of the congregation to support those with heart problems by asking if transportation or companionship during doctor visits is needed or desired. Congregants can be encouraged to visit those with heart problems when hospitalized or to bring them meals after hospital discharge. The religious community can be an enormous source of support for those with heart problems, especially those who may be struggling with disability or other physical challenges caused by health issues. Doing so, at a very minimum, communicates to the individual that they are not alone, that they are an important part of the religious community, and that others care and are willing to take concrete steps to demonstrate such care. Such activity may help to preserve the helping person’s own heart health, as research has found that volunteering to help others is associated with a significant decrease in numerous CVD risk factors (Burr et al., 2016). Thus, there are many ways that both health professionals and religious professionals can utilize the information presented in this chapter.

SUMMARY AND CONCLUSIONS Heart disease is a disabling, deadly, and costly medical condition that is common throughout the United States, Canada, Europe, and the world. The causes of heart disease, particularly CHD, are well-​known and include demographic, socioeconomic, genetic, biological, environmental, cultural, social, psychological, and behavioral influences. Almost all of these factors are affected in one way or another by religious beliefs and practices. In this chapter, we hypothesized ways that religious involvement might impact the development and course of heart disease through direct and indirect pathways (mostly indirect). We also reviewed earlier and more recent quantitative research examining the relationship between religiosity and cardiovascular illness, with a particular focus on CHD. A wide range of results has been reported, sometimes suggesting the benefits of religious involvement, but also frequently reporting no effect and sometimes even finding that greater religious involvement predicts worse CHD outcomes (although whether religiosity actually worsens heart disease or is a coping response to the illness needs further investigation). We emphasize here the need for more long-​term prospective studies to determine whether and how religiosity impacts the development and course of heart disease, and encourage the development and testing of religious interventions in RCTs. A number of clinical applications of the existing research findings have also been recommended for health professionals and religious professionals seeking

Heart Disease • 395

to help those with heart disease and those at high risk for developing it (all persons over age 45). The widespread occurrence of heart disease around the world, together with the ready availability of religious communities, argues for a better understanding of how religion impacts

396 •  P h y sical H ealth

heart disease and of how religious resources can be utilized to prevent or moderate its course. In the next chapter, we examine the relationship between religiosity and hypertension, a common condition known to adversely affect the heart, the brain, and the vascular system more generally.

21 Hypertension My doctors told me this morning my blood pressure is down so low that I can start reading the newspapers. —​Ronald Reagan

IN THIS CHAPTER we examine the relationship between religiosity and high blood pressure or hypertension. Hypertension is a serious and common illness. According to the most recent recommendations from the American College of Cardiology/​ American Heart Association Task Force on Clinical Practice Guidelines, normal blood pressure (BP) is considered to be less than 120 mmHg systolic and less than 80 mmHg diastolic (Whelton et al., 2018, Table 7). “Elevated” BP is defined as a systolic BP of 120–​129 mmHg and a diastolic BP of less than 80 mmHg. “Stage I hypertension” is defined as a systolic BP of 130–​139 mmHg or a diastolic BP of 80–​89 mmHg or taking anti-​hypertensive medication. “Stage II hypertension” is defined as a systolic BP of 140 mmHg or higher or a diastolic BP of 90 mmHg or higher or taking anti-​hypertensive medication. A “hypertensive crisis” exists when BP exceeds 180/​120, signaling that a physician must be contacted immediately, given the risk of cerebrovascular events

(e.g., stroke), coronary heart disease events (e.g., myocardial infarction or heart attack), and/​or precipitation of kidney complications (acute renal failure, potentially leading to end-​ stage renal disease). In an observational study of over 1 million patients aged 30 years or older, elevated BP of any degree (beyond normal BP as defined above) predicted an increased risk of developing cardiovascular disease, chest pain (angina), myocardial infarction, heart failure, stroke, peripheral vascular disease, and abdominal aortic aneurysm (Rapsomaniki et al., 2014). Until the late stages of the disorder, there are usually no clinical symptoms or signs that alert people that they have high BP. As a result, hypertension is known as the “silent killer.” Indeed, most cases are found during routine physical exam. Kearney and colleagues (2004) found that patient awareness of hypertension ranged from 25% in South Korea to 75% in Barbados, and treatment ranged from 11% in Mexico to 66%

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0021

in Barbados. Even among those taking anti-​ hypertensive medication, BP was controlled in only 5% (South Korea) to 58% (Barbados) of cases. Thus, hypertension is often unrecognized, untreated, or under-​treated. Using the current definitions above, the prevalence of hypertension (Stage I or II) in the United States, after adjusting for age and gender, among those aged 20 years or older in 2011–​2014 was 46% (Whelton et al., 2018, Table 7). The prevalence was 48% among men and 43% in women. Thus, nearly half of the US population (especially men) have a diagnosis of Stage I or II hypertension. No other chronic health condition is more common. Among Black Americans, the rate is 59% in men and 56% in women. Among all Americans aged 65 or older, 77%–​79% of men and 75%–​85% of women have hypertension. Among Americans age 45 years without hypertension, the 40-​year risk of developing hypertension was 93% for African Americans, 92% for Hispanics, 86% for Whites, and 84% for Chinese Americans. In other words, most people in the United States will develop high blood pressure if they live long enough. Rates of hypertension vary worldwide by region and country. In a systematic review of 135 population-​based studies from 90 countries involving 968,419 adults conducted between 1995 and 2014, Mills et al. (2016, 2020) found that the prevalence of Stage II hypertension (defined as average systolic BP > 140 or average diastolic BP > 90 or use of anti-​ hypertensive medication) was 31.1%, which indicates that an estimated 1.4 billion people had this condition in 2010. This was distributed across high-​income countries (28.5%, 95% CI =​ 27.3%–​29.7%) and low/​middle-​income countries (31.5%, 95% CI =​30.2%–​32.9%), with particularly high rates in South Asia, sub-​Saharan Africa, and Central and Eastern Europe. The change in prevalence of hypertension between 2000 and 2010 differed depending on country income level; there was a 2.6% reduction in hypertension prevalence in high-​income countries (especially Australasia, North America, Western Europe, and Asia-​Pacific regions), but a 7.7% increase in low/​middle-​income countries (Oceana, East Africa, South and East Asia, West Africa) (Mills et al., 2020). As noted above, 398 •  P h y sical H ealth

individuals with any level of high BP are at increased risk of having a heart attack, stroke, renal failure, peripheral vascular disease, and aortic aneurysms. The estimated number of deaths worldwide associated with systolic BPs of 110–​115 or greater was 10.7 million, approximately 20% of all deaths. For those with systolic BP of 140 or greater, the figure was 7.8 million deaths (14% of all deaths) (Forouzanfar et al., 2017). No doubt, elevated BP is a serious health problem in the United States and worldwide. The American Heart Association (2020c) has estimated that the total annual direct costs of treating hypertension in the United States will be $220.9 billion by 2035.

CAUSES OF HYPERTENSION Risk factors for hypertension are genetic, age-​ related, socioeconomic, psychological, social, behavioral, and cultural/​ environmental. After reviewing these risk factors, we will later consider how religious involvement might influence each one. In addition, there are a number of sociodemographic, cultural, and environmental factors that may confound the relationship between religiosity and BP—​ i.e., factors that are related to both religiosity and BP that create a relationship not because of an effect of religiosity on BP or an effect of BP on religiosity. These include age, ethnicity, socioeconomic/​e ducational status, environmental/​ cultural context, and perhaps other risk factors for hypertension as well.

Genetic Adoption and twin studies have found that genetic factors account for approximately 40% of the variation in BP between individuals (Rossi et al., 2017). Average BP is determined by several physiological functions, especially cardiac output and peripheral resistance, which are systems that affect extracellular fluid volume, cardiac contractility, and peripheral vascular tone, doing so through renal, neural, and endocrine pathways. All of these are potentially influenced by genetic factors. Early studies found a significantly higher correlation between the BPs of identical (monozygotic) twins compared to those of non-​identical

(dizygotic) twins, indicating that average BP levels tend to run in families (Stocks, 1930). Among monozygotic twins the correlation between blood pressures ranged from r =​0.55 to 0.85 for systolic BP and r =​0.54 to 0.80 for diastolic BP, compared to r =​0.25 to 0.50 for systolic BP and r =​0.27 to 0.54 for diastolic BP in dizygotic twins (Havlik et al., 1979).

Normal Aging Normal aging is associated with an increase in BP over time. Increases in arterial stiffness and vascular resistance occur with aging, as do changes in the heart (increases in cardiac hypertrophy) with the passage of time, both contributing to increases in BP. There is a linear increase in average systolic BP from age 30 through 84 in the US population and similar increases in diastolic BP and mean arterial pressure; however, after age 50–​60 years, diastolic BP actually declines some (Franklin et al., 1997). Based on analysis of data from the US Framingham Heart Study that took both changes in vascular resistance and the aging heart into account, Maksuti et al. (2016) found that between age 20 and 80, average systolic BP increased from 100 to 150 mmHg, whereas diastolic BP decreased from 76 to 69 mmHg.

Socioeconomic Status (SES) Compared to those with high SES, individuals with low SES are disadvantaged in terms of economic, educational, occupational, residential, and recreational resources. This places these individuals at increased risk of exposure to stressors such as unemployment, crime, violence, and inactivity, all of which increase the risk of hypertension (Cuevas et al., 2017). In the United States, race/​ethnicity and SES are closely related, since Black and Hispanic households have considerably less income than White households (Williams et al., 2016). Furthermore, childhood adversity and low SES appear to interact in a way that increases risk of hypertension (Crowell et al., 2016). The discrimination that minority groups often endure adds further to increasing the risk of high BP in these groups (Sims et al., 2012).

Psychological Psychological factors have long been known to increase risk of hypertension (Harrell, 1980). The very word itself, hyper-​“tension,” emphasizes the impact of psychological stress on the disease. In a systematic review, Liu and colleagues (2017) found that psychosocial stress increased odds of hypertension by 140% (OR =​ 2.40, 95% CI =​1.65–​3.49); furthermore, those with hypertension had a 169% higher odds of experiencing significant psychosocial stress compared to normotensive persons (OR =​2.69, 95% CI =​2.32–​3.11). Depression or anxiety, which often results from psychosocial stressors, also increases the risk of hypertension. For example, in a meta-​ analysis of nine prospective studies involving 22,367 participants, depressive symptoms increased risk of hypertension by 42% (Meng et al., 2012). A recent meta-​analysis of 22 prospective studies found an 18% increased risk of developing hypertension in depressed persons (HR =​1.18, 95% CI =​1.02–​1.36). Among studies that used a continuous scale of depressive symptoms, with every unit increase on the scale there was a 6% increased risk of hypertension (HR =​1.06, 95% CI =​1.01–​1.12) (Prigge & Jackson, 2017). Furthermore, the coexistence of both depression and hypertension increases the risk of poor cardiovascular outcomes (Graham et al., 2019). Recent research has provided a greater understanding of the biological mechanisms that underlie the depression-​BP relationship (Bergantin, 2020). Anxiety also increases the risk of developing hypertension (Johnson, 2019). Based on a meta-​analysis of 37 studies involving 1,565,699 participants followed for 1 to 24 years, the risk of developing cardiovascular disease in those with anxiety increased by over 50% independent of depression and other risk factors (HR =​1.52, 95% CI =​1.36–​1.71) (Batelaan et al., 2016). This is particularly true for hypertension. In a meta-​analysis of eight prospective studies involving 80,146 participants (including 2,394 persons with hypertension), the pooled adjusted HR indicated that significant anxiety predicted a 55% increased risk of hypertension (HR =​1.55, 95% CI =​1.24–​1.94), independent of location, how anxiety was measured, age, Hypertension • 399

gender, study sample size, quality of study methods, or length of follow-​up (Pan et al., 2015). Anxiety also appears to mediate the relationship between emotional reactivity and BP increases among patients with hypertension (Ifeagwazi et al., 2018). In contrast to psychosocial stress, depression, and anxiety, the experience of psychological well-​ being has been associated with physiological resilience. Psychological well-​ being, particularly optimism and emotional vitality (i.e., active engagement with the world, emotional regulation, and overall feelings of well-​ being), predicts a significantly lower risk of developing hypertension (Begley et al., 2000; Ostir et al., 2006; Trudel-​Fitzgerald et al., 2014).

Social Social support may also play an important role in protecting individuals from developing hypertension. Research conducted nearly 35 years ago found that low instrumental support among Black Americans was associated with a 50% greater likelihood of having hypertension, especially in low-​income Blacks (Strogatz & James, 1986). Among older Asians, social support has also been associated with better control of hypertension (with lower depression partially meditating this effect) (Zhu et al., 2019). Greater social support has this effect in part by reducing stress-​related health behaviors that increase BP (e.g., alcohol use, smoking, poor diet, worse compliance with medication), as well as by preventing or alleviating the harmful physiological responses to stress by improving the ability to cope with life stressors (Schnall, 2016).

Behavioral Health behaviors that predict an increase in risk of hypertension include excessive alcohol intake (Fuchs et al., 2001; Klatsky, 2004), cigarette smoking (Bowman et al., 2007; Virdis et al., 2010), exposure to passive cigarette smoke (Aryanpur et al., 2019), e-​cigarette use (Skotsimara et al., 2018), lack of regular physical exercise (Börjesson et al., 2016; Wen & Wang, 2017), unhealthy diet including excessive salt 400 •  P h y sical H ealth

intake (He et al., 2013; Ndanuko et al., 2016), and increased body mass index (BMI) (Cai et al., 2014). All of these factors predict a greater incidence of hypertension in large prospective studies (e.g., see Gao et al., 2015). In contrast, individuals who do not smoke, exercise regularly, consume a healthy diet, and maintain an ideal body weight have a significantly lower risk of developing high BP.

Cultural/​Environmental Cultural factors can also influence the risk of hypertension. The kind of diet (including salt intake) that is consumed may be affected by family and cultural traditions, especially in areas of the world where traditions related to food choice are passed down from generation to generation, such as in the Middle East, Africa, South America, and other regions of the world where tribal influences are particularly strong. Cultural traditions not only affect diet and food preference, but also attitudes toward weight and obesity. As noted in Chapter 19, certain cultures may view obesity as a sign of success, from both an economic and reproductive perspective. Cultural influences may also determine whether a person is an “insider” or an “outsider.” Such distinctions may be based on compliance with sacred traditions passed from generation to generation, being accountable to others within the culture, and acting the same as others (Peters et al., 2006). Sacred traditions may be religious or secular in nature. The environment may also increase risk of hypertension in several ways. Individuals (or their ancestors) living in geographical regions where the climate is hot may be more likely to retain salt. This may compensate for heavy sweating in these areas, which causes the loss of salt and increases risk of dehydration and death, especially in societies where outside physical work is necessary for survival (i.e., regions near the equator in Central and South America, Africa, and the Middle East, for example). Furthermore, evolutionary theorists argue that individuals in these regions may also experience early death due to salt-​wasting conditions such as diarrhea, dehydration, and infections, thereby selecting out individuals who retain salt. This might also apply to

the difficult working conditions that many Africans had to endure when brought as slaves to America (Cooper et al., 1999). Discrimination against African Americans, Hispanics, and other minorities today may also affect BP due to repressed anger over being treated differently from others, such as being passed up for opportunities in education and employment (Dressler, 1996). Changing cultures may also increase the risk of hypertension, i.e., moving from a primarily agricultural society to a modern technological one (e.g., from Mexico to the United States or from Africa to Europe) bringing with it changes in diet (consumption of high-​salt, high-​fat, high-​ sugar foods) and physical activity (engagement in sedentary occupations) (Dressler, 2004). The psychosocial stresses of migration, being away from family members, being discriminated against and marginalized due to outsider status, and experiencing increased economic stress all have effects on BP beyond diet, weight, and physical activity (Dressler, 2004).

RELIGION AND BLOOD PRESSURE Religiosity can affect many of the risk factors for hypertension described above. In exploring these influences, we begin with a case vignette. Case Vignette Sarah is a 57-​year-​old hard-​driving businesswoman. Over the past 15 years, she worked herself up to the position of vice president in her company. Sarah’s mom developed high blood pressure (BP) in her fifties, and in her seventies had a stroke that affected her ability to drive, care for herself, and even swallow food. Her mom spent the last 3 years of her life in a nursing home, barely able to move on her own, requiring nurse’s aides to turn her every 2 hours to prevent the development of bedsores, which she eventually developed and died from (septicemia). Sarah, worried that she might be in store for the same kind of future, had 10 years earlier begun a regimen of

regular exercise, attention to diet and weight, and limitation of her alcohol intake. She also tried to keep her stress level down. This was the most difficult and challenging aspect of her life, given the demands and pressures of her job. In recent years, Sarah had begun to take her religion more seriously, as this helped her put things into perspective. In the past 5 years, Sarah and her husband had begun to attend synagogue more regularly. This provided them with a circle of friends with whom they could socialize and depend on when needed. The teachings of the rabbi also helped in her personal habits and relationships at work, emphasizing the need to treat colleagues honestly and fairly and regularly practice forgiveness. Sarah also found that reading the Torah and praying to God helped to calm her nerves and reduce the pressure she felt to control everything in her life, especially the outcome of business decisions. She believed that just as God had led the Israelites through the Red Sea and into the Promised Land, God would also walk with her and guide her to make the best possible decisions for her family and business. Sarah also saw her doctor for regular checkups at least once a year. Although her cholesterol was borderline high, her BP remained in the normal range.   

Returning to the question of how religion might influence BP (i.e., reduce it or keep it from increasing into the hypertension range), we carefully examine how religiosity might affect hypertension risk factors. As reviewed above, those risk factors are genetic (inherited), getting older (aging-​related), economic (poorer, access to fewer resources to combat hypertension), psychological (stress, depression, anxiety), social (poor social support, increased loneliness), behavioral (unhealthy habits), and cultural/​environmental influences (diet, weight, and activity-​related). Much of this discussion is theoretical, although when Hypertension • 401

research exists to back up the statements made, it will be cited.

Genetic Factors How might religious involvement influence genetic risk factors for hypertension? Religiosity may influence genetic risk, including the hereditary risk across generations, through epigenetic influences that affect the stress-​response system. Epigenetic experiments in animal models demonstrate how stress-​related experiences in one generation can be passed on to offsprings’ stress responses (Franklin et al., 2010; Dias & Ressler, 2014; Dickson et al., 2018; see also Chapter 16). Increased stress-​reactivity, in turn, may affect BP. Decreased reactivity due to improved coping via religion may help to lower it, both in parents and offspring. Because religion may also have effects on survival (Chapter 27), this may have allowed certain groups of people with high BP to survive, individuals who otherwise might have succumbed to the disorder (via cardiovascular-​ related deaths). Thus, given the long historical tradition of religious involvement among African Americans, the high rate of hypertension in this ethnic group may indicate that religiosity enabled those with hypertension to survive, compared to their less religious hypertensive counterparts. Blacks are the most religious ethnic group in the US population (Taylor et al., 1999; Chatters et al., 2008), and as noted above, many Blacks have high BP. This may help to explain why the inverse relationship between religiosity and BP in Blacks is relatively weak, compared to that for other ethnic groups (see below), since less religious African Americans with hypertension may not survive. Black race, then, represents a confounding factor in the relationship between religiosity and hypertension that should be adjusted for in statistical analyses.

Age-​Related Religious involvement is less likely to influence age-​ related changes in BP. Whether individuals are religious or not, BP tends to increase with age. There are notable exceptions in this regard, e.g., cloistered religious nuns (Timio et 402 •  P h y sical H ealth

al., 1988, 2001). Regardless, it is a well-​known fact that religiosity increases with increasing age, whether this is due to a cohort effect, a period effect, an effect of selective mortality (since religious people live longer), or simply an increase in religiosity as people grow older, wiser, more experienced, and their need for religion increases more as health problems increase and death approaches (Koenig et al., 1988a; Chatters & Taylor, 1989; Argue et al., 1999). Since older persons are generally more religious, and are more likely to have hypertension, age represents a demographic confound that, like race, must be controlled when examining the relationship between religiosity and BP.

Demographic and Economic As just noted, religiosity increases with age and differs depending on race. What about gender? Women tend to be more religious than men, especially among Christians (Trzebiatowska & Bruce, 2012; Pew Research Center, 2016). While generally true in other religions as well, this is not always the case. For example, gender differences in religiosity among Muslims are not as great as in Christians and vary by country and religious practice (Moaddel & Karabenick, 2008; González, 2011). Likewise, gender differences in religiosity are almost nonexistent in Jews, at least with regard to synagogue attendance (Sullins, 2006). Gender differences in BP also appear to vary by age, with men having a higher prevalence of hypertension up to age 45, with nearly equal rates between age 45 and 64, but after age 64, women have a higher prevalence of hypertension than men (Doumas et al., 2013). Thus, depending on a population’s age composition and religion, gender may confound the relationship between religiosity and BP either one way or another. Regardless, it is always a good idea to control for gender in statistical analyses, while considering these trends. In contrast to gender, the relationship between SES, hypertension, and religiosity is much clearer. Hypertension, as noted above, is much more common among those with lower SES. Likewise, religiosity is also more common among the poor and disenfranchised members

of society, as many have documented (Paul, 2010; Brandt & Henry, 2012). Brandt & Henry (2012) note, “At this point it is clear that members of low-​status social groups are more likely to be religious, a finding observed by sociologists, political scientists, and psychologists. . .” (p. 321). Here too, then, there is potential for confounding in the relationship between religiosity and hypertension, requiring that SES be carefully controlled for.

Psychological So far, we have primarily been discussing factors that confound the relationship between religiosity and hypertension due to a characteristic being related to both religiosity and hypertension, which often result in a tendency for religiosity to be positively related to or to predict increased risk of hypertension (selective survival, older adults, women, Black race, lower SES, etc.). However, we now begin to discuss how religiosity itself may influence BP through psychological, social, and behavioral mechanisms. Focusing here on psychological factors, religious involvement could potentially influence BP by improving the ability to cope with stress (since stress increases BP), reducing depression, decreasing anxiety, and increasing psychological well-​being (see Chapters 4, 5, 8, and 12), each of which affect BP, as noted above. There is every reason, then, to expect that religiosity might lower BP because it appears to improve many aspects of mental health that increase BP. On the other hand, religiosity may also reinforce unhealthy guilt and shame due to “sins” (perceived indiscretions) that may have the opposite effect, especially among individuals prone to such negative emotions (vs. the psychopath, where guilt/​shame are remarkably absent).

Social Religiosity is also positively related to greater social support, less loneliness, and greater marital and family stability (see Chapters 14 and 15), which are related to lower BP. By providing support during periods of stress, loss, and transition, religious involvement may help to reduce the “tension” in hypertension. Being part of a faith community and having

a strong marital and family life not only provide resources for dealing with stress, but also surround the individual with those who might encourage the person with BP problems to seek treatment for it and adhere to that treatment. Of course, as noted below, being part of an outgroup (e.g., no religion or a different religion than the dominant one) may affect BP in the opposite direction due to social stressors.

Behavioral Religion’s effects on behavior are one of the strongest ways, if not the strongest way, that religiosity could influence BP and the likelihood of developing hypertension. The teachings of most religions are generally opposed to unhealthy behaviors such as smoking, excessive alcohol intake, illicit drug use, and pursuing a slovenly sedentary lifestyle (see Chapters 17 and 18), all of which can increase BP. Furthermore, participation in religious practices, regardless of religion, may involve physical activity, including getting to and from religious services, along with physical activity during the service (kneeling, standing, bowing, waving hands and arms) (see Chapter 18). Some religious activities that on the surface appear sedentary may actually involve some type of physical activity. Tibetan Buddhist monks, for example, spend a lot of time sitting while meditating. This sedentary behavior is quite different from simply lounging around sitting on the couch. Instead, meditating for hours each day for monks includes chanting, involvement in Buddhist teaching activities, and sometimes walking (see Buddhist walking meditation below). Respect for the physical body as the “temple of the Holy Spirit” may also influence the types of food that religious persons eat. As noted in Chapter 19, highly religious individuals tend to eat a healthier diet, one that may lower BP. Unfortunately, those who are more religious also tend to consume more of this healthy diet than others, resulting in weight gain and sometimes obesity (which has the opposite effect on BP). Furthermore, dietary practices in some religions may encourage consumption of foods high in fat and salt, which can increase BP. While members of certain religious groups Hypertension • 403

such as Seventh Day Adventists (SDA) consume a largely vegetarian diet with significantly less meat and cholesterol-​containing foods, other religions may have less healthy eating traditions. For example, one early study found that Jews consumed fewer calories than Italians, but ate more animal fat (Epstein et al., 1956a,b). Since they consume fewer calories overall, however, Jews are less likely to be overweight compared to other religious groups (Ferraro, 1998), which will likely improve their BP. In fact, a recent study of 80,805 women in the United States found that BP was significantly lower in Jewish women compared to Catholic or Protestant women (Saeed et al., 2018). For both Jews and Christians, using salt to season food has traditionally been encouraged and in fact commanded in scripture: “And every meal-​offering of thine shalt thou season with salt; neither shalt thou suffer the salt of the covenant of thy G-​d to be lacking from thy meal-​offering; with all thy offerings thou shalt offer salt” (Vayikra [Leviticus] 2:13).1 Jesus also emphasized that salt was good, but once it lost its flavor, should be discarded: “You are the salt of the earth. But if the salt loses its saltiness, how can it be made salty again? It is no longer good for anything, except to be thrown out and trampled underfoot” (Matthew 5:13).2 For example, kosher meat can be heavily salted since one way to prepare it is to soak the meat in cold water for half an hour, salt it thoroughly, and leave it covered in salt on a draining-​board. Salt is also used in Shinto religious ceremonies, particularly purification rituals. Thus, there are no prohibitions in these religions (or any others, to our knowledge) against using salt, and if anything, salting food is encouraged. However, since vegetarian diets are generally low in salt content and higher in potassium and other minerals that promote sodium excretion, Buddhists, SDA, and other religious groups that encourage such diets may have an advantage in this regard over members of other religious faiths (and be at lower risk of developing hypertension).

In summary, there are numerous behavioral reasons why those who are more religious might experience lower BP; however, there are also certain food preparation practices with religious roots that may increase BP. Therefore, the particular religious tradition should always be considered when examining the relationship between religiosity and hypertension.

Cultural/​Environmental Cultural traditions are often closely associated with religion, and these traditions can affect the kinds of foods (or the way they are prepared) that religious people eat, thereby affecting risk of hypertension. Given the emphasis placed on family in most religions, religiosity may reinforce unhealthy family dietary practices that are passed down from generation to generation. Religiosity may also affect “insider-​ outsider” status in some communities, where persons who are not religious or are from a religious tradition other than the dominant one may experience social exclusion and subtle biases that increase stress and affect BP. Likewise, however, religious persons living in secular areas of the world may also experience social exclusion and subtle biases because of their religious beliefs, increasing stress and affecting BP. When examining the relationship between religiosity and BP, such factors must be considered and controlled for. Religious individuals may also be more likely to come from geographical regions that historically have been associated with higher BP due to salt retention, a physiological function that may increase survival in these environments. As noted above, African Americans and individuals migrating from Africa tend to be among the most religious groups. At the same time, they may also be at increased risk of developing hypertension due to a tendency to retain salt. As a minority group, Blacks are also at increased risk of discrimination, social exclusion, and socioeconomic stresses that add to their risk of hypertension. While religiosity

1. Jewish Bible. Jewish Publication Society Bible, 1997. Retrieved on 3-​13-​2020 from http://​www.bres​lov.com/​bible/​Leviti​cus.htm. 2. New International Version of the Holy Bible. Biblica, Inc: The International Bible Society, 2011. Retrieved on 3-​13-​2020 from https://​ www.bible​gate​way.com/​pass​age/​?sea​rch=​Matt​hew+​5%3A13&vers​ion=​NIV.

404 •  P h y sical H ealth

may help such individuals cope with such stressors, as numerous studies have shown (Bierman, 2006; Brewster et al., 2016; Ellison et al., 2017; Bierman et al., 2018; Vang et al., 2019), it may not be enough to counter these physiological and socioeconomic effects on BP. Furthermore, there is some evidence that for certain religious groups, such as Muslims in non-​ Muslim-​ majority countries, greater religiosity is actually associated with greater perceived discrimination and worse mental health (Ghaffari & Ciftci, 2010). This effect may depend on how religiosity is assessed. At least one study has found that while strong psychological identification with Islam increased the negative mental health effects of discrimination, greater frequency of religious practice actually reduced the negative effect of discrimination on mental health (Jasperse et al., 2012). There is little question, then, that the relationship between religiosity and hypertension is a complex one, with many reasons why greater religiosity might be related to lower BP and numerous reasons why it may be related to higher BP, both in terms of the effect of religiosity on BP and in terms of religiosity being associated with sociodemographic characteristics that may confound this relationship. Reviews of the research on religion and hypertension confirm this speculation (Meng et al., 2019).

RESEARCH ON RELIGIOSITY AND BLOOD PRESSURE It is now time to examine systematic research that has studied the effects of religiosity on BP. As usual, we focus here on large cohort studies that track individuals over time and randomized controlled trials (RCTs) that examine religious/​spiritual interventions, although some notable cross-​sectional studies in specific populations are also mentioned. Studies conducted prior to 2010 and then the more recently published research will be reviewed. A full list of high-​quality studies and lesser quality but unique studies may be found in the Appendix.

Early Research Of the 59 studies published prior to 2010 that examined the relationship between religiosity

and BP, or examined the effects of a religious/​ spiritual intervention on BP (Koenig et al., 2001a, 2012), 29 studies (49%) reported significant inverse relationships with BP or positive effects on BP, 6 studies (10%) reported negative effects on BP (worsening BP), 20 studies (34%) reported no effect, and 4 studies (7%) reported mixed findings depending on religious characteristic measured. Of the 59 studies, 31 (53%) were cross-​sectional, 11 (19%) were prospective, and 17 (29%) were single-​group experimental studies or RCTs. Of the cross-​sectional studies, 13 (42%) reported inverse relationships between religiosity and BP (or hypertension), 5 (16%) reported positive relationships, and 13 (42%) found no association. Of the 11 prospective studies, 3 (27%) reported positive effects of religiosity (lowered BP), 1 (9%) reported negative effects (increased BP), 4 (36%) reported no association, and 3 (27%) reported mixed results. Of the 17 experimental studies or RCTs, 13 (76%) reported that a religious/​spiritual intervention resulted in a reduction of BP, no studies reported an increase in BP, 3 studies (18%) reported no association, and 1 study (6%) reported mixed results. Almost all RCTs and experimental studies involved Eastern religious meditation (transcendental meditation, yoga, Buddhist walking meditation). Of particular interest among early studies was a 20-​year and, later, a 32-​year prospective study of 144 Catholic nuns and 144 community-​dwelling women in Italy finding that BP increased little over time among the nuns compared to a significant age-​related increase among the community-​dwelling women (Timio et al., 1988; 2001). During follow-​up, BP remained relatively stable among nuns, without a single person experiencing an increase in diastolic BP above 90 mmHg. In contrast, the average BP of community-​dwelling women increased progressively with age so that by the end of the 32nd year of follow-​up there was a greater than 30 mmHg systolic and 15 mmHg diastolic difference between the two groups (p < 0.0001). In a 3-​to 6-​year follow-​up of 4,000 older largely Christian adults in North Carolina, Koenig et al. (1998e) found that religious involvement at baseline significantly predicted lower BP 3 years later in African Hypertension • 405

Americans and younger elderly (ages 65–​74). Watching religious TV or listening to religious radio, however, was associated with higher BP in cross-​sectional analyses. In a 1-​year prospective study of 944 community-​dwelling older adults (92% non-​Christian) in Taiwan, Yeager et al. (2006) reported that religious attendance weakly predicted a lower likelihood of diastolic hypertension on follow-​up (B =​−0.57, 0.05, p < 0.10), and no effect was found on systolic hypertension. In a prospective study of 1,439 women age 42–​ 52 in Chicago (36% African American), Fitchett and colleagues (2009) reported that higher scores on the 8-​item Daily Spiritual Experiences Scale (more daily spiritual experiences) predicted an increase in BP over a 3-​year follow-​up.

Recent Research Since 2010, a number of additional cross-​ sectional, longitudinal, and experimental studies or RCTs have been conducted. Some of the higher-​quality studies are now reviewed here. C ROSS -​SE C TI O N AL

One study of 594 Tibetan monks found that after controlling for potential risk factors, compared with those engaged in Buddhist religious activities (meditation, chanting, Buddhist teaching) less than 8 hours per day, those engaged in such activities 10-11 hours per day were 80% less likely to experience hypertension (OR=0.22, 95% CI=0.07–0.71), and those meditating 11 hours or more per day were about 90% less likely to experience hypertension (OR=0.11, 95% CI=0.03–0.40) (Liu et al., 2019). Overall, regression analyses controlling for other factors found that time spent in Buddhist activities was associated with a significant reduction in both systolic BP (b =​−0.36, p =​0.004) and diastolic BP (b =​−0.35, p =​0.01). In a study that compared the prevalence of hypertension by religious group among 1,770 persons age 25 or older in Benin, West Africa (33% with hypertension), multivariate analyses revealed that animists (who made up 32% of the sample) were nearly twice as likely as Christians to have hypertension (OR =​1.97, 95% CI =​1.48–​2.46) (Desormais et al., 2019). 406 •  P h y sical H ealth

Researchers admitted that the reason for this was not clear, although they suspected diet and other lifestyle factors (which were not exhaustively controlled for). The practice of Ramadan fasting among Muslims is another dietary health behavior that may influence BP, if only temporarily. Alam and colleagues (2019) studied 78 Pakistani men age 20–​85 who fasted for 16 hour/​days between sunrise and sunset for 29 consecutive days during Ramadan. On average, participants reduced their systolic BP from 140.6 mmHg to 124.2 mmHg (p < 0.0001) and diastolic BP from 107.6 to 102.9 mmHg during fasting. Improvements in BP persisted to some degree for up to 1 month post-​fasting, when assessments were stopped. RETROSP ECTIVE COH ORT STUDY

Kobayashi et al. (2015) conducted a retrospective cohort study that followed 40,035 persons (51% Shinto, 42% Buddhist, 1% Christian) initially presenting at an annual health checkup program in 2005 at a hospital in Tokyo, Japan. Excluded from the analysis were all those who had a past history of cardiovascular disease, cerebrovascular disease, and pulmonary disease (COPD, lung cancer, etc.), with the rationale that those with chronic disease might be more religious. This resulted in a final sample of 36,965 included in statistical analyses. Participants were reassessed between 2006 and 2010, with 1 to 5 years of follow-​up data. Religiosity was measured with a single question: “Are you religious?” Based on response, participants were classified into four groups: not at all religious, slightly [religious], somewhat [religious], and religious. Of the sample, 37.8% were at least somewhat religious. Among women at baseline, compared to those who were not religious at all, women who were slightly or somewhat religious were significantly less likely in cross-​sectional analyses to have hypertension (OR =​0.80, 95% CI =​ 0.58–​0.94, and OR =​0.76, 95% CI =​0.65–​0.90, respectively), and there was a similar trend for those indicating they were “religious” (OR =​ 0.83, 95% CI =​0.83–​1.00). However, no such association was found in men. In longitudinal analyses, religiosity did not predict the development of hypertension in the overall sample

(OR =​0.94, 95% CI =​0.85–​1.05). Furthermore, it did not predict changes in systolic (b =​−0.13, 95% CI =​−0.53 to 0.27) or diastolic BP (b =​ −0.16, 95% CI =​−0.42 to 0.09), after adjusting for age, gender, occupation, health habits (smoking, excessive alcohol consumption, regular exercise), clinical risk factors (diabetes, dyslipidemia), BMI, time, and baseline BP. However, as is often the case, some of the covariates that researchers controlled for as confounders, such as health habits (all of which were related to religiosity in a healthy direction in this sample), may have been mediators of the religiosity-​ BP relationship. Longitudinal analyses were not stratified by gender, so it is not known whether the inverse relationship between religiosity and hypertension in women at baseline translated into religiosity predicting future cases of hypertension or high BP.

support from church members at baseline predicted significantly fewer new cases of hypertension after adjusting for the above covariates, including religious attendance (OR =​0.84, 95% CI =​ 0.72–​0.99, p =​0.04). Controlling further for BMI slightly attenuated the association (OR =​0.86, 95% CI =​0.73–​1.01, p =​0.065). In a 9-​ year prospective study, Hill et al. (2017b) analyzed data from two waves of the Mexican Health and Aging Study carried out in 2003 and 2012 to examine the impact of religious involvement on biological functioning. Participants were a systematically identified sample of 772 individuals and their spouses age 50 or over currently living in Mexico. Religious participation was assessed by a single item: “How frequently do you participate in events organized by your church?” (never, once in a while, once a week or more). Frequency of religious participation was then categorized and examined as (1) “once in a while” vs. “never,” and P RO S P E C TI VE COHORT S T UDIE S (2) “once or more per week” vs. “never.” In addiIn a 4-​year prospective study, Charlemagne et tion, change in religious participation between al. (2016a) followed 5,720 community-​dwelling 2003 and 2012 was also calculated (i.e., a change adult Seventh Day Adventists in North America, score). These three religious variables were used examining the effects of religious attendance to predict biological functions in 2012 (including and religious support on the development of diastolic and systolic BP). Biological outcomes self-​reported hypertension during follow-​up (n were measured as both continuous variables and =​534 new cases). Baseline religious variables dichotomized variables based on high vs. low were frequency of religious attendance and a risk levels. Regression models were used to con12-​ item measure of religious social support trol for age, gender, education, marital status, (emotional support given, emotional support household income, and self-​rated health. received, negative social interactions, anticResults indicated that for continuous diaipated support). In baseline cross-​ sectional stolic BP, respondents participating in religious analyses, which adjusted for age, gender, eth- activities once in a while (vs. never) in 2003 nicity, education, economic status, alcohol had significantly lower diastolic BP in 2012 (b use, regular exercise, and compliance with a =​ −2.66, p < 0.01); likewise, those who particivegetarian diet, frequent religious attendance pated weekly or more (vs. never) also tended to was associated with a lower likelihood of self-​ exhibit lower diastolic BP (b =​−1.96, p < 0.10). reported hypertension (OR =​0.75, 95% CI =​ For high-​risk diastolic BP, respondents partic0.58–​0.98), as was anticipated social support ipating in religious activities once in a while from fellow church members (OR =​0.89, 95% (vs. never) also tended to be less likely to expeCI =​0.82–​0.97). These effects, however, were rience high diastolic BP (OR =​0.68, p < 0.10). reduced to nonsignificance when BMI was No effect of religious participation on systolic added to the model. In prospective analyses BP was found. No effect of change in religious from 2006/​2007 to 2010/​2011, frequency of participation was found for either diastolic or religious attendance at baseline did not predict systolic BP, although change in religious particinew cases of self-​reported hypertension (after pation between 2003 and 2012 was small (averadjusting for age, gender, ethnicity, education, age change score =​0.13, SD 0.92). economic status, alcohol use, regular exercise, Cozier and colleagues (2018) analyzed data and vegetarian diet). However, anticipated from the Black Women’s Health Study, based Hypertension • 407

on 8 years of follow-​up that involved 43,179 participants (mean age 45). The purpose was to examine the relationship between religion/​spirituality (R/​S) in 2005 on the incidence of new cases of hypertension between 2007 and 2013. There were 5,194 incident cases of hypertension that developed during this time, with cases defined as self-​reported “physician-​diagnosed hypertension with use of either antihypertensive medications or diuretics” (99% confirmed by medical records or physician checklists). R/​S was assessed by two questions from the Fetzer Institute’s Brief Multidimensional Measure of Religiousness/​Spirituality (“To what extent is your religion or spirituality involved in understanding or dealing with stressful situations in any way?” and “To what extent do you consider yourself a religious or spiritual person?”) and by two questions from the Duke University Religion Index (“How often do you attend religious services?” and “How often do you pray?”). Cox proportional hazards regression was used to identify predictors of incident hypertension, while controlling for age, smoking status, alcohol consumption, weight, geographic region, education, exercise, medical diagnoses, diet, perceived stress, SES, depressive symptoms, experiences of racism, child abuse, victimization, insurance status, and physical exam within the past 2 years (some of these possibly being mediators of the effect of religiosity, particularly health habits). Results indicated that a high level of R/​S coping was associated with a 13% reduced risk of hypertension (incident risk ratio [IRR]=​ 0.87, 95% CI =​0.75–​1.00) in the full model, which included other religious variables. This association was found to be strongest in women with high levels of perceived stress, where the risk was nearly 25% lower (IRR =​ 0.77, 95% CI =​0.61–​0.98, with p-​value for the interaction =​0.01). In contrast, frequent prayer (once/​day or more vs. < once/​week) was associated with an increased risk of developing hypertension in the overall sample, but only after other religious variables were added to the model (IRR =​1.14, 95% CI =​1.01–​1.29, for 1–​2 times/​day; IRR =​1.12, 95% CI =​0.99–​ 1.27, for several times/​day). No significant effects were found for other indicators of R/​S. There is some concern that adding all religious 408 •  P h y sical H ealth

variables into the same model may have led to multicollinearity. Researchers concluded: “R/​S was associated with a decreased risk of hypertension in African-​ American women, especially among those reporting high levels of stress.” Suh et al. (2019) analyzed data collected from a random national sample of 2,912 participants in the US Health and Retirement Study (average age 66) to examine the effect of frequency of religious attendance on biological risk in this 4-​year prospective study conducted between 2006 and 2010. Religious attendance responses ranged from “not at all” to “more than once a week,” and were categorized as (1) no or yearly attendance, (2) monthly attendance, and (3) weekly attendance or more. Biological functions including systolic BP and diastolic BP were assessed in 2006 and 2010. Controlled for in all regression analyses were age, gender, race/​ethnicity, education, marital status, employment status, household wealth, financial debt, and the baseline outcome measure in 2006. Results indicated no evidence of an effect of 2006 religious attendance on changes in systolic or diastolic BP from 2006 to 2010. As reviewed in the previous chapter, Ahrenfeldt et al. (2019) analyzed data from an 11-​year prospective study of 23,864 individuals age 50 or over participating in the Survey of Health, Aging and Retirement in Europe (SHARE). Participants were followed from 2004/​2005 to 2015 over 6 waves of data collection. Participants’ religious involvement was categorized at baseline as “more religious” (people who pray, take part in a religious organization, and are religiously educated), “less religious” (people who pray, without taking part in a religious organization or being religiously educated), and “non-​religious” (people who do not pray, do not take part in a religious organization, and are not religiously educated). Hypertension was assessed at each wave by asking participants if a doctor had ever told them that they had hypertension. Logistic regression models were used to control for European region, gender, age at interview, education, marital status, and employment. Results indicated that no measure of religious involvement was associated with self-​reported

hypertension in either cross-​sectional or longitudinal analyses. Spence et al. (2020) examined the effects of religious attendance on risk of hypertension over 12 years in 44,281 non-​hypertensive women (93%–​ 95% white Caucasian) participating in the Nurses’ Health Study-​II. Religious attendance assessed in 2001 was examined as a predictor of incident hypertension between 2001 in 2013. A total of 11,773 incident cases of self-​ reported physician-​ diagnosed hypertension developed during follow-​ up. Results indicated that women who frequently attended religious services at baseline in 2001 were significantly less likely to develop new cases of hypertension during the 12-​ year follow-​ up, controlling for age, pre-​tax household income, race, geographical region of residence, country of birth, perceived stress, physical, emotional, and sexual abuse during childhood or adolescence, self-​reported physician diagnoses of chronic illness, family history of hypertension, hypercholesterolemia, contraceptive use, menopausal status and hormone replacement therapy, BMI, cigarette smoking, alcohol consumption, physical activity, and diet. Also controlled for was social integration assessed by marital status, number of close contacts, frequency of seeing close contacts, participation in social, community, or workgroups, and the presence and frequency of interaction with a confidant. This is an extraordinary number of control variables, included in an effort to eliminate any sources of confounding. Compared to women who never or almost never attended religious services, those attending less than once/​ month were 3% less likely to develop hypertension (hazard ratio [HR]=​0.97, 95% CI =​0.91–​1.03), those attending between 1 and 3 times/​month were 6% less likely (HR =​0.94, 95% CI =​0.88–​1.00), those attending about once/​week were 7% less likely (HR =​0.93, 95% CI =​0.88–​0.98), and women attending more than once/​week were 9% less likely (HR =​0.91, 95% CI =​0.86–​0.97). These findings also indicated a dose-​response effect on incident hypertension (ptrend =​0.001). The primary mediator of this relationship was BMI, explaining 11.5% of the attendance-​ hypertension effect (p < 0.001). Researchers concluded: “. . . religious service attendance was modestly associated

with hypertension in an inverse dose-​response manner and [was] partially mediated through body mass index. Future research is needed on biological or social reasons for the lower risk of hypertension” (p. 193). Finally, Chen et al. (2020a) conducted a 3-​ to 12-​year follow-​up of 92,008 young, middle-​ aged, and older adults examining the effect of religious attendance on health outcomes, including self-​reported physician-​diagnosed hypertension in the young adult and older cohorts. The results of the combined meta-​ analytic estimate indicated no significant effect (RR =​0.95, 95% CI =​0.79–​1.15), after controlling for age, gender, race/​ethnicity, marital status, geographic region, income, level of education, wealth, employment status, health insurance, childhood abuse, prior religious service attendance, prior health status, health behaviors, multiple indicators of positive emotions, negative emotions, social integration, heavy drinking, smoking, exercise, health problems, illicit drug use, sexually transmitted infections, and other covariates. This again leaves open the possibility that some of the control variables may actually have been variables that explained the effects of religious attendance on self-​reported incident hypertension (i.e., mediators vs. confounders), though the confounders were controlled for in the period prior to the religious service attendance assessment. EXP ERIM EN TAL STUD IES

Ayazi et al. (2018) conducted a single-​group experimental study in 74 healthy African American men age 23–​ 47, examining the impact of a lab reactivity protocol on measures of systolic and diastolic BP. The reactivity protocol involved active speech and anger recall stressors with 5-​minute baseline and recovery periods. The effects of John Henryism Active Coping (JHAC) and education level on BP was examined at high and low levels of religious attendance (ORA), private religiosity (NOR), and intrinsic religiosity (IR). The goal was to determine if measures of religiosity buffered cardiovascular responses to the anger recall stressor. As noted in the previous chapter, JHAC is a coping response indicative of being a high striver who actively copes with stressors Hypertension • 409

in life. Results indicated a recovery period by education by JHAC interaction on diastolic BP at low but not high levels of private religiosity. In other words, at low education and low NOR, diastolic BP levels increased significantly during anger recall and ensuing recovery for high JHAC individuals. Researchers concluded: “Thus, being deprived of education and private religious activity may put these African-​ American men in a vulnerable situation where higher effort coping [JHAC] may exacerbate their cardiovascular reactivity [diastolic BP responses] and recovery to anger induction” (p. 296). Another recent single-​group study examining the effects of religiosity on cardiovascular responses to a stressor in 50 college students found that those scoring higher on intrinsic religiosity as measured by the Huber scale had lower average and less reactive systolic BP (Schnell et al., 2020). R A N D O M I ZE D CONT ROLLE D T R I A L S ( RC TS )

As in the previous chapter, we do not review here double-​blinded RCTs examining the effects of remote intercessory prayer or thought projection (telepathy) on BP. The reason for not doing so is the controversial nature of such research, particularly since there is no scientific mechanism to explain such effects, and it is thus not clear the extent to which such questions are reasonably accessible to empirical statistical analysis (VanderWeele, 2017d). However, RCTs can be designed to examine religious interventions that are scientifically plausible based on well-​established psychological, social, or behavioral mechanisms. Beiranvand et al. (2014) randomized 160 Muslim patients with mild pain while recovering from cesarean surgery (C-​section) under spinal anesthesia to either a religious intervention or a control group. Both groups wore headphones, one group with the headphones turned on and the other group with the headphones turned off. The headphone-​on group listened to and meditated on a healing Islamic phrase: “Ya man esmohu davaa va zekrohu shafaa, Allahomma salle ala mohammad va aale mohammad” for 20 minutes (prayer meditation 410 •  P h y sical H ealth

group). Researchers emphasized that this prayer reminds individuals of Allah and is a doctrinal testimony of faith, which benefits individuals by causing relaxation, calmness, mindfulness, and peacefulness. Physiological outcomes (including BP) were assessed before, during, 30 minutes, 60 minutes, 3 hours, and 6 hours after the 20-​minute meditation. Results indicated no significant differences in BP between groups at any point in time (although significant differences in pain level post-​C-​ ­section between groups were identified at 3 and 6 hours, favoring the intervention group). As reviewed in the previous chapter, Gainey et al. (2016) randomized 23 patients with type II diabetes (age 50–​75) living in Thailand to either a traditional walking exercise (n =​11) or a Buddhist-​based walking meditation (n =​12). Participants were excluded if they had attended an exercise program (including yoga) within the past 6 months. Buddhist walking meditation involved an aerobic walking exercise combined with Buddhist meditation. Participants in the Buddhist intervention group voiced “Budd” and “Dha” while setting each foot on the floor, with the goal of practicing mindfulness while walking. Both interventions were performed for 50 minutes three times per week over 12 weeks. Single in-​ person measurements of systolic and diastolic BP were performed twice, before and after the exercise training interventions. Results indicated that both systolic and diastolic BP decreased significantly in the Buddhist walking group (systolic BP from 145 down to 128 and diastolic BP from 85 to 78) but not in the traditional walking exercise group (systolic BP 147 to 143 and diastolic BP from 87 to 86). Between-​group differences were also significant at p < 0.05 for both systolic and diastolic BP. Sanaeinasab et al. (2021) randomized 84 pregnant women in Iran to either a religious Islamic cognitive-​ behavioral intervention (four 90-​minute group sessions over 8 weeks) or a treatment as usual control group with the purpose of comparing effects on stress, anxiety, depression, and BP, and improving delivery outcomes. Results indicated significant between-​group difference in systolic and diastolic BPs at 3-​month follow-​up, favoring the intervention group. In contrast, Asmand et al. (2019) found that, in an Islamic intervention

focused on Qur’anic teachings in 34 women with hypertension in Iran, the intervention did not lower BP when compared to a control group (even though it significantly reduced anxiety). There have also been numerous other Eastern religious meditation studies conducted since 2010. In one of the latest meta-​analyses of RCTs examining the effects of meditation on BP from 1980 to 2015, reviewers identified 19 studies (L. Shi et al., 2017). The studies were categorized into transcendental meditation (TM) and non-​transcendental meditation (non-​TM, i.e., Buddhist mindfulness, breathing awareness meditation, and other meditation types). Results were reported depending on how BP in these RCTs was measured: 24-​hour ambulatory BP monitoring (ABPM) or non-​ ABPM. For studies using ABPM measurement, investigators reported a pooled systolic BP effect of −2.49 mmHg (95% CI =​−7.51 to 2.53) for TM (statistically nonsignificant) and −3.77 mmHg (95% CI =​−5.33 to −2.21) for non-​TM (a statistically significant reduction in systolic BP). Regarding diastolic BP, the pooled effect was −4.26 mmHg (95% CI =​−6.21 to −2.31) for TM interventions (statistically significant) and −2.18 mmHg (95% CI =​−4.28 to −0.09) for non-​TM interventions (significant). For studies using non-​ABPM measurements of BP, effects were larger. The authors concluded: “Non-​ transcendental meditation may serve as a promising alternative approach for lowing both SBP and DBP” (p. 696). However, authors were more hesitant in recommending TM interventions, calling for more studies.

Summary Early research conducted before 2010 indicated that 49% of studies found that religiosity was associated with lower BP or less hypertension, 10% reported religiosity was associated with higher BP, and the remaining studies indicated no association (34%) or mixed findings (7%). With regard to the 11 longitudinal cohort studies, 27% reported that religiosity predicted lower future BP, 9% reported religiosity predicted higher BP, 36% found no effect, and 27% reported mixed findings. Of the 17 experimental studies or RCTs, 76% reported that a religious/​ spiritual intervention (almost all

meditation studies) caused a significant reduction in BP. More recent research since 2010 has generally confirmed this mix of findings. Of the 9 prospective cohort studies, 4 (44%) found that religiosity predicted a lower BP or reduced risk of future hypertension, whereas 5 (56%) reported no effect; no studies reported an increased risk. Of the 7 experimental studies or RCTs (not counting TM and non-​TM studies), 5 (71%) reported that a spiritual/​religious intervention lowered BP, and the remaining 2 RCTs (listening to Qur’an recitation or practicing Islamic teachings) had no effect on BP. In conclusion, a significant minority of prospective studies suggest that religiosity reduces BP or prevents the development of hypertension and only one study has found that religiosity increases BP over time, whereas the majority of studies find no effect or mixed results. However, over 70% of experimental studies or RCTs show that religious interventions lower BP. Likewise, many clinical trials involving Hindu or Buddhist forms of meditation report that these interventions lower BP. Given the complex dynamics involved in how religiosity might increase or reduce BP, as discussed above, the mix of results reported from observational studies reported here are expected (especially when suspected mediators of religion’s effects on BP are controlled for as confounders). Concerns about reverse causation are arguably less of an issue here, since hypertension (the silent killer) is usually not associated with any symptoms that would affect religiousness (i.e., the need to mobilize religious coping to deal with unpleasant symptoms). Lack of symptoms is often a reason why people with this condition fail to take their anti-​hypertensive medication.

ANTI-​H YPERTENSIVE MEDICATION ADHERENCE Since 2010, at least three studies (all cross-​ sectional and of low to modest quality) have examined the relationship between religiosity and medication adherence among those with hypertension. In the first of these, Kretchy and colleagues (2013) analyzed data collected on 400 hypertensive patients ages 18 or older in Ghana, Africa (which is 71% Christian and 18% Hypertension • 411

Muslim as a country). The 10-​item Spiritual Perspective Scale (SPS; Reed) and two items from the DUREL (ORA and NORA) were used to assess spirituality and religiosity, respectively. Scores above the mean on the SPS were considered “high spirituality” and below the mean “low spirituality.” The 8-​ item Morisky Medication Adherence Scale was used to assess medication adherence (low adherence was defined as scores of less than 8). Logistic regression was used to adjust for demographics and comorbid health conditions. High spirituality (but not high religiosity) was associated with a greater likelihood of medication non-​adherence (OR =​2.68, 95% CI =​1.20–​5.96, p =​0.016). Abel and Greer (2017) surveyed 80 community-​dwelling Black women with hypertension age 18–​60 living in North Carolina to examine the relationship between religious involvement and compliance with anti​hypertensive medications. Religious involvement was assessed by a 9-​item scale developed by the investigators. Medication adherence was assessed using an 8-​item medication adherence subscale of the 14-​item Hill-​Bone Compliance to High Blood Pressure Therapy Scale (with lower scores indicating greater compliance). In addition, trust in the healthcare provider was assessed with the 11-​item Trust in Physician Scale. Of the 80 women, 20 (25%) were adherent (requiring a perfect adherence score) and 60 (75%) were non-​adherent. Bivariate correlations indicated nonsignificant correlations between medication adherence and individual indicators of religious involvement. However, there was a trend toward a higher percentage of adherent women attending religious services weekly or more compared to non-​ adherent women (75% [15/​20] vs. 60% [36/​60], respectively, r =​−0.20, p =​0.08). Medication adherence was strongly correlated with trust in healthcare providers, although there was no significant relationship between spiritual/​religious variables and healthcare provider trust. The correlation between the total religiosity/​ spirituality score and medication adherence score was not reported, nor were multivariate analyses conducted. Finally, Fikriana and colleagues (2019) surveyed a random sample of 225 patients with grade 3 hypertension (systolic 160–​179 mmHg 412 •  P h y sical H ealth

or greater and/​ or diastolic 100–​ 109 mm or greater) living in Indonesia (a country that is 87% Muslim). The purpose was to determine the predictors of medication adherence. Among predictors examined were age, gender, family history of hypertension, length of hypertension, social support, and responses to the COPE Inventory (Carver). The COPE Inventory included a subscale of turning to religion (2–​4 items, depending on version of COPE administered, which was not specified). Medication adherence was measured using the Hypertension Self-​ Care Profile questionnaire. Results indicated that only 16% were in the “good enough” category of medication adherence. Turning to religion (called “return to religion”) was significantly correlated with medication adherence (r =​0.32, p < 0.001). Regression analyses controlling for other predictors revealed that turning to religion remained a significant and independent correlate of medication adherence (b =​0.18, p =​0.01). Thus, as with the relationship between religiosity and BP, the findings are mixed with regard to religiosity and hypertensive medication adherence and, to our knowledge, there are no prospective studies that have yet examined this relationship. In general, religiosity tends to be associated with better treatment adherence (see Appendix), and this finding likely transfers over to adherence with anti-​hypertensive medication (although not always).

RECOMMENDATIONS FOR FUTURE RESEARCH Given the current mix of findings, and the general lack of high-​quality prospective cohort studies that have actually measured BP (relying on self-​report of hypertension instead), further research is clearly needed. In particular, large prospective studies designed from the start to examine the impact of religiosity on BP are lacking. Until funding for such research becomes available, analyses of existing data sets with measures of religiosity and BP will have to do. Given that religiosity does not have a direct effect on BP, but rather acts indirectly through psychological, social, and behavioral pathways, relatively large samples are needed to detect such relatively subtle effects. This is especially

true given the complexity of this relationship, with numerous confounders and mediating variables affecting results. Furthermore, the assessment of hypertension in many of the prospective studies examined above was by self-​reported physician diagnoses, not actual measured BP using a standard protocol. Thus, future studies should measure BP rather than simply relying on self-​report. One of the concerns that we have repeatedly raised when discussing prospective studies is the lumping of potential mediators of the religiosity-​BP relationship into the category of “confounding variables.” The effect that religiosity has on BP is not a magical or supernatural one, but one that must be explained by psychological, social, and behavioral variables. Mediating variables through which religiosity is likely to influence BP include psychological, social, and behavioral characteristics. True confounding variables are those such as gender, age, race, SES, and other demographic characteristics that are common to both highly religious individuals and high BP. These must be controlled for in analyses examining the religiosity-​BP relationship. Recall from Chapter 3 that mediating variables do not confound and thus nullify a relationship, but rather explain how that relationship has come about. Ideally, to be considered a “mediating” variable, the characteristic must be assessed between the exposure and the outcome, i.e., after the religiosity exposure (not at the same time or prior to the religious exposure) and before BP is measured (VanderWeele, 2015). One can potentially try to control for these variables from data collection waves temporally prior to the R/​S assessment to try to ensure that such variables are confounders and not mediators. However, given the stability of many mediating characteristics (e.g., habits such as smoking, alcohol use, exercise, diet, social interactions, and even mental health characteristics), these are unlikely to change much over time, particularly during short intervals. Moreover, the fact is that most prospective studies have thus far measured potential mediating variables at the same point in time that religiosity was measured, which means that those variables could be either confounders or mediators. However, concluding—​as some

researchers have done—​that all such plausible mediators are simply confounders (rather than explanatory mediating variables) would seem inappropriate. Thus, when designing and analyzing data from future studies, confounders should be distinguished from mediating variables. Practically speaking, this would involve first presenting a model with religiosity as the independent variable and BP or hypertension as the dependent variable, including confounders such as demographics. This would then be followed (in a hierarchical manner) by a model with potential mediators to examine how (i.e., the mechanism by which) religiosity might affect the dependent variable (BP) or by using more sophisticated mediation modeling strategies (VanderWeele, 2015). That would be followed by a third model examining interactions between religiosity and confounders such as race, gender, age, and SES to determine whether any of these confounders modify the effects of religiosity on BP. Religiosity should also be examined as a modifier of the relationship between BP risk factors, such as high stress level on BP. Randomized controlled trials (RCTs) are also needed to test the efficacy of religious interventions on BP and on the prevention or amelioration of hypertension. With few exceptions, most RCTs thus far have utilized Eastern forms of meditation as the intervention and, in the vast majority of studies, these spiritual practices have been shown to reduce BP. What are lacking are RCTs examining interventions based on Western forms of spiritual practice to determine if these interventions likewise reduce BP. There are many forms of Western spiritual/​religious practice that might be utilized in this regard, including contemplative forms of prayer, engaging in religious forms of volunteering, participating in religious activities such as religious worship services, reading religious scriptures, or listening to sacred scriptures being recited (as in the Beiranvand et al., 2014, study above). All interventions should be patient-​centered, i.e., and adapted to the particular religious faith of the participant. This should be done not only to maximize effects by utilizing the person’s own religious faith, but also in order to provide culturally competent, patient-​centered care when these interventions Hypertension • 413

are applied in clinical practice. RCTs are needed, but also single-​ group experimental studies, which are simpler and require far fewer resources and funding support than RCTs.

CLINICAL APPLICATIONS There is much that healthcare providers and religious professionals can do based on what we now know about the effects that religiosity may have on BP, the risk of developing hypertension, or effects on the course of illness over time.

Health Professionals After taking a spiritual history to gather information on whether religion is important in a person’s life, the next step for the healthcare provider is to obtain a BP using a standard protocol (BP taken after 5 minutes of sitting relaxed with arm extended at heart level, then calculating an average of three measurements). This is particularly important for those over the age of 45 and Blacks of any age. If BP is elevated or hypertension is present, then there are medical treatments available to help lower the BP. This is essential to avoid the negative consequences of hypertension such as a paralyzing stroke, and kidney or heart damage. For those who are religious, the healthcare professional may decide to support or even encourage religious beliefs or practices that may help to lower the BP or reduce life stress that may be increasing the BP. Religious/​spiritual practices include meditation or contemplative prayer, rooted in the person’s specific faith tradition. Given the positive results from studies of Eastern meditation, even in the absence of research on Western forms of meditation or contemplative prayer, it is reasonable to suspect that these might be useful in lowering BP and therefore warrant recommending. Religious beliefs and practices may also be utilized by healthcare professionals to help reduce risk factors that are contributing to the development of hypertension in religious patients with BP problems. As reviewed above, these risk factors include cigarette smoking, excessive alcohol use, physical inactivity, consumption of an unhealthy diet, lack of attention to weight, and other behaviors that might 414 •  P h y sical H ealth

in some way damage the “temple of the Holy Spirit” in Christian or Western faith traditions. This also applies to patients from Eastern religious traditions, which as noted in previous chapters, usually emphasize good health behaviors as part of their religious doctrine. In addition, for religious individuals with hypertension requiring medication, religious beliefs may also be utilized to improve medication adherence. Guilt can sometimes be healthy.

Religious Professionals Religious professionals can also play an important role in helping members of their congregation keep their BP low. First, clergy can alert members of their congregation, particularly at-​risk individuals such as older adults and/​or African Americans, to the dangers of uncontrolled BP and to the need to see a healthcare professional to have their BP monitored (or do it at home using an electronic BP device, or at a local neighborhood pharmacy). As repeatedly noted above, hypertension is a silent killer that is often associated with no overt signs or symptoms. Congregations can also put on “health fairs” where a parish nurse, congregational nurse, or other trained health professional takes the BP of members using a standard protocol (Ogedegbe & Pickering, 2010). Second, education of members of the congregation about the treatments for hypertension is an important role that clergy can play. This includes providing information about factors that influence BP and ways that individuals can utilize their religious resources to reduce BP as a way of honoring the body as the temple of the Holy Spirit or being faithful to religious teachings in other ways. Clergy may invite a health professional to speak on this topic during an adult Sunday school class or other special religious gatherings during the week. Members can be educated about simple religious interventions that can reduce hypertension, such as meditation on positive scriptures, contemplative prayer, and so forth. Such practices can also be used to reduce BP-​related risk factors such as heavy alcohol use, cigarette smoking, unhealthy food consumption, high salt intake, physical inactivity, and lack of attention to weight control. This should be

emphasized both on the individual level and on the faith-​ community level, especially in terms of foods that are prepared and served at religious gatherings (which, as indicated in Chapter 19, are often far from healthful). Third, clergy may emphasize the importance of complying with medication prescribed to control BP and inform members of the congregation what might happen if they fail to do so. As noted in other chapters of this volume, caring for a healthy congregation will be a lot easier than visiting members in the hospital after a stroke or myocardial infarction. Thus, there are many ways that religious professionals can impact the risk of developing hypertension and its treatment. Clergy have close and regular contact with individuals in a community, much more so than do healthcare professionals.

SUMMARY AND CONCLUSIONS Hypertension is a widespread and deadly medical condition in both the United States and around the world. This is particularly true for certain subgroups of the population, such as African Americans, older individuals, and those with poor access to healthcare or to treatments that can lower BP. Psychological, social,

behavioral, cultural, and environmental risk factors for hypertension are now well-​known, and controlling these risk factors can help to lower BP and prevent hypertension. As discussed in this chapter, there are many reasons why greater religious involvement might help to lower BP or prevent the development of hypertension. Systematic research shows that in a significant number of systematic studies (cross-​ sectional, longitudinal, and RCTs), religious involvement is related to lower risk of developing hypertension and likewise, religious/​spiritual interventions have the ability to lower BP. The relationship between religiosity and BP, however, is a complex one, with many factors serving to confound this relationship when examined in observational studies. We have discussed some of these influences and have made recommendations on how to address them when conducting research. Suggestions have also been made on studies needed in the future, and for ways of analyzing and interpreting the data collected. Finally, recommendations for clinical practice were made for both healthcare providers and religious professionals on how to harness the benefits of religion in preventing the development, improving the course, and mitigating the consequences of hypertension. One of those dreaded consequences is stroke, the subject of the next chapter.

Hypertension • 415

22 Cerebrovascular Disease If you’re going through hell, keep going. —​Winston Churchill

THIS CHAPTER EXAMINES the relationship between religiosity and cerebrovascular disease (CBVD), particularly the most widespread form of CBVD, stroke. Stroke is the second most common cause of death and disability worldwide (Mozaffarian et al., 2015), and is the most devastating physical consequence of hypertension (one of the strongest risk factors for stroke). The relationship between religiosity and stroke is even more complex than the one between religiosity and hypertension. In order for religiosity to influence the occurrence of stroke, the effects must go through two separate mediators. Not only does religiosity have to affect psychosocial and behavioral factors (1st mediator), it must also affect medical conditions that influence stroke risk (such as hypertension, cardiac, and vascular risk factors; the 2nd mediator) in order to ultimately influence stroke incidence. Thus, stroke is a “double” distal outcome that religiosity may influence: the proximal outcome is psychosocial and

behavioral factors, the first distal outcome is biological conditions that increase risk of stroke, and finally, the second distal outcome is stroke or other vascular brain events (double distal outcome). The reason for emphasizing this at the very beginning of the chapter is to lower expectations of being able to identify a strong direct relationship between religiosity and cerebrovascular events, and to encourage the careful examination of indirect effects acting through mediators that religiosity affects (psychosocial and behavioral factors impacting blood pressure (BP), vascular health, cardiac functions), which then affect risk of stroke and other cerebrovascular events. This underscores the importance of being aware of the different presentations of CBVD and factors that influence these conditions, particularly modifiable risk factors, which account for more than 80% of that risk (Kuklina et al., 2012). In this chapter, we will not be discussing the impact of religiosity on helping people to cope

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0022

with the physical disability and life-​ altering consequences of stroke. Chapters 4 (on coping with life changes) and 28 (on physical disability) address this topic. Here, we focus on religiosity’s effects, if any, on the risk of having a first-​ time stroke, other manifestations of CBVD (carotid artery thickness, transient ischemic attacks), and physical outcomes following stroke (size of stroke, recurrence of stroke, development and progression of disability, and mortality rate). The role that religion plays in coping with stroke and disability, however, is relevant to the stroke outcomes above since these outcomes may be influenced by psychosocial and behavioral factors that religiosity impacts.

TYPES AND PREVALENCE OF CEREBROVASCULAR DISEASE Types Cerebrovascular disease (CBVD) is a subcategory of cardiovascular disease (CVD). The other subcategories of CVD are atherosclerotic heart disease, myocardial infarction, heart failure, cardiac arrhythmia, heart valve problems, and congenital heart disease (American Heart Association, 2020a). There are basically two types of CBVD events: cerebral thrombosis or infarction due to arterial occlusion (“ischemic stroke”), and intracerebral or subarachnoid hemorrhage (“hemorrhagic stroke”). For ischemic stroke, there are five subtypes based on etiology: large artery atherosclerosis, small-​ vessel disease, cardioembolic stroke (e.g., due to emboli sent from the heart), other determined etiology, and cryptogenic ischemia stroke (Adams et al., 1993). Another categorization compresses ischemic stroke into four subtypes: large-​vessel cervical or intracranial atherosclerosis with stenosis, cardioembolic, lacunar, and infarct of uncertain cause (Petty et al., 2000). The most common types of ischemic stroke are cardioembolic and infarct of uncertain cause (Petty et al., 2000; Gulli et al., 2016). Both ischemic and hemorrhagic stroke are included under the general term “stroke,” which makes up the bulk of CBVD. An individual may also have a “transient ischemic attack” or TIA, which often presents with symptoms similar to

that of a stroke, but with only temporary physical deficits that revert to normal after a short period. TIAs often herald the eventual occurrence of a completed stroke, resulting in deficits that do not revert to normal and are permanent. Stroke may also occur “silently” without outward manifestations or physical deficits. An accumulation of small silent strokes over time may contribute to subtle impairments in cognitive and physical function, and in advanced stages, lead to severe cognitive impairment and disability (multi-​infarct or vascular dementia; see Chapter 23).

Prevalence Worldwide, 16.9 million persons experience a stroke every year (Feigin et al., 2017b), and the vast majority of these (80%–​90%) are ischemic strokes (Go et al., 2014). The next most common cause of stroke is intracerebral hemorrhage, followed by subarachnoid hemorrhage. Although ischemic stroke is the most common type, hemorrhagic stroke accounts for a substantial proportion of the disability and mortality from stroke. In the United States, an American has a stroke about once every 40 seconds (American Heart Association, 2020b). The incidence of stroke in the United States is 795,000 per year, with 77% being a first-​time stroke and 23% being recurrent (Go et al., 2014). By 2030, it is projected that 3.9% of those age 18 or older in the United States will have had a stroke (Ovbiagele et al., 2013).

CONSEQUENCES OF STROKE The major consequences of stroke are disability and functional impairment, mortality, and the costs due to medical care and lost productivity.

Disability Stroke is one of the leading causes of serious long-​ term disability, especially in older adults. In 2005, approximately 3% of men and 2% of women of all ages in the United States reported they were disabled because of a stroke (American Heart Association, 2020b). According to the Global Burden of Disease, Injuries, and Risk Factors Study 2013 (GBD Cerebrovascular Disease • 417

2013), stroke was the second most common cause of disability-​adjusted life-​years (DALYs) in developing countries (after ischemic heart disease; IHD) and the third most common cause of DALYs in developed countries (after IHD and low back/​neck pain) (Feigin et al., 2017b). In the Framingham cohort study, there were 2,938 persons age 65–​94 who were stroke-​free in 1982. Among these individuals, 220 persons (7.5%) had a first-​ever stroke between 1982 and 1999 and survived for at least 6 months (Kelly-​Hayes et al., 2003). Of these individuals, almost half (43%) were experiencing moderate to severe neurological deficits at 6 months post-​stroke. Among those with deficits, approximately half were experiencing reduced mobility from hemiparesis, 30% were unable to walk without assistance, 19% had difficulty speaking or understanding (aphasia), 35% had symptoms of depression, and 26% were in a nursing home. When examined by gender, women were more likely to be dependent in activities of daily living (ADLs) than men (33.9% vs 15.6%), were less likely to walk unassisted (40.3% vs 17.8%), and were more likely to be in nursing homes (34.9% vs 13.3%). However, these statistics may have been influenced by the fact that men were more likely to die from the initial stroke, and therefore the men alive at 6 months post-​stroke were likely a highly select group of survivors. Overall, then, 26% remained disabled to the point that they were unable to care for their basic activities of daily living and 50% had reduced mobility from hemiparesis. In a study of 2,625 individuals (average age 73) living in London (UK) who had suffered their first-​ever stroke, only 723 (28%) lived for another 10 years (Crichton et al., 2016). These individuals tended to be younger at their initial stroke (average age 62). Of the 262 who survived 15 years, their age at initial stroke was even younger (average age 58). Of the 15-​year survivors, 87% were living at home, 34% had mild disability, 14% moderate disability, and 15% severe disability. Thus, among this highly select group of survivors, severity and age at initial stroke influenced the resulting disability. In another study of 290 first-​stroke patients (86% ischemic stroke) in Rochester, Minnesota, among those who survived up to 90 days, 25% 418 •  P h y sical H ealth

were in a nursing home and among those surviving 1 year, 22% were in a nursing home (R.D. Brown et al., 1999).

Mortality In the United States, 1 out of every 19 deaths is due to a stroke, making it the fourth most common cause of death in the country (Go et al., 2013) with a total of 146,383 deaths in 2017 (American Heart Association, 2020b). Every 3 minutes and 35 seconds, a person in the United States dies from a stroke. The mortality rate was higher for hemorrhagic stroke (68%) compared to ischemic stroke (57%) in one large study (Koton et al., 2014). Worldwide, stroke is the second leading cause of death, after ischemic heart disease (Feigin et al., 2017a). The highest rates of mortality from stroke (especially ischemic stroke) occur in Eastern Europe, Africa, and Central Asia. Mortality from intracerebral hemorrhage is greatest in East and Southeast Asia. Deaths due to subarachnoid hemorrhage are the most common type in Southeast Asia and Mongolia.

Economic Costs The costs of stroke are due to medical expenses and lost productivity, which are substantial and are projected to increase substantially over time. In 2030, it is projected that the direct medical costs for stroke in the United States will be $184 billion (up from $72 billion in 2012); the indirect costs from lost productivity are projected to be $57 billion in 2030 (up from $34 billion in 2012) (Ovbiagele et al., 2013). At the individual level, the lifetime medical cost per person with an ischemic stroke in the United States (including inpatient care, rehabilitation, and follow-​up care) was estimated at $140,048 in 2009–​2012 (Johnson et al., 2016). Inpatient costs account for 70% of post-​stroke medical costs during the first year, and severe strokes cost twice as much as mild strokes (Go et al., 2014).

RISK FACTORS FOR STROKE Risk factors for stroke and CBVD are similar to those for CVD more generally. Note that stroke

is preventable to a considerable degree (Katan & Luft, 2018; Graber et al., 2019). Ten risk factors account for over 90% of strokes: hypertension, diabetes, cardiac causes (atrial fibrillation, heart failure, etc.), hypercholesterolemia, physical inactivity, poor diet, obesity, psychosocial factors (depression, anxiety, social isolation), smoking, and excess alcohol consumption (O’Donnell et al., 2016). All are modifiable to some degree. Since religiosity is related to many of these risk factors, particular emphasis will be placed on the impact that these characteristics have on stroke risk. There are also characteristics that increase risk of stroke, but are not modifiable, and sometimes these confound the relationship between religiosity and stroke. As each risk factor is discussed, the reader should be alert for connections with religiosity that might be causal (religiosity influencing the risk factor), reverse-​causal (the risk factor influencing religiosity), or confounding (the risk factor related to both religiosity and stroke, creating an artificial association between that two that must be adjusted for in statistical analyses). Reviewed here are demographic, genetic, biological, psychological, social, and behavioral characteristics that increase risk of stroke or the development of CBVD.

Demographic: Age, Gender, Race, and Socioeconomic Status It is clear that increasing age is associated with stroke. Kelly-​Hayes (2010) notes that the incidence of stroke doubles with each decade after age 45, and that more than 70% of all strokes occur in those age 65 or older. The findings are more uncertain with regard to gender. According to Redon et al. (2011), women are more likely to have a stroke than men in Europe and Central Asia, especially among those age 75 or older. Cordonnier et al. (2017) also report that hypertension and atrial fibrillation are more common among women than men, and women are at increased risk of stroke due to pregnancy and the postpartum state (see below). However, not all studies agree that men have an advantage in this regard, particularly in the United States. For example, in a 10+​year follow-​up of 25,789 persons aged 45 years or older participating in the US Reasons

for Geographic and Racial Differences in Stroke (REGARDS) study, V. Howard and colleagues (2019) found that between age 45 and 64, White women had a significantly lower risk of ischemic stroke than White men (IRR =​0.68, 95% CI =​0.49–​0.94). Black women also had a lower risk of stroke than Black men (IRR =​0.72, 95% CI =​0.52–​0.99). The lower risk of stroke among women continued between age 65 and 74 among Whites, but not among Blacks. Among those 75 years or older, no gender difference in risk of stroke was found for either race. Overall, African Americans between age 45 and 64 experience a 3-​fold greater stroke risk compared to White Americans, although these differences disappear after age 85 (see V. Howard et al., 2019, for references). This racial difference in stroke risk is primarily due to higher BP, diabetes, and obesity, although genetic factors also play a role. Low socioeconomic status (SES) increases risk of stroke by 30% to 65% and is associated with both more severe deficits and higher mortality (Wolfe et al., 2002; Addo et al., 2012). Those with lower education and income also experience a 44%–​ 319% greater risk of disability following stroke (Bettger et al., 2014). Based on data from the South London stroke registry, Chen and colleagues (2015) found that those in the lowest SES group (compared to the highest) were 75% more likely to have poor stroke outcomes, even after controlling for stroke severity and other clinical characteristics.

Genetic Factors Twin studies indicate that stroke has a considerable genetic component. Identical twins are twice as likely to experience a stroke sometime during their lives compared to fraternal twins, giving an estimate of heritability of about 40% (range 10%–​66%) (Malik & Dichgans, 2018). Stroke tends to aggregate in families, especially when it occurs before age 65, where there is a 3-​fold or more increased risk of ischemic stroke among offspring (Seshadri et al., 2010). Among genetic determinants that contribute to stroke risk, carotid intimal-​medial wall thickness (CA-​ IMT) is particularly important because it is an indicator of subclinical atherosclerosis and a Cerebrovascular Disease • 419

strong risk factor for future stroke, especially ischemic stroke (Humphries & Morgan, 2004).

13,472 controls, the findings were quite similar (O’Donnell et al., 2016).

Biological/​Medical

CAROTID ARTERY IN TIM A- M ​ ED IA TH ICKN ESS ( CA-​IM T)

There are a number of biological/​medical risk factors for stroke, including hypertension, CA-​IMT, cardiac causes (atrial fibrillation or heart failure), high cholesterol, and diabetes. There are also gender and stroke-​specific risk factors.

CA-​IMT is the thickness of the carotid artery walls that feed blood to the brain and is considered a general measure of arterial atherosclerosis. In a study of 5,028 persons of various ethnic backgrounds participating in the Multi-​ Ethnic Study of Atherosclerosis (MESA), all free of cardiovascular disease at baseline, 42 HY P E RTE N S I O N experienced a first-​time stroke during a 3-​year Nearly half (46.0%) of US adults had hyper- follow-​up (Polak et al., 2011). CA-​IMT rate of tension in a 2013–​ 2016 report (American change was significantly associated with stroke Heart Association, 2020b). Hypertension is incidence; participants in the upper quartile of among the strongest of all risk factors for CA-​IMT rate of change were more than twice stroke, regardless of stroke type (Faraco & as likely to experience a stroke compared to Iadecola, 2013). The strength of the association those in the lower three quartiles combined between BP and stroke rises linearly from 115/​ (HR =​2.18, 95% CI =​1.07–​4.46). These find75 mmHg, and this effect is consistent in both ings were independent of age, gender, systolic men and women, all regions of the world, and BP, taking hypertension medication, LDL and all subtypes of stroke, whether fatal or non- HDL cholesterol, diabetes, smoking, education, fatal (Lawes et al., 2004). Based on data from and income. In a more recent review, Luca et al. randomized controlled trials (RCTs) of medica- (2019) underscores the importance of includtions used to lower BP among persons aged 70 ing measurements of CA-​ IMT and carotid on average, a 10 mmHg reduction in systolic BP artery plaque as part of stroke-​risk assessment produces a one-​third reduction in stroke risk guidelines. (Lawes et al., 2004). More recent research supports these findATRIAL F IBRIL L ATION ings. In a large case-​control study involving 84 centers in 22 countries and 2,337 partici- Atrial fibrillation is a cardiac arrhythmia that pants, 66% of participants had hypertension often results from coronary artery disease (either self-​reported history of hypertension affecting the conduction system of the heart. or BP > 160/​90). Those with hypertension were Instead of the heart beating with a regular over three times more likely to experience an rhythm, it beats irregularly, thereby interischemic stroke compared to those without rupting blood flow out of the heart. This often hypertension (OR =​3.14, 95% CI =​2.67–​3.71); causes clots to form in the heart, which are then for intracerebral hemorrhagic stroke, the risk pumped out into the arteries and to the brain, was over 9 times higher (OR =​9.18, 95% CI =​ where the clots plug up vessels that supply 6.80–​ 12.39) (O’Donnell et al., 2010). Those blood to the brain, causing an ischemic stroke. odds ratios (ORs) held after controlling for Atrial fibrillation is known to increase the risk smoking status, waste-​to-​hip ratio, diet risk of stroke by about 5-​fold, and counts for 25%–​ score, physical activity, diabetes mellitus, alco- 30% of all ischemic strokes and transient ischhol intake, psychosocial factors (psychosocial emic attacks (TIAs) (Pistoia et al., 2016). stress, depression), cardiac causes, and ApoB (apolipoprotein B) to ApoA1 ratio, and assoH IGH CH OL ESTEROL ciations were particularly strong among those age 45 or younger. In a later follow-​up by this More than one-​ third (38.2%) of Americans research group of 13,447 stroke cases and have a total cholesterol of 200 mg/​dL or higher 420 •  P h y sical H ealth

(American Heart Association, 2020b). When comparing 3,000 stroke cases (2,337 with ischemic stroke, 663 with hemorrhagic stroke) and 3,000 controls from 22 countries, O’Donnell et al. (2010) found a nearly 50% increase in risk of ischemic stroke among those with LDL/​HDL cholesterol ratios in the top one-​third compared to those in the bottom one-​third (OR =​1.47, 95% CI =​1.17–​1.86). Interestingly, however, the reverse was true for hemorrhagic stroke (OR =​0.43, 95% CI =​0.43–​0.30–​0.62), which investigators had difficulty explaining. More recently, research has confirmed that non-​HDL cholesterol is associated with an increased risk of stroke, particularly ischemic stroke and especially in men (Wang et al., 2018; Saito et al., 2019). D I A BE TE S

Given the rapid increase over the past 10 years in the percentage of Americans who are overweight or obese (Hales et al., 2018), nearly 1 in 10 US adults (9.8%) were diagnosed with diabetes in 2016 (American Heart Association, 2020b). Diabetes is also common worldwide, with an estimated 347 million people with the disorder (Peters et al., 2014). Those with diabetes have a significantly greater risk of stroke (all types). In a review and meta-​analysis of 102 prospective studies, Sarwar and colleagues (2010) found that the hazard ratio (HR) for stroke among those with diabetes was 2.27 (95% CI =​1.94–​2.65) for ischemic stroke, 1.56 (95% CI =​1.19–​2.05) for hemorrhagic stroke, and 1.84 (95% CI =​1.59–​2.13) for unclassified stroke. This means the presence of diabetes increased risk for stroke by 56% to 127%. Similarly, in a review of 64 cohort studies including 775,385 individuals who experienced 12,539 strokes (all kinds), Peters et al. (2014) reported a risk ratio (RR) of 2.28 (95% CI =​1.93–​2.69) for women and 1.83 (95% CI =​1.60–​2.08) for men with diabetes. Finally, in a review of type II diabetes and stroke incidence among 1.9 million individuals followed for 5.5 years, Shah et al. (2015) found that the risk of ischemic stroke was increased by almost 75% (RR =​1.72, 95% CI =​ 1.52–​1.95). Thus, the risk of stroke regardless of type (although especially ischemic stroke) is approximately double in those with diabetes compared to non-​diabetics.

GEN D ER AN D STROKE- S ​ P ECIF IC RISK FACTORS

In a systematic review and meta-​analysis of 78 studies conducted in the United States (70 with a longitudinal design and 8 with a case-​control design), Poorthuis and colleagues (2017) reviewed gender-​specific risk factors for different kinds of stroke. For women experiencing an ischemic stroke, significant risk factors were having a history of hypertension during pregnancy (gestational hypertension, pre-​eclampsia, eclampsia; RR =​1.80, 95% CI =​1.49–​2.18) and having a history of gestational hypertension alone (RR =​1.81, 95% CI =​1.44–​2.27). The risk of hemorrhagic stroke was greater for women who experienced natural menopause at age 55 or older compared to those who did so at younger ages (50–​54) (RR =​2.24, 95% CI =​1.19–​4.21); for women with a history of gestational hypertension, the risk of hemorrhagic stroke was also increased (RR =​5.08, 95% CI =​1.80–​14.34). Male-​specific risk factors for ischemic stroke were receipt of androgen deprivation therapy (RR =​1.19, 95% CI =​1.05–​1.34), orchiectomy (RR =​1.21, 95% CI =​1.00–​1.46), and erectile dysfunction (RR =​1.35, 95% CI =​1.18–​1.53). Thus, women experiencing hypertension at any time during pregnancy and those experiencing menopause at later ages were at increased risk for stroke, as were men with lower levels of testosterone from any cause.

Psychological Psychological or emotional stress, depression, and anxiety also increase risk of stroke, and are particularly important in terms of triggering a stroke. Numerous reviews and meta-​ analyses have reported a strong relationship between psychological stress and future risk of stroke (Booth et al., 2015; Kotlega et al., 2016; Kivimaki & Steptoe, 2018; Graber et al., 2019). With regard to individual studies, in O’Donnell and colleagues’ (2010) case-​control study involving 3,000 case-​ control pairs recruited from 22 countries, psychosocial stress increased risk of all stroke types by 30% (OR =​ 1.30, 95% CI =​1.06–​1.60), especially ischemic stroke. Depression, in turn, increased stroke risk by 35% overall and 47% for ischemic stroke (OR Cerebrovascular Disease • 421

=​1.47, 95% CI =​1.19–​1.83). In their more recent case-​control study involving 26,919 participants from 32 countries, O’Donnell et al. (2016) compared 13,447 acute first-​stroke cases (10,388 ischemic strokes and 3,059 strokes from intracerebral hemorrhage) to 13,472 control hospitalized patients with other health conditions. Risk of stroke was more than double among those experiencing psychosocial stressors (measured by a combined of stress at home and work, life events, and depression) (OR =​2.20, 99% CI =​ 1.78–​ 2.72), which was independent of nine other established stroke risk factors. This finding was particularly strong in China (OR =​6.27) and South Asia (OR =​4.11) for ischemic stroke and in China (5.12) and in Eastern and Central Europe and the Middle East (OR =​4.68) for intracerebral hemorrhage. Likewise, in a 12-​year prospective study of 330,367 US adults participating in the National Health Interview Survey, psychological distress increased risk of death from CBVD in a stepwise manner from 19% (low stress) up to 74% (high stress; HR =​1.74, 95% CI =​1.32–​2.28) (Yang et al., 2020). While psychological factors influence the development of CBVD to a considerable degree, their role in triggering stroke among those with preexisting CBVD is probably even greater (Guiraud & Touzé, 2013; Kivimaki & Steptoe, 2018). In addition, psychosocial factors may also affect disease outcomes after stroke in terms of size, recurrence, disability, and mortality (Kivimäki & Steptoe, 2018). The physiological mechanisms by which psychological distress increases risk of stroke or affects its course are not well understood (Cohen et al., 2015; Lightbody et al., 2017). However, acute and chronic stress, anxiety, and depression are known to increase overall body inflammation. Increased body inflammation affects the arteries that supply blood to the brain, causing plaque to build up and to narrow these arteries to the point where they are unable to supply necessary oxygen and blood to brain tissues. This results in ischemia, infarction, and death of brain cells, resulting in an ischemic stroke. It also increases the stiffness/​ brittleness of intracerebral arteries, which increases risk of hemorrhagic stroke. Furthermore, autonomic nervous system (sympathetic and parasympathetic) and hypothalamus-​pituitary-​adrenal 422 •  P h y sical H ealth

(HPA) responses to psychological stress combine to increase platelet activation, fibrinogen levels, blood viscosity, and coagulation factors that favor clot formation and precipitation of ischemic stroke. Other mechanisms include the effects of psychological stress on other risk factors for stroke (e.g., hypertension, diabetes, hypercholesterolemia) and on negative health behaviors (smoking, obesity, excessive alcohol intake). Psychological factors may also interact with demographic characteristics such as SES to increase risk of stroke. Lazzarino and colleagues (2013) found that those with high psychological distress and low SES were over 30% more likely to die from stroke (HR =​1.31, 95% CI =​1.13–​ 1.51, p < 0.001), whereas among those with high distress and high SES, greater psychological distress did not increase risk of stroke death.

Social Low social support and social isolation are known risk factors for stroke, hypercholesterolemia, and atherosclerosis more generally (Rozanski et al., 1999; Valtorta et al., 2016). In a review of 23 studies, including 16 prospective studies, including 3,002 stroke events during follow-​up periods ranging from 3 to 21 years, poor social relationships were associated with a 32% increased risk of incident stroke (RR =​1.32, 95% CI =​1.04–​1.68) (Valtorta et al., 2016). There were no differences by gender. With regard to individual studies, Dupre (2016) analyzed data from a random national sample of 23,289 persons over age 50 in the US Health and Retirement Study. Participants were followed from 1992 to 2010, examining the effect of marital history on stroke incidence. Over 2,000 strokes occurred during the 18-​year follow-​up. Risk of stroke was significantly higher among participants who were divorced (OR =​1.30, p < 0.01), remarried (1.34, p < 0.001), or widowed (OR =​1.67, p < 0.001) compared to those who were continuously married (results controlled for age, gender, study cohort, urban-​rural residence, and geographic region). Similarly, Gafarova and colleagues (2019) followed a random sample of 657 men and 689 women age 25–​64 in Siberia, Russia, over a period of 16 years, examining risk

factors for new-​onset stroke. After controlling for education, occupational status, marital status, and age, stroke risk among those with low social network scores was over twice as high in both men (HR =​2.2, 95% CI =​1.3–​3.8) and women (HR =​2.2, 95% CI =​1.1–​4.5). Among those with few close social contacts, the risk of stroke was also twice as high in men (HR =​2.0, 95% CI =​1.27–​3.61) but four times higher in women (HR =​4.1, 95% CI =​1.7–​10.2). The mechanism for the effect of low social support on stroke risk is thought to be a combination of influences, including worse psychological health due to more difficulty coping with life stressors from lack of support, poorer health behaviors, higher BP, and worse immune functioning. There are also physiological mechanisms that help to explain this effect. Social isolation appears to be related to lower levels of brain-​derived neurotrophic factor (BDNF). Low BDNF, which plays a major role in brain neurogenesis, angiogenesis, and neuronal survival, has been associated with a nearly 50% increased risk of stroke (Pikula et al., 2013). In the Framingham Heart Study that involved 3,294 participants (Salinas et al., 2017), those who were socially isolated also tended to have lower levels of serum BDNF (OR =​0.69, 95% CI =​0.47–​1.00, p =​0.05) in cross-​sectional analyses after controlling for age and gender, whereas those with more emotional support had higher BDNF levels (OR =​1.27, 95% CI =​1.04–​1.54). Over time in that study, participants with greater emotional support (particularly those who could count on someone to listen to them if they needed to talk) experienced a lower risk of incident stroke over a median 11-​year follow-​ up (HR =​0.59, 95% CI =​0.41–​0.83). There was also a significant interaction between social relationships and smoking status on stroke risk, such that among smokers who had someone to listen to them, the risk of stroke was more than 75% lower compared to those who did not (HR =​0.23, 95% CI =​0.10–​0.57).

Behavioral Perhaps the strongest risk factors for CBVD involves behaviors. These include cigarette smoking, drug use, physical inactivity, poor nutrition, and failure to control weight.

SM OKIN G AN D D RUG USE

In 2018, the rate of current smoking among US adults age 18 or older was 13.7% (22.6% for Native Americans/​Alaska Natives, 14.6% for African Americans, 15.0% for Caucasian Whites, 9.8% for Hispanics, and 7.1% for Asians) (CDC, 2019). Smoking increases the risk of stroke, especially hemorrhagic stroke, in a dose-​response manner (Shah & Cole, 2010). Use of cocaine, methamphetamines, and other stimulants increases risk of stroke by either increasing BP (causing blood vessels in the brain to leak or rupture, resulting in a hemorrhagic stroke) or by causing cerebral blood vessels to constrict (thereby limiting blood flow to the brain, causing an ischemic stroke) (Esse et al., 2011). Methamphetamine use in particular carries a high stroke risk, especially hemorrhagic stroke, which accounts for 1%–​5% of all methamphetamine-​related deaths. Overall, amphetamines cause 6%–​13% of hemorrhagic strokes and 2%–​6% of ischemic strokes among young adults (Lappin et al., 2017). AL COH OL CON SUM P TION

Heavy alcohol use is another risk factor for stroke, especially ischemic stroke. In a review of 27 prospective studies reporting data on 1,425,513 individuals, Zhang et al. (2014) found that this relationship appears to be J-​ shaped. In other words, low alcohol intake (< 15 grams/​day) reduces risk of stroke compared to no alcohol use, moderate alcohol use (15–​30 grams/​day) is not associated with stroke risk, and heavy use (> 30 grams/​day) predicts a significant increased risk of stroke. For reference, 13.2 grams is contained in a bottle of beer, 10.8 grams in a small glass of wine, and 15.1 grams in a drink of liquor. The relationship between heavy alcohol use (particularly binge drinking) and stroke is especially strong among those with hypertension, an effect that appears to be independent of smoking (Hillbom et al., 2011). P H YSICAL IN ACTIVITY AN D D IET

In 2016, only 24.3% of US adults met the 2018 Physical Activity Guidelines for Americans; in 2017, 25.9% of US adults engaged in no Cerebrovascular Disease • 423

leisure-​time physical activity (American Heart Association, 2020b). Regular physical activity has been shown to both decrease the risk of stroke (Kyu et al., 2016) and reduce the severity of stroke (Reinholdsson et al., 2018). Physical exercise improves many risk factors for stroke, including hypertension, diabetes, obesity, and cholesterol, reducing psychological stress as well. In 2016, 47.8% of Americans consumed a poor diet according to the American Heart Association healthy diet criteria (American Heart Association, 2020b). Adherence to a Mediterranean diet (one that is high in vegetables, fruits, whole grains, beans, nuts and seeds, and olive oil) has been shown to significantly reduce risk of both hemorrhagic and ischemic stroke (Chen et al., 2019). In contrast, diets high in sodium (salt) and low in potassium increase risk of stroke in a dose-​response manner (Jayedi et al., 2019). W E I GH T

As noted in Chapter 19, nearly 40% of the US population age 20 or older are obese, which increases to close to 50% among African and Hispanic Americans (Hales et al., 2018; American Heart Association, 2019b). Likewise, approximately one-​third of the world’s population is now overweight or obese (Chooi et al., 2019). The risk of stroke, especially ischemic stroke, increases with increasing weight (Strazzullo et al., 2010), especially in those with a BMI of greater than 25 (Liu et al., 2018). In that population group, there is a linear dose-​ response relationship between BMI and risk of stroke. Furthermore, increased weight also adversely affects rehabilitation following a stroke (Kalichman et al., 2016). In summary, there are numerous demographic, genetic, biological, psychological, social, and behavioral characteristics that increase risk of stroke. Religious involvement may influence (or be influenced by) many of these factors, affecting the relationship between religiosity and stroke.

RELIGION AND STROKE Having reviewed the causes of stroke, we now examine how religiosity might impact the 424 •  P h y sical H ealth

development and course of CBVD, stroke in particular. We begin with a case vignette.

Case Vignette Rebecca awoke that morning with a feeling that something was different. Soon, she realized that she could not move her right arm or leg and when she cried out for help, her words seemed jumbled. Age 73 with a history of hypertension and diabetes, Rebecca lived with her husband in a senior apartment complex. He was making coffee in the kitchen when he heard the strange sounds coming from the bedroom. When he saw the expression on his wife’s face and heard her mumbled cries for help, he immediately called 911. At the hospital, the doctors diagnosed Rebecca with a left hemispheric stroke that affected her right side and ability to produce speech. She remained in the hospital for a week until she was stabilized and on appropriate blood thinners to prevent further damage and was then discharged to a rehabilitation setting. It was hard for the first couple of weeks being in the nursing home and feeling helpless and completely out of control. So, she prayed. When her children were small, Rebecca had started going to church, and for the past 50 years had been a devout believer. Although she couldn’t understand why God would allow this to happen to her, she really had no other place to turn. Yes, her husband and children were very supportive and made frequent visits. However, most of her time was spent alone, with just herself and her thoughts. Rebecca’s faith was all she had now, and she believed that God still had a purpose for her life. She spent much of her time reading the Bible, and as her condition improved, she began to look outside of herself and her problems. She tried to help her roommate, who was completely disabled by dementia and unable to care for even her most basic needs. She also expressed

thanks to God that her condition was not like her roommate’s. She began reaching out to and encouraging other patients at the facility as well, which helped her feel better about herself. After three months of rehabilitation, Rebecca was discharged back home with her husband. She had made numerous friends at the nursing home, and once a week she and her husband would go back to the home and visit those friends.   

Although the above case says little about the effect of religiosity on stroke risk, it does illustrate the role that religious involvement can play in terms of coping following a stroke and the effects that this may have on disease progression and disability. As with the relationship between religiosity and hypertension, the one between religiosity and stroke is a complex one. Hypothetically, there are many ways that religiosity could affect the development and course of CBVD at least indirectly by influences on stroke risk factors. As noted earlier, religiosity can directly affect psychological, social, and behavioral characteristics that lead to the development of medical conditions that increase stroke risk (hypertension, diabetes, high cholesterol, cardiac arrhythmias). Thus, the influence of religiosity on risk of stroke is likely to be primarily indirect through these other pathways. Since religiosity primarily influences CBVD and stroke indirectly, this will affect the strength of the relationships examined. Demographic characteristics (e.g., older age, female gender, Black race, low SES) may also be related to both stroke risk and religiosity, thereby creating an artificial relationship as a result of confounding, requiring that demographic factors be controlled for in statistical analyses. Reverse-​ causation may also be an issue where, as in the case vignette above, those who experience a stroke may develop disability, which causes them to turn to religion for comfort and support, thus creating a positive relationship between religiosity and stroke. With this background, how might religious

involvement influence the risk of developing a CBVD, precipitating a CBVD event (e.g., stroke), or affecting the course of CBVD acting through factors that increase risk of CBVD?

Demographics While religiosity may not have much influence on demographic characteristics such as age, gender, race, or SES, as noted above, these characteristics can confound the relationship between religiosity and CBVD risk. As noted in previous chapters, religious involvement increases with increasing age, is higher in women than men, is more frequent in African Americans than in White Americans, and is more common among the poor (lower social class, lower SES). Stroke is also more common in older adults, African Americans, those with low SES, and is inconsistently related to gender (although it tends to be more frequent in women at older ages given their greater longevity). Thus, analyses examining the relationship between religiosity and stroke or the impact of religiosity on stroke over time must control for these demographic characteristics. Demographic characteristics are also likely to confound the relationship between religiosity and stroke risk factors, including hypertension, diabetes, serum cholesterol, smoking, physical activity level, alcohol and drug use, psychological and social factors.

Genetic As indicated above, genetic factors account for approximately 40% of the risk of stroke. How religiosity might impact stroke risk through genetic factors is poorly understood. However, epigenetic influences during infancy that affect stress reactivity later in life is one pathway (see Chapter 16). Epigenetic changes affect stress-​ reactivity later in life, and these changes may be passed on to future generations (Dias & Ressler, 2014; Janusek et al., 2019). If they are less stressed, depressed, addicted, socially isolated, or experiencing marital conflict, religious caretakers may be more available to infants and able to meet their basic needs for love and nurturance. If that is the case, then religiosity might impact BP reactivity and other physiological Cerebrovascular Disease • 425

stress responses that increase risk of vascular disease more generally and CBVD in particular, especially in later life.

Biological/​Medical Major medical risk factors for stroke include hypertension, cardiac causes, carotid artery disease, high cholesterol, and diabetes. Religiosity may influence stroke risk by affecting one or more of these risk factors.

that family conflict during early life, which in adulthood results in fewer pleasant social interactions and more frequent social conflict, predicts increased CA-​IMT during later adulthood, thereby increasing risk of stroke (Loucks et al., 2014; John-​Henderson et al., 2016). If parental religiosity is associated with greater marital and family stability, then it may decrease CA-​ IMT during adulthood and reduce the development of atherosclerotic vascular disease more generally that affects blood vessels in the brain that branch off the carotid artery.

HY P E RTE N S I O N

Although the evidence is certainly not definitive, nearly half of all studies, including a significant number of prospective studies (see Chapter 21), report that religious involvement is related to lower BP or reduced likelihood of hypertension, one of the strongest risk factors for stroke. CA RD I AC CAU SE S

Religiosity may also impact risk of stroke by effects on the heart. In our systematic review of studies examining religiosity and heart disease (Chapter 20), the majority of studies published prior to 2010 found an inverse relationship between religiosity and coronary heart disease (CHD), as well as several studies since then. Furthermore, a significant minority of prospective studies found that religiosity predicted better outcomes from CHD. Considerable research indicates that CHD, particularly in the context of an acute myocardial infarction or congestive heart failure, increases the risk of atrial fibrillation (Kralev et al., 2011; Zoni-​Berisso et al., 2014), which is among the strongest risk factors for stroke (see above). CA ROTI D A RTE RY DIS E AS E

Religious involvement may also affect the development of carotid artery disease. As noted above, CA-​IMT is an indicator of atherosclerotic vascular disease affecting the carotid arteries. CA-​IMT is also a measure of atherosclerotic vascular disease more generally, including small arteries that branch off the carotid artery and supply blood to the brain. There is evidence 426 •  P h y sical H ealth

H IGH CH OL ESTEROL

Hypercholesterolemia is another risk factor for vascular atherosclerosis, CA-​ IMT thickness, and stroke, which religiosity could influence by affecting the quality of diet consumed. As indicated in Chapter 19, the majority of studies show that people who are more religious eat a healthier diet and often consume more vegetables (vs. high-​cholesterol-​containing meats and unhealthy fats). Our review of religiosity and serum cholesterol studies (see Appendix) found that the majority reported an inverse relationship between religiosity and high cholesterol, supporting this logic. D IABETES

Diabetes is a strong risk factor for stroke (Kivimäki & Steptoe, 2018). The relationship between religious involvement and diabetes is unclear, since those who are more religious tend to be overweight, and being overweight is associated with a greater chance of developing adult-​onset type II diabetes. However, there is research indicating that religiosity is positively associated with compliance in terms of diabetic self-​care activities (healthy diet, regular exercise, blood glucose testing, foot care, not smoking), thereby improving diabetic control among those with diabetes (Samuel-​ Hodge et al., 2000; Newlin et al., 2008; Watkins et al., 2013; Heidari et al., 2017). This is particularly true for African Americans, who are at high risk for having both diabetes and hypertension, a deadly combination that significantly increases risk of stroke (Kivimaki & Steptoe, 2018).

Psychological Given the effects that psychological stress has on (1) developing CBVD (increasing risk by 30% to 220%), (2) triggering a stroke, and (3) affecting stroke outcome, and the effects that religious involvement has on coping with stress (Chapter 4), this provides rationale for hypothesizing a beneficial effect of religiosity on stroke risk through this pathway. Similarly, depression and anxiety are both known to increase stroke risk, and religiosity is inversely related to both of these conditions in one-​half to two-​thirds of studies, with the evidence for depression being especially strong (Chapters 5 and 8). Again, these serve as plausible mechanisms by which religious beliefs and practices could reduce stroke risk. Given the impact of emotional distress on stroke outcome (size of stroke, disability from stroke, and recurrence of stroke), the possible benefits of religious belief and practice in relieving that distress are notable (Giaquinto et al., 2007).

Social Low social support and social isolation increase risk of stroke by one-​third to more than double (see above). Given the positive relationship between religious involvement and social support reported in more than 80% of studies, religiosity could reduce CBVD and stroke risk by surrounding the individual with a caring community of like-​minded believers that could increase social support during times of stress and reduce social isolation. Attendance at religious services and involvement in other social religious activity may be particularly important in this regard.

Behavioral Health behaviors known to increase risk of stroke include cigarette smoking, drug use, alcohol consumption, physical inactivity, poor diet, and increased weight. These are some of the strongest risk factors that lead to the development of CBVD. Every one of these is modifiable, and anything that positively affects these behaviors has the potential to reduce risk of stroke, precipitation of stroke,

and disease course following stroke. Religious involvement is inversely related to every one of the unhealthy behaviors mentioned above. Religiosity was reported to be related to less cigarette smoking in 90% of studies (Chapter 17), less alcohol consumption and drug use in over 85% of studies (Chapter 10), more physical activity and exercise in the majority of studies (Chapter 18), better diet in the majority of studies (Chapter 19), and possibly lower weight, though the evidence for this is less clear (Chapter 19). As noted earlier, being overweight or obese dramatically increases the likelihood of developing type II diabetes (Tirosh et al., 2011) and risk of stroke, an effect that is independent of diabetes (Bazzano et al., 2010). Although earlier cross-​sectional studies found that religious people tended to weigh more than the nonreligious, some more recent prospective studies have found that religiosity or religious activity predicts either a reduction in weight/​BMI or has no effect (Chapter 19). More than any other pathway, then, the effects of religiosity on health behaviors is where religion likely has its greatest impact on stroke risk. Indeed, religiosity’s role in developing self-​control of harmful health behaviors helps to explain many of religion’s positive health effects (McCullough & Willoughby, 2009), and protection from stroke may be one of them.

RESEARCH ON RELIGIOSITY AND CEREBROVASCULAR DISEASE The above speculations provide mechanisms by which greater religious involvement might reduce the development of CBVD, lower stroke risk, and improve physical outcomes following stroke. Unfortunately, there have not been many high-​quality studies that have examined these possibilities. This is particularly true with regard to prospective cohort studies that have followed individuals for a sufficient duration to determine the impact of religiosity on indicators of CBVD, such as stroke and atherosclerotic carotid artery disease (CA-​IMT). Below, we review earlier research conducted prior to 2010 and more recent research published since then. Again, emphasis is placed on prospective cohort studies when available. Cerebrovascular Disease • 427

Early Research Among studies published before 2010, our systematic review identified two cross-​sectional studies, three prospective studies, and a single RCT.

those who did not attend services (OR =​1.64, 95% CI =​1.09–​2.48, p < 0.05). RETROSP ECTIVE COH ORT STUDY

Assuming that clergy are more religious than others, differences in death from stroke among clergy ought to provide information about the C ROSS -​SE C TI O N AL S T UDIE S religiosity-​stroke relationship. Doody and colAnalyzing data from a national random sam- leagues (2000) conducted a 7-​year retrospective ple of 14,192 community-​dwelling US adults, cohort study of 145,000 radiologic technolObisesan and colleagues (2006) found that ogists, which included 1,103 technologists participants who attended religious services classified as nuns (Catholic sisters). Standard more frequently were significantly less likely mortality ratios (SMR) from different causes, to report having had a stroke (told by their including CBVD, were determined. SMR for physician they had a stroke). This was partic- CBVD was compared between the nuns and (1) ularly true for White men (OR =​0.61, 95% CI the other female radiologic technologists and =​0.41–​0.90) and African American women (2) US white females in general. Investigators (OR =​0.34, 95% CI =​0.19–​0.61), after adjust- found no difference in death from CBVD ing for age, education, marital status, region between nuns and other female technologists of country, and metropolitan residence. This (SMR =​1.10, 95% CI =​0.80–​1.40). However, effect persisted in African American women nuns had significantly (20%) fewer deaths from (OR =​0.35, 95% CI =​0.19–​0.66, p < 0.01) CBVD than US females more generally (SMR =​ after further adjustment for mobility lim- 0.80, 95% CI =​0.60–​0.98). Differences in alcoitations, current smoking status, poor self-​ hol use and smoking may have explained the reported health, and hypertension (some difference, as only 11% of nuns reported ever of which might have been mediators of the smoking cigarettes and one might assume that association). Thus, the likelihood of having a they were not heavy drinkers either. stroke was nearly two-​thirds lower in African American women who attended religious serP ROSP ECTIVE COH ORT STUD IES vices weekly or more. Feinstein et al. (2010) analyzed data from The first of three longitudinal studies was conthe MESA study (Multi-​ Ethnic Study of ducted by Colantonio and colleagues (1992), Atherosclerosis) that involved 6,814 adults age who followed a random sample of 2,812 adults 45–​84 living in large US cities (average age 63; age 65 or older participating in the Yale Health 50% African American or Hispanic) and was and Aging Study. Frequency of religious attendesigned to examine risk factors for CVD. Of dance, self-​rated religiosity, and religion as a the baseline sample (T1), 80% were followed source of strength and comfort were assessed up after 4 years (T2; n =​5,474). At T2, three at baseline in 1982. Incidence of stroke was religious characteristics were assessed: reli- determined during follow-​ up (1982–​ 1988). gious attendance, private religious activity, Uncontrolled analyses revealed that, compared and daily spiritual experiences (the latter by a to those who never attended religious services, 5-​item scale). Risk factors for stroke assessed attendees were 14% less likely to experience a at T2 included ankle-​brachial index, CA-​IMT, new-​onset stroke during follow-​up (RR =​0.86, and hypertension. After adjusting analyses for 95% CI =​0.79–​0.94). Religious attendance was age, sex, race, education, and income, investiga- the only psychosocial variable (among deprestors unexpectedly found a positive correlation sive symptoms, marital status, social network between daily religious attendance and CA-​ index, and number of types of support) to IMT (a measure of CBVD that is often asymp- predict stroke incidence. When age, gender, tomatic). Daily attendees were 64% more likely housing stratum, hypertension, diabetes, physto have CA-​IMT > 90th percentile compared to ical function, and smoking were controlled for, 428 •  P h y sical H ealth

however, the effect of religious attendance was attenuated and nonsignificant. The controlling for hypertension, physical functioning, and smoking status, i.e., known inverse correlates of religious attendance and possible mediators of the effect of religious attendance on stroke risk, may have accounted for this. Berges and colleagues (2007) examined the effects of religious attendance on physical functioning after stroke in a population-​based random sample of 3,050 Mexican American participants age 65 or over living in five Southwestern US states. Four waves of data collection occurred between 1993 and 2001. Average age at baseline was 73.0 years in 1993. The target sample for this analysis was 118 persons who reported a first-​time stroke and impaired physical functioning due to the stroke during a 3-​year follow-​up period. The outcome was change in ADL disability, IADL (instrumental activities of daily living) disability, and lower body function (Performance Oriented Mobility Assessment POMA). Results indicated that participants attending religious services at least once a week at baseline were significantly less likely to experience declines in ADL ability (F =​5.95, p =​0.017), IADL ability (F =​3.95, p =​0.05), and lower body dysfunction (F =​5.32, p =​0.024) following the stroke, controlling for age, gender, marital status, education, heart attack, diabetes, arthritis, baseline value of each outcome, and time when stroke occurred. In a 5-​year prospective study of 932,264 community-​ dwelling adults in Northern Ireland, O’Reilly and colleagues (2008) examined the predictors of death from stroke between 2001 and 2006 (age range 25–​74, with 70% under age 55). Religious denomination was the only measure of religiosity, although one category was “other/​none” that included non-​Christians and those who indicated “none” for religious affiliation (n =​58,208). According to the Northern Ireland Census in 2001, 0.4% of the population reported a non-​Christian religious affiliation and 2.0% indicated “none” for religious affiliation (NISRA, 2019). Thus, the vast majority of individuals in the “other/​none” category consisted of those indicating “none.” Among men (stroke deaths =​1,016), compared to Catholics, those in the “other/​none” category experienced a slightly increased risk of

death from stroke, though with a confidence interval containing the null, during the 5-​year follow-​up (HR =​1.13, 95% CI =​0.85–​1.50). Among women (stroke deaths =​921), compared to Catholics, the “other/​none” group had a slightly decreased (again with a confidence interval containing the null) risk of dying from stroke during follow-​up (HR =​0.73, 95% CI =​ 0.51–​1.06). Analyses were controlled for age, marital status, education, social class, car availability, tenure, and population density of area of residence. In the MESA study above, Feinstein et al. (2010) conducted a 4-​year follow-​up from T2 to T3 to identify incident stroke and TIAs. A total of 11 TIAs and 24 strokes were identified. No religious measure (religious attendance, private religiosity, or daily spiritual experiences) predicted TIA or stroke, although as indicated above, the small number of TIAs and strokes reduced the statistical power of this study to identify predictors, which the investigators readily admitted. RAN D OM IZED CON TROL L ED TRIAL ( RCT)

Castillo-​ Richmond and colleagues (2000) at Maharishi University, in Fairfield, Iowa, examined the effects of transcendental meditation (TM) on CA-​IMT using B-​mode carotid ultrasound. African Americans over age 20 with high BP (130–​179 mmHg systolic and 80–​109 mmHg diastolic) were randomly assigned to either TM or a health education control group. After a week of initial instruction, follow-​ up meetings were held every 2 weeks for 2 months and then once/​month for 3 months, with subjects practicing TM for 20 minutes twice daily for 7 months. The health education group received similar amounts of instruction and home practice. Carotid ultrasound was used to measure CA-​IMT at baseline and 6 to 9 months later. Of the 138 initial participants, only 60 subjects completed pretest and post-​ test assessments of carotid IMT, 31 in TM group and 29 in the health education control group (“Fiscal restrictions precluded completion of posttest evaluation for all subjects”). Results indicated that the TM group showed a significant decrease of –​0.098 mm in CA-​IMT Cerebrovascular Disease • 429

compared to the control group, which experienced an increase of 0.054 mm in IMT (p =​ 0.04, controlled for age and baseline CA-​IMT).

religion (p < 0.0001). Although statistical significance was not provided for death by stroke (and differences are therefore presumed to be nonsignificant), those who indicated a religious affiliation experienced a slightly lower rate of Recent Research death by stroke (7.4%) compared to those with Since 2010, we have identified one cross-​ no affiliation (8.0%). In contrast, those who sectional and seven prospective cohort studies attended religious services weekly had a slightly that examined the relationship between religi- higher rate (7.6%) compared to those who had osity and CBVD. not attended services in the past month (7.1%). Finally, those who indicated a great deal of strength or comfort from religion (7.4%) had a C ROSS -​SE C TI O N AL S T UDIE S slightly lower risk of stroke death compared to Anyfantakis et al. (2013) conducted a study those who indicated no such strength/​comfort involving 195 Greek-​ speaking participants (7.6%). These uncontrolled comparisons were (50% female, mean age 67 years, almost all not discussed in the paper. Christian Orthodox) living in the rural town Morgenstern et al. (2011) followed 669 medof Spili on the island of Crete. Religiosity was ical patients with new-​onset stroke for a period assessed with the Royalty-​Free Interview for of 1 to 5 years. Participants were all patients Spiritual and Religious Beliefs (RFI-​SRB), which with stroke admitted to seven hospitals in assesses strength and importance of religious/​ Nueces County, Texas, between 2004 and 2008 spiritual beliefs by six questions, with the total (out of 3,053 patients with CBVD admitted score ranging from 0 to 60. Among biological during this time). Participants (54% Mexican characteristics determined was CA-​IMT, mea- American) were interviewed at the time of sured by carotid ultrasound. Uncontrolled stroke hospital admission. A wide range of psyanalyses indicated that those scoring below chosocial variables were assessed, with the time the median on the RFI-​SRB had significantly frame being pre-​stroke (psychological adjustgreater CA-​ IMT values compared to those ment, fatalism, optimism, depressive sympscoring at or above the median (CA-​IMT mm =​ toms, and religious/​spiritual importance). The 1.53, SD =​0.50, compared to 1.01, SD =​0.10, latter was assessed by asking about the imporrespectively, p < 0.001). tance of R/​S as a source of meaning in life and the importance of R/​S beliefs for what they did every day, with responses ranging from 0 (not PRO S P E C TI VE C OHORT S T UDIE S at all important) to 3 (very important). Stroke Schnall and colleagues (2010) analyzed data on severity was assessed by medical record review, 92,395 women age 50–​79, followed for an aver- and recurrent ischemic stroke, intracerebral age of 7.7 years, with the goal of identifying the hemorrhage, and subarachnoid hemorrhage effects of religious involvement on CVD out- were determined based on a standard study comes, including stroke. Measures of religiosity protocol (Brain Attack Surveillance in Corpus included religious affiliation (yes vs. no), fre- Christi, or BASIC project). All-​cause mortality quency of attendance at religious services, and was determined from the medical record for strength and comfort from religion. Outcomes in-​ hospital mortality, Texas Department of included all-​ cause mortality, coronary heart Health databases, and Social Security Death disease (CHD) events, CHD mortality, and Index. Recurrence of stroke and all-​ cause stroke mortality (documented by self-​report, mortality was assessed through December 31, confirmed by medical record review). Baseline 2009. Cox proportional hazards regression was religious involvement was examined as a pre- used to determine effects of predictors on time dictor of death. All-​cause mortality was sig- to recurrence or mortality, and linear regresnificantly lower among those with a religious sion was used to examine the cross-​sectional affiliation (p =​0.05) and those who indicated relationship with stroke severity. Results india great deal of strength and comfort from cated that R/​S did not have a significant effect 430 •  P h y sical H ealth

in bivariate or multivariate analyses on stroke severity, recurrence, or mortality. Feinstein and colleagues (2012) prospectively followed 2,433 young adults (age 18–​ 30 in 1985–​1986) living in Chicago, Illinois; Minneapolis, Minnesota; Oakland, California; and Birmingham, Alabama, who were followed up through 2006 (20 years later). In the second wave of data collection (1987–​1988), demographic, biological, and medical risk factors were assessed, along with frequency of religious participation (“How frequently do you participate in religious activities?” with responses ranging from never to once/​week or more). At the 20-​year exam, CA-​IMT was assessed using high-​ resolution B-​ mode ultrasound. Logistic regression models were used to examine the effects of religious activities on cardiovascular outcomes, including CA-​ IMT, controlling for demographics (age, gender, race, income, education) and risk factors (systolic BP, diastolic BP, BMI, triglycerides, total cholesterol, HDL cholesterol, diabetes, and smoking). Any level of religious participation in 1987–​1988 predicted a significantly lower risk of CA-​IMT > 90th percentile compared to no religious participation, independent of demographics and risk factors (OR =​0.56, 95% CI =​0.38–​0.83). Note that these effects were present after controlling for BP, BMI, cholesterol, and smoking, i.e., possible mediators of the effects of religiosity on CA-​IMT. When analyses were stratified by race, after controlling for demographics and risk factors, effects were present only in Whites (OR =​0.38, 95% CI =​0.22–​0.68), not Blacks (OR =​0.77, 95% CI =​0.42–​1.44). As reviewed in Chapter 20, Li and colleagues (2016b) examined the relationship between 1996 religious attendance and incidence of CVD events and mortality (including CBVD events and mortality) in 74,534 women followed for 18 years from 1996 to 2012 in the Nurses’ Health Study. Religious attendance in 1992 was controlled for as a covariate, and those diagnosed with CVD before 1996 were excluded. In addition to 1992 attendance, many other demographic, socioeconomic, and social, mental, behavioral, and physical health variables were controlled for. Mediators assessed after the 1996 religious attendance exposure were depressive symptoms, smoking, alcohol

consumption, diet quality, number of close friends, having someone close to talk to, optimism, and phobic anxiety. Based on information contained in the article’s online Appendix (eTable 6), death from CBVD was significantly lower in those who attended religious services more frequently in 1996. Compared to those who never attended religious services, those who attended greater than once per week were significantly less likely to die from CBVD compared to those who never attended (HR =​0.74, 95% CI =​0.55–​1.00, p for trend =​0.002), independent of all risk factors. With regard to stroke incidence during follow-​up (eTable 9), analyses adjusting for age only indicated that those who attended religious services frequently were less likely to experience a stroke than those who never attended (HR =​0.87, 95% CI =​0.77–​ 0.98, p for trend =​0.02). After adjusting for all covariates, the effect was somewhat reduced (HR =​0.87, 95% CI =​0.76–​1.00, for weekly attendance versus never). Although some of the 1992 covariates that were controlled for may also have been subsequent mediators, because they were controlled for in 1992, they were in the primary analyses prior to religious service attendance in 1996 (suggesting they were confounders). Saeed et al. (2018) analyzed data from a 12-​ year prospective study of 80,805 women age 50–​ 79 participating in the Women’s Health Initiative. Although investigators did not look at the effect of religiosity on stroke risk (only an abstract of study results is available), they did compare the frequency of incident stroke between Jewish, Catholic, and Protestant women. We have not included comparisons of CBVD risk between religious denominations in this review up until now. However, given the recency, large sample size, and the long-​term follow-​up of this cohort study, we are summarizing the findings here. Cox proportional hazards regression models were used to examine relationships, adjusting for age, ethnicity, body mass index, systolic BP, cigarette smoking, atrial fibrillation, and congestive heart failure. Results indicated that compared to Catholic women, Jewish women were at a significantly lower risk of ischemic stroke (HR =​0.78, 95% CI =​ 0.65–​0.94, p < 0.008) and any stroke (HR =​0.78, 95% CI =​0.67–​0.92, p < 0.008). Cerebrovascular Disease • 431

Researchers concluded that there was a reduced risk of stroke among postmenopausal Jewish women. No explanation was provided. Ahrenfeldt et al. (2019) analyzed data from an 11-​year prospective study of 23,864 community-​ dwelling adults age 50 or older living in 10 European countries, examining effects of baseline religiosity on subsequent development of chronic illnesses, including self-​reported stroke (i.e., “Has a doctor ever told you . . . ?”). As noted in previous chapters, religiosity was assessed by frequency of prayer, taking part in a religious organization, and religious education at baseline; participants were further categorized as “more religious” (people who pray, take part in a religious organization, and are religiously educated), “less religious” (people who pray, without taking part in a religious organization or being religiously educated), and “nonreligious” (people who do not pray, do not take part in a religious organization, and are not religiously educated). Controlled for in analyses were European region, gender, age, education, marital status, and employment status. Results indicated that at baseline, stroke was 32% less likely among those taking part in a religious organization (OR =​0.68, 95% CI =​0.50–​ 0.95) in cross-sectional analyses; a similar trend was noted for belonging to a religious organization after adjustment for wave in the longitudinal analysis (OR =​0.80, 95% CI =​0.62–​1.03). Likewise, the more religious people (vs. others) were also less likely to have experienced stroke at baseline (OR =​0.67, 95% CI =​0.46–​0.99) in cross-sectional analyses. However, no effects of baseline religiosity were found on incidence of stroke in longitudinal analyses. Finally, as described in the previous chapter, Chen et al. (2020a) conducted a 3-​to 12-​year follow-​up of 92,008 young, middle-​aged, and older adults, examining the effect of religious attendance on health outcomes, one of which was self-​reported physician-​diagnosed stroke in the middle-​ aged and older cohorts. The results of the combined meta-​analytic estimate indicated no significant effect (RR =​1.00, 95% CI =​0.87–​1.14), after controlling for multiple demographic characteristics, mental health, health behaviors, social integration, and prior religious service attendance. Again, this leaves 432 •  P h y sical H ealth

open the possibility that some of the control variables may have been those that explained the effects of religious attendance on self-​ reported stroke (i.e., mediators vs. confounders), though all of the control variables were adjusted for in the previous wave, thereby mitigating the possibility that they were mediators for the baseline religious service attendance exposure. Denomination. Results from earlier research has provided mixed findings when comparing CBVD rates across religious group, with Jews in Manitoba, Canada, reported to have higher rates of stroke than Catholics/​Protestant and Mennonites (Abu-​Zeid et al., 1975); non-​Jews in Michigan and Ohio having a higher family history of CBVD than Jews (Friedman & Hellerstein, 1968); non-​ Mormons in Canada having a greater risk of CBVD than Mormons (Jarvis et al., 1977); non-​ Seventh-​ Day Adventists in California having a higher risk of CBVD than SDAs (Phillips et al., 1980); and Christians in Greece having a greater incidence of stroke compared to Muslims (Papadopoulos et al., 2006). Based on this research, there appears to be little stability in pattern of results. SUM M ARY

If the findings from earlier and more recent research are combined, of the three cross-​ sectional studies, two found that greater religiosity was associated with less CBVD, and one study reported the opposite. A retrospective cohort study found that Catholic nuns had less CBVD than the general population, but rates did not differ from that in other female radiology techs. Of the 10 prospective cohort studies, 4 found that religiosity predicted less CBVD (or less functional disability following stroke), though this included one that had substantially attenuated and nonsignificant associations when additional covariates (possibly mediators) were controlled. In contrast, 6 studies reported no effect of religiosity on risk of stroke or CBVD; no prospective study reported negative effects. With regard to differences in CBVD across religious groups, there is no clear pattern. However, a large recent study of US nurses found that Jewish women were less likely

to have a stroke compared to Protestant or Catholic women. Earlier research had suggested that Mormons, Seventh-​Day Adventists, Mennonites, and Muslims had lower stroke rates than members of other religious groups. Finally, an RCT of Hindu-​based transcendental meditation found a significant reduction in carotid artery intima-​media thickness following 9 months of the intervention compared to a control group. The question of causation vs. reverse causation remains an issue. Religious involvement may help to prevent stroke and lessen the disability that stroke causes; likewise, people may turn to religion to cope following a stroke (creating an artificial positive correlation), and stroke may prevent a person from accessing religious resources, particularly involvement in religious community activity (creating an artificial negative correlation). The findings with regard to CA-​IMT, however, are less subject to such dynamics since CA-​IMT is often asymptomatic. In that regard, three of four studies have reported positive effects or less CA-​IMT in the more religious, whereas one study reported greater CA-​IMT.

RECOMMENDATIONS FOR FUTURE RESEARCH Based on theoretical considerations, there are several reasons to think that religious involvement might affect the development of CBVD, influence the occurrence of CBVD events such as stroke, and impact the course of CBVD (stroke recurrence and effects on physical functioning), especially when demographic confounders such as race and SES are taken into account. Several large prospective studies reviewed above reported this finding. However, others did not. The effects that religiosity has on CBVD likely occur over many decades, beginning in early childhood, with effects slowly accumulating over time, acting through psychological, social, and behavioral mechanisms, as well as through effects of religious involvement on hypertension and other medical disorders. Unfortunately, only a few of the current ongoing large prospective cohort studies examining CBVD development or outcomes have included the assessment of religious variables

at baseline. It is quite possible that religiosity exerts its effects on CBVD gradually by affecting many indirect intermediary pathways over many years. If this is so, and life experiences and behaviors affected by religiosity earlier in life are important, then one would need a study with very long follow-​up, starting in childhood or young adulthood, to assess this. This might help to explain why, despite the evidence that religiosity affects many pathways relevant for CBVD, the current evidence for an effect on CBVD itself is not as manifest. The studies may begin too late in life, have too short a follow-​up, and too often control for mediating variables. Furthermore, no longitudinal studies to our knowledge have been designed from the start to examine the impact of various dimensions of religiosity on CBVD, designing the study in a way that considers the multiple pathways by which religious involvement might impact CBVD across the life span (see above). Additionally, only a single religious variable (rather than a validated measure with established psychometric properties) has generally been included in longitudinal studies; and these studies typically have been designed for an entirely different purpose, with the religious variable included as an add-​on only. We recommend that leaders of large cohort studies include reliable measures of religiosity in future waves of data collection in ongoing studies. There are several such measures in this regard that are 10 items or less—​see Chapter 2. Furthermore, the design of future large cohort studies examining the development, precipitation, and course of stroke and other CBVD events should consider including religious measures at the very beginning of the study, carefully choosing those measures based on aspects of religiosity most likely to impact a specific CBVD outcome. Unfortunately, constraints based on questionnaire length, lack of funding, and lack of priority have prevented this from happening thus far. More objective measures of CBVD also need to be examined as the primary outcome, rather than relying on participant self-​report alone. There are several indicators of CBVD based on medical records that could be examined in future prospective studies. These include stroke (ischemic and hemorrhagic), TIAs, vascular Cerebrovascular Disease • 433

dementia (due to multiple small strokes), and CA-​IMT. As noted earlier, the latter is an indicator of atherosclerotic vascular disease in the major arteries that supply blood to the brain, which can be easily assessed by carotid artery ultrasound. Furthermore, religiosity has been found in both cross-​ sectional and prospective studies to predict CA-​IMT, and an RCT has shown that a spiritual intervention (transcendental meditation in the Hindu tradition) may reduce CA-​IMT in a matter of 7–​9 months (Castillo-​Richmond et al., 2000). Thus, Ca-​IMT is a sensitive, often asymptomatic, measure of CBVD that may be used in prospective studies and RCTs to examine the impact of religiosity or religious interventions on CBVD. Finally, when analyzing the relationship between religiosity and CBVD, it is important to distinguish control variables from mediators (as noted in many other chapters, specifically Chapter 3). If a relationship is found between religiosity and CBVD or stroke after controlling for confounders (age, gender, race, SES, etc.), this provides some evidence for an effect. Controlling further for possible mediators (medical conditions such as hypertension, as well as psychological, social, and behavioral variables) may help to explain how religiosity affects these outcomes, rather than explain the relationship away (e.g., Colantonio et al., 1992). Distinguishing control variables from mediators or explanatory variables is particularly important at the analysis phase of observational studies. As noted several times now, mediators should ideally be assessed after the religious exposure is measured, rather than at the same time, when they could be either mediators or confounders. Controlling for these variables prior to baseline religiosity can be helpful in ensuring these are not mediators of baseline religiosity, though, even then, they may still be mediators of prior religiosity if effects take many decades to accumulate. This possibility may in part explain why many studies do not observe an association. Again, studies starting earlier in life, with a longer follow-​up, possibly using repeated measures of religiosity and statistical methods to handle the cumulative effects of time-​ varying exposures (Robins, 2000; VanderWeele et al., 2016a), may prove important for establishing the needed evidence. 434 •  P h y sical H ealth

As exemplified by the Castillo-​ Richmond et al. (2000) study, RCTs can be designed to examine the effects of religious/​spiritual interventions on the possibility of reversing CBVD. Religious interventions could be conducted in high-​ risk African American populations, for whom religion is often very important and who are frequently at high risk for CBVD due to hypertension, obesity, diabetes, and hypercholesterolemia. Note that participants in the Castillo-​ Richmond et al. study were African Americans, hypertensive (average BP 146/​ 83), had an average age of 55 years, and 71% were female. Similar studies could be designed using Christian, Muslim, or Jewish forms of meditation, centering prayer, or other religious activities (meditating on scriptures, reciting scriptures, engaging in religiously motivated volunteer activities, etc.). Given that the Castillo-​Richmond et al. study is the only RCT in the literature of which we are aware, there is considerable room for conducting intervention studies of this type, with short-​term outcomes (< 1 year) focusing on CBVD indicators such as CA-​IMT and long-​term outcomes (over decades) examining stroke, TIAs, or vascular dementia.

CLINICAL APPLICATIONS The development of CBVD often occurs over many years, making it difficult to see how clinicians and religious professionals might advise individuals in this regard. However, more immediate outcomes include the occurrence of stroke in those with hypertension and/​or diabetes and the impact of CBVD events (particularly stroke) on physical functioning after the event.

Clinicians By taking a spiritual history, clinicians may identify religious resources that can be utilized to help in this regard. Supporting religious beliefs and activities in which patients are already engaged, particularly those that have promise for preventing CBVD events and improving outcomes, is unlikely to cause much harm and may bolster self-​care activities. The spiritual history provides clinicians with an

opportunity to identify, support, and possibly encourage religious teachings (patient-​ centered, of course) that reduce CBVD risk factors or assist in physical recovery from stroke or other CBVD events. Patient education is another important intervention that should be considered, such as providing information about how religious beliefs and practices may be utilized to reduce stroke risk. As usual, clinicians will want to reduce high-​ risk health behaviors such as excessive alcohol use, cigarette smoking, consumption of a high-​fat/​high-​cholesterol diet, high salt intake, being overweight or obese, and noncompliance with self-​care activities in those with diabetes or hypertension. In the Christian tradition, for example, engagement in behaviors that reduce CBVD risk may be motivated by efforts to preserve and honor the body as the temple of the Holy Spirit. Patients at high risk for stroke may be encouraged to engage in religious activities such as meditation, centering prayer, attendance at religious services, and participation in religious volunteer activities, which may help to reduce anxiety or depression, expand the individual’s support network, and increase purpose and meaning in life. Among those who have experienced a stroke accompanied by physical deficits, clinicians may also utilize patients’ religious beliefs to help motivate them to engage in the hard work of rehabilitation necessary to recover physical functions. Depression and loss of motivation frequently follow a disabling stroke and will worsen stroke outcomes by leading to physical deconditioning and increasing risk of another stroke, which in turn may be followed by greater disability and increased depression, leading to a downward spiral. Religious beliefs, practices, and support from a religious community may help to break this sequence of events, which, while common, is not inevitable.

Religious Professionals There are also many applications that religious professionals might consider. Educating their congregations through sermons, inviting health experts to speak on the topic, and developing of institution-​based health programs are some possibilities. Clergy, particularly those

who have large African American congregations for example, might consider giving a sermon on health behaviors that reduce CBVD and preserve God’s temple, enabling members to serve God for many years into the future. Clergy may utilize some of the information included in this chapter that describes behaviors and medical conditions that increase risk of stroke. Likewise, an experienced healthcare professional, either inside or outside of the congregation, may be invited to teach a religious education class on the role that religion can play in promoting health, including the present—​albeit not definitive—​evidence for its role in preventing the development of CBVD. That person could also talk on the role that religious belief and practices play in controlling emotions that can precipitate stroke, and on the importance of engaging in faith-​ based activities that help to relieve stress, decrease depression, and increase positive emotions, all of which are good for the brain. Finally, health programs may be developed in religious congregations to increase access to regular checkups, including BP, blood sugar, and/​ or cholesterol (perhaps conducted by a congregational nurse, for example) and to facilitate referral to health professionals who can manage any abnormalities detected. Likewise, such programs may instruct members on how to prepare healthy foods for religious gatherings, such as those contained in the Mediterranean diet, and avoiding high-​calorie, high-​fat, high-​cholesterol foods that increase body inflammation and body weight leading to the development of CBVD. Religious communities can also provide exercise programs that combine worship and physical activity, such as prayer walking, that can help lower BP and control weight. Research shows that religious involvement is associated with increased optimism, a key component of resiliency among patients hospitalized after suffering a CBVD event (Liu et al., 2020). This finding was independent of the only two other characteristics that impacted optimism, which were general self-​efficacy (positive correlate) and resignation to the stroke (negative correlate). Optimism and purpose in life have been shown to be important predictors of physical functioning following disabling Cerebrovascular Disease • 435

events such as stroke (Brenes et al., 2002; Kim et al., 2020). Health ministries may also help to organize faith community support for members of the congregation who have a stroke or other CBVD event that requires them to go through the hard work of rehabilitation. The goal is to provide encouragement, social support, and practical assistance in order to counter the discouragement that often follows such events and to increase optimism and purpose in life. Few community groups are as readily available to such individuals as their religious community, especially when programs in these institutions provide religious rationales for changing behavior to promote health.

SUMMARY AND CONCLUSIONS This chapter has examined the effects of religious involvement on the development of CBVD, on the precipitation of CBVD events such as stroke, and on the health outcomes that follow (recurrent stroke, disability, death). We have emphasized that CBVD is the leading cause

436 •  P h y sical H ealth

of serious long-​term disability in later life and the second most common cause of death worldwide, second only to ischemic heart disease. We have also described demographic, genetic, biological/​ medical, psychological, social, and behavioral characteristics that increase risk of stroke, and explained how religious involvement might prevent CBVD and stroke by its effects on those risk factors. This was followed by a review of early and more recent studies examining the relationship between religiosity and CBVD, the impact of religiosity on CBVD, and the effects of spiritual interventions on CBVD. While much research remains to be done, results of these studies show promise for religious involvement as a way to reduce the development of CBVD, prevent stroke, and decrease its negative health consequences. Application of religious or spiritual interventions to reverse the course of CBVD has also been considered. Recommendations for future research were made and applications to clinical practice for health and religious professionals were discussed. In the next chapter, we will examine the role that religiosity can play in the prevention of dementia, which is often a long-​term consequence of CBVD.

23 Alzheimer’s Disease and Other Dementias Cognition reigns but does not rule. —​Paul Valéry

IN THIS CHAPTER we examine the relationship between religiosity, cognitive function, and dementia, paying special attention to Alzheimer’s disease, since the latter is the most common cause of progressive cognitive decline in later life. The focus here is on the effect that religious involvement has on preventing Alzheimer’s disease and other dementias, modifying their course, and reducing cognitive impairments that occur with normal aging. First, we examine the different forms of dementia, their prevalence, health consequences, and costs. Second, we review the known causes of cognitive decline and dementia. Third, we hypothesize how religious involvement might theoretically influence age-​ related cognitive decline and development of dementia. Finally, we examine research on the relationship between religiosity and cognitive decline with aging and specifically in those with Alzheimer’s disease or other dementias. We then make recommendations for future research and discuss

clinical applications. Not addressed in this chapter are the effects of religious involvement on how persons with dementia or their caregivers cope with the disease (see Chapter 4), except briefly when making recommendations for clinical application.

TYPES OF DEMENTIAS There are six major types of dementia: Alzheimer’s disease (AD), vascular dementia (VaD), frontotemporal dementia (FTD), Lewy body dementia (LBD), alcohol-​related dementia, and dementia with mixed causes. There are also milder forms of cognitive impairment often lumped into the category of mild cognitive impairment (MCI), which may or may not precede the onset of dementia. In addition, there is a non-​pathological form of cognitive impairment that occurs with increasing age called age-​ associated memory impairment (AAMI). All pathological forms of cognitive impairment

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0023

(dementia) are now classified in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-​5) under the category of “major neurocognitive disorder.” The criteria for this diagnosis include a significant decline in one or more cognitive function categories: learning and memory, language, executive function, complex attention, perceptual-​motor or visuospatial skills, or social cognition. The degree of decline must interfere with the ability to independently perform activities of daily living (American Psychiatric Association, 2013). The decline in cognition is also usually slow and progressive over time (except for vascular dementia, where there is a “step-​wise” decline).

people age, especially when AD is also present. As a result, causes and risk factors for AD are now being viewed as related to (a) AD pathology specifically, (b) other pathologies that contribute to AD, and (c) resilience in the presence of AD pathology. AD, based on pathological evidence alone, makes up about 44%–​56% of dementias (Patnode et al., 2020). Among the oldest old, it is likely that the accumulation of other comorbid brain pathologies account for an even greater percentage of dementias than AD pathology (James & Bennett, 2019). The symptoms of AD worsen slowly over time. There is a preclinical phase that may last for many years, followed by gradual cognitive decline that likewise occurs over many years. Early symptoms may involve trouble remembering recent conAlzheimer’s Disease (AD) versations, names, or events, along with apathy AD is a slowly progressive, irreversible brain (loss of interest) and depression in some cases. disorder that causes mental deterioration with These symptoms will progress to ultimately disorientation, memory disturbance and con- involve impaired communication, disorientation, fusion, accounting for 60%–​80% of all demen- confusion, poor judgment, changes in behavior, tias (including mixed dementias where AD is a and in the end, difficulty speaking, swallowing, component) (Alzheimer’s Disease Association, and walking. The natural history of the disease 2019). The 2018 National Institute on Aging–​ from onset to death ranges from 2 to 15 years, Alzheimer’s Association research framework although some individuals may live for as long as for AD defines it as “a biological process mea- 20 years after diagnosis (Patnode et al., 2020). As noted above, the pathological process in sured by brain pathology or biomarkers, spanning the cognitive spectrum from normality to AD involves deposition in the brain of amyloid dementia” (James & Bennett, 2019, p. 65). This β-​protein (Aβ), pathologic tau protein (leading to recent definition emphasizes the biological pro- neurofibrillary tangles), and neurodegeneration. cesses involved when brain pathology is exam- Amyloid protein is thought to initiate an inflamined during autopsy (or with biomarkers while matory response that results in degeneration or alive). This differs from earlier definitions that destruction of neurons. Treatments for AD have were based primarily on clinical symptoms and been quite modest in terms of beneficial effects, signs. At autopsy, the primary findings in AD primarily serving to slow the progression of the are neurofibrillary tangles and senile plaques in disease rather than stop or reverse its course. the brain. The neurofibrillary tangles consist of Nevertheless, there are thought to be person-​ abnormal accumulations of abnormally phos- specific differences that help to explain the phorylated tau within the cytoplasm of certain “neural reserve capacity” that may be responsineurons. Senile plaques are made up of a cen- ble for the absence of clinical symptoms among tral core of beta-​amyloid protein, surrounded individuals with AD pathology (Bennett, 2017). by abnormal neuronal processes. That neural reserve is what could be modifiable Many other brain diseases, including cere- by attitude or lifestyle changes (influenced by brovascular disease, atherosclerosis, white religiosity). This can affect the risk of developing matter changes, Lewy body disease, TAR DNA-​ AD symptoms in the presence of AD pathology. binding protein 43 disease, and hippocampal sclerosis, are thought to contribute to the pre- Vascular Dementia (VaD) sentation of AD (James & Bennett, 2019). The 10% of individuals with accumulation of these other brain pathologies Approximately 5%–​ is thought to contribute to risk of dementia as dementia have evidence of VaD alone (Alzheimer’s 438 •  P h y sical H ealth

Disease Association, 2019). VaD results from cerebrovascular disease (strokes) due to blockage or breakage of blood vessels in the brain and consequent death of tissue or bleeding within the brain. Vascular dementia may also be due to blockage of many small vessels supplying blood to the brain that occurs gradually over time (“small vessel disease” resulting in “white matter changes”), often without the person reporting a history of stroke. Exactly where the blood vessel blockage occurs in the brain will determine the symptoms and signs. VaD (previously known as multi-​infarct dementia) is characterized by a step-​wise loss of ability to perform mental and physical activities. When possible, it is important to differentiate VaD from AD since the control of blood pressure and use of anti-​platelet drugs may help to prevent repeated strokes and thus halt the progression of VaD. In the majority of cases, however, VaD is progressive and worsens over time. In about 20%, AD and VaD occur together (see discussion of mixed dementia below).

functional limitations develop later, whereas in PDD, cognitive symptoms develop after the diagnosis of Parkinson’s disease and associated disability. LBD more generally is due to the presence of “Lewy bodies,” which are abnormal clumps of the protein “alpha-​synuclein” that develop in neurons of the basal ganglia and cerebral cortex. Many of symptoms of LBD are similar to those found in AD, although its presentation may be quite different during the early stages, including difficulty sleeping (REM disorders), well-​formed visual hallucinations, and difficulty coordinating vision with space. These symptoms may occur without significant memory impairment, which may develop later. Approximately 5%–​10% of those with dementia have LBD alone, although LBD may often be comorbid with AD (Alzheimer’s Disease Association, 2019).

Alcohol-​Related Dementia

Heavy alcohol use may be a contributing factor in up to 24% of all dementias (Gupta & Warner, Frontotemporal Dementia (FTD) 2008; Ridley et al., 2013). The relationship FTD involves the deposition of abnormal between alcohol use and cognitive impairment tau protein or “transacted response DNA-​ is similar to that between alcohol and stroke binding” protein in neurons of the frontal in being J-​shaped (i.e., some benefits at low to and temporal lobes of the brain. The most moderate alcohol consumption and rapid worscommon type of FTD is called Pick’s disease, ening of cognition as consumption increases). often diagnosed by brain scans showing a The threshold of alcohol intake necessary to shrinkage of the frontal lobes. FTD often cause dementia has been estimated to be 5 occurs among younger persons (60% of FTD years of 35 drinks/​week for men or 28 drinks/​ cases occur in persons age 45–​60 years), mak- week for women, although more than 2 drinks/​ ing it the most common type of dementia in day over longer periods has been associated those under age 60 (National Institute on with a trend toward increased risk (Mukamal Aging, 2019). Overall, FTD makes up about et al., 2003). Alcohol-​ induced pathological 3% of all dementias and 10% of dementias brain changes are due to many possible causes, occurring in persons under age 65 (Hogan including chronic neurotoxicity, oxidative stress, et al., 2016). Early symptoms of FTD include excitotoxicity, and mitochondrial damage. marked changes in executive functioning Repeated alcohol withdrawal also contributes and behavior (FTD behavioral variant) or to brain damage. progressive difficulties with language and speech (FTD language variant).

Dementia with Mixed Causes

Lewy Body Dementia (LBD) There are two types of LBD: dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD). DLB is distinguished from PDD in that cognitive symptoms develop first and

Nearly 50% of those with dementia have pathological evidence of more than one type of dementia (Brenowitz et al., 2017). The likelihood of mixed dementia increases with age, and the prevalence is highest among those age 85 or older (James et al., 2012). Mixed dementia Alzheimer’s Disease and Other Dementias • 439

is most commonly due to a combination of AD and VaD or LBD.

Mild Cognitive Impairment (MCI) MCI is distinguished from dementia in that the cognitive impairment does not impair independence in daily functioning. MCI has been called by several names, including “cognitive impairment no dementia” (CIND), mild neurocognitive disorder (as now categorized in DSM-​5), and mild cognitive disorder, with various definitions and criteria for diagnosis. MCI is diagnosed when there are concerns about cognitive impairment reported by patient or family, and when these impairments are modest in nature and do not interfere with daily function (or the person is able to compensate for cognitive deficits). There are amnestic (impaired memory) forms of MCI and non-​amnestic forms, as well as single domain or multi-​domain types. The prevalence of MCI is about 16%–​20% among older adults, which is about twice as common as dementia (Roberts & Knopman, 2013). Studies have found that about one-​third (32%–​38%) of those with MCI eventually go on to develop dementia, whereas 10%–​40% may regress to normal cognitive function over time (Patnode et al., 2020).

Age-​Associated Memory Impairment (AAMI) There has not been much recent research on the prevalence of AAMI, which is considered to be a normal decline in memory with increasing age. However, not all older adults have this condition. In a study of a random sample of 1,049 subjects age 60–​78 years from eastern Finland, only about half (53.8%) were diagnosed as having AAMI (57.4% of men and 51.3% of women) (Koivisto et al., 1995). In that study, AAMI was determined by cutoff scores on memory tests, excluding those with scores of less than 24 on Mini-​Mental State Exam (MMSE), who were categorized as having significant cognitive dysfunction. Given the early date of this study, some of the participants with MMSE scores of 24 or higher may have had MCI, which was not a term used at the time. 440 •  P h y sical H ealth

PREVALENCE AND COSTS OF DEMENTIA As noted above, the prevalence of dementia increases with age. In 2017, the World Health Organization estimated that between 2015 and 2050, the percentage of people over age 60 will almost double, from 12% to 22%. Worldwide, 35.6 million people had dementia in 2010, a number that is expected to increase to 65.7 million by 2030 and 115.4 million by 2050 (Prince et al., 2013). The percentage of all people with dementia who live in low-​or middle-​income countries is expected to increase from 58% in 2010 to 63% by 2030 and to 71% by 2050. In the United States, 8.8% of adults age 65 or older were diagnosed with dementia in 2012. The distribution of dementia by age group in that study was 3.2% of those age 65–​74, 9.9% of those age 75–​84, and 29.3% of those age 85 or older (Langa et al., 2017).

Other Demographic Correlates The prevalence varies by race and gender. Dementia occurs in 11%–​21% of Blacks compared to 5%–​11% of Whites (roughly double) and is higher in women (16%) than men (11%) among those over age 70. Gender differences, however, may be due to the longer survival of women (Patnode et al., 2020). The prevalence of dementia is also lower among those with more education; this may be due to (a) the direct effect of education on the brain, (b) the relationship between higher education and positive health behaviors, and/​or (c) greater access to healthcare among those who are better educated.

Financial Costs Given the high prevalence of dementia in later life and the increasing age of populations around the world, the financial costs are high now and are projected to be much higher in the future. In the United States alone, the estimated total health, long-​term care, and hospice care costs of those with dementia in 2019 was $290 billion, a figure that does not include costs of uncompensated care provided by family caregivers (estimated at $34 billion per year) (Alzheimer’s Disease Association, 2019).

CAUSES OF DEMENTIA AND COGNITIVE IMPAIRMENT

although it may also contribute to the development of AD (Köhler et al., 2015; Stefanidis et al., 2018). Specific cardiovascular diseases Of all demographic characteristics (age, race, known to increase risk are coronary artery disgender, socioeconomic status [SES]), increas- ease, atrial fibrillation, left-​ventricular valvular ing age is the strongest predictor of Alzheimer’s disease, heart failure, hypertension, diabetes, disease, other dementias, and cognitive impair- and hyperlipidemia (Di Marco et al., 2014). ment. However, there are numerous other Diabetes, hyperlipidemia, and cerebrovascular influential factors, including genetic, medical/​ disease are similarly associated with increased disease-​related, environmental, psychological, dementia risk. social, and behavioral characteristics, some of which may be modifiable (Cooper et al., 2015).

Psychological Factors

Genetic/​Epigenetic First-​ degree relatives (children, brothers, or sisters) of persons with AD are three to four times more likely to develop the disorder over a lifetime, compared to those with no affected first-​ degree relatives. The heritability of dementia and cognitive dysfunction decreases with age depending on when impairments first manifest, dropping from approximately 80% at age 65 to 60% at age 80 (Lee & Sachdev, 2014). Genetic factors are thought to play a particular role in dementia that develops before the age of 65, including dementia related to Down’s syndrome, Huntington’s disease, Parkinson’s disease dementia, frontotemporal dementia, and early onset familial AD. However, genetic variants account for only about 24%–​33% of AD cases (Ridge et al., 2013). There are also a number of susceptibility genes—​ particularly APOE-​e4—​that may interact with environmental factors (as epigenetic influences), thereby increasing the risk of late-​onset disease. For example, the presence of the APOE-​e4 gene increases the risk of AD by 2-​fold in those without head trauma and 10-​fold among those with head trauma (Tang et al., 1996). Likewise, APOE-​e4 carriers may be at particularly high risk of developing dementia if they are heavy alcohol drinkers (Kivipelto et al., 2008).

Medical Disease Several medical conditions are known to affect the development of dementia or to increase the risk of cognitive decline with aging. Cardiovascular disease increases the risk of dementia, particularly vascular dementia,

Individuals with depression or anxiety are more likely to develop cardiovascular disease (see Chapters 20–​22). As noted above, cardiovascular disease increases the risk of dementia, thus providing an indirect pathway by which psychological factors may affect cognitive functioning. Depression by itself, however, has also been shown to impair cognitive functioning both in the short term and long term. For example, in a systematic review of 18 longitudinal studies including 2,119,627 participants with an average age ranging from 55 to 81, Chan et al. (2019) found that depression increased risk of dementia by 31%–​50%, regardless of whether antidepressant medication was taken or not. Likewise, in a systematic review and meta-​ analysis of 35 studies that included 14,158 individuals with MCI, the presence of depressive symptoms predicted a 69% increased risk of later developing dementia in community-​ based samples (RR =​1.69, 95% CI =​1.49–​1.93) (Tan et al., 2019). At least four mechanisms help to explain how depression may increase risk of dementia and cognitive decline with aging (Linnemann & Lang, 2020). First, elevated cortisol levels that occur with depression cause hippocampal neuronal damage, adversely affecting large pyramidal cells in particular. Second, depression may be precipitated in later life by brain changes that occur as a result of cerebrovascular disease, a known risk factor for dementia. Third, neuroinflammatory processes present in depression—​including increased activation of microglia, changes in transforming-​growth-​ factor beta 1 signaling, increased levels of pro-​ inflammatory cytokines, and reduced levels of anti-​ inflammatory cytokines—​ may lead Alzheimer’s Disease and Other Dementias • 441

to inflammatory processes in the brain that adversely affect cognitive function. Finally, brain-​ derived neurotrophic factor (BDNF), which plays a key role in the proliferation, differentiation, and the maintenance of neuronal integrity in the hippocampus (the region of the brain responsible for memory and cognitive function), is reduced in depression. While depression may increase risk of dementia, it is also possible that dementia may increase the risk of psychological distress (reverse-​ causation), which may occur in the early or prodromal stage of Alzheimer’s disease and other dementias when memory loss and functional decline are first recognized by the individual (Modrego, 2009). Greater life stress and anxiety, especially among those with low education, are also predictors of increased dementia risk (Gilsanz et al., 2019). In contrast to negative emotions such as depression and anxiety, psychological well-​ being, meaning and purpose in life, and personality traits such as conscientiousness predict a lower risk of cognitive decline with aging and reduced likelihood of developing dementia, including AD and MCI (Boyle et al., 2010; Sutin et al., 2018; Terracciano et al., 2014; Kaup et al., 2019).

Social Factors Social isolation and loneliness may also be risk factors for dementia. A national US poll conducted by the University of Michigan (2018) found that one-​third (34%) of older adults age 50–​80 indicated a lack of companionship and 27% felt socially isolated. In a 2014–​2015 survey conducted in the United Kingdom, more than one in eight people reported having no close friends (Express, 2017). Loneliness, in turn, is a known risk factor for the development of dementia, associated with a 26% increased risk based on a meta-​ analysis of eight longitudinal studies involving 37,339 individuals average age 65–​ 83 (RR =​1.26, 95% CI =​1.14–​1.40; Lara et al., 2019a). The health effects of loneliness across the life span, including negative effects on cognitive functioning, are equivalent to smoking 15 cigarettes per day based on cross-​sectional and prospective studies (Boss et al., 2015; Lee et 442 •  P h y sical H ealth

al., 2019; Lara et al., 2019b). Furthermore, social isolation predicts a significant decline in cognitive function (episodic memory and overall mental status) independent of other risk factors (Yu et al., 2021). Studies have also shown that individuals living with family are at lower risk of dementia (Chen et al., 2011), whereas never married individuals are at greater risk (Helmer et al., 1999; Sundström et al., 2016).

Environmental Factors The environment, including the intrauterine environment, may increase risk of dementia later in life (Gomez-​Pinilla et al., 2005; Walsh et al., 2019). For example, if a mother smokes (or is exposed to secondhand smoke from a partner/​spouse), is a moderate or heavy consumer of alcohol, or experiences chronic stress from an unstable marriage or partner relationship, this will deplete brain reserves in the developing fetus (a reserve that will remain depleted after birth for the remainder of the person’s life). During infancy and childhood, a stressful environment due to maternal or paternal emotional illness, domestic abuse, and/​ or family instability will deplete that reserve further. During the teen years, access to and use of alcohol or drugs including marijuana may continue to erode brain reserve (see below). As individuals age, they will depend more and more on brain reserves to prevent the development of cognitive impairment. As noted above, those with larger reserves—​ even if they are genetically predisposed to develop dementia—​will be less likely to experience cognitive impairment with aging. Gene-​ environment interactions may further deplete cognitive reserve.

Health Behaviors Health behaviors, as potential risk factors, are of particular interest since they are often modifiable. Modifiable factors might include alcohol consumption, cigarette smoking, illicit drug use (marijuana, amphetamines, opiates), sedentary physical activity, risky sexual activity, low or absent prosocial activity, unhealthy diet, and being overweight or obese.

A L C O H O L C ONS UMPT ION

As discussed above, persons who consume large amounts of alcohol every day will deplete cognitive reserve. Research indicates that heavy drinkers have larger ventricular and sulcal size in middle age, indicative of brain shrinkage, on structural MRI scans (Ding et al., 2004). Risk of dementia has also been shown to increase by 57% among moderate-​ to-​ heavy drinkers compared to light drinkers based on a 43-​year longitudinal study of 12,326 twins in Sweden (Handing et al., 2015); such individuals also develop dementia at an earlier age. I L L I C I T D RU G US E

Use of illicit drugs has been associated with an increased risk of cognitive impairment and dementia, including marijuana use during the teen years (Hulse & Lautenschlager, 2005; Amen et al., 2017), amphetamine use (Tzeng & Liu, 2019), and opiate use among drug addicts (Anthony et al., 2010). C I GA RE TTE SMOKING

Cigarette smoking predicts an increased risk of all-​ cause dementia, a risk that decreases among those who stop smoking depending on how long it has been since they quit (Batty et al., 2018; Deal et al., 2020). Long-​term exposure to secondhand smoke is also known to increase the risk of late-​life dementia (Barnes et al., 2010). P H Y SI CA L ACT IV IT Y

As reported in many prospective studies, regular physical activity and exercise are associated with lower risk of dementia and slow cognitive decline with aging (Kulmala et al., 2014; Deckers et al., 2015; Guure et al., 2017; Stephen et al., 2017). Physical exercise increases blood flow to the brain in a way that preserves cognitive functions. RI SK Y S E XUAL ACT IV IT Y

Risky sexual activity can often result in sexually transmitted diseases such as syphilis, HIV,

or herpes virus infection, infections known to be associated with increased risk of dementia (McArthur, 2004; Miklossy, 2015; Harris & Harris, 2015; Steel & Eslick, 2015). P ROSOCIAL ACTIVITY

Altruistic behavior has also been associated with better cognitive functioning in communitydwelling older adults (Corrêa et al., 2019). ​ Prosocial activities such as volunteering have been shown to increase the size of the hippocampus in a 2-​year randomized controlled trial (RCT) involving adults age 60 or over, whereas control group members demonstrated a decline in hippocampal size over time (Carlson et al., 2015). D IET

Adherence to a Mediterranean diet (including high fruit and vegetable intake) may also reduce dementia risk (Scarmeas et al., 2006; Livingstone et al., 2017; Knight et al., 2016). In contrast, a high intake of total dietary fats—​ particularly trans-​unsaturated fats—​has been shown to increase that risk (Di Marco et al., 2014). High intake of fish may also reduce risk, in part due to increased ingestion of omega-​3 fatty acids. WEIGH T

Being overweight or obese increases the risk of late-​life cognitive decline and development of dementia (Tolppanen et al., 2014). High total calorie intake has also been associated with a 50% greater risk of Alzheimer’s disease (Di Marco et al., 2014). M OD IF IABL E RISK FACTORS

Modifiable risk factors for dementia and cognitive decline with age include physical health (less cardiovascular and cerebrovascular disease), psychological health (less depression, more positive emotions, greater conscientiousness), social and family support (reduction of isolation and loneliness), and positive health behaviors (diet, physical activity, alcohol consumption, drug use, cigarette smoking). These Alzheimer’s Disease and Other Dementias • 443

modifiable risk factors also influence medical, environmental, and possibly even genetic factors (through epigenetic influences) that contribute to dementia risk. Furthermore, of particular interest here, all of these modifiable risk factors are also influenced by religious involvement.

RELIGION, COGNITIVE IMPAIRMENT, AND DEMENTIA Does greater religious involvement affect cognitive functioning in later life, forestall the development of dementia, or alter the course of Alzheimer’s disease/​dementia? We begin with a case vignette.

Case Vignette The neurologist and popular author Oliver Sacks illustrates the power of ritual in his description of Jimmie. Jimmie has Korsakoff’s syndrome, a condition associated with profound loss of memory that occurs in alcoholic dementia. Below is a description by Sacks of Jimmie as he receives Holy Communion, a sacred sacrament in the Christian tradition (Catholicism, in this case): I did, and I was moved, profoundly moved and impressed, because I saw here an intensity and steadiness of attention and concentration that I had never seen before in him or conceived him capable of. I watched him kneel and take the Sacrament on his tongue, and could not doubt the fullness and totality of Communion, the perfect alignment of his spirit with the spirit of the Mass. Fully, intensely, quietly, in the quietude of absolute concentration and attention, he entered and partook of the Holy Communion. He was wholly held, absorbed, by a feeling. There was no forgetting, no Korsakoff’s then, nor did it seem possible or imaginable that there should be; for he was no longer at the mercy of a faulty and

444 •  P h y sical H ealth

fallible mechanism—​that of meaningless sequences and memory traces—​ but was absorbed in an act, an act of his whole being, which carried feeling and meaning in an organic continuity and unity, a continuity and unity so seamless it could not permit any break. (Sacks, 1985, p. 23)   

Theoretically, there are many reasons why religious involvement might be related to better cognitive function or impact risk of developing AD and other dementias. We address this now by theorizing how religious beliefs and practices might impact the risk factors for dementia discussed earlier.

Genetic/​Epigenetic There are at least two pathways by which religiosity might impact genes that increase dementia risk. The first pathway is through DNA methylation and histone modification resulting from greater maternal and other forms of nurturing during infancy. Such genetic modifications are known to affect not only the offspring’s stress responses but also the stress responses of future generations (see Chapter 16). The second pathway is by gene-​ environment interactions involving the APOE-​ e4 allele. In fact, research has already reported that religiosity may modify the effect of the APOE-​e4 on the development of MCI in adults age 55 or older (Wang et al., 2017).

Medical Disease As indicated in Chapters 20–​ 22, religious involvement may indirectly reduce the risk of coronary heart disease, hypertension, and cerebrovascular disease—​medical conditions that strongly predict the development of dementia and cognitive impairment in later life.

Psychological Factors Since religious coping is often used to deal with life stressors and may often moderate the

effect of those stressors on mental health (see Chapter 4 and Appendix), this is one pathway by which religiosity could reduce the negative effects of life stressors on cognitive functioning. Other ways that religious involvement may affect dementia risk are by reducing depressive symptoms (Chapter 5), increasing positive emotions (Chapter 12), and influencing personality traits such as conscientiousness and agreeableness (Chapter 11). Thus, there are several psychological mechanisms by which religiosity might impact cognitive function and dementia risk.

Social Factors Religious involvement is associated with greater social support, larger social networks, and less loneliness (Chapter 15). Religiosity is also associated with a greater likelihood of marital stability, family stability, and early family environmental warmth (Chapter 14). These influences may result in a lower risk of dementia in later life and slower decline of cognitive functions with aging.

Environmental Factors

AL COH OL CON SUM P TION

Rates of alcohol use and abuse during the teenage years and during early and middle adulthood are significantly lower among those who are more religious, as shown in the vast majority of cross-​sectional and prospective studies (Chapter 10). IL L ICIT D RUG USE

Likewise, religiosity predicts a significantly lower likelihood of using marijuana and other illegal drugs during youth and adulthood (Chapter 10). CIGARETTE SM OKIN G

As reviewed in Chapter 17, those who are more religious are less likely to start smoking, less likely to associate with those who do, and more likely to stop smoking, thereby affecting risk of late-​life dementia through this pathway. Not smoking also lowers the risk of cardiovascular and cerebrovascular diseases that affect cognitive function. P H YSICAL ACTIVITY

Parental religiosity, as noted above, likely influences maternal mental, social, and behavioral health during pregnancy, thereby preserving cognitive reserve during intrauterine brain development and following birth. Likewise, a more stable family environment during infancy, childhood, and the teen years may further maintain cognitive reserve. Prosocial peer groups during the teen years and young adulthood, often associated with religious community involvement, also provide an environment that fosters the maintenance of cognitive reserve at an age when the latter may be rapidly depleted due to alcohol use, drug use, or life stressors due to unplanned pregnancy, delinquency-​related incarceration, poor grades, school dropout, or other negative life events.

In general, research shows that religious individuals tend to be more physically active and less sedentary (Chapter 18). Greater physical activity and regular exercise, in turn, will benefit cognitive function across the life span.

Health Behaviors

Volunteering to help others and engagement in other altruistic prosocial activities are also more common among those who are more religious, as they are often commanded by religious beliefs and sacred scriptures. This is yet

The encouragement of positive health behaviors by religious groups has the greatest potential to impact cognitive functioning in later life.

RISKY SEXUAL ACTIVITY

Because religious individuals are less likely to have multiple sexual partners, engage in sex outside of marriage, and participate in other risky forms of sexual behavior, they are less likely to develop sexually transmitted diseases (syphilis, HIV, herpes) known to increase dementia risk (see Appendix). P ROSOCIAL ACTIVITY

Alzheimer’s Disease and Other Dementias • 445

another pathway by which religiosity might impact dementia risk, given the effects of volunteering on social interaction and cognitive function in later life (Griep et al., 2017). DI E T

Those who are more religiously involved tend to consume a healthier diet in the majority of studies (see Chapter 19). A healthier diet should translate into better cognitive function as well. W E I GH T

Because of the emphasis in religious communities on gathering together for fellowship and meals (often high-​ calorie meals), increased weight has been shown in some studies to be problematic for the religiously active. Although the majority of prospective studies have not found that religiosity predicts weight gain over time (Chapter 19), this nevertheless represents a pathway by which community religious involvement could adversely affect dementia risk.

Summary The above discussion describes the many pathways by which religious involvement might impact cognitive function across the life span and thereby influence the development of dementia in later life. We now turn to what research studies have found on the relationship between religiosity, cognitive function, and dementia, as well as on how religious involvement affects the course of illness among those diagnosed with Alzheimer’s disease. As we review this research, readers should recall that certain demographic characteristics (age, gender, race, SES) may confound the relationship between religiosity and cognitive functioning.

QUANTITATIVE RESEARCH In this section, we review research examining the relationship between religiosity, cognitive functioning, and Alzheimer’s disease/​dementia. As usual, we focus on large cohort studies and experimental studies when they are 446 •  P h y sical H ealth

available. Large cross-​sectional studies are also reviewed to descriptively document the association between religious involvement and cognitive function. Reverse causality, however, is a major concern with cross-​sectional research given that significant cognitive impairment or dementia may also adversely affect religious belief (a highly complex cognitive activity) as well as religious social involvement, thus creating an inverse relationship between the two that has nothing to do with the effects of religiosity on memory or cognitive function. We first review research conducted in 2010 or earlier, and then examine research published more recently, within the past 10 years. The findings from cross-​sectional research, prospective studies, and experimental studies are presented, in that order (see Appendix for all studies).

Early Research Research systematically reviewed in the first and second editions of the Handbook uncovered a number of high quality early studies, most of which we review here. CROSS-​SECTION AL

Zhang (2010) examined the relationship between religious activity and cognitive functioning in a systematically identified sample of 8,703 participants age 80–​105 who participated in the Chinese Healthy Longevity Survey. Religious activity was assessed by a question on how often participants engaged in religious activity (every day, sometimes, or never). In this study, 84% never participated in any religious activity. After controlling for optimism, happiness, exercise, other leisure-​time activities, physical disability, age, education, urban residence, ethnicity, and marital status, religious participation was associated with a 30% lower odds of cognitive impairment in women (OR =​0.70, p < 0.01) and a 54% reduction in men (OR =​0.46, p < 0.01). P ROSP ECTIVE

Van Ness and Kasl (2003a) analyzed data from a 6-​year prospective study of a random sample of 2,812 community-​dwelling older adults in

New Haven, Connecticut, to examine whether baseline religiosity predicted changes in cognitive function over time. Participants were initially surveyed in 1982 and then again in 1985 (n =​1,847) and 1988 (n =​1,245). Religiousness was assessed by frequency of religious attendance, a two-​item measure of religious identity (self-​rated religiosity and comfort/​support derived from religion), and religious affiliation. Cognitive function was assessed using the Short Portable Mental Status Questionnaire (SPMSQ); participants with scores of 0 or 1 were considered unimpaired, whereas those scoring 2–​ 10 were considered cognitively impaired. Various religious variables (measured in 1982) were used to predict cognitive function in 1985 and 1988, controlling for 1982 cognitive function. Weekly religious attendance in 1982 predicted a lower likelihood of cognitive impairment in 1985 (OR =​0.64, 95% CI =​ 0.49–​0.85), although by 1988 the association disappeared (OR =​1.00, 95% CI =​0.71–​1.41). Covariates assessed in 1982 included religious affiliation, marital status, social engagement, cigarette smoking, hypertension, and stroke, some of which may have been mediators or explanatory variables (not confounders). Religious identity was not related to cognitive functioning in either 1985 or 1988 after adjustment for confounders and possible mediators. Furthermore, while having no religious affiliation was unrelated to cognitive impairment in 1985, it was related to less cognitive impairment in 1988 (OR =​0.86, 95% CI =​0.23–​0.76). Given the high mortality rate in this sample, a heavy attrition of less religious persons with dementia (particularly between 1985 and 1988) could explain these results, as in the Beeri et al. (2008) study below. In fact, investigators note that, “infrequent religious attendees in 1982 who became cognitively impaired by 1985 were more likely to die by 1988” (p. S27), supporting the selective mortality hypothesis. Hill and colleagues (2006b) prospectively followed a random sample of 3,050 community-​ dwelling older Mexican Americans from 1993–​ 1994 to 2000–​ 2001 (7 years). Participants were age 65 or over living in Texas, California, New Mexico, Arizona, and Colorado (part of the Hispanic Established Populations for

Epidemiologic Studies in the Elderly [EPESE]). Four waves of data collection were included in the analysis, which used linear growth curve modeling to predict cognitive function trajectories over time. The only religious variable assessed at baseline in 1993–​1994 was religious attendance. Cognitive functioning was measured using the MMSE. Analyses controlled for baseline cognitive function, functional disability, sensory impairments, health behaviors, psychological distress, chronic diseases, demographics, and social engagement (again, both confounders and potential explanatory variables). Compared to the reference category of never/​almost never attending services, there was a linear increase in cognitive function with each category of increased frequency of attendance (B =​+​0.16 for yearly, p =​ns; B =​+​0.54 for monthly, p < 0.05; B =​+​0.62 for weekly, p < 0.01; and B =​+​0.75 for more than weekly, p < 0.01). This effect amounted to an average 2.25 points slower decline on the MMSE among frequent attendees during the 7-​ year study period. While this may seem like a small effect, the average rate of cognitive decline across the 7-​year study period for all participants in the sample was only 5.13 points. Yeager and colleagues (2006) analyzed data from a 4-​year prospective study of a random national sample of 4,049 persons aged 60 or older in Taiwan, China, examining effects of religiosity on health, including cognitive function. Religious variables assessed at baseline in 1999 included religious affiliation (78% Buddhist or Tao), frequency of religious attendance, a 12-​item index of religious beliefs, and an 18-​item religious practices index. Cognitive functioning was measured using the SPMSQ in 1999 and 2003. Regression models controlled for demographics, health behaviors, physical functioning, social factors, and baseline cognitive function (again including confounders and possible mediators in the same models). Those indicating no religious affiliation at baseline had significantly less cognitive decline at the 4-​year follow-​up compared to those affiliated with Tao or traditional folk religion (reference category) (B =​−0.055, p < 0.05), although the sample size had dropped from 4,049 at baseline to 2,930 by the 4-​year follow-​up, again raising the possibility of selective mortality. Compared to those at Alzheimer’s Disease and Other Dementias • 447

baseline who said they never attended religious services, however, those who attended services “often” experienced significantly less cognitive decline over the 4-​year follow-​up (B =​−0.05, p < 0.05). Kaufman et al. (2007) examined the effect of religiosity/​spirituality (R/​S) on progression of cognitive impairment among 70 outpatients with AD being seen at neurology clinics in Toronto, Canada. Participants were age 49–​94 years (average age 78) and were followed for 12 months. R/​S was measured at baseline using the 5-​ item Duke Religion Index (assessing religious attendance, private religious activity, intrinsic religiosity), in addition to questions about self-​rated religiosity and self-​rated spirituality. Change in cognitive function from baseline to 12-​month follow-​up was assessed using the MMSE. All patients met standard neurological criteria for probable AD or AD and had MMSE scores of 10 or higher (moderate to severe disease). Results did not provide evidence of an association of religious attendance, self-​rated religiosity, or intrinsic religiosity with change in cognitive function during follow-​up. However, patients scoring higher on self-​rated spirituality (p =​0.01) and on private religious practices (p =​0.003) had significantly less cognitive decline, controlling for baseline cognitive function, age, gender, and education. Note, however, that the sample size of this study was very small, limiting power to detect associations. Using data from the Hispanic EPESE (the same baseline sample as Hill et al. above), Reyes-​Ortiz and associates (2008) examined the moderating effect of religious attendance on the relationship between depressive symptoms and cognitive function in 2,759 older Mexican Americans followed from 1993–​1994 to 2004–​2005 (an 11-​year prospective study). Religious attendance, depressive symptoms (CES-​D), and cognitive function (MMSE) were assessed at baseline and at 2, 5, 7, and 11 years of follow-​up. General linear mixed modeling was used to examine the effect of depressive symptoms on cognitive function over time, predicting trajectories of cognitive decline and incorporating time-​dependent covariates. Frequent religious attendance predicted higher MMSE scores at baseline and all follow-​ups (p < 448 •  P h y sical H ealth

0.01). High CES-​D scores (> 16) predicted lower MMSE scores at baseline and all follow-​ups. Slopes of MMSE decline were steeper for infrequent religious attendees (as Hill had reported) and for those with high CES-​D scores. There was also a three-​way interaction among attendance, depressive symptoms, and time predicting MMSE score decline (b =​−0.177, p < 0.001). The effect of high CES-​D scores on cognitive decline was stronger in those with low church attendance (b =​−0.60, SE =​0.03) than the effect of CES-​D scores on cognitive decline in high attendees (b =​−0.37, SE =​0.04), a finding that was independent of demographics, sensory impairments, comorbidities, and functional status. Corsentino and colleagues (2009) also examined the moderating effects of religious attendance on the relationship between depressive symptoms and cognitive decline, but this time using data from the Duke EPESE (55% African American, 45% White Caucasian) collected in North Carolina. This was a 3-​ year prospective study (1986–​1989) of a random sample of 4,000 adults age 65 or over, with 2,938 surviving to the 1989 follow-​up. Religious attendance, depressive symptoms (CES-​D), and cognitive function (SPMSQ) were assessed at baseline and follow-​up. Analyses were controlled for demographics (age, gender, race, marital status), socioeconomic characteristics (income, literacy, education), physical functioning, chronic health problems, social support, baseline depressive symptoms, and baseline cognitive function (again not differentiating between confounders and explanatory variables). Results indicated that baseline frequency of religious attendance predicted a slower decline in SPMSQ scores during the 3-​year follow-​up (p < 0.001). There was also a three-​ way interaction among gender, religious attendance, and depressive symptoms at baseline on change in SPMSQ scores over time. Among women, the two-​way interaction between religiosity and depressive symptoms was significant (b =​−0.019, p =​0.01) such that high CES-​D scores predicted a greater decline in cognitive function in those attending religious services infrequently compared to the effect of depression on cognitive decline in those attending services frequently. This interaction

was in the opposite direction for men, although it did not pass the p < 0.05 threshold. In a prospective study of 64 outpatients with Alzheimer’s disease seen at Padova Hospital, Italy, Coin et al. (2010) examined the effect of religious activity at baseline on changes in cognitive functioning assessed over 12 months using the MMSE. The Behavioral Religiosity Scale (BRS) was used to assess religiosity. The BRS measures frequency of religious attendance, praying, reading religious literature, and watching or listening to religious programs on TV or radio. Two groups of patients were formed based on religious activity, one with no or low religious activity (LR) and one with moderate or high religious activity (HR). In addition to cognitive function, researchers also assessed physical functioning, behavioral disturbances, and stress level. During the 12-​month follow-​up, patients in the LR group experienced a marked worsening in total cognitive and behavioral test scores. LR group patients were almost seven times more likely than those in the HR group to experience a 3-​point decrease in MMSE score (OR =​ 6.7, 95% CI =​1.8–​24.7). Researchers concluded that higher religious activity predicted slower cognitive and behavioral decline in outpatients with Alzheimer’s disease. The sample size of this study was again, however, very small. In contrast to the above studies that report a positive effect of religiosity on cognitive function or a moderating the effect of religiosity on the relationship between depression and cognitive function, researchers analyzing data from a 36-​year follow-​up of middle-​aged Jewish men in Israel found the opposite. Two reports from the same cohort (Davidson et al., 2004; Beeri et al., 2008) examined the effects of religious education and religiosity on development of dementia during follow-​up among male civil servants and municipal employees. Davidson et al. (2004) provide an abstract of the study, whereas Beeri et al. (2008) provide the entire report, which we summarize here. Religion was assessed in 1963 by single items asking about (a) religious education (exclusively religious, exclusively secular, or mixed) and (b) religiosity (1 =​least religious [non-​believers, agnostics], 2 =​secular, 3 =​traditional, 4 =​religious, 5 =​most religious [Heredim]). Covariates assessed in 1963 were age, SES, and area of birth. Of the

11,876 participants originally assessed in 1963, there were 2,604 still alive at the 36-​year follow-​ up. Of those, 1,890 were assessed for dementia using DSM-​IV criteria (average age 79) in 1999 and comprise the sample for all analyses. Results indicated that approximately 18% were diagnosed with dementia in 1999. Rates of dementia were 27.1% among those receiving an exclusively religious education, 12.6% in those with mixed education, and 16.1% in those with an exclusively secular education. With regard to religiosity, rates were 9.7% among agnostics/​nonbelievers, 17.7% among secular, 14.1% among traditional, 19.3% in religious, and 28.8% in Heredim (most religious). Logistic regression controlling for age, SES, and area of birth indicated that compared to those with an exclusively religious education (n =​482), those with mixed or secular education were less likely to develop dementia (OR =​0.58, 95% CI =​0.48–​ 0.65). Likewise, compared to the most religious group (Heredim) (n =​312), other groups (agnostic, secular, traditional, religious) were less likely to have dementia (OR =​0.54, 95% CI =​0.40–​0.74). As in the Van Ness and Kasl (2003a) study, those who were most religious were significantly less likely to die from cardiovascular disease during follow-​up (Goldbourt et al., 1993), with the possibility that those with dementia in the most religious group may have been more likely to survive to the 1999 assessment, compared to those with dementia in less religious groups who may have died prior to 1999 (which the researchers acknowledge). EXP ERIM EN TAL

Smith (2008) conducted a nondenominational prayer intervention among nursing home residents with moderate to late-​stage dementia. Participants were assessed before and after the prayer intervention (i.e., a single-​ group experimental study). Although few details are available, the prayer intervention was reported to achieve a significant increase in quality of life among those in the treatment group compared to the control group. Other than Eastern meditation studies (see below), this is the only experimental study of the effects of a religious intervention on cognitive function that we could locate prior to 2010. Alzheimer’s Disease and Other Dementias • 449

Recent Research

multi-​morbidity (two or more of chronic conditions), physical functioning, mental health Since 2010, only a few studies have examined (Euro-​D scale), demographic factors (age, sex, the effects of religiosity on cognitive function, marital status, household size, education, SES), most among community-​dwelling older adults and social participation. Logistic regression (with only one exception, to our knowledge, analyses were stratified by multi-​ morbidity involving patients with AD in South Korea). status (yes vs. no). In those with and without Again, we focus here on large cross-​sectional multi-​ morbidity, participation in religious and prospective studies. activities was associated with a lower likelihood of dementia. Wang et al. (2017) examined the relationC ROSS -​SE C TI O N AL ship between religiosity, cognitive impairment, Using a cross-​ sectional/​ retrospective design, and the presence of apolipoprotein E (APOE) researchers conducted a door-​to-​door survey gene polymorphisms in 2,410 community-​ of 778 Muslims aged 65 or over in northern dwelling adults age 55 or older residing in the Israel, examining how midlife leisure-​activities Ningxia Province (western mainland China). (including prayer) related to current cognitive Religious involvement was assessed using the impairment (Inzelberg et al., 2013). Praying Chinese version of the 5-​item Duke University was measured by asking about the number of Religion Index (DUREL), which assesses relihours spent in prayer per month during mid- gious attendance, private religious activities, life at age 20–​60 (verified by family members). and intrinsic religiosity. APOE gene status was Participants were divided into three groups: determined using a standard method (a high-​ 448 normal controls, 92 with AD, and 238 with resolution melting curve protocol). Cognitive MCI, each determined using standard measures functioning was determined by neuropsy(MMSE and Brookdale Cognitive Screening chological testing that included the MMSE. Test). Participants also had a clinical evaluation Clinical examination confirmed the presence by a neurologist. The relationship with prayer of MCI. Logistic regression was used to analyze could not be assessed in men since almost all the results while controlling for demographic (94%) were engaged in midlife prayer. Among and health variables. A significant interaction women (n =​394), results indicated that a higher was found between religiosity and the presence percentage with normal cognitive function of the APOE-​e4 allele in predicting MCI. Risk reported praying during midlife (87%) com- of MCI was highest in those with the APOE-​e4 pared to those with MCI (71%) or AD (69%) (p allele and low religiosity (OR =​1.95, 95% CI =​ < 0.0001). After controlling for age and educa- 1.24–​3.07), whereas among those with high tion, women engaging in prayer during midlife religiosity, the APOE-​e4 allele was not associwere 45% less likely to experience MCI (OR =​ ated with increased risk (OR =​0.70; 95% CI =​ 0.55, 95% CI =​0.33–​0.94, p =​0.03), although 0.47–​1.04). the relationship with AD did not reach statistiSun and colleagues (2018) analyzed data cal significance (OR and 95% CI not provided). from a systematically identified sample of 1,347 Amount of prayer during midlife (i.e., hours/​ community-​dwelling Muslims of Hui ethnicmonth) was not related to either MCI or AD. ity age 55 or older living in western mainland Sowa et al. (2016) analyzed cross-​sectional China, examining the relationship between data on 57,391 individuals age 50 or older liv- religiosity (DUREL) and cognitive function ing in 16 European countries. Participation in (MMSE). Controlling for age, education, genreligious activities was assessed by asking par- der, and depressive symptoms (Geriatric ticipants if they had attended or taken part in Depression Scale; GDS), high religiosity was the activities of a religious organization within associated with a lower likelihood of MCI (OR =​ the past 12 months (yes vs. no). The presence 0.69, 95% CI =​0.52–​0.93, p =​0.01). Structural of AD or dementia was determined by self-​ equation modeling demonstrated that depresreport. Regression models controlled for num- sion significantly mediated the relationship ber of self-​reported chronic health conditions, between religiosity and MCI, explaining 33% 450 •  P h y sical H ealth

of the total variance, suggesting that religiosity may have decreased the likelihood of developing MCI by reducing depression. Again, however, these were cross-​sectional analyses. Foong et al. (2018) analyzed data from a national random sample of 2,322 community-​ dwelling adults age 60 or older in Malaysia. The purpose was to examine whether intrinsic religiosity moderated the relationship between depression and cognitive function (as did Hill et al., 2006b, and Ortiz et al., 2008). Intrinsic religiosity was assessed by the 6-​item intrinsic religiosity (IR) subscale of the Revised Intrinsic/​Extrinsic Religious Orientation Scale (Gorsuch & McPherson, 1989). Depression was assessed by the GDS and cognitive function by the Montréal Cognitive Assessment (MOCA). Controlled for in analyses were age, gender, marital status, years of education, and household income. Hierarchical multiple regression analysis indicated that depressive symptoms were inversely related to cognitive function (b =​−0.099, p < 0.001). IR, in turn, was positively related to cognitive function (b =​0.037, p < 0.05). Again, researchers found that there was a significant interaction between IR and depression, such that the relationship between depressive symptoms and cognitive impairment was significantly weaker among those with high IR (compared to those with low IR). Jung and colleagues (2019) examined the relationship between various aspects of religiosity and cognitive function in 325 patients with AD seen at a psychiatry outpatient clinic in South Korea. Participants were over age 60 and met diagnostic criteria for AD according to DSM-​IV. Cognitive functions were assessed using the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) evaluation, which assesses memory, language, and constructional ability. Religiosity was measured by the 5-​item DUREL (organizational religious activity [ORA], non-​ organizational religious activity [NORA], and intrinsic religiosity [IR]). Regression analyses and structural equation models controlled for age, gender, and years of education. Average age of participants was 79.2 years, 72% were women, and 55% indicated a religious affiliation (42% Christian, 13% Buddhist). Results indicated that ORA was positively associated with memory (partial r =​0.18, p =​0.001), language (r =​0.15, p

=​0.008), and constructional ability (r =​0.24, p < 0.001). NORA was significantly associated with memory (r =​0.13, p =​0.02) and constructional ability (r =​0.23, p < 0.001), but not language. IR was significantly associated with memory (r =​0.17, p =​0.002) and constructional ability (r =​.19, p =​0.002), but again not with language. The final structural equation model (which explained 58% of the overall variance in cognitive function) indicated that overall religiosity (ORA, NORA, IR) was significantly and positively associated with overall cognitive function (b =​0.30, p < 0.001). P ROSP ECTIVE

We identified five prospective studies since 2010 that examined the effects of religiosity on cognitive function in older adults over time. Cohen-​Mansfield and colleagues (2016) explored the association between changes in religious involvement and cognitive function in a random sample of 1,191 Jewish participants age 75–​94 in Israel. Participants were followed for an average of 3.5 years between 1989–​1990 (Wave 1) and 1993–​1994 (Wave 2). Religiosity was assessed by religious identity and change in religiousness. Religious identity was categorized as ultra-​Orthodox/​Orthodox, traditional, and secular. Perceived changes in religiousness were examined retrospectively (presumably at Wave 1) by asking about participants’ level of observance of commandments/​ traditions currently compared to 20 years ago (more, the same, less); objective change in religious identity between Waves 1 and 2 was also examined. Cognitive difficulties were measured using by the Orientation-​Memory-​Concentration Test (OMCT). MANCOVA was used to examine the effect of change in religiousness (assessed retrospectively and objectively) on cognitive functioning, controlling for age, gender, and education. Cognitive difficulties (time of assessment not specified) were significantly more common among those who reported less religious observance currently than 20 years ago, compared to those who reported the same level of religious involvement (10.4 vs. 8.3, p < 0.01). There was also borderline evidence for a relationship between objective change in religious identity from Wave 1 to Wave 2 (vs. no change) Alzheimer’s Disease and Other Dementias • 451

and cognitive impairments assessed at Wave 2 (10.5 vs. 9.1, p =​0.059). Given that researchers did not specify when cognitive measures were administered, and did not appear to control for baseline cognition, this provides only limited evidence that religiosity affects the development of cognitive difficulties over time. Hwang et al. (2018) examined the effects of social activities on cognitive functioning in a random sample of 5,948 community-​dwelling adults age 45 or older in South Korea. Among social activities was “participation in religious meetings” (24.7%). Multi-​level mixed models were used to examine the effects of various social activities on changes in MMSE scores over 9 years of follow-​up, controlling for age, other social gatherings, volunteer work, marital status, work status, rural residence, education, income, physical activity, alcohol intake, smoking, physical functioning, depression, and physical comorbidity. There was no evidence for an association between participation in religious meetings and changes in cognitive functioning assessed by the MMSE over time (b =​ −0.10, SE =​1.79, p =​0.96), nor did effects vary by age group (age 45–​64 or age 65+​). Kraal et al. (2019) surveyed a random national sample of 16,069 adults age 52 or older participating in the US Health and Retirement Study, following participants over a 6-​year period (2006–​2012). Frequency of religious attendance, private prayer, and level of religious belief (4-​item measure) were assessed at baseline. Episodic memory, the outcome, was measured at all four follow-​up assessments with a list learning task, i.e., a standard measure of this memory component. Structural equation models using latent growth curve analysis were used to predict memory trajectories during follow-​up, controlling for age, gender, education, wealth, chronic diseases, and depressive symptoms. In cross-​sectional analyses at baseline, religious attendance and prayer were both positively associated with initial memory performance (b =​0.013, SE =​0.004, p < 0.001, and b =​0.014, SE =​0.005, p =​0.009), whereas religious belief was negatively associated (b =​ −0.010, SE =​0.004, p =​0.006). No religious variables predicted change in episodic memory during longitudinal follow-​up. 452 •  P h y sical H ealth

In a prospective study of 10,741 persons age 80 or over in China (Chinese Longitudinal Health and Longevity Survey), Mao et al. (2020) examined the effects of specific leisure activities, including engagement in religious activities, on change in cognitive functions of participants over a 3-​year period. After controlling for multiple covariates (activities of daily living, participation in other leisure activities, age, gender, education level, marital status, living pattern, residents, smoking status, alcohol consumption, diet, regular exercise, BMI, hypertension and other chronic illnesses, housework, baseline MMSE scores) using Cox proportional hazards models, no evidence was found for an effect of participation in religious activities on development of cognitive impairment (HR =​1.13, 95% CI =​0.93–​1.37). Note, however, that 85% of participants never engaged in any religious activities and only 3.7% did so regularly. The short follow-​up time of 3 years may also have reduced the power to detect effects. Finally, Lekhak et al. (2020) analyzed data from a prospective study of prayer and meditation on changes in episodic memory over a 12-​ year period involving a random sample of 1,135 community-​dwelling adults age 50 or over participating in the US Health and Retirement Study. Generalized estimating equation regression models were used to examine the effects of prayer/​meditation on changes in episodic memory, examined every 2 years from 2000 to 2012. Episodic memory was assessed by a standard measure of immediate word recall and delayed word recall. Prayer and meditation were assessed in the year 2000 by two questions asking respondents if they (a) ever meditated and (b) ever prayed privately in places other than a church or synagogue (yes vs. no). Also assessed were chronic health problems, age, race, gender, marital status, and education. The results indicated that prayer (but not meditation) positively predicted better episodic memory over time (b =​0.50, SE =​0.22, p < 0.05), independent of demographic factors and chronic health problems. For the entire group, there was on average a 0.15-​point decline in episodic memory as participants grew older (p < 0.001). However, there was a weak interaction between prayer and age, such that those who prayed

actually had a small 0.04-​point increase in episodic memory score as they got older (B =​0.04, SE =​0.02, p =​0.05). Researchers concluded: “This study illustrates the benefits of prayer in preserving memory and provides much-​needed empirical basis for community-​level interventions to enhance memory in later life” (p. 30). E XP E RI ME N TAL S T UDIE S

Attempts to examine the effects of “spiritual” interventions in patients with mild to moderate dementia have reported positive effects on cognition, although they have often involved approaches that are primarily psychological (not religious) in nature (e.g., Wu & Koo, 2016). These interventions have frequently focused on meaning/​ purpose, social relationships, and addressing hopes and fears, with religious beliefs and activities sometimes tacked on at the end of the intervention (or avoided completely). There have also been a number of qualitative studies demonstrating the benefits of spiritual nursing interventions on improved outcomes in patients with dementia (likewise often utilizing a wide range of psychosocial approaches and outcomes often redefined as “spiritual”) (see Ennis et al., 2013, for a review). Eastern forms of meditation have been shown in RCTs to reduce cognitive impairment in older adults and in those with dementia (see Marciniak et al., 2014, for a review). For example, in a small RCT involving 20 participants with MCI age 55 or over in the Czech Republic, Marciniak et al. (2020) found that Buddhist-​ based mindfulness meditation improved psychomotor speed compared to a “cognitive training” control group (p =​0.049).

Summary Many of the cross-​sectional studies reviewed above indicated that religious beliefs and practices were related to less cognitive impairment in those with and without dementia, and in several prospective studies, religious service attendance predicted less decline in cognitive functioning over time. As with a number of other outcomes reviewed in this Handbook, religious service attendance was more consistently associated with less cognitive impairment than

other variables assessing religiosity. Among the exceptions to positive results among prospective studies were those where (1) mediators were not distinguished from confounders, and/​or (2) selective mortality may have caused the death of less religious individuals with dementia, leaving highly religious persons with dementia still alive in the cohort on follow-​ up (making it appear that religious survivors had the same or more cognitive impairment/​ dementia than nonreligious survivors). On the other hand, reverse-​ causality may have also accounted for some of the positive effects of religiosity on cognitive functions, i.e., cognitive impairment interfering with religious activity. Further research is clearly needed to sort out causal inference in these observational studies. Finally, a few religious and broadly spiritual/​ psychological interventions appear to improve cognitive function in older adults and in those with dementia. Although this is primarily true for studies involving Eastern religious forms of meditation, it may also be true for Western forms of prayer. Again, more research is needed on the effects of patient-​ centered religious interventions on cognitive function, based on the incorporation of specific religious beliefs and practices.

THE BRAIN AND RELIGIOSITY Research has also examined the relationship between religiosity and specific brain regions affected by disease. For example, it has long been known that hyper-​religiosity may occur in some cases of temporal lobe epilepsy, although only in a small percentage of patients (typically less than 5%) (Devinsky & Lai, 2008). Right temporal lobe atrophy in those with frontotemporal dementia has also been associated with hyper-​ religiosity in some recent case reports (Everhart et al., 2015; Veronelli et al., 2017) as well as in earlier studies (Postiglione et al., 2008; Chan et al., 2009). Finally, hyper-​ religiosity has been associated with right hippocampal atrophy (the hippocampus is part of the medial temporal lobe) (Wuerfel et al., 2004). However, the exact meaning of “hyper-​ religiosity” (vs. philosophical-​type experiences/​ tendencies) based on the way this has been Alzheimer’s Disease and Other Dementias • 453

measured makes it difficult to interpret what these findings actually mean. In one of the few longitudinal studies of older adults using MRI scans to assess structural brain changes over time, a Duke University study examined 306 adults age 58 or older during a 2-​to 8-​year follow-​up (Owen et al., 2011; Hayward et al., 2011). Being “born again” (i.e., having a life-​ changing religious or spiritual experience) predicted a mixture of brain changes: greater bilateral hippocampal atrophy, but less left orbito-​frontal cortex (OFC) atrophy. In that study, either Catholic religious affiliation or having no religious affiliation predicted greater left hippocampal atrophy, whereas greater frequency of religious attendance predicted greater left OFC atrophy. Religious behaviors, whether public or private, had no effect on hippocampal volumes. Other researchers have likewise reported a wide range of findings when examining the relationship between religious involvement and areas of brain structure or function based on neuropsychological tests (Johnstone et al., 2012). Thus, the search for a “God spot” in the brain remains as elusive as ever. Finally, in an attempt to identify a mechanism by which religiosity may affect brain structure and function, Mosqueiro and colleagues (2019) measured BDNF levels on admission (n =​101) and discharge (n =​91) among patients hospitalized for depressive disorder in Brazil. BDNF is a key factor in the brain, responsible for synaptic plasticity, dendritic/​neuronal fiber growth, and neuronal survival. Furthermore, low levels of serum BDNF have been associated with significant cognitive decline in prospective studies of older adults (Paulsen et al., 2020). In the Mosqueiro et al. study, religiosity was assessed at discharge using the DUREL, focusing on the last three items that assess IR. Serum BDNF levels were collected within 72 hours of hospital admission and within 48 hours of discharge. Controlled for in analyses were severity of depressive symptoms on admission and discharge, as well as age, gender, smoking, psychological resiliency, and psychiatric treatments. At the time of discharge, IR was positively and significantly related to BDNF levels in cross-​sectional analyses (r =​0.19, p =​0.03). 454 •  P h y sical H ealth

Furthermore, there was a statistically significant increase in BDNF levels from admission to discharge (43.6 ng/​ml to 53.8 ng/​ml, p =​ 0.05) in high IR patients, whereas there was no increase from admission to discharge in low IR patients (47.6 ng/​ml to 43.6 ng/​ml, p =​0.40). Between-​subject analysis (those with high and low IR) indicated a significant effect of high vs. low IR on BDNF levels at discharge (F =​12.0, p =​0.001). Multivariate analysis of variance controlling for age, gender, psychological resilience, depressive symptoms on admission, depressive symptoms on discharge, and cigarette smoking revealed a significant effect favoring high IR (λ =​0.74, F =​6.2, p < 0.01) on change in BDNF levels. Controlling for antidepressant treatments (known to increase BDNF levels), high IR remained a significant predictor of BDNF at discharge (β =​0.26, t =​2.64, p =​0.01). If religiosity does increase BDNF levels, this may help to explain one physiological mechanism by which religiosity affects cognitive functioning in later life (perhaps beginning in young to middle adulthood).

RECOMMENDATIONS FOR FUTURE RESEARCH As in other chapters, we recommend that future research focus on large-​scale, long-​term prospective studies and RCTs whenever possible. With limited funding support, however, this remains somewhat of an ideal. Unfortunately, cross-​sectional studies (the easiest and most affordable) tell us little about whether religiosity improves cognitive functioning with aging, prevents the development of dementia, or slows cognitive decline in those with dementia. As noted earlier, significant cognitive impairment can interfere with the complex cognitive functions involved in religious belief and commitment, and may adversely affect religious activities, thereby potentially explaining some of the inverse correlations found between religiosity and cognitive function or dementia in cross-​sectional studies. Only prospective studies and RCTs can answer questions about causal inference in this context, and these types of studies are often costly and difficult to carry out well. Nevertheless, smaller, less costly prospective studies can add important evidence

in this regard, particularly when using cross-​ lagged analyses or other more advanced methods of longitudinal data analysis (VanderWeele, et al., 2016a). When conducting future prospective studies, multi-​ item measures of religious belief, commitment, and behavior should be utilized to measure religious involvement as a predictor, as various aspects of religiosity may act synergistically. As noted in Chapter 2, several comprehensive relatively brief measures exist with strong psychometric properties (e.g., Worthington et al., 2003; Koenig et al., 2015a). Religiosity should be assessed at multiple times during prospective studies so that the impact of changes in religiosity over time can also be examined. Likewise, objective measures of different aspects of cognitive function (memory, language, constructional ability, etc.) should be administered at each wave of data collection since different dimensions of religiosity may affect different aspects of cognitive function (and vice versa). When examining risk of dementia, standard diagnostic criteria based on structured clinical interviews using DSM criteria should be utilized, particularly when examining different types of dementia (Alzheimer’s disease, vascular dementia, frontotemporal dementia, Lewy-​body dementia, etc.), each of which may be affected differently by religious belief, commitment, and activity. Since both cognitive impairment and religious involvement are more common in Blacks, women, and the socioeconomically deprived, future observational studies that examine effects on cognitive function or dementia need to carefully control for these confounders (i.e., race, gender, and education/​ SES). Likewise, as repeatedly emphasized in this volume, researchers need to clearly distinguish between confounders and mediators that explain how religiosity influences cognition (VanderWeele, 2015). If the effect of religiosity on cognitive functioning disappears when confounders are controlled, then there is truly no effect. However, when mediators are controlled for and the relationship goes away, this may explain how religiosity affects cognition. An additional challenge, discussed above, is that with an older population, religious service attendance may itself exert a substantial influence on mortality

and selectively keep alive less-​well individuals who are religious, thereby potentially biasing associations evaluating effects of service attendance on cognitive function/​dementia. Indeed, some evidence suggests that this phenomenon may be at play (Van Ness & Kasl, 2003a; Li et al., 2018b). Analyses that proceed in spite of this selection bias will potentially yield overly conservative estimates of the effect of service attendance on cognitive function/​ dementia (Chiba & VanderWeele, 2011; Li et al., 2018b). Finally, religious interventions need to be developed that utilize a person’s religious beliefs and practices, particularly those found to affect cognitive functions in observational studies. These interventions then need to be tested in RCTs. While interventions based on Eastern meditation are important, particularly for those affiliated with Eastern religions, emphasis needs to be paid on culturally appropriate patient-​centered treatments. In Western societies, patient-​centered religious interventions are also needed that utilize religious resources based on the core beliefs and practices of Western religious traditions such as Christianity, Judaism, and Islam. Interventions of this type have not yet been developed, nor have they been tested in RCTs. This method alone (the RCT) is the only way to definitively show that religion impacts cognitive function in later life or slows cognitive decline in those with dementia.

CLINICAL APPLICATIONS Clinical applications always begin with taking a thorough spiritual history. This is true for mental health professionals, medical professionals, and clergy. This involves identifying religious beliefs and practices important to the person, as well as exploring prior experiences with religion during both childhood and adulthood. Such a history may need to be taken from a close relative or caregiver of the person with AD or other dementia, particularly in advanced cases. Helping professionals should always start, however, with the patient him-​or herself and then obtain collateral information from family members or friends (obtaining consent from the patient to do so, to the extent that this is possible). Religious beliefs, commitments, and Alzheimer’s Disease and Other Dementias • 455

experiences are often the last cognitive, affective, and behavioral functions to go in those with dementia. These experiences are deeply ingrained within the brain and are not easily lost. For Christians, even those with severe dementia, prayers (such as the Lord’s Prayer) and/​or hymns (such as “Amazing Grace”) may be recited or sung by the affected individual with a little prompting, thereby providing comfort and sometimes even calming agitation (Witzke et al., 2008; Friedrich et al., 2021). For an example of how religious music can reactivate a person with dementia, someone who is ordinarily mute and capable of giving only yes or no responses, see the Memory & Music Project (2020). In most cases, helping professionals should support the religious beliefs and practices of the person with dementia, unless religious experiences cause fearful or agitating delusions or hallucinations (which require psychotropic medication) or severe guilt or shame (that may require religious rituals such as confession, with constant reminders of divine forgiveness). In that case, greater attention to pastoral considerations may be important. This also applies to those caring for family members with dementia, as these caregivers are often carrying a heavy burden. Caregivers scoring high on religiosity have been shown in multiple studies to cope better with caregiving duties than those who are less religious (Hebert et al., 2007; Koenig et al., 2016a; Yoon et al., 2018). Emphasizing the importance of continued religious involvement by patient and caregiver may provide benefits to both. Part of that support may involve education about factors that influence the development and course of dementia and how religious resources can help in that regard. Religious beliefs can also be utilized to motivate healthy behaviors that help to preserve cognitive function, honoring the body and mind as the “temple of the Holy Spirit” (e.g., avoiding alcohol, reducing smoking, eating a healthier diet, reducing salt intake, controlling weight, reducing blood pressure, staying physically active, and so forth). This can take place either on the individual level or at the religious community level. With regard to the latter, health programs may be designed specifically for this purpose, especially in congregations 456 •  P h y sical H ealth

with a high percentage of middle-​age or older adults. Clinicians and clergy may also implement simple religious interventions among older religious patients or congregants by encouraging them to engage in religious activities such as meditation, prayer, involvement in scripture study or prayer groups, or in religious volunteering to meet the needs of those within and outside the faith community. As noted above, such behaviors may help to reduce dementia risk or delay the cognitive decline associated with normal aging. Such recommendations also apply to caregivers of those with dementia. Caregivers should also be encouraged to take time off from their caregiving activities to nourish the spirit and engage in religious fellowship or other pleasant activities to help relieve the burden of caregiving. Without such times of “respite,” caregivers may quickly become isolated, discouraged, and exhausted, ending up needing to place the loved one in a nursing home. Clergy can also encourage members of their congregation to check on, provide companionship to, or provide respite to stressed caregivers as a way of maintaining their own mental health and cognitive function as they age. Volunteers may be sought to sit with the patient for a couple of hours while the caregiver has a break to do things they enjoy. Liability issues, however, must be considered for non-​family members, and specific training on how to safely provide such respite care will be needed. Finally, as emphasized under recommendations for future research, religiously integrated cognitive-​behavioral interventions are needed to reduce cognitive decline in older adults with mild cognitive impairment. Such interventions may be designed to be implemented by either mental health or religious professionals. Secular interventions of this type have been developed to address symptoms of anxiety and other mental health problems in those with early dementia and have been found to be quite helpful (Paukert et al., 2010; Tonga et al., 2016). Similar interventions have also benefited stressed family members caring for those with dementia (Losada et al., 2015; Hopkinson et al., 2019). However, to our knowledge, religiously integrated interventions like these have not yet been developed for persons with

dementia or their caregivers, although some preliminary efforts in this regard have been made, at least for caregivers (Glueckauf et al., 2009; Kazmer et al., 2018).

SUMMARY AND CONCLUSIONS In this chapter we examined the effects of religious involvement on decline in cognitive function that occurs with normal aging and in the setting of Alzheimer’s disease and other dementias. After describing the six major types of dementia, we reviewed research on the prevalence of dementia and the costs of providing medical, institutional, and home care to the cognitively impaired. Next, genetic/​epigenetic, medical, psychological, social, environmental, and behavioral causes of dementia and cognitive decline were examined, with a focus on modifiable risk factors. This was followed by a discussion of how religiosity might impact cognition through effects on modifiable risk factors, especially psychological, social, environmental, and behavioral factors. The core of this chapter, however, focused on reviewing

the results of systematic research that has examined the effects of religiosity on cognitive functioning among older adults and those with dementia, emphasizing prospective and experimental studies. In summary, the majority of studies suggest that greater religiosity, in particular greater religious service attendance, may slow the cognitive decline seen with aging and in those with dementia, although further research is needed to confirm these initial findings. Also reviewed were studies examining the presence of hyper-​religiosity among older adults experiencing atrophy of specific brain regions (particularly the temporal lobes and hippocampi in particular). We also discussed a study that recently found higher levels of brain-​ derived neurotrophic factor (BDNF) among highly religious depressed patients, which may be one pathway by which religiosity affects cognitive function. Finally, recommendations for future research (particularly prospective studies and RCTs) were made and clinical applications were suggested for clinicians, religious professionals, and those responsible for the care of those with dementia and their families.

Alzheimer’s Disease and Other Dementias • 457

24 Immune Function Optimal functioning of the immune system, it turns out, is dependent upon feeling good. —​Marcey Shapiro

IN THIS CHAPTER, we examine the impact of religious involvement on immune system functioning, systemic inflammation, and risk of infection, as indicators of immunity. The immune system is of critical importance in maintaining physical health, and represents one pathway—​perhaps the key pathway—​by which religiosity could affect physical health and longevity. An overactive immune system can produce widespread inflammation (increasing the risk of cardiovascular disease, autoimmunity, and many other age-​related illnesses), while an underactive one increases the risk of infection or development of cancer—​both adversely affecting physical health. Emotional health, social involvement, and health behaviors are known to impact immune function, levels of inflammation, and susceptibility to infection. Because religious involvement may influence mental, social, and behavioral health, this could be a mechanism by which religiosity affects immunity, modulates levels of inflammation,

and influences the development and course of infection. The purpose of this chapter is to carefully lay out this logic and examine evidence for it. We begin by explaining the purpose and the components of the immune system.

THE IMMUNE SYSTEM In brief, the immune system prevents outside invaders (viruses, bacteria, fungi, i.e., pathogens) from gaining a foothold in the body and prevents inside invaders (when internal errors lead to malignant transformation of cells) from doing likewise. The immune system also assists in the healing process following physical injury. It accomplishes these tasks in two basic ways: innate immune responses and adaptive immune responses (Thompson, 2015; McComb et al., 2019). Innate immune responses occur rapidly, soon after exposure to the invader. Exposure produces an inflammatory response and sensitizes

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0024

other immune cells for future long-​ term responses to the pathogen. Innate immunity involves small molecules (complement), natural killer cells, dendritic cells, and macrophages that, when encountering the invader, immediately react to kill and remove it. Natural killer (NK) cells of the innate immune system monitor tissues for viral invasion or the development of cancer cells (pathogens). Dendritic cells expose a specific part of the pathogen (called an “antigen”) to cells of the adaptive immune system for long-​term sensitivity, producing memory of the invader for future responses. Macrophages are large phagocytic cells derived primarily from monocytes and are particularly important in chronic infection because they remove large particles and necrotic debris. Other cells of the innate immune system include polymorphonuclear cells (neutrophils, basophils, eosinophils) and mast cells. Neutrophils makeup about 50%–​60% of all white blood cells (WBCs) and have the ability to destroy infecting microbes, whereas basophils make up about 1 percent of WBCs, eosinophils about 1%–​6% of WBCs, and most of the rest of WBCs are lymphocytes (see below). Mast cells (< 1% of WBCs) are specialized inflammatory cells that release histamine in response to infection, causing inflammation and leading to wound healing, but also allergic reactions. WBCs, as part of both the innate and adaptive immune system, are mobile units that quickly circulate throughout the blood and lymphatics to areas where external pathogens are invading to destroy them. When the immune response involves dendritic cells, macrophages, NK cells, and T cells (below), this is called “cellular immunity.” In addition, part of this immediate response involves the release of antibodies, cytokines, and complement into body fluids, which is called “humoral immunity.” Adaptive immunity, in contrast to innate immunity above, involves a much slower response but one that can more accurately target the pathogen should it invade the body at some future point in time. B and T “memory” cells, which are activated by dendritic cells and macrophages of the innate immune system, make up the adaptive immune response. Should re-​exposure to a pathogen occur, these cells will be quickly mobilized to fight the invader. Activated B cells make antibodies

(immunoglobulins IgG, IgM, IgA, IgD, and IgE) directed at specific antigens (parts of the pathogen) to which they have been exposed. These antibodies then attach themselves to the pathogen, signaling other immune cells to kill the invader. Activated T cells (CD8 and CD4, in particular) also recognize pathogens to which they have been exposed in the past and rapidly kill them by attacking infected cells. There are several types of T cells: T-​helper cells (CD4, which produce pro-​ inflammatory cytokines), cytotoxic T cells (CD8), natural killer-​T cells (CD56), T memory cells, and regulatory T cells. Regulatory T cells are specific for antigens on cells that the body should not respond to, producing anti-​inflammatory cytokines to protect the body from unnecessary inflammation. The T and B cells of adaptive immunity are also called lymphocytes. T cells make up about 70%–​ 80% of lymphocytes that circulate in the blood, 90% of thoracic duct lymphocytes, 30%–​40% of cells in lymph nodes, and 20%–​ 30% of lymphoid cells in the spleen. B cells make up about 10%–​15% of lymphocytes that circulate in the blood, 50% of lymphocytes in the spleen, and 10% of lymphocytes in bone marrow. However, natural killer cells described above are also a type of lymphocyte, but one that is part of the immediate (innate) immune response. Lymphocytes overall make up about 20%–​50% of all WBCs. Monocytes, which make up about 2%–​10% of WBCs, function as part of both the innate and the adaptive immune system. The places where WBCs, tissue histiocytes, and plasma cells are made are the spleen, lymph nodes, and lymph nodules, where they arise from reticulum cells in these organs. Cytokines are a category of proteins secreted by helper T cells (pro-​inflammatory) and regulatory T cells (anti-​ inflammatory) that are important in the signaling of other components of the immune system (Turner et al., 2014; Himmerich et al., 2019). These proteins are critical for normal immune system functioning and coordinate many immune activities. Cytokines influence gene activation that results in cellular growth and differentiation, and in this way regulate immune responses. Almost 30 different kinds of cytokines exist, including interleukins (e.g., IL-​1, IL1-​β, IL-​2, IL-​4, IL-​5, IL-​6, IL-​7, IL10, IL-​12, IL13, IL-​15, Immune Function • 459

IL-​17, IL-​21), lymphotoxins (LT), interferons (INF-​α, INF-​ β, INF-​ γ), tumor necrosis factor (TNF-​α), and transforming growth factor (TGF-​β). Cytokines are divided into four major groups: T helper 1 (Th1) cytokines (IL-​2, IL12, IFN-​γ), T helper 2 (Th2) cytokines (I-​4, IL-​5, IL-​ 13), pro-​inflammatory cytokines (IL-​1, IL1-​β, IL6, IL-​8, IL-​17, IL-​21), and anti-​inflammatory cytokines (IL-​10, TGF-​β). Th1 cytokines (INF-​ γ, IL-​ 2, IL-​ 12), pro-​ inflammatory cytokines (e.g., IL-​6), and TNF-​α tend to promote inflammation, whereas the Th2 cytokines (e.g., IL-​4) and anti-​inflammatory cytokines (e.g., IL-​10) tend to reduce inflammation. To complicate matters further, Th1 and Th2 cytokines modulate each other’s production. Pro-​inflammatory Th1 cytokines inhibit cells that produce anti-​inflammatory Th2 cytokines, and Th2 cytokines inhibit cells that produce Th1 cytokines. The Th1/​Th2 ratio is important since the balance between pro-​ inflammatory and anti-​inflammatory cytokines must be carefully regulated in order to avoid excessive inflammation (high ratios occur in autoimmune diseases) or inadequate inflammation (low ratios occur in seasonal allergies, asthma, food and drug allergies, and anaphylactic reactions). Cytokines have multiple effects throughout the body as they circulate about in blood, including fever, lethargy, decreased appetite, and stimulation of cortisol production through activation of the hypothalamic-​ pituitary-​ adrenal (HPA) axis (Gulati et al., 2016). Of particular interest here is that the Th1/​Th2 ratio has been found to be altered during states of chronic stress or depression (Komori, 2017). These alterations during negative emotional states such as depression are “extremely unspecific,” often making the results from studies examining cytokine levels and negative mental health states difficult to interpret (Himmerich et al., 2019). Nevertheless, since cytokines are relatively inexpensive to measure, many studies have included them as measures of immune function, and especially as indicators of inflammation. C-​reactive protein (CRP) is a substance produced by the liver, as well as by macrophages, endothelial cells, and lymphocytes, and is a commonly used indicator of systemic inflammation. Increased during infection and strongly 460 •  P h y sical H ealth

predictive of cardiovascular disease, CRP plays an important role in inflammatory processes and responses to infection, enhancing lymphocyte production of cytokines, particularly interleukin-​ 6 and tumor necrosis factor-​ α (Sproston & Ashworth, 2018).

Interactions In order to maintain homeostasis in the body, both during health and times of assault by infectious microbes or internal invaders, a detailed feedback system exists that controls different components of the immune system. Mobilized immune cells and inflammatory proteins change rapidly and respond to one another’s fluctuations over time. Psychological stress also influences these interactions through the fight-​flight response that is regulated by the HPA-​axis and sympathetic nervous system, and the nature of such effects may differ depending on whether stressors are acute or chronic. This complex and dynamic nature enables the immune system to change quickly when needed to maintain physical integrity, while being strongly influenced by psychological cues giving signals that the body (or person) is in danger.

DETERMINANTS OF IMMUNE FUNCTION In order to understand how religious involvement might impact immune function, it is important to know what factors affect immune functions. It is through these pathways that religiosity will most likely have an influence. Factors that may influence immune function include demo­graphic, biomedical and genetic factors, environmental influences, gene-​ environment interactions, and psychological, social, and behavioral effects, some of which may be modifiable. Each will be reviewed below.

Demographic Influences Age and gender are non-​modifiable influences on immune function. Increasing age is known to decrease the vigor of immune responses to bacteria and certain viruses (Ventura et al., 2017). This effect is called “immune-​senescence.”

Because the production of “naïve” T cells decreases after age 60, older persons are less able to mount an immune response to novel infectious agents (i.e., those that have not been encountered earlier in life). There is also a decline in the functioning of natural killer cells with increasing age, which reduces the older adult’s ability to fight off viral infections and prevent the development (or progression) of certain cancers. B cells also do not work as well in older adults, especially when responding to vaccines intended to produce antibodies. There is also an up-​regulation (increase) of pro-​inflammatory cytokines with aging, particularly IL-​6 (Ershler & Keller, 2000; Ventura et al., 2017). As a result of these immune system changes, pneumonia and septicemia (blood infection) combined are the third most common cause of death in older persons, surpassed only by heart disease and chronic lower respiratory diseases (Tinetti et al., 2012). Autoimmune disorders may also increase in later life due to the decline in immune components (regulatory T cells) that control the immune response. With regard to sex, women are known to have stronger immune systems than men (Angele et al., 2014), possibly due to sociological and behavioral factors, as well as the adverse effects that testosterone has on the immune system (Foo et al., 2017) compared to the positive effects that estrogen has (Roved et al., 2017). Thus, for example, it is not surprising that more men than women have died of COVID-​19; indeed, men are nearly three times more likely to require intensive care unit (ICU) admission (OR =​2.84, 95% CI =​2.06–​3.92) and are 39% more likely to die from the infection (OR =​1.39, 95% CI =​1.31–​1.47) (Peckham et al., 2020). Women, however, are more likely than men to suffer from autoimmune disorders (Ngo et al., 2014). Other demographic factors related to immune responses are socioeconomic status (SES), education, and race or ethnicity. Lower SES and education have been associated with poorer immune function and increased risk of infection (Cavigelli & Chaudhry, 2012), as has Black race (Dowd et al., 2014). Demographic factors must be considered when examining the relationship between religiosity and immune function. Older adults, women, persons with

lower SES or low education, and ethnic minorities are significantly more likely to be religious, all of whom except for women have worse immune function. Thus, demographic factors such as these are likely to confound the relationship between religiosity and immune function, requiring their careful control in studies examining this association.

Biomedical Certain medical conditions result from an underactive immune system and others from an overactive one. On the one hand, an underactive immune system can be either primary, due to genetic influences, or secondary, arising from taking medication such as steroids or chemotherapy or from conditions such as diabetes, kidney disease, liver disease, HIV infection, malnutrition, or trauma (Thompson, 2015). Those at the age extremes such as newborns (who have not had an opportunity to build up their immune system yet) and the elderly (due to a weakening of the immune system in later life, as noted above) are also known to have altered immune systems. Anesthesia and the breaching of the person’s mucosa or skin by endotracheal intubation, mechanical ventilation, or insertion of intravenous or urinary catheters, can challenge and sometimes overwhelm the immune system. On the other hand, autoimmune disorders occur when the immune system is overactive, attacking normal body tissues as if responding to outside invaders. Autoimmune disorders include multiple sclerosis, thyroiditis, rheumatoid arthritis, lupus erythematosus, and a wide range of other conditions with varying manifestations. In this case, disease results from an unregulated and overactive immune system that is damaging various body systems.

Genetic Factors Research indicates that genetic factors influence immune function. This is manifested by increased susceptibility to infection (Kenney et al., 2017) and reduced resistance to cancer (Bhatia & Kumar, 2014). With regard to genetic control of susceptibility to viral infection, viruses have over time attempted to subvert Immune Function • 461

the human immune system, thus placing evolutionary pressure on survival. Enard and colleagues (2016) have estimated that as much as 30% of the evolution of the human genome has been due responses to viral infections. In one of the first examples of the role that genetics plays in susceptibility to infection, Herndon and Jennings (1951) found that the rate of poliovirus infection between twins varied significantly by type of twin, being more prevalent among monozygotic (identical) twins than among dizygotic (non-​ identical) twins. Genetic polymorphisms (different forms of genes) are known to lead to under-​or overproduction of certain cytokines that influence the severity of viral infection (Kenney et al., 2017). Certain genes such as the IFITM3 gene have been reported to influence the morbidity and mortality associated with influenza infection (Everitt et al., 2012). However, given the adaptability of the human immune system, genetic influences make up only a small portion in terms of disease susceptibility, with the majority due to nonheritable influences (Brodin & Davis, 2017).

Environment Exposure to environmental toxins, particularly among the poor in crowded inner cities or those working in blue-​collar occupations, may adversely affect immunity. Benzenes are a class of chemical contained in volatile solvents, such as paint removers, kerosene, and degreasers, that are available commercially and domestically. Benzenes can produce an aplastic anemia that is associated with a greatly reduced number of granulocytes, which impairs the immune system’s response to bacterial infections. Likewise, polycyclic aromatic hydrocarbons, produced when coal, oil, gas, wood, garbage, and tobacco are burned, may also adversely affect immune functions. Environmental toxins can also lead to a breakdown of the body’s tolerance to autoimmunity, leading to a range of autoimmune disorders (Selmi et al., 2012). These include certain metals such as mercury, gold, or silver. In contrast, lack of certain metals such as selenium can also lead to autoimmune disorders, such as autoimmune thyroiditis.

462 •  P h y sical H ealth

Gene-​Environment Interactions Gene-​environment interactions also play a role in the likelihood that someone with a particular genetic makeup will become infected or develop cancer (Fairfax & Knight, 2014). For example, an unstable physical or family home environment may interact with genetic makeup to impair immunity through effects on gene expression, such as might occur among those with adverse childhood experiences (Steel et al., 2020).

Psychological A wide range of psychological factors, both negative and positive, can impact immune function. M ATERN AL STRESS

Beginning in utero, maternal stress has been shown to adversely affect not only the mother’s immune system, but also that of the developing fetus (Marques et al., 2015). Maternal stress may increase inflammation during pregnancy, thereby affecting the offspring’s developing HPA axis, altering glucocorticoid-​immune coordination later in life, and increasing the risk of future immune system dysregulation and emergence of neuropsychiatric conditions (Hantsoo et al., 2019). This is in addition to maternal behaviors such as alcohol or drug use that may further impair the fetus’s future immune system. CH RON IC STRESS

Dhabhar (2014) has reviewed the effects that psychological stress has on immune system functioning, distinguishing the effects of acute from chronic stress. Acute stress lasting for minutes or hours has a positive impact on both innate and adaptive immunity, enhancing dendric cell, neutrophil, macrophage, and lymphocyte maturation, as well as increasing the production of cytokines, thereby improving wound healing, protecting against infections and malignant growths, and improving responses to vaccination.

Long-​term stress lasting for days or months, however, has the opposite effect—​resulting in a dysregulation of both the innate and adaptive immunity. Chronic stress causes resistance to the anti-​ inflammatory effects of glucocorticoids (Cohen et al., 2012), resulting in a more aggressive immune response and increased inflammation. This dysregulation adversely affects the Th1/​Th2 cytokine balance, resulting in chronic low-​grade inflammation, suppressing protective immune responses (T cells) and increasing pathogenic responses.

in turn have major effects on the brain, regulating both mood and neuroendocrine activity (Himmerich et al., 2019). The Th1/​Th2 cytokine ratio is altered during depression (i.e., pro-​inflammatory Th1 cytokines increase and anti-​ inflammatory Th2 cytokines decrease) (Komori, 2017). IL-​6, TNF-​𝛼, and other pro-​ inflammatory cytokines that increase during chronic stress may themselves lead to depression; however, whether this inflammatory response is the cause or the result of depression remains controversial (Valkanova et al., 2013; Himmerich et al., 2019). Persons experiencing bereavement, compared to nonbereaved conTRAU MATI C ST RE S S trols, have also been found to have higher levThe severe stress experienced by those with els of systemic inflammation, maladaptive gene post-​ traumatic stress disorder (PTSD) has expression in immune cells, and lower antibeen associated with high levels of pro-​ body response to vaccination, which is consisinflammatory cytokines such as IL-​1𝛽, IL-​6, tent with the research findings for depression and TNF-​ 𝛼, with levels even exceeding those (Knowles et al., 2019). present in major depression (Renna et al., 2018). Deficits in attention and processing COM P L EXITY speed, executive function, and memory in PTSD are all thought to lead to or to be the As noted earlier, different components of the result of immune dysregulation (Quinones et immune system interact with each other in al., 2020). a complex fashion to maintain homeostasis, with levels of cytokines and other inflammatory markers increasing or decreasing over A N XI E TY time in response to acute and chronic stressIn a systematic review of 14 studies involving ors. Cytokines often affect each other’s levels, 1,188 patients with generalized anxiety disor- with anti-​inflammatory cytokines (IL-​4, IL-​10) der (GAD) and 10,623 controls, Costello and being released in response to increases in pro-​ colleagues (2019) reported significantly higher inflammatory cytokines (IL-​6, INF-​γ, TNF =​α). levels of CRP, INF-​γ, and TNF-​α among individ- Both these and other inflammatory markers uals with GAD compared to controls in at least are further modulated by stress hormones such two studies, and at least one study reported as cortisol, epinephrine, and norepinephrine as increased levels of 10 other pro-​inflammatory part of the fight-​flight response (Hänsel et al., cytokines. Fear and anxiety-​ based disorders 2010; Himmerich et al., 2019). Thus, levels of such as GAD, panic disorder, phobias, and PTSD systemic inflammation assessed by blood tests are thought to activate the stress response sys- may be dependent on the particular marker and tem. The result is the release of cytokines from the particular time when stressors or psychoboth central and peripheral immune cells, and logical states such as depression or anxiety are dysregulation of sympathetic and parasym- measured. pathetic nervous systems that lead to further adverse immune system changes (Michopoulos P OSITIVE EM OTION S et al., 2017). Besides the effects of negative psychological states such as chronic stress, depression, and D E P RE SS I O N anxiety, positive emotions may also influence As noted above, psychological stress is a strong immune function, but in the opposite direction. inducer of cytokine production, and cytokines Activation of reward systems, of which positive Immune Function • 463

emotions and expectations are an important part, is known to boost innate and adaptive immune responses (Dantzer et al., 2018). For example, expectation of reward in animal models has been shown to increase antibacterial activity of monocytes and macrophages, reduce bacterial load, and heighten T cell responses (Ben-​Shaanan et al., 2016). In humans as well, positive affect (e.g., happiness, joy, excitement, enthusiasm, contentment), for example, have been found to increase natural killer cell activity among healthy women experiencing daily negative moods (Valdimarsdottir & Bovbjerg, 1997). Likewise, optimism and positive emotions such as joy and awe have been associated with better cell-​mediated immunity and lower levels of pro-​ inflammatory cytokines such as IL-​6 in healthy college students (Segerstrom & Sephton, 2010; Stellar et al., 2015). Greater recall of positive life experiences by older adults has been associated with higher CD4 (T helper cell) counts and lower CD4 activation (Kalokerinos et al., 2014). Greater meaning and purpose in life have also been associated with higher anti-​inflammatory cytokine levels such as IL-​4 in pregnant women (Mitchell & Christian, 2019), whereas loss of meaning appears to mediate the relationship between stress level and antibody titers to Epstein-​Barr virus, an indicator of immune system impairment (Van Tongeren et al., 2017). In a meta-​analytic review of intervention studies designed to improve mood, Ayling et al. (2020) found a moderate to large effect on increasing salivary IgA (effect size g =​0.65), reflective of improved immune function. Finally, the personality trait of conscientiousness (but not agreeableness) was reported to predict lower CRP levels and a slower increase in CRP over a 4-​year follow-​up (Allen & Laborde, 2017). Thus, while negative emotions adversely influence immune functions, positive emotions and certain personality traits may enhance those functions.

Social In a recent meta-​analysis of 41 studies involving 73,037 participants, social support and social integration were related to lower systemic inflammation as reflected by lower levels of pro-​inflammatory cytokines and other 464 •  P h y sical H ealth

inflammatory markers (Zr =​−0.073, 95% CI =​ −0.10 to −0.05) (Uchino et al., 2018). This was true for IL-​6 (Zr =​−0.078), TNF-​α (Zr =​ −0.076), and CRP (Zr =​−0.064), all with 95% CI less than 1.00, indicating statistical significance. When converted to odds ratios, these findings indicate an approximately 25% reduction in level of these indicators of inflammation. Social integration, in particular, is related to lower levels of CRP in later life, after controlling for age, gender, and race, reducing the risk of having high CRP levels by 14%–​41% (Yang et al., 2016). The effects of social support on systemic inflammation appear to occur across the life span from young adulthood to later life. For example, a prospective study of 48 mother-​infant dyads found that lower maternal parenting stress and higher social support when infants were age 12 and 18 months predicted lower infant salivary CRP 6 months later and decreasing levels of infant CRP over time (Nelson et al., 2020). Greater social support has also been associated with greater virus suppression and lower viral load in blood (p < 0.0001) among HIV-​positive individuals, modifying the relationship between depression, substance use, sexual risk-​ taking, and HIV viral load (Friedman et al., 2017).

Behavioral We focus here on the effects of physical activity/​ exercise, diet, weight, cigarette smoking, excessive alcohol, and illicit drug use on immune function, inflammation, and infection risk. P H YSICAL ACTIVITY/​EXERCISE

Regular physical activity has anti-​inflammatory effects, as indicated by a reduction in pro-​ inflammatory cytokines, an increase in anti-​ inflammatory cytokines, and a reduction in visceral fat (which is pro-​ inflammatory) (Gleeson et al., 2011). Regular exercise of moderate intensity has also been associated with a lower risk of upper respiratory infection (URIs) compared to sedentary adults (Nieman et al., 2011). The only exception to the beneficial effects of exercise on immunity is the immunosuppression effect that long hours of hard training has in elite athletes, which has been

found to increase the risk of URIs, although even this finding is controversial (Simpson et al., 2020). Randomized controlled trials (RCTs) demonstrate that exercise training decreases pro-​inflammatory markers, especially CRP and TNF-​α. These effects are particularly strong in survivors of prostate and breast cancer, and among cancer survivors in general (Khosravi et al., 2019). DIET

Christ et al. (2019) note, “The consumption of Western-​type calorically rich diets combined with chronic overnutrition and a sedentary lifestyle in Western societies evokes a state of chronic metabolic inflammation, termed metaflammation” (p. 794). A Western lifestyle like the one above activates the immune system in ways that lead to chronic metabolic disorders, diabetes, cardiovascular diseases, and neurodegenerative disorders, in addition to autoimmune disorders. Western diets (rich in refined sugars, salt, white flour, processed meats, animal fats, food additives) are known to trigger inflammatory responses in the body. In contrast, diets such as the Mediterranean diet (high in vegetables, whole grain cereals, fruits, beans, nuts, fish, and liberal use of olive oil) have the opposite effect in that they lower the levels of several inflammatory markers. Omega-​3 unsaturated long chain fatty acids (found in fish, nuts, and seeds) are also known to have anti-​inflammatory effects. High-​fiber diets, typically those rich in vegetables, fruits, beans, and whole grains, help to modulate the immune system through several mechanisms, including the inhibition of cytokine secretion. Siracusa and colleagues (2019) have emphasized that Western-​style diets promote both intestinal and extra-​intestinal inflammation, adversely affecting intestinal mucosal immunity involving CD4+​ T cells and resulting in a greater susceptibility to infection and autoimmune diseases. Intake of vitamins such as A, B6, B12, folate, C, D, and E, and trace elements such as zinc, copper, selenium, and iron, may also help to prevent or treat a wide range of infections (Calder, 2020; Jayawardena et al., 2020).

WEIGH T

Being overweight or obese increases inflammation, adversely affecting many immune functions and increasing risk of infection, particularly viral infections (Rojas-​Osornio et al., 2019). Excess body fat causes a low-​grade chronic inflammation, decreases macrophage activation, and increases pro-​ inflammatory cytokine production, all of which impair resistance to infection. When compared to non-​ obese controls, obese individuals experience worse innate immunity, antigen presentation and phagocytosis, adaptive immune responses, and activation and functioning of CD4+​and CD8+​T cells, resulting in higher peak viral loads among those infected and a delay in the clearance of viruses (Honce et al., 2019). CIGARETTE SM OKIN G

Cigarette smoking (CS) has adverse effects on both innate and adaptive immunity (Alrouji et al., 2019). The mechanism is thought to be due to immune cell activation, increased secretion of inflammatory cytokines (IL-​ 1β, IL-​6, IL-​10, IL-​12p70, TNFα, IFN-​γ), adverse effects on macrophages, dendritic cells, and T cells, and abnormal functional changes in B cell responses, all of which lead to chronic immune cell recruitment and inflammation. CS may also increase the likelihood of autoimmune disorders such as multiple sclerosis, inflammatory bowel disease, psoriatic arthritis, rheumatoid arthritis, systemic lupus erythematosus, and Graves’ disease by interfering with immune regulatory processes (Perricone et al., 2016). EXCESSIVE AL COH OL USE

Research has shown that even a single alcohol binge in healthy adults can adversely affect neutrophil function, reduce circulating monocytes, and increase anti-​inflammatory cytokine levels, especially 2–​5 hours post-​binge (Afshar et al., 2015; Stadlbauer et al., 2019). In fact, any amount of alcohol consumption has been shown to affect immune responses, altering the number and function of cells of the innate and adaptive arms of the immune system, an effect that is particularly evident

Immune Function • 465

in later life (Boule & Kovacs, 2017). Alcohol also appears to have a dose-​dependent effect on immune function depending on level of intake. In a review of this subject, Barr and colleagues (2016) reported that moderate alcohol consumption (up to 1 drink per day for women, 2 drinks per day for men) may reduce inflammation and improve responses to vaccination, whereas chronic heavy drinking (more than moderate) was found to reduce lymphocyte numbers and increase risk of infection. As noted earlier, maternal alcohol use adversely affects the fetus’s immune system (via lymphocyte and cytokine production, with consequences for susceptibility to infection), some of which may be long-​lasting (Reid et al., 2019). I LLI C I T D RU G US E

Individuals with substance use disorders other than alcoholism are also at greater risk of infection, including hepatitis A, hepatitis B, hepatitis C, HIV, bacterial, and fungal infections (Kolla et al., 2020). Besides direct inoculation of pathogens into the body, transmission due to sharing of needles, unsafe sexual practices, and poor hygiene, another major cause of increased infection risk is the suppression of immune functions. Effects on the immune system include reduced phagocytosis, adverse effects on cytokine production and chemotaxis, and alterations in the functioning of T lymphocytes, B lymphocytes, and macrophages. Marijuana use is also known to have negative effects on immune functions (Cabral et al., 2015).

Summary A healthy immune system is crucial for survival. Many factors, both non-​ modifiable and modifiable, influence immunity. Of particular interest here are modifiable factors that religious involvement might influence. This leads to the next section on the role that religiosity plays in immunity. We begin with a case, and then hypothesize how religion might impact immune function based on the known determinants of immunity reviewed above. 466 •  P h y sical H ealth

RELIGIOSITY AND IMMUNITY Case Vignette John, a 35-​year-​old gay man living in San Francisco, went to his doctor because he was feeling tired all the time. He was particularly concerned because his partner had been diagnosed as positive for HIV about three months ago. Since the diagnosis, John and his partner had taken special precautions to avoid transmitting the infection, although his partner had probably been infected for some time prior to his learning about it. When John was initially tested after his partner’s diagnosis, he was HIV negative. With these recent symptoms, though, John was scared. His symptoms had been present about two weeks when he finally mustered up enough courage to see his doctor. He hoped that his fatigue was due to a recent cold or the extra stress at work. The doctor carefully examined him and drew some blood. The “rapid test” for HIV in the office was negative, although only a specific blood test could rule out HIV infection for sure and this had to be sent to an outside laboratory. The doctor told John that his physical exam was normal, and that he would call him when results of the blood test came back in 1–​2 weeks. About 10 days later, John got the call he was waiting for from his doctor. His test had come back positive. John was shocked and began to feel overwhelmed. He had the dreaded disease from which many of his friends had died. The doctor assured him that there were medications he could take that would help control the infection. However, John had many friends who were HIV positive and knew what might lie ahead for him. Although raised in the church and always a believer, John had not attended religious services or prayed regularly for many years. Given this diagnosis, however, he began to think more about

religion. He also knew that there was a church in another part of the city that many gay men attended and thought he would feel comfortable there. In fact, one of his closest friends attended this church regularly and had been encouraging John to go with him. He decided to give his friend a call and take him up on the offer. Over the next couple of months, John became a regular churchgoer, began to pray privately, and to study the Bible. For the next several years, he continued his religious activity and encouraged others to join him, including his partner. However, his partner wanted nothing to do with religion, and after a while, John got tired of asking. After 5 years, his partner had progressed to AIDS and after 3 more years died. Ten years after his diagnosis, John was doing well and had not yet developed AIDS.   

As indicated in John’s case above, religion may have a positive effect on immune functioning. It also might not, or may have the opposite effect, especially if religious beliefs promote exclusion, alienation, and discrimination. Based on the known determinants of immunity summarized above, we now theorize how religious involvement might either improve or worsen immune function. If religion has effects on the immune system, these are likely to occur through biomedical, psychological, social, and behavioral pathways.

Biomedical Given the importance of gene-​ environment interactions, the religious involvement of parents—​either during in-​utero development or during infancy—may affect an offspring’s expression of various genes that regulate immune functions. As noted above, adverse childhood experiences (ACEs) can lead to long-​ term negative effects on immune function, and if such experiences are less common among religious families (see Chapter 14), then those negative effects may be reduced (particularly

among low socioeconomic groups where ACEs and religious involvement are both common). Another biomedical pathway through which religion might impact immune function is by lowering the likelihood of contracting medical illnesses such as HIV infection and other conditions resulting from intravenous (IV) drug use or multiple sexual partners, activities known to be less common among religious persons (see Chapter 10 and the Appendix on risky sexual behavior).

Psychological Religious involvement could impact immune function through several psychological pathways, including effects on depression, anxiety, and chronic stress, due at least in part to the effects that religious coping has in dealing with life stressors (see Chapters 4, 5, and 8). Life stressors may themselves be less common among religious persons due to greater adherence to moral standards, thereby lowering their risk of alcohol abuse and drug use, criminal behavior resulting in arrest and imprisonment, infidelity and divorce, failure to complete education, or job loss due to a lack of personal responsibility (see Chapters 13 and 14). This likely applies to maternal stress as well (Chapter 14 and 16), given its impact on the developing immune system of the fetus and newborn. Religious individuals are also more likely to experience positive emotions such as greater psychological well-​being, life satisfaction, happiness, meaning and purpose in life, optimism and hope (see Chapter 12), all of which are known to have positive influences on immune function. Finally, those who are more religious are more likely to be conscientious (Chapter 11), a personality trait that religions emphasize and can be developed over time, one that is associated with better immune function, as noted earlier.

Social Support and Integration Literally hundreds of studies have found that religious involvement is related to more social support and greater social integration (see Chapter 15). If these social resources are related to better immune functions, as numerous Immune Function • 467

studies have shown, then this is yet another route by which religiosity—​particularly public religious involvement—​may result in a stronger immune system.

Behavioral Given the constraints that religious teachings have on behavior, and the impact that health behaviors have on immune function, this is likely one of the most important pathways by which religious involvement could impact immunity. Those who are more religious are more physically active (Chapter 18), often consume a healthier diet (Chapter 19), are less likely to smoke cigarettes (Chapter 17), are less likely to use alcohol or consume excessive amounts, and are less likely to use illicit drugs (Chapter 10). The relationship between religiosity and weight is less clear, although no religious faith tradition encourages overeating or gluttony, and all emphasize self-​restraint and self-​control. Religions also encourage altruistic behaviors rather than self-​centered ones, e.g., volunteering to help others and giving to charities, which have been associated with slower disease progression in those with HIV (Ironson, 2008).

Summary On the one hand, many pathways exist by which religiosity could positively affect a wide range of immune functions, decrease inflammation, and/​ or lower risk of infection. On the other hand, religious beliefs that increase guilt, shame, or a sense of helplessness due to inability to adhere to high religious moral standards, could have the opposite effect. Likewise, religious behaviors that promote close physical contact during the flu season or pandemics such as COVID-​19 may also increase risk of infection.

RELIGION-​I MMUNITY RESEARCH We now examine evidence for the hypotheses above by reviewing systematic quantitative research that has examined the relationship between religious involvement and immune 468 •  P h y sical H ealth

functions, inflammation, susceptibility to infection, and course of infection. As usual, earlier research published in or prior to 2010 is reviewed, followed by an examination of more recent research published since then. Again, we focus here on prospective studies and RCTs when available, although cross-​sectional studies are also reviewed because they provide initial evidence for an association (even though they contribute little evidence toward causal inference).

Early Research In our systematic review presented in the first and second editions of the Handbook, nine studies examined religious activity and cytokine levels, mostly pro-​ inflammatory cytokines. Two cross-​ sectional studies examined the relationship between religiosity and the pro-​inflammatory cytokine IL-​6: one reported lower IL-​ 6 (Koenig et al., 1997b) and one reported no association (Ai et al., 2009b). Four studies were longitudinal: two predicting lower IL-​6 levels (Lutgendorf et al., 2004; Aksungar et al., 2007) and two reporting no effect (Koenig et al., 1997b; Yeager et al., 2006). Four studies examined religious/​spiritual interventions: one reported that the intervention reduced IL-​6 (Pace et al., 2009), one indicated increased levels of IL-​6 and IFN-​γ and decreased IL-​10 (Jones, 2001), one indicated increased IFN-​γ and no effect on other cytokines (McCain et al., 2008), and one indicated mixed results depending on cytokine (increased INF-​γ, but decreased IL-​6, IL-​4, and IL-​10) (Witek-​Janusek et al., 2008). Studies have also examined the relationship between religiosity and other indicators of inflammation, specifically CRP and fibrinogen. Eight reports from cross-​sectional studies examined the relationship with CRP: four reported inverse associations or trends in that direction (King et al., 2001; King et al., 2002; Ford et al., 2006; Gillum et al., 2008a), three reported no association (Lutgendorf et al., 2004; Yilmaz et al., 2008; Nelson et al., 2009), and one indicated lower fibrinogen levels in those who were more religious (a positive finding; Ford et al., 2006). A single prospective case-​control study found that Ramadan fasting predicted lower CRP levels (Aksungar et al.,

2007), and a single experimental study found that a religious/​spiritual intervention had no effect on CRP (Sivasankaran et al., 2006). With regard to studies of the relationship between religious involvement and cell counts (lymphocyte numbers or function, NK cell numbers or function, antibody levels, and delayed type hypersensitivity responses), there were 19 reports. Eleven cross-​sectional studies examined these relationships: 4 indicated positive associations (Woods et al., 1999; Messina et al., 2003; Dalmida et al., 2009; Li et al., 2005), 6 reported no association (Meredith et al., 2001; Chang et al., 2003; Chandra et al. 2006; Ramer et al., 2006; Cotton et al., 2006; Lissoni et al., 2008a), and 1 indicated mixed findings (Sephton et al., 2001). There were also five longitudinal studies: three predicted positive effects (Ironson et al., 2006a; Ironson et al., 2006b; Lissoni et al., 2008b) and two indicated no effects (Trevino et al., 2010; Latifynia et al., 2007). Three experimental studies examined religious/​spiritual interventions: all reported positive effects (McCain et al., 2008; Witek-​ Janusek et al., 2008; Davidson et al., 2003). With regard to susceptibility to infection or course of infection (including viral load among infected individuals), there were four cross-​sectional studies: two reported less infection among the more religious (Trinitapoli & Regnerus, 2006; Gillum & Holt, 2010b), one found a trend in that direction (Chandra et al., 2006), and one indicated no association (Ramer et al., 2006). There were also seven prospective studies: five reported positive effects (Merchant et al., 2003; Tully et al., 2006; Pereira et al., 2010; Ironson et al., 2006a; Ironson et al., 2006b) and two indicated no association (Ford et al., 2005; Trevino et al., 2010). A single experimental study reported no effects (Ikedo et al., 2007). Thus, the general trend in these findings indicates a positive effect of religious involvement on protection from infection or a better course of infection, although several high-​quality studies reported no effect. Overall, then, the findings from these 51 reports from earlier studies are mixed, but generally favor a positive effect of religiosity on either immune functions or infection: 28 reports (55%) indicated positive effects, 20 (39%) reported no effect, and 2 (4%) found

mixed positive and negative effects depending on indicator. Only one study reported negative effects (an experimental study examining the impact of Qigong in Hong Kong; Jones, 2001), which also reported an increase in the pro-​ inflammatory cytokine IFN-​γ, a finding that is difficult to interpret since this may indicate either a positive or a negative effect on immune function. McCain et al.’s (2008) study is an example of an early high-​quality RCT of a spiritual intervention in 252 HIV-​positive individuals, which we now describe in detail. Participants (average age 42) were randomized to four groups: cognitive-​behavioral relaxation training, tai chi training, a spiritual growth intervention, and a wait-​listed control group. The three interventions (all involving group interventions) were administered over 10 weeks. Immune system outcomes were (1) CD4, CD8, and CD57 lymphocyte numbers, (2) NK cell cytotoxicity, (3) cytokine levels (pro-​inflammatory IFN-​γ, TNF-​α, and IL-​6, and anti-​inflammatory IL-​ 4 and IL-​10), and (4) lymphocyte proliferation. The spiritual growth (SG) intervention followed the Spirit-​10 protocol developed by nurse researcher Inez Tuck. That intervention sought to facilitate the exploration of personal spirituality and the spiritual self, with the purpose of connecting one’s spirit with self, others, nature, God, or a higher power, and integrating spirituality into daily life. Results indicated that the SG intervention significantly increased lymphocyte proliferation compared to the control group, although no differences were found between SG and the other active group interventions on this outcome. The SG intervention, however, was the only intervention that significantly increased IFN-​γ levels compared to the control group, increasing follow-​up median IFN-​γ levels 11.2 times greater than in the control group (95% CI =​2.21–​57.0). The role that IFN-​γ plays in the immune system is in directly inhibiting viral replication, and in exerting immunostimulatory and immunomodulatory effects; thus, it can be either pro-​ inflammatory or anti-​inflammatory, or both. INF-​γ levels may be either lower (Himmerich et al., 2019) or higher (Inserra et al., 2019) in those with negative psychological states such as depression, Immune Function • 469

and may be either decreased (Dahl et al., 2014) or unaffected by antidepressant medications (Wang et al., 2019), making it difficult to make generalizations about the meaning of the dramatic INF-​γ increases seen in response to the SG intervention above. Furthermore, since participants in this study had impaired immunity to begin with (due to being HIV-​positive), generalization and interpretation of the treatment effects found here to HIV-​ negative patients must be made cautiously. Several other clinical trials in non-​HIV patients, however, have also reported increases in INF-​γ following religious or spiritual interventions (Jones, 2001, in healthy adults; Witek-​Janusek et al., 2008, in early stage breast cancer). As noted above, besides increasing IFN-​γ levels, the SG intervention produced significant improvements in lymphocyte proliferation, which is a clear indication of improved immune functioning in HIV-​positive individuals.

Recent Research Since 2010, a number of additional studies have been reported, which we describe below in detail. Like earlier research, these studies are categorized by outcome (indicators of inflammation, e.g., cytokines, CRP, immune cell functioning or products, and susceptibility to infection or course of infection) and by design (cross-​ sectional, prospective, experimental). For a full list of the studies, see Appendix.

obtained, they were analyzed using repeated-​ measures ANOVA. Results indicated no difference in IL-​6 levels between treatment groups, although the anti-​inflammatory IL-​10 level was significantly higher in the intervention group compared to the control group, as was the IL-​ 10/​IL-​6 ratio (p < 0.05). Berk and colleagues (2015) examined changes in pro-​inflammatory cytokines IL-​6, IL-​1β, TNF-​α, IFN-​γ, and IL-​12-​p70, as well as changes in anti-​inflammatory cytokines IL-​4 and IL-​10, in response to a religious intervention. This was part of an RCT comparing 10 weeks of religious cognitive-​ behavioral therapy (RCBT) with conventional CBT (CCBT) for depression among those with chronic medical illness in North Carolina and Los Angeles. Cytokine levels were obtained at baseline, 12 weeks (immediately post-​intervention), and 24 weeks (3-​month follow-​up after end of trial). No difference in effects was found between the two treatment groups over time for any cytokine except for the anti-​inflammatory cytokine IL-​10. Contrary to expectation, those in the RCBT group were more likely to experience a reduction in IL-​10 over time compared to those in the CCBT group (an effect that persisted at the 3-​month follow-​up after the intervention). Furthermore, higher baseline religiosity (independent of treatment group) predicted an increase in IFN-​γ and IL-​12-​p70, both pro-​ inflammatory cytokines (again, the opposite of expected). Baseline religiosity did not predict changes in anti-​inflammatory cytokines.

C YTO K I N E L E VE LS

IL-​6 has been described as the “keystone cytokine in health and disease” (Hunter & Jones, 2015), and is the most frequently examined pro-​inflammatory cytokine studied with regard to the relationship with religiosity. As noted earlier, about half of earlier studies found an inverse relationship between religious involvement and IL-​6. Two relatively recent clinical trials deserve brief description here. Kurita et al. (2011) nonrandomly assigned 57 nursing home patients in Japan to either listening to 30-​minute weekly chaplain sermons over 20 months or to an age-​ matched control group that did not. While it is unclear how often cytokine measures were 470 •  P h y sical H ealth

C- R ​ EACTIVE P ROTEIN ( CRP )

CRP is a marker of increased systemic inflammation that has been strongly correlated with poor cardiovascular outcomes (see above). Several large cross-​sectional studies and a number of prospective cohort studies have recently examined the relationship to religious involvement. In a cross-​sectional study of a random US national sample of 1,939 older adults, Hill et al. (2014) examined the relationship between frequency of religious attendance and CRP, finding a significant inverse relationship (B =​−0.09, SE =​ 0.03, p < 0.01) independent of age, gender, race/​ ethnicity, education, and income. In a cross-​sectional study of a random US national

sample of 1,589 community-​ dwelling adults of all ages, Krause et al. (2016a) found that the relationship between lifetime trauma and increased CRP was completely offset for study participants who frequently prayed for others (indicating a positive buffering effect). Ironson and colleagues (2018) analyzed data on a random US national sample of 643 adults age 50 or over with a history of having experienced two or more severe life stressors; after controlling for age, gender, education, body mass index (BMI), smoking, alcohol use, and social support, a greater frequency of religious attendance predicted significantly lower CRP (β =​ −0.11, p =​0.006). Attending religious services at least monthly reduced the likelihood of having high CRP (> 30 mg/​L) by 25% after adjustments for age, sex, race, education, body mass index (OR =​0.62, 95% CI =​0.42–​0.91). Finally, Tavares et al. (2019) analyzed data from a random US national sample of 4,734 community-​dwelling older adults (average age 68) participating in the 2006 wave of the Health and Retirement Study, finding that intrinsic religiosity moderated the relationship between high stress levels and CRP (p =​0.02), similar to the finding of Krause et al. (2016a). Among recent prospective studies, Ferraro and Kim (2014) used longitudinal data to examine the relationship between frequency of religious attendance and CRP among a random US national sample of 1,124 community-​dwelling older adults followed over a 5-​year period, controlling for baseline CRP and multiple other demographic, mental, behavioral, and physical health characteristics. Although no substantial evidence for an effect was found in Whites (B =​ 0.02, SE =​0.01, p =​ns, n =​990), there was a significant inverse relationship between religious attendance and CRP in Blacks (B =​−0.13, SE =​ 0.05, p < 0.05, n =​134). Likewise, in a 9-​year prospective study involving a systematically identified sample of 772 community-​dwelling adults age 50 or older in Mexico, Hill and colleagues (2017b) found that attending religious services once per week or more in 2003 (vs. no attendance) predicted a significantly lower level of CRP in 2012, controlling for age, gender, education, household income, marital status, activities of daily living, and self-​rated health (B =​−0.22, p < 0.05); unfortunately, baseline

CRP in 2003 was not measured or included in the model. Finally, in a 4-​year prospective study of a random US national sample of 2,912 adults over age 50 assessed between 2006 and 2010, Suh and colleagues (2019) found that frequency of religious attendance in 2006 predicted a lower level of CRP in 2010, controlling for CRP in 2006 along with age, gender, marital status, employment status, race/​ethnicity, education, household wealth, and financial debt (B =​−0.64 for continuous CRP and B =​−0.18 for high CRP). Researchers noted that the likelihood of having high CRP was 16% lower for those who attended religious services weekly compared to those who attended yearly or not at all. These findings, however, were at a statistical trend level only (p < 0.10). OTH ER IN F L AM M ATORY M ARKERS

Other indicators of increased inflammation include D-​ dimer, s-​ VCAM, Cystatin-​ C, and mRNA data from circulating leukocytes. Hybels et al. (2014) examined the cross-​sectional relationship between frequency of religious attendance and IL-​6, s-​VCAM, and D-​dimer in a random sample of 1,423 older adults in North Carolina. Results indicated a significant inverse relationship between religious attendance and all three indicators (r =​−0.11, p < 0.0001; r =​ −0.12, p < 0.0001; and r =​−0.10, p =​0.0002, respectively). These were uncontrolled correlations since the purpose of the study was to examine predictors of physical functioning in older adults, not inflammation. In another cross-​ sectional study, Simons et al. (2019) measured inflammation level in 413 African Americans (average age 29) to determine whether religiosity (assessed by a 5-​ item measure of religious importance, attendance, and private activities) was associated with expression of the Tp53 cancer suppressor gene. Inflammatory responses were assessed using mRNA data from 19 circulating leukocytes, a commonly used measure of inflammation. Structural equation modeling, controlling for racial discrimination, support from Black friends, gender, education, marital status, health insurance, diet, exercise, alcohol use, cigarette smoking, and physical illness, Immune Function • 471

demonstrated a significant inverse relationship between religiosity and inflammation (b =​ −0.11, SE =​0.047, p < 0.05). Inflammation was also found to mediate the positive relationship between religiosity and Tp53 gene expression. Tp53 is the most powerful and well-​known of the cancer suppressor genes. In the 4-​year prospective study of Suh and colleagues (2019) described above, which involved 2,912 US adults over age 50, researchers also examined the effects of religious activity on Cystatin-​C, another marker of chronic inflammation. As with CRP, weekly religious attendance (compared to yearly attendance or not at all) was inversely related to Cystatin-​C measured as a continuous variable (B =​−0.02, p < 0.10) and also when dichotomized into high vs. low Cystatin-​C levels (B =​−0.22, p < 0.05). These analyses controlled for baseline Cystatin-​C. I MM U N E C E L L S

This section summarizes recent studies examining the relationship between religiosity and immune cell counts, function, and antibody production. Several cross-​ sectional studies were identified. In a consecutive sample of 221 patients with metastatic cancer presenting at a palliative care clinic in Sao Paulo, Brazil, researchers examined the relationship between a 15-​item measure of religious practices and several inflammatory markers, including white blood cell (WBC) count, CRP level, and neutrophil-​ lymphocyte rate (NLR) (Paiva et al., 2014). In unadjusted analyses, frequency of religious practices was inversely related to all three markers (r =​−0.17, p < 0.05, for WBC count; r =​−0.20, p < 0.01, for CRP; and r =​−0.14, p < 0.05, for NLR). WBC subpopulations found to be significantly lower were neutrophils (p =​ 0.009), monocytes (p =​0.004), and eosinophils (p =​0.10). These findings were particularly strong for the measure of individual prayer activity. Analyses were not adjusted for possible confounders since the focus of the study was on survival, not immune system function. In terms of antibody production, where lower levels are reflective of better containment of the pathogen, Lawrence and colleagues (2017) examined the cross-​ sectional 472 •  P h y sical H ealth

relationship between family/​ personal religiosity and cytomegalovirus (CMV) antibodies among 1,319 Jewish young adults in Jerusalem (average age 32). CMV antibodies (anti-​CMV IgG) are known to be positively associated with pro-​inflammatory cytokines, memory T cells devoted to suppression of latent CMV, and fewer naïve T cells available to respond to new infections, all leading to chronic immune activation and inflammation. High levels of anti-​ CMV IgG antibodies predict the development of atherosclerosis, cardiovascular morbidity, and cardiovascular mortality. In this study, religiosity was assessed by maternal religious orthodoxy (secular, tradition, religious, orthodox, ultraorthodox), paternal lay religious leadership, and young adult religious orthodoxy. All three religious measures were positively related to higher anti-​CMV IgG titers at p < 0.0001, indicating worse immune function among the more religiously orthodox. In contrast, Garcini and colleagues (2019) found the opposite in a case-​control study of 44 recently bereaved older adults in Texas who had lost their spouse in the last 90 days and 44 age-​gender matched controls (average age 68 years for the entire sample). Religious involvement was assessed by attendance at religious services or other religious activities in a typical week (responses dichotomized into yes vs. no). Multivariate analyses controlled for age, education, smoking, alcohol consumption, depression, BMI, physical health, gender, and ethnic minority status. Results indicated that CMV IgG antibody titers were significantly lower among church attenders compared to non-​ attenders (B =​−0.56, SE =​0.26, p < 0.05); furthermore, attendance significantly interacted with bereavement status (B =​0.33, SE =​0.16, p < 0.05) such that church attendance moderated the positive relationship between bereavement status and CMV antibody production. Of particular interest for our purposes here are prospective studies that have examined the effects of religious involvement on CD4 cell counts in HIV-​positive patients, a vulnerable group with weakened immune functions. CD4 count is a measure of disease severity, such that counts lower than 200 indicate a diagnosis of AIDS. Ironson et al. (2011) at the University of Miami conducted a 4-​year prospective study

of 101 HIV-​positive individuals examining the effects of “view of God” on CD4 counts, controlling for baseline CD4 count, age, gender, education, and ethnicity. Both positive and negative views of God were assessed using a 12-​item measure (6 items assessing a positive view of God as benevolent/​loving/​merciful/​forgiving and 6 items assessing a negative view of God as harsh/​judgmental/​punishing). Results indicated that a positive view of God predicted significantly higher CD4 cell counts during the follow-​up period (B =​0.21, t =​2.19, p =​0.03), whereas a negative view of God predicted a significant decline in CD4 cells (B =​−0.34, t =​ −4.92, p < 0.001). In a second study by this group, Kremer and colleagues (2015) followed 177 HIV-​ positive patients over a 4-​year period, examining the effects of spiritual coping on CD4 count preservation. Spiritual coping was based on a measure derived from interviews with patients and essays written by patients on how they coped with HIV and other life traumas. Spiritual coping was assessed on a 9-​point scale ranging from negative to positive spiritual coping (−4, where 0 indicates no spiritual coping). Growth curve analyses were performed using hierarchical linear modeling. “Longitudinal spiritual coping” (whether assessed at baseline or across the follow-​up period was not clear) was found to significantly predict CD4 preservation, controlling for demographics (age, gender, ethnicity, education), baseline biological parameters, substance use disorder, and cumulative viral load suppression (B =​0.33, SE =​0.18, p =​ 0.025). CD4 cells declined 2.25 times faster over 4 years among those using negative spiritual coping compared to those using positive spiritual coping. I N F E C TI O N

Susceptibility to infection and course of infection reflect the ability of the immune system to contain the infectious agents, and thus serves as a proxy for immune system functioning for researchers examining downstream effects. In addition to susceptibility to infection, assessed by likelihood of becoming infected or having symptoms of infection, direct measurement of viral concentration in blood is often used to

assess the course of an infection. Several recent cross-​sectional studies have examined associations between religious involvement and infection. Bear in mind that religious gatherings may increase exposure to infectious agents and risk of transmission, thereby affecting associations between religiosity and infection. In a small cross-​ sectional study, notable because of its relatively simple but direct methodology, Callen et al. (2011) asked 82 community-​ dwelling older adults in Florida whether they had recently experienced symptoms of infection. Symptoms were assessed using a 28-​item measure asking about respiratory, skin/​eye, genitourinary, gastrointestinal, and flu-​like symptoms. Participants completed the 38-​item BMMRS, a measure that assesses religiosity/​ spirituality across 11 domains. Uncontrolled analyses revealed that while negative religious attitudes or activities (struggles with religion, having problems with members of their congregation, and loss of faith) were significantly and positively related to symptoms of infection (r ranging from 0.33 to 0.42), other religious indicators (daily spiritual experiences, religious values/​beliefs, positive religious coping, supportive interactions with other congregants, intrinsic religiosity) were significantly and inversely related to such symptoms (r ranging from −0.22 to −0.35). Of course, the small convenience nature of the sample, cross-​ sectional design, and lack of controls make any conclusions from this study quite preliminary. Puzek and colleagues (2012) analyzed cross-​ sectional data from a random national sample of 1,005 young adults age 18–​25 in Croatia to examine the relationship between religiosity and risk of infection with chlamydia, a sexually transmitted bacterium. Religiosity was assessed in terms of attendance at religious services, importance of religion, and religiosity of friends. Chlamydia trachomatis DNA was assessed in urine samples using polymerase chain reaction technology. Results indicated that chlamydia infections were present in 5.3% of women and 7.3% of men. However, no relationship was found between any of the religious variables and likelihood of chlamydia infection. Examining a random US national cross-​ sectional sample of 1,977 community-​dwelling older adults age 57–​ 85, Hill et al. (2014) Immune Function • 473

analyzed the relationship between religiosity and antibodies to the Epstein-​Barr virus (EBV), where high antibody levels reflect poorer immune system control of the virus. After adjusting analyses for age, gender, race/​ethnicity, education, and income, higher frequency of religious attendance was associated with a 15% greater likelihood of having low (vs. moderate) EBV antibody levels (OR =​1.15, 95% CI =​ 1.03–​1.28). Krause and Ironson (2017d), however, found the opposite in a cross-​sectional study of God-​ mediated control and EBV infection in a systematically identified national sample of 1,745 US adults. God-​mediated control was assessed by three items (“I rely on God to help me control my life”; “I can succeed with God’s help”; and “all things are possible when I work together with God”). Results indicated a positive relationship between God-​mediated control and EBV antibody titers (B =​0.09, SE =​ 0.015, p < 0.01), reflecting poorer control of the virus by the immune system. Analyses were adjusted for age, gender, education, marital status, frequency of religious attendance, and frequency of private prayer. Age significantly moderated the relationship between God-​ mediated control and EBV titers, such that the positive relationship was present only in younger adults age 18–​40 (B =​0.21, SE =​0.037, p < 0.001), not in those age 40 or older. With regard to religious attendance, however, greater attendance was inversely related to EBV antibody titers (B =​−0.057, SE =​0.011, p < 0.05) in the final model. Furthermore, in a second report from this study, Krause (2019) found that emotional support received from fellow church members was also associated with lower EBV titers in Hispanics of all ages (b =​−0.023, p < 0.05), although no relationship was found in Whites. At least two prospective studies have examined the effect of religiosity on risk of infection or course of infection. Raghavan and colleagues (2013) examined the effects of baseline religiosity on response to treatment of 87 patients with hepatitis C infection over a 24-​to 48-​week treatment period. Religiosity was assessed by strength and comfort derived from religious faith and frequency of religious attendance. The primary outcome was sustained viral 474 •  P h y sical H ealth

response (SVR) at 3–​6 months post-​therapy, i.e., undetectable virus in the blood. Although there was no overall difference between high and low religiosity groups, logistic regression controlling for age, gender, race, risk factors, employment status, language, and education, revealed an interaction between religiosity and gender (p =​0.04, n =​55). Among men, but not women, higher religiosity was associated with a greater likelihood of a sustained viral response (OR =​21.3, 95% CI =​1.1–​403.9). However, the small sample size and wide confidence interval should be noted. Chen and VanderWeele (2018) examined the effects of religious attendance on history of sexually transmitted infections (STIs) in a large sample of 5,589–​7,458 adult children (average age 15 at baseline) of women participating in the Nurses’ Health Study during an 8-​to 14-​year follow-​up. Investigators found that those attending religious services at least once per week compared to those who never attended were at subsequent reduced risk of having had an STI (RR =​0.79, 95% CI =​0.66–​ 0.95). Analyses controlled for age, race, gender, geographic region, prior health status or health behavior, including prior history of STIs, along with multiple socioeconomic, demographic, and health characteristics of mothers as well. These analyses also controlled for past number of sexual partners, early sexual initiation, and history of teen pregnancy. Given control for past frequency of sexual contact, it is possible some of the effect may have been due to effects of immune function in preventing such infections from occurring, rather than only through number of sexual partners, although both remain as possible explanations. VIRAL L OAD

An important indicator of course of infection is concentration of virus in the blood (i.e., viral load, or VL). Several prospective studies have now examined the effects of religiosity on VL among those infected with HIV. In the 4-​year prospective study of 101 HIV-​positive patients described earlier, Ironson and colleagues (2011) found that having a positive view of God as benevolent/​forgiving/​merciful predicted a significant decrease in VL over time

(B =​−0.09 × 10−2, t =​−2.13, p =​0.03), whereas a negative view of God had the opposite effect (B =​0.13 × 10−2, t =​3.23, p =​0.002). These results were controlled for age, gender, education, ethnicity, anti-​retroviral treatment (ART), and baseline VL. In the 4-​year prospective study by Kremer et al. (2015) reviewed above, investigators examined the effects of spiritual coping on VL (in addition to CD4 count) in 177 HIV-​positive patients. Longitudinal spiritual coping predicted a greater likelihood of having undetectable VL, controlling for age, gender, ethnicity, education, substance use disorder, and baseline VL (B =​0.012, SE =​0.005, p =​0.02). The rate of undetectable VL at follow-​up in those who used positive spiritual coping was more than 4 times greater than in those who used negative spiritual coping. In a study involving 382 patients with HIV/​AIDS in Alabama (median age 35; 60% African American, 84% male), Van Wagoner and colleagues (2016) examined the effects of religious attendance on VL 12 months after initiating HIV care. A high VL (HIV viremia) was defined as greater than 200 copies/​ml. Baseline religious attendance was dichotomized as current church attendance vs. no current or past attendance. Multivariate logistic regression revealed that current religious attendance predicted a 50% reduction in likelihood of having HIV viremia at the 12-​month follow-​up, independent of age, race, gender, sexual behavior, CD4 count, education, insurance status, living arrangements, consistency of care, having started ART, and HIV disclosure (OR =​0.50, 95% CI =​0.20–​0.90, p < 0.05). Unfortunately, baseline VL was not included in the analysis, preventing researchers from saying whether religious attendance predicted a decrease in VL. The sample size of the study, however, was quite small. Finally, Ironson and colleagues (2020) examined the effects of a stressful death/​divorce on changes in VL over 12 months in 157 patients with HIV/​AIDS. Among predictors of change in VL was a 4-​item measure of religious coping (RC) assessed using Carver’s COPE scale. A total of 45 participants had experienced death or divorce within the past 3 months. These individuals were compared to 112 controls

who had not experienced such a stressor. There were no differences between the stressed and control group based on age, gender, race/​ethnicity, education, or medication regimen at baseline. Change over time in RC was examined as a predictor of change in VL using mixed models regression. Compared to the control group, those with a recent history of death or divorce experienced a significant increase in VL over time. Baseline RC tended to predict a slower increase in VL, but did not reach statistical significance (F =​3.25, p =​0.07). In order to identify buffers that might reduce this increase in VL among the bereaved/​divorced, researchers examined the effects of change in social support and change in RC. Results indicated that an increase in RC after death/​divorce of a partner predicted a slower increase in VL over time compared to no increase in RC (p =​0.01). Neither baseline social support nor change in social support predicted change in VL. For studies of religion’s effects on willingness to be vaccinated, see Chapter 30 on disease prevention.

Summary In the above review of recent research on religiosity and immune function (i.e., indicators of inflammation, immune cell numbers and antibody responses, susceptibility to infection and changes in viral load), we summarized results from 14 cross-​ sectional reports, 12 longitudinal reports, and 2 clinical trials testing religious interventions. Multiple reports from some studies were summarized where researchers analyzed different aspects of religion or different outcome measures. Of the 14 cross-​sectional reports, 11 found a significant association between religious involvement and better immune outcomes; 1 reported a worse immune outcome; 1 indicated no association; and 1 reported a mixture of findings (significant positive and negative associations). Of the 12 longitudinal reports, 11 indicated that religiosity predicted significantly better immune function and 1 found a trend in that direction (p < 0.10). Of the two clinical trials, one reported that a spiritual intervention (listening to sermons) had a positive effect and one reported that religious CBT had a negative effect on indicators of inflammation. Overall, Immune Function • 475

was only a single prospective longitudinal study with control for baseline outcome that provided the evidence for that outcome. For example, this was the case for Cystatin-​C and for CMV IgG antibodies. For some outcomes, such as CRP and CD4 count and viral load, there were two or three well-​designed studies providing evidence. While results were reasonably consistent across outcomes, to strengthen the evidence base further, more longitudinal studies for each specific outcome are needed. Indicators of immune system functionRECOMMENDATIONS FOR ing are many, as described above, and involve FUTURE RESEARCH various components of the innate and adapAlthough the results from more recent research tive immune responses, as well as the funcindicate greater consistency in the findings, tional consequences of immune functioning, most studies reported thus far suffer from a such as susceptibility to infection, speed of range of methodological weaknesses. Cross-​ recovery from infection, and microbe concensectional studies tell us little about whether trations in blood. With regard to components religious involvement actually affects immune of the immune system, the least expensive function (or vice versa); longitudinal studies to measure are the pro-​ inflammatory cytothat fail to control for baseline levels of the kines (IL-​6, IL-​1β, IL-​12, IFN-​γ, TNF-​α), CRP immune function are little better than cross-​ (an acute-​phase protein of hepatic origin that sectional studies; and well-​ done prospective increases in response to inflammation), and studies on immune cell numbers and function anti-​inflammatory cytokines (IL-​4, IL-​10), all are few. Furthermore, only a handful of clini- of which can be obtained from a single blood cal trials have examined the impact of religious sample. Unfortunately, cytokine dynamics are or spiritual interventions, most involving complex, and the findings are not always conEastern meditation, and only a few were RCTs sistent. For example, Myint and colleagues (Davidson et al., 2003; McCain et al., 2008; Pace (2005) reported an increased Th1/​Th2 cytokine et al., 2009; Berk et al., 2015). Thus, further ratio (pro-​inflammatory/​anti-​inflammatory) research is needed to determine whether reli- in depression, whereas Pavón et al. (2006) gious involvement (including religious activi- reported a decreased Th1/​Th2 ratio. In a meta-​ ties such as attending religious services, private analysis conducted by Dowlati et al. (2010), prayer, scripture study, scripture recitation, researchers concluded that only two pro-​ listening to religious music, religious sermons, inflammatory cytokines (IL-​6 and TNF-​α) were and religiously integrated psychotherapies) or consistently elevated in depression. Thus, lack level of religious commitment improves vari- of consistency in findings must be considered ous aspects of innate and adaptive immunity, when interpreting results from studies examreduces inflammation, decreases susceptibility ining the relationship between religiosity and to infection, or speeds recovery from infection. cytokine levels. Based on our previous reasoning and the Besides effects on cytokine levels, there is a findings reviewed above, there is notable notable need for studies examining the impact preliminary evidence that such effects exist. of religiosity on immune cell numbers and However, much research remains to be done, functioning over time (CD4 or T helper cells, especially as concerns accumulating prospec- CD8 or cytotoxic T cells, and CD56 or natural tive evidence for the effects of specific aspects killer T cells), antibody production in response of religiosity on specific immune function to immunization, and antibody levels to CMV outcomes. In several instances, for any given and EBV herpes viruses (as an indication of the immune function or infection outcome, there immune system’s ability to keep these viruses then, the results from recent research confirm the findings from earlier studies indicating that the majority of findings indicate a beneficial effect of religiosity on immune function, as we hypothetically predicted based on the relationship between religiosity and known risk factors for immune dysfunction. Multiple biomedical, psychological, social, and behavioral pathways exist by which religious involvement might help to retain or improve immunity, although huge research gaps still exist that need filling.

476 •  P h y sical H ealth

dormant). Unfortunately, the cost of repeated assessments of immune cells numbers and function is quite high, and the lack of funding in this area has limited research on the impact of religious involvement on these important outcomes. Studies examining downstream effects of immune function, such as susceptibility to infection or course of infection, are also needed. Least expensive are assessing subjective symptoms of infection (e.g., cold or flu symptoms) as measured by the Carr Infection Symptom Checklist (Groer & Davis, 2006), which was used in the study by Callen et al. (2011). Alternatively, time to symptom resolution might be compared between religious and nonreligious persons, matched for the initial appearance and severity of symptoms. More expensive, but necessary, is the examination of objective measures of infection such as microbe concentration in blood (e.g., viral load). Another possibility is the comparison of infection rates in religious vs. nonreligious persons after experimental inoculation with an infectious agent (see below). There are several psychometrically solid measures of religious commitment that we would encourage researchers to use in such studies, particularly the 10-​item Hoge Intrinsic Religiosity Scale (IRS), Huber’s 15-​ item Centrality of Religion Scale (CRS), Koenig’s 10-​item Belief into Action Scale (BIAC), and Worthington’s 10-​item Religious Commitment Scale (RCI). Few of the existing studies have used such multi-​item measures that are assessing the degree to which religious involvement is central in a person’s life. It is possible that religious involvement must reach a certain threshold of devotion before it is able to impact attitudes and behaviors to the extent that is necessary to affect immune functions. However, here as elsewhere, often a single-​item measure of frequency of religious service attendance can be a powerful, albeit crude, indicator of commitment. OTH E R S TU DY DE S IG N FE AT URE S A RE A L SO I M PORTANT

Given their potential to confound the relationship between religiosity and immune outcomes, all observational studies (whether

cross-​sectional or prospective) should control for demographic factors related to immune function, such as older age, gender, race/​ethnicity, and socioeconomic status. Prospective studies, which are a priority here, also need to always control for baseline measures of the immune outcome so that effects of religiosity on change in immune function can be examined. Randomized controlled trials (RCTs) designed from the very start to examine the effect of religious involvement on immune function would also substantially strengthen the evidence. In order to determine whether or not religiosity truly affects immune function, only an RCT can provide definitive evidence in this regard. Ideally, given the relatively large immune system reserve present in young healthy persons, an RCT would be conducted in a vulnerable population with little immune reserve so significant effects could be more easily detected (e.g., older persons, or those with illnesses that adversely affect immune functioning, such as those infected by HIV). Many of the studies reviewed above that have reported significant results have been conducted in such populations. Of course, one cannot randomize religiosity itself, but several alternative approaches are possible. For example, a religious intervention such as religiously integrated psychotherapy for depression (Berk et al., 2015) could be administered and changes in immune function (inflammatory indicators, immune cells) or consequences (susceptibility to infection, course of infection) examined over time. Effects could be compared to those in individuals randomized to a nonreligious intervention or an attention-​ control group. Other religious interventions that boost religious beliefs, coping, or activities could also be examined in RCTs (e.g., among Muslims, reciting the Qur’an or listening to recitation of the Qur’an). Researchers might conduct a study similar to that of Cohen et al. (1991), which involved intranasal placement of droplets containing an infectious agent. This could be done in a group of volunteers who would then be randomized to a religious intervention or a comparable secular intervention or an attention control group, followed by an examination of immune responses, likelihood and severity of infection, and speed Immune Function • 477

of recovery from infection over time. The need to establish an effect, though, may not be so urgent that it would be worth infecting people to obtain such evidence. Studies of this type are more likely to detect effects in vulnerable populations such as older adults or others with already weakened immune systems and little immune reserve. Admittedly, studies in vulnerable populations are risky and ethical considerations must be weighed carefully. RCTs of this type are typically complex, expensive, and challenging to conduct. However, their promise is that they may help answer the question of whether religiosity truly affects immune function and determine the magnitude of such effects. Again, the question remains of whether studies of this type (particularly those that involve purposely infecting others) are ethical, even if conducted among volunteers. Is the evidence gained from such studies really worth the danger of crossing ethical boundaries? At a minimum, researchers must struggle with such issues.

CLINICAL APPLICATIONS

benefits of both social support and religious faith, which the evidence suggests enhances immune functions (although as noted earlier, it may increase risk of pathogen transmission during pandemics). As usual, all recommendations should be patient-​centered and based on the patient’s religious belief system. Clinicians should always educate patients about factors that adversely affect immune function, such as excessive alcohol intake, cigarette smoking, consuming an unhealthy diet, excessive weight, lack of regular physical activity, and social isolation. Since many religious belief systems discourage these practices, health professionals may utilize patients’ beliefs to help motivate them to avoid unhealthy behaviors, and instead engage in healthy ones. For mental health professionals, religiously or spiritually integrated therapies for depression, anxiety, or chronic stress should be considered for religious older persons and those with weakened immune systems.

Religious Professionals

Religious professionals may also use the information contained in this chapter to educate members of their congregation about the immune system, the importance of maintaining healthy immunity, and ways that religious faith and practice can assist in this regard. Religious activities Healthcare Providers that may strengthen immune function include The spiritual history should help to identify meditation, prayer, active involvement in the religious beliefs and practices that are import- faith community, volunteering for religious reaant to the patient. These can be supported and sons, and engagement in other altruistic faith-​ encouraged to boost immune function, particu- based prosocial activities. Health behaviors that larly for those with weakened immune systems may do likewise include reducing alcohol use, that make them vulnerable to infections and cessation of cigarette smoking, consumption of related medical conditions (e.g., cancer, auto- a healthy Mediterranean diet, control of weight, immune disorders, diseases from chronic low-​ engagement in regular moderate exercise, and grade inflammation). Religious patients may be other behaviors discussed earlier in this chapter. informed of the research suggesting that reli- Congregants with immune system impairments gious involvement may boost certain aspects or autoimmune disorders should be encouraged of immune function, which may help protect to utilize their religious faith to cope with these them from some illnesses. Providing scientific disorders, as well as to see their doctor regularly evidence concerning the effects of engaging in and comply with prescribed treatments. Faith religious practices may increase religious indi- and medicine can work together, as they address viduals’ efforts to maintain their physical health, different but complementary aspects of health. preserve the body as a sacred practice, and As noted in prior chapters, clergy can also increase resistance to immune system–​related be encouraged to develop congregational disorders. Attendance at religious services could health ministries that emphasize both physibe particularly helpful in that it combines the cal and emotional health, as well as encourage The research reviewed in this chapter has practical implications for healthcare providers and religious professionals.

478 •  P h y sical H ealth

a prosocial religious faith, which may help to enhance immune function and maintain congregational and community health. Members of the congregation who are nurses or physicians should consider participating in such health ministries and motivating others to do as well. Religious scriptures can be utilized in sermons and religious education classes to persuade and inspire members to participate in these health ministries, both as instructors and as learners (see Table 24.1). As suggested by the example of John above, the buffering effects on depression and anxiety of participation in a faith community may enhance both immune function directly and improve adherence to treatment for those with a medical condition involving impaired immunity, such as HIV.

SUMMARY AND CONCLUSIONS As repeatedly emphasized above, the relationship between religiosity and the immune system is a complex one. In the end, whether the impact of religiosity on immune function is positive or negative may depend on the particular individual, the particular time in the person’s life when religious involvement is assessed, the person’s current health condition (especially, the state of their immune system), religious upbringing, previous life experiences, and level of religious maturity/​devotion, as well as their temperament and genetic makeup. This chapter began with a description of the various molecules, proteins, and cells that comprise the immune system, focusing on the innate and adaptive arms of immunity. Markers of inflammation, such as pro-​and anti-​ inflammatory cytokines and C-​reactive protein (CRP), were described. Emphasis was placed on the interaction between different parts of the immune system necessary to maintain physiological homeostasis. Next, determinants of immune function were reviewed, including demographic influences, biomedical effects, genetic factors, environmental factors, gene-​ environment interactions, psychological influences (maternal stress, chronic adult stress, traumatic stress, anxiety, negative emotions such as depression, and positive emotions), social factors (social support, integration, isolation), and behavioral factors (physical activity/​

Table 24.1  Religious Scriptures Encouraging Efforts to Maintain Physical Health Christian Tradition (New Testament of the Holy Bible) 1 Corinthians 3:17 (the physical body as God’s temple) 1 Corinthians 6:19–​20 (the physical body as temple of Holy Spirit) 1 Corinthians 9:27 (importance of disciplining the physical body, bringing it under control) 1 Corinthians 10:31 (attitude toward drinking and eating) Ephesians 5:18 (limit ingestion of intoxicants) 1 Timothy 4:8 (value of physical training, exercise) 3 John 1:2 (prayer for good physical health) Jewish Tradition (Jewish Bible) Shemot 15:26 (G-​d protects from disease and heals) Yermiyah 30:17 (G-​d’s promise to restore health and heal wounds) Yermiyah 33:6 (G-​d as the source of physical health and healing) Tehilim 91 (three times mentions protection from pestilence and plague) Tehilim 139:14 (fearfully and wonderfully made is the physical body) Mischlei 4:20–​22 (words of Scripture are life and health to the entire body) Mischlei 16:24 (the physical healing effects of kind words) Mischlei 17:22 (cheerful heart is good medicine) Muslim Tradition (Holy Qur’an) Qur’an 2:168 (emphasis on diet/​nutrition) Qur’an 2:222 (importance of personal hygiene) Qur’an 2:233 (importance of breastfeeding) Qur’an 5:90 (avoidance of alcohol) Qur’an 7:31 (avoiding excesses) Qur’an 16:14 (emphasis on diet/​nutrition) Qur’an 38:41–​42 (importance of physical activity) Hindu Tradition Bhagavad Gita 6:17 (behaviors to maintain health) (continued) Immune Function • 479

Table 24.1  Continued Carakasamhita Sutra 28:45 (importance of diet/​nutrition) Carakasamhita 1:1:20 (curative nature of Atharvaveda hymns) Susrutasamhita 7:2 (ingestion of uncontaminated food) Carakasamhita 3:3:7 (ingestion of pure water) Artharvaveda 6:57:3 (avoidance of injury, harm, and disease) Buddhist Tradition Dhammapada 1–​2 (the person and physical body are a result of their thoughts) Dhammapada 190–​192 (Four Noble Truths, detaching from craving) Dhammapada 197–​198 (physical health consequences of detachment from craving) Dhammapada 204 (health is the greatest gain) Dhammapada 273–​289 (Eightfold Path to achieve health) Majjhima Nikāya, Cullakammavibhanga Sutta, No. 135a (causes of sickness and health) Cankama Sutta, AN 5:29 (physical health benefits of walking and exercise) a See also Mahathera, N. (1998). The Buddha and His Teachings. Taiwan: Buddha Educational Foundation Taipei, pp. 256–​260.

480 •  P h y sical H ealth

exercise, diet, weight, cigarette smoking, excessive alcohol use, illicit drug use). A case was then presented on how religious involvement may affect immunity in an immunocompromised individual, followed by hypothesized pathways by which religious beliefs/​ activities could impact immune functioning (biomedical, psychological, social, and behavioral). This was followed by a review of early and recent research on the relationship between religiosity and immune function, examining associations with inflammatory markers, immune cells (number and function), and downstream effects of immune functioning (susceptibility to infection and course of infection). The majority of these studies have found a beneficial relationship between religiosity and lower levels of inflammation, higher numbers of immune cells, lower susceptibility to infection, and improved course of infection. Recommendations for future research were then made, with a focus on prospective studies and RCTs, while keeping ethical considerations in mind. Finally, applications for health professionals and religious professionals were provided. In the next chapter, we examine the relationship between religiosity and the endocrine system, as stress hormones play a key role in regulating immunity.

25 Stress Hormones But for my faith in God, I should have been a raving maniac. —​Gandhi

THE FOCUS OF this chapter is on the relationship between religious involvement and endocrine functions, specifically hormones involved in the stress response. Stress hormones play a key role in mediating the effects of psychological and social stress on the body, acting both directly to affect cardiovascular health and indirectly to modulate immune functions that affect susceptibility to infection, cancer, and autoimmune diseases. The primary stress hormones are cortisol, norepinephrine (noradrenaline), and epinephrine (adrenaline). We will also briefly examine oxytocin, which has been called the “anti-​stress hormone” (Olff et al., 2013). Hormones are chemical messengers that mediate the relationship between psychosocial stressors and immune function, and may help to explain how religiosity influences immunity. Stress hormones prepare the body to fight off, flee from, or freeze during an attack that threatens physical survival (or emotional well-​being). This is a physiological and physical

response common to animals ranging from insects to humans (Tort & Teles, 2011). Recent research indicates a complex circular relationship that involves psychological states influencing endocrine functions, which in turn affect immune functions, which feedback to affect endocrine functions, both in turn influencing psychological states (see Irwin & Cole, 2011). We begin by describing the body’s response to acute and chronic stress, and then discuss in more detail the hormones involved in the stress response.

STRESS HORMONES There are three major hormones released during the stress response: cortisol, epinephrine, and norepinephrine. Cortisol and epinephrine are activated by the hypothalamic pituitary adrenal (HPA) axis, whereas norepinephrine release results from activation of the sympathetic nervous system (SNS). During periods of rest

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0025

when stress level is low or absent, the parasympathetic nervous system (PNS) is activated, which then serves to turn off the SNS to keep the system in balance. When individuals affiliate with each other or engage in maternal-​like behaviors, the hormone oxytocin is released. The activities and purposes of these hormones are now discussed.

Cortisol Cortisol secretion results from activation of the HPA axis. Under normal conditions, the amount of cortisol in blood varies throughout the day and night with the highest levels found around 30 minutes after waking up in the morning (called the cortisol awakening response, CAR). Levels start to increase rapidly between 4:00 a.m. and 8:00 a.m., and then after peaking 30 minutes after awakening, decline slowly over the remainder of the day, reaching their lowest point in the evening and remaining low until gradually increasing again around 3:00 a.m. The increases and decreases in cortisol from baseline depend on whether stresses in the environment are acute or chronic. During acute short-​ term stress there is a rapid increase in serum cortisol as part of the fight-​flight response. Cortisol has many physiological effects aimed at preparing the body for maximum physical effort to either fight or escape a threat, and then returning the system back to baseline after the physical or psychological threat has passed. The acute effects of cortisol include increasing blood glucose, retaining sodium and water, excreting potassium, increasing sensitivity of the vascular system to epinephrine and norepinephrine, reducing inflammation (at high levels by decreasing histamine release from immune cells and stabilizing lysosomes), increasing vigilance and cognitive performance, and improving memory of short-​ term emotional events (called “flashbulb memories,” designed to help the person remember what to avoid). These functions serve to increase arousal, focus attention, enhance fear memory and learning, and mobilize energy (glucose) in order to confront short-​ term threats. Among individuals involved in high-​risk situations, such as those in hazardous occupations in law enforcement, the diurnal 482 •  P h y sical H ealth

cortisol curve appears to be increased throughout a 24-​hour period (Planche et al., 2019). When stress is severe and prolonged, there may be a reduction or blunting of the CAR, a flattening of the decline in cortisol during the rest of the day, and an overall decrease in total 24-​hour cortisol output (area under the curve, or AUC). This is seen in conditions such as burnout and post-​traumatic stress disorder (PTSD) (Sin et al., 2017), which cause a state of chronic low-​grade inflammation throughout the body (see below). This low-​grade inflammation leads to cardiovascular disease, increased physiological aging (due to shortening of telomere lengths in cells throughout the body), development of age-​related diseases, and cognitive impairment due to cortisol-​induced damage to hippocampal neurons in the brain (Schoenfeld & Gould, 2012; Gupta & Morley, 2011).

Epinephrine Epinephrine and norepinephrine belong to a class of chemical messengers called catecholamines, which are active in both the central and peripheral nervous systems. During acute stress, there is activation of the medullary portion of the adrenal glands by adrenocorticotropic hormone (ACTH) and by the SNS, resulting in an outpouring of epinephrine (adrenaline) into the blood stream. The adrenal medulla secretes 75%–​80% of all epinephrine in the body and also produces a smaller amount of norepinephrine (Klabunde, 2011). Increased epinephrine in the blood elevates heart rate and strength of cardiac contractions, causes vasoconstriction in most arteries and veins, and vasodilates arteries in muscles and the liver (through β2 receptor activation). Stress-​related increases in epinephrine (and norepinephrine below) play a crucial role in the development of hypertension, cardiac arrythmias, cardiomyopathy, myocardial infarction, stroke, type II diabetes, and may affect prognosis in each of these conditions (Parati & Esler, 2012; Steptoe & Kivimaki, 2013; Vaccarino et al., 2014).

Norepinephrine Epinephrine is produced from norepinephrine, which is a metabolite of dopamine. The release

of corticotropin releasing hormone (CRH) from the hypothalamus during acute stress initiates the release of ACTH from the pituitary and consequently an increase in serum cortisol and epinephrine from the adrenal glands. Even before that, however, the hypothalamus works together with the amygdala to immediately activate the norepinephrine-​ producing neurons in the locus coeruleus and lateral tegmental nuclei in the midbrain and brainstem. These neurons have projections throughout the brain and spinal cord. They serve to activate the SNS, increase levels of norepinephrine in the blood, and reduce PNS activity (which as noted above, opposes and turns off the SNS). The primary source of circulating norepinephrine (75%–​ 80%) is spillover from the sympathetic nerves that surround blood vessels. Norepinephrine increases during emotional stress, causing a transient increase (and then slowing) of heart rate, an increase in strength of heart contractions (via β1 receptor activation), and vasoconstriction in most arteries (with α1 and α2 receptor activation), thereby increasing blood pressure.

Oxytocin

affiliative touch such as hugging, cuddling, and following sexual intercourse. Because of its role in long-​term bonding, oxytocin may also be a factor in forming groups and in preferential treatment of in-​group members compared to those outside the group.

ACUTE STRESS RESPONSE Summarizing and expanding on what was said above, endocrine responses to stress depend on whether the stress is acute and time-​limited, or chronic and prolonged. When a person perceives danger or experiences psychological stress, the SNS and HPA axis are immediately activated. Sights, sounds, and other perceptions that indicate a threat activate the amygdala, which is an area next to the hippocampus located deep within the temporal lobes of the brain. The amygdala processes the information and coordinates a response. If the amygdala interprets danger, it instantly sends a distress signal to a group of adrenergic neurons in the locus coeruleus of the dorsal pontine tegmentum of the brainstem (the control center for the SNS) and to the hypothalamus located nearby. The locus coeruleus immediately activates the SNS, which releases norepinephrine that redirects blood to large muscles, increases blood pressure, and increases alertness, preparing the body to confront the stressor. The HPA axis is also activated to produce CRH, which travels in the blood through a short portal of arteries to the pituitary gland, which then produces ACTH, which circulates via arteries to the adrenal glands located above the kidneys, where it stimulates the adrenal cortex to produce cortisol and epinephrine. Cortisol, epinephrine, and the norepinephrine released from SNS nerve endings then act in concert to prepare the body to fight or escape from the danger. Once the threat has passed, these hormones then provide feedback to the amygdala and hypothalamus to calm the system down and return it to baseline.

Oxytocin is a hormone synthesized primarily in the magnocellular oxytocin neurons of the hypothalamus, which have projections to the forebrain structures, the amygdala, and the posterior pituitary. Stimulation of these projections occurs when individuals affiliate with and touch one another. Oxytocin also increases after acute stress, especially relationship stress, leading to affiliative behaviors that serve to reduce relational disharmony (Sippel et al., 2017). Oxytocin, known as the anti-​stress hormone, serves to modulate the HPA axis by providing negative feedback to the pituitary when corticotropin is released from it and increases production of cortisol. However, oxytocin does much more than just serve as a modulator of the stress response. Oxytocin also causes contractions before birth and the release of milk during breast feeding. In particular, oxytocin CHRONIC STRESS RESPONSE (“the love hormone”) is involved in mother-​ infant bonding and in the development of If the threat or stressor continues over time romantic relationships during adulthood. and becomes chronic, this causes a different As noted above, oxytocin is released during set of physiological changes. Although the Stress Hormones • 483

stress response system evolved over time to be extremely adaptive to acute stressors, this is not the case for chronic stressors. One can speculate that either humans escaped from whatever threatened their survival, or they didn’t and were killed. Long-​term stress was not an issue. Humans have yet to evolve successful adaptions for dealing with stressors that last for days, weeks, months, or sometimes even years. In these circumstances of prolonged stress or distress, the body tends to break down slowly over time. Chronic stress is associated with increased levels of norepinephrine and epinephrine due to an overactive SNS that has lost its “off” switch. As noted above, cortisol levels may remain chronically high, or in some circumstances, may drop to levels below baseline due to down-​regulation of glucocorticoid receptors (lowered sensitivity) in the hypothalamus and amygdala, as seen in PTSD and various forms of emotional exhaustion. As noted earlier, this results in accelerated atherosclerosis, elevated blood pressure, insulin resistance, osteoporosis, slower wound healing, chronic inflammation, decreased antibody production in response to vaccination, reduced resistance to infection and cancer, increased development of autoimmune disorders, and damage to hippocampal regions of the brain, leading to cognitive impairment and dementia (McEwen, 1998; Tort & Teles, 2011; Schoenfeld & Gould, 2012; Gupta & Morley, 2011; Dhabhar, 2014).

STRESS HORMONES AND THE IMMUNE SYSTEM Cortisol The effects of cortisol on immune functioning (and vice versa) are carefully modulated and controlled by a set of complicated feedback loops (Capuron & Miller, 2011). The effects of cortisol differ depending on how much time has passed since the initial stressor, whether the stressor continues, the mental and physical health of the person at the time of the stressor, and the individual’s history of prior psychiatric problems and stressful experiences. In the short term, the effects of cortisol are highly adaptive and immune system enhancing, 484 •  P h y sical H ealth

increasing the efficacy of wound healing, enhancing resistance to infection, and improving responses to vaccination (Dhabhar, 2014). However, if acute stress is experienced during states of immune system activation, such as autoimmune or allergy-​related disorders, then the pro-​inflammatory effects of cortisol may worsen these conditions. In animal models, cortisol at high doses causes atrophy of the thymus gland, lymphopenia, monocytopenia, and otherwise suppresses inflammation and cell-​ mediated immunity. Cortisol also causes leukocytes to redistribute from the blood into lymph nodes, bone marrow, and skin, making them less available to fight infection. This includes reduction of T cell proliferation and decreases in phagocytosis (i.e., the ability to engulf and destroy pathogens). Cortisol also suppresses cell-​mediated immunity by reducing production of IL-​2 and IL-​12, cytokines necessary for T cell activation. Cortisol causes IL-​2-​producing T cells to be less responsive to IL-​1 and less able to produce T cell growth factor. Cortisol also inhibits NK cell activity, decreases the pro-​ inflammatory cytokine interferon-​ γ, increases IL-​ 4 (anti-​ inflammatory cytokine), and decreases the IL-​ 2:IL-​4 ratio. In addition, cortisol suppresses the production of IL-​12, which is the main inducer of the Th1 pro-​inflammatory response. Most of these are the acute effects of cortisol. When chronically elevated due to ongoing stress, cortisol may have either pro-​inflammatory or immune-​ suppressive properties. Sustained high levels of cortisol (as occurs in depression) can also cause a down-​regulation of glucocorticoid receptors on immune cells, making those cells less sensitive to the anti-​ inflammatory effects of cortisol so that they may, in fact, overcompensate, making cortisol pro-​inflammatory. For example, pro-​inflammatory cytokines such as interferon-​γ and IL-​6 are usually elevated in depression, where cortisol levels are often chronically high. Not only does cortisol affect cytokines and other immune functions, but cytokines released from immune cells also affect cortisol secretion and HPA axis activity as part of a negative feedback loop (Capuron & Miller, 2011). In summary, chronic stress-​induced changes in responses to cortisol may cause chronic low-​

grade inflammation due to pro-​inflammatory effects, or in contrast, may result in immuno-​ suppression, with a reduction in leukocyte numbers, suppression of leukocyte function, and activation of other immuno-​suppressive processes. The latter may lead to slower wound healing, decreased efficacy of vaccination, reduced resistance to infection, and increased risk of cancer, whereas the former may result in the onset or worsening of autoimmune diseases (Tort & Teles, 2011; Dhabhar, 2014).

Nor-​epinephrine and Epinephrine Catecholamines are also known to have effects on immune functions, although as usual, the relationship is a complex one. Nerve fibers from the SNS extend into lymph nodes, the thymus, and other immune organs. The release of norepinephrine from these nerve endings and of epinephrine from the adrenal glands activates β adrenergic receptors on helper T and suppressor T lymphocytes, B lymphocytes, natural killer cells, monocyte/​ macrophage cells, and dendritic cells, thereby altering their function. Stimulation of these adrenergic receptors typically inhibits T and B cell responses and NK cells’ cytotoxicity, as well as suppressing monocyte/​macrophage and dendritic cell functions. Stimulation of adrenergic receptors may also increase production of pro-​inflammatory cytokines IL-​6 and IL-​8, which are known to stimulate the growth of cancer cells. Both acute and chronic stress are accompanied by high levels of circulating catecholamines, usually decreasing T cell responses, anti-​viral immune reactivity, and NK cell activity, thereby increasing risk of infection and allowing the development and spread of cancer (Sarkar et al., 2013).

production of Th2 cytokines (IL-​ 4, IL-​ 10) (anti-​ inflammatory cytokines that depress macrophage activation and cell-​ mediated immunity). This combined effect may result from cortisol’s effect on increasing sensitivity of T cells to the effects of catecholamines, and from catecholamines’ effect on increasing the sensitivity of T cells to effects of cortisol. Such immune-​ suppressive effects may have clinical consequences, including altered control of spontaneously developing malignant tumors, as noted above (Sarkar et al., 2013). The combined influence of cortisol and catecholamines on immune functions may also depend on whether stress is acute or chronic. The complex nature of these effects reflects the role of the HPA axis and SNS in fine-​tuning immune functions.

FACTORS AFFECTING CORTISOL AND CATECHOLAMINES Given this discussion of the effects of cortisol, norepinephrine, and epinephrine on cardiovascular and immune functions, we now examine demographic, biomedical, psychological, social, and behavioral factors that influence levels of these stress hormones. This information will be necessary for understanding how religious involvement could impact levels of these hormones.

Demographic Factors

Stress hormones appear to vary by gender (higher levels in men) (Masi et al., 2004), by socioeconomic status (higher levels in those with low SES) (Castro-​Diehl et al., 2014), and to some extent by age as well (see Almela et al., 2011, for review). There is also evidence that Combined African American race is associated with lower High levels of cortisol and catecholamines levels of cortisol, epinephrine, and norepinephoperate together to modulate the balance of T-​ rine when compared to Caucasian Americans, helper 1 (Th1) and T-​helper 2 (Th2) cell func- although among alcohol abusers, these stress tions, such as the production of cytokines hormone levels are higher in African Americans (Salicru et al., 2007). Studies have shown that than in Caucasian Americans. Cortisol and the combination of cortisol and catechol- sympathetic nervous responses to stress also amines decreases Th1 cytokines (IFN-​γ, IL-​12) appear to be heightened at older ages, although (cytokines that activate macrophages, NK cells, results from studies vary (Almela et al., 2011). and cell-​ mediated immunity) and increases These demographic risk factors suggest that Stress Hormones • 485

gender, socioeconomic status, race, and possibly age may confound the relationship between religiosity and stress hormones (since all of these characteristics are also related to religiosity), and therefore must be controlled for in observational studies.

Psychological Stress

Cortisol, norepinephrine, and epinephrine responses to acute and chronic psychological stress have already been described above. The impact of psychological stress on levels of these hormones is similar to the effects of physical stress or a physical attack. Threats to happiBiomedical ness, self-​esteem, employment, completion of The most common medical disorders affecting education, possessions, or loved ones activate cortisol levels in the body are Cushing’s dis- the HPA axis and SNS in exactly the same way ease and Addison’s disease. Cushing’s disease as outside threats to bodily integrity. Although is a condition resulting from overproduction ACTH, cortisol, and catecholamines increase of cortisol by the adrenal cortex due to a local acutely to prepare the body to fight or run, negadrenal tumor or to a tumor of the pituitary ative feedback loops may return levels back to gland that produces ACTH. Addison’s disease baseline after the stressor passes or with the results from lack of production of cortisol, and passage of time if the stressor continues. As indicated earlier, if the stressor is promay be due to infection of the adrenal cortex, longed and severe, as in PTSD, cortisol levels autoimmune disease, or destruction of the may return to normal or drop below normal pituitary that results in a lack of ACTH proas receptors recalibrate, whereas catecholduction. There are also medical disorders that amine levels often remain elevated (Strawn & result in the underproduction or overproducGeracioti, 2008). Repeated episodes of acute tion of catecholamines. The most common stress are also quite different from chronic disorder resulting in underproduction of catstress where there are no intervals of decreased echolamines is dopamine-​β-​hydroxylase defistress that enable the system to return to baseciency, a congenital disorder characterized by line. While repeated episodes of stress may sympathetic noradrenergic denervation and merge into chronic stress and thus be diffiadrenomedullary failure. The most common disorder resulting in overproduction of cate- cult to distinguish, the former does not allow cholamines is pheochromocytoma, a benign habituation of hormone receptors as occurs in vascular tumor made up of catecholamine-​ chronic stress (Rohleder, 2019). While acute producing cells in the adrenal medulla or psychological stress increases cortisol and catsympathetic paraganglia. Likewise, hyperthy- echolamine levels, listening to relaxing music, roidism may also present with symptoms of practicing yoga, or engaging in mindfulness-​ catecholamine excess due to stimulation of based activities are known to reduce cortisol, decrease SNS activity, and increase oxytocin noradrenergic receptors. Excessive amounts of cortisol or catechol- release (Ooishi et al., 2017; Pascoe et al., 2017a; amines may also result from external adminis- Luberto et al., 2018). tration of these hormones or from drugs that stimulate their endogenous production. These Depression substances may be used for medical reasons (e.g., methylphenidate), or may result from On average, depressed persons tend to have self-​ administration for recreational purposes higher ACTH and cortisol levels compared to (e.g., cocaine, amphetamines, methamphet- nondepressed individuals, but lower levels of amines, and other stimulants). The latter acti- CRH (Stetler & Miller, 2011). Cortisol levels vate catecholamine receptors in the same way are particularly high for those suffering from that norepinephrine and epinephrine do, often melancholic or psychotic depressions and leading to down-​regulation of those receptors among those with depression severe enough as tolerance develops. Symptoms of depression to require hospitalization. ACTH levels are and fatigue result when these drugs are reduced consistently high throughout the day in those with depression and cortisol levels are lowest or stopped. 486 •  P h y sical H ealth

in the morning and highest in the afternoon, while CRH levels are particularly low in the morning. This means that “cortisol production during depression is influenced by other factors besides ACTH and CRH, and the ACTH production is not solely a function of CRH levels . . . and suggests possible adrenal medullary-​or immune-​mediated stimulation of cortisol production in the adrenal cortex” (Stetler & Miller, 2011, p. 123). Furthermore, cortisol levels often do not decrease in response to exogenously administered cortisol (dexamethasone suppression test [DST]), as would be expected if the HPA axis negative feedback loop operated normally. The reason is that the HPA axis is no longer subject to regulation, i.e., cortisol levels may remain high regardless of exogenously administered cortisol, especially for those with melancholic, endogenous, or psychotic depression. Once clinical remission is achieved following treatment with antidepressants, the lack of cortisol suppression is partially reversed (Carroll et al., 2007). Although the DST has fallen into disfavor as an indicator of depression due to inconsistency of findings and difficulty discriminating depression from other psychiatric disorders (Mokhtari et al., 2013), a positive DST has recently been shown to predict severe or violent suicidal behavior in depressed patients (Alacreu-​Crespo et al., 2020). Depression is also characterized by a state of increased SNS activity, with increased levels of epinephrine and norepinephrine in blood (Veith et al., 1994; Carney & Freedland, 2017), while at the same time norepinephrine levels in the brain may be low (Lambert et al., 2000). The release of CRH from the hypothalamus activates the locus coeruleus and leads to increased production of norepinephrine peripherally due to increased SNS activity (Arit et al., 2003). An overactive SNS in relationship to the PNS has been found in those with major depression, causing decreased heart rate variability (HRV), which depends on the ratio of PNS to SNS activity (Thayer et al., 2010). Decreased HRV, a well-​ established predictor of heart disease, is thought to be one reason for the positive relationship between depression and cardiovascular disease (Carney & Freedland, 2017).

Anxiety As noted earlier, cortisol levels tend to be low rather than high in patients with PTSD due to negative feedback inhibition (Pan et al., 2018). A similar down-​regulation of HPA-​axis activity has also been found in other anxiety states, such as generalized anxiety disorder, where morning salivary cortisol levels have been found to be low (Hek et al., 2013). In social anxiety disorder, however, there is a robust cortisol increase in response to acute psychosocial stress (Roelofs et al., 2009), and this increase is greater in men than in women (Zorn et al., 2017). Symptoms of anxiety disorders are often similar to those reported by individuals with physical health problems characterized by high catecholamine levels in blood. As indicated earlier, high catecholamine levels may result from a neuroendocrine tumor of the adrenal medulla (pheochromocytoma) that presents with anxiety symptoms (Kalk et al., 2011). Increased levels of urinary norepinephrine, epinephrine, and cortisol have also been associated with anxiety symptoms in several studies, indicating increased HPA-​axis and SNS hyperactivity (Hughes et al., 2004; Paine et al., 2015). The most consistent finding in PTSD is an increase in peripheral norepinephrine levels, although study findings may vary (Yehuda et al., 1998; Kalk et al., 2011). Therapies that reduce SNS activity and catecholamine levels often produce relief of anxiety. As in depression, high levels of norepinephrine in the brain (associated with anxiety disorders such as panic attacks) do not always translate into high norepinephrine levels in the blood, urine, or saliva, where it is typically measured.

Positive Emotions Since cortisol and catecholamine levels are often high during stress, depression, and anxiety, one might wonder whether positive emotions are associated with lower levels of these hormones. Positive emotions include a sense of well-​being, happiness, positive affect, peacefulness, and purpose in life. Brummet and colleagues (2009) found that high positive emotions (positive affect) were associated with lower morning blood norepinephrine and Stress Hormones • 487

salivary cortisol levels, even after controlling for age, race, gender, smoking status, income, and body mass index. Positive emotions are often elicited by recalling past positive events, which has been shown to buffer the effects of acute stress on cortisol levels (Speer & Delgado, 2017). Positive affect has also been shown in prospective studies to predict a steeper decline in cortisol throughout the day (a reduction in overall 24-​hour cortisol production) (Hoyt et al., 2015). However, the effects may also go in the other direction since cortisol itself may regulate positive affect and, in some cases, may actually improve well-​ being, at least acutely (Hoyt et al., 2016). Likewise, a recent meta-​ analysis reported a small positive correlation between oxytocin (the “anti-​stress hormone”) and cortisol (the “stress hormone”), confusing matters even further, while underscoring the complexity of hormonal responses to emotions (Brown et al., 2016). There is clear evidence, however, that interventions that generate positive emotions, such as Buddhist-​ based mindfulness meditation or even taking a walk in a natural environment such as a forest, decrease serum cortisol and reduce SNS activity (Heckenberg et al., 2018; Kobayashi et al., 2019).

Social Support Social support, social integration, and the opposite, social isolation or loneliness, affect stress hormone levels. Studies indicate that supportive social experiences provide a sense of social inclusion that reduces perceptions of stress and accompanying physiological responses (Eisenberger, 2012; Eisenberger & Cole, 2012). Among humans and social animals (mammals and nonhuman primates), social isolation is associated with larger cortisol awakening responses and greater total cortisol output over 24 hours in both cross-​sectional and prospective studies (Hawkley et al., 2012). In an early experimental study where older adults in their late eighties were randomized to either a social activation program or a control group, those in the social program were found to have a significantly lower plasma cortisol at 3-​to 6-​ month follow-​ up compared to the control group (Arnetz et al., 1983). Furthermore, those 488 •  P h y sical H ealth

in the control group also experienced a significant decrease in their height over a 6-​month period, perhaps reflecting the adverse effects that cortisol has on bone mineral density. Social support has also been shown to buffer the association between psychosocial stressors and cortisol among college students (McQuaid et al., 2016), as well as the association between depressive symptoms and cortisol in adolescents (parental support, in particular) (Guan et al., 2016). Supportive interactions during infertility treatment have also been found to predict lower cortisol levels (Malina et al., 2019). In contrast, feelings of loneliness are associated with increased physiological responses to psychosocial stressors (Brown et al., 2018). Similar results have been reported for catecholamines. For example, in an experimental study of 38 cohabitating couples, Grewen and colleagues (2005) found that greater partner support at baseline was inversely related to age-​ adjusted norepinephrine levels among women. In another study, Wirtz and colleagues (2006) examined the relationships between social support, salivary cortisol, plasma epinephrine, and norepinephrine before and after a stressor in 22 hypertensive and 26 normotensive men (mean age 44). Results indicated that (1) social support was lower in hypertensives than normotensives; (2) hypertensives had higher levels of cortisol, epinephrine, and norepinephrine after a laboratory-​induced stressor; and (3) increases in epinephrine levels in response to stress were highest in hypertensives with low social support. In another study, Wirtz and colleagues (2009) examined the relationship between social support and physiological responses to a laboratory stressor in 63 medication-​ free nonsmoking men (mean age 37), finding that lower social support predicted an increase in norepinephrine levels both before and after the stressor. Similarly, in a study of women with ovarian cancer, tumors from women with high depressive symptoms and low social support demonstrated increased intra-​ tumor concentrations of norepinephrine, suggesting that beta-​adrenergic stimulation by norepinephrine may be a mediator of disease onset or progression (Lutgendorf et al., 2009). Finally, a review of research on oxytocin reported a significant increase in serum levels of this anti-​ stress

hormone during positive social interactions and affiliative behaviors (Uchino & Way, 2017). Thus, many studies find that greater social support is related to lower cortisol, lower circulating catecholamines, and higher oxytocin levels. This makes sense since social support is known to buffer against psychological stress, increase positive emotions, and promote social interactions that influence levels of these hormones in the body. Matthews and Tye (2019) have recently described the physiological mechanisms underlying such effects.

(Blaine et al., 2019). Chronic exposure to alcohol leads to disturbances in noradrenergic activity that become most evident during states of alcohol withdrawal, characterized by anxiety, adrenergic hyperactivity, and central nervous system stimulation due to high levels of norepinephrine (Patkar et al., 2004; Haass-​ Koffler et al., 2018). P H YSICAL ACTIVITY

The effect of physical activity and exercise on stress hormone levels depends on whether that activity is short-​term or long-​term in nature Behavioral Factors and on the dose of exposure (i.e., length and Cigarette smoking, alcohol use, physical activ- intensity of activity) (Peake, 2020). Exercise ity, sleep, and diet are known to impact stress acutely causes a release of stress hormones into hormone levels, and are of particular interest the circulation to meet the demands of greater here since they could serve as mediators of reli- muscle activity. Plasma epinephrine and norgiosity’s effect. epinephrine increase in an exponential manner with increasing intensity of exercise. Plasma ACTH and cortisol levels also increase, but only C I GA RE TTE SMOKING after a certain intensity of moderate short-​term Cigarette smoking acts centrally to stimulate exercise (> 60% V02 max), and they increase the SNS, causing supraphysiological levels of even more during moderate long-​term exercise catecholamines in blood (Lowery et al., 2019). and high-​ intensity exercise. Catecholamines Cigarette smoking stimulates the HPA-​ axis show a similar pattern as cortisol, with drawith acute increases in ACTH and epineph- matic increases after a certain intensity threshrine that peak within 20 minutes, followed by old of physical activity has been reached. a slower increase in serum cortisol, peaking at If the intensity of activity is kept constant 60 minutes following a smoking session (Mello, and the duration is extended, levels of stress 2010). Serum cortisol is also positively cor- hormones tend to plateau, followed by slowly related with number of cigarettes smoked per increasing levels with continued activity. When day, and smoking cessation reduces cortisol lev- the activity stops, however, levels of stress horels (Steptoe & Ussher, 2006; Wong et al., 2014). mones decrease to baseline or below baseline during recovery. The only exception is with intensive physical training, such as during A L C O H O L C ONS UMPT ION competitive events, or when exercise duraAs with smoking, ingestion of alcohol stim- tion is prolonged to hours or even days among ulates the HPA-​ axis with acute increases in those in the military, when return to baseline cortisol and catecholamine levels, especially hormone levels occurs very slowly or not at in nondependent drinkers. In animal mod- all (Hackney & Ağgön, 2019). The effects of els, chronic alcohol consumption is known chronic exercise training are less certain, with to increase basal catecholamine levels, espe- some investigators finding an attenuation of cially after stress (Patterson-​ Buchendahl et increases in HPA axis and SNS activity after al., 2005). Acute alcohol intoxication increases weeks of intense training when individuals are norepinephrine synthesis and release, but exposed after a period of rest to the same absochronic alcohol use leads to down-​regulation lute workload. Although such hormone changes of central alpha-​2 adrenergic receptors (Haass-​ with physical activity or exercise may be immuKoffler et al., 2018), resulting in blunted HPA-​ nosuppressive to some degree (especially with axis responses and neuroendocrine tolerance intense exercise training; see Chapter 24), both Stress Hormones • 489

acute exercise and chronic training have been found to increase antibody responses to vaccination, and mild repeated stress from moderate chronic training has also been shown to improve the rate of wound healing, decrease the risk of upper respiratory viral illnesses, and reduce the prevalence and severity of a range of chronic diseases (Peake, 2020). SLEEP

The HPA axis and SNS are down-​ regulated during sleep, such that blood levels of cortisol, epinephrine, and norepinephrine all decrease (Tan et al., 2019). Slow-​wave sleep during the first half of the night promotes the release of growth hormone and prolactin when levels of cortisol and catecholamines are at their lowest level. Loss of sleep and disordered sleep result in decreases in slow wave sleep and increases in both cortisol and catecholamine levels (Irwin et al., 1999). DI E T A N D W E I G HT

Cortisol levels are higher among individuals who consume a high-​ protein diet compared to those who eat a high-​ carbohydrate diet (Martens et al., 2010), and ingestion of a high-​ protein meal has been shown to increase serum cortisol levels acutely (Field et al., 1994). In contrast, vitamin C and foods containing high concentrations of vitamin C (e.g., oranges, lemons, blueberries, spinach) are known to reduce cortisol levels to baseline after exercise (Singh, 2016). Furthermore, daily consumption of breakfast cereal has been associated with lower cortisol levels, even when compared to eating breakfast regularly but without cereal (Smith, 2002). Caloric restriction decreases SNS activity, particularly when combined with exercise, and does likewise for serum cortisol levels, at least among overweight individuals (DeJonge et al., 2010; Buffenstein et al., 2000). As noted in Chapter 19, obesity is known to affect cortisol levels in that adipose tissue can produce cortisol along with other substances that affect the HPA axis (Vicennati et al., 2014). Obese adults have higher hair cortisol, a more accurate measure of long-​term cortisol levels in the body (Van der Valk et 490 •  P h y sical H ealth

al., 2018). There are also bidirectional effects such that obesity may increase cortisol levels and cortisol may increase obesity, producing a vicious cycle. In contrast, prospective studies of children have found that being overweight or obese during preschool years (age 3–​5) predicts a lower morning cortisol, lower diurnal slope, and lower cortisol reactivity to stress during middle-​school years (age 7–​10), suggesting a blunted cortisol response (Ruttle et al., 2013; Doom et al., 2020). Research in adults has also found that greater abdominal fat is associated with lower morning cortisol levels, suggesting down-​regulation of the HPA axis in response to the negative feedback resulting from high cortisol levels secreted from fat tissue (see Doom et al., 2020). With regard to catecholamine levels, in contrast, numerous studies have reported a decrease in SNS activity and lower plasma catecholamine concentrations among overweight or obese individuals when compared to those of normal weight (Zouhal et al., 2013), which may be due to adrenal medullary dysfunction in obesity (Reimann et al., 2017).

Summary Many factors, including demographic characteristics, medical disorders, medications, acute and chronic psychological stress, depression, anxiety, positive emotions, social support, and health behaviors (cigarette smoking, alcohol consumption, physical activity levels, sleep, diet, and weight) influence cortisol and catecholamine levels. Among psychosocial factors that may buffer the effects of stressful life experiences on hormone levels, one not yet discussed, but the focus of what follows, is religion.

RELIGION AND STRESS HORMONES As discussed above, numerous physical, psychological, social, and behavioral pathways exist through which religious involvement might impact stress hormone levels. After presenting a case vignette involving a young schoolteacher, we theorize on how religiosity might impact cortisol, catecholamine, and oxytocin levels in the body, acting through the mediators discussed earlier.

Case Vignette Mahir is a 30-​ year-​ old single schoolteacher who works in an urban inner-​city district of New York City. She teaches the 7th grade. In her first year of teaching at the school, her students were rowdy and disruptive. They talked loudly and sometimes even fought during class, often failed to complete their homework, and were completely unresponsive when asked to change their behavior. She tried many different strategies to regain order in the classroom, including punishing individual students and having the entire class stay after school. Approaching the school principal was not helpful, as he simply told her to get control of the class, put up with it, or find another teaching position. Mahir was frustrated and extremely stressed over these experiences, as she felt completely helpless to do anything about her students’ behaviors. This was made worse by having only recently moved to the area and not having friends to support her. During the winter season of that year, Mahir came down with one cold after another, including spending an entire week in bed with severe fatigue, cough, and a high fever, likely a case of influenza. In order to find friends and get connected with a community, Mahir, who is Hindu, decided to visit a few temples close to her home. The members at one temple in particular seemed really friendly, and she noticed that there were many young adult professionals around her age there, so she started attending regularly. It was a large temple, and several people there were schoolteachers with whom she began to associate. Soon, she was sharing her classroom problems with them. These fellow congregants were quite sympathetic and suggested some things she could do to get her students to cooperate. They also encouraged her to practice 30 minutes of yoga meditation every day before class. After a couple of months, Mahir began to feel

less stressed, isolated, and lonely. As her self-​confidence increased, she began to take charge in her classroom. A year later, Mahir joined the temple and now has a support group of friends. She has also begun to enjoy teaching, much more so than the prior year. When winter came again, she remained healthy throughout the season without a single cold.   

Theoretically, religious involvement has the potential to affect stress hormones by improving coping with stress, preventing or relieving depression/​ anxiety, enhancing positive emotions, boosting social support, and improving health behaviors.

Coping with Stress As described in Chapter 4, religious belief and practice help to reduce the frequency of stressors and improve coping with those that cannot be prevented. Research indicates that religious involvement can buffer the effects of psychosocial stressors on mental health, including stressors such as financial strain, social isolation, chronic illness, poor subjective health, peer victimization, sexual or child abuse, unemployment, severe trauma, divorce or death, and racial discrimination, to mention just a few (see Appendix). By preventing or relieving acute or chronic stress, religious beliefs and activities have the potential to lower levels of cortisol and catecholamines in the body. If religious involvement promotes a more stable family life (Chapter 14), then a healthier intrauterine environment and fewer adverse childhood experiences will have a positive effect on HPA axis and SNS responses to stress during adolescence and adulthood.

Depression and Anxiety Both depression and anxiety are associated with higher levels of serum, salivary, and urinary cortisol and norepinephrine. The majority of studies find that religiosity is inversely related to depressive symptoms and predicts Stress Hormones • 491

faster remission from depression (Chapter 5), and a number of quantitative studies report the same for anxiety symptoms and disorders (Chapter 8). If depressive and possibly anxiety symptoms are less frequent among the more religious, then this should result in lower levels of these stress hormones in the body.

Positive Emotions Persons who experience more positive emotions have lower levels of stress hormones and higher levels of anti-​stress hormones. Religious involvement, in turn, is related to more positive emotions, greater psychological well-​being, life satisfaction, happiness, optimism, and meaning and purpose in nearly 80% of studies (Chapter 12), and so should also be related to lower levels of stress hormones. However, failure to live up to the high moral standards that religious traditions emphasize can also lead to guilt, shame, and negative social evaluation, which can increase HPA-​axis and SNS activity (Miller et al., 2007; Rohleder et al., 2008).

Social Support Religious involvement is related to greater social support, greater social integration, and less loneliness and social isolation (Chapter 15). Given the effects that such social factors have on stress and anti-​stress hormone levels, this should result in lower cortisol, lower epinephrine and norepinephrine, and greater oxytocin levels in the more religious. Of course, in those who are socially ostracized from religious communities because of their lack of belief, amoral behavior, or prohibited lifestyle choices—​ especially in religious areas of the world—​the opposite may also occur. The same social forces may be operative in highly secular areas of the world, leading to feelings of social isolation and exclusion in those who are religious, and in this way adversely affecting stress hormone levels.

18, and 19). Given that these health behaviors influence stress hormone levels in the body, better health behaviors represent significant pathways by which religious involvement could affect these hormones. However, given the less certain effect of religiosity on weight (which may be positive, negative, or unrelated), the impact on stress hormones through this pathway is less clear.

Summary In principle, then, religious involvement could have a positive, negative, or no effect on stress hormone levels. The complexity involved in maintaining HPA axis and SNS homeostasis in response to acute and chronic stress, normal diurnal fluctuations in hormone levels, negative feedback loops, and decreases in receptor sensitivity, complicate the task of investigating the relationship between religiosity and these biomarkers. The influences of demographic factors such as age, gender, race, and socioeconomic status on both stress hormones and religiosity add yet another layer of complexity. Given this background, let us now examine the findings from quantitative research that has attempted to evaluate these relationships.

RESEARCH ON RELIGION AND STRESS HORMONES As usual, we review early research conducted prior to 2010 and then more recent research published since 2010. Since the amount of this research is relatively limited, we attempt to briefly review most of the published studies, particularly high-​ quality prospective studies and randomized controlled trials (RCTs).

Early Research We examined the research findings separately for cortisol, catecholamines, and oxytocin.

Health Behaviors

CORTISOL

Greater religiosity has been associated with less cigarette smoking, less alcohol and drug use or abuse, greater physical activity, and better diet in the vast majority of studies (Chapters 17,

Prior to the year 2000, at least 10 studies had examined the relationship between cortisol and religiosity/​spirituality (R/​S) or R/​S interventions. The one observational study that

492 •  P h y sical H ealth

examined the relationship between religiosity per se and cortisol level was a paper presentation by Schaal and colleagues (1998). These investigators examined the cross-​ sectional relationship between religious involvement and salivary cortisol in 112 women with metastatic breast cancer. Evening salivary cortisol level was significantly lower among women who indicated that religious or spiritual expression was important (p < 0.01); no relationship, however, was found with religious attendance. Nine of the remaining 10 studies assessed the effects of Hindu-​or Buddhist-​based meditation. Seven of the nine studies reported that these Eastern spiritual practices resulted in a significant lowering of cortisol levels. Between 2000 and 2010, 19 additional studies were published, of which 11 examined the relationship with religiosity or the effects of a Western R/​S intervention on cortisol levels. Six reported a significant inverse relationship between religiosity and cortisol and the remaining 5 studies found no association. The 8 remaining studies involved Eastern meditation (Buddhist, Hindu, or Chinese). Five of the 8 meditation studies reported a significant lowering of cortisol, and 3 studies found no effect. One of the clinical trials examining Eastern meditation also prospectively examined the effects of faith (assessed by the 4-​item subscale of the FACIT-​Sp) on salivary cortisol, reporting a significant reduction in cortisol even after controlling for baseline cortisol (Bormann et al., 2009). In summary, of the 29 studies examining relationships with or effects on cortisol, 19 (66%) reported significant inverse relationships or reported that R/​S interventions lowered cortisol or improved diurnal cortisol release patterns. All of the remaining studies found no association or no effect. No studies found that R/​S correlated with higher cortisol or reported an increase in cortisol following an R/​S intervention. CATE C H O L A M INE S

Only one study published before the year 2000 examined the effect of R/​S on catecholamine levels. This was a clinical trial involving tai chi meditation (based on Taoist and Confucian

Chinese spirituality). Jin (1992) randomized 96 experienced tai chi practitioners to one of four groups: tai chi, brisk walking, meditation, and neutral reading. All subjects underwent laboratory stressors, and then received one of the four interventions above, with urinary catecholamines measured before and afterward. Epinephrine decreased significantly more after tai chi than after meditation (F =​6.47, p =​ 0.01), but norepinephrine levels increased significantly more after tai chi than after neutral reading (F =​12.9, p < 0.001). Since physical exercise increases catecholamine levels, however, the increase after tai chi (a spiritual form of exercise) was not surprising. Between 2000 and 2010, five additional studies examined R/​ S and catecholamine levels; two were observational studies and three involved Eastern meditation. One was a 32-​year prospective study of 144 secluded Catholic sisters in Umbria, Italy, who were compared to 138 healthy laywomen from the community (Timio et al., 2001). The second was a cross-​ sectional study involving 853 older adults participating in the MacArthur Successful Aging Study (Maselko et al., 2007). Both reported a significant inverse relationship between religiosity and urinary catecholamines (norepinephrine and epinephrine). Of the three Eastern meditation studies, one found that Buddhist mindfulness meditation had no effect on serum catecholamines (Robert-​McComb et al., 2004), whereas two reported that Hindu yogic meditation significantly reduced serum norepinephrine (Curiati et al., 2005) and urine norepinephrine (Granath et al., 2006). In summary, of the six studies published prior to 2010, four studies (67%) reported a decrease in catecholamine levels in response to Eastern spiritual interventions; one reported significant positive and negative effects (decreased epinephrine, but increased norepinephrine); and one found no effect. Two observational studies found lower catecholamine levels among those who were more R/​S, both measuring urinary catecholamines. One of those studies reported significantly lower norepinephrine and epinephrine levels; the other found significantly lower epinephrine only, and only in women (Maselko et al., 2007). Stress Hormones • 493

OX Y TO C I N

the three meta-​analyses indicated only small effects. We now briefly review 5 of the higher-​ We were unable to identify any studies of reliquality cross-​sectional studies, all 4 prospective giosity and oxytocin prior to 2010. Research on studies, and 5 of the RCTs and nonrandomspirituality, religiosity, and oxytocin has only ized CTs. emerged within the past decade. Merritt and McCallum (2013) examined the relationship between religious coping (RC, assessed by the 34-​item positive and negative Recent Research RCOPE scale) and salivary cortisol in 30 African Since 2010, numerous additional studies have American caregivers and 48 African American examined the relationship between R/​S and noncaregivers, finding in the overall sample stress hormone levels (cortisol, epinephrine, that RC was related to higher (worse) daily cornorepinephrine, oxytocin), including prospec- tisol slopes (partial r =​0.25, p =​0.04), after contive studies, single group experimental studies, trolling for caregiver status, age, and education. and RCTs examining R/​ S interventions (see In contrast, Anyfantakis et al. (2013) surveyed Appendix for a full listing). 195 older adults (average age 67), finding that serum cortisol levels were lower among those scoring above the median score on the Royal C O RTI SO L Free Interview for Spiritual/​Religious Beliefs Most of the research on religiosity and stress (12.3, SD =​5.8, vs. 18.2, SD =​5.1, p < 0.001, hormones, as well as the highest-​quality stud- no controls). Bellinger et al. (2014) examined ies, has examined cortisol. At least 29 stud- the association between a 29-​ item multidiies have examined this relationship or have mensional measure of religiosity and 12-​hour reported the results of R/​S interventions in urinary cortisol in 132 persons with major the past 10 years. Most were small studies depression in the setting of chronic illness, involving samples of fewer than 100 partic- finding no association between the two. In a ipants. Thirteen of the 29 studies were cross-​ study of 41 breast cancer survivors in Missouri, sectional or case-​control, 4 were prospective, Hulett et al. (2018) found a positive association 4 were single-​ group experimental studies, between frequency of daily spiritual experiand 8 were RCTs or nonrandom CTs. Of the ences and higher (worse) peak salivary corti13 cross-​sectional studies, 7 (54%) reported sol awakening responses (r =​0.34, p =​0.03). lower cortisol levels with increasing religios- Finally, in one of the largest cross-​sectional ity, 4 (31%) reported no association, and 2 studies to date, Allen et al. (2020) analyzed (15%) reported higher cortisol levels in those data on 700 men age 35–​85 participating in the who were more religious. Of the 4 prospective MIDUS-​II study, reporting a steeper (healthier) studies, 3 reported that greater religiosity pre- cortisol slope among Whites scoring higher on dicted lower future cortisol levels, and 1 study a 6-​item measures of R/​S coping (b =​−0.004, t =​ found a trend toward predicting higher corti- 3.28, p =​0.001, n =​641), but found no evidence sol. Of the 4 single-​group experimental stud- for an association in Blacks (b =​0.004, t =​ 0.9, ies that involved prayer therapy, meditation, p =​0.36, n =​59). Analyses were controlled for or the effects of religiosity on physiological age, education, race, smoking, atypical sleep responses to stress, 2 reported a positive effect schedule, medications, and protocol non-​ on reducing cortisol and 2 found no effect. Of adherence. Note that these cross-​ sectional the 8 RCTs, 4 reported a decrease in cortisol studies, here and earlier, cannot provide evilevels, 3 found no effect, and 1 reported mixed dence for causality because while religiosity results (lower and higher cortisol, depending may lower (or increase) stress hormones, it is on time frame). In addition, 3 meta-​analyses also possible that the experience of stress will of Buddhist-​based mindfulness, Hindu-​based lead people to (or away from) religion. meditation (including transcendental meditaSeveral prospective studies have also examtion), and Hindu-​based yoga reported signif- ined the religiosity-​ cortisol relationship. In icant reductions in cortisol, although two of describing these studies (as in most other 494 •  P h y sical H ealth

chapters), we make efforts to identify when predictors and outcomes were measured in order to assess the timing of effects that might provide evidence toward causal inference. The timing of measurement, however, in some studies was not provided. Turner-​Cobb et al. (2010) conducted a small study of 15 patients initially hospitalized with brain injury in the United Kingdom. They examined the effects of a 2-​item measure of RC on salivary cortisol that was measured on awakening, at noon, and at 6 p.m. and 9 p.m. Salivary cortisol was measured at four follow-​up times over 6 months and analyzed using repeated measures ANOVA. Results indicated that greater RC at baseline (T1) predicted lower T1 total cortisol output throughout the day (AUC, rho =​−0.69, p < 0.01, no controls, n =​15) and lower T1 diurnal cortisol change (rho =​−0.58, p < 0.05). RC at T1 also predicted T2 total cortisol output at the 6-​month follow-​up (rho =​−0.75, p < 0.05, n =​ 9), although it is not clear whether T1 cortisol output was controlled for in that analysis. In a second prospective study, Assari et al. (2015b) followed 227 Black adolescents over time, finding that frequency of participation in religious activities (assessed by a 5-​item scale) in 1994 (T1) predicted significantly lower salivary cortisol (average of 3 collected specimens after 11:00 a.m.) six years later in the year 2000 (T2) (b =​−0.283, SE =​0.021, p < 0.01). Analyses were controlled for age, parental employment, and intact family, and effects were particularly strong in males (b =​−0.368, SE =​0.031). T1 cortisol was not controlled for, thus preventing conclusions about the effects of religiosity on change in cortisol over time. As part of an RCT, Berk et al. (2015) examined the effects of baseline religiosity (using a 29-​item measure) on urinary cortisol levels assessed at four points in time over 6 months in 132 persons with chronic medical illness and major depression (see Bellinger et al., 2014). Growth curve models were used to analyze the data. There was borderline evidence that religiosity predicted a weak increase in urinary cortisol level over time (b =​0.001, SE =​0.001, t =​ 1.83, p =​0.07) independent of treatment group. In the final and fourth prospective study, Tobin and Slatcher (2016) analyzed data from a 10-​ year prospective study of 1,470 participants in

the MIDUS study, a national probability sample of US adults age 25–​74. Religious participation was assessed by attendance at religious services and participation in other religious groups in 1995–​1996 (T1), and salivary cortisol was measured in 2004–​2006 (T2). Also assessed at T2 was RC by a 4-​item measure of positive RC and a 2-​item measure of negative RC. Salivary cortisol was assessed at T2 on four consecutive days at four times each day (awakening, 30 min later, before lunch, and at bedtime). Multi-​level growth curve models were used to examine the effects of T1 religious participation and T2 RC on T2 cortisol slope, controlling for age, gender, education, waist circumference, race/​ethnicity, and average wake-​up time. T1 religious participation predicted a steeper (healthier) cortisol slope (b =​−0.002, SE =​0.001, p < 0.05) across the four days of saliva sampling at T2. Again, cortisol was not measured at T1, preventing determination of causal effects. Negative RC at T2 was inversely related to religious participation at T1, and served to mediate the observed relationship between religious participation at T1 and cortisol slope at T2. In the first of eight RCTs, Sahmeddini et al. (2014) randomized 60 Iranian pregnant primiparous women during the first stage of labor to either a religious intervention or a control group. During active labor, participants in the intervention group listened to the Qur’an being recited for 45 minutes using headphones, while the control group had no audio playing through the headphones. Serum cortisol levels were assessed before and after the intervention in both groups. Results indicated that the religious intervention reduced cortisol levels significantly more following the intervention compared to levels in the control group (101.5μg/​l [SD =​48.0] vs. 226.5 [SD =​105.8], p < 0.001). In the RCT referred to earlier that examined the effects of religious CBT (RCBT) vs. conventional CBT (CCBT) for depression in 132 persons with chronic medical illness (Berk et al., 2015), growth curve models indicated a weak trend toward a reduction of urinary cortisol over time in both groups (time effect B =​−0.03, SE =​0.02, p =​0.18, intent-​to-​treat analysis). However, no difference was found between the two treatment groups on urinary cortisol Stress Hormones • 495

change (group by time interaction B =​−0.04, SE =​0.03, t =​1.17, p =​0.25). A third RCT examined the effects of Buddhist-​based walking meditation on serum cortisol assessed after an 8-​ hour overnight fast, compared to a traditional walking exercise (control group) (Gainey et al., 2016). This small study involved 23 patients with type II diabetes age 50–​75 who were randomized to Buddhist walking meditation (n =​12) or the control group (n =​11). Both groups exercised on a treadmill for 30 minutes/​day three times/​week over 12 weeks. Results indicated significant within-​ group and between-​group differences favoring the Buddhist walking meditation group. Serum cortisol was reduced from 9.6 μg% (SE =​1.1) to 6.1 (SE =​0.5) in the intervention group compared to a change of 9.3 (SE =​0.08) to 8.9 (SE =​ 0.8) in the control group (p < 0.05 for difference between groups). A fourth study, a nonrandomized CT, involved 30 advanced cervical cancer patients nonrandomly assigned to either a religious logotherapy intervention (n =​15) or to a control group (n =​15) in Surakarta, Indonesia (Soetrisno et al., 2017). All participants received standard medical treatment for advanced cervical cancer, including radiotherapy and chemotherapy. Patients in the intervention group received religious logotherapy in six weekly 45-​minute sessions, whereas those in the control group received standard medical treatment only. Serum cortisol was measured before and after the intervention in both groups (few other details were provided). Results indicated a significant reduction in cortisol in the intervention compared to the control group (average between-​group difference =​7.6 [units unknown], 95% CI =​4.8–​9.5, p < 0.001). Finally, Kiran et al. (2017) conducted an RCT in 147 patients in India, average age 55, scheduled for elective coronary artery bypass graft (CABG) surgery. Within 24–​ 48 hours of surgery, participants were randomized to either an intervention group receiving Rajyoga meditation training (n =​73) or a standard pre-​ surgery counseling group (n =​74). Rajyoga meditation training was provided to both patients and their caretakers. Intervention group participants received three 30-​minute training sessions during which they received 496 •  P h y sical H ealth

counseling and were instructed to practice Rajyoga meditation each day before breakfast, lunch, and dinner for at least 10 minutes. Serum cortisol levels were measured at 8:00 a.m. on the morning of the day of surgery, on the second postoperative day, and on the fifth postoperative day. On the morning of surgery (T1), cortisol levels were similar in both groups (10.2 μm/​dl, SD =​1.9, vs. 11.1, SD =​ 3.0, p =​0.06). On the 2nd postop day (T2), both groups experienced an increase in cortisol level, but the average cortisol increase in the Rajyoga meditation group was significantly lower than in the control group (13.9μmg/​dl, SD =​1.7, vs. 17.6, SD =​3.2, p < 0.001). On the 5th postop day (T3), cortisol levels dropped in both groups compared to T2; however, cortisol levels in the control group were significantly lower than in the Rajyoga group (6.4, SD =​2.4, vs. 8.6, SD =​1.4, respectively, p < 0.001), indicating mixed findings depending on time of assessment. In summary, while the findings from observational and experimental studies reviewed here are promising, study designs varied widely using different measures of cortisol, assessed at different times during the day. Samples were often small and control variables in both cross-​ sectional and prospective studies were frequently inadequate. CATECH OL AM IN ES

Considerably less research exists on the relationship between religiosity and catecholamines (norepinephrine and epinephrine) compared to studies on religiosity and cortisol. Since 2010, we could locate only three cross-​sectional studies, one prospective study, one experimental study, one RCT, and one meta-​analysis of RCTs involving two studies of Eastern spiritual interventions (both involving Hindu forms of meditation). We review all of these studies below. Imamura et al. (2015) examined the association between religion-​related death beliefs (e.g., belief in life after death) and salivary 3-​ methoxy-​4-​hydroxyphenylgycol (sMHPG), a major metabolite of norepinephrine, in 346 community-​ dwelling older adults in rural Japan. No association was found between a

4-​item measure of belief in life after death and sMHPG level. Zangeneh et al. (2014) examined the association between fasting during Ramadan (an indicator of religiosity) and epinephrine/​ norepinephrine levels among 40 fasting and nonfasting women with polycystic ovary syndrome being seen at an infertility center in Iran. Serum levels of catecholamines were obtained before 8 a.m. on all participants. Results indicated significantly higher levels of both epinephrine and norepinephrine among the 20 nonfasting women compared to the 20 fasting women in uncontrolled analyses (epinephrine =​135 pg/​ml, SD =​98, vs. 99 pg/​ml, SD =​83, respectively, p =​0.15; norepinephrine =​1430 pg/​ml, SD =​404, vs. 1176 pg/​ml, SD =​439, respectively, p =​0.04). This finding, however, is consistent with reports that caloric restriction in general decreases SNS activity (see references above). The third and final cross-​ sectional study involved 132 depressed individuals with chronic medical illness participating in the RCT referred to earlier (Bellinger et al., 2014). The relationship between religiosity and urinary epinephrine and norepinephrine was examined during the baseline evaluation. Religiosity was assessed by a 29-​item scale that assessed frequency of religious attendance, private prayer, intrinsic religiosity, daily spiritual experiences, and RC. Results indicated that those with higher intrinsic religiosity, assessed by the 10-​ item Hoge intrinsic religiosity scale, had significantly lower urinary norepinephrine (OR =​ 0.94, 95% CI =​0.89–​0.99, p < 0.05). Analyses were controlled for age, education, gender, race, physical functioning, and severity of depressive symptoms. No association was found with epinephrine, nor were associations found between any other religious variables and norepinephrine or epinephrine. In the only prospective study we could identify, Berk and colleagues (2015) examined the effects of baseline religiosity on measures of urinary catecholamines assessed at baseline, 12-​week, and 24-​week follow-​up among 132 depressed participants in the RCT described above. Growth curve models indicated no effect of baseline religiosity on urinary epinephrine or norepinephrine levels during the 24-​week follow-​up.

The single-​group experimental study examined the effects of Hindu transcendental meditation (TM) on catecholamine levels in 5 experienced TM meditators in Grenada, Spain (Infante et al., 2010). Hourly blood samples for epinephrine and norepinephrine were obtained from 9:00 a.m. to 9:00 p.m., after participants had fasted for 12 hours prior to the 9:00 a.m. sample. Participants meditated for one hour between 12:00 noon and 1:00 p.m. using the TM-​ Sidhi technique. Both epinephrine and norepinephrine levels dropped to their lowest 12-​hour period level at 2:00 p.m., one hour after the meditation session. For epinephrine, the drop was from approximately 145 pg/​ml at 12:00 noon (pre-​TM) to 51 pg/​ml (SD =​8.7) at 2:00 p.m. For norepinephrine, the drop was from approximately 150 pg/​ml at 12:00 noon to 97 pg/​ml (SD =​8.7) at 2:00 p.m. Although the statistical inference for the change was not provided, researchers themselves drew the conclusion that TM had an effect on the sympathetic-​adrenal medullary system. In the only RCT we could identify (Berk et al., 2015), researchers found that both RCBT and CCBT for depression in 132 individuals with chronic medical illness decreased urinary epinephrine levels during the 24-​week follow-​up from baseline (time effect B =​−0.24, SE =​0.05, t =​4.51, p < 0.0001). There was a weak trend for RCBT to be more effective than CCBT in reducing epinephrine levels (group × time interaction B =​0.13, SE =​0.07, t =​1.88, p =​0.06, intent-​ to-​treat analysis). No difference between treatments was found for norepinephrine. Finally, a meta-​analysis of Eastern Hindu yoga/​ meditation techniques (Pascoe et al., 2017b) found only two RCTs that had examined effects on catecholamine levels, neither finding significant reductions compared to that in attention-​control groups (Curiati et al., 2005; Chhatre et al., 2013). In summary, there is little evidence to date that religiosity is associated with lower catecholamine levels or that R/​ S interventions reduce those levels (weak evidence from cross-​ sectional studies, no evidence from a single prospective study, and minimal evidence from a single-​group experimental study and one RCT). The quality of studies, however, has been relatively poor. Stress Hormones • 497

OX Y TO C I N

As noted earlier, oxytocin has been called the “anti-​stress” or “love” hormone because of its affiliation-​enhancing effects. We were able to locate seven cross-​sectional studies examining the relationship between religiosity and oxytocin (or oxytocin gene receptor polymorphism), no prospective or longitudinal studies, two experimental studies, and three RCTs. Two of the latter RCTs examined the effects of oxytocin on R/​S, but not vice versa. More recent experimental studies and RCTs have examined the effects of an R/​S intervention on oxytocin levels, although their quality has been relatively poor given small sample sizes. All studies identified are briefly described here. The first studies (to our knowledge) to examine the relationship with religiosity did not measure oxytocin level per se, but rather assessed polymorphisms of oxytocin receptor gene (OXTR), a gene that plays a significant role in the functionality of oxytocin in the body. There are at least seven single-​nucleotide polymorphisms (SNPs) of the OXTR gene: rs237878, rs237885, rs2268493, rs2268494, rs2254298, rs53576, and rs2268498. The most commonly studied SNP of the OXTR is rs53576. Individuals who possess two G alleles (compared to one or two A alleles) of the OXTR rs53576 have been shown to demonstrate more prosocial bonding, sociability, empathy, maternal-​type behaviors, and social sensitivity, all suggesting greater functionality of oxytocin (Kogan et al., 2011; Smith et al., 2014). Sasaki et al. (2011a) examined the relationship between religiosity and polymorphisms of the OXTR gene rs53576 SNP in 242 participants, 134 from South Korea and 108 from Southern California (average age 25). Religiosity was assessed using the 10-​ item Religious Commitment Inventory (Worthington). Psychological distress was measured using the Brief Symptom Inventory and the Perceived Stress Scale. Polymorphisms of the OXTR rs53576 gene were determined (AA, AG, GG) using a standard genotyping procedure. The distribution of these polymorphisms in the Korean sample was 42.5% AA, 41.0% AG, and 16.4% GG, and in the American sample, the distribution was 12.0% AA, 38.0% AG,

498 •  P h y sical H ealth

and 50.0% GG (this difference in distribution of genotypes is well-​known when comparing Asian vs. Western populations). There was no difference between European Americans and South Koreans on religiosity, and there was no association between religiosity and OXTR genotypes (average religiosity score was 3.05 in AA, 3.14 in AG, and 2.63 in GG). Next, these researchers examined whether the relationship between religiosity and psychological distress was moderated by an interaction between OXTR polymorphisms and Korean/​ American status. Hierarchical regression analyses revealed that religiosity was associated with less psychological distress in Koreans (b =​−0.19, p =​0.03), but with somewhat more distress in Americans (b =​0.17, p =​0.08). When examined by OXTR polymorphism status, results indicated no relationship between religiosity and psychological distress by Korean/​American status in those with AA or AG genotype (low-​ functioning OXTR). However, among those with GG genotype (high-​functioning OXTR), religiosity predicted less psychological distress in South Koreans (b =​−0.43, p =​0.04) and more psychological distress for Americans (b =​0.39, p =​0.004). In a later experimental study involving 110 American college students, Sasaki et al. (2015) reported that religious priming (vs. a neutral prime) increased self-​control behaviors for participants with the high-​functioning GG genotype more so than for those with the low-​ functioning AA/​ AG genotypes. Furthermore, this gene by religious priming interaction emerged only in a social context when participants were interacting face-​to-​face with each other. Results should be interpreted cautiously as sample sizes are small and especially small with regard to interaction analyses. In another cross-​ sectional study examining the relationship between religiosity and OXTR gene rs2254298 SNP, Anderson and colleagues (2017) examined 192 participants in New York City who were either at high risk (n =​96) or low risk (n =​96) for major depression. Importance of religiosity/​ spirituality (R/​ S) was assessed with a single question. Results indicated that after adjusting for age and gender, a significant association was found between high personal importance of R/​S and presence of the OXTR minor A allele (AA or AG)

in the low-​risk group (b =​0.527, p =​0.02), but not in the high-​risk group. Note that the GG genotype of the rs2254298 SNP (in contrast to the GG genotype of rs53576) has been associated with a dismissing attachment style, belief that relationships are of secondary importance, and lower empathic concern (Costa et al., 2009; Montag et al., 2012). This is the opposite of that described for the prosocial GG genotype of the OXTR rs53576. In a third cross-​sectional study, which again did not actually measure oxytocin, Fisher and colleagues (2015) examined the relationship between R/​S and personality traits typically associated with high serum levels of oxytocin (i.e., prosocial and empathetic). This study analyzed data on 34,831 individuals identified from US and European Internet dating sites on whom information on personality traits and R/​S was available. Religiosity was assessed by a single question asking whether the participant identified with a particular religion. If yes, they were considered religious; if no, they were considered nonreligious. The nonreligious category included agnostics, atheists, no religious affiliation, and those indicating they were “spiritual but not religious.” Results indicated that self-​identified religious persons were 50% more likely to have psychological traits characterized as prosocial or empathic (OR =​1.50, 95% CI =​1.40–​1.50). Researchers concluded that religious persons were more likely to report traits indicating greater caring or nurturing, qualities associated high levels of oxytocin. In one of the first studies to actually measure oxytocin levels, Kelsch et al. (2013) cross-​ sectionally examined the relationship between spirituality and serum oxytocin levels in 79 HIV-​positive individuals in Florida. Spirituality was assessed by a single question measuring self-​ rated spirituality and by the Ironson-​ Woods Spirituality/​Religiosity Scale. Spiritual transformation was also assessed based on whether the person had ever had a life-​changing spiritual experience. Greater spirituality was positively associated with oxytocin levels (r =​ 0.27, p =​0.02). Spiritual transformation was also related to greater oxytocin levels (r =​0.26, p =​0.02). Researchers reported that the median oxytocin levels in those who had experienced a

spiritual transformation was twice as high as in those who had not. In a second cross-​sectional study, Holbrook et al. (2015) examined the relationship between spirituality and salivary oxytocin in 34 college students (devout Christians, average age 22 years) attending Brigham Young University in Utah. Spirituality was assessed by a single question asking about the extent to which the participant considered him-​or herself a spiritual person. Also assessed was frequency of religious attendance. Results indicated that spirituality was significantly and positively related to salivary oxytocin level (b =​2.44, SE =​0.90, p =​0.01), after controlling for frequency of attendance, positive affect, gender, and relationship status. In fact, spirituality was the only characteristic significantly related to oxytocin level. In another cross-​sectional study, Imamura and colleagues (2017) examined the relationship between “belief in life after death” and serum oxytocin level in 317 healthy adults age 65 or older in rural Japan. Although not measured in this study, the primary religions in Japan are Shintoism and Buddhism. Belief in life after death was assessed by a 4-​item measure of this construct. Controlling for age, gender, loss of spouse, living with family, and delayed recall, results indicated that belief in life after death was associated with lower levels of serum oxytocin (b =​−0.006, SE =​0.002, p =​ 0.006). These results are the opposite of those reported by Kelsch et al. (2013) and Holbrook et al. (2015). Researchers explained this finding based on the possibility that higher oxytocin levels during relational distress may serve to promote the re-​establishment of relationships between people. Older people in Japan who believe in life after death may have less desire for affiliation or show less social affiliation because they have formed secure attachments with covert figures in the afterlife. This finding illustrates how religious culture may impact the relationship between religious belief and oxytocin level. In the last cross-​sectional study, Tønnesen and colleagues (2019) examined the relationship between religiosity and serum levels of neuropeptide Y (NPY) and oxytocin in 60 healthy female California college students (average age 21). NPY is present throughout Stress Hormones • 499

the central nervous system and plays an important role in promoting psychological well-​being, anxiety regulation, and resilience to stress. Religiosity was assessed by the 10-​ item Religious Commitment Inventory (Worthington), which consists of intrapersonal and interpersonal religious commitment subscales. Results indicated a significant association between overall religiosity and NPY (r =​ 0.26, p < 0.05) and a weak borderline positive association with oxytocin (r =​0.24, p =​0.07). Analysis of subscales revealed that intrapersonal religious commitment was significantly related to oxytocin (r =​0.29, p < 0.05), whereas interpersonal religious commitment was also related to oxytocin but only at a trend level (r =​0.26, p =​0.05). None of these analyses was controlled for potential confounders. At least two RCTs have examined the effects of intranasal oxytocin injection on spiritual beliefs and feelings. In the first study, Van Cappellen et al. (2016) randomized 83 men age 35–​64 to either an intervention that involved intranasal oxytocin administration (three full sprays of intranasal oxytocin in each nostril; n =​41) or to a control group that received a placebo (n =​42). A single question asked about importance of spirituality in life (spiritual importance). Also administered was the 18-​item spiritual transcendence scale (STS; Piedmont). Change in spirituality as assessed by the single-​item measure, and the STS was the primary outcome in this study. Also examined were the modifying effects that polymorphisms of the OXTR gene (rs53576) and CD38 gene (rs6449283 and rs3796863) might have on the spirituality-​inducing effects of oxytocin. Results indicated that intranasal oxytocin significantly increased spirituality in terms of both spiritual importance and scores on the STS. This effect persisted for at least 1 week afterward based on the spiritual importance item. The effect on spirituality was found to be moderated by oxytocin genotypes. For the OXTR rs53576 SNP, individuals with AA or AG genotype demonstrated a significant increase on the STS measure in response to intranasal OT (vs. the placebo control condition), whereas those with the GG genotype did not increase significantly. Researchers acknowledged that prior research had shown 500 •  P h y sical H ealth

that individuals with the GG genotype usually had a better response to either exogenous or endogenous OT, making these findings preliminary. In a second RCT, Cortes and colleagues (2018) attempted to replicate the findings of Van Cappellen et al. (2016). This study, conducted in Sweden, involved 116 men and women (average age 27, 51% women), with 59 randomized to the intranasal oxytocin group and 57 to the placebo group. Religiosity, spirituality, mysticism, “sensed presence,” and “absorption” (hypnotizability) were measured using established scales. Religiosity was assessed by a 6-​item scale (Granqvist), spirituality by Piedmont’s STS, mysticism by a 30-​ item scale (Hood), sensed presence by a 3-​item scale (Persinger, authors), and absorption by a 34-​item scale (Tellegen). Results indicated no effect of intranasal oxytocin on increasing spirituality, mysticism, sensed presence, or absorption. Likewise, none of the oxytocin-​ related genotypes (OXTR rs53576 or CD38 rs3796863) moderated these relationships. However, an interaction with absorption was found. Among those with low absorption scores, oxytocin significantly increased spirituality relative to placebo, whereas among those with high absorption scores, oxytocin significantly decreased spirituality relative to placebo (thus canceling out each other in the overall analysis). Religiosity was only examined as a control or moderating variable in analyses examining the effects of oxytocin on spirituality (with no moderation by religiosity). A single-​group experimental study and an RCT have more recently examined the effects of a religious or spiritual intervention on oxytocin levels. In the experimental study, Machida et al. (2018) examined the effects of a Zen Buddhist meditation intervention on salivary oxytocin in 32 healthy participants average age 46 in Japan; the majority of participants were experienced meditators. The meditation focused on altruism and appreciation (Arigato breathing, gratitude Zen, joyful Zen, and nirvana Zen). Oxytocin levels were assessed before and after the 1-​hour intervention. Results indicated that salivary oxytocin levels significantly increased from 66.3 pg/​ml (SD =​6.7) to 90.6 pg/​ml (SD =​ 18.7) (p =​0.03).

In the RCT, Mehr and colleagues (2020b) in Iran randomized 15 women with breast cancer (clinical stage 1 or 2) to twelve 90-​minute sessions of a distinctively Muslim spiritual/​ religious intervention, to twelve 90-​ minute sessions of a non-​psychological training intervention focused on physical care, or to a non-​ intervention control group (5 participants each). In this highly underpowered study, no difference was found between the two interventions (or each other) and the control group on serum oxytocin levels assessed at baseline, immediately following the intervention, and at 3-​month follow-​up. In summary, there is some cross-​sectional evidence that religiosity is related to higher levels of salivary or serum oxytocin or oxytocin-​ related personality traits. Among the four studies that actually measured oxytocin, the three reported significantly higher levels of oxytocin in those who were more R/​S, whereas the last study conducted in a Japanese sample reported lower oxytocin levels among those with belief in life after death (likely based on religious cultural factors). Greater R/​ S also appears to be related to the presence of more affiliation-​ related prosocial polymorphisms of the OXTR gene, although the findings are not consistent. Whether intranasal oxytocin increases spirituality or spiritual-​like experiences remains unknown based on two RCTs with conflicting results. The two experimental studies examining the effects of R/​S interventions on oxytocin levels have likewise reported inconsistent results. Thus, much remains unknown about how R/​S beliefs or practices impact oxytocin level (or vice versa), although there is some suggestion of a relationship.

RECOMMENDATIONS FOR RESEARCH As described earlier, there are reasonable explanations for why greater religiosity ought to be related to lower levels of stress hormones (cortisol, epinephrine, and norepinephrine) and higher levels of anti-​stress hormones (e.g., oxytocin). The research suggests that, in general, those who are more religious have lower levels of stress hormones (perhaps especially cortisol) and higher levels of oxytocin. However,

most studies are of low quality, there are few prospective studies, and even fewer experimental studies or RCTs examining Western religious interventions. Furthermore, the few prospective studies available often did not control for baseline stress hormones. Eastern spiritual interventions (Hindu meditation, yoga practices, and Buddhist-​ based meditation/​ mindfulness), in contrast, have been relatively consistent in lowering levels of stress hormones, particularly cortisol, although effects in general are relatively weak. There remain large research gaps that need filling, particularly with regard to examining the effects of traditional forms of religious involvement (attending religious services, personal prayer, scripture reading, religious volunteering) on stress hormone levels. We now make several recommendations in this regard. First, as usual, prospective studies are needed to examine the effects of religiosity on stress hormone levels, particularly studies that control for baseline concentrations and thus are able to determine effects on change in hormone levels over time, providing better evidence for causal inference. However, this does not mean that cross-​sectional studies are of no use, since establishing that an association exists (and whether positive or negative) may serve as the basis for future prospective studies. Some of the cross-​sectional studies have suggested an association, but these studies cannot provide evidence for causality because while religiosity may lower (or increase) stress hormones, it is also possible that the experience of stress will lead people to or away from religion. An example of needed studies (both cross-​sectional and prospective) are those that examine stress hormone levels in religious and nonreligious “first responders” such as police, firefighters, and emergency medical technicians, since these individuals tend to have higher baseline levels of stress hormones that may adversely affect their future health (Planche et al., 2019). The same applies to individuals in other high-​stress occupations, including current and former military personnel involved in combat operations. Likewise, studies are needed in older adults experiencing multiple stressors that increase their baseline stress hormone levels. Whether cross-​ sectional or prospective, studies must Stress Hormones • 501

carefully control for age, gender, race, and socioeconomic status, each of which is related to both religiosity and stress hormone levels. Second, particular attention must be paid to the time of day when hormone levels are measured, given their diurnal fluctuations, and method of assessment (serum, urinary, salivary) since some methods are less sensitive than others (see below) (El-​Farhan et al., 2017). Hormone concentrations are heavily dependent on psychological and social stressors, and on the time interval since stressors have occurred; this must be considered when interpreting results. Complex feedback loops exist between stress hormones levels, brain areas responsible for hormone production and release, and brain receptors that may be up-​or down-​regulated depending on whether stressors are acute or chronic. Thus, researchers must learn to negotiate the ongoing dynamics of HPA-​axis and SNS responses to stress over time that ultimately determine the level of stress hormones in the body. Such concerns pose particular problems for observational (vs. experimental) studies when examining the effects of religiosity on stress hormone levels. Third, as indicated above, methods of assessing stress hormones must be carefully considered, balancing cost and accuracy. Cortisol and catecholamine levels in urine may be less accurate because of difficulty obtaining complete 12-​ hour or 24-​ hour urine collections, thus affecting the power to detect effects due to measurement error. The accuracy of measurement methods that determine stress hormone levels in urine (vs. serum or saliva) may also be an issue. Unfortunately, the cost of obtaining serum hormone levels is substantially higher than for urine or saliva, due to handling costs and the need for medical personnel to draw blood. Obtaining adequate funding for studies on religiosity may be a challenge, requiring researchers to seek to insert religious measures into existing studies designed for other purposes. Finally, there is need for RCTs designed from the very start to determine the effects of religious interventions on cortisol, epinephrine, norepinephrine, and oxytocin levels. As repeatedly emphasized throughout this volume, RCTs are a more definitive way to 502 •  P h y sical H ealth

determine whether religious practices actually affect physical health, including stress hormone levels. While numerous Eastern meditation studies have reported reductions in these hormones, almost no such studies based on Western religious traditions have been published thus far. Studies examining the effects of religiously integrated psychotherapy on stress hormone levels in highly distressed, anxious, or depressed individuals, those in whom cortisol and epinephrine/​norepinephrine are known to be elevated, is an example of the type of research needed. Serving as a model for such studies is Berk et al.’s (2015) description of an RCT examining the effects of religious vs. conventional CBT on stress hormone levels in medically ill depressed patients. However, that study had limitations that may have affected results, including issues related to weaknesses in methodology. Correction of these issues in future RCTs is needed to increase the accuracy of findings. Experimental studies conducted under laboratory conditions that examine changes in hormone levels when religious and nonreligious individuals are placed in highly stressful situations are also needed. Smaller samples are usually needed for such studies and lower budgets as well, although the experience of those who conduct such studies, and of their staff, is crucial. In summary, much further research is needed to better understand if, how, in whom, and under what conditions religious belief and activity impact stress hormone levels. Type and intensity of religious belief and commitment may be important in this regard. Religious interventions using a patient-​ centered approach (i.e., based on the patient’s own religious tradition) are needed to help correct abnormal levels of stress hormones that may be present in vulnerable individuals encountering frequent life change and trauma. Nevertheless, there is preliminary information from research already done (summarized above) that warrants at least tentative steps toward clinical application.

CLINICAL APPLICATIONS How might knowledge about the relationship between religiosity and stress hormones,

and the effect that religious beliefs/​practices of this type must be done in a respectful and may have on levels of cortisol, epinephrine/​ patient-​ centered manner, not a clinician-​ norepinephrine, and oxytocin, be relevant to centered one. interactions that patients have with healthcare professionals and clergy?

Religious Professionals

Applications also exist for clergy, who might consider educating those who come to them Medical and psychiatric patients are constantly for pastoral care about stress responses and facing stresses related to traumatic life events the physiological changes that occur as a result involving themselves or loved ones, and/​or life-​ in the body (increases in cortisol, epinephrine, limiting symptoms of pain or disability that norepinephrine, and decreases in oxytocin), adversely affect their health and well-​ being. thereby increasing risk of disease and disability. Psychological and social stressors, either acute This includes emphasizing religious practices or chronic, impact levels of stress hormones in that may help to reduce stress hormone levels, the body that, in turn, impair immune func- such as prayer or engaging in spiritual forms tions (increasing risk of infection and cancer), of meditation, and encouraging affiliation-​ influence levels of inflammation in the body, type prosocial activities that may increase the elevate blood pressure, lead to coronary heart anti-​ stress hormone oxytocin, activate the disease, induce cardiac arrhythmias, and con- PNS, and deactivate the SNS. As recommended tribute to the development of cerebrovascular for healthcare professionals, this may involve disease (e.g., stroke and dementia). Thus, cli- encouraging individuals to take time to nournicians must seek ways to reduce stress hor- ish their trust in, dependence on, surrender to, mones (cortisol, epinephrine, norepinephrine) and love of the Divine, or to engage in prosoand increase anti-​stress hormones (oxytocin), cial altruistic activities that involve expressing or return them to healthier homeostatic levels love and care for fellow congregants or needy following psychosocial or physical stressors. As individuals outside the religious community. noted above, one of those ways may be through Religious professionals may do so when (a) religion. counseling individuals in private pastoral care As usual, all clinical interventions begin by sessions, (b) providing sermons to the entire taking a spiritual history, which is intended congregation, or (c) conducting special educato identify whether the patient has religious tional programs held in the church, mosque, resources that may be helpful in coping with temple, or synagogue. stressful circumstances, which may impact Clergy who feel that they do not have the stress hormone levels. Once such resources are expertise or knowledge to explain the physioidentified, then clinicians may choose to sup- logical processes involved in the stress response port and encourage their use. This may involve and/​or to describe the negative impact of psyattending religious services, engaging in reli- chological or spiritual distress on the body gious community activities with one another, may also consider inviting medical, nursing, seeking support from members of that com- or mental health professionals to provide premunity, and in particular, providing support to sentations on this topic, particularly those who those members as well. This may include partic- will endorse religious ways to counteract that ipation in religious forms of volunteering and distress. This may help motivate individuals other pro-​social community activities. Private to alter negative health behaviors that may religious activities such as prayer or meditation increase stress hormone levels or to engage might also be encouraged: Christian prayer/​ in religious practices that reduce the bad hormeditation for Christians, Muslim prayer for mones and increase the good ones. In this way, Muslims, Jewish prayers for Jews, and Eastern religious professionals can help to enhance the forms of focused meditation, mindfulness, mental, physical, and spiritual health of those yoga, and prayer for Hindus and Buddhists. As who come for pastoral care, and this in turn may repeatedly noted in this book, interventions improve the health of the entire congregation.

Healthcare Professionals

Stress Hormones • 503

SUMMARY AND CONCLUSIONS We have focused in this chapter on the relationship between religious involvement and stress hormones, particularly cortisol, epinephrine, norepinephrine, and the anti-​ stress hormone oxytocin. Physiological responses to acute and chronic stress were first described, and then specific stress hormones were reviewed and changes when responding to stress were discussed. This was followed by a description of how stress hormones impact the immune system, and vice versa. Next, factors that influence levels of cortisol and catecholamines in the body were described, including demographic, biomedical, psychological (stress, depression, anxiety, positive emotions), social support, and health behaviors (cigarette smoking, alcohol consumption, physical activity, sleep, diet, and weight). A case vignette was then described of a

504 •  P h y sical H ealth

young schoolteacher who ultimately found that engagement in a religious community helped to reduce her stress and improve her physical resilience. We speculated on how religious involvement might impact stress hormones acting through the psychological, social, and behavioral pathways known to affect stress hormone levels. The heart of this chapter, as usual, involved a description of early and more recent research examining the relationship between religiosity/​ spirituality and levels of cortisol, epinephrine, norepinephrine, and oxytocin, and the impact of religious/​spiritual interventions on these hormones. This was followed by recommendations for future research and suggestions for clinical application by healthcare and religious professionals. In the next chapter, we focus on the role that religious involvement plays in the prevention and course of a medical condition affected by both immune and endocrine systems: cancer.

26 Cancer Cancer is a word, not a sentence. —​Author unknown

NO OTHER MEDICAL diagnosis evokes more fear than cancer. The thought of cancer brings forth images of pain, disability, loss of hair, uncontrolled bodily functions, fatigue, isolation, and imminent death. As indicated in Chapter 4, many people use religious beliefs to cope with their immediate emotional response when learning about a diagnosis of cancer. For many, their religious faith also enables them to live through or live with this dreaded diagnosis. In this chapter, our focus is not on the role that religion plays in helping people cope with cancer, but rather on the effect that religious involvement has on the risk of developing cancer, and if that occurs, the impact that it has on the course of disease over time. Are religiously active people as likely to develop cancer as those who are less religious? Do religious beliefs and practices affect the spread of cancer? Does religiosity affect the length of survival among those with cancer? These are the questions that this chapter will address. But first, let us review

what we know about cancer—​how common, how deadly, and how costly it is. We will then review demographic, genetic, biomedical, environmental, psychological, social, and behavioral factors that influence the development and course of cancer. Of particular interest here are psychological, social, and behavioral factors that might be affected by religious beliefs, commitments, and practices.

PREVALENCE AND COSTS OF CANCER In 2005, the prevalence of cancer in the United States was 11.1 million, i.e., 3.6% of the population had a history of cancer. By 2016, that figure had increased to 15.5 million, or 4.8% of the population (Bluethmann et al., 2016). In 2019, there were 1,762,450 new cases of cancer diagnosed in the United States, and an estimated 607,000 people were expected to die of cancer (Siegel et al., 2019). Of deaths

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0026

from cancer, approximately half (45%) are due to modifiable risk factors (cigarette smoking, being overweight or obese, alcohol intake, physical inactivity, unhealthy diet) (Islami et al., 2018). The incidence of new cancer diagnoses remained stable in women between 2006 and 2015, but increased by 2% per year in men. The death rate from cancer declined 1.4% annually for women and 1.8% for men between 2007 and 2016, likely due to improved treatments. The most common newly diagnosed cancers in 2019 were breast cancer (268,600), lung cancer (228,150), prostate cancer (174,650), colorectal cancer (145,600), and melanoma (96,480) (American Cancer Society, 2019). Worldwide in 2015, cancer was either the first or the second leading cause of death before age 70 in 91 of 172 countries (Bray et al., 2018). In 2018, cancer was the second leading cause of death in the United States, barely behind cardiovascular disease, and was expected to soon eclipse it (Xu et al., 2020). Cancer is now the leading cause of death in several other high-​income countries such as Canada, Saudi Arabia, Sweden, and the

United Arab Emirates (Dagenais et al., 2020). Incidence and 5-​year survival rates for the most common cancers are presented in Table 26.1 (National Cancer Institute, 2020a). In 2018, the estimated national expenditures for cancer care in the United States varied by cancer site, ranging from $1,543,900,000 for cervical cancer to $19,700,000,000 for female breast cancer (National Cancer Institute, 2020b).

DETERMINANTS OF CANCER In this section we examine the demographic, genetic, biomedical, environmental, psychological, social, and behavioral factors that affect the risk of developing cancer and that influence disease course.

Demographic Older age increases the risk of developing cancer. This is thought to be a result of the increasing senescence of the immune system with age. Three-​quarters (77%) of all cancers develop in

Table 26.1  Five-​Year Survival Rates for Different Types of Cancer (All Stages) for the Period 2010–​2016 in United States C A NC E R S I T E

A N N UA L I N C I DE N C E ( PE R 1 00,0 00)

Breast Lung and bronchus Prostate Colon and rectum Melanoma Lymphoma Urinary bladder Kidney Thyroid Uterus (body) Leukemia Pancreas Oral cavity and pharynx Cervix All cancers

68.9 54.2 50.2 38.2 22.7 22.2 20.0 16.3 15.7 14.8 14.1 13.1 11.4 3.8 442.4

5- ​Y E A R S UR V I VA L R AT E (% ) TO TA L

ME N

WOME N

90.0 20.5 97.8 64.6 92.7 74.6 76.9 75.2 98.3 82.7 63.7 10.0 66.2 66.1 67.4

83.6 17.1 97.8 64.0 91.1 73.5 78.3 74.5 95.9 —​ 64.6 10.0 65.6 —​ 66.4

90.0 24.2 —​ 65.1 94.8 76.0 72.4 76.3 98.9 82.7 62.4 10.0 67.7 66.1 68.5

Source: National Cancer Institute (2020a). Cancer survival statistics. National Cancer Institute: Division of Cancer Control and Population Sciences (https://​seer.can​cer.gov/​csr/​1975_​2​017/​res​ults​_​mer​ged/​top​ic_​s​urvi​val.pdf).

506 •  P h y sical H ealth

persons age 55 or older, and this is particularly true for cancers of the breast, colon, and prostate. Indeed, experts have noted that over 90% of men over age 90 have cancer cells in their prostate (Garnick, 2009). Gender differences in cancer risk are also commonly found, with men at considerably greater risk than women. For example, when examining cancer incidence data from five continents provided by the International Agency for Research on Cancer, Edgren et al. (2012) reported that the incidence of cancer was significantly higher in men than in women for 32 of 35 cancer sites. Whether race plays a role remains uncertain, to at least some degree. Investigators have reported greater colorectal cancer incidence and death rates (Siegel et al., 2014), higher prostate cancer death rates (Benjamins et al., 2016), and lower cancer survival overall (Ward et al., 2004) in Blacks compared to Whites in the United States. However, other researchers have found no significant difference in incidence or death rate from cancer between Blacks and Whites. For example, DeSantis et al. (2016) found that the lifetime probability of being diagnosed with cancer among Black men and Black women in the United States in 2016 was 41% and 34%, respectively, compared to 42% and 39%, respectively, in Whites. Similarly, the death rate from cancer among Black men and Black women was 23% and 19%, respectively, compared to 23% and 20% in White men and White women, respectively. Whether or not researchers find a difference based on race may depend on the particular cancer and the particular study location. For example, Benjamins et al. (2016) found that the death rate from prostate cancer in Blacks was higher than Whites in Los Angeles, but not in Minneapolis. Socioeconomic status (SES) also makes a difference in terms of developing and dying from cancer (as well as in explaining differences by race) (Ward et al., 2004; Hastert et al., 2016). The effects of SES in this regard are thought to be largely a result of poor health behaviors or increased risk of exposure to carcinogens based on living and work circumstances.

Genetic Most cancers result from damage to genes that occur during one’s lifetime, not from inherited

genes. Genetic risk factors vary widely by cancer type, and only about 5% of cancers have a strong hereditary component. Breast cancer is one of those. The number of first-​degree relatives (parent, sibling, or child) with breast cancer substantially increases risk of developing the disease. A woman with only one first-​ degree relative has an 80% increased relative risk (RR) of breast cancer (RR =​1.80, 95% CI =​1.70–​1.91); if two first-​degree relatives have breast cancer, the risk increases nearly 3-​fold (RR =​2.93, 95% CI =​2.37–​3.63); and if three first-​degree relatives have it, the risk is nearly 4-​ fold (RR =​3.90, 95% CI =​2.03–​7.49) (Rousset-​ Jablonski & Compel, 2017). Nevertheless, inherited mutations of the BRCA1 and BRCA2 genes (the most common genes that increase risk) account for only about 5%–​10% of all breast cancer cases (Nelson et al., 2014). As with breast cancer, a family history of prostate cancer in a first-​ degree relative increases the risk of developing the disease in men by 2-​fold to 3-​fold, and this risk increases by number of first-​ degree family members affected; however, only 5%–​10% of prostate cancers are considered hereditary (Giri & Beebe-​Dimmer, 2016). With regard to colorectal cancers, again, the risk is increased by 2-​fold to 3-​fold in those with a first-​degree relative who has the cancer (or colorectal polyps); again, while about 20% of colorectal cancer patients have an affected relative, less than 10% are due to inherited gene mutations (Graff et al., 2017). Genetic susceptibility also plays a role in lung cancer, especially in those who develop the condition at a younger age (true also for prostate and breast cancers). However, only a few specific inherited gene mutations or other genetic factors have been identified that increase lung cancer risk (Kanwal et al., 2017). Other factors are clearly responsible for the majority of cancers.

Biomedical Medical treatments can increase risk of several cancers. For example, high-​ dose radiation to the chest when treating breast cancer can increase risk of lung cancer (Huang et al., 2017). Likewise, the risk of breast cancer is increased after radiation therapy to the chest Cancer • 507

for lymphoma (Krul et al., 2017). Post­meno­ pausal hormone replacement therapy increases the risk of breast cancer, especially estrogen-​ dependent tumors (Wang et al., 2017). Some medications, though, can actually decrease cancer risk. For example, nonsteroidal anti-​ inflammatory drugs such as aspirin or ibuprofen may reduce the risk of colorectal cancer, or at least increase the likelihood of early detection (Cao et al., 2016; Tomic et al., 2019).

Environmental Environmental causes include exposure to chemicals or radiation at work or home, or to cancer-​ causing agents in food or household chemicals. Likewise, cancer risk is increased by exposure to chemicals such as radon or asbestos, metals such as chromium, cadmium, or arsenic, and secondhand smoke or air pollution (lung cancer). Approximately 2%–​5% of cancers are due to occupational exposures, although estimates vary widely, depending on the definition of such exposures (Colditz, 2009). Environmental pollutants, such as asbestos from insulation in homes, air pollution, secondhand smoke, and radon from indoor air, may account for as many as 11% of lung cancers in Europe, while chlorination byproducts in water increase risk of bladder cancer (Boffetta, 2006). Exposure to ultraviolet radiation, polycyclic aromatic hydrocarbons, volatile organic compounds such as benzene, and heavy metals increases the risk of skin cancer (Baudouin et al., 2002). Adverse childhood experiences, particularly physical abuse, may also affect cancer risk (Morton et al., 2012; Ports et al., 2019). In the Health and Retirement Study, the largest and most representative panel study of older adults in the United States, Kemp and colleagues (2018) found that two or more parental risk behaviors (e.g., physical abuse by a parent, a parent with alcohol/​substance abuse issues, a parent who smoked before age 18) were associated with a higher likelihood of cancer in later life, independent of adult health and socioeconomic factors. Gene-​environment interactions are likely responsible for many cancers, particularly breast, colorectal, and lung cancer (Carbone et al., 2020). 508 •  P h y sical H ealth

Psychological Psychological factors are known to influence the development and course of cancer. We briefly review here the research for psychological stress, depression, anxiety, and their opposite, positive emotions. P SYCH OL OGICAL STRESS

A meta-​analysis of 165 studies by Chida and colleagues (2008) discovered that stress-​ related psychosocial factors predicted a higher cancer incidence in healthy populations (HR =​ 1.06, 95% CI =​1.02–​1.11, p =​0.005); a greater risk of dying from cancer (HR =​1.03, 95% CI =​ 1.02–​1.04, p < 0.001); and a greater risk of dying from all causes (HR =​1.29, 95% CI =​ 1.16–​1.44, p < 0.001). In a later meta-​analytic review of 11 prospective studies, Bahri et al. (2019) reported that a history of stressful life events increased the risk of breast cancer by more than 10% among women (RR =​1.11, 95% CI =​1.03–​1.19). The effect of stress on cancer risk is even greater when stress is chronic and continues over time. For example, in a case-​ control study of 582 young women (≤ 40 years old) with early-​onset breast cancer and 540 young controls with benign breast disease, P. Li et al. (2016) reported that chronic marital stress (a disharmonious marital relationship) predicted a 16% increased risk of being in the early-​onset group (OR =​1.16, 95% CI =​1.06–​ 1.26), independent of other risk factors. Antoni and Dhabhar (2019) have explained the physiological mechanisms underlying the increased cancer risk with chronic stress. They argue that the adverse effects of chronic stress on immune function lead to an increased risk of developing cancer and a poorer cancer prognosis. The existence of cancer itself is evidence that the immune system has failed to prevent the initiation and progression of the disease. Chronic psychological stress leads to suppression of protective immunity, to induction or exacerbation of chronic inflammation, and to enhancement of immunosuppressive mechanisms. Increased catecholamine levels and changes in cortisol levels and cortisol receptor sensitivity in chronic stress promote carcinogenesis and cancer metastasis (Moreno-​Smith

et al., 2010; Antoni & Dhabhar, 2019). Pro-​ inflammatory cytokines and other inflammatory markers (e.g., IL-​ 6, IL-​ 1β, CRP) are elevated during chronic stress, which increases cell growth and survival by activating oncogenes, inhibiting tumor-​suppressor genes, and promoting angiogenesis (tumor vasculature) and tumor microenvironment, all leading to the growth and spread of the cancer (Sephton et al., 2009; Antoni & Dhabhar, 2019). Chronic stress-​induced changes in cortisol add to the effects of catecholamines in suppressing cell-​ mediated immunity necessary to stop cancer onset and spread (Sephton et al., 2009). D E P RE SS I O N AND ANXIE T Y

In a meta-​ analysis of 76 prospective studies involving 105 samples, Pinquart and Duberstein (2010) reported that a depression diagnosis and high levels of depressive symptoms both predicted an increase in cancer mortality, elevating mortality when depression was assessed either before cancer diagnosis or after diagnosis, independent of confounding physical health factors. In the P. Li et al. (2016) study above, negative emotional experiences of all types were also found to increase the risk of developing early-​onset breast cancer. This is especially true when depression is both extended in duration (dysthymia) and severe (major depression). In a meta-​analysis of 25 studies involving 1,469,179 participants and 89,716 incident cases of cancer, depression predicted a 15% increased future risk of cancer overall (RR =​1.15, 95% CI =​1.09–​1.22), especially liver cancer (RR =​1.20, 95% CI =​ 1.01–​1.43) and lung cancer (RR =​1.33, 95% CI =​1.04–​1.72) (Jia et al., 2017). For example, in patients with ovarian cancer, depression is known to suppress natural killer cell cytotoxicity and T-​ cell cytokine production necessary for cancer containment (Lutgendorf et al., 2008). Research also indicates that anxiety increases the risk of cancer progression in animal models (Dhabhar et al., 2012), and similar effects are thought to occur in humans. In a meta-​analysis of 51 cohort studies involving 2,611,907 participants with a mean follow-​up of 10.3 years, Wang et al. (2020) found that depression and

anxiety combined predicted a 13% increased risk of developing cancer (adjusted RR =​1.13, 95% CI =​1.06–​1.19), a 21% increased risk of dying from cancer (RR =​1.21, 95% CI =​1.16–​ 1.26), and a 24% risk of dying from any cause in patients with cancer (RR =​1.24, 95%=​1.13–​ 1.35). Cancers of the lung, oral cavity, skin, and prostate were especially more likely to develop in those with both increased depression and anxiety. Among patients with breast cancer, lower anxiety prior to surgery predicts a greater production of IL-​2 after T-​cell receptor stimulation, indicating a healthier immune response and at least potentially slower disease progression (Blomberg et al., 2009). Antoni and Dhabhar (2019) note that when life stressors occur—​including the diagnosis of cancer and stressors related to its treatment—​this contributes to faster tumor growth and metastasis, an effect that may be especially strong in those with inherited or acquired high trait anxiety. P OSITIVE EM OTION S

In contrast, positive emotions such as having hope and optimism may affect susceptibility to cancer or course of cancer in the opposite direction. Loss of hope, a prominent symptom in severe depression, has been associated with both the development of cancer and a worsening course of disease, possibly mediated by proinflammatory cytokines (Antoni & Dhabhar, 2019). For example, Everson and colleagues (1996) followed 2,428 men age 42–​60 over 6 years, examining the effects of hopelessness on mortality from various causes. A dose-​response relationship was found between hopelessness and cancer mortality with over a 2-​fold increased risk for moderate hopelessness (relative hazard [RH] =​2.25, 95% CI 1.10–​4.58) and an even greater increase for high hopelessness (RH =​2.61, 95% CI 1.03–​6.64). Adjusting analyses for other risk factors did not change these findings. Likewise, Watson and colleagues (2005) followed 578 patients with early-​stage breast cancer for 10 years, finding that cancer deaths or recurrences were over 50% more common among women who initially scored high on helplessness/​ hopelessness, independent of Cancer • 509

other predictors (OR =​1.53, 95% CI 1.11–​2.11). Similarly, Lehto and associates (2007) followed 59 patients with localized melanoma for 7 to 10 years, finding that hopelessness again predicted shorter survival times. More recently, hopeful breast cancer patients demonstrated higher cytotoxic T-​ cell (CD8+​) proliferation than those who were not hopeful, suggesting that a hopeful attitude improves cellular immunity, which may have explained their longer survival (S.  Kim et al., 2011). In contrast, poorer adjustment to breast cancer predicted greater breast cancer recurrence and mortality in 578 breast cancer patients followed for 10 years (Watson et al., 2012). Being more optimistic may also influence cancer outcomes. Studies report a worse prognosis and shorter cancer survival in patients who score high on pessimism (or low on optimism). In a study of 238 cancer patients followed for 8 months, Shultz and colleagues (1996) found that endorsement of a pessimistic life orientation strongly predicted cancer morality, especially among younger patients age 30–​ 59. Byrnes and colleagues (1998) reported that a pessimistic attitude was associated with lower NK-​cell activity and decreased cytotoxic T cell (CD8) percentage in a sample of Black women, increasing risk for future progression of cervical dysplasia to invasive cancer. Likewise, Allison and associates (2003) found that patients having a more optimistic attitude survived significantly longer after a diagnosis of head and neck cancer. More recent research supports these observations. In a prospective study of 534 patients with lung cancer, Novotny and colleagues (2010) found that those with a pessimistic explanatory style died on average 6 months earlier than other patients, an effect which persisted after adjustment for known predictors. Likewise, in the Women’s Health Initiative, a 15-​year prospective study of nearly 100,000 postmenopausal women, Tindle and colleagues (2009) reported that pessimistic women, particularly those with high levels of cynical hostility, were 23% more likely to die from cancer-​ related causes. For African American women in the sample (n =​8,000), there was a 142% increase in cancer risk among those with cynical hostility. Optimistic African American 510 •  P h y sical H ealth

women, on the other hand, were 44% less likely to die of cancer-​related causes. SOCIAL

Social support, a known stress buffer, has been associated with higher natural killer cell cytotoxicity and with higher percentages of natural killer cells both in the tumor and in the peripheral circulation among women with ovarian cancer (Lutgendorf et al., 2005; Lamkin et al., 2008). In another study, women with breast cancer who reported they were socially isolated or without close friends were twice as likely to die from the disease compared to more socially integrated women (Kroenke et al., 2006). Physiologically, social isolation has been associated with higher levels of tumor norepinephrine, a factor known to stimulate tumor growth, in women with ovarian cancer (Lutgendorf et al., 2011). Similarly, You and colleagues (2014) found that cancer patients with genes associated with loneliness had significantly shorter mean survival times. Likewise, in a 48-​year review of the literature, Coughlin (2019) found that breast cancer patients who were married (and presumably had greater support) experienced significantly improved survival. Higher social support also predicts lower levels of inflammatory cytokines (e.g., IL-​ 6) in breast cancer survivors, thus lowering the risk of tumor spread (Hughes et al., 2014). Finally, Chou et al. (2012) reported that breast cancer patients who had increased contact with friends and family following their diagnosis experienced a significantly lower risk of death over a 13-​year follow-​up (HR =​0.31, 95% CI =​0.17–​0.57). In conclusion, social support and integration appear to be important in maintaining immune functions that limit tumor spread and increasing survival among cancer patients, particularly women.

Behavioral Health behaviors of particular relevance to the development and course of cancer include cigarette smoking, chronic alcohol use, physical inactivity, unhealthy diet, excess body weight, risky sexual activity, and failure to seek timely medical care and regular screening for cancer.

C I GA RE TTE SMOKING

Islami et al. (2018) note that cigarette smoking accounts for approximately 29% of all cancer deaths in the United States, especially from cancers of the oral cavity and pharynx, larynx, lung, esophagus, pancreas, cervix, kidney, bladder, stomach, colorectal sites, liver, blood (acute myeloid leukemia), and certain types of prostate and ovarian cancer. Besides smoking cigarettes, cigar smoking also increases risk of cancers of the lung, oral cavity, and esophagus (Sauer et al., 2019). Likewise, pipe smoking and water pipe smoking increase risk of lung, esophageal, and gastric answers. Chewing tobacco or using snuff can increase risk of oral, esophageal, and pancreatic cancers. Finally, secondhand smoke is responsible for approximately 3% of all lung cancer deaths each year (Islami et al., 2018). C H RO N I C A L C OHOL US E

Alcohol use, particularly when chronic and excessive, increases risk of mouth, pharynx, larynx, esophageal, stomach, pancreas, liver, colorectal, and breast cancers. Overall, alcohol is responsible for approximately 4% of cancer deaths in the United States (Islami et al., 2018). Consuming three or more alcoholic drinks per day over time is associated with an increased risk of developing cancers of the stomach and pancreas. Cigarette smoking and alcohol, when used together, dramatically increase risk of all cancers mentioned above, and 70% of alcoholics are heavy smokers (Sauer et al., 2019). P H Y SI CA L I N ACT IV IT Y

Approximately 2% of all cancer deaths are due to inadequate physical activity or lack of exercise (Islami et al., 2018). Physical activity has been associated with lower rates of endometrial and postmenopausal breast cancer, as well as fewer cancers of the esophagus, liver, and breast (in premenopausal women) (Sauer et al., 2019). U N H E A LTH Y DIE T

Islami and colleagues (2018) estimate that approximately 5% of all cancers are due to

consumption of unhealthful diets, i.e., those high in processed meats and red meat, and low in non-​starchy vegetables, fruits, and whole grain foods and dietary fiber. This especially applies to colon cancer, but also to mouth, pharyngeal, laryngeal, esophageal, and stomach cancer, as well as to certain types of breast cancer (Sauer et al., 2019). EXCESS BODY WEIGH T

Excess body fat increases the risk of many cancers, in part due to the production of hormones by fat tissue that increases cancer risk (Avgerinos et al., 2019). Approximately 7% of all cancers are due to excess body weight, an effect which is second only to that of cigarette smoking (Islami et al., 2018). Being overweight or obese has been associated with an increased risk of cancers of the uterus, esophagus, stomach, liver, kidney, brain, pancreas, colon and rectum, breast (especially in postmenopausal women), thyroid, as well as certain types of lymphoma, multiple myeloma, and prostate cancer (Sauer et al., 2019). RISKY SEXUAL ACTIVITY

Risky sexual activity (e.g., multiple partners, extramarital sex) has been indirectly associated with an increased cancer risk due to cancers caused by sexually transmitted viral infections (Sauer et al., 2019). These include the human papillomavirus (HPV), human immunodeficiency virus (HIV), and herpes viruses (HV). HPV infection is associated with cancers of the cervix, anus, oral oropharynx, vagina, vulva, and penis. HIV infection is associated with Kaposi’s sarcoma, non-​Hodgkin and Hodgkin lymphoma, anal cancer, and cervical cancer. HV is primarily responsible for increasing risk of cervical cancer. M ED ICAL CARE AN D CAN CER SCREEN IN G

Receiving regular medical care, including cancer screening, is known to increase early identification of cancer and initiation of treatment. Regular screening can detect many cancers at a stage when they can be treated and before they Cancer • 511

spread to other organs. Cancers detectable by screening include those of the cervix, breast, colon, prostate, lung, and skin. For example, in a study of 6,333 patients with breast cancer in Canada, 36.5% were detected by screening mammography alone, 54.8% by mammography and physician-​ performed clinical breast exam, and 8.7% by clinical breast exam alone (Provencher et al., 2016). In summary, modifiable health behaviors are responsible for a large proportion, perhaps as much as 50% of all cancers. The effects of religious involvement on these modifiable health behaviors may be a major pathway by which religion could affect the risk and course of cancer.

RELIGION AND CANCER The above description of risk factors for cancer helps to lay the foundation for a discussion of how religious involvement might impact risk of cancer and among those with cancer, speed of metastasis and cancer death. First, however, let us describe a case vignette that illustrates the role that religion can play in someone with cancer.

CASE VIGNETTE Ms. CG is a 58-​year-​old woman who presented to her family physician’s office for a refill of her blood pressure medication. She had run out for a few days, and her blood pressure was high when the nurse took it. Ms. CG had no complaints and, in fact, was quite pleasant and outgoing, enough to be noticed by the nurse, who remarked about her cheerful demeanor to the doctor. When the doctor asked why she had allowed her blood pressure medication to run out, she responded that she had been quite busy with evaluations and oncology visits related to a recent diagnosis of breast cancer and had inadvertently forgotten to get her medications refilled. After briefly reviewing her medical records, the doctor noticed that she had been seen 3 months previously by one of his partners for follow-​up of heart disease and hypertension. His partner had ordered a screening mammogram at the time, which was positive, and she had been referred to the 512 •  P h y sical H ealth

cancer center, where they diagnosed her with metastatic breast cancer. She had been receiving chemotherapy for the past 6 weeks and had experienced numerous side effects, including nausea, some cognitive symptoms, and hair loss, requiring her to take a leave of absence from work. When she was explaining all this, the doctor took note of her positive attitude and outlook during the encounter, despite the diagnosis and difficult treatment regimen she had been enduring and would be facing. Ms. CG described her recent oncology clinic visits without a hint of sadness, discouragement, or fear. Curious, the doctor asked her how she had managed to stay so positive in the face of this serious life-​threatening illness. Her answer was immediate: “lots of prayer.” Elaborating further, Ms. CG said she had a very supportive family, and was receiving much spiritual support and prayer from her pastor and a loving church family. She explained her diagnosis this way: “I have cancer, but I do not claim it—​it is all in the Lord’s hands.” How might religion impact the development and course of cancer in people like Ms. CG? We now theorize on ways that religious involvement might do so, based on what is known about the determinants of cancer described above, particularly through modifiable risk factors.

Demographics As noted above, several demographic factors such as age, gender, race, and SES may be relevant. Given that demographic factors may be related to both religious involvement and risk of cancer, it is essential that these characteristics be controlled for when examining the relationship between the two.

Environment The religiosity of parents may influence both the intrauterine and early home environments, including the quality of maternal nurturing received by the infant (Chapter 14) and the likelihood of child abuse and other adverse childhood experiences (ACEs) known to impact neuroendocrine and immune responses that affect cancer risk (Chapters 24 and 25). Greater

religiosity is also associated with a lower risk of parental alcohol and drug abuse and lower likelihood of parental smoking, factors that could increase cancer risk in offspring (through exposure to secondhand smoke and increased access to alcohol/​drugs).

Psychological Religious involvement could affect cancer risk and prognosis through effects on mental health. This might be accomplished by reducing the number of stressful life events (due to greater adherence to moral standards), decreasing chronic stress or improving its management (due to religious coping resources), lowering depression and anxiety, increasing positive emotions (joy, peace, meaning and purpose, hope, optimism), and buffering the effects of negative life events (Chapters 4, 5, 8, 12, and Appendix). As discussed above, all of these influence the risk of cancer and affect cancer outcomes.

Social Religious involvement is also associated with greater social support, less loneliness, and larger social networks (Chapter 15), factors associated with a lower risk of cancer, improved coping with cancer, and better cancer outcomes. Members of faith communities are also more likely to discourage harmful behaviors among each other that increase risk of cancer (e.g., smoking, excessive alcohol use, risky sexual activity).

Behavioral Religious beliefs and practices may have their greatest effects on the development and course of cancer through this pathway. There is little question that religious persons are less likely to smoke (Chapter 17), less likely to misuse alcohol (Chapter 10), are generally more physically active (Chapter 18), are more likely to consume a healthy diet (Chapter 19), and are more likely to receive regular medical care and undergo cancer screening (see Appendix and Chapter 30). As we have repeatedly emphasized, religious scriptures in the Christian tradition

emphasize respect for the body as the “temple of the Holy Spirit,” as do other faith traditions that promote care for the physical body, thus helping to motivate members to obtain regular medical care. There is also a greater flow of health information in religious communities, including information about the need for cancer screening. However, the possibility also exists that some faith traditions may discourage seeking medical attention, and instead rely exclusively on religious beliefs/​ practices for protection. These traditions may also emphasize religious healing practices (e.g., prayer) at the first sign of illness—​ such as a lump in the breast—​ thereby delaying diagnosis and early treatment if medical attention is not sought. Religious beliefs and practices of this type may be used to justify avoiding medical care, particularly when fear of discovering cancer (not strength of faith) is really the underlying motive. Religious healing practices are particularly common among Protestant Pentecostals (Van Ness et al., 2003b) and in African Americans (Moorman et al., 2019).

Summary Thus, there are many reasons why those who are more religious should have a lower risk for cancer, and when cancer develops, why the illness should take a more benign course. However, as with other physical health conditions, the effects of religiosity on cancer risk and outcome are likely to be indirect, operating through environmental, psychological, social, and behavioral pathways (which may weaken effects that can be measured). Furthermore, many factors may confound the relationship between religiosity and cancer risk or course, given the association that both have with demographic factors such as age, gender, race, and SES.

RESEARCH ON RELIGION AND CANCER To what extent does quantitative research verify these theoretical considerations regarding the impact that religious involvement has on the risk of developing cancer or surviving with it? As usual, we first summarize research Cancer • 513

conducted prior to 2010 reported in the first and second editions of the Handbook, and then examine in greater detail the research conducted since 2010.

Early Research Early cross-​sectional and case-​control studies, along with a few prospective studies, reported a lower cancer risk (and death) among Mormons and Seventh-​Day Adventists and higher risk among Jews (particularly Ashkenazi Jews). With regard to degree of religious involvement (religiosity) and cancer, there were at least 31 reports from 28 studies examining the relationship with cancer risk, course, or mortality, or effects thereon. Of those 31 reports, 13 were cross-​ sectional (CS) or case-​ control (CC) designs (note that CC designs are better than CS but not as good as prospective), 5 were retrospective, and 13 were prospective. Of the 13 CS/​CC reports, 10 indicated a lower risk of cancer or cancer mortality, 2 reported no association, and 1 indicated greater cancer mortality among the more religious. Of the 5 retrospective analyses, 2 indicated less cancer and 3 indicated no association. Of the 13 longitudinal analyses, 5 reported beneficial effects of religiosity, 1 indicated a trend in that direction, and 7 reported no association; no studies found detrimental effects. Overall, then, 18 of 31 (58%) reports reported a lower risk of developing cancer or dying from it, 12 (39%) indicated no association, and 1 found a positive association between religiosity and the presence of cancer. We now briefly review 6 of the highest-​quality prospective studies and the one case-​control study reporting a positive association with religiosity. Reynolds and Kaplan (1990) examined the effects of church membership and church attendance assessed at baseline in 1965 on cancer incidence and survival over a 17-​year follow-​up of 6,848 participants in the Alameda County Study, which was conducted in the San Francisco Bay area. After adjusting for age, smoking, physical health, household income, and alcohol consumption, investigators found no effect of church membership or attendance (> once/​month vs. less) on cancer incidence or mortality. Some of the control variables in the 514 •  P h y sical H ealth

analysis may have been mediators (e.g., smoking, alcohol consumption). Ringdal (1996) conducted a 3-​ year prospective study of 253 cancer inpatients at University Hospital of Trondheim in Norway, assessing religiosity at baseline by a 2-​ item measure of religiosity (belief in God, support from religious beliefs). Cox proportional hazards regression modeling indicated no effect of religiosity on survival after controlling for confounders and covariates, which included hope and life satisfaction. Both of the latter variables likely played a role as mediators of religiosity’s effects on survival. After their removal from the model, there was some evidence that religiosity predicted a 14% lower risk of dying (HR =​ 0.86, 95% CI =​0.72–​1.01, p =​0.06). Van Ness et al. (2003b) conducted a 10-​year prospective study of 322 breast cancer patients in New Haven, Connecticut, finding that women who reported no current religious affiliation were over 4 times more likely to die during follow-​ up compared to women indicating a religious affiliation (HR =​4.39, 95% CI 1.42–​ 13.64). Among the 45% of the sample who were African American, those who were not religious at all (i.e., indicated no religious affiliation, knew no one in their congregation, considered themselves not at all religious, and received no support or comfort from religion) were over 10 times more likely to die during follow-​up (HR =​10.7, 95% CI 3.32–​34.16), adjusting for age, education, income, marital status, occupational rank, race, comorbidity index, estrogen receptor, histologic grade, lymphatic status, obesity, stage at diagnosis, self-​rated health, alcohol, smoking, and other risk factors. Oman and colleagues (2002) examined the effect of religious attendance on cancer mortality using data from 6,545 persons followed from 1965 to 1996 in the Alameda County Study described earlier. Compared to those who attended religious services at least weekly, participants who attended services less than weekly in 1965 were 33% more likely to develop cancer during the 31-​year follow-​up (RH =​1.33, p < 0.05, adjusting for age, sex, period effect, ethnicity, and family income). This effect, however, was partially explained by differences in health status over time, when subsequent health status (which may have served as a mediator) in

1965, 1974, 1983, and 1994 was included in the model as a time-​varying covariate. With regard to specific cancers in that study, the strongest effect of religious attendance was on digestive cancers, where infrequent attendance predicted a 73% increased risk (RH =​1.73, p < 0.05) after controlling for age, sex, period effect, and demographics. This effect persisted even after controlling for health status (RH =​ 1.63, p < 0.05), but was attenuated when social connections and health behaviors were controlled for (characteristics that may have explained the effect, not explained it away). Kroenke and associates (2006) examined predictors of survival in a 6-​year prospective study of 2,835 women with breast cancer from the U.S. Nurses’ Health Study. Religious attendance was measured prior to diagnosis. During follow-​up, 224 women died and about 50% of deaths were from the breast cancer itself (n =​ 107). Cox proportional hazard models were used to examine predictors of mortality from all causes and specifically from breast cancer, controlling for 17 covariates. Religious attendance was not related to either all-​cause mortality or breast cancer mortality after covariates were controlled. The large number of covariates adjusted for in the model and relatively small number of deaths, however, may have influenced these findings. Schnall and colleagues (2010) analyzed 8-​year follow-​up data on 92,395 women participating in the Women’s Health Initiative, examining the effects of religious affiliation, frequency of religious attendance, and strength and comfort from religion on mortality from various causes. While there were weak trends toward fewer deaths from cancer among those indicating a religious affiliation vs. not (42.4% vs. 47.1%, respectively) and among those attending religious services more than weekly vs. less often (39.8% vs. 44.5%), there were significantly fewer cancer deaths among those who indicated they received a great deal of strength and comfort from religion compared to those indicating no comfort from religion (39.4% vs. 51.2%, p < 0.0001). However, these analyses did not control for confounders and so contribute very little evidence. In the only early report of a negative effect of religiosity on cancer mortality, MacArthur

et al. (2007) conducted a case-​control study examining the occupations of women age 20 years or older who died from breast or reproductive cancers between 1950 and 1994 in British Columbia, Canada. Women religious (sisters/​nuns) (n =​30) were significantly more likely to die from these causes compared to a matched group of control women dying from other causes (OR =​1.79, 95% CI =​1.16–​2.75). Never having breastfed or having had children may have explained this finding, since breastfeeding is known to reduce the risk of breast cancer (Jelly & Choudhary, 2019) and high parity reduces risk of uterine or endometrial cancer (Raglan et al., 2019).

Recent Research Since the year 2010, a number of studies have examined the relationship between religiosity and cancer incidence or mortality. For a complete listing of these studies, see the Appendix. Here, we first examine the risk of developing cancer (cancer incidence) and then explore cancer mortality, with a preference for prospective cohort studies. RISK OF CAN CER

In a 14-​year prospective study of a systematically acquired sample of 6,950 adolescents (average age 15) from across the United States, Chen and VanderWeele (2018) examined the effects of baseline religiosity in 1999 on the likelihood of having an abnormal cervical pap smear (suggestive of early cancer) among 4,636 women age 23–​ 30 in 2007–​ 2013. Religiosity was assessed by frequency of attendance at religious services and frequency of prayer or meditation, which were each examined in separate analyses, controlling for age, race, gender, geographic region, health status, emotional status (depression), and health behaviors (overweight/​obesity, smoking, drinking, marijuana use, other drug use, prescription drug misuse, number of sexual partners, early sexual initiation, history of sexually transmitted infections, history of teen pregnancy), as well as the mother’s age, race, marital status, social and economic status, depression, and smoking. Generalized estimating equations were used to analyze the data, and Cancer • 515

sensitivity analyses were performed along with Bonferroni correction of p-​values. Compared to those who never attended religious services, those who attended at least once per week were 18% less likely to have an abnormal pap smear (a pre-​cancerous finding) on follow-​up (RR =​ 0.82, 95% CI =​0.71–​0.95, p < 0.01). Compared to those who never prayed, those who prayed once per day or more were 26% less likely to have an abnormal pap smear (RR =​0.74, 95% CI =​ 0.63–​0.88, p < 0.0019). Ahrenfeldt et al. (2019) analyzed data from an 11-​year prospective study of 23,864 persons age 50 or older participating in the European Survey of Health, Aging, and Retirement Study, in order to examine the effects of religious participation on the development of various physical health conditions, including cancer. Participants were a population-​based sample from 10 European countries assessed at baseline in 2004–​2005 (Wave 1) and again in 2006–​2007 (Wave 2), 2011 (Wave 4), and 2015 (Wave 6). Religiosity at Wave 1 was assessed with three questions: (1) taking part in a religious organization within the past month; (2) frequency of prayer; and (3) history of a religious education. Individuals were categorized as “more religious” if they prayed, took part in a religious organization, and had a religious education; “less religious” if they did not pray, but took part in a religious organization and had a religious education; and “nonreligious” if they indicated no to all three questions. Participants with cancer at baseline in 2004–​ 2005 were excluded from the analysis to avoid reverse-​causation. Logistic regression analyses controlled for European region, gender, age, education, marital status, and employment status, with p-​values corrected using the Holm-​ Bonferroni method. Results indicated that taking part in a religious organization at Wave 1 predicted a 22% lower likelihood of developing cancer during follow-​up through Wave 6 (OR =​ 0.78, 95% CI =​0.60–​1.00). Those who prayed at Wave 1 were also less likely to have developed cancer by Wave 6 (statistics not provided, although CI appeared to be 1.00 or lower). Compared to other participants, those who were “more religious” at Wave 1 were 33% less likely to develop cancer (OR =​0.67, 95% CI =​ 0.46–​0.95) by Wave 6. 516 •  P h y sical H ealth

The effects of religiosity on gene expression may also influence cancer risk. For example, Simons et al. (2019) examined the effects of religiosity and other characteristics on expression of the Tp53 cancer suppressor gene among 413 African Americans (average age 29). Tp53 gene expression was determined by genome-​ wide transcriptomic analysis at Rutgers University. Inflammation, as a possible mediator of any relationship between religiosity and Tp53 gene expression, was assessed in the manner typically performed at the Rutgers’s repository. Religiosity was measured by a 5-​item scale that included questions about the importance of spiritual beliefs, frequency of participation in religious services, prayer, meditation, and other religious activities. Controlled for in these cross-​sectional analyses were gender, education, age, weekly income, work status, marital status, health insurance, cigarette smoking, alcohol consumption, diet, exercise, and self-​ reported illnesses. Structural equation modeling was used to examine the data. Results indicated that religiosity was inversely related to level of inflammation (b =​−0.108, p < 0.05), which was inversely related to Tp53 gene expression (−0.171, p < 0.01), independent of other covariates. The indirect effect of religiosity through inflammation on Tp53 gene expression was significant (b =​0.019, 95% CI =​ 0.004–​0.045, p < 0.05). Investigators explained that inflammation likely increases risk of cancer by reducing expression of the Tp53 cancer suppressor gene, and that religiosity may help to protect against cancer by increasing expression of this gene through reduction in stress-​ related inflammation. Genes inherited by members of some religious groups may also increase risk of developing cancer. For example, Jews with Ashkenazi Jewish ancestry may be at particular risk for pancreatic, breast, and colon cancers due to the presence of high-​risk genetic mutations in BRCA1, BRCA2, MSSH2, and MSH6 (Hamada et al., 2019). CAN CER M ORTAL ITY

Minority religious groups appear to be at greater risk of dying from cancer in some countries. This has recently been shown to be true

for Muslims (vs. Buddhists) in Thailand and for Christians (vs. Hindus) in India (Virani et  al., 2018; Saxena et al., 2019). However, rates of uterine cancer among Buddhists in Thailand are increasing (compared to Muslims), perhaps due to lower parity among Buddhists in recent years (Saeaib et al., 2019). With regard to the effects of religiosity on cancer mortality, Yun et al. (2012) prospectively followed 481 terminally ill cancer patients in South Korea for an average of 4 months examining the effects of complementary and alternative medicine (CAM) practices on survival. Among the CAM practices assessed was prayer. Analyses were adjusted for physical performance status and a propensity score. The propensity score was based on the probability of being a CAM user based on age, gender, marital status, education level, job status, religion, performance status, metastasis, primary cancer site, and reason for terminal status. Results indicated that those who prayed more at baseline (2005–​2006) tended to die sooner than those who did not pray (HR =​1.56, 95% CI =​1.00–​2.43). Again, however, more frequent prayer by advanced cancer patients as death approached may not have been particularly surprising, especially given the very short follow-​ up (roughly 4 months). In a 16-​year prospective study of 74,534 nurses participating in the US Nurses’ Health Study, Li and colleagues (2016b) examined the effects of religious attendance in 1996 on survival between 1996 and 2012. Religious attendance in 1992 was controlled for as a covariate, and those diagnosed with cancer before 1996 were excluded from the analysis. In addition to religious attendance in 1992, controlled for in analyses were many other demographic, socioeconomic, and social, mental, behavioral, and physical health covariates. Compared to women who never attended religious services, the risk of dying from cancer between 1996 and 2012 was 21% lower among those attending services more than once/​week (HR =​0.79, 95% CI =​0.70–​0.89). Furthermore, as religious attendance increased, the likelihood of dying from cancer decreased in a dose-​response manner (p for trend 20–​25 cigarettes/​ Xi et al., 2017). The most common causes of day) smokers among men were 1.47, 2.02, and death from alcohol use are cardiovascular, gas2.38, respectively, whereas in women the RRs trointestinal, unnatural (accident/​ suicides), were 1.50, 2.02, and 2.66, respectively. Thus, neoplastic, and respiratory diseases (Abdul-​ in both men and women, the risk of death is Rahman et al., 2018). increased by nearly 50% among light smokers, double among medium smokers, and approximately two and one-​half times in heavy smok- D RUG USE ers. A more recent study has confirmed these findings. Lariscy et al. (2018) analyzed data on Drug-​induced causes of mortality worldwide 456,800 US respondents age 35 or older fol- have become common since the year 2000, lowed for 4,191,832 person-​years during which especially among younger adult opioid users, 69,142 deaths occurred. The all-​cause mortality where the mortality rate is 15 times that of nonrisk during follow-​up for current smokers was users in the general population (Degenhardt et over twice that of nonsmokers (RR =​2.29 for al., 2011). The problem is growing both within women, RR =​2.23 for men, both p < 0.001). and outside the United States. In terms of Among former smokers, the risk was increased disability-​adjusted years of life lost due to opiby 35% in women and 30% in men (again, p < oid dependence, this number increased from 0.001 for both). Cigarette smoking is probably 5.3 million in 1990 to 9.2 million in 2010 the most important modifiable risk factor for (nearly doubling worldwide) (Degenhardt et al., mortality that exists today. Likewise, use of 2014). In 2016, for example, 22% of all deaths smokeless tobacco increases risk of mortality among men age 15–​64 in the United States and by almost 25% (RR =​1.22, 95% CI =​1.11–​1.34) 16% of all deaths in women were due to drug use (Glei & Preston, 2020). In fact, the increase (Sinha et al., 2018). 530 •  P h y sical H ealth

in midlife mortality in the United States since 2010 has been largely driven by drug-​related mortality. Treatment for drug use, in turn, has been shown to significantly reduce mortality (Sordo et al., 2017).

CI =​1.13–​2.03). These effects were weaker or nonexistent among those meeting the current recommendations for MVPA. The research is clear that increased physical activity decreases mortality risk, and being sedentary increases it.

P H Y SI CA L ACT IV IT Y

D IET

In a recent meta-​analysis of six prospective cohort studies, Chastin et al. (2019) reported that daily light-​ intensity physical activity reduced risk of all-​ cause mortality by 29% (HR =​0.71, 95% CI =​0.62–​0.83). The amount of physical exercise determines the degree of reduced mortality. In a meta-​analysis of eight studies involving 36,383 adults (average age 63) followed for 6 years (mean), during which 2,149 deaths occurred, Ekelund and colleagues (2019) found that compared to individuals in the lowest quartile of physical activity, those in the second quartile were over 50% less likely to die (HR =​0.48, 95% CI =​0.43–​0.54), those in the third quartile were nearly two-​thirds less likely to die (HR =​0.34, 95% CI =​0.26–​ 0.45), and those in the fourth quartile (the most active) were nearly three-​quarters less likely to die (HR =​0.27, 95% CI =​0.23–​0.32). For light physical activity, the corresponding hazards ratios (HRs) were similar at 0.60 (95% CI =​0.54 =​0.68), 0.44 (95% CI =​0.38–​0.51), and 0.38 (95% CI =​0.28–​0.51). For moderate-​ to-​­vigorous physical activity (MVPA), hazard ratios were 0.64 (95% CI =​0.55–​0.74), 0.55 (95% CI =​0.40–​0.74), and 0.52 (95% CI =​0.43–​ 0.61). For time engaged in no physical activity (i.e., sedentary time), HRs from least to most were 1.28 (95% CI =​1.09–​1.51), 1.71 (95% CI =​ 1.36–​2.15), and 2.63 (95% CI =​1.94–​3.56). Again, these findings demonstrate a dose-​ response effect of physical activity on reducing mortality during follow-​up. The findings from Ekelund et al.’s meta-​ analysis were recently confirmed by a study that examined “sitting time” and all-​cause mortality among 149,077 adults age 45 or older in New South Wales, Australia, that followed participants for 9 years (Stamatakis et al., 2019). Among those engaged in no MVPA, ­persons who spent more than 8 hours/​day sitting (compared to less than 4 hours) experienced a more than 50% increase in mortality (HR =​1.52, 95%

Diet quality impacts mortality and risk of chronic disease. Schwingshackl and colleagues (2017) examined the effects on all-​cause mortality from ingestion of foods categorized into 12 different food groups. In this meta-​analysis of 19 prospective studies, a total of 121,141 deaths took place during follow-​up. The RR of mortality was calculated for amount of daily intake of each food group. Listed from lowest to highest mortality risk, the food groups were: nuts (RR =​0.76, 95% CI =​0.69–​0.84), legumes (RR =​0.90, 95% CI =​0.85–​0.96), whole grains (RR =​0.92, 95% CI =​0.89–​0.95), fish (RR =​ 0.93, 95% CI =​0.88–​0.98), fruits (RR =​0.94, 95% CI =​0.92–​0.97), vegetables (RR =​0.96, 95% CI =​0.95–​0.98), refined grains (no effect), dairy (RRs ranging from 0.97 to 1.16, depending on number of servings), sugar-​sweetened beverages (RR =​1.07, 95% CI =​ 1.01–​ 1.14), eggs (RR =​1.07, 95% CI =​1.01–​1.15), red meat (RR =​1.10, 95% CI =​1.04–​1.88), and processed meats (RR =​1.23, 95% CI =​1.12–​1.36). Researchers concluded that the optimal consumption of beneficial foods resulted in a 56% reduction of all-​cause mortality, whereas ingestion of highest-​risk foods resulted in a 2-​fold increase in mortality. As emphasized in Chapter 19, the Mediterranean Diet (MD) is the diet most highly rated for disease prevention by health professionals. Research on mortality risk confirms this recommendation. In a systematic review and meta-​analysis of 30 prospective studies during which 225,600 deaths occurred, degree of adherence to the MD (assessed by the Mediterranean diet score, or MDS) was examined as a predictor of all-​ cause mortality (Eleftheriou et al., 2018). For each increase of 1 standard deviation on the MDS, there was a 21% decrease in mortality during follow-​up (RR =​0.79, 95% CI =​0.77–​ 0.81). When components of the MD were examined, the most beneficial effects were observed for the consumption of fruit (RR =​ Mortality • 531

0.88, 95% CI =​0.83–​0.94) and vegetables (RR =​ 0.94, 95% CI =​0.89–​0.98). Intake of meat predicted the highest mortality risk (RR =​1.07, 95% CI =​1.01–​1.13). When a similar meta-​analysis was conducted among older adults (age 65+​), for every point increase on the MDS there was a 5% (95% CI =​4%–​7%) lower risk of all-​cause mortality. The authors concluded that adherence to the MD predicted a linear dose-​response effect on increasing longevity (Bonaccio et al., 2018). OV E RW E I GH T

Calorie restriction in mice is known to extend life span in the range of 10%–​ 40% (Finch 2010). Higher fat intake, in turn, increases atherosclerosis, dementia, and cancer in animal models, reducing their longevity. The same is true for humans, where being overweight increases risk of premature mortality. In one of the largest systemic reviews to examine the effects of excess weight on mortality, Di Angelantonio and colleagues (2016) conducted a meta-​analysis of 239 prospective studies with an average follow-​up of 13.7 years involving 10,625,411 participants in Asia, Australia and New Zealand, Europe, and North America. In order to reduce confounding and eliminate reverse causation, only nonsmokers without chronic diseases who survived at least 5 years into the observation period were included in the analyses, resulting in 3,951,455 persons, of whom 385,879 died during follow-​up. The risk of mortality increased linearly in a dose-​ dependent fashion from being mildly overweight defined as a BMI of 25.0–​27.5 (HR =​ 1.07, 95% CI =​1.07–​1.08), to being moderately overweight defined as a BMI of 27.5–​30.0 (HR =​1.20, 95% CI =​1.18–​1.22), to being grade 1 obese with a BMI of 30.0–​< 35.0 (HR =​1.45, 95% CI =​1.41–​1.48), to being grade 2 obese with a BMI of 35.0–​< 40.0 (HR =​1.94, 95% CI =​1.87–​2.01), to being grade 3 obese with a BMI of 40.0–​< 60.0 (HR =​2.76, 95% CI =​2.60–​ 2.92). Similar findings were reported by Aune et al. (2016) in a systematic review and meta-​ analysis involving 230 prospective studies with 30.3 million participants with 3.74 million deaths. While there remains some debate with regard to the effect of being just overweight (but not obese) on mortality risk, the effect of 532 •  P h y sical H ealth

being obese seems clearly detrimental (Kodama et al., 2009; Flegal et al., 2013). L ACK OF REGUL AR M ED ICAL CARE

The obtaining of regular medical care has long been known to increase longevity, and this has not changed (Shapiro et al., 1971; Lee et al., 2013; Okura et al., 2020). Regular medical care involves engaging in recommended cancer-​ screening procedures (e.g., colonoscopy, mammography, cervical exams), receiving regular dental hygiene care to address gum and teeth issues, acquiring recommended vaccinations, obtaining maternal prenatal care and later medical care for infants and children, and seeing healthcare providers to manage acute and chronic health conditions.

Summary The above discussion of risk factors for early mortality provides a backdrop for understanding the different ways by which religious involvement may affect longevity. Of particular relevance here is the impact that religiosity might have on psychological, social, and behavioral characteristics that affect mortality risk. Researchers must also consider that certain characteristics such as demographic factors may confound the relationship between religiosity and mortality. We now present a brief case vignette that illustrates how religiosity may affect longevity, and then discuss how religious involvement might influence mortality indirectly through the pathways described above.

RELIGION AND LONGEVITY Case Vignette On January 3, 2009, after the death of the Guinness Book of World Records’ oldest person, Maria de Jesus, next in line was Gertrude Baines from Los Angeles. Born to former slaves near Atlanta in 1894, she was described at the age of 114 as spry, cheerful, and talkative. When she was 112 years old, Ms. Baines was asked by a CNN correspondent to explain why

she thought she had lived so long. Her response: “God. Ask him. I took good care of myself, the way he wanted me to.”1 Let us now take a closer look at how religion might affect how long a person lives by associations with and influences on demographic, genetic, biomedical, environmental, psychological, social, and behavioral risk factors.

(and be passed on to future generations), which increases susceptibility to chronic stress and its negative effects on longevity. Greater family stability due to religious involvement by parents and effects of religious beliefs on attitudes toward the value of children may influence the quality of maternal nurturing that infants receive (Chapter 14), thereby affecting their longevity in later life.

Biomedical

Most demographic characteristics have the potential to confound the relationship between religiosity and mortality, as we have emphasized in previous chapters examining the effects of religion on specific physical illnesses such as cardiovascular disease and cancer. On the one hand, religious people tend to be older, Black (or other minority race), and lower in SES, each of which predicts greater mortality. On the other hand, women tend to be more religious than men, and women live longer than men. Thus, if these demographic characteristics are not taken into account in statistical analyses, this may bias the findings in one way or another.

As indicated in previous chapters, many of the leading causes of death are non-​communicable diseases (e.g., heart disease, hypertension, stroke, cancer). These conditions may be influenced by religious involvement in ways that are protective. Likewise, religiosity may affect susceptibility to communicable infections, given the effects that religion may have on boosting immune functions, while possibly increasing the risk of exposure through greater social interaction (Chapter 24). Furthermore, given the influence that maternal stress can have on “fetal programming” and its effects on later age-​related diseases, this is yet another pathway by which parental religious involvement may influence offspring life span.

Genetic

Environmental

Members of some religious groups may be at risk for certain cancer-​ promoting genes that increase the risk of mortality. For example, Ashkenazi Jews may be at greater risk for breast cancer (Chapter 26). Similar to the demographic characteristics described above, increased genetic risk of this type may confound the relationship between religion and longevity. The environment may also interact with genes in modifiable ways that increase mortality risk. For example, in Chapter 16 we discussed the impact that maternal nurturing during early infancy may have on DNA methylation, histone modification, and non-​coding RNA, all without altering the DNA sequence of nucleotides. These structural gene changes may alter the infant’s stress responses later in life

Less is known about how religiosity might impact exposure to toxins, adverse neighborhood characteristics, public or workplace health regulations, and access to medical care. However, if greater religiosity during the teen years reduces teen pregnancy, delinquent or irresponsible behaviors, and drug/​ alcohol use—​actions that often interfere with education and later potential for employment—​then religious involvement may also influence the type of environment in which a person eventually lives and their ability to afford health insurance that affects their access to medical care. Likewise, religious communities may also be environmentally healthier ones, given that social capital (volunteerism, neighborhood involvement, shared norms) is usually higher in

Demographic

1. Correspondent (2009). 114-​year-​old US woman to be world’s oldest. Cable Network News (CNN.com). January 3. Retrieved on 7-​9-​ 2020 from: http://​www.cnn.com/​2009/​WORLD/​ameri​cas/​01/​03/​old​est.woman.gertr​ude.bai​nes/​index.html.

Mortality • 533

neighborhoods with a high density of religious congregations (see Appendix for studies).

group influences foster healthier lifestyles. As a result, religious people simply live healthier lives, as illustrated by Ms. Baines’s response to the CNN reporter in the case vignette above. Psychological Greater religiosity is related to less cigarette If psychological stress (acute or chronic), smoking (Chapter 17), lower levels of alcohol adverse childhood experiences, certain per- and drug use (Chapter 10), increased levels sonality traits such as low conscientiousness of physical activity (Chapter 18), and greater and high neuroticism, and higher levels of likelihood of consuming a healthy diet in the depression or anxiety increase mortality risk, majority of studies (Chapter 19). Less clear is then religious involvement could influence lon- the relationship between religiosity and being gevity through these psychological pathways. overweight or obese, which may adversely Religiosity may do so by reducing psychological affect mortality. Whether or not religious peostress by improving coping with stress, decreas- ple tend to be overweight, however, remains ing stressful life events (by promoting adher- controversial given recent large prospective ence to moral standards), fostering healthy studies, and may vary by context (Chapter personality traits, and reducing depression/​ 19). Religious involvement also tends to be anxiety (as documented in prior chapters). Of associated with a greater likelihood of receivcourse, the opposite is also possible. If religi- ing regular medical care, being compliant with osity increases guilt and enhances neuroticism medical prescriptions, and having a lower (as Freud claimed), then the effects on longev- incidence of dental caries and periodontitis ity might be in the other direction. (see Appendix for studies). Certain religious groups, though, may advocate for dependence on religion for health and healing rather than Social medicine, which may lead to less regular medHumans are social animals. Over a century of ical care, lower rates of childhood and adult research has demonstrated that positive social vaccinations (e.g., HPV, influenza, COVID-​19), interactions are a key to health and well-​being. and decreased disease screening procedures. In Poor social support and greater loneliness, as those instances, religiosity is likely to increase noted above, increase risk of mortality through mortality risk. well-​established physiological processes. Cross-​ sectional, prospective, and experimental studSummary ies have consistently demonstrated that religious involvement is related to greater social Based on the discussion above, there are numersupport and lower levels of loneliness (Chapter ous reasons why religious involvement ought to 15). Having more positive social interactions be related to greater longevity. However, there during which support is received from and is is also rationale for suggesting that it might given to others, as strongly emphasized by the not be. We now examine the findings from earcore teachings of all major religious traditions lier and more recent systematic, quantitative (e.g., “love thy neighbor”), is likely to impact research on the relationship between religiosity the life span in positive ways. Even the health and mortality. benefits of volunteering appear to be greater among those who are more religious compared RESEARCH ON RELIGION to those who are less religious (McDougle AND MORTALITY et al., 2014). As in previous chapters, we focus here on prospective cohort studies that are capable of proBehavioral viding evidence for causal inference. We first The greatest impact that religion may have briefly summarize the results of published on longevity, though, may be through behav- quantitative studies conducted prior to the ioral pathways. Religious teachings and peer year 2010 (research that is detailed in the first 534 •  P h y sical H ealth

and second editions of the Handbook), and then review research performed more recently since 2010. Fortunately, many studies have now examined the effects of religiosity on mortality.

Early Research With regard to religious denomination, studies conducted prior to the year 2000 consistently found that Seventh-​Day Adventists, Jews, and Mormons experienced greater longevity compared to members of other religious groups. In contrast, Christian Scientists and members of the Faith Assembly (a small religious denomination in Indiana), known to forgo medical care in preference to spiritual treatments, have higher mortality rates than members of other religious groups. There were also 13 studies (case-​control or retrospective in design) that compared mortality among clergy, priests, and nuns with that of non-​clergy, with 12 finding longevity greater among clergy and one reporting no association. With regard to non-​clergy populations, there were 33 studies, of which 28 were prospective, 4 were case-​control, and 1 was a clinical trial. Of the 28 prospective studies, 17 (61%) found that religiosity predicted greater longevity, 6 reported no association, 4 reported mixed or complex results, and 1 reported shorter longevity. The single study reporting greater mortality was conducted in nursing home patients who became more religious as death approached. Among the 4 case-​control studies, 3 reported positive effects of religiosity, and a clinical trial of transcendental meditation (TM) reported greater longevity among those in the TM group (Alexander et al., 1989). Between 2000 and 2010, there were 51 additional studies published, of which 44 were prospective, 6 were retrospective, and 1 was a case-​control study. Of the 44 prospective studies, 32 (73%) reported that greater religiosity predicted lower mortality during follow-​up. This was also true for 1 of 6 retrospective studies and the 1 case-​control study. Two studies, however, reported that religiosity increased mortality risk, which included one prospective study where the frequency of private religious activity such as prayer predicted greater mortality in hemodialysis patients, and

one retrospective study that compared members of the clergy to those engaged in other occupations. Included here were three studies that compared mortality in clergy with that in non-​clergy, with one prospective study finding lower mortality among Catholic sisters, one retrospective study indicating mixed results comparing Catholic sister radiology technicians to other technicians, and one retrospective study finding greater deaths from dementia among clergy compared to those in other occupations (Park et al., 2005). Overall, then, there were a total of 97 studies examining effects of religiosity on mortality (including clergy studies) conducted prior to 2010. Of those 97 studies, 67 (69%) reported that greater religiosity was associated with lower mortality. Among the 72 prospective cohort studies, 49 (68%) reported this finding. Two prospective studies (3%) reported the opposite, both assessing frequency of private religious activities such as prayer in those with serious health problems, one in nursing home patients (Janoff-​ Bulman et al., 1982) and one in hemodialysis patients (Parkerson & Gutman, 2000).

Recent Research More than 50 additional studies have examined the effects of religiosity on mortality since the first and second editions of the Handbook (see Appendix for a complete list). Almost all of these have been prospective cohort studies. Of the 49 prospective studies, 35 (71%) reported that religious involvement predicted lower mortality, confirming the earlier findings (68% of 72 prospective studies prior to 2010 predicting the same). One denominational study found greater longevity among Seventh-​ Day Adventists (a conservative Christian denomination) compared to non-​ Adventists in the United States (Fraser et al., 2020), and a second denominational study found that Catholics age 25–​64 in Switzerland lived longer than those with no religious affiliation, although the opposite was true for those age 65 or older (Lerch et al., 2010). We summarize below 10 of the highest-​quality prospective studies that have examined the effects of religiosity on mortality (reviewed by year of publication), along with Mortality • 535

studies that reported greater mortality among the more religious. Zeng et al. (2011) analyzed data collected on 15,973 participants (6,956 persons age 65–​ 84 and 9,017 age 85 or older) participating in the Chinese Longitudinal Healthy Longevity Survey between 2002 and 2005, which involves the “largest sample of the oldest-​ old ever conducted in the world” (i.e., 9,017 persons age 85–​109). A single question was asked at baseline in 2002 asking about religious participation: “At present time, do you participate in religious activities regularly?” Response categories were at least once per week (6.4%), less than once per week (11.1%), and do not participate (82.5%). Mortality of participants was assessed through 2005. Controlled for in Weibull parametric hazard models were demographics (age, gender, rural vs. urban residence, ethnicity, education, economic independence), social/​family support and connections (marital status, proximity to children, living alone), seven leisure activities (including participation in organized social activities other than religion), accessibility of medication, health practices (smoking, alcohol consumption, exercise), and overall health status (level of frailty based on cognitive function, activities of daily living, physical performance, self-​rated health, self-​reported changes in health, hearing and vision loss, psychological distress, any serious illness in past two years, and several specific chronic illnesses), i.e., a substantial list of confounders and potential explanatory variables. In the overall sample, compared to those not participating in religious activities, those who participated frequently were 21% less likely to die during the 3-​year follow-​up (HR =​0.79, p < 0.001). This was particularly true among those age 65–​84 (HR =​0.60, p < 0.01) and in men (HR =​ 0.53, p < 0.05). Because effects were stronger in younger men than in older men, researchers speculated that the positive effects of religious participation on health practices and lifestyles among younger men may have had a greater impact on preventing death, compared to the oldest old approaching their life-​span limits. This study is important because it demonstrates that the health benefits of religion are even present in secular regions of the world 536 •  P h y sical H ealth

where religious activities are discouraged (e.g., Communist China). Pantell et al. (2013) analyzed data on 16,849 adults participating in the Third National Health and Nutrition Examination Survey (NHANES-​III), a national random sample of US adults age 25 or over collected between 1988 and 1994, with a median follow-​up time of 14.1 years. Frequency of religious attendance was assessed as part of the Berkman-​Syme Social Network Index at baseline. Cox proportional hazards models were used to predict mortality through 2006, controlling for health behaviors (smoking, obesity), blood pressure, cholesterol, self-​ rated overall health status, sociodemographic characteristics (age, race, education, income), and other social isolation factors (being unmarried, infrequent social contact, and no club associations). Results indicated that among both women and men, infrequent religious activity (less than four times per year) predicted a 35% and 27% increased risk of mortality during follow-​up (HR =​1.35, 95% CI =​ 1.17–​1.56, and HR =​1.27, 95% CI =​1.13–​1.42, respectively, both p < 0.001). Li and colleagues (2016b) examined the effects of religious attendance in 1996 on all-​ cause mortality among 74,534 women U.S. Nurses’ Health Study followed for 16 years from 1996 to 2012. There were 13,537 deaths during the 1,104,175 person-​years of follow-​ up. The statistical design rigorously controlled for other covariates, including frequency of religious attendance in 1992; furthermore, those diagnosed with cardiovascular disease or cancer before 1996 (baseline for this analysis) were excluded. Likewise, demographic, socioeconomic, and social, mental, behavioral, and physical health variables were controlled for, and separate analyses also evaluated mediators assessed after the 1996 religious attendance exposure including depressive symptoms, smoking, alcohol consumption, diet quality, number of close friends, having someone close to talk to, optimism, and phobic anxiety. Compared to women who never attended religious services, all-​ cause mortality among women attending more than once/​week (after adjusting for covariates) was 33% lower than that of non-​ attendees (HR =​0.67, 95% CI =​0.62–​0.71). There was also a significant gradient of effect

such that mortality during follow-​up decreased in a dose-​ response manner as frequency of religious attendance increased (p for trend < 0.001). Of the mediators analyzed, higher social support, fewer depressive symptoms, less cigarette smoking, and greater optimism were mediators that explained 23%, 11%, 22%, and 9%, respectively, of the estimated effect on overall mortality risk. McDougle et al. (2016) analyzed data collected on a random sample of 10,317 persons graduating from Wisconsin high schools in 1957 who participated in the Wisconsin Longitudinal Study. Those who reported information on use of coping strategies in the 2004 follow-​up were analyzed for this report (n =​ 3,146, average age 65). Religious coping was assessed in 2004 with two questions beginning with the stem: “When you have problems or difficulties in your family, work, or personal life, how often do you seek comfort through . . . ?” followed by (1) praying, or (2) attending a religious or spiritual service. In addition, self-​ rated religiosity was assessed on a 1–​5 scale from not at all religious to extremely religious. Mortality was then assessed during the 5-​year period between 2004 and 2009. Hierarchical logistic regression was used to analyze the data while controlling for demographics (age, gender, education, net worth, employment status), social embeddedness (marital status, hours volunteering, number of friend visits, extraversion), mental and physical health (number of illnesses, self-​rated health, functional status, smoking, drinking, BMI, depression, stressful life events, cognitive status), secular coping strategies (active, passive, volunteering to cope), and self-​rated religiosity. Results indicated that coping by attending religious services predicted a 28% lower mortality (b =​ −0.33, p < 0.01, OR =​0.72), whereas coping by praying predicted a 66% increased mortality (b =​ 0.51, p < 0.01, OR =​1.66). Note that some of the variables controlled for in these analyses may have been mediators of the effect, not confounders. Idler and colleagues (2017) analyzed data on 18,370 participants age 50 or older in the US Health and Retirement Study. Participants were interviewed in 2004 and followed up through 2014. Religious affiliation, frequency

of religious attendance, and importance of religion in life were assessed in 2004, with all-​ cause mortality examined from 2004 to 2014. Cox proportional hazards models were used to analyze the effects of religious variables on mortality, controlling for demographics (age, gender, race, US-​born status, education, household income, household worth), health status (number of chronic conditions, days spent in bed in past month, self-​ rated health, count of symptoms, pain, activities of daily living, vision and hearing impairments), depressive symptoms, self-​reported emotional/​psychiatric problems, self-​reported memory problems, health behaviors (smoking, alcohol use, BMI, physical exercise, health promotion/​ prevention activities), and social ties (marital status, family size, frequency of socializing, volunteering/​ caregiving). Compared to those who never attended religious services, those who frequently attended were 35% less likely to die during the 10-​year follow-​up (HR =​0.65, 95% CI =​ 0.57–​0.74, p < 0.001). With increasing religious attendance there was a dose-​response effect on mortality (35% for frequent attendees, 23% for regular attendees, and 13% for occasional attendees). Among those who indicated that religion was very important, there was a 4% increased risk of mortality (HR =​1.04, 95% CI =​ 1.00–​1.07, p < 0.05). Again, note the large number of covariates included in these models, which included both confounders and possible mediators or explanatory variables. In a later analysis of this sample, Idler found that the effects of religious attendance were stronger in Blacks than in Whites (Idler, 2020). VanderWeele et al. (2017a) analyzed data on 36,613 participants in the Black Women’s Health Study who were followed from 2005 to 2013. In 1995, when the study first started, participants were age 21–​69 (mean age 38). During the 8-​year follow-​up there were a total of 1,393 deaths. Religious involvement was assessed by attendance at religious services, frequency of prayer, use of religious coping, and self-​rated religiosity. Proportional hazards models were used to examine the effects of religious characteristics on mortality, adjusting for age, perceived stress education, BMI, cigarette smoking, alcohol consumption, SES, exercise, quality of diet, health insurance, physical Mortality • 537

examination, geographical region, daily racism, depressive symptoms, child abuse, history of cancer, myocardial infarction, and stroke. After controlling for these covariates (confounders and possible mediators), frequent attendees (several times/​week) experienced a 32% lower mortality risk (HR =​0.68, 95% CI =​0.56–​0.84) compared to those who never attended religious services, with a dose-​response effect for attendance increasing from 19% to 32% (p for trend < 0.01). Those who prayed several times per day were at slightly higher risk of mortality (HR =​1.08, 95% CI =​0.85–​1.37, p =​not significant [ns]), whereas those who often used religion to cope were at slightly lower risk (HR =​ 0.84, 95% CI =​0.69–​1.03, p =​ns) as were those who indicated they were very religious/​spiritual (HR =​0.84, 95% CI =​0.69–​1.02, p =​ns). Lawrence et al. (2019) analyzed data on 20,410 participants in the 1988–​2002 General Social Surveys in the United States, connecting responses with mortality data from the National Death Index through 2009 covering a 6-​to 20-​year period. Most participants (82%) were under age 65, White Caucasian (82%), and female (56%). The original purpose was to examine the effects of marital happiness on health and longevity. However, effects of attendance at religious services was included as a covariate in Cox proportional hazards models examining the effects of happiness on mortality. Controlled for in these analyses were marital happiness, sociodemographic characteristics (gender, race, parental status), SES (income, education, employment status), location in United States, and survey year. Compared to those attending religious services more than once per week, those who never attended were 25% more likely to die during follow-​up (HR =​ 1.25, p < 0.01), again with a dose-​response effect ranging from 25% increased risk to a 6% risk from never attending to attending once a week, respectively. Kim and VanderWeele (2019) examined the effects of religious attendance on mortality in 5,200 US adults participating in the US Health and Retirement Study, a national random sample of persons age 50 or over. Examined was frequency of religious attendance in 2008 and risk of mortality from 2010 to 2014 using the National Death Index (675 deaths). Linear 538 •  P h y sical H ealth

regression and logistic regression models were used to examine the effects of 2008 religious attendance on mortality during follow-​ up, controlling for frequency of religious attendance in 2006, age, gender, marital status, race, education, insurance status, total wealth, smoking, exercise, alcohol use, BMI, health conditions, social integration, social participation, living situation, contact with children, family, and friends, and physical functioning. Of particular interest in this report were the effects of mediators on the relationship between religious attendance and mortality. Mediators were assessed in 2010, 2 years after the 2008 religious attendance exposure. For those attending religious services once or more per week in 2008, the likelihood of dying during the 2-​to 6-​year follow-​up period was 39% lower than for non-​attendees (OR =​0.61, 95% CI =​0.42–​0.87). The focus of this study was the examination of the proportion of the attendance-​mortality effect mediated through other variables. When mediators of the mortality advantage were examined, greater life satisfaction explained 5.3% of the effect (p < 0.001), fewer depressive symptoms 1.1% (p =​0.05), less hopelessness 1.9% (p =​0.01), less anxiety 3.6% (p < 0.01), less trait anger 2.0% (p < 0.05), less state anger 2.2% (p < 0.05), more contact with friends 10.7% (p < 0.01), more ­exercise 5.4% (p < 0.001), less alcohol consumption 2.6% (p < 0.05), and better physical functioning 0.4% (p < 0.001). In a second study conducted outside the United States (besides the Zeng et al., 2011, study above) again in the Far East, Zimmer et al. (2020) analyzed data from the 1989 Survey of Health and Living Status of the Elderly in Taiwan, which involved 3,849 respondents who represented a random sample of persons age 60 or over. Mortality during follow-​up between 1989 and 2007 was determined by the Taiwan Death Registry. Religiosity was assessed at baseline in 1989 with a single question: “How often do you worship gods, perform rites, pray and read religious texts?” The researchers note that this question does not refer to participation in religious services or frequency of temple attendance, but instead emphasizes personal private aspects of worship. Gompertz proportional hazards regression modeling was used to

control for demographics (gender, mainlander status, age, marital status, rural residence), SES (education, economic condition), health (chronic conditions, functional limitations, self-​rated health), health behaviors (smoking, drinking alcohol, engagement in sports), social involvement (emotional support, living alone, social activity, leisure activity score), and psychological well-​being (life satisfaction, depressive symptoms) in a series of eight models. After controlling for demographics, religiously active individuals were significantly less likely to die during follow-​up (b =​−0.146, p < 0.01). Controlling also for SES slightly weakened this effect (b =​−0.131, p < 0.01), as did progressively adding health conditions (b =​−0.123, p < 0.01), health behaviors (b =​−0.109, p < 0.01), social involvement (b =​−0.115, p < 0.01, alone without health behaviors), and psychological well-​being (b =​−0.120, p < 0.01, alone without social involvement or health behaviors). In the final model with all covariates included (confounders and possible mediators), religiously active individuals were still significantly less likely to die during follow-​up (b =​−0.100, p < 0.05). Based on this finding, the researchers concluded that a religiously active 60-​year-​old Taiwanese female is expected to live more than 1 year longer than her nonreligious counterpart, all other things being equal. Finally, Hill et al. (2020b) analyzed data on 14,743 participants in the Mexican Health and Aging Study between 2003 and 2015. Frequency of religious attendance was the only religious variable assessed in 2003: “How frequently do you participate in events organized by your church?” Cox proportional hazard regression modeling with time-​ varying covariates was used to estimate the relative risk of mortality, controlling for age, gender, marital status, locality size, residence in high out-​migration state, education, and financial status. Possible mediators examined were chronic conditions, functional limitations, cognitive functioning, mental health (depressive symptoms), social support, and health behaviors. After adjusting analyses for both control variables and possible mediators, attending religious services once or more per week predicted a 19% reduction in mortality during the 12-​year follow-​up (HR =​ 0.81, 95% CI =​0.72–​0.91, p < 0.001).

We now review the two studies reporting that those who were more religious experienced greater mortality (i.e., found only negative effects). Toussaint et al. (2012) analyzed data from a national random US sample of 1,232 adults age 66 or older examining the effects of forgiveness on longevity. Included among predictors were conditional forgiveness by God (measured by 3 items, i.e., assessing conditions that must be met for such forgiveness) and unconditional forgiveness by God (1 item, i.e., “God forgives me right away for things I have done; there is nothing I must do first”). Participants were followed over a 3-​year period (2001–​2004) during which 208 persons died. Hierarchical logistic regression was used to control for gender, education, marital status, age, race, region of United States, smoking, and alcohol intake. No effect was found for “God’s conditional forgiveness” on mortality. However, “God’s unconditional forgiveness” predicted significantly greater mortality when included alone in the model (b =​0.255, p < 0.01). However, this effect was reduced to only a trend level once other predictors (particularly age, education, and marital status) were controlled (b =​0.206, p < 0.10). Researchers hypothesized that believing in unconditional forgiveness from God may reduce motivations based on guilt to adhere to religious teachings about appropriate health behaviors, providing license to indulge in unhealthy pleasures. Although plausible, there was only borderline evidence of an association after standard controls were taken into account. Farzanegan et al. (2020) examined the impact of religiosity on delirium severity and mortality among critically ill Shi’a Muslims hospitalized in intensive care units (ICUs) at six academic medical centers in Iran. All participants had to be endotracheally intubated and on mechanical ventilation and be a full-​code (requiring resuscitation). Delirium (assessed by the Confusion Assessment Method for ICU; CAM-​ICU) and in-​ hospital mortality were the primary outcomes. A total of 4,200 patients were included in the final analysis, of whom 1,169 died. Religiosity was assessed through the patient’s designated surrogate (and confirmed by the patient if their condition improved and they were able to respond). A 5-​item religiosity measure assessed Mortality • 539

(1) performance of five obligatory daily prayers, (2) Nafilah prayers, (3) fasting during Ramadan and other recommended days, (4) reading the Qur’an daily, and (5) performing additional acts of faith (e.g., following the Sunnah, saying non-​obligatory prayers, reading sermons of notable imams). Based on responses, participants were categorized into “more religious” (n =​1,704), “moderately religious” (n =​1,778), and “less religious” (n =​718). Bivariate analyses indicated that there was an inverse relationship between religiosity and delirium. However, among those in the high delirium group (n =​ 2,170), in-​hospital mortality was significantly greater among those who were more religious (32.8%; n =​63) compared to the moderately religious (29.1%; n =​367) and those who were less religious (23.8%; n =​171) (p =​0.003). Analyses were not controlled for other covariates (confounders or mediators).

Summary Of the 10 high-​quality prospective studies chosen here to review, 8 (80%) found that greater religious involvement predicted a significant reduction in mortality and 2 reported mixed results. Six of the 8 positive studies (and both studies with mixed findings) found that religious attendance was the only religious variable that predicted greater longevity, whereas in China and Taiwan, a more generic measure of religious participation (and only religious variable measured) was the significant predictor. Two of the 10 studies reported mixed findings, where religious attendance predicted lower mortality in both studies, and private religious activities such as praying and self-​ reported importance of religion predicted greater mortality. Finally, of the two studies that reported only negative effects of religiosity, one finding was borderline in statistical significance (p < 0.10) and the second study of in-​hospital mortality among intubated ICU patients with high delirium scores. Most studies were conducted in the United States, although three studies were conducted in other countries (China, Taiwan, and Iran). Based on earlier research and more recent findings, religious involvement (particularly religious attendance) predicts lower mortality 540 •  P h y sical H ealth

during follow-​up in the vast majority of studies (nearly 70% of over 100 prospective studies), thus underscoring the impact that religiosity may have on physical health. This finding has been reported in studies that controlled for numerous confounders and even some possible mediators, and have followed participants for periods ranging from 1 year to 65 years. The magnitude of this effect is considerable. Three systematic reviews of the literature have reported that religion’s effect on survival is comparable to that of cholesterol-​ lowering drugs, exercise-​ based cardiac rehabilitation, or fruit/​vegetable consumption (McCullough et al., 2000; Hall, 2006; Lucchetti et al., 2011). Furthermore, one systematic review found that the impact of religiosity on mortality was similar in magnitude to that of 60% of 25 systematic reviews of other health interventions (Lucchetti et al., 2011). Some researchers, however, have argued that the effect of religiosity on mortality depends on the cultural context, with effects larger in more religious areas of the world (Stavrova, 2015; Ebert et al., 2020, based on tombstone analysis). The argument is a reasonable one, in that the strength of religiosity’s effects on health may depend on context. However, the same dynamic also occurs in the opposite direction. Just as in religious areas where the nonreligious may come under psychological and social pressures because they are different, the same is also true for religious persons in social and cultural contexts that are hostile to religion, thus perhaps neutralizing any benefit to survival that religiosity might provide in that context. Despite this dynamic, as noted above, religious involvement has predicted lower mortality in both contexts, even in quite secular regions of the world such as in northern Europe, Taiwan, and China (where religious persecution is widespread) (see studies in Appendix). While, as noted in the beginning of the chapter, regions of the world with higher religiosity tend to have lower life expectancy, the existing evidence indicates that, within any country, religious service attendance tends to be associated with greater longevity. On the basis of the existing research, it thus seems that the country-​level associations between religiosity and longevity arise from the fact that economic development

often eventually leads to lower religiosity, rather than religiosity itself leading to lower longevity. Again, almost all of the existing evidence suggests, in contrast, that across different contexts and countries, religiosity itself leads to longer life span.

RECOMMENDATIONS FOR FUTURE RESEARCH Most of the research on religiosity and mortality has involved Judeo-​Christian populations in the United States, and to a lesser extent those in Europe and Israel. There are also a few studies that have been done in China and Taiwan, which are primarily Buddhist and Tao in religious affiliation. Very few studies have been done in Muslim-​majority populations, except two recently conducted studies from Iran. Of the two, one study was published only in Persian (Farsi), except for the English abstract, and examined in-​hospital mortality only (Bagheri et al., 2019). The other study examined mortality in severely ill ICU patients, again assessing only in-​hospital mortality (Farzanegan et al., 2020). As of early 2021, we are not aware of any prospective studies of religiosity and mortality among community-​dwelling Muslim-​majority populations. Such studies are thus needed in Muslim populations—​members of the second most common religion in the world, one that could soon eclipse Christianity in numbers (Pew Research Center, 2015). Furthermore, to our knowledge, there have been no studies of religiosity and mortality in other highly religious areas of the world, including Africa and South America. The reason for this is probably because prospective studies are expensive to conduct and research funding is often limited or unavailable in these regions with developing economies. Besides populations in which religion’s effects on mortality need further study, improvements in methodology are also needed to reduce the possibility of reverse causation, as several of the studies above have already implemented. Indeed, frequency of religious activity—​ particularly frequency of religious attendance—​may actually be an indicator of physical health. Those capable of engaging in such practices must be healthy enough to do so. Eliminating physically ill persons at baseline

in prospective studies can help to address this issue, as was done by Li et al. (2016b). There is also the possibility of reverse causation in the other direction, depending again on religious measure. As people become sicker and closer to death, they often turn to religion, increasing their frequency of prayer and other forms of religious coping, thereby increasing the likelihood that greater personal or private religious activity will predict an increase in mortality risk, especially when follow-​ up periods are short and death rate is high (as might occur when examining in-​hospital mortality among the severely ill). Highly religious individuals may also be more comfortable with dying, and therefore less likely to engage in life-​prolonging procedures or treatments to extend life in futile medical situations. Alternatively, highly religious individuals may also pray for a miracle and be unwilling to “give up on God,” demanding that everything be done to keep the person alive until that miracle occurs (e.g., ventilator support, resuscitation, other life-​ prolonging treatments, avoidance of hospice) despite the presence of untreatable medical conditions (Phelps et al., 2009). This dynamic may be particularly common in ethnic minority communities who do not trust the healthcare system to provide them with equitable care, and instead depend on their religious faith for healing. These dynamics must be considered and taken into account when designing future studies. Another methodological issue has to do with distinguishing confounders from mediators/​explanatory variables when conducting analyses and interpreting results. See Chapter 3 for an explanation of the differences between confounders and mediators. Briefly, confounders are variables related to both religiosity and mortality (such as age, gender, race) that could account for the relationship between the two in observational studies, even if religiosity itself had no effect on longevity. In contrast, mediators or explanatory variables serve to explain how religiosity affects mortality, i.e., the underlying psychological, social, and behavioral mechanisms involved. Mediators do not explain away the relationship between religiosity and longevity (as confounders do), but rather describe how religious involvement accomplishes its health benefits (or risks). Mortality • 541

Consequently, if an investigator controls for mental health conditions, social support and integration, and health behaviors, and the result is that no relationship is found between religiosity and mortality, this does not mean that no relationship exists. It may mean only that psychological, social, and behavioral factors have fully explained the effect. In order to establish whether a particular covariate is truly a mediator, the mediator should ideally be measured after baseline religiosity is assessed (not concurrently or beforehand) and before the outcome, and confounders should ideally be measured before the religiosity variable. Again, Li et al. (2016b) serves as a model study in this regard. Most of the research showing that religiosity predicts greater longevity has measured religiosity in terms of attendance at religious services. A few studies have also assessed other indicators of religiosity, often single items assessing self-​rated religiosity or private religious activity such as prayer or religious coping. These indicators of religiosity, however, have only rarely been found to impact longevity, and sometimes appear to predict greater mortality (perhaps, as noted above, due to reverse causation). As in the previous chapter on cancer, although religious service attendance is highly predictive, we recommend that researchers also consider using multi-​item measures of religiosity that assess religious devoutness or intrinsic religious commitment, indicators of sustained religious involvement over time rather than forms of religiosity that increase in response to distress (foxhole religion). Sustained religious commitment across multiple domains of religious involvement may be what it takes to impact and maintain attitudes/​behaviors that affect physical health (see Chapter 2). Finally, the length of an individual’s exposure to religious involvement needs to be considered. The total effect that religiosity has on physical health is likely to accumulate over many years, depending on the intensity of religious involvement. For example, an individual who has lived a devout religious life for 50 years is more likely to accumulate the health benefits of religion than a person who has been religious for only 1 year, perhaps starting after they became sick. Length of exposure, then, cannot be ignored, 542 •  P h y sical H ealth

just as it would not be ignored when studying any other mortality risk factor (e.g., cigarette smoking, measured by number of cigarettes smoked per day multiplied by years smoking, called “pack-​years”). However, of the more than 100 prospective studies of religion’s effects on mortality, perhaps only one (Li et al., 2016) has examined length of exposure. As noted in prior chapters, marginal structural models (Robins et al., 2000; VanderWeele et al., 2016a) can be a helpful tool to examine the effects of sustained religious service attendance over time, while also accounting for time-​varying confounding. The extent to which religion impacts longevity based on exposure across the life span is indeed a complex task for those wanting to determine the overall effect that religiosity has on health and longevity. This has been a particular issue in observational studies since, as noted above, most of that research has assessed religiosity at only one point in time and then has examined survival from that point onward. Measuring religious involvement at only one time point in such studies is a poor measure of lifetime exposure, especially when researchers remove the effects of religion’s prior effects on health by controlling for health status at the time that religiosity is measured. Furthermore, researchers seldom assess whether religiosity has changed since baseline (increased, decreased, or remained the same) during the observation period, which could also contribute to level of exposure. Given the stability of religious beliefs and practices over time, examining the effects of religious involvement at one point in time on future survival will probably only provide a ballpark estimate of the magnitude of religion’s overall effect. Once again, marginal structural models can be useful to address these questions. Thus, future research studies should seek to assess total lifetime exposure to religion and the intensity of that exposure when examining whether religiosity affects longevity and how much of an overall effect it has.

CLINICAL APPLICATIONS Many of the applications proposed here for clinicians and religious professionals are similar to those mentioned in earlier chapters.

Clinicians Applications for clinicians involve taking a spiritual history, supporting the patient’s religious beliefs and practices, and perhaps educating religious patients about the benefits that religious involvement may have on their health, particularly active involvement in a religious community. Religious patients can be encouraged to engage in healthy behaviors such as cessation of smoking, light alcohol use, regular exercise, attention to healthy diet, weight reduction, and maintenance of an ideal body weight, as a way of honoring their physical body as sacred. For patients who are socially isolated, clinicians might consider encouraging involvement in a faith community, especially religious patients who have a history of such involvement but have reduced or stopped attending services for a variety of reasons. As noted in previous chapters, religious clinicians could consider giving education classes in their own faith communities, teaching fellow congregants the benefits (and potential risks) that religious involvement may have on physical health and longevity. Clinicians may also need to have discussions with patients toward the end of their lives about the role that religion can play in a peaceful death. Of particular importance is reviewing the patient’s and family’s beliefs about miracles, particularly in medically futile situations where treatment is being aggressively pursued.

Religious Professionals For religious mental health professionals (chaplains, pastoral counselors, religious counselors), applications include educating others about the health benefits of religious involvement. This may also include utilizing clients’ religious resources as part of interventions to enhance their mental, social, and behavioral health in ways that can impact longevity. For community clergy, applications involve the education of congregants in sermons and religious education classes about the health benefits of religious faith. This may include the development of health ministries within congregations to reinforce such concepts and provide opportunities for members to apply them in their own lives and in the lives of others.

As recommended for clinicians (and perhaps in collaboration with those clinicians), clergy must educate members of their congregation about death and dying, particularly when further medical efforts to prolong survival are no longer indicated and it is time to use their faith to achieve a peaceful death. The goal here is a delicate one that involves helping to maintain hope, while at the same time recognizing the reality of circumstances. As noted in the previous chapter, achieving this goal may require addressing issues related to long-​standing conflicts with family and friends, making efforts to both give and receive forgiveness from those involved. Several excellent articles have been written about the tasks of dying and spiritual needs of those at the end of life (Corr, 1992; Hermann, 2001). Clergy are also ideally positioned to help those who are dying to say goodbye to family members in this life and to help those family members or friends release the dying person into the next life. Clergy, particularly from conservative and fundamentalist faith traditions, should also be prepared to deal with beliefs that the dying person and family members may have about hell and the possibility of eternal separation from loved ones. Patients may express regret over the way they have lived, for example by smoking and developing cancer. Or a family member may believe that a loved one must confess Jesus Christ as their Lord and Savior or be eternally damned and forever separated from them. This may create much suffering for both the family member and the dying person. Such discussions can be uncomfortable to have, but often cannot be avoided. A kind and gentle approach (with an emphasis on God’s unlimited love and forgiveness) may bring great comfort to both the dying person and grieving family members. Religious patients and family members will almost certainly look to their clergy for help in resolving such issues, requiring those clergy to carefully balance theological beliefs with a spirit of compassion and understanding.

SUMMARY AND CONCLUSIONS This chapter has focused on the effects of religiosity on mortality, where longevity may serve Mortality • 543

as a measure of the cumulative effects of religious attitudes, beliefs, and practices on physical health across the life span. We began the chapter by discussing the average length of life, which has increased dramatically over the past several centuries both in the United States and around the world, but appears to have stabilized and actually declined in the United States during the past few years. Next, risk factors for mortality were examined, including demographic, genetic, biomedical, environmental, psychological, social, and behavioral influences. This was followed by a case vignette illustrating the effects of religiosity on longevity, and then by theorizing about how religious involvement might impact longevity through known mortality risk factors discussed earlier. We then reviewed systematic quantitative research examining the effects of religiosity

544 •  P h y sical H ealth

on mortality, covering both earlier and more recent research, with a focus on high-​quality prospective studies. Summarizing the findings, we concluded that nearly 70% of over 100 prospective studies have reported that religious involvement, particularly religious attendance, predicts greater longevity. Based on published reviews of this research, the effects of religion on longevity were found to be comparable to those of cholesterol-​lowering drugs, exercise-​ based cardiac rehabilitation, or fruit/​vegetable consumption. Recommendations for future research were then provided, followed by suggestions for application by clinicians and religious professionals. In the next chapter, we examine the effects of religiosity on physical disability, an aspect of health that for some may make death a preferable outcome to a life drastically altered by physical health impairments.

28 Physical Disability If the head and body are to be well, you must begin by curing the soul, that is the first thing. —​Plato

IN THIS CHAPTER we focus on the effects of religious involvement on the development and course of physical disability. We do not examine the effects of religion on coping with disability, other than in the clinical applications section of this chapter, since this area is covered in Chapter 4. Rather, the emphasis here is on whether religious involvement can help to prevent the development of physical disability with aging as accidents occur or chronic illnesses develop, threatening the ability to function independently without assistance. Physical disability is present when people have difficulty performing activities of daily living (ADLs) necessary to care for basic and instrumental needs. Basic ADLs include activities such as eating, toileting, dressing, bathing, transitioning from bed to chair, or other activities involving movement; these are also called physical ADLs. Instrumental ADLs involve higher-​order tasks, such as shopping, housekeeping, managing money, telephone

use, traveling in the community, or preparing meals. Physical disability is not an all or none phenomenon, but rather exists on a spectrum from minor functional impairment to complete and total disability requiring 24-​ hour care. Physical disability is most accurately determined by objective assessment of physical abilities. Since physical disability is often determined in questionnaires by self-​reported ability to perform ADLs, it is more of a subjective evaluation of one’s physical abilities than an objective one, thus allowing psychosocial factors to contribute. While some of those psychosocial factors may protect an individual from negative perceptions and distressing experiences of physical disability, others may increase or exaggerate such perceptions for any given level of objective physical impairment. Subjective perceptions of disability are particularly important since they may lead to greater objective physical impairment.

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0028

For example, two people of similar health have a stroke of similar severity, both initially with partial hemiparesis, making it difficult to use the right side of the body. One person is emotionally devastated by the stroke, gives up, and stops trying to do things for himself. That person becomes physically deconditioned and ends up in a wheelchair, able to do few things independently, needing to be increasingly cared for by others. The second person accepts her right-​sided weakness, and instead makes every effort to compensate and strengthen affected muscles. That person works hard to rehabilitate and soon is able to use a walker to get about, and while needing assistance with some activities, is able to perform most ADLs independently. Likewise, consider two people with congestive heart failure with the same objective level of illness severity. One perceives herself as severely disabled and magnifies physical impairments, whereas the other emphasizes the activities he can do, seeing himself as only moderately disabled and still capable of performing many activities independently. Thus, factors other than objective physical disability—​particularly psychological and social factors—​determine one’s level of physical functioning. Religious involvement may be related to perceptions of disability and ultimately to objective disability through psychological, social, and behavioral pathways.

problems with independent living at 6.8%, difficulty with hearing at 5.9%, vision at 4.6%, and self-​care at 3.7% (with some overlap between categories). Unsurprisingly, percentages were higher in persons age 65 or over: 26.9% for mobility limitations, 9.5% for cognition, 14.9% for hearing, 6.6% for vision, 9.8% with independent living, and 5.5% for self-​care. Overall, significant physical disability was present in 41.7% of older adults, compared to 28.6% of those in middle age and 16.6% of young adults. Thus, nearly half of all community-​ dwelling adults age 65 or over in the United States have some form of disability, not counting older adults who are institutionalized in nursing homes or other non-​community settings. The above study also found that disabilities at all ages were more common among (1) women (except for hearing and self-​care), (2) persons living in poverty, (3) individuals living in the Southern United States, and (4) those with certain chronic conditions such as arthritis and heart problems. Among older adults, Asians were least likely to experience physical disability (34.8%) and American Indian/​Alaska natives were most likely (54.9%); in between were White Caucasians (40.2%), Blacks (46.7%), and Hispanics (50.5%). Furthermore, certain lifestyle factors in all age groups were associated with greater disability, including cigarette smoking, being overweight or obese, and having hypertension or diabetes. PREVALENCE AND COST OF Worldwide, 15.6%–​ 19.4% of persons age PHYSICAL DISABILITY 15 and older have some level of disability, The latest available data on the prevalence and 2.2%–​3.8% experience disability that sigof disability come from the US Centers for nificantly interferes with functioning (WHO, Disease Control (CDC). This information was 2011). Between 1990 and 2017, there was a collected during the 2016 Behavioral Risk 66% increase in years lived with disability for Factor Surveillance System (BRFSS), a random-​ health conditions that might benefit from digit-dialing telephone survey of community physical rehabilitation (Jesus et al., 2019). adults age 18 or older in the United States Even after taking the increase in world popu(Okoro et al., 2018). Participants in that survey lation into account, there was still an increase included 121,674 persons age 18–​44; 174,413 of 17% in years lived with disability (which persons age 45–​64; and 162,724 persons age 65 could be at least partly explained by increases or older. The BRFSS survey assessed six types in longevity). The most common causes of disof disability: hearing, vision, mobility, cogni- ability worldwide based on the 2017 Global tion, self-​care, and independent living. Overall, Burden of Disease Study vary by age. Among 25.7% of all US adults (61.4 million) reported those under age 10, nutritional deficiencies and some type of disability. Difficulty with physical diabetes predominate; among those in middle mobility was most common at 13.7%, whereas age, musculoskeletal problems such as low back cognitive disability was present at 10.8%, pain and headache are primary causes, along 546 •  P h y sical H ealth

with depression; and among those age 65 or older, musculoskeletal disorders, sense organ diseases, and cancer are most likely (James et al., 2018). Providing healthcare to those with physical disability is expensive. In the United States alone, the total national disability-​associated healthcare expenditure in 2006 was $397.9 billion, of which $161.1 billion was covered by Medicaid and $119.0 billion by Medicare (Anderson et al., 2011). The $397.9 billion figure in 2006 is equivalent to $508.9 billion in 2020 dollars. This does not include the increase in expenditures between 2006 and 2020 due to an aging population surviving with chronic illness due to improved medical care, but often with physical disability. This figure also does not include the cost incurred by family members who must often care for loved ones with disability, nor the time taken off from work to do so. There are also many secondary health consequences of disability, including bowel and bladder problems (urinary tract infections and kidney stones), accidents (including falls), fatigue, deconditioning, osteoporosis, depression and suicide, weight gain, chronic pain, and the development of pressure sores or ulcers (CDC, 2020a). Physical disability is one of the strongest predictors of nursing home placement (Hatoum et al., 2009; Dufournet et al., 2019). Hatoum and colleagues (2009) found that for every 1-​point decline in ADLs on a scale from 0 to 30, the risk of nursing home admission increased by 3% (after controlling for cognitive function). This means that a 10-​ point drop in ADL score increases the risk of nursing home placement by almost one-​third. Population projections for the United States indicate that dramatic increases in the number of persons with disabilities and the cost of caring for them are expected in the future. This is due to the aging of baby boomers and the fact that women—​who live longer than men—​have high rates of disability (Vespa et al., 2018). This trend will no doubt increase pressure on the healthcare system and government funding sources.

whether anything can be done to change them. Non-​modifiable risk factors usually need to be controlled for as confounders when examining the effects of religiosity on physical disability, whereas modifiable risk factors may be considered mediators or explanatory variables through which religion has an effect on physical disability, though such variables may also be confounders if assessed prior to religious involvement. However, non-​ modifiable and modifiable risk factors may interact with each other in affecting physical function, so this too must be considered. With regard to the Handbook, a central purpose of discussing individual characteristics that increase risk of physical disability is to identify ways that religious involvement might impact disability through these pathways.

DISABILITY RISK FACTORS

Lower SES and lower education are both predictors of increased physical disability among older adults and individuals at any age. Increased education improves knowledge

Risk factors for disability are categorized below as non-​ modifiable and modifiable, based on

Non-​Modifiable Age, sex, and race cannot be modified, whereas socioeconomic status (SES), genetic factors, and some medical conditions may be modifiable to some extent. Increasing age, particularly over age 75, is associated with increased disability (Kostadinovic et al., 2019). Female gender is also associated with greater problems with physical functioning because of lower muscle mass and increased adiposity in comparison to males (Straight et al., 2015). Mexican Americans and African Americans are more likely to have physical limitations in later life compared to White Americans, and this is thought to be due to these ethnic minorities’ involvement in more strenuous and dangerous jobs that may be associated with workplace injuries or musculoskeletal trauma (Andrasfay & Goldman, 2020). With regard to genetics, conditions present since birth that cause lifelong disability include spina bifida, muscular dystrophy, Down’s syndrome, and other inherited disorders that affect neurological, muscular, and/​or skeletal systems.

Partially Modifiable

Physical Disability • 547

about health behaviors, enhances one’s sense of personal control, and expands access to healthcare resources (Kostadinovic et al., 2019). Socioeconomic conditions may be modified to some degree by individual motivations and government policies at the societal level. Genetic factors may be modified to some extent by genetic counseling. Inherited influences that increase risk of obesity or arthritis, while difficult to change, may also be altered by attention to diet, weight, and regular exercise. Medical illnesses associated with increasing age are also modifiable to some extent, particularly if affected by psychological, social, and behavioral factors (see below). With increasing age, however, chronic illnesses accumulate, and the physical body eventually wears out. Certain infectious diseases acquired in childhood such as polio may have lifelong effects on physical functioning, which can be improved to some extent by good medical care and the use of assistive devices.

Modifiable Modifiable risk factors for physical disability include medical illnesses and accidents, access to and timely seeking of medical care, psychological states both negative (stress, depression, anxiety, neurosis) and positive (purpose and meaning, optimism and hope, happiness and well-​being), social interactions (social support and integration that reduce social isolation and loneliness), and health behaviors (cigarette smoking, excessive alcohol use, illicit drug use, physical inactivity, and obesity). Psychosocial, behavioral, and physical factors often interact to produce a downward spiral of worsening disability, which adversely affects mental, social, and behavioral health, which in turn further worsen physical disability. MED I CA L I L L N E S S /​ACCIDE NTS

The most common cause of disability in the United States is arthritis/​ rheumatism. In 2013–​2015, over 50 million US adults (23% of the population) had physician-​ diagnosed arthritis, of whom nearly half (44%) had physical activity limitations due to the condition (Barbour et al., 2017). Although the prevalence 548 •  P h y sical H ealth

of osteoarthritis (the most common form of arthritis) increases with age, there are certain behaviors under the person’s control that may limit its progression. For example, the type of exercise may increase or decrease risk, with running causing greater physical strain on weight-​bearing joints compared to cycling or swimming. Likewise, some types of work may place greater strain on joints, such as jobs with greater physical demands on the body compared to office work. Cardiovascular diseases (including stroke), chronic obstructive lung disease, dementia, diabetes, and several other chronic medical conditions increase risk of physical disability, yet are modifiable by improving health behaviors (Bauer et al., 2014). Accidents, particularly motor vehicle accidents, may likewise be prevented by avoiding drugs and alcohol and obeying traffic laws. P SYCH OL OGICAL FACTORS

Psychological factors that adversely affect physical functioning include perceived stress, certain personality styles, depression, and anxiety. Those that enhance physical function include having purpose and meaning in life, being optimistic and hopeful, and experiencing other positive emotions that serve to motivate individuals to care for themselves and thereby recover more quickly from illnesses that may otherwise lead to chronic disability. Perceived stress during midlife has been shown to increase risk of disability decades later. For example, in a 28-​year prospective study of 2,994 male and female Finnish municipal employees age 44–​58, compared to those with no stress symptoms, participants who at baseline reported negative reactions to work, problems with cognition, trouble with sleep, or complained about somatic stress symptoms were 2–​3 times more likely to experience physical mobility limitations 28 years later (Kulmala et al., 2013). The personality trait of neuroticism may also increase risk of developing physical impairments for any given level of objective disability (Jang et al., 2003). Neuroticism, as noted in Chapter 11, involves excessive worrying, nervousness, emotionality, insecurity, feelings of inadequacy, and hypochondriacal concerns.

Depression is a widespread cause of physical, social, and occupational disability. According to a report from the World Health Organization in 2015, depression was present in over 322 million people (4.4% of the world’s population), making it the leading cause of disability in the world (WHO, 2017; Friedrich, 2017). The number of individuals worldwide with depression increased by 18.4% between 2005 and 2015, with nearly half of affected persons living in Southeast Asia and the Western Pacific region. In an early review of prospective studies examining depression and disability in older adults, Lenze and colleagues (2001) reported that among subjects not disabled at baseline, the existence of depression increased the risk of developing future physical disability by over 60%. Depression reduces work participation (increased sick leave) and work functioning (loss of productivity), increases the risk of physical illness (vascular disease, and possibly cancer, osteoporosis, and hip fracture), adversely affects compliance with medication and other treatments, increases smoking and physical inactivity, interferes with rehabilitation, and reduces social interaction and support. Anxiety disorders, which are particularly prevalent in North, Central, and South America, are the sixth most common cause of disability worldwide, increasing between 2005 and 2015 by 14.9% (WHO, 2017). In a prospective study of 4,757 general practice patients from across Europe who were assessed at baseline, and 6, 12, and 24 months later, Stegenga et al. (2012) found that those with significant anxiety levels were more likely to have low levels of physical function at baseline and during follow-​up (β =​ −4.12, 95% CI =​−5.39 to −2.86), an effect that was even greater if both depression and anxiety were present at the same time (β =​−5.74, 95% CI =​−7.38 to −4.10). These effects persisted after controlling for age, sex, marital status, education, lifetime depression, employment status, financial strain, immigrant status, and ethnicity. The authors speculated that depression and/​or anxiety may have increased the likelihood of developing medical illnesses that adversely affected physical functioning. Poor physical functioning, in turn, also predicted an increase in depression (OR =​1.83, 95% CI =​1.08–​3.10), and an even larger increase in

anxiety (OR =​2.79, 95% CI =​1.52–​5.12, after adjustment for confounders) during the 24-​ month follow-​up. The largest increase in risk was seen among those with high levels of anxiety and depression present together at baseline (OR =​5.05, 95% CI =​2.55–​9.99). In contrast to the effects of negative emotions, having greater purpose and meaning in life predicts a lower likelihood of developing physical disability over time (Mota et al., 2016; Musich et al., 2018; Ribeiro et al., 2020). Psychological resilience characterized by a sense of greater purpose in life has been shown to buffer the negative effects that chronic illness has on physical disability (Manning et al., 2016; E.S. Kim et al., 2017). Having specific goals in life influences a person’s motivation to recover from illness, prompting them to participate actively in rehabilitation programs—​ whether that involves recovery from surgery or from childhood illnesses (Smith & Zautra, 2004; Harrison and Stuifbergen, 2006). Indeed, having a reason to live at any age will increase the likelihood that individuals will expect more of themselves and thus engage in function-​ maintaining physical activities. Likewise, individuals who are more optimistic and hopeful are more likely to engage in treatment recovery efforts (Martz & Livneh, 2016). For example, in a prospective study of 65 patients undergoing spine surgery, Skolasky and colleagues (2008) found that those who were more optimistic prior to surgery were more likely to attend physical therapy sessions during the 6 weeks following surgery. Likewise, in a prospective study of 33,326 women with no major chronic diseases at baseline, participants scoring high on optimism were more likely to be free of chronic diseases, have no subjective memory impairment, and have no major physical limitations when assessed 8 years later (James et al., 2019). Similar findings were reported for a 6-​to 8-​year prospective study of 5,698 men and women participating in the US Health and Retirement Study, where those who were more optimistic experienced a 24% increased likelihood of remaining free of chronic diseases, having no significant memory impairment or any major physical limitations (HR =​1.24, 95% CI =​1.11–​1.38) (E. S. Kim et al., 2019). Physical Disability • 549

Positive emotions such as well-​being, satisfaction with life, and feeling happy predict faster recovery of physical function in those with disabling neurological or musculoskeletal disorders. For example, Ostir and colleagues (2008) assessed 832 older adults for 3 months after suffering a stroke and admission to an inpatient medical rehabilitation facility. Positive emotions were assessed at discharge with a composite measure of feeling good, happy, hopeful about the future, and enjoying life. High scores on this measure at discharge predicted higher overall functional status (b =​ 0.70, p =​0.001), better motor status (b =​0.37, p =​0.003), and better cognitive status (b =​0.30, p =​0.0001) 3 months later. Positive emotions also appear to delay the onset of disability with increasing age. In a 3-​ year prospective study of 9,981 community-​ dwelling adults in Australia, baseline happiness and life satisfaction predicted more than a 50% greater likelihood of having no long-​ term health limiting conditions on follow-​up (OR =​1.53, 95% CI =​1.1.35–​1.75, and OR =​ 1.51, 95% CI =​1.25–​1.82, respectively, both p < 0.0001) (Siahpush et al., 2008). Finally, in a meta-​analysis of 17 prospective studies examining the impact of psychological well-​being, positive affect and life satisfaction on the recovery and survival of physically ill patients (all ages), Lamers et al. (2012) found an overall 39% increase in recovery from physical illness (likelihood ratio [LR] =​1.39, 95% CI =​1.06–​ 1.82) and 11% increase in survival (LR =​1.11, 95% CI =​1.03–​1.19) among those scoring high on these positive emotions. S O C I A L I N TE RACT IONS

Supportive interactions with others also affect the development of physical disability. Simply being married reduces the likelihood of having physical limitations in later life (Kostadinovic et al., 2019). Having supportive relatives and friends helps to buffer against depression and anxiety, enhances motivation to recover (gives people a reason to recover), and increases participation in social events that require physical activity. However, the opposite is true for negative social exchanges with close family members and friends (Rook & Charles, 2017). 550 •  P h y sical H ealth

Engaging in altruistic activities also impacts risk of disability by mobilizing the person to help others, which may both distract them from their own health problems and activate them in a way that enhances their physical functioning. Both cross-​sectional and prospective studies find that volunteers and those providing help to others experience fewer physical disabilities. For example, in a survey of 2,016 members of the Presbyterian Church from across the United States, giving help to others was associated with significantly better physical functioning, assessed using the SF-​36 (Schwartz et al., 2003). Likewise, Brown and colleagues (2005) found that giving help to either kin or non-​kin was positively associated with ability to perform ADLs in 1,118 older adults living in Brooklyn, New York. Of course, with these cross-​sectional studies, the reason for better physical functioning in volunteers may be that engaging in volunteer activities requires good physical functioning. Nevertheless, prospective studies report similar findings. Morrow-​Howell et al. (2003) examined the effects of volunteering on physical disability in more than 2,500 community-​ dwelling adults age 60 or over whom they assessed over 3–​5 years. Volunteering predicted significantly less functional disability at follow-​ up. Likewise, in a 2-​year prospective study of 4,860 persons over age 70, Luoh and Herzog (2002) found that, compared to non-​volunteers or those volunteering less than 100 hours per year, those who volunteered 100 hours or more were significantly less likely to experience ADL limitations, an effect that persisted after adjusting for demographics, SES, and baseline functional limitations. More recent prospective studies and randomized controlled trials (RCTs) confirm these earlier findings (Carr et al., 2018; Varma et al., 2016). H EALTH BEH AVIORS

Behaviors such as cigarette smoking, excessive alcohol use, drug misuse/​abuse, physical inactivity, and excessive food intake with unhealthy weight gain play a major role in the development of physical disability with aging, as does access to regular healthcare services and willingness to seek healthcare.

For example, in a 13-​year prospective study of 1,769 women, age 56–​68 (SWAN: Study of Women’s Health Across the Nation), Sternfeld et al. (2017) reported that for every 1-​point increase on a measure of healthy lifestyle (HLS: smoking, physical activity, and diet) at baseline, the time to complete a 4-​meter walk was 0.06 seconds faster when measured 13 years later, independent of confounders. Likewise, in a 20-​ year prospective study of 6,825 participants followed from midlife to early old age (54–​84 years), those reporting persistent physical inactivity or declining activity, a recent or past history of smoking, and current or past heavy drinking experienced a significantly higher risk of physical disability (Artaud et al., 2016). In that study, risk of disability increased with number of unhealthy behaviors, with a 2.7-​ fold increase among those with 2–​3 unhealthy behaviors (OR =​2.69, 95% CI =​2.26–​3.19). With regard to cigarette smoking, a meta-​ analysis of prospective studies involving a total of 61,905 participants reported a 22% increased risk of “frailty” among those with a history of smoking (RR =​1.22, 95% CI =​ 1.12–​1.33, p < 0.001) (Amiri & Behnezhad, 2019). Among current smokers in that review, the risk was increased by 63% (RR =​1.63, p < 0.001). Despite recent reports on the benefits of moderate drinking, even moderate alcohol use is known to cause cerebral cortical shrinkage (Topiwala et al., 2017) and some forms of cancer (Boissoneault, Lewis, & Nixon, 2016), increasing the risk of physical disability in later life. Heavy alcohol use, though, predicts large changes in brain structure, cognitive functioning, and increased risk of dementia, a major cause of disability in later life (Rehm et al., 2019). Prescription and nonprescription drug misuse/​abuse, particularly opioids and benzodiazepines, are associated with increased ADL impairment and increased risk of falls (and disability-​causing fractures) in persons of all ages (Ford et al., 2018), but particularly older adults (Grella & Lovinger, 2012). Illicit drug use also leads to more rapid progression of several chronic diseases that lead to physical disability (Bundy et al., 2018; Raposeiras-​Roubin et al., 2017). In contrast, regular physical activity helps to keep muscles and tendons strong and loose,

improves balance, and enhances the ability to move about freely and painlessly. As a result, exercise, exercise training, and physical activity reduce the likelihood of back problems and musculoskeletal pain, delay disability in persons with arthritis, and reduce the disability associated with coronary heart disease (Gabriel et al., 2017; Falck et al., 2019). Physical inactivity, in turn, increases risk of deconditioning and development of impairments in multiple domains of physical functioning (Stenholm et al., 2016; Cunningham et al., 2020). Being overweight or obese, which physical activity and exercise help to protect against, also increases risk of developing physical limitations across the life span. Obesity in both midlife and later life is associated with increased physical disability, more than doubling the risk for both men and women (Rogers et al., 2020; Meadows & Bower, 2020). A vicious downward cycle often results, as overweight individuals find it more difficult to be physically active, and as moving about becomes more strenuous and tiring, this leads to further weight gain and less physical activity. Access to and timeliness of seeking medical care may help to reduce physical frailty by identifying disabling illnesses early on and treating them in a timely fashion (Meade et al., 2015; Davidsson & Södergård, 2016). Obtaining psychiatric care for depression and other emotional disorders in those who are disabled may also reduce disability or prevent its progression, breaking the downward cycle described earlier. Willingness to seek healthcare is another important factor. This depends to some extent on being hopeful and optimistic, possessing healthcare literacy and adequate finances, being willing to acknowledge the presence of illness, and having a healthcare advocate.

Summary Physical disability is widespread in the United States and around the world, and is very costly to disabled persons, their families, and society. There are demographic, genetic, biomedical, psychological, social, and behavioral characteristics that increase the risk of physical impairments interfering with physical functioning. Physical Disability • 551

We now turn to the role that religiosity might play in forestalling disability. If religiosity does impact the development and course of physical disability, then it may well do so through one or more of the risk factors described above. After providing a case vignette that illustrates the impact that religious involvement can have on recovery from disability, we theorize how religiosity might do so through the various disability risk factors described above.

RELIGION AND DISABILITY Case Vignette Bill is a 66-​year-​old retired mill worker. He worked hard most of his life and saved his money for retirement, planning to spend time on hobbies, travel with his wife to see more of the United States, and visit friends and family. Bill and his wife were regular churchgoers and spent a lot of time volunteering for their church’s food kitchen and hospital visitation ministry. This was an activity they both enjoyed, one that enriched their relationship and led to many new friends. One morning, however, Bill woke up and found his speech garbled and had difficulty moving his right arm and leg. He was terrified and made signs to his wife to call an ambulance. The ambulance soon arrived and rushed him to the hospital. The doctor in the emergency room immediately examined him and transported him to the radiology suite, where he had an emergency brain MRI. At the same time, a nurse started an intravenous line and after the films were taken, the doctor injected some medicine into his veins. The MRI indicated that Bill had experienced a stroke involving his brain’s speech center and motor cortex affecting his right side. After four days in the hospital, he was discharged to a rehabilitation center, where he began physical therapy. Throughout this time, Bill and his wife prayed that God would heal him or give them both strength to cope with

552 •  P h y sical H ealth

the stroke. Friends at church were also praying for him, and the pastor and several church members came to visit while he was in the hospital. Bill worked hard during his time at the rehabilitation center. Although he and his wife could do without the travel, they didn’t want to give up volunteering together at church, and Bill was determined that this stroke would not stop them. With much effort, he slowly improved and regained partial use of his right leg and arm, enabling him to move about independently with a walker. Speech therapy also helped to improve his speech, although it remained difficult for others to understand him. To compensate, he used a writing board to communicate. By the time he was discharged from rehab, church members had built rails in their bathroom and around the house that he could hold onto with his left hand and thus get about without a walker. Church members also brought meals for two weeks while Bill and his wife adjusted to being at home. They also mowed the grass and kept the yard nice until Bill could hire a yardman to take over the job. After two months at home, Bill and his wife felt ready to start volunteering again at the church’s food pantry, and two months after that, they tried hospital visitation. Bill’s speech had improved considerably, and if he had trouble getting across a point, he used the writing board. Although life had changed and they could not do everything they had planned, Bill and his wife were making a difference in people’s lives and were thankful for this. There are many ways that religious involvement may affect the development of disability and what happens after someone has become disabled. We now theorize on the various pathways by which religiosity could impact physical disability.

Demographic Factors Religious beliefs and practices cannot change a person’s age, sex, race, genes, or the development of inherited childhood illnesses. However,

growing up in a religious home and abiding by religious beliefs and moral values during youth could affect a person’s SES later in life, the availability of resources to manage their disability, and the presence of health insurance that could increase access to healthcare for conditions that cause disability. As noted in earlier chapters, if religious involvement during adolescence and young adulthood prevents problems with substance abuse, delinquency, and out-​ of-​ wedlock pregnancies, then these young people will be more likely to complete their education, get a good job (one that does not involve a lot of physical labor that could adversely affect their musculoskeletal system), and live in a safe neighborhood (where physical assault is less likely and green space for exercise is more available).

Medical Illness/​Accidents If religious involvement is associated with lower blood pressure (Chapter 21), less cardiovascular disease and stroke (Chapters 20 and 22), less chronic lung disease from smoking (Chapter 17), lower rates of some cancers (Chapter 26), and less dementia (or cognitive decline) in later life (Chapter 23), then the physical disability caused by these medical conditions will be less. Furthermore, if religious persons are less likely to use mind-​altering substances (Chapter 10) when driving or in other potentially dangerous situations, are more likely to obey driving laws, and less likely to engage in risky activities, then disability-​ causing automobile accidents and other unintentional injuries will also be less common.

Psychological Factors If religious beliefs and moral values help to form the way a person lives and treats others, then stressful life events and chronic stressors will be less common and less likely to result in physical disability. Likewise, if religious beliefs help persons to cope better with life’s challenges (Chapter 4), which include the development of disability, then rates of depression and anxiety will be lower (Chapters 5 and 8), and positive emotions will be more frequent (Chapter 12). As noted earlier, depression and anxiety both

increase risk of physical disability and are frequent in those with disability, worsening its course over time. Positive emotions such as life satisfaction, well-​being, optimism, hope, and meaning and purpose in life have the opposite effect, helping to forestall the development of disability and motivating individuals with disabling health conditions to actively engage in rehabilitation efforts.

Social Interactions As noted earlier, supportive social interactions with others, including having a stable marital relationship and family life, reduce the likelihood of physical impairments later in life. Furthermore, having more social support helps people recover more quickly from health conditions that cause functional impairments. Because religious involvement increases the likelihood of a stable and satisfying family life (Chapter 14), fosters a larger social network and greater social support (Chapter 15), and encourages altruistic prosocial activities (Chapter 15), then family and friends will be more available to encourage physical activity and motivate the person to seek timely healthcare as needed. Likewise, if physical disability does occur, family members and social resources will be available to help the person more fully engage in rehabilitation efforts, cope better with whatever disability remains (as with Bill in the case vignette above), and be around to provide practical assistance with ADLs if necessary.

Health Behaviors As noted above, some of the most common causes of physical disability are modifiable health behaviors. People who smoke cigarettes, use large amounts of alcohol, become addicted to prescription or nonprescription drugs, engage in a sedentary lifestyle, consume unhealthy diets, or gain excessive amounts of weight are more likely to develop physically disabling conditions as they age. Religious involvement, in turn, is related to less cigarette smoking (Chapter 17), less use of alcohol and drugs (Chapter 10), more physical activity (Chapter 18), and a healthier diet (Chapter 19). Religious Physical Disability • 553

persons are also more likely to seek regular medical care and tend to be more adherent to medical treatments (see Appendix for studies), thereby positively impacting the course of medically disabling conditions. Therefore, it makes sense that lifelong religious involvement ought to help prevent the development of physical disability through these behavioral pathways. However, if religious individuals are more likely to be overweight or obese, or avoid medical care because they prefer religious healing practices, then physical disability could be more common in such individuals.

Summary There are many pathways through which religiosity might impact physical functioning as physical impairments accumulate over time with aging. The extent to which such positive effects are evident in empirical studies should be assessed. What has systematic quantitative research discovered about the effects of religious involvement on physical disability?

RESEARCH ON RELIGION AND PHYSICAL DISABILITY One challenge that exists when interpreting research on religion and disability is the issue of reverse causality. On the one hand, religious involvement may be related to less physical disability only because physically healthy people are more able to engage in religious activities, thus leading to an inverse or seemingly protective relationship between religion and disability. This is most evident when considering the effects that physical disability may have on attending religious services. Young persons with chronic health conditions are less able to attend religious services (Whitehead, 2018). The same is true for older adults as they develop disabling chronic conditions. On the other hand, physical disability may be powerfully motivating for people to turn to religion in order to cope with the distress caused by the disability, resulting in a positive association between religiosity and disability. In that case, disabled individuals will be more religious than those who are healthy and physically able, disguising any benefits that religious involvement 554 •  P h y sical H ealth

might have in preventing disability. For this reason, cross-​sectional studies tell us very little about the causal relationship between religion and physical functioning. This may also be true to some extent for prospective studies when follow-​up periods are short. However, longitudinal studies are always more able to provide evidence for causality and so will be the focus of our review below. RCTs can tell us even more about whether specific religious behaviors truly impact physical functioning, although there are few studies of religious interventions in this regard. In this section, earlier research conducted prior to 2010 is first summarized, and then research published since 2010 is examined in more detail, again with a heavy emphasis on prospective studies and RCTs.

Early Research A total of 61 quantitative studies published prior to 2010 examined the relationship between religiosity and physical functioning. These studies are detailed in the first and second editions of the Handbook. Of those 61, there were 43 cross-​sectional or case-​control studies, 15 prospective studies, and 3 experimental studies or RCTs. Of the 43 cross-​sectional studies, 10 (25.6%) reported a beneficial association between religiosity and better physical functioning and 1 study reported a trend in that direction, 14 (32.6%) reported a detrimental relationship between religiosity and better physical functioning, 14 (32.6%) reported no association, 3 reported mixed results (positive and negative associations depending on religious characteristic), and 1 reported results that were difficult to interpret. Of the 15 prospective studies, 8 (53.3%) reported a positive effect of religiosity on physical functioning, 1 (6.7%) reported a detrimental effect, 3 (20.0%) found no effect, and 3 reported mixed findings. Of the three prospective studies reporting mixed findings, researchers typically found that attendance at religious services predicted an increase in physical functioning (or less decline), and private religious activities such as prayer and religious coping predicted a worsening of functional impairments. Only one study, however, reported only negative effects

of religiosity on physical functioning and no beneficial effects. This was a 2-​year prospective study of 268 seriously ill hospitalized older adults in North Carolina (Pargament et al., 2004). Investigators found that 3 of 12 positive forms of religious coping (religious forgiveness, seeking religious direction, religious conversion) and 5 of 9 negative forms of religious coping (punishing reappraisal, demonic reappraisal, spiritual discontent, marking religious boundaries, pleading for direct intercession) predicted worse ADL impairment on follow-​up 2 years later, controlling for baseline impairments. Many of these associations, however, were also present at baseline (Koenig et al., 1998d), indicating that religious coping efforts may have been a response to (not a cause of) difficulties with physical functioning. Of the 3 experimental studies or RCTs, all reported positive effects of a spiritual or religious intervention on physical function. In conclusion, while the majority of cross-​sectional studies reported either no association between religiosity and physical functioning or an association between religiosity and worse physical functioning, the majority of prospective studies and experimental studies reported positive effects.

Recent Research Since 2010 there have been several more prospective studies and a few experimental studies examining the effects of religiosity on physical functioning, many with designs improved over earlier studies. We will now review in greater detail 10 of these more recent prospective cohort studies in addition to the experimental trials (for a complete list of studies, see Appendix). P RO S P E C TI VE S T UDIE S

Much of this research, but not all of it, involves older adults who are more vulnerable to the development of physical disability. Since physical functioning changes more rapidly in later life, there is greater potential to identify effects of religiosity on that change. The effects of religiosity on physical functioning also depend to some extent on length of follow-​up, since

physical disability does not occur overnight, and if there is no change in functioning during the follow-​up period, then no effect of religiosity will be found (since there is no change to predict). We review the studies in order of year of publication below. Son and Wilson (2011) analyzed data from a 10-​year prospective study (1995–​2005) involving 3,257 community-​dwelling adults age 25–​ 74 years participating in the National Survey of Midlife in the United States (MIDUS). The purpose was to examine the effects of having a religious upbringing, retrospectively assessed in 1995, on physical function (ability to perform ADLs and self-​ratings of health) in 2005. Religious upbringing was assessed by the question: “How important was religion in your home when you were growing up?” (not at all important =​0 to very important =​3). Religiosity was also assessed by attendance at religious services, importance of religion, and religious coping. Psychological well-​being included emotional well-​being, thriving in their personal life, and social well-​being. Functional outcomes were the ability to perform basic ADLs (two items), instrumental IADLs (seven items), and self-​rated health (SRH; single item). Religiosity, psychological well-​being, and functional outcomes were assessed in both 1995 and 2005 and were included in structural equation models (SEMs). SEM was used to examine the effects of religious upbringing (“home religion”) on basic ADLs, IADLs, and SRH (functional outcomes) assessed in 2005, controlling for age, gender, race, marital status, education, income, and employment status. Results indicated no effect of religious upbringing on ability to perform ADLs or IADLs in 2005, although religious upbringing did positively affect 2005 SRH indirectly through 1995 psychological well-​being (b =​0.007, p < 0.01) and 1995 emotional well-​being (b =​0.006, p < 0.01). In a 2-​year prospective study (2005–​2007) of a random sample of 1,011 Medicare/​ Medicaid beneficiaries age 65 or older, Krause and Hayward (2012e) examined the effects of religiosity on functional disability, assessed by ability to perform physical ADLs (PADLs) and instrumental ADLs (IADLs). Religiosity at baseline (2005) was assessed by frequency of religious attendance (one item) and closeness of Physical Disability • 555

relationship to God (3-​item index). Assessed at both baseline (2005) and follow-​up (2007) were 15 PADLs and IADLs. Structural equation modeling was used to control for age, gender, education, providing of emotional support to others, baseline and follow-​up measures of meaning in life, and 2005 PADLs and IADLs. Results indicated that both religious attendance and closeness of relationship with God were positively related to increased meaning in life; increased meaning in life, in turn, significantly predicted fewer problems with physical functioning over time. Although it was possible that greater religiosity positively affected change in physical functioning indirectly through changes in meaning in life, the “direct effect” of 2005 religious attendance and 2005 relationship with God on 2007 PADLs and IADLs was not significant. There was no mention of whether the total effect (i.e., the direct effect plus indirect effects through meaning in life) of religious attendance or relationship with God on change in physical functioning was significant. Caplan et al. (2013) examined the effects of religiosity on changes in physical function over 4 years in 177 older community-​dwelling adults with cancer (excluding skin cancer) living in Alabama. Religiosity was assessed as organizational (ORA), non-​ organizational (NORA), and intrinsic religiosity (IR) using the 5-​Duke University Religion Index (DUREL). Basic ADLs (7 items) and IADLs (6 items) were assessed at baseline and follow-​up. Controlled for in logistic regression models were age, race, gender, marital status, rural residence, education, income, cognitive functioning, medical comorbidity, and baseline physical functioning. Results indicated that baseline ORA and NORA both predicted a lower risk of developing impairments in physical ADLs over time (OR =​0.614, p =​0.015, and OR =​0.438, p =​0.025, respectively). Neither ORA nor NORA affected IADLs; and IR had no effect on either physical ADLs or IADLs. Hill and colleagues (2016a) analyzed data from a 17-​year prospective study of 2,482 older Hispanic adults living in the Southwestern United States (Hispanic Established Popula­ tions for the Epidemiologic Study of the Elderly [EPESE] study). The purpose was to examine the effects of baseline religious attendance in 556 •  P h y sical H ealth

1993–​1994 on mobility trajectories of older Mexican Americans through 2010. A single question assessed frequency of religious attendance. Mobility was objectively measured using the Performance Oriented Mobility Assessment (POMA) scale, which assesses (1) standing balance, (2) a timed 8-​foot walk at normal pace, and (3) a timed test of 5 repetitions of rising from a chair and sitting down. Growth mixture modeling was used to analyze the data, controlling for age, gender, immigrant status, education, and household income, as well as cognitive functioning, depressive symptoms, and social integration, engagement, and support. There were three mobility trajectories identified, reflecting high mobility, moderate mobility, and low mobility. The likelihood of being classified as having low mobility (vs. high mobility) was significantly lower among those who attended religious services yearly (OR =​ 0.04), monthly (OR =​0.09), weekly (OR =​0.13), or more than weekly (OR =​0.04), compared to those who never or almost never attended services (all p < 0.05). Cohen-​ Mansfield et al. (2016) examined the effects of change in religiosity on physical functioning in 1,170 Jewish Israeli participants age 75–​94 followed from 1989–​1992 Wave 1 to 1993–​1994 Wave 2. Religiousness was assessed by religious identity and subjective change in religiousness over time. Religious identity was assessed by the categories Ultraorthodox/​ Orthodox (most religious), Traditional, and Secular (least religious). Changes in religiousness were assessed by (1) retrospective report at Wave 1 of change in observance of commandments and traditions today compared with 20 years ago (10.3% more, 75.7% the same, 14.0% less), and (2) change in religious identity measured between Waves 1 and 2. Physical functioning at both waves was assessed by ability to perform ADLs (7 items) and IADLs (7 items). Results indicated that participants who indicated they had become less religious over time at Wave 1 (vs. remaining the same) experienced significantly worse physical functioning (ADL and IADLs) at Wave 1 in cross-​sectional analyses (n =​1,170), controlling for age, gender, and education using MANCOVA (multivariate analysis of covariance). In longitudinal analyses (n =​608), MANCOVA analyses indicated

that compared to those who did not change religious identity, those who changed religious identity between Waves 1 and 2 (approximately 25%), while experiencing more depressed affect and loneliness, did not experience a worsening of their physical functioning from Wave 1 to Wave 2. Ahrenfeldt et al. (2017) analyzed data from a 9-​year prospective study of 14,255 adults age 50 or over participating in the Survey of Health, Aging, and Retirement in Europe (SHARE) from 2004–​2005 (Wave 1) to 2013 (Wave 5). The purpose was to examine the effects of religiosity at baseline on the development of functional limitations during the follow-​up period. Religiosity was assessed by (a) frequency of prayer, (b) having had a religious education, and (c) having taken part in a religious organization within the past month. Participants were also categorized as more religious (prayed, had a religious education, participated in religious organization), less religious (prayed only), and nonreligious (none of the above). Functional limitations were assessed by PADLs, IADLs, and activity limitations measured by the Global Activity Limitations Index (GALI) at each of the 5 waves. Analyses controlled for baseline health, European region, gender, age, education, marital status, and employment using longitudinal mixed effects models, with p-​values corrected for multiple comparisons. Results indicated that taking part in a religious organization at baseline predicted a 14% lower likelihood of developing limitations in global activities during follow-​up (GALI, OR =​ 0.86, 95% CI =​0.75–​0.98); furthermore, the development of PADL limitations and IADLs limitations also tended to be subsequently less frequent (OR =​0.88 and OR =​0.85, respectively, but did not pass the p < 0.05 threshold). The “more religious” participants (compared to others) also experienced a 24% reduction in ADL limitations (OR =​0.76, 95% CI =​0.58–​ 0.99). Praying was a particularly strong predictor of fewer global activity limitations in the northern region of Europe (OR =​0.70, 95% CI =​ 0.58–​0.83) and the southern region (OR =​0.72, 95% CI =​0.61–​0.85), but not the western region of Europe. The importance of this study is that (1) the findings are from relatively secular parts

of Europe, and (2) they involve more than simply religious attendance as a predictor. Li and colleagues (2018b) analyzed data from a 16-​ year prospective study involving 34,807 women participating in the Nurses’ Health Study from 1996 to 2012. The average age of participants in 2012 ranged from 66 to 91 years. Researchers sought to examine the effect of social integration on healthy aging, where “healthy aging” was defined as (1) no history of major chronic disease diagnosis, (2) no self-​reported impairment in memory, and (3) no major impairment of physical functioning or mental health (15.1% of the sample met these criteria in 2012). An item on the index measuring social integration assessed in 1996 was frequency of religious attendance. Age-​adjusted and multivariable-​adjusted logistic regression models were used to examine the effects of social integration overall and religious attendance in particular on likelihood of being a healthy ager (vs. “usual ager”). Frequency of religious attendance did not predict healthy aging (multivariable-​adjusted OR =​0.99, 95% CI =​0.91–​1.08). However, researchers hypothesized that if frequency of religious attendance is associated with prolonged survival (as has been established specifically for this cohort; see Li et al., 2016b) then this may have kept unhealthy persons alive during follow-​ up, reducing the number of healthy agers in 2012 among those who had attended religious services in 1996. Indeed, when examining only a 4-​year follow-​up, rather than a 16-​year follow-​ up so as to mitigate these selection effects, there was stronger evidence for a beneficial effect on healthy aging. This explanation could also account for null findings reported in other long-​term prospective studies. Latham-​Mintus et al. (2019) analyzed data from the US Health and Retirement Study from 2008 to 2010, examining the effect of childhood disadvantage (economic and health) on recovery from mobility limitations. Retrospectively assessed childhood economic disadvantage, assessed in 2008, was measured by childhood SES, having to move for financial reasons, and mother’s education. Childhood health disadvantage was measured by self-​rated childhood health before age 16 and number of childhood medical conditions. Mobility limitations were Physical Disability • 557

assessed in 2008 and 2010 by self-​reported difficulty walking one block, difficulty walking several blocks, difficulty climbing one flight of stairs, and difficulty climbing several flights of stairs; those who indicated difficulty with any of these indicators were categorized as having limited mobility. Religiosity was assessed using four items that measured religious beliefs (e.g., “I believe in a God who watches over me”) and religious coping (e.g., “I find strength and comfort in my religion”). Multinomial logistic regression models were used to examine improvements in mobility limitations over time, controlling for demographic characteristics, adult SES and marital status, measures of psychosocial resiliency (mastery, optimism), and health risk behaviors. Results indicated no effect of religiosity on recovery from mobility limitations (OR =​0.99, 95% CI =​0.90–​1.08). Kim and VanderWeele (2019) examined mediators of the effect of attending religious services on survival in 5,200 participants in the US Health and Retirement Study followed between 2006 and 2014. Among the mediators examined were problems with physical functioning. Covariates assessed in 2006 (before the religious attendance exposure in 2008) and controlled for in mediator analyses were sociodemographic factors (age, gender, race, marital status, education, health insurance, total wealth), baseline health (major health conditions), social factors (living with spouse, contact with children, contact with other family, contact with friends, social participation, social integration), and health behaviors (smoking, alcohol, BMI, physical functioning by a 15-​item measure ADL and IADLs limitations). Mediators were assessed in 2010, 2 years after religious attendance was assessed in 2008, thus fulfilling a necessary criterion to be a mediator. Mediators included positive psychological factors (life satisfaction, optimism, mastery, positive affect, purpose in life), psychological distress (depression, hostility, hopelessness, loneliness, negative affect, anxiety, anger), social factors (living with spouse, contact with children, contact with other family, contact with friends), health behaviors (exercise, alcohol, smoking, BMI), other psychosocial factors (sense of control over health, sense of control over finances, financial strain), and 558 •  P h y sical H ealth

finally, physical functioning. Results indicated that physical functioning served as a significant mediator of the effect of religious attendance on all-​cause mortality, explaining 0.40% of the estimated effect for each point on the 15-​item scale (p < 0.001). Although the effect of religious attendance in 2008 on physical functioning in 2010 was not reported, religious attendance was clearly related to less decline in functioning over that 2-​year period, or it would not be a mediator of the effect of attendance on mortality. Orr et al. (2020) analyzed data from the Irish Longitudinal Study on Aging, a study involving 6,122 adults age 50 or over in Ireland who were followed for 10 years. The objective was to examine the effects of religious affiliation and religious attendance, assessed at baseline in 2009–​2010 on two objective measures of physical functioning, the Timed Up and Go (TUG) test and grip strength scores. The TUG test measures functional mobility by having the participant stand up from a chair, walk 3 meters, turn around, walk back, and sit down. Grip strength was assessed by squeezing a standard dynamometer. These measures were assessed every 2 years after baseline for a total of 5 waves. Religious attendance was determined by a single question: “About how often do you go to religious services?” Religious attendance was assessed only in Catholics, who made up 88% of the sample. Linear mixed effects regression analysis was used to examine the effects of religious affiliation and attendance on changes in physical function, controlling for age, self-​rated health, number medications, marital status, education, smoking status, number of ADL limitations, days of vigorous physical activity, depressive symptoms, and height, all assessed at baseline. Cross-​sectional analyses at baseline indicated that those with no religious affiliation had lower (better) TUG scores and greater grip strength, but were also younger than those with a religious affiliation. Longitudinal analyses indicated that religious affiliation was not associated with TUG scores overall, or in men or women separately when analyses were stratified by gender. However, low-​attending Catholic women at baseline experienced significantly higher TUG scores at follow-​up, indicating worse mobility compared to high-​attending

Catholic women. There was also a significant interaction with age such that high-​attending Catholic women had a TUG score of 12.72 seconds at age 80 compared to a TUG score of 15.90 seconds in low-​ attending Catholic women. Similarly, low-​attending Catholic men at age 80 had an average TUG score of 13.49 seconds compared to 12.05 seconds for high-​ attending Catholic men. No effect of religious affiliation or religious attendance was found on grip strength among men or women after controlling for other covariates. Thus, frequent religious attendance (but not religious affiliation) predicted better physical functioning over time, especially among Catholic women. E XP E RI ME N TAL S T UDIE S

We now describe two experimental studies that have examined the effects of a religious intervention on physical functioning or the moderating effects of religiosity on the effectiveness of an intervention to improve physical functioning. Aberer et al. (2018) conducted a small quasi-​ experimental study examining the effects of engaging in Ignatian religious/​spiritual (R/​S) exercises on mental health and physical functioning in 24 patients with serious dermatological conditions (systemic sclerosis, lupus erythematosus, or melanoma). Ignatian R/​ S exercises are intended to increase the sense of God’s presence in life, deepen prayer, improve moral-​based decision-​making, and emphasize an active life of service to others. Participants were self-​selected based on personal preference (not randomized) into one of three groups: (1) a group receiving the Ignatian spiritual exercises once a week for 90 minutes over a period of 8 weeks (n =​10); (2) a group that attended a single 90-​minute lecture by a dermatologist about the dermatological disease, followed by a 30-​minute discussion and two telephone interviews over 8 weeks (n =​7); and (3) a control group without intervention (n =​7). Participants completed assessments at baseline and after the interventions. Outcome measures included the Multidimensional Inventory of Religious/​Spiritual Well-​Being (MI-​RSWB), which assesses existential and religious well-​ being. Physical function was measured by the

Physical Component Score (PCS) of the SF-​36, and mental health by the Mental Component Score (MCS). Change scores were compared between the groups using the Kruskal-​Wallis H test. Results indicated no difference between the two treatment groups except on the Hope Transcendent subscale of the religious well-​ being dimension of the MI-​ RSWB, favoring the Ignatian R/​S exercises group. Both interventions significantly improved the MCS component of the SF-​36, compared to the control group. No difference was found between Ignatian R/​S exercises group and the control group on the PCS (physical functioning). Allen et al. (2019) sought to identify subgroups of African American patients with knee or hip osteoarthritis in which a Pain Coping Skills Training (PCST) intervention might have greater efficacy compared to a wait-​list control (WLC) group. A total of 248 participants were randomized to either the PCST group (n =​124) or the WLC group (n =​124). The primary outcome was clinical improvement on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), which includes a physical function score. Results indicated that the subgroup that achieved the largest improvement in functioning to the PCST intervention were those who had scores of 12 or higher (maximum 15) on the intrinsic religiosity subscale of the Duke Religion Index (DUREL). Thus, improvements in WOMAC functioning in response to the PCST intervention were greatest among those who were more intrinsically religious.

Summary Of prospective studies, which tell us the most about the effects of religiosity on physical functioning, more than half of 15 early studies (53%) reported a positive effect of religiosity on functioning. Of the 10 more recent high-​ quality prospective studies reviewed in detail above, 5 (50%) found that greater religious involvement predicted less decline in physical functioning over time. Of the 5 past and more recent experimental studies or RCTs, 4 reported a positive effect of religiosity or R/​S interventions on physical functioning. Thus, the majority of prospective and experimental Physical Disability • 559

research suggests that religiosity, especially attendance at religious services, has a positive impact on physical functioning over time. This is true despite the fact that greater religious involvement may help older adults with poorer physical function survive longer, thus biasing results of prospective studies toward finding either no effect or a negative effect of religiosity on physical function (see Li et al., 2018b, and Chapter 27). While numerous studies found no effect (or mixed effects, with religious attendance usually predicting better functioning and subjective religiosity, or private religious activities predicting worse), only one prospective study reported negative effects alone on physical function; this involved a study of religious coping in medically ill hospitalized patients, where reverse causation due to turning to religion may have been a factor.

RECOMMENDATIONS FOR RESEARCH The impact that religious involvement has on physical functioning is particularly important as the large cohort of baby boomers age into later life and improvements in medical care extend the longevity of people throughout the world, particularly those with chronic disabling conditions. Given the financial pressures on governments to provide for those with physical disabilities, any psychosocial factor that helps prevent the development of disabilities in later life deserves attention—​especially from healthcare researchers and public policymakers. As countries throughout the world, including the United States, become more and more secular (Voas & Chaves, 2018), this may have implications for the prevalence of disability and future costs of caring for older adults with physical impairments. We make several recommendations below to help guide researchers as they plan ahead. First, research that seeks to examine the effects of religious involvement on changes in physical disability over time is neither easy nor inexpensive, since the effects of religiosity on physical functioning likely accumulate over many decades, requiring repeated assessments over long periods of time. As a result, few if any studies have yet examined the impact of 560 •  P h y sical H ealth

religious involvement across the life span, from childhood through adulthood, on the likelihood of developing physical disability in later life. Such studies are necessary in order to capture the overall effect that exposure to religion may have on different dimensions of physical functioning, the mechanism by which this occurs (i.e., effects on specific disability risk factors), and the life stages when these influences are most likely to occur. Second, as emphasized repeatedly above, cross-​sectional studies tell us very little about the effect of religiosity on the development of physical disability, given the high likelihood of reverse causation. There is little doubt that religious activity is influenced by physical disability, particularly religious activities that require physical mobility (e.g., attendance at religious services, practicing the five daily prayers in Islam that involve considerable physical activity, going on religious pilgrimages such as the Hajj or Umrah). There is also little question that problems with physical activity increase religious involvement as persons turn to religion to cope with the stress that disability causes. Thus, researchers must bear in mind these dynamics when designing studies, analyzing results, and interpreting the findings. Third, prospective studies are needed to help sort out causal inference, especially those that (1) control for baseline physical functioning when seeking to predict future functioning; (2) assess religious variables at multiple time points; and (3) distinguish confounders from mediators by assessing confounders prior to the religious exposure and mediators after the exposure but prior to the outcome. As usual, large samples and long-​ term follow-​ up are likely to yield the most accurate and stable results. However, there is a limitation to the number of questions that can be asked in large prospective studies, sometimes resulting in the collection of relatively superficial information, perhaps especially for religious variables. Given the complex interactions between religiosity and physical disability over time, this makes interpretation of results quite difficult, even from well-​ designed studies. For this reason, qualitative research involving detailed subjective reports from a subset of participants in

these studies can be helpful in aiding the interpretation of quantitative findings. Fourth, the development and testing of religious/​ spiritual interventions for treating impairments in physical functioning are needed that can be utilized in religious patients with mobility limitations. Such interventions may be directed at helping to motivate those with functional impairments to work hard in rehabilitation in order to regain their physical functioning following accidents, surgery, or medical illnesses that cause such impairments (stroke, heart disease, etc.). Fifth, as with most studies on religion and health, particularly prospective and experimental studies, almost all of this research has been conducted either in the United States, Canada, Europe, or Israel (Judeo-​ Christian majority countries). Very few prospective studies on religiosity and physical functioning have been conducted thus far in South or Central America, Africa, the Middle East, the Far East, North or Central Asia, or in Hindu-​, Buddhist-​ , or Muslim-​ majority countries. This must be a priority for future research. However, lack of funding support is a serious barrier to conducting high-​quality studies of this type in these regions and religions. These economic challenges have prevented such research in the past and may continue to do so in the future unless governments place a higher priority on such studies. Nevertheless, there are large cohort studies now taking place in different areas of the world, including those mentioned above, that are examining the effects of psychosocial factors on physical health and functioning. Inclusion of measures of religiosity either at baseline or during future waves of data collection is a relatively low-​cost way of generating data that can be used to examine the impact of different religions on physical functioning in areas of the world not yet studied. Finally, as recommended in previous chapters, the types of religious measures to include in future prospective and experimental studies should be carefully selected based on the rationale for finding likely effects on physical functioning. Ideally, psychometrically validated multidimensional measures of religious involvement, particularly those assessing

enduring religious commitment, could be utilized to supplement single items of religious attendance (where reverse causation may explain positive effects on physical functioning) or measures of religious coping, subjective religiousness, or prayer (where reverse causation may be responsible for negative effects on functioning). Likewise, attempts to assess duration of lifetime exposure to religious involvement (e.g., using measures of religious history), rather than simply assessing current religious activity, should also be a priority in future studies.

CLINICAL APPLICATIONS In this section, we put forward a number of recommended applications based on what is currently known. These suggestions are relevant to health professionals seeing patients in the clinic/​hospital and to religious professionals caring for members of a congregation. The many losses caused by physical disability, particularly following abrupt changes in physical functioning, can cause great suffering and may adversely affect quality of life in many ways. This is reflected in the high rate of depression among physically disabled persons, which increases the risk of further disability and physical decline (Lenze et al., 2001; Milaneschi & Penninx, 2014). As suggested earlier, clinicians and religious professionals may utilize a religious person’s beliefs to motivate self-​care in ways that minimize physical disability following potentially disabling events, and when disability develops, help the person to either regain functioning or learn to live with their impairments. More specific recommendations now follow for each group.

Healthcare Professionals After taking a spiritual history, clinicians are encouraged to support the patient’s religious beliefs that endorse behaviors that prevent the development of physical disability or, as noted above, motivate patients to make the necessary efforts to rehabilitate following disabling events. If the clinician feels comfortable making such supportive interventions, then he or she should proceed cautiously and sensitively, Physical Disability • 561

generally limiting suggestions to those that reinforce the patient’s preexisting religious beliefs. The following are several examples in different faith traditions of how a clinician may proceed (these recommendations also apply to religious professionals). The clinician may, in a sensitive and kind manner, point out to a religious Christian patient that there are scriptures that emphasize honoring the physical body as God’s temple (1 Corinthians 6:19), underscoring the need to engage in activities that prevent the development of disability or engage in the often difficult efforts necessary to recover from it. Likewise, to a devout Islamic believer, the clinician may support teachings in the Qur’an and Hadith that emphasize this point as well. There is a Hadith in Sunni Islam that says, “A person’s body has a due right over him,” which has been interpreted as emphasizing the need to preserve or regain healthy physical functioning so that the individual can serve Allah (Al-​Dhahabi, 1961, p. 6). Similarly, in Judaism, the Talmudic scholar Rashi has said that not caring for the body “is a slight to the King [God] because humanity is made in the likeness of God’s image and Israel are God’s children” (Arston, 2020). Finally, the Buddha has been quoted as saying: “To keep the body in good health is a duty . . . otherwise we shall not be able to keep our mind strong and clear” (source unknown). Discussing such perspectives will of course generally be easier if the clinician and the patient share the same religious views, but could in principle be employed even if they do not. One could also envision providing written materials with these various perspectives across religious traditions. The major faith traditions emphasize the importance of activities to preserve health and maximize physical functioning, which include making vigorous efforts during rehabilitation to recover from conditions that threaten physical functioning. The clinician may reinforce the point that physical disability may interfere with the person’s ability to engage in religious activity and religious service to others, thus providing further rationale for such efforts. Again, the purpose of the clinician in pointing out and supporting such beliefs is to help motivate patients to make lifestyle changes or engage in 562 •  P h y sical H ealth

rehabilitation efforts that are often painful. As noted above, this must be done cautiously and gently, without causing excessive guilt, shame, or discouragement over failures that may actually worsen physical functioning. TRAN SFORM IN G SUF F ERIN G

Despite all efforts to minimize disability or rehabilitate from illness, physical disability will sometimes develop and persist. In that case, patients’ religious beliefs may be utilized to transform disability-​related suffering into an act of religious worship and service to the Divine. Christian scriptures emphasize that it is a privilege to suffer for Christ. Philippians 1:29 says, “For it has been granted to you on behalf of Christ not only to believe on him, but also to suffer for him.” Although this Scripture primarily refers to suffering as a result of being persecuted as a believer, the idea extends to other forms of suffering, such as having to bear with physical disability that cannot be reversed. The early seventeenth-​century theologian Brother Lawrence said, “God often permits us to suffer a little, to lead us on to maturity, and to drive us into his arms. So, offer him your pains. They come from him, or by his permission, so turn them into an offering to lay at his feet—​his will for you accepted and carried through” (Winter, 1971, pp. 137–​138). There is also a common belief in Islam that physical illness is a trial allowed by God to help purify the individual, to compensate for previously committed sins, and to provide an opportunity for future rewards, particularly if the sickness and suffering are handled with patience and forbearance. This belief gives the illness meaning and purpose, which by itself can help relieve the emotional suffering caused by the disability. The Muslim theologian Fazlur Rahman points to a Sunni Hadith suggesting that God may intentionally inflict a disabling illness in order to provide an opportunity to enter into the ranks of the truly faithful (which otherwise might not be possible) (Rahman, 1998, p. 37). Rahman illustrates this point further by describing the story of a Sufi saint, who when sick was told by her friend, Sufyani, “If you pray to God he will ease your suffering.” She replied, “O Sufyani! Do you not know who has

willed my suffering? Is it not God?” He replied, “Yes.” She said, “If you know this, why do you ask me to pray for what contradicts His will?” (Rahman, 1998, p. 49). In fact, the time of illness in Islam is considered such a holy state that the sick individual has special influence with God, says Rahman, citing a Hadith saying: “The Prophet encouraged visitors to request the sick person to pray for them because the state of the sick and the helpless is so pure that God hears their prayers. . . . God also visits the sick and says, ‘O my servant! Health unites you with yourself, but sickness unites you to Me’ ” (Rahman, 1998, p. 59). Likewise, writing from the Jewish perspective, Levinson (1987) notes, “Suffering may be an opportunity to atone for our sins in this world. Rabbis also speak of the birth pangs of the Messiah, implying that the good will often be the outcome that follows suffering. Samuel S. Cohon, a professor of Jewish Theology in the United States of America wrote: ‘Personal suffering and death appear as punishments which satisfy the Divine claims of justice and restore the bonds of union with God. . . . The righteous are purified by their chastisements in this world in order to enjoy unmarred bliss in the hereafter’ ” (p. 129). While enduring suffering, the Jewish believer is encouraged to rely on God for strength. The psalmist writes: G-​d is our refuge and strength, a very present help in trouble. Therefore will we not fear, though the earth do change, and though the mountains be moved into the heart of the seas; Though the waters thereof roar and foam, though the mountains shake at the swelling thereof. There is a river, the streams whereof make glad the city of G-​d, the holiest dwelling-​place of the Most High. G-​d is in the midst of her, she shall not be moved; G-​d shall help her, at the approach of morning. (Tehilim 46:2–​6, Jewish Bible, 1997) This scripture promises that no matter how physically disabled a person may be, G-​d is there as a refuge and source of strength that will enable her or him to endure that disability. Thus, religious beliefs may be utilized to help the disabled person accept whatever disability

is present and endure it for religious reasons in the hope that good will somehow result if the suffering is handled with patience as a sacred act of devotion to God, who has promised in the scriptures to reward the person for such service. One reason why this may be helpful is because it gives the disabled person a sense of purpose and meaning in life literally based on their problems with physical functioning. This applies not only to the disabled patient, but also to stressed family members responsible for providing care, thereby lightening the burden of caregiving, as research has found (Koenig et al., 2016a).

Religious Professionals Religious mental health professionals, along with chaplains, pastoral counselors, and community clergy, may also utilize the theological sayings and holy scriptures above to give meaning and purpose to physical limitations. There are many other actions that religious professionals can do as well. Because negative forms of religious coping are relatively common among those with severe disability (feeling punished by God, questioning God’s power, feeling abandoned by their faith community), clergy should be alert to this possibility and discuss with individuals why they feel this way. This approach is arguably preferable to trying to dissuade the person from having such painful feelings. Having those feelings validated by clergy may help individuals to process these negative emotional expressions and work through them. Chaplains and pastoral counselors are ideally positioned to address these kinds of religious struggles, which are frequently a manifestation of the distress and discouragement often associated with disability. They can also help chronically disabled individuals deal with the stigma that they may feel in our performance-​oriented society, by helping them realize they are loved by God and have worth just as they are (Brock & Swinton, 2012). Clergy may also play an important role in making faith community participation assessable to those who are disabled. This may include installing a ramp to allow people in wheelchairs or using walkers to get more easily into the building; installing headphones or Physical Disability • 563

other technology to allow those with hearing impairments to listen to the sermon and participate in other parts of the service; and providing transportation and other physical health assistance to allow them to attend religious services. Organizing a health ministry, especially for larger religious bodies with a significant number of older congregants, is another way to mobilize volunteers from the congregation to meet the needs of disabled members. With regard to families of those with physical disabilities, clergy can help by either providing supportive counseling to stressed caregivers or by identifying members of the congregation who may be available to provide respite to caregivers to give them a break from caregiving duties (although liability issues may be an issue here and so need to be addressed). Ideally, health professionals and religious professionals should work together to meet the needs of the disabled person and those caring for him or her, as each professional has something unique to contribute that complements and reinforces what the other has to offer.

obtain health insurance that increases access to medical care. We then summarized risk factors that might be considered fully modifiable, including the development of certain disabling medical conditions, preventable accidents, and unhealthy behaviors that increase the risk of developing physical impairments. Also reviewed were factors that reduce the likelihood of developing physical disability or its progression, including positive psychological states such as having purpose and meaning, having worthwhile life goals to strive for, being optimistic and hopeful, engaging in supportive social interactions, receiving support from friends and family, and especially, providing support to others in need by volunteering and engaging in other altruistic activities, as one’s physical health allows. Next, we provided a case vignette that exemplified the role that religion can play in the life of someone who experienced sudden physical disability due to a stroke. This case then serves as the basis for theorizing about the pathways through which religion might impact physical disability, emphasizing effects on disability risk factors discussed earlier. We then reviewed SUMMARY AND the research, including early and more recent CONCLUSIONS studies, that has quantitatively examined reliWe began this chapter by defining physical dis- gion’s impact on developing or recovering from ability and examining its prevalence and cost physical disability. Large prospective studies in the United States and around the world. and a few experimental studies were the focus, Non-​modifiable, partially modifiable, and fully over half of which have found that (1) religiosmodifiable risk factors for physical impair- ity predicts less future physical impairment, ments were then reviewed, with an eye toward and (2) religious or spiritual interventions potential pathways through which religious may reduce physical disability. We concluded involvement might impact disability. Non-​ this chapter by making recommendations for modifiable risk factors include age, sex, race, future research and by providing suggestions and some genetic causes. Socioeconomic sta- for clinical application relevant to both healthtus was considered a partially modifiable risk care providers and religious professionals. In factor, in that psychosocial factors can influ- the next chapter, we examine the relationship ence the completion of education, likelihood of between religiosity and chronic pain, one of the obtaining a good job, knowledge about healthy most distressing and disabling of all physical lifestyles and their practice, and ability to conditions.

564 •  P h y sical H ealth

29 Chronic Pain Let me not beg for the stilling of my pain but for the heart to conquer it. —​R abindranath Tagore

THIS CHAPTER IS about the relationship between religiosity and physical pain, chronic pain in particular. We do not address here the use of religion to cope with pain, but rather the relationship between religious involvement and the severity of the pain experience. Pain is an extraordinarily complex symptom that has physiological, psychological, social, and behavioral components, and is frequently misunderstood. Pain is a subjective experience that is self-​reported, so there is no objective way to verify whether a person is experiencing pain or not, though an obvious physical injury would certainly be strong indication of the reality of pain. Because of the psychological, social, and behavioral components of pain, especially when endured over a prolonged period of time, there is potential for religious involvement to affect the pain experience.

DEFINITION AND TYPES OF PAIN Due to the complex nature of pain, we take considerable space here to address the various definitions and distinctions concerning pain. The International Association for the Study of Pain (IASP) defines pain as “[a]‌n unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Merskey & Bogduk, 1994). There are basically three types of pain: physiologic, neuropathic, and psychogenic. Seldom does any one of these exist entirely separate from the others, especially when pain persists over time.

Physiologic (Nociceptive) Pain Physiologic pain has biological causes related to inflammation around, trauma to, or physical

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0029

irritation of nerves (i.e., nociceptive causes). The latter can occur anywhere along nerve paths from endings in the skin, to nerve roots entering into the spinal cord, or to connections in the central nervous system and brain (Steeds, 2016). Physiologic pain of this type is divided into somatic and visceral pain. Somatic pain results from activation of peripheral nerve receptors in the skin, muscles, and deep tissues of the body. It is typically described as well localized, sharp, or aching. Visceral pain, on the other hand, results from infiltration, compression, distension, or stretching of organs within the body cavity (intestines, liver, etc.). This type of pain is often described as poorly localized, deep, squeezing or pressure-​like, and may be accompanied by other symptoms such as nausea, vomiting, or sweating.

damage, it becomes a disorder itself and is called “maldynia” (Dickinson et al., 2010). Neuropathic and other maladaptive pain syndromes are in this class, which includes “chronic overlapping pain conditions” that are driven by central nervous system sensitization: fibromyalgia, temporomandibular disorders, irritable bowel syndrome, vulvodynia, myalgic encephalomyelitis/​ chronic fatigue syndrome, interstitial cystitis/​painful bladder syndrome, chronic prostatitis, endometriosis, chronic tension headaches, migraine headaches, and low back pain (Veasley et al., 2015). There is a physiological basis for pain that is due to disordered processing of nerve signals such as occurs in neuropathic pain, although in maldynia this may be mixed with psychologic components.

Neuropathic Pain

Psychogenic Pain

Pain is also generated by non-​ nociceptive causes that can be categorized as pathophysiologic (or neuropathic pain) and psychopathologic (or psychogenic pain) (Khan, 2019). These are important to distinguish, although this can be a difficult task in practice. Neuropathic pain is caused by a lesion or disease of peripheral fibers and central neurons, resulting in altered and disordered transmission of sensory signals into the spinal cord and processing in the brain (Colloca et al., 2017). Neuropathic pain is differentiated from nociceptive pain as follows. Neuropathic pain involves a pathological process in the somatosensory system that produces a projection of pain into a territory of innervation (Treede, 2018). Examples of neuropathic pain include diabetic neuropathy, post-​herpetic neuralgia, peripheral nerve injury pain, trigeminal neuralgia, radiculopathy, post-​stroke pain, pain following amputation, and pain from infections such as HIV and leprosy. Thus, neuropathic pain is due to damage of nerves or activation of abnormal pain pathways in the central nervous system. Neuropathic pain is physiologically different from other types of chronic pain resulting from rheumatoid arthritis, which results from joint inflammation with alteration in pain-​producing chemicals at the site of inflammation (Costigan et al., 2009). When pain no longer serves its primary purpose, i.e., a useful warning sign of tissue

In contrast, psychogenic pain (or functional pain) has no physiological basis. In the past, pain without any obvious tissue damage was considered psychogenic. Neuropathic pain and chronic overlapping pain conditions (where there is somatosensory system damage, but not necessarily in the painful region) has been differentiated from psychogenic pain, which is due entirely to psychological causes (Treede, 2018). Referring to the definition of psychogenic pain given by the American Psychiatric Association, Beneitez and Nieto (2017) define psychogenic pain as “pain symptoms with an obvious role of psychological factors in their etiology and no associated identifiable factors found, or if there were any, the intensity of the pain did not correspond to the seriousness of the medical findings” (p. 43). While psychogenic pain may be distinguished from nociceptive pain by the presence of psychological factors and the absence of medical findings, the differentiation from neuropathic pain is considerably more difficult. Since pain is a subjective experience, there is often no way to distinguish pain due to tissue damage (unless obvious) from neuropathic pain (damage to the somatosensory system, but with no tissue damage in the pain area) from psychogenic pain (due to psychological causes alone). Furthermore, both nociceptive pain and neuropathic pain have significant psychological

566 •  P h y sical H ealth

consequences, and psychogenic pain from depression, social rejection, or grief has been shown to follow similar pain pathways as nociceptive or physiologic pain (MacDonald & Leary, 2005). In fact, acetaminophen (Tylenol) has been shown to reduce psychological pain just as it relieves nociceptive pain (DeWall et al., 2011). Therefore, experts recommend that if a person reports an experience as pain, it should usually be accepted as pain. In the majority of cases, though, pain has a physical cause in the region where it is experienced (Treede, 2018).

Chronic Pain IASP defines chronic pain as “pain which has persisted beyond normal tissue healing time,” which usually means it has been present for a period of 3 months or longer in the absence of other factors, i.e., ongoing tissue damage or inflammation (Merskey & Bogduk, 1994). Members of IASP, however, have suggested that 6 months might be a better time frame than 3 months for research purposes (Merskey & Bogduk, 1994, p. 212). Furthermore, definitions of chronic pain have varied widely in research studies examining its prevalence, with rates ranging from 8.7% to 64.4% depending on the definition (Steingrímsdóttir et al., 2017). The International Classification of Disease, 11th edition (ICD-​11), defines chronic pain as pain that persists or recurs for 3 months or longer and is associated with significant emotional distress or functional disability. Under this chronic pain category are seven conditions: (1) chronic primary pain (e.g., non-​musculoskeletal, non-​neuropathic back pain, chronic widespread pain, fibromyalgia, irritable bowel syndrome); (2) chronic musculoskeletal pain (osteoarthritis, rheumatoid arthritis); (3) chronic headache and orofacial pain; (4) chronic neuropathic pain; (5) chronic post-​ traumatic and post-​ surgical pain; (6) chronic visceral pain; and (7) chronic cancer pain (Treede et al., 2015).

PREVALENCE AND FINANCIAL COSTS OF CHRONIC PAIN Based on the 2016 US National Health Interview Survey, 20.4% of adults age 18

or older have chronic pain, with nearly half (8.0%) indicating high-​ impact chronic pain (Dahlhamer et al., 2018). This means more than 1 out of every 5 Americans age 18 or older (> 50 million people) suffers from chronic pain, and nearly 1 out of 10 (20 million people) indicates that the pain has significantly limited their life or work activities every day or on most days during the past 6 months (i.e., high-​impact pain). Thus, more adults in the United States experience chronic pain at some level than have diabetes, heart disease, and upper respiratory infections combined (Buttorff et al., 2017). The age-​adjusted prevalence of chronic pain in 2016 was higher in non-​Hispanic White adults than in all other racial or ethnic groups, higher in veterans than in non-​veterans, and higher in those with Medicaid, Medicare, or other public healthcare insurance (Dahlhame et al., 2018). Chronic pain is also a worldwide problem, with an estimated 1.5 billion or more persons suffering from this condition (Gardner & Sachdeva, 2019). In terms of years lived with disability, the 2016 Global Burden of Disease Study indicated that pain and pain-​ related diseases (including accompanying mental disorders such as depression) are the leading cause of disability and disease burden in the world (Vos et al., 2017). Based primarily on studies of high-​income countries in Europe, the prevalence of chronic pain-​causing conditions ranges from 10% to 40% (Guido et al., 2020). In a meta-​analysis involving 12 studies of chronic pain in developing countries (South America, Africa, Asia) involving 29,902 participants, Sá et al. (2019) reported a prevalence of 18% (95% CI =​10%–​29%), similar to that in the United States reported above. However, other research reviews on the prevalence of pain in low-​and middle-​income countries have placed the prevalence of chronic pain without clear etiology to closer to 35% (95% CI =​ 26%–​42%) (Jackson et al., 2016). Prevalence, of course, depends on definitions, which can vary across studies. Low back pain is estimated to be the most common cause of chronic pain worldwide, and not surprisingly, is more likely to occur in older adults (Jackson et al., 2016; Gardner & Sachdeva, 2019). The ATHLOS (Ageing Trajectories of Health—​Longitudinal Chronic Pain • 567

Opportunities and Synergies) project has sought to harmonize data from 17 community-​ based cohort studies of aging involving 38 countries around the world and more than 411,000 individuals (Guido et al., 2020). Their 10-​year projections for pain prevalence among those age 66 or over indicate a 10%–​ 20% increase from 2015 to 2025. Thus, chronic pain is becoming more and more common, despite advances in medical care. In the United States, the total estimated cost of chronic pain in 2011 due to medical costs, lost productivity, and disability programs was estimated at $560 billion (Institute of Medicine, 2011). This figure is equivalent to $644 billion in 2020 dollars, not including costs due to the additional increase over the past decade in the population age 65 or older with chronic pain. We were unable to obtain estimates of the worldwide costs of medical care and loss of productivity that result from chronic pain, although those costs are likely to be enormous given the prevalence rates above.

Here we focus on demographic, environmental, genetic, medical, psychological, social, and behavioral risk factors for the development of chronic pain, with a particular eye for pathways by which religiosity might influence either the severity of chronic pain or its endurance. None of the factors we will discuss here influences the presence, severity, and endurance of chronic pain in isolation from the others. Rather, there is a complex interaction among non-​modifiable, partially modifiable, and fully modifiable risk factors for chronic pain that must be understood. The causes for chronic pain are known to be multifactorial, operating through a complex web of causation. Furthermore, chronic pain has physical, psychological, social, and emotional consequences that may be difficult to distinguish from factors that increase the risk of chronic pain, making the identification of the original causes of pain even more challenging. Much of the information in this section comes from reviews by Borsook et al. (2018) and Mills et al. (2019).

DETERMINANTS OF CHRONIC PAIN

Non-​modifiable

Numerous factors influence the intensity and duration of pain. In the context of any given acute physical insult of similar intensity that causes tissue damage and nerve injury, some individuals experience limited or rapidly resolving pain, whereas others develop chronic pain that persists over time. For example, after experiencing nerve damage following surgery, 15%–​50% of persons may develop pain, of whom 10%–​15% develop relatively severe chronic pain, which Borsook and colleagues (2018) call “pain stickiness.” What about the other 85%–​90% of individuals whose pain resolves? Why does pain tend to remit in some people, whereas others go on to experience persistent pain over months or years? Besides the intensity and duration of pain, the endurance of pain is also important since in some cases the severity and persistence of pain may not be modifiable. In contrast, a person’s beliefs, attitudes, and behaviors that influence the ability to endure pain without allowing it to overwhelm them may be modifiable. 568 •  P h y sical H ealth

Non-​modifiable risk factors for chronic pain include age, sex, ethnicity, and genetic factors that are not environmentally influenced. These factors must be controlled for in analyses when examining the effects of religious involvement on chronic pain. AGE

Age increases the risk of chronic pain because as people age they are more likely to acquire pain-​causing diseases such as shingles (with post-​herpetic neuralgia), osteoarthritis, autoimmune disorders, and to experience injuries that cause chronic pain (Fayaz et al., 2016; Dahlhamer et al., 2018). Nearly 50% of community-​dwelling older adults and 80% of nursing home patients suffer from chronic pain (Gibson et al., 2007). Nevertheless, there is also evidence from experimental studies that pain threshold and pain tolerance can increase with increasing age in some individuals (Gibson & Farrell, 2004). Chronic pain is also not infrequent among younger persons, as evidenced by a recent population-​based study in 42 countries

that found a prevalence of over 20% among adolescents (headache, stomachache, or backache) (Gobina et al., 2019). Younger age may be a particular risk factor for post-​surgical pain (Bruce & Quinlan, 2011). GENDER

Women are more likely to experience chronic pain than men, or at least more likely to report it. Research indicates that women have lower pain thresholds and tolerance and are more likely to experience negative responses to pain (Malon et al., 2018). Hormonal differences may play a role in this regard, as well as the possibility that women may be more likely to catastrophize and ruminate about their pain, in contrast to men who are more likely to underreport pain or deny it (Sorge & Totsch, 2017). RAC E /​E TH N I C IT Y/​CULT URAL BAC KGRO U N D

African Americans have been reported to experience more pain and pain-​ related disability than White Americans (Janevic et al., 2017), and a similar finding has been reported in Blacks in the United Kingdom for musculoskeletal pain (Macfarlane et al., 2015). The latter report, however, found that the effect of race on pain was reduced (but did not disappear) when income, employment, and adverse events were controlled for. Certain cultural backgrounds may also be associated with a greater or lesser emotional responsivity to pain (e.g., Irish less, Hispanic or Italian more) (Campbell & Edwards, 2012). G E N E TI C /​H E R E DITARY

Although there is no “chronic pain gene,” chronic neuropathic pain has been associated with certain polymorphisms of the HLA, COMT, GCH1, OPRM1, and TNFA genes (Veluchamy et al., 2018). Furthermore, sensitivity to pain as well as pain tolerance may be at least partially inherited (Nielsen et al., 2008). Of course, there are also genetic factors that influence the development of painful medical conditions such as osteoarthritis and autoimmune disorders with an inflammatory component.

Partially Modifiable Risk factors that may be at least modifiable in part are education, environment, and socioeconomic status (SES), and the expression of genes affected by the environment (epigenetic influences). SOCIOECON OM IC/​EN VIRON M EN TAL

Lower SES has been related to greater pain severity and greater pain-​ related disability (Janevic et al., 2017). Likewise, lower levels of education, greater neighborhood deprivation, and higher perceptions of income inequality have all been associated with more frequent reports of chronic pain (Jordan et al., 2008). Manual laborers (compared to white-​ collar workers) are more likely to accumulate injuries at work that increase the risk of developing pain syndromes. Unemployment increases risk of chronic pain, in that pain reports are less frequent among those engaged in paid employment or voluntary activity compared to those who are unemployed (Macfarlane et al., 2015). Behavioral factors that interrupt the completion of education (teen pregnancy, drug use, delinquency, legal problems) or psychosocial factors that adversely affect employment status (lower conscientiousness, less dependability, lower sociability), then, are likely to increase the risk of chronic pain later in life. Finally, physical and/​or sexual abuse during childhood has been associated with the development of chronic pain, particularly chronic pelvic and abdominal pain (Fishbain et al., 2014). Family environments in such cases may be modifiable. Genes can influence the development of chronic pain in at least three different ways: moderation of the inflammatory stress response, sensitization of the nervous system to pain, and alteration of immune responses. These are thought to have an influence on neuroinflammation, a common physiological mechanism in chronic pain (Borsook et al., 2018). All of these are potentially influenced by psychological, social, and behavioral factors. The environment may also interact with genetic or hereditary influences on pain perception or endurance in ways that affect the risk of chronic pain (Kerr & Burri, 2017) or the transition from acute Chronic Pain • 569

pain to chronic pain (Buchheit et al., 2012). For example, toxins in the environment, certain medications, an unhealthy diet, and environmental stressors can affect DNA methylation, histone acetylation, RNA interference, or introduce other epigenetic modifications that affect pro-​inflammatory cytokine production, responsiveness to endogenous steroids, and sensitivity to pain-​relieving medications. As noted above, early childhood abuse or neglect may likewise interact with susceptibility genes to affect stress responses later in life that lead to inflammation of nerves and chronic pain. B I OME D I CA L

Medical conditions that increase risk of chronic pain include headache (tension and migraine), low back pain, osteoarthritis, rheumatic disorders (e.g., adult and juvenile rheumatoid arthritis), diabetic neuropathy, neuropathic pain syndromes, fibromyalgia, cancer-​related pain, post-​surgical or post-​traumatic pain, chronic dental caries or temporomandibular joint problems, chronic visceral or abdominal disorders, inflammatory bowel disease, chronic pelvic disorders, and medical conditions resulting from accidents or injuries (particularly those affecting the spinal cord or peripheral nerves) (Treede et al., 2019). When chronic pain is related to disability compensation for injury, this adds yet another level of complexity, one that may be difficult to modify. Many of the medical causes of chronic pain above coexist with one another, as noted earlier, leading to chronic overlapping pain conditions. These illnesses are often affected by psychological, social, and behavioral factors, which in turn may be influenced by religious involvement.

Modifiable Determinants of chronic pain that are potentially fully modifiable are psychological, social, and behavioral factors, which can interact together to affect pain perception and endurance. PSY C H O L O GI CAL

The impact of psychological factors on the development, persistence, and consequences 570 •  P h y sical H ealth

of chronic pain remains poorly understood. However, Ronald Melzack (Melzack & Wall, 1965; Melzack, 1999) proposed a theory that could explain the physiological mechanism by which psychosocial factors influence pain. He knew from previous research that the severity of pain could not be entirely explained by nociceptive or physical causes alone. Pain intensity also appeared to be affected by attention, anxiety, suggestion, and other psychosocial influences. In his “gate theory” of pain, Melzack proposed that pain signals from an injured body part were modulated at the spinal cord level by other simultaneous somatic inputs and by descending influences from the brain. He proposed that a mechanism in the spinal cord dorsal horns acted like a “gate” to inhibit or facilitate transmission of pain impulses based upon a combination of peripheral nerve and descending brain inputs. This theory has received repeated confirmation by other investigators over the years, with only minor modifications (Mendell, 2014). Melzack and researchers since then have found that intense stimulation over certain trigger points on the body surface may diminish or completely eradicate certain types of pain. Similarly, psychological influences such as past experience, intense attention, and other cognitive activities have been proposed as other ways to inhibit or increase pain transmission by “closing” or “opening” the gate. Psychological factors influencing the experience of pain and development of chronic pain include coping behaviors, depression, anxiety, personality, and positive emotions. As noted above, these are often influenced by pain itself in a bidirectional manner, leading to a downward spiral that helps to maintain the pain over time. Beliefs, attitudes, and coping behaviors are known to affect the experience of chronic pain and the resulting pain-​related disability. For example, passive coping strategies that rely primarily on resting, taking medication, or using hot/​cold packs have been associated with an increased risk of pain-​related disability, compared to engagement in more active coping behaviors such as paced exercise, correction of posture, relaxation, stretching, engagement in distracting behaviors, or participation in social activities (Blyth et al., 2005; Edwards et  al.,

2016). The ability to successfully cope with pain often involves recasting the problem in a way that motivates the person to take part in active coping behaviors that promote problem resolution rather than rumination (De Vlieger et al., 2006). As stressed in Acceptance and Commitment Therapy (ACT), positive coping behaviors, such as accepting the pain rather than trying to control the pain, being psychologically flexible when dealing with the pain, and engaging in values-​based actions, all help to reduce the pain, enhance the ability to endure the pain, and may reduce the disability caused by the pain (Edwards et al., 2016). Depression is closely linked to chronic pain. Research indicates that depression is both a cause of persistent pain and a consequence of chronic pain, and that outcomes over time are worse when both are present together (IsHak et al., 2018). Among patients with no pain symptoms at baseline, major depression predicts an increased risk of future chronic pain by nearly 3-​fold (Currie & Wang, 2004). In a meta-​ analysis of 11 prospective studies, Pinheiro et al. (2015) found a 59% increased odds of developing a new episode of back pain among those having symptoms of depression but no back pain at study entry (OR =​1.59, 95% CI =​1.26–​ 2.01). In that research, those with the most severe level of depression experienced a more than 2.5 increased odds of developing back pain over time (OR =​2.51, 95% CI =​1.58–​3.99). The co-​occurrence of chronic pain and depression may be due to neuroplastic changes in the brain caused by one condition that increases the risk of the other (Sheng et al., 2017). Suicide risk is also significantly increased among those with chronic pain, with individuals at greatest risk having a combination of depressive symptoms, problems with anger, poor health behaviors, a history of childhood adversities, recent stressful life events, and a family history of depression/​suicide (Racine, 2018). Anxiety also increases the risk of chronic pain. Fear often stimulates avoidance behavior (such as abstaining from physical activity) that can lead to chronic pain, particularly when the person interprets the pain as unavoidably catastrophic (De Vlieger et al., 2006; Hasenbring et al., 2014). In a systematic review and meta-​ analysis of 22 studies, Theunissen et al. (2012)

found that 10 of 22 studies (45%) reported a significant effect of pre-​ surgical anxiety on the development of post-​surgery chronic pain (pooled OR =​1.76, 95% CI =​1.07–​2.90). This may be especially true for those suffering from post-​ traumatic stress disorder (PTSD). In a review of 19 studies by Fishbain et al. (2017), 16 (84.2%) of those studies found a significant association between chronic pain and PTSD. Among veterans with PTSD, more than 50% of veterans reported chronic pain. Personality may also influence the development of chronic pain. Naylor et al. (2017) found that individuals with greater harm avoidance (fearful, pessimistic, sensitive to criticism, needing reassurance) and lower self-​ directedness (difficulty defining and setting meaningful goals, low motivation, passive coping) are more likely to experience chronic pain. The development of a “pain personality” is thought to be caused by chronic pain itself, although causality may be bidirectional. This personality type is often found in those with headache or migraine, fibromyalgia, temporomandibular disorder, trigeminal neuropathy, musculoskeletal disorders, and various other chronic pain syndromes. Over 60 years ago, George Engel (1959) provided a psychoanalytic explanation for the experience of chronic pain. He described the “pain-​prone” personality as developing in someone who in the past had experienced suffering, defeat, or intolerance of success; conscious or unconscious guilt; an unfulfilled aggressive drive; and feelings of loss or fear of threatened loss of a relationship. The experience of chronic pain, according to Engel, served to atone for this guilt, substitute for unfulfilled aggressive drives, or replace feelings of loss or fear of relationship loss. This psychoanalytic explanation, however, has fallen into disfavor, at least in part because the explanation may be more appropriate for psychogenic pain (Roy, 1985; Gamsa, 1994). More recently, investigators have concluded that there is no consistent evidence for a typical pain-​ prone personality (Gamsa, 1994; Nicholas, 2018), although the theory may have some merit in certain cases. Positive emotions have an effect that is opposite that of negative emotions on the development and persistence of chronic pain. Chronic Pain • 571

Positive emotions confer resiliency by reducing the likelihood of pain catastrophizing and increasing cognitive flexibility. Emotions of this type include positive thinking, optimism, hope, and positive self-​talk (Edwards et al., 2016). Such positive psychological states are known to broaden the scope of attention and thinking, to widen the range of thoughts and possibilities for action, and to increase cognitive flexibility, thereby expanding resourcefulness in coping with pain. For example, in a study of 95 patients with chronic pain, Ong and colleagues (2010) found that the experience of more positive emotions (enthusiastic, happy, energetic, alert, proud, active, joyful, interested, calm, satisfied, relaxed) was inversely correlated with daily pain catastrophizing (r =​−0.42, p < 0.01, n =​1,237 person days). Studies also indicate that positive emotions foster more adaptive recovery from pain-​causing conditions (Zautra et al., 2005; Ong et al., 2015). SOCIAL

Social influences on the development and expression of chronic pain are substantial. Social/​interpersonal factors include the social environment, extent of social interactions, social support, and in counseling sessions, therapeutic relationships (Meints & Edwards, 2018). Individuals with chronic pain conditions (e.g., spinal cord injury, multiple sclerosis, surgical amputation) who have more social support do better in terms of pain outcomes (Hanley et al., 2004; Jensen et al., 2011). The quality of the social interaction and support, however, may be determinative. When there is a high degree of solicitousness in social interactions, such as taking over of tasks or encouraging less physical activity, this predicts greater pain-​related disability (Jensen et al., 2011). Achieving an appropriate balance between social support and solicitousness is important in all situations and settings. Enabling a person with chronic pain to be as independent as possible in caring for their physical needs is crucial, so creating dependency must be avoided at all costs. Family relationships also affect pain severity and disability (Boone & Kim, 2019). Cognitive and behavioral responses of parents of children with painful conditions also influence the 572 •  P h y sical H ealth

child’s likelihood of developing a chronic pain syndrome (Palermo & Holley, 2013). These include parental catastrophizing of the pain, attention paid to the pain, and solicitous behaviors that discourage children from engaging in regular activities (Noel et al., 2015). Quality of the marital relationship can also affect pain. For example, having a spouse with an avoidant or anxious attachment style has been associated more severe symptoms in the partner with pain (Gauthier et al., 2012). Other social factors that influence the development of chronic pain more generally include the quality of social interactions at work (supportive, adversarial, solicitous), with peers and friends, and with healthcare providers (quality of the working alliance) (Edwards et al., 2016). H EALTH BEH AVIORS

Health behaviors may be adaptive or maladaptive in terms of their effects on chronic pain (Anderson et al., 2016; Edwards et al., 2016). Adaptive behaviors include exercise (aquatics, aerobics, and strength training) (Geneen et al., 2017), attention to diet and eating habits (Brain et al., 2019), weight loss if overweight or obese (Bigand et al., 2018), adequate sleep (Haack et al., 2020), and implementation of pain-​ management strategies such as relaxation or mindfulness (Majeed et al., 2018). Maladaptive behaviors may either lead to the development of chronic pain or be a consequence of having a pain-​disorder. These include cigarette smoking (Mills et al., 2019), alcohol or illicit drug use to dull the pain (Mills et al., 2019), physical inactivity leading to deconditioning (Geneen et al., 2017), and weight gain due to uncontrolled eating habits (Bigand et al., 2018). Religious beliefs are known to influence both adaptive and maladaptive health behaviors.

RELIGION AND CHRONIC PAIN Religious involvement may impact the development and course of chronic pain through each of the socioeconomic, environmental, epigenetic, biomedical, psychological, social, and behavioral pathways described above. We will first describe a case vignette that illustrates

how religion can affect chronic pain, and then theorize how religious involvement might affect the pain experience in terms of its intensity, duration, endurance, and consequences. Case Vignette This case of an older woman with severe chronic pain was described in an issue of the Journal of the American Medical Association (JAMA) (Koenig, 2002). Mrs. AB is an 83-​year-​old African American woman living in the Boston area. She has multiple serious medical problems, including hypertension, diabetes, goiter, and in particular, spinal stenosis, and bursitis in several joints. One of the complications of her diabetes and spinal stenosis is a poly-​motor and sensory neuropathy that causes chronic and unrelenting pain. Her internist has tried to relieve her pain with anti-​ inflammatory drugs, anticonvulsants, and narcotic analgesics such as tramadol, codeine, oxycodone, and fentanyl. But none of these has improved the severity of her pain, including alternative medical treatments such as acupuncture and massage. As a result, the pain has been categorized as a narcotic-​resistant neuropathic pain syndrome. Neurological consultation also has not identified a treatable cause for the pain. Mrs. AB has few material resources and lives alone in a senior housing apartment. Despite the disabling pain, she performs all activities of daily living independently and requires no outside assistance. Her internist, a professor at Harvard Medical School, has attempted to treat her symptoms for many months without success, and now expresses frustration about what to do next. However, there is something about Mrs. AB that is different from other chronic pain patients he treats. She appears to be doing quite well psychologically in spite of the near constant severe chronic pain. She is usually positive, hopeful, and optimistic about her condition. Dumbfounded, the doctor asks her

how she maintains such a positive attitude. When asked this question, she has repeatedly given the same response. She says her faith in God is what has helped her to endure the pain. Her exact words, documented during a clinic visit and reported in the JAMA article, are these: I don’t dwell on the pain, you know. Some people are sick and have pain, and it gets the best of them. Not me. Praying eases the pain, it takes it away. Sometimes I pray when I am in deep, serious pain; I pray, and all at once the pain gets easy. Praying helps me a lot. I feel that has helped me more than the medication. A doctor is a doctor. Not everybody is bound to believe in God. It’s your own mind, your thoughts, and your belief. The doctor gives you the medicine. God works through the doctor. He is a great physician and he heals, but you have to believe. I believe in God. He’s my guide and my protector. Whenever you pray, you will get healing from God. You will. But you must have that belief. Because if you don’t believe in God and turn your life over to him, it’s nothing doing. You can’t just pray, “God, I’m suffering, and I ask you to heal my body.” It don’t work like that. You have to really be a child of God. (Koenig, 2002, p. 487)

HOW MIGHT RELIGION IMPACT CHRONIC PAIN? It is difficult to fully unpack Mrs. AB’s explanation. However, we nevertheless now hypothesize how religious involvement might impact the experience of chronic pain, beginning with a theoretical model and then discussing in detail the socioeconomic, biomedical, environmental, psychological, social, and behavioral pathways through which this might occur. Lazarus and Folkman’s (1984) transactional theory of stress and coping can be used to make sense of how religion could help a person like Chronic Pain • 573

Mrs. AB endure severe pain that cannot be relieved by medical means. This model argues that the impact of a stressor like chronic pain on a person depends on how that individual perceives, evaluates, and appraises the pain. Appraisals of this type may be primary or secondary. Primary appraisal occurs when an individual evaluates their situation as being a threat, challenge, or harmful event. Secondary appraisal then follows, where the person takes stock of whether they have adequate resources to meet the demands the stressor may put on them. Religiosity can influence both types of cognitive appraisal. For example, in primary appraisal, a religious person may view their pain in a positive manner that gives it meaning and purpose, perhaps as an opportunity for spiritual growth, a way to make restitution for past sins, or for Christians, perhaps as a way to participate in the “sufferings of Christ.” In secondary appraisal, religious involvement may provide social and cognitive resources that will enable the person to withstand or successfully deal with the pain. Such resources may involve support from members of their congregation or support from God, inspiration derived from reading religious scriptures that makes the person feel capable of coping with the pain, or meditation practices such as mindfulness or centering prayer that may help to reduce the pain. In contrast, if the individual views their pain as a punishment from God or generates anger toward God, then distress from pain may be magnified and religious coping resources cut off. Thus, the manner in which a person’s religious beliefs influence (a) how they make sense of the pain and (b) whether they have sufficient resources to cope with the pain will likely influence the severity of the pain, their ability to endure it, and their ability to function. Based on these primary and secondary appraisals of pain, we now examine how religious involvement might affect the pain experience through the known risk factors for chronic pain reviewed earlier.

Socioeconomic Low SES is associated with chronic pain and pain-​related disability (see above). As noted in 574 •  P h y sical H ealth

prior chapters, being raised in a religious home and being guided by religious values and morals lowers the likelihood of having education interrupted by drug/​alcohol use, being detained for delinquent or criminal behaviors, or becoming pregnant out-​of-​wedlock as a teenager. If education can be completed, then the chances of obtaining a well-​paying job, or a non-​manual job where physical injuries are less common, a home in a safe neighborhood, and good health insurance to cover medical costs will all be greater, lowering the risk of developing chronic pain. However, religious involvement is also associated with lower SES and racial minority status, so this must be taken into consideration. These are principally confounders of religiosity-​pain associations rather than mediating pathways.

Environmental Adverse childhood experiences (ACEs), particularly physical and/​or sexual abuse, increase the likelihood of developing chronic abdominal or pelvic pain, and may worsen other pain syndromes as well (see above). These may also interact with pain-​sensitivity genes, increasing the likelihood of developing chronic pain in later life through epigenetic mechanisms. If raised in a religious family where children are valued, carefully monitored in a two-​ parent home, and provided with a stable childrearing environment, then the likelihood of experiencing ACEs will be lower, reducing the risk of later pain syndromes.

Biomedical Medical conditions responsible for the development of chronic pain are known to be influenced by psychological, social, and behavioral factors related to religious involvement. These medical conditions include “tension” headaches, migraine headaches, low back pain, pain-​related inflammatory disorders, fibromyalgia, pain due to organ invasion by cancers (from smoking, excessive alcohol use, other negative health behaviors), irritable bowel syndrome, chronic pelvic pain, and chronic fatigue syndrome. Furthermore, having a peer group with prosocial inclinations, as might be found

within a religious community, may also reduce the likelihood of high-​risk behaviors that result in accidental injury and chronic pain.

Psychological If religious involvement increases the likelihood of healthy active coping behaviors (Chapter 4), then this may increase pain endurance and reduce pain-​ related disability (see transactional theory of stress and coping above). However, if religious beliefs encourage passive ways of dealing with pain or decrease individual responsibility for engaging in behaviors that reduce pain, then this may exacerbate pain in the long run. Both religiosity itself and also improved coping with pain will reduce rates of depression (Chapter 5), anxiety (Chapter 8), and substance abuse (Chapter 10), which often worsen pain. All of these conditions are less common among those who are more religious. Likewise, if religiosity increases positive emotions such as well-​being, life satisfaction, optimism, hope, and a sense of purpose and meaning in life (Chapter 12), then the ability to endure pain may be increased and disability from the pain reduced.

Social

Gender Race/ethnicity Genes/heredity

Those who are more physically active, eat a healthier diet, obtain adequate sleep, relax by engagement in prayer or meditation, and are less likely to smoke cigarettes, over-​consume alcohol, or use illicit drugs are more likely to experience lower levels of pain, recover more quickly from pain-​ causing disorders, and be less disabled by them. Religious involvement is related to all of these behaviors in a healthier direction (Chapter 17–​ 19) and therefore may improve pain outcomes through these pathways. If religious involvement promotes overeating during fellowship activities that causes excess weight gain, however, then it may worsen chronic pain. Finally, greater adherence to medical treatment (e.g., analgesics) among those who are more religious may also impact

Risk Factors Partially Modifiable Socioeconomic Environmental Epigenetic Biomedical Modifiable Coping behaviors Depression Anxiety Personality traits Social support Health behaviors

Chronic Pain

Age

Behavioral

(severity and endurance)

Non-modifiable Controls

Religiosity

Individuals with greater social support and positive interactions with others have better pain outcomes. On the one hand, if religious involvement increases the opportunity for positive

social interactions, expands social networks, and increases social support (Chapter 15), then chronic pain may be less severe, resolve more quickly, be endured more easily, or cause less pain-​related disability. On the other hand, if interactions with church members are stressful or negative in nature, then the opposite may the result. Furthermore, if the religious beliefs of members of a congregation cause them to love and support those with chronic pain by taking over activities that those persons can do for themselves (i.e., over-​solicitous helping behaviors), then pain outcomes may be made worse by fostering dependency.

FIGURE 29.1.  Pathways by which religiosity may affect chronic pain and vice versa. Chronic Pain • 575

the pain experience, as some research has found (El-​Masry et al., 2018).

Summary There are many pathways by which religious beliefs, practices, and values could impact the development, course, and endurance of chronic pain (Figure 29.1). Pain may be alleviated or worsened depending on the individual’s particular religious beliefs, how strongly they are held, and how pain is cognitively appraised based on those beliefs. We now focus on systematic quantitative research that has examined the effects of religiosity on pain severity, endurance, and disability.

RESEARCH ON RELIGION AND CHRONIC PAIN In reviewing the research, we first briefly summarize early research conducted prior to 2010 and then present more recent research published since, again focusing on the highest-​ quality studies with a particular emphasis on prospective studies and randomized controlled trials (RCTs). As indicated earlier, we do not examine research on the role that religiosity plays in coping with pain, which has been addressed to some extent in Chapter 4 and exhaustively reviewed elsewhere (Ferreira-​ Valente et al., 2022).

Early Research Prior to 2010, there were at least 55 studies that examined the relationship between religiosity/​ spirituality (R/​S) and pain, or the effects of an R/​S intervention on pain (see first and second editions of the Handbook). Of the 37 cross-​ sectional studies, 8 (22%) reported that pain was less frequent among those who are more religious, 12 (32%) found more pain among the more religious, 13 (35%) reported no association, and 4 (11%) indicated mixed or complex results. Of the 4 prospective studies, 1 indicated that religiosity at baseline predicted less severe pain over time, 1 reported it predicted worse pain, and 2 indicated that religion had no effect. Of the 14 RCTs or experimental studies, 13 (93%) reported that R/​S interventions 576 •  P h y sical H ealth

(usually Eastern forms of spiritual meditation) produced significant reductions in pain severity. Thus, while R/​S involvement was either unrelated to pain or related to worse pain in the majority of cross-​sectional studies and to better or worse pain in prospective studies, most clinical trials and experimental studies reported that R/​S interventions reduced pain severity. Although there is insufficient space here to describe the 14 RCTs or experimental studies, we now review the two prospective studies that reported opposite results. In a prospective study conducted within the context of an RCT, Turner and Clancy (1986) followed 74 chronic low back pain patients over an 8-​week treatment period. Participants were living in Washington State and were participating in a 3-​arm RCT during that time. At baseline and follow-​up, prayer as a coping strategy was assessed by the praying and hoping subscale of the Coping Strategy Questionnaire. Although diverting attention and praying at baseline was significantly and positively related to higher pain level, increased use of praying and hoping strategies during the 8-​ week follow-​ up predicted a decrease in pain severity over time (r =​ −0.21, p < 0.05). L. Cohen and colleagues (2005) followed 122 women in Toronto, Canada, before and after gynecologic surgery. Assessed prior to surgery and examined as a predictor of pain outcomes after surgery, religious coping (RC) was measured using a 2-​item subscale of the brief COPE: “I’ve been trying to find comfort in my religion or spiritual beliefs,” and “I’ve been praying or meditating.” The pain rating index (PRI) subscale of the McGill Pain Questionnaire was used to measure pain quality at 48 hours and 4 weeks after surgery. In addition, morphine consumption during the first 24–​ 48 hours after surgery was determined. In contrast to the Turner and Clancy study above, RC prior to surgery predicted a significantly greater use of morphine after surgery (β =​0.21, p =​0.04) and higher pain scores at the 4-​week follow-​up (β =​0.34, p =​0.001). Baseline pain ratings were not done, so it is not known whether RC prior to surgery was associated with greater pain as well. Distress level prior to surgery (measured by the Impact of Events Scale) was significantly higher (r =​ +​0.21, p < 0.05) among women

with higher baseline RC scores, supporting the latter possibility. Nevertheless, the multivariate analyses above controlled for baseline distress level.

overall association was found between prayer and pain severity, religious affiliation also moderated that relationship (β =​0.27, p < 0.01), such that prayer among those who were religiously affiliated was associated with lower pain severity (whereas the trend was opposite Recent Research in the unaffiliated). The highest-​ quality studies published since Burke and colleagues (2017) analyzed data 2010 are now reviewed in order of study design on a community-​dwelling population of 34,525 (cross-​sectional, prospective, RCTs) and year of adults participating in the 2012 US National publication. Health Interview Survey. The purpose was to examine the relationship between three forms of meditation (mantra, mindfulness, and spiriC RO SS -​SE C TI ONAL tual) on the likelihood of reporting back pain. Not much can be concluded from cross-​ Mantra meditation involved Eastern religious sectional studies other than determining that forms of contemplation such as transcendenthere is an association. Nevertheless, estab- tal meditation; mindfulness meditation based lishing that association may be important in on Buddhist practices; and spiritual meditasome populations. With cross-​sectional stud- tion centered around Christian contemplaies, however, any benefits that religious prac- tive prayer, Sufi Muslim Dhikr meditation, tice may have on pain are likely to be nullified Jewish meditation within the Kabbalah traby the fact that persons often turn to religion dition, or other forms of Western meditation. in response to pain, especially when severe. In Multivariable logistic regression examined the that case, the result could be that negative and relationship between each of these three forms positive associations cancel each other out, of meditation and reports of back pain, conleaving no association (or a positive or nega- trolling for sociodemographic, health behavtive association depending on which effect is iors, Complementary and Alternative Medicine (CAM) use, subjective health, functional limstronger). In a small study of 202 chronic pain patients itations, mental health, insurance status, and in Belgium, Dezutter et al. (2011) examined healthcare-​seeking behavior. Results indicated the associations between prayer, pain sever- that 4.1% of the population indicated one or ity, and pain tolerance. This analysis was based more of the three meditation practices during on the theory that religious individuals might the previous 12 months (1.6% mantra medcognitively appraise their pain more positively itation, 1.9% mindfulness, 3.1% spiritual). (as we had theorized earlier). Among those Meditators as a group were more likely to with a religious affiliation (63%), the majority report back pain than non-​meditators (38.5% were Catholic. Prayer was assessed by a single vs. 27.4%, p < 0.001). In multivariable analyses, question: “How often do you pray?” Pain sever- spiritual meditation (but not mantra or mindity was measured by three questions, and pain fulness meditation) was associated with a 31% tolerance by eight questions. Cognitive reap- greater likelihood of experiencing back pain praisal was determined by a 4-​item positive (OR =​1.31, 95% CI =​1.02–​1.68). reinterpretation and growth subscale of the X. Liu et al (2018) analyzed data from a COPE Inventory (Carver). Results indicated a population-​based survey of 2,052 community-​ positive association between prayer and pain dwelling residents (57% over age 45) in Liuyang tolerance (r =​0.18, p < 0.05), which, as hypothe- City located in the Hunan province in south-​ sized, was explained by more positive cognitive central China. Although not the primary purappraisals of pain. This association was mod- pose of the study, among the variables assessed erated by religious affiliation (interaction β =​ were religion and pain intensity. Religion was −0.25, p < 0.05), such that prayer was associ- measured by a single question asking if the ated with greater pain tolerance only in those participant was a “follower of a religion” (10% who were religiously affiliated. Although no indicated yes). Pain intensity in the past month Chronic Pain • 577

was assessed by a visual analog scale ranging from 0 (no pain) to 10 (worst pain imaginable). Bivariate analyses indicated an inverse relationship between religion and pain intensity (r =​−0.09, p < 0.01), although evidence for the association no longer passed the p < 0.05 threshold when a regression model controlled for socioeconomic, physical, social, and mental health characteristics. Brammli-​Greenberg and colleagues (2018) analyzed data from a random sample of 4,057 adult participants in the 2004 Israel National Health Survey, with the purpose of examining the relationship between religiosity and health. Included among health characteristics assessed was the experience of pain. Religiosity was measured by Jewish religious affiliation ranging from the most religious (Haredi Jews) to the least religious groups (nonreligious traditional and secular). Pain was defined as “ever having had either arthritis or rheumatism, chronic back or neck pains, strong headaches or other chronic pain.” Controlled for in regression analyses were age, gender, ethnicity, area of residence, and education. Results indicated that the distribution of religion was 6% Haredi, 9% religious, 12% traditional-​religious, 26% traditional-​nonreligious, and 47% secular. Multivariate analyses revealed that Haredi Jews (the most religious) were 42% less likely to experience pain than secular Jews (OR =​ 0.58, 95% CI =​0.43–​0.79, p < 0.001). Thus, results from cross-​ sectional studies are mixed on whether there is an association between religiosity and pain and whether that association is positive or negative, which is not surprising given the bidirectional effects, as noted earlier (also see “Causal Inference” below). PRO S P E C TI VE ST UDIE S

Unfortunately, there have been few if any recent prospective studies examining the effects of religiosity on pain over time. We were able to identify only two such studies, one of which (the second one) examined the effects of headache pain on future religious attendance, rather than the effects of attendance on pain. In the first study, Basinski et al. (2013) examined the effects of religiosity on quality 578 •  P h y sical H ealth

of life and pain intensity among 92 patients with chronic pancreatitis following a neurolytic celiac plexus block (NCPB) to relieve the pain. Participants were separated into two groups soon after the surgical procedure: Group 1 indicated no contact with the church or very sporadic contact, and Group 2 indicated they were religious and were regular participants at church mass (all participants were Catholic in this study conducted in Gdansk, Poland). Pain was assessed on a visual analog scale (VAS) ranging from 1 (no pain) to 10 (worst pain); this was done every 3 hours during the 3-​day period before the NCPB procedure, every 3 hours for one week after the NCPB, and once a day up to and including the 4th week after the procedure. Quality of life was assessed with the 30-​item QLQ-​C30 at baseline and at 1 and 4 weeks following NCPB. Results indicated that level of pain was similar in each group prior to NCPB (Group 1 =​7.6 ± 0.9 vs. Group 2 =​7.3 ± 0.2), and was similar 1 week after the procedure (Group 1 =​4.0 ± 0.9 vs. Group 2 =​4.1 ± 0.3) and 4 weeks after the procedure (Group 1 =​3.3 ± 0.4 vs. Group 2 =​3.2 ± 0.5), with both groups showing significant improvement (p < 0.001). These are the only statistics provided (i.e., no comparisons made on pain severity between the two groups). Visual inspection of the numbers indicated little or no difference between groups in terms of response to NCPB. Increases in overall quality of life, however, did improve significantly more in Group 2 (religious group) than in Group 1 at week 1 and week 4 following the procedure (both p < 0.05). In the second study, Tronvik et al. (2014) analyzed data collected on 24,610 participants in the Nord-​Trondelag Health Survey (HUNT) survey between 1995–​ 1997 (Wave 2) and 2006–​2008 (Wave 3). The intention, however, was to examine the effects of headache on religious attendance. Frequency of religious attendance was assessed at the final Wave 3 with the question: “How often in the last 6 months have you been to church/​prayer house?” Frequent attendees were designated as attending services at least once per month. Headache was measured at Wave 2 and Wave 3 by the question: “Have you suffered from headache during the last 12 months?” Controlled for were age, gender, education, smoking, physical activity,

body mass index, chronic musculoskeletal complaints, systolic blood pressure, anxiety, and depression. Results indicated a 13% increase in the odds of being a frequent attender at religious services at Wave 3 among those with headache at Wave 2 (OR =​1.13, 95% CI =​1.05–​ 1.22). Individuals suffering from more severe headaches (i.e., migraines) at Wave 2 had 25% higher odds of being frequent church attenders at Wave 3 (OR =​1.25, 95% CI =​1.19–​1.40). Researchers explained that religious activities may be a coping strategy among those with headache pain (as we had suggested above). Unfortunately, these studies contribute little information to help answer the question of whether religiosity predicts improvements in pain intensity or endurance over time.

In a second RCT conducted in Iran, 80 Shia Muslim patients were randomized to either a religious intervention group or a control group to examine the effects on pain following coronary artery bypass graft surgery (Nasiri et al., 2014). After surgery, when patients were still in the ICU, researchers randomized 40 patients to the prayer intervention and 40 patients to a usual care group. The religious prayer intervention consisted of asking patients to recite for 10–​15 minutes the Hazrate Zahra, one of the most common phrases expressing praise to Allah/​God among Muslims. This consists of reciting the phrase Allahu Akbar (“God is the greatest”) 34 times, Alhamdulilah (“all praise and thanks to God”) 33 times, and Subhan Allah (“glorious is God”) 33 times. The intervention took place at the same time on days 1, 2, and 3 after surgery. A VAS ranging from 0 RA N D O MI ZE D CONT ROLLE D (no pain) to 10 (worst pain) was used to meaTRI A L S ( R C TS) sure pain levels before and after the intervenSix RCTs examined the effects of a religious/​ tion in both groups, administered by a nurse spiritual intervention on pain level, almost all who was blind to treatment group. There were conducted in acute pain situations (not in per- no differences in age, gender, education, marsons suffering from chronic pain). In the first ital status, ethnicity, urban-​ rural residence, clinical trial, 160 Iranian Muslim women who history of hospitalization, or history of surgery had recently undergone a C-​section with mild between the two treatment groups at baseline. pain (VAS 1–​ 3) were randomized to either Results indicated a significant between-​group 20 minutes of listening to a recited prayer difference in pain reduction at days 1, 2, and 3, meditation using headphones (n =​80) or to favoring the prayer intervention group. Within-​ a control group (n =​80; headphones turned group pain reduction in the prayer group off) (Beiranvand et al., 2014). The prayer was was also significant on all 3 days following “Ya man esmoho davaa va zekroho shafa, the intervention, whereas there was no pain Allahomma salle ala mohammad va ale moham- reduction in the control group. mad” (remembrance of Allah and the doctrinal Feuille and Pargament (2015) randomized testimony of faith in Islam). Pain intensity and 74 persons with migraine headaches (mostly physiological markers were assessed before, college students in Ohio) to one of three treatduring, and 30 minutes, 60 minutes, 3 hours, ment groups: standardized mindfulness (n =​ and 6 hours after the prayer meditation. Age, 22), simple relaxation (n =​25), or spiritualparity, income, education, and occupation ized mindfulness (n =​27). Participants were were similar between both groups at baseline. 80% women, 72% White, and 70% Christian. Results indicated no differences in pain level Standardized mindfulness involved the between the two groups prior to, during, or at Buddhist technique of staying engaged in the 30 and 60 minutes after the prayer meditation. present, as described by Kabat-​Zinn (2003). However, pain level was significantly lower at Relaxation involved sitting quietly with eyes 3 hours and 6 hours in the prayer meditation closed, relaxing muscles, and calming the mind. group compared to controls (VAS 1.5 vs. 3.0, p Spiritualized mindfulness involved cultivating =​0.03, and 1.3 vs. 3.0, p =​0.003, respectively). a spiritual connection by arousing a “feeling Researchers also indicated that prayer medita- that you are closer to something within and tion caused less postoperative nausea/​vomit- around you, something more fundamental or ing (p < 0.001) and more relaxation (p < 0.001). sacred” (e.g., the Holy Spirit in Christianity). Chronic Pain • 579

Pain was assessed by the 6-​ item Headache Impact Test and Cold Presser Test (CPTest, examining time spent with hands in ice water at 2°C). There were no differences at baseline between groups on gender, religious affiliation, belief in God, frequency of prayer, history meditation, university affiliation, age, other religious characteristics, headaches per month, or severity of headache, except there were fewer Whites in the spiritualized mindfulness group. After 2 weeks of daily practice, results indicated no difference between intervention groups on headache pain level or CPTest, though the sample size of about 25 per group was small, limiting power to detect differences. Meints et al. (2018) randomized 208 pain-​free undergraduate students at Indiana University–​Purdue University in Indianapolis to three groups: active prayer (repeating phrase “God, help me endure the pain”), passive prayer (repeating phrase “God, take the pain away”), or no prayer (repeating phrase “the sky is blue”). These phrases were repeated during the CPTest. The purpose of this study was to examine the effects of prayer and race on pain tolerance. ANCOVA (analysis of covariance) was used to examine the main effects of group and interaction effects of race and praying on pain tolerance, controlling for use of prayer as a pain-​coping strategy (CSQ-​R praying/​hoping subscale) and general tendency toward pain catastrophizing (PCS scale). There was borderline evidence that those in the active prayer group had greater cold pain tolerance than those in the passive prayer group (p =​0.06) and greater pain tolerance than those in the no prayer group (p =​0.03). In a study conducted in Austria, Sollgruber and colleagues (2018) randomized 113 long-​ term meditation practitioners and novices (average age 41.5) to either a Taoist meditation group (n =​57) or a relaxation group (n =​ 56), with the intention to compare effects on pain intensity and endurance. Pre-​and post-​ intervention pain perception was assessed using Quantitative Sensory Testing (QST) and the CPTest. The QST assesses thresholds for warmth, cold, and pain detection, as well as pain intensity for cold and heat. The meditation intervention involved paying attention to breathing, focusing attention on a place of 580 •  P h y sical H ealth

rest within oneself, and saying a mantra (“I am loved, protected, and guided, embedded in the big picture”). This meditation was described as a Taoist form of meditation with similarities to Hindu and Tibetan Buddhist practices. Those in the relaxation group were taught to relax by calming themselves and not thinking about anything stressful, without sleeping. Both meditation and relaxation groups spent a single 20-​minute session in these headphone-​ guided interventions. At baseline there were no differences between groups on any QST or CPTest measures. Change scores were calculated in each group following the intervention and results compared. Pain tolerance to the CPTest increased significantly more in the meditation group compared to the relaxation group (24.6 vs. 20.0 seconds, p =​0.01). Pain intensity for heat also decreased significantly more in the meditation group compared to the relaxation group (−9.48 vs. −3.33, p < 0.01). There were no significant between-​group differences on any other QST measure. Finally, Keivan et al. (2019) examined the effects of an R/​ S intervention on pain intensity and satisfaction during dressing changes in 64 Muslim burn patients in Iran. Participants were randomized to the experimental or control group. Spiritual care sessions were conducted by the help of a nurse, a clergy person, and the patient’s companion. Pain intensity and satisfaction were assessed before and after the intervention. Those in the experimental group received the spiritual care program during three sessions conducted on three days. The spiritual care program involved religious and psychological support for 20–​30 minutes before the dressing change, listening to recorded verses of the Qur’an during the dressing change, and receiving support from a family member or close friend and religious support from the clergy person after the dressing change. Those in the control group received routine care for pain and received three 45–​60 minute sessions of counseling by a therapist unfamiliar with the research. Pain intensity and pain satisfaction were each assessed by a standard 0–​10 VAS and numerical rating scale (NRS), respectively. There were no significant differences between the two groups on pain intensity or satisfaction at baseline. Results

indicated that the average pain intensity score decreased with each intervention session on the VAS from 8.5 pre-​intervention down to 6.9 after first session, 6.0 after second session, and 4.4 after the third session (compared to 7.7, 8.3, 8.4, and 8.3 in the control group, respectively, p < 0.001). Likewise, satisfaction with pain on the NRS increased in the experimental group from 2.2 before the intervention to 6.5 after the intervention (compared to 2.5 before and 2.3 afterward in the control group, p < 0.001). Thus, the majority of recent RCTs continue to show a positive impact of R/​S interventions on reported pain levels, just as they had in research published prior to 2010.

Summary The majority of cross-​sectional studies (earlier and more recent) have found either no association or more severe pain among the more religious, findings that are likely due at least in part to the effects of pain on religious involvement (prayer and religious coping activities being mobilized in response to pain). Of the few prospective studies that have examined the effects of religiosity on change in pain levels over time, the findings have been mixed, with one early study finding positive associations, one finding negative associations, and the rest reporting no associations, with all involving only short follow-​up periods (a few months) and small sample sizes. The vast majority of clinical trials and experimental studies, in contrast, have found that R/​S interventions reduce pain severity or increase pain tolerance. Thus, further research is needed to fill the many gaps in our current knowledge about the effect that religious involvement has on acute and chronic pain.

RECOMMENDATIONS FOR FUTURE RESEARCH When conducting future research and interpreting the results of past research on religiosity and pain, especially observational research, we have several points to consider and recommendations to make regarding (1) causal inference, (2) selective mortality, (3) control

for non-​modifiable risk factors and consideration of moderating effects, and (4) need for prospective studies and RCTs testing religious interventions for chronic pain.

Causal Inference When conducting observational studies, the issue of causal inference is crucial, especially when examining the religion-​ pain relationship, which is almost certainly bidirectional in nature (Figure 29.1). The experience of physical pain increases the likelihood that individuals will turn to religion, particularly prayer, to cope with the distress caused by the pain. For example, studying a random sample of 382 community-​ dwelling persons in San Diego County with musculoskeletal complaints, Cronan and colleagues (1989) found that among 19 unconventional methods used to alleviate pain, prayer was the most common (44%) and was the second most helpful (54% indicating “very” helpful). Similarly, Glover-​ Graf et al. (2007) found that 61% of pain clinic patients in Texas indicated that prayer was their most frequent response to pain, second only to taking medication (89%). In a study of 245 US veterans in Connecticut, religious activities in 21% were among the most common ways of coping with pain, 46% rating them as quite or extremely effective (Barry et al., 2004). In the Glover-​Graf et al. (2007) study, 40% of patients indicated they had become more religious/​spiritual after the onset of the pain, compared to 4% of those who said they had become less religious/​spiritual. Increased prayer in response to pain is especially common among older adults (Dunn & Horgas, 2004; Andruszkiewicz et al., 2017; Booker, 2019). If pain increases religious activities, one might expect that prayer (and other religious coping behaviors) and pain severity would be positively correlated. This is analogous to the relationship between depressive symptoms and antidepressant use. Depressed people turn to antidepressants to relieve their symptoms, resulting in a positive association between depressive symptoms and antidepressant use, where the causal direction is from depression to antidepressant use. Thus, a positive correlation between religiosity and pain might well Chronic Pain • 581

mean something similar, rather than that religious activities increase pain (just as a positive correlation between antidepressant use and depression might be interpreted as meaning that antidepressants increase depressive symptoms, which is clearly not the case). This would be especially true in cross-​sectional studies or prospective studies with only short follow-​up periods.

Selective Mortality Besides considering the causal direction in the religion-​pain relationship, one must also take into account the high rate of suicide among those with chronic pain. In a study of 123,181 persons who committed suicide in the United States between 2003 and 2014, 10,789 (8.8%) had evidence of chronic pain, a percentage that increased from 7.4% in 2003 to 10.2% in 2014. If religiosity is inversely related to suicidal ideation, attempts and completions, as the vast majority of studies show (see Chapter 7, and Fuller-​ Thomson & Kotchapaw, 2019), then religious persons with chronic pain are more likely to survive and to be available in studies than those who are less religious and have ended their lives prematurely due to the pain. This “survival effect”—​both concerning suicide specifically but also longevity more generally—​ is also likely to increase the likelihood of a

positive association between religiosity and chronic pain, just as does turning to religion to cope in response to the pain.

Confounders and Moderation When examining the relationship between religiosity and pain in observational studies, it is important to carefully control for non-​ modifiable risk factors such as age, gender, and race/​ethnicity, since religiosity is positively correlated with older age, female gender, and minority status (African American, in particular), each of which is also positively related to pain, potentially explaining positive associations between religiosity and pain due to confounding. Researchers may also forget that religiosity may also moderate the relationship between chronic pain and effects on quality of life and level of physical disability (Figure 29.2).

Need for Prospective Studies/​RCTs Few prospective studies have examined the effects of religiosity on the experience of chronic pain over time, and the studies conducted thus far have involved small sample sizes and short follow-​ups, and are generally of low quality. As a result, there is a great need for prospective studies in those with chronic

Religiosity Non-modifiable Controls

Gender Race/ethnicity

Chronic Pain

Age

Genes/heredity

FIGURE 29.2.  Moderating effect of religiosity on pain outcomes. 582 •  P h y sical H ealth

Pain Outcomes Physical disability Depression Anxiety Passivity Pessimistic Hopeless Unhappiness Loss of joy Loss of meaning Loss of purpose Social withdrawal Insomnia Smoking Alcohol/drug use Addiction Physical inactivity Poor diet Overweight/obese Early mortality

pain that involve large sample sizes and long-​ term follow-​up and that carefully control for baseline confounders, including pain severity. While we have theorized above how religiosity might relieve pain or increase pain tolerance, it is also possible that religious inclinations to find meaning in pain and suffering may lead to an increased awareness of it. Further research with prospective observational studies is needed. It is also possible that while religious service attendance, as well as religious beliefs and commitments, may not themselves substantially affect chronic pain, certain religious practices such as prayer and meditation might serve to help relieve pain, as the evidence from randomized trials indicates. Pain may be an outcome for which private religious practices in fact have the larger effects. There have, however, been few RCTs examining religious interventions in those with chronic pain of moderate to severe intensity. This is the group in whom medical treatments have been particularly ineffective over the long term, often worsening the situation by resulting in opiate addiction and early mortality (Ekholm et al., 2014). With only a few notable exceptions, most clinical trials in persons with chronic pain have involved Eastern religious forms of meditation (Hindu yoga, Buddhist mindfulness, Taoist meditation, transcendental meditation), and these studies have generally been positive. What has largely been missing are clinical trials examining the effects of Western religious interventions on severity or endurance of pain among those with a history of chronic pain. This is particularly important given the recent limitations placed on healthcare providers concerning the prescription of opiates in those with chronic pain (Pergolizzi et al., 2019), increasing the urgency of developing faith-​based interventions and testing their efficacy in clinical trials.

CLINICAL APPLICATIONS Based on the rationale for why religious involve­ ment ought to impact chronic pain and the research reviewed above, how might clinicians and religious professionals utilize this information?

Clinicians Given the potential benefits of religious involvement on the development, severity, and endurance of chronic pain, healthcare professionals should consider identifying and supporting patients’ religious resources, encouraging positive religious reappraisals of the pain, identifying and addressing spiritual struggles, and recommending simple religious/​spiritual interventions for pain. ID EN TIF Y REL IGIOUS RESOURCES

As usual, healthcare professionals should begin by taking a spiritual history when treating patients with chronic pain. The spiritual history will identify past and current religious resources that may be utilized to help relieve or at least cope with the pain. When positive and reported to help, these resources should be encouraged and supported. Although many such patients will already have mobilized religious resources, particularly prayer and other religious coping activities, they may not always be employed in the most effective fashion. Understandably, religious activities may be primarily directed at relieving the pain, rather than accepting, enduring, or otherwise coping with it. When pain remains severe despite prayer, this may lead to discouragement, sometimes anger at God or their faith community, and loss of hope. Recall that a clinical trial described earlier found that prayers focused on “taking the pain away” were less effective in improving pain tolerance than were those focused on “helping to endure the pain” (Meints et al., 2018). Many patients with chronic pain may have stopped attending religious services because of the physical activity involved, fearing that such activity may worsen the pain. Reduction or cessation of public religious involvement, however, may contribute to deconditioning due to lack of physical activity, but more importantly, to loss of positive social interactions and support, social withdrawal, and symptoms of depression. Besides attending religious services, engagement or re-​engagement in religious volunteer activities by ministering to the needs of others may also help to distract attention from the pain, thereby serving to relieve Chronic Pain • 583

or enable the sufferer to better endure it. Thus, clinicians should encourage patients’ religious efforts to (a) accept and endure the pain rather than focusing entirely on relieving it; (b) resume social religious activities, particularly if these activities have been important to them in the past; and (c) consider volunteer activity to shift focus on others’ needs and away from their own. Clinicians are also in an ideal position to identify the spiritual needs and religious struggles of chronic pain patients and refer them to chaplains or pastoral counselors for help. The spiritual needs of chronic pain patients are many and may add to the sometimes heavy burden of those with unrelenting pain. Even if pain cannot be relieved, paying attention to spiritual needs may improve the patient’s quality of life. Spiritual needs may be addressed by praying for and with others, praying alone, participating in religious ceremonies, spending time with someone to reflect on and discuss the meaning of life, spending time in nature either alone or with a companion, and passing along life experiences to others (Ganasegeran et al., 2020). This includes working through spiritual struggles (below). PO S I TI VE RE L I GIOUS RE APPRAISALS

Clinicians (and religious professionals) may also consider helping patients develop more positive ways of viewing pain, particularly pain that cannot be relieved by conventional means. Recall our earlier discussion of how positive cognitive reappraisals or positive reframing of pain may help individuals to endure pain even if it does not lower pain severity (Dezutter et al., 2011). As discussed in the previous chapter on disability, religious beliefs may provide powerful ways of viewing pain in a way that gives it meaning and purpose. The manner in which religious beliefs are utilized to deal with the pain, however, may vary depending on religious tradition. For example, Muslims may decide to accept and endure pain in a positive manner in order to compensate for “bad deeds” or to accumulate “good deeds.” Some Muslims believe that accumulating good deeds in this life is necessary in order to “outweigh” bad deeds since the balance of good and bad 584 •  P h y sical H ealth

deeds will determine their ultimate destination after death (Koenig & Al Shohaib, 2014). For Christians, rightly accepting and enduring pain may be viewed as following the example of Christ and therefore have eternal significance in terms of “filling up what is lacking in Christ’s afflictions” (Colossians 1:24). Similar to Muslims, Catholic Christians may believe in redemptive suffering, in which pain is accepted and offered up in union with the pain that Jesus suffered on the cross in order to compensate for one’s sins or for the sins of others (such as living or deceased family members) (Angelica, 2017) or as an opportunity to turn one’s will toward God. SP IRITUAL STRUGGL ES

Negative religious coping involves feeling anger toward God, feeling punished by God, questioning God’s love and power, or feeling deserted by one’s faith community. As Harris and colleagues (2018) demonstrated, such spiritual struggles are strongly correlated with pain catastrophizing and interfere with patients’ engagement with social, cognitive, emotional, physical, and recreational activities. Thus, it is important that clinicians either help patients to work through the spiritual struggles or refer them to skilled spiritual caregivers who are trained to address such issues. Doing so may help to improve pain endurance and reduce the suffering caused by the pain. REL IGIOUS IN TERVEN TION S

Current treatments for chronic pain focus on medications, application of appliances (e.g., transcutaneous nerve stimulation devices), other non-​ pharmacological methods (paced exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-​based stress reduction), cognitive behavioral therapy, and invasive surgical procedures. None of these treatments has been particularly effective, as illustrated by the over 100 million people in the United States alone who suffer from chronic pain. There is plenty of room, then, for R/​S approaches to improve the treatment of chronic pain, particularly since they are readily available, cost little or nothing, and have few or no side effects.

Several comprehensive reviews now exist that describe R/​S interventions shown to be effective for chronic pain (Wachholtz & Fitch, 2018; Vasigh et al., 2018). Consequently, clinicians may encourage patients with chronic pain to engage in religious activities such as meditation that have been proven in clinical trials to help reduce pain (see above). The meditation technique recommended, however, should be patient-​centered, i.e., based on the patient’s own faith tradition. For Hindus, various forms of yoga, focused meditation, or transcendental meditation may be useful in this regard (Plante, 2010; Gray & McCormack, 2019). For Buddhists, mindfulness meditation has been shown to have small but important effects on alleviating pain or improving quality of life in many studies (Hilton et al., 2017). Those who are secular or less religious may also benefit from this form of meditation. For religious Christians, Muslims, and Jews, various forms of meditation, such as centering prayer for Christians, Taffakur or Dhikr meditation for Muslims, and Kabbalah-​ type meditation for Jews, may serve a similar purpose (Plante, 2010; Tan, 2011).

them to attend. Clergy may also encourage members of the congregation to provide both emotional and practical forms of support. This may involve taking the person out to lunch, providing healthy meals, accompanying them on walks in nature or other forms of paced physical activity, praying for and with them, and providing practical services such as lawn care or housekeeping. However, clergy should instruct helpers to encourage those with chronic pain to do as much as they can for themselves and not be over-​solicitous in ways that may foster dependency. Clergy may also provide opportunities for those with chronic pain to engage in volunteer activities (within the limits of their physical abilities) that involve caring for the needs of others in the congregation or those outside the religious community. As noted earlier, this may be a powerful way of distracting the person’s attention away from their pain and onto the needs of others. Chronic pain often drains meaning and purpose from life, and so providing such opportunities for service may help to reinfuse meaning in life that makes the endurance of pain worthwhile.

Religious Professionals

SUMMARY AND CONCLUSIONS

Many of the suggestions for clinicians above apply equally to religious professionals and counselors who may encounter individuals with chronic pain either as patients (e.g., chaplains or pastoral counselors) or as members of their congregation (community clergy). This especially applies to those with chronic pain who may need help working through spiritual struggles or negative forms of religious coping related to their pain. Religious professionals also may help such patients to utilize their religious beliefs to cognitively reframe pain in positive ways that give it meaning and purpose (as described above). Community clergy should make efforts to contact members of their congregation with chronic pain who have reduced or stopped attendance at religious services because of the pain. Clergy should encourage these individuals to re-​engage in such activities, and perhaps even go so far as to help arrange transportation or provide other assistance that will enable

We began this chapter by discussing the different types of pain, particularly the term “chronic pain.” We then examined how widespread chronic pain is in the United States and around the world, including its socioeconomic and physical health consequences. This was followed by a description of factors that influence the experience of chronic pain, including non-​ modifiable characteristics (age, gender, race/​ethnicity, genes), those that are partially modifiable (socioeconomic, gene-​environment interactions, medical illnesses), and those that are potentially fully modifiable (psychological, social, behavioral). A case vignette was then presented of an older woman with severe chronic pain and the role that religion played in helping her cope with and endure it in a way that minimized the disability that pain caused. This was followed by speculation on how religious involvement might influence the severity, endurance, and consequences of chronic Chronic Pain • 585

pain through the risk factors for pain discussed earlier. The heart of this chapter focused on systematic quantitative research examining cross-​sectional associations between religiosity and pain, effects of religious involvement on pain in longitudinal studies, and the efficacy of religious/​spiritual interventions for relieving pain. Results of earlier and more recent observational studies indicated that religiosity was either unrelated to pain or associated with greater pain levels, which we hypothesized was likely due to the turning to religion in an effort to cope with the pain. The few prospective studies were mixed in their findings, some reporting positive associations, negative associations,

586 •  P h y sical H ealth

or no associations with pain. Despite this, the vast majority of RCTs indicated that R/​ S interventions were effective in relieving pain among those with acute or chronic pain. Recommendations for future research (and advice on how to interpret the findings from past studies) were then provided, and suggestions made for clinical application relevant to clinicians and religious professionals. In the next chapter, we explore the effects of religiosity on disease detection and prevention behaviors, and examine ways that religion may either increase or decrease the risk of medical illness and health problems through this mechanism.

30 Disease Prevention, Detection, and Treatment Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship. —​Buddha

IN THIS CHAPTER we examine the relationship between religiosity or religious involvement and participation in disease prevention, detection, and treatment activities. Such engagement is important in terms of both individual and public health, especially with regard to the prevention of communicable diseases (Adini et al., 2019) and the early detection of cancer (Sauer et al., 2017). Preventing disease by encouraging healthy lifestyles and timely vaccinations, identifying diseases early before they have a chance to progress, and ensuring adherence to medication and overall treatment regimens have become a priority for governments around the world faced with the daunting task of providing healthcare to aging populations. Without some kind of strategy to keep people healthy and forestall the development of chronic illness and disability, it is clear that before long resources will not be sufficient to provide care for all those in need, at least not

at the level to which most people in Western countries have been accustomed. The major determinants of health known to be under the individual’s control are personal behaviors, the social environment, and, to some extent, public policies. Personal behaviors related to health include decisions to not smoke (or quit smoking), exercise regularly, engage in safe sexual practices, control weight, eat healthy foods, behave sensibly in terms of risk-​ taking, engage in disease-​prevention activities, seek regular medical care, and comply with prescribed treatments. The social environment consists of interactions with family, friends, co-​workers, and others in ways that influence mental or physical health. Although one cannot choose one’s family of origin, the choice of how and with whom one interacts is under the individual’s control. Finally, public policies involve laws having to do with exposures in the environment.

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0030

In this chapter, we examine the role that religion plays in the prevention of disease through timely vaccinations and regular medical/​dental care, detection of disease early through screening, and adherence to treatment, each with the goal of maintaining or improving health. Religious or spiritual (R/​S) beliefs and behaviors may influence decision-​making in all of the above. Thus, it is fitting to conclude our series of physical health chapters with a focus on these issues.

DISEASE PREVENTION The top 10 causes of death in the United States in 2017 were (1) heart disease, (2) cancer, (3) unintentional injuries, (4) chronic lower respiratory diseases, (5) stroke, (6) Alzheimer’s disease, (7) diabetes, (8) influenza and pneumonia, (9) kidney disease, and (10) suicide (Murphy et al., 2018). Almost all of these conditions are preventable to some extent and depend largely on individual decision-​ making. The Office of Disease Prevention and Health Promotion (ODPHP) was established by Congress in 1976 as part of the US Department of Health and Human Services (DHHS) in order to keep the nation healthy “by setting national public health objectives and supporting programs, services, and education activities that improve the health of all Americans” (DHHS, 2020a). This mission is to be accomplished by initiating, coordinating, and suppor­ ting disease-​ prevention and health-​promotion activities, programs, policies, and information. Consequently, ODPHP has prepared two major documents that describe disease-​ prevention and health-​ promotion objectives for the US population called Healthy People 2020 and Healthy People 2030 (forthcoming) with the goal of helping individuals of all ages increase life expectancy, improve quality of life, and eliminate health disparities based on gender, race, income, disability, geographic location, or sexual orientation. ODPHP has provided a list of the 12 leading health indicators that have become a priority in maintaining public health and well-​ being (DHHS, 2020b; Table 30.1). These areas have been the focus of the US government’s efforts to maintain a healthy population by preventing the development of disease,

588 •  P h y sical H ealth

Table 30.1  Top Areas of Focus for Disease Prevention and Health Promotion in the United States (1) Preventive services (ensuring childhood and adult vaccinations, cancer screening) (2) Environmental quality (improving air quality, reducing secondhand smoke exposure) (3) Injury and violence (minimizing injury deaths, homicide) (4) Mental health (decreasing suicide, identifying and treating adolescent and adult major depression) (5) Social determinants (maximizing high school graduation rates, optimizing the social environment) (6) Substance abuse (preventing adolescent alcohol or illicit drug use and binge drinking) (7) Tobacco use (reducing adolescent and adult smoking) (8) Nutrition, physical activity, and obesity (increasing vegetable intake, aerobic physical activity/​muscle strengthening, and preventing obesity) (9) Reproductive and sexual health (providing comprehensive reproductive services for sexually active women, screening for sexually transmitted diseases) (10) Maternal, infant, and child health (reducing infant deaths, preterm births) (11) Oral health (encouraging regular dental visits) (12) Access to health services (maximizing access to medical insurance and a primary care provider) Source: DHHS (2020b). US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People. Retrieved on 2-​23-​2021 from https://​www.health​ ypeo​ple.gov/​2020/​lead​ing-​hea​lth-​ind​icat​ors/​2020-​LHI-​Top​ics.

identifying diseases early, and treating them effectively. Based on those priority areas, disease prevention includes (1) receiving vaccinations

during childhood and adulthood that will prepare the immune system to fight off viral infections and other pathogens; (2) obtaining a good education and participating in prosocial community activities; (3) engaging in healthy behaviors that will preserve health throughout the life span; and (4) advocating for public policies that promote health.

Vaccinations At the beginning of the twentieth century, infectious diseases were the leading cause of death worldwide, with tuberculosis, pneumonia, and diarrheal disease causing 30% of all deaths (Cohen, 2000). When vaccinations are not obtained on schedule, populations are

vulnerable to outbreaks of preventable diseases (Hargreaves et al., 2020). A list of recommended vaccinations provided by the US Centers for Disease Control (CDC) is provided in Table 30.2. The top threats to public health are all viral infections, for which vaccinations are now available—​including poliomyelitis, avian influenza, Ebola virus disease, yellow fever, chikun­gunya virus, Zika virus, and the Middle East respiratory syndrome coronavirus (MERS-​ CoV) (Christian et al., 2017; Peeri et al., 2020). Recently added to the list is vaccination for the severe acute respiratory syndrome coronavirus 2 (SARS-​CoV-​2). At no time in history has the importance of vaccination been more evident than during the COVID-​19 pandemic of 2020–​2022.

Table 30.2  Recommended Childhood and Adult Vaccinations, Doses, and Age Schedule 2022 Childhood (age 18 or younger) Diphtheria, tetanus, and pertussis (DTaP) (5 doses: age 2 mo, 4 mo, 6 mo, 15–​18 mo, 4–​6 yr) Hepatitis B (HepB) (3 doses: birth, 1–​2 mo, 6–​18 mo) Haemophilus influenzae (Hib) (4 doses: 2 mo, 4 mo, 12 mo, 15 mo) Pneumococcal conjugate (PCV13) (4 doses: 2 mo, 4 mo, 6 mo, 12–​15 mo) Inactivated poliovirus (IPV) (4 doses: 2 mo, 4 mo, 6–​18 mo, 4–​6 yrs) Influenza (IIV) (annual vaccination in 1–​2 doses age 6 mo–​12 yr; 1 dose age 17–​18 yr) Measles mumps and rubella (MMR) (2 doses: 12–​15 mo, 4–​6 yr) Varicella (chickenpox) (VAR) (2 doses: 12–​15 mo, 4–​6 yr) Meningococcal meningitis (2 doses: 7–​10 yr, 13–​15 yr) Rotavirus (RV1) (2 doses: 2 mo, 4 mo) Hepatitis A (HepA) (2-​dose series: 12–​18 mo) SARS-​CoV-​2 Adulthood (age 19 or older) Influenza inactivated (IIV) (1 dose annually) Tetanus, diphtheria, pertussis (1 dose TDaP, then Td or Tdap booster every 10 years) Measles, mumps, rubella (1 or 2 doses depending on indication) Varicella (2 doses if born in 1980 or later; 2 doses if over age 50) Herpes Zoster recombinant (2 doses after age 50) Human papilloma virus (2–​3 doses from age 19 through 45) Pneumococcal conjugate (2 doses: 1 dose age 19–​65, 1 dose after age 65) Hepatitis A (2–​3 doses depending on vaccine) Hepatitis B (2–​3 doses depending on vaccine) Meningococcal A, C, W, Y, B (1–​3 doses depending on indication) Haemophilus influenza type B (one or three doses depending on indication) SARS-​CoV-​2 (2-​dose series separated by 2–​4 weeks) Source: CDC (2020c). Adult and child immunization schedules 2020. Centers for Disease Control. Accessed on 2-​23-​21 from https://​ www.aafp.org/​fam​ily-​physic​ian/​pati​ent-​care/​pre​vent​ion-​welln​ess/​immuni​zati​ons-​vacci​nes/​immun​izat​ion-​schedu​les.html.

Disease Prevention, Detection, and Treatment • 589

However, there has been considerable resistance within the general public to vaccinations in recent years (Johnson et al., 2020). Based on the 2014 National Immunization Survey, nearly 40% of parents in the United States were non-​adherent to the recommended immunization schedule for children, especially those with incomes below the poverty level (Hargreaves et al., 2020). Indeed, it is the latter population subgroup that is often the most religious. This trend of resistance has continued for the recent COVID-​19 pandemic, where a Gallup Poll of the US population conducted between July 20 and August 2, 2020, found that more than one-​third of Americans (35%) were unwilling to be vaccinated even “[i]‌f an FDA-​approved vaccine to prevent coronavirus/​COVID-​19 was available right now at no cost” (O’Keefe, 2020). Opinions were split by political party, with 19% of Democrats indicating reluctance to be vaccinated compared to 41% of Republicans. Resistance to vaccination exists not only in the United States but in other parts of the world as well (Goldberg & Richey, 2020), often fueled by social media (Johnson et al., 2020). Resistance to influenza vaccines in the United States, however, was high before the recent COVID-​ 19 pandemic, with only 62.6% of children age 6 months through 17 years and 45.3% of adults age 18 years or older vaccinated during the 2018–​2019 influenza season (CDC, 2020b). Reasons for resistance to vaccination (particularly among parents) include distrust of the federal government, regulatory agencies, and pharmaceutical companies; greater trust in homeopathic or naturopathic practitioners more than in trained physicians and nurses; and misinformation about adverse reactions to vaccines (death, seizures, autism, allergic reactions, and so forth). Although there is some truth in all of these concerns, the health benefits of vaccination far outweigh the potential adverse effects, with the benefits compared to that of wearing seatbelts (Rémy et al., 2015; Giubilini & Savulescu, 2019).

Education and Pro-​social Community Involvement Graduating from high school (and preferably college) will increase the likelihood that a 590 •  P h y sical H ealth

person will obtain a well-​paying job that will allow them to live in a safe neighborhood, afford health insurance, and acquire knowledge about behaviors that improve or maintain health. Another social determinant of health is being part of a community that is safe, provides emotional support, models prosocial behavior, and discourages delinquent or criminal activities that increase risk of poor health outcomes (both mental and physical for the individual and the community).

Healthy Habits and Behaviors Establishing and maintaining good health behaviors throughout life is essential for disease prevention. These include early habits of regular exercise, a healthy diet, and limited calories to prevent excessive weight gain; avoidance of cigarettes, alcohol, tobacco, and illicit drug use during adolescence; limited alcohol use during adulthood; and engagement in safe sexual practices at any age.

Public Policy This category includes laws and policies regarding driving speed limits, seatbelt use, immunization of children, prevention of smoking, regulation of workplace activities, establishing air quality and water standards, and limitation of exposure to other environmental toxins. The individual’s role is to advocate for policies that affect these environmental exposures in a way that promotes health, and once such laws and regulations are established, to obey them.

Regular Medical and Dental Care If individuals do not seek regular medical and dental care, then disease prevention will be less likely. Obtaining such healthcare services on a regular basis often requires having adequate finances to pay for these services out of pocket and/​or having insurance that provides access to them. Even if such access is available, persons must still make the effort to visit a primary care provider (PCP) for health maintenance and a medical specialist when needed (the same applies to dental care). Finally, the individual must comply with treatments recommended

and necessary follow-​up. Considerable individual effort, then, is necessary to ensure that disease is prevented and treated properly. I N SU RA N C E

In the absence of universal healthcare coverage (and sometimes even with it), some type of government-​funded or private insurance will be necessary to cover the costs of evaluation and treatment. Medical and dental care are expensive, and someone has to pay for these services. Many do not have the financial resources to pay the entire cost of such services out of pocket. P RI MA RY CA R E PROV IDE R (PCP)

Having a regular PCP, someone who can perform regular evaluations, recommend screening procedures, and coordinate medical care when specialists are needed, has long been encouraged (Starfield et al., 2005). Having a single PCP in charge of healthcare helps to maintain continuity of care, thereby increasing quality and cost-​ effectiveness, as well as improving patient satisfaction. Those without a PCP often end up receiving care in the emergency room (the most expensive form of healthcare) when symptoms of disease are prominent and illness has advanced to a point where effective treatment may be limited (Palmer et al., 2014). RE GU L A R D E N TAL CARE

Individuals are also responsible for seeking regular dental care from a general dentist who can provide preventive care, fill caries, and coordinate care provided by dental specialists (periodontists, orthodontists, oral surgeons). As indicated earlier, dental or gum problems can promote systemic inflammation that results in cardiovascular and a host of other inflammatory disorders.

Task Force (USPSTF) is responsible for making recommendations with regard to early detection of conditions that are readily treatable before long-​term health problems develop. The USPSTF recommends screening for infectious diseases (hepatitis B, HIV, syphilis, chlamydia/​ gonorrhea, latent tuberculosis), high-​risk medical conditions (hypertension, diabetes, osteoporosis, fall risk, childhood and adolescent obesity), health behaviors (cigarette smoking, physical activity, diet), mental health conditions (major depression, unhealthy alcohol use, illicit drug use), and cancer (cervical, breast, colorectal, lung) (Table 30.3). The USPSTF provides ratings on the latest screening recommendations, which range from “A” (highly recommended due to substantial benefit) to “D” (not recommended). These recommendations are specified in terms of age group, risk status, pregnancy status, and gender. IN F ECTION S

Early detection of communicable or infectious diseases is important in limiting individual as well as public health risks by vaccination, containment, distribution of medical treatments, and efforts to identify vulnerable populations (Adini et al., 2019). The infections with an “A” rating for screening include hepatitis B, human immunodeficiency virus (HIV), and syphilis among persons at. Those with a “B” rating (recommended, benefit moderate) are chlamydia/​ gonorrhea, hepatitis C, and latent tuberculosis. Screening in women for the human papilloma virus (HPV), which can cause cervical cancer and several other malignancies, is at this time optional. M ED ICAL CON D ITION S

Screening has also been recommended for various medical conditions, particularly for (a) conditions where treatments are readily available, diseases where screening is relatively easy, EARLY DISEASE DETECTION (b) (c) conditions that are prevalent in the popuDisease detection involves identifying illnesses lation, and (d) disorders where health conseearly on before they have a chance to take root quences are serious. Primary care physicians in the body. This is primarily accomplished by (family physicians, internists, pediatricians, regular medical and dental care and by disease-​ obstetrician-​g ynecologists) are encouraged to screening activities. The US Preventive Services screen for high blood pressure (A rating), Rh(D) Disease Prevention, Detection, and Treatment • 591

Table 30.3.  US Preventive Services Task Force Screening Recommendations 2020 S CR E E NI NG T E S T

G RO U P R E C OMME NDE D

G R A DE

Cervical cancer Colorectal cancer Hepatitis B virus Human immunodeficiency virus

Women age 21–​65 Adults age 50–​75 Pregnant women Pregnant women Persons age 15–​65 Younger or older at risk Adults age 18 or older Pregnant women Persons at risk for infection All adults Women age 50–​74 (biennial) Women age 40–​49 (biennial) Overweight adults age 40–​70 Asymptomatic pregnant women Adults age 50–​80 smoking history Women age 65 or over Postmenopausal < 65 at risk Age 6 years or older Adults and children Adolescents and adults Adults age 18 or older Sexually active women < 25 Women age >24 at risk Adults age 65–​75 ever smoked Pregnant women Birth to age 5 years Adults age 65 or over Adults at risk for CVD Adults age 18–​79 Individuals at risk Children age 3–​5 years Men ages 55–​69 Men age 70 or older Asymptomatic women Asymptomatic adults Women age 30–​65 (every 5 years)

A A A A A A A A A A B C B B B B B B B B B B B B B B B B B B B C D D D Optional

High blood pressure Rh(D) incompatibility Syphilis infection Tobacco use Breast cancer Type II diabetes Lung cancer Osteoporosis Obesity, childhood/​adolescent Depression Unhealthy alcohol use Unhealthy drug use Chlamydia/​gonorrhea Abdominal aortic aneurysm Asymptomatic bacteriuria Dental caries Fall risk Heathy diet/​physical activity Hepatitis C Latent tuberculosis Vision screening Prostate cancer Ovarian cancer Thyroid cancer Human papilloma virus (HPV)

Source: US Preventive Services Task Force recommendations. Retrieved on 2-​23-​2021 from https://​www.usprev​enti​vese​r vic​esta​skfo​ rce.org/​usp​stf/​rec​omme​ndat​ion-​top​ics/​usp​stf-​and-​b-​reco​mmen​dati​ons. A =​recommended; high certainty that net benefit is substantial B =​recommended; high certainty that net benefit is moderate C =​selective offering to individuals based on health professional decision and individual choice D =​not recommended.

incompatibility in pregnant women (A rating), type II diabetes in overweight adults (B rating), osteoporosis in older women (B rating), and childhood/​adolescent obesity (B rating). More rare conditions (e.g., aortic aneurysm in 592 •  P h y sical H ealth

older adults with a history of smoking) and other medical conditions in various population groups, such as asymptomatic bacteriuria in pregnant women and risk of falling in older adults, have B rating recommendations.

BRE A S T CA N C E R

In 2017 there were 252,710 invasive breast cancer cases and 40,610 deaths in the United States alone from this cause (Siegel et al., 2017). The death rate from breast cancer has been declining since 1989 due to early detection during biennial screening procedures, particularly mammography. Given the high mortality, it is surprising that recommendations for screening are at the B level for women age 50–​74 and at the C level for women age 40–​49. In 2015, 64% of US women age 40 or over reported having a mammogram in the past 2 years as recommended (Sauer et al., 2017). Those at greatest risk for not having a mammogram were uninsured women (31% had a mammogram in the past 2 years) and recent immigrants (46% had one). Although lack of screening for those groups is primarily due to socioeconomic issues, these are also some of the most religious groups in the population. L U N G CA N C E R

There were 222,500 cases of lung cancer in 2017 in the United States and 155,870 deaths (Siegel et al., 2017). As with other malignancies, rates of lung cancer have been decreasing over the past 30 years due to a reduction in cigarette smoking. Screening for cigarette smoking, the major cause of lung cancer, has A level recommendations for all adults. Lung cancer screening with low-​dose spiral computed tomography has been recommended for men and women age 55–​74 who are current smokers with at least a 30 pack-​year history of smoking, or former smokers who have quit within the past 15 years. In 2015 there were approximately 7 million former and current smokers in this category; however, only 3.2% of current high-​risk smokers and 4.6% of former smokers had this screening procedure within the past year (Sauer et al., 2017). C O L O RE C TA L CANCE R

In 2017 there were 135,430 colorectal cancer cases in the United States and 50,260 deaths (Siegel et al., 2017). As with breast cancer, the decline in colorectal cancer in recent years has

been due to increased colorectal cancer screening and improved treatments. In 2015, compliance with the recommended colorectal cancer screening (a home-​based fecal test in the past year, sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years) among men and women over age 50 was 63%, again leaving much room for improvement (Sauer et al., 2017). Again, the uninsured (25% meet recommended screening guidelines) and recent immigrants (34%) were those at greatest risk for not having colorectal cancer screening. CERVICAL CAN CER

In 2017, there were 12,820 cases of invasive cervical cancer and 4,210 deaths in the United States, with declines over the past 30 years largely due to screening with the Pap test (Siegel et al., 2017). Among US women in 2015, 81% age 21–​65 had a Pap test within the past three years as recommended (Sauer et al., 2017). The lowest rates of screening were again in uninsured women (61% met this recommendation) and recent immigrants (68% did so). P ROSTATE CAN CER

In 2017, there were 161,360 new prostate cancer cases in the United States and an estimated 26,730 deaths (Siegel et al., 2017). Death rates from prostate cancer have been declining over the past 30 years due to improvements in treatment (for new cases and recurrences) and early detection using the prostate-​specific antigen (PSA) blood test. The use of PSA for prostate cancer screening has been controversial since there are experts who feel there is not enough evidence to recommend routine screening that could result in overdiagnosis and unnecessary risk of side effects from treatments (incontinence, impotence, etc.). Thus, the recommendation is that PSA screening be done for men of average risk beginning at age 50, depending on “shared decision-​making” between patient and physician. However, routine PSA screening of asymptomatic men is no longer recommended, particularly in those age 70 or older. The rate of PSA testing for prostate cancer within the past year during 2015 in US men age 50 or older was 34% (Sauer et al., 2017).

Disease Prevention, Detection, and Treatment • 593

OT H E R CA N C E RS

There are currently no recommendations for screening asymptomatic individuals for skin, ovarian, or thyroid cancers, or for cancers where screening tools are not yet available. MI SC E L L A N E O US HE ALT H C O N D I TI O N S

Screening for dental caries and gingivitis (given their role in tooth loss, cardiovascular disease, and systemic inflammation) for those of all ages and vision screening for children age 3–​5 years is recommended (B level). MEN TA L H E A LT H

Screening is also recommended for major depression, unhealthy alcohol use, and illicit drug use or prescription drug abuse (B level).

COMPLIANCE WITH MEDICAL TREATMENT Once treatments are prescribed, the individual must decide whether to comply with medications and/​or other aspects of the treatment regimen. In 1985, the US Surgeon General C. Everett Koop bluntly stated: “Drugs don’t work in patients who don’t take them” (Osterberg & Blaschke, 2005). According to the World Health Organization (2003), poor treatment compliance is “a worldwide problem of striking magnitude” (p. 22) averaging around 50%. In the United States, 30%–​50% of patients fail to adhere to long-​term medications (Marcum et al., 2013). Anything that increases adherence to medication and other treatment recommendations will improve health outcomes.

FACTORS AFFECTING DISEASE PREVENTION, DETECTION, AND TREATMENT In addition to challenges related to healthcare access, factors that affect disease-​prevention activities (e.g., regular healthcare, vaccinations), early disease detection (through screening), and treatment compliance include psychological and social influences. 594 •  P h y sical H ealth

The Health Beliefs Model has been used for more than 70 years to explain how psychological and social characteristics influence decisions to participate in disease-​prevention and health-​ promotion activities (Rosenstock, 1974). This model attributes such decisions to six factors: (1) perceived susceptibility to an illness or disease; (2) perceived severity or impact of the disease on their health; (3) perceived benefits in the particular health-​promoting behavior; (4) perceived barriers such as the financial cost or difficulty in completing the behavior; (5) external and internal cues to action, such as advice from healthcare professionals and persons in their social network (external) or symptoms of physical discomfort (internal); and 6) the belief that the person has the ability to engage in the health-​promoting behavior (Orji et al., 2012). Others have added “health knowledge” and “social support” to factors influencing disease prevention, detection, and treatment activities (Huang et al., 2016). Health knowledge involves the information that a person has about preventive healthcare behaviors, which is dependent heavily on level of education (Kenkel, 1991). Health knowledge is also dependent on one’s social network, where information about disease prevention is informally circulated among group members. Social support includes self-​esteem support, respect, and acceptance; informational support; social befriending and companionship; and instrumental support (financial or provision of practical physical help) (Cobb, 1976). Each of these forms of support can influence decisions regarding disease prevention, disease screening, and treatment compliance (Huang et al., 2016). Included among social relationships is the relationship between the healthcare provider and the patient. If this relationship is a good one, in which the patient feels supported and heard by the practitioner, then he or she is more likely to engage in disease-​prevention behaviors, to agree to screening tests, to seek healthcare from the provider regularly and when needed, and to comply with recommendations and treatments offered (Demak & Becker, 1987; Ward, 2018). There are also psychological factors that adversely affect the engagement in disease-​ prevention and health-​promotion activities. For

example, depression causes a loss of interest, decreased energy, impaired concentration, and reduced motivation for self-​care. Not surprisingly, then, the presence of depression adversely affects health-​ promotion activities (Bogner & Wittink, 2004) and treatment compliance (DiMatteo et al., 2000). Severe mental illness may reduce a person’s ability to adequately respond to even acute physical health problems, let alone participate in disease-​prevention activities (Druss & Silke, 2006). Substance use disorders can likewise interfere with disease prevention, early detection, and treatment compliance, for many obvious reasons including lack of finances, reduced motivation, low self-​ esteem, and loss of meaning and purpose in life, to mention just a few (Merrill et al., 2002; Druss & Silke, 2006). Finally, absence of adequate support from family members or close friends in one’s social network may prevent health-​ promotion activities such as seeking regular healthcare, vaccinations, disease screening, and treatment adherence (Miller & DiMatteo, 2013; Lemstra et al., 2018).

RELIGION AND DISEASE PREVENTION, DETECTION, AND TREATMENT As indicated earlier, many of the psychological, social, and behavioral factors that serve as barriers to or facilitators of disease prevention, early detection, and treatment compliance are influenced by religious beliefs and practices. We present a brief case vignette below to illustrate the negative effects that religion can have in this regard. The case is then followed by a description of pathways by which religion may have either a positive or negative impact. Case Vignette Dr. Wilson smiled as she finished the physical exam and returned to her desk in the examination room. “Well Mrs. Mercheson, you have turned 50 this year, so you are going to need some tests,” the doctor announced. “What kind of tests?” Mrs. Mercheson asked nervously. “Don’t worry, just routine tests to screen

you for cancer, like your mammogram, a colonoscopy, and because of your family history, a bone scan,” replied Dr. Wilson. Mrs. Mercheson responded, “I don’t need any tests, so you don’t need to order them.” “What do you mean?” asked the doctor somewhat shocked. The patient responded, “The Lord will take care of me. I don’t need to be checked for all those things. My faith will protect me.” Dr. Wilson asked incredulously, “You are going to rely on your religious beliefs and not have your mammogram or other tests? You are putting yourself at serious risk,” the doctor expressed with some degree of emotion. Mrs. Mercheson responded confidently, “The Lord will take me in His good timing. Until then, I don’t need these tests and don’t want to pay for them.” The doctor, trying to maintain her composure, responded, “Maybe we should talk more about this, Mrs. Mercheson. Can you tell me a bit more about your faith in the Lord?”

Religious beliefs may either help or hinder disease prevention, screening, or treatment activities. The core beliefs of most major world religions, as documented in their sacred scriptures, tend to promote health, lower disease risk, and foster responsible care for the body. As repeatedly emphasized in previous chapters, the physical body in Christianity is considered a sacred temple in which God dwells, and believers are expected to treat it with reverence (1 Corinthians 6:9). Likewise, Judaism views humans as the pinnacle of a “very good” creation and holds positive attitudes toward the physical body that is created in God’s image (Genesis 1:27, 31). Jewish scriptures emphasize physical prowess and beauty, regulate sexual behavior, forbid physical mutilation, and have dietary laws that often promote health and prevent disease (Abrams, 1999). Similarly, Islam holds a high view of the physical body. Muslims are told to care for their bodies by not eating excessively (Qur’an 7:31), by engaging in exercise (Kahan, 2003), and by going to the

Disease Prevention, Detection, and Treatment • 595

doctor when sick (Koenig & Al Shohaib, 2014). Finally, Buddhists value the physical body in the context of the human birth, considered a precious event, and emphasize the importance of a healthy body as an aid to pursuing the Buddhist path (Wilson, 2004). Of course, there are also religious teachings in every world religion that might be interpreted as devaluing or relativizing the value of the physical body, especially its sensual nature or pride in its physical appearance. These religious views, then, may hinder disease detection and treatment compliance. Christians may be taught to “turn problems over into God’s hands” as a way of coping with situations that cannot be changed. Unfortunately, sometimes these teachings are misapplied to situations that can be changed but that require action and courage on the individual’s part. There are some within certain Christian denominations who teach that sickness should not be acknowledged or “claimed” and that admitting to illness is why the condition developed. Thus, denying sickness (or a lump in the breast, for example) may be a way that some individuals use religion to cope. Religious beliefs can also be used as an excuse to avoid seeing the doctor when the person is actually fearful of what the doctor might find (which may have been the case for Mrs. Mercheson above). Finally, religious persons may be more likely to distrust science and health experts, relying instead on informal information flow within their faith community (some of which may include myths or conspiracy theories that counteract expert views). Finally, various ascetic practices within Christianity have emphasized submitting the physical body (with its sensual desires) to the person’s “will” as part of spiritual training. While ascetic practices may promote certain health behaviors, they may also hinder others. Although asceticism has never occupied a particularly prominent place in Jewish scriptures, and some rabbis view asceticism as a sin against God’s will, this practice was not foreign to Jewish lifestyles during certain periods in history and may also occasionally be seen today (Jewish Virtual Library, 2008). In Islam, which like Judaism has largely rejected asceticism, some devout Muslims have sought to return to the way of life practiced by Muhammad, 596 •  P h y sical H ealth

who reportedly spent long periods in solitary vigils, fasting and praying. Accepting Allah’s will, as strongly emphasized within Islam, may also prevent some from taking actions to prevent disease or detect it early. Similarly, some teachings within Buddhism depict the body as unwholesome and as an object of disgust in order to counter attachments to sensual pleasures (Wilson, 2004). Also, teachings in Buddhism and Hinduism regarding a person’s “karma” may promote a fatalism that discourages the seeking of healthcare when needed. Finally, instead of seeking traditional medical care, some religions may encourage the treatment of physical or mental health problems by religious healers who utilize religious healing practices. Thus, religious teachings may promote a neglect of the physical body and lead to illness or disease. These teachings, however, are not common in any of the major world religions today. Religious beliefs and practices may also influence disease prevention and health promotion indirectly through the psychological, social, and behavioral pathways described earlier. For example, if religiosity is related to less depression (Chapter 5), less severe mental illness (Chapters 6 and 9), and less substance use or abuse (Chapter 10), then this may help to prevent the development of many diseases, often by increasing a person’s motivation and ability to engage in health-​maintenance activities. Religiosity is also related to better health behaviors, such as less smoking, more exercise, and consuming a healthier diet (Chapters 17–​19), which are at the core of many disease-​ prevention recommendations (Table 30.1). Likewise, if religious involvement helps individuals to complete their education (due to prevention of behaviors that disrupt education, such as drug or alcohol abuse, delinquency, or teen pregnancy), then this will increase knowledge about disease prevention, and participation in such activities will likely be higher during adulthood. Religious involvement may also lead to greater emotional and instrumental support and larger social networks (Chapter 15), thereby resulting in a greater flow of healthcare information and encouragement for individuals to utilize that information in their daily lives. This

may increase efforts to obtain vaccinations, participate in disease screening activities, or comply with treatment recommendations. Religious persons also tend to be more agreeable and compliant in general (Chapter 11), thus increasing the likelihood that they will carry through on healthcare professionals’ recommendations. Alternatively, as noted earlier, religious views toward vaccination and other disease-​prevention practices that some may consider controversial can be used to justified nonparticipation (Pelčić et al., 2016). Likewise, belief in faith healing, as practiced by some contemporary religious groups (e.g., Christian Scientists, Pentecostals) and many indigenous cultures around the world, may result in a lower likelihood of seeking traditional medical services (Anderson, 2002; Struthers et al., 2004; Harley, 2006).

SYSTEMATIC RESEARCH The effects of religiosity on disease prevention, detection, and treatment compliance, then, depend on many factors. We now review systematic quantitative research that has examined cross-​sectional associations and prospective studies concerning influences that religious beliefs and behaviors may have on these health practices. We begin by reviewing earlier and then more recent studies on disease-​prevention activities, focusing on seeking medical care and obtaining vaccinations. This is followed by a review of the research on religiosity and early disease detection with an emphasis on screening procedures for infection, cancer, and other medical conditions. Finally, we review research on religiosity, medication adherence, and treatment compliance.

Early Research Because of the relatively few studies published during or prior to 2010 examining the effects of religiosity on disease prevention, disease detection, and treatment compliance, we briefly review all of the studies here regardless of quality. D I SE A SE P RE V E NT ION

Previous chapters have documented the effects of religiosity on health behaviors (cigarette

smoking, exercise, diet and weight) that are known to prevent the development of many acute and chronic diseases. We limit our review here to research on religiosity and disease-​ prevention activities, focusing primarily on vaccinations intended to prevent the development of disease. With regard to knowledge about disease-​prevention activities, in a study conducted in the Midwestern United States, Apel (1986) found that such knowledge was significantly greater among Lutherans who were active church members than in those who were less active in the church. Concerning healthcare-​seeking behavior, King and Pearson (2003) found that frequent attenders at religious service were more likely than less frequent attendees to receive care from a single provider, indicating greater continuity of medical care, which is known to improve disease prevention. Both of these studies were cross-​ sectional in design, preventing conclusions regarding causal inference. Seven early cross-​sectional studies examined associations between religiosity and likelihood of obtaining vaccinations. One study found a positive association with religiosity, one found no association, and five reported negative associations (i.e., a lower likelihood of obtaining recommended vaccinations by those who were more religious). The positive study found that parents indicating a religious affiliation in the Netherlands were more likely to have plans to vaccinate their children compared to those indicating no affiliation (Hak et al., 2005). In the study finding no association, researchers examined the relationship between religious attendance and vaccination for the human papilloma virus (HPV) among high school girls in the San Francisco Bay area (Mathur et al., 2010). Five largely descriptive cross-​sectional studies reported reduced vaccination rates and negative consequences in small non-​ traditional religious groups. These included the description of rubella outbreaks among the Amish in the United States (Anonymous, 1991), poliomyelitis outbreaks among Reformed and Orthodox Reformed members in the Netherlands (Conynvan Spaendonck et al., 1996), measles out​ breaks among those claiming religious or philosophical exemptions from vaccination laws in the United States (Salmon et al., 1999), a

Disease Prevention, Detection, and Treatment • 597

measles outbreak in a small religious group in Minnesota (Ehresmann et al., 2004), and a pertussis outbreak among the Amish in Delaware (CDC, 2006). Finally, in an opinion piece, the author discussed religious opposition by Muslim fundamentalists to immunization programs against polio (Warraich, 2009). In the only prospective study, to our knowledge, researchers examined the effects of religiosity on vaccination rates for influenza. Benjamins and Brown (2004b) analyzed data from a 2-​year longitudinal study of a random sample of 6,055 older US adults, average age 77. Controlling for demographics, socioeconomic status, and physical and mental health, participants who indicated religion was very important at baseline had a 75% higher odds (compared to those indicating religion not important) of having a flu shot between baseline and follow-​up 2 years later (OR =​1.75, p < 0.01). Compared to non-​affiliated individuals, those with a religious affiliation in that study had 114% to 443% more likely to have had a flu shot (Jews in particular, OR =​4.43, p < 0.001). In a single early randomized controlled trial (RCT), Daniels and colleagues (2007) examined the effectiveness of a church-​based program to increase vaccination rates among members. Fifteen churches in the San Francisco Bay area were randomized to either an on-​site adult vaccination program (influenza and pneumococcal) or to a no-​vaccination program control group. A total of 186 church members (44% African American, 43% Latino) participated. Results indicated that 80% (90 of 112) in the intervention group obtained influenza vaccinations compared to 46% (32 of 70) in the control group (OR =​4.8, 95% CI =​2.5–​9.4). Likewise, 66% (58 of 88) of those in the intervention churches received the pneumococcal vaccine compared to 35% (20 of 57) in control churches (OR =​3.6, 95% CI =​1.8–​7.2). Investigators concluded that an on-​site faith-​ based vaccination program increased vaccination rates in African American and Hispanic communities. Other than churches being the site of the vaccination program, however, the intervention itself was not particularly faith-​ based (although participation was encouraged

598 •  P h y sical H ealth

by church leaders and may have been justified on religious grounds). D ISEASE ID EN TIF ICATION

With regard to studies examining disease detection, we focus here on disease screening. The few studies published prior to the year 2000 are first reviewed, and then the results of those published between 2000 and 2010 are summarized (along with the earlier reports). One of the first studies was conducted in 1967 in Washington County, Maryland, when Kuemmerer and Comstock (1967) examined a random sample of 7,787 junior and high school students in the county. Students who attended church less frequently were more likely to have large tuberculosis (TB) skin reactions, indicating infection with TB that had not been detected previously through screening, compared to students more involved in religion (frequent attenders). In another early study, Naguib et al. (1968) conducted a case-​control study of 2,612 white women age 30–​45 in rural Washington County. Participants were mailed self-​use pipettes for cervical cancer screening. Women who used and returned the pipettes (n =​1,970) were more likely to be members of religious and social organizations than those who did not use the pipettes (n =​642) (45% vs 30%). Among Christians, participation in screening was positively related to frequency of church attendance; 81% of women who attended church once a week or more participated in the screening program compared to 60% for women who never attended religious services. Socioeconomic and demographic factors, however, were not controlled for in either study above. In a third study, Fox et al. (1998) surveyed 1,517 female church members age 50–​80 from 45 churches in Los Angeles County, comparing them to a random community sample of 510 female residents of similar age in Los Angeles County (case-​control design). Church members and those indicating they were highly religious were more likely to have regular clinical breast exams and participate in regular mammography screening than general community residents. This was particularly true for those with incomes of less than $10,000/​year. Associa­tions

weakened and were reduced to nonsignificance when controlling for sociodemographic (age, race, income, education, health status, marital status, depression status) and physician characteristics, although some of those may have been mediators. Authors concluded that frequent church attendance contributed to better mammography screening practices. Many additional studies on religiosity and screening were conducted between 2000 and 2010 (see Appendix of second edition of the Handbook). At least 42 studies reported 56 associations/​ effects (6 studies reported multiple screening outcomes for different physical body sites). Including the 3 early studies described above, there were 45 studies that reported 59 associations/​effects. Of these 59 effects, 37 were cross-​ sectional analyses, 12 were prospective analyses, and 10 were results from experimental studies or RCTs. Of the 37 cross-​sectional findings, 20 (54%) indicated positive associations between disease-​screening practices and religiosity (2 at a trend level), 9 (24%) indicated negative associations (1 at a trend level), and 8 (22%) reported no association. Of the 12 prospective findings, 11 (92%) reported positive associations of religiosity with subsequent screening behaviors and 1 indicated mixed effects depending on the particular religious indicator examined. Of the 10 experimental studies or RCTs, 8 (80%) reported positive findings (1 at a trend level) and 2 reported no effect of religious interventions. Several of these intervention studies involved church-​ based interventions that included an explicitly religious component, although others were screening/​prevention programs simply held in religious settings. C O MP L I A N C E

Compliance here involves adherence to prescribed medications, clinic visits, or attendance at peer group meetings such as Narcotics Anonymous (NA), Alcoholics Anonymous (AA), or medical illness support groups. Prior to 2010, 25 studies had examined the relationship between religiosity and compliance. Of those, 16 were cross-​sectional, 8 were prospective, and 1 was an RCT. Of the 16 cross-​sectional studies, 6 (38%) reported a positive association, 2 (13%) found a negative association, 6

(38%) reported no association, and 2 (13%) indicated mixed or complex results. Of the 8 prospective studies, 5 (63%) reported that religiosity had positive effects on compliance, 2 (25%) reported negative effects, and 1 reported no association. A single RCT reported a positive effect of a faith-​based cocaine treatment program on cocaine use. We describe several of the prospective studies here (see Appendix for all studies). The earliest prospective study was a 3-​year follow-​ up of 126 chronic hemodialysis patients in the Washington, D.C., area (O’Brien, 1982). Patients with no religious affiliation at baseline showed the worst compliance with the hemodialysis treatment regimen, whereas frequent church attenders showed the highest compliance, although no statistics were provided. Likewise, in a 6-​month prospective study of 101 poly-​drug users in London, spiritual beliefs at baseline significantly predicted location at follow-​up (whether in treatment or not) (F =​4.3, p < .007), which in turn predicted drug use and frequency of NA self-​help attendance (Christo & Franey, 1995). In contrast, a study of 411 cocaine addicts recruited from several large US cities found that those without a religious affiliation were more likely to attend 12-​step self-​help meetings during a 4-​to 24-​ week follow-​up, compared to those with a religious affiliation (Weiss et al., 2000). Likewise, a survey of a random sample of 608 Jewish parents of infants in Israel assessed at 2, 4, and 6 months following birth found that ultra-​ orthodox Jewish parents were significantly more likely to place their babies in a non-​prone position when put to sleep (against medical recommendations, increasing their risk of sudden infant death syndrome) compared to other less religious groups (Sivan et al., 2004). In the only early RCT we could locate, Stahler and colleagues (2007) examined the effects of a faith-​based intervention to increase retention in a residential treatment program for cocaine-​addicted Black women in Philadelphia. Participants were randomized to either the intervention (n =​8) or a usual care control group (n =​10). Central to the intervention was the use of church volunteers (mentors) to support cocaine-​dependent women in the intervention group. Weekly meetings were held

Disease Prevention, Detection, and Treatment • 599

between participants and their mentors, during which they sang spiritual songs, read from the Bible, and were taught life-​skills training that emphasized a spiritual worldview. Participants were also encouraged to attend church meetings with their mentors, who introduced them to families in the church community to help with integration. Participants were assessed at intake, and 3 and 6 months later. Results indicated that those randomized to the intervention were significantly more likely to remain in treatment at the 3-​month (88% vs. 40%, p =​ 0.04) and the 6-​month (75% vs. 20%, p =​0.02) assessments.

Recent Studies We summarize here studies since 2010 that have examined the relationship between religiosity and disease prevention (through vaccination), early identification (through screening), and treatment compliance. As usual, prospective studies and clinical trials are emphasized. D ISEASE P REVEN TION

In Chapters 17, 18, and 19, we reviewed the effects of religiosity on health behaviors that reduce disease risk. This is likely the most important way that religious involvement prevents disease. However, we examine here the S U M MA RY O F E ARLY S T UDIE S effects of religiosity on healthcare seeking in Concerning disease prevention, religious involve­ general and vaccination in particular as other ment may increase the likelihood of seeing a ways of preventing disease. At least three cross-​ control studies since 2010 single provider, thus increasing the continuity sectional or case-​ have reported that those who are more reliof care, and may be related to more general gious may delay healthcare-​ seeking behaviors, knowledge about disease prevention. However, and one prospective study found no effect of several small religious groups expressing objecreligious attendance on the use of preventive tions to vaccination have experienced disease healthcare services (Chen et al., 2020a). outbreaks, likely due to failure to vaccinate. Among studies reporting a delay in healthThere is also at least one prospective study care seeking, Vu et al. (2016) found that greater showing that vaccination against the flu may religiosity among American Muslim women be more common among those who are more was associated with a delay in seeking medical religious, and a study showing that church-​ care because of difficulty finding a female phybased adult intervention programs may help to sician. A second study found that religiosity in increase vaccination rates. With regard to early Turkey among mostly Muslim participants was identification of disease through screening, associated with a delay in seeking psychological while cross-​ sectional reports indicate mixed services for mental health problems (Rogers-​ results, prospective studies and clinical trials in Sirin et al., 2017). The third study found that the vast majority of studies reported increased more religious African American women (comdisease screening among those who were more pared to less religious) were more likely to presreligious and increased effectiveness of church-​ ent with ovarian cancer at a late stage in the based interventions compared to control disease (Moorman et al., 2019). groups for improving screening practices for With regard to vaccination, our systematic breast and cervical cancer. Finally, with regard review conducted between 2010 and 2020 to compliance with medical and psychiatric uncovered 39 studies examining the relationtreatments, the majority of prospective studies ship between religiosity and completed vaccifound that compliance is higher among those nation or willingness to be vaccinated or have who are more religious, and a single clinical their children vaccinated (see Appendix; all trial indicated increased treatment retention studies were cross-​ s ectional and generally of among cocaine addicts receiving a supportive lower quality). Four studies (10%) found that religious intervention. We now examine the greater religious involvement was associated extent to which these early findings have been with positive attitudes toward vaccination or replicated in more recent studies. completed vaccination rates; 16 studies (41%) found negative attitudes toward vaccination or 600 •  P h y sical H ealth

failure to vaccinate; 18 studies (46%) reported no association with religiosity; and one study reported mixed positive and negative results. These findings are generally consistent with earlier reports of reduced vaccination or negative attitudes toward vaccination among the more religious, but now including both non-​ mainstream and mainstream religious groups. Nearly half of the recent studies indicating a negative relationship between religiosity and vaccination (i.e., 7 of 16) involved vaccination for the human papilloma virus (HPV), which is intended to prevent cervical, oral, penile, and head and neck cancers (but is still optional in terms of recommended vaccinations). Religious resistance against the HPV vaccine may be due to parents’ concern over sending a message to youth that it is okay to have sex (Constable & Caplan, 2020). Two of the 16 negative studies examined religious attitudes toward vaccination to prevent COVID-​19, during a time when such vaccines had not yet been developed. These studies found that religiosity is related to significantly greater COVID-​19 vaccine hesitancy (Olagoke et al., 2020; Callaghan et al., 2020). In a review of religious attitudes toward measles vaccination (part of the required MMR vaccination triad), Wombwell and colleagues (2015) concluded that objections to vaccination based on religious beliefs often centered on the use of aborted human fetus tissue and animal (pork)-​derived gelatins in the preparation and production of the vaccine. In addition, however, they noted that objections to vaccination in religious communities were also based on concerns related to vaccine safety and efficacy, rather than religious belief. This likely applies to other vaccinations as well, particularly those to prevent COVID-​19. What is clear from these more recent studies is that religious involvement is either unrelated to vaccination or related to unfavorable attitudes toward it, unless the benefits of vaccination are well established, outweigh religious concerns about vaccine components, and are widely understood within the faith community. D I SE A SE D E T E CT ION

As noted above, early disease detection through screening is essential for identifying illnesses

at a stage when they are still treatable, particularly for breast cancer, cervical cancer, and colon cancer. Since 2010, our systematic review identified an additional 32 studies examining the relationship with religiosity (see Appendix). Of those, 28 were cross-​sectional in design, 2 were prospective, and 2 were RCTs. Of the 28 cross-​ sectional studies, 16 (67%) found positive associations between religiosity and disease screening, 6 (21%) reported negative associations, 4 studies (14%) reported no association, and 2 reported mixed results. Of the 2 prospective studies, both conducted in the United States, 1 reported no effect of religiosity on obtaining disease screening tests (Holt et al., 2018), and 1 found a positive effect of religiosity on likelihood of having a mammogram in Hispanics (Cadet et al., 2020). Of the 2 RCTs, 1 reported that a nonspiritual intervention (vs. a spiritual one) improved fecal stool testing for colorectal cancer (Holt et al., 2013) and one found a positive effect of a spiritually framed breast cancer screening message (vs. a traditional message) on mammography intentions (Best et al., 2016). In the prospective study by Holt et al. (2018), 766 African Americans were followed for an average of 2.5 years, finding no evidence for an effect of baseline church-​based religious support on increased likelihood of (1) having a mammogram within the past 2 years, (2) ever having had a PSA test for prostate cancer, or (3) ever having had a colonoscopy. In the second, a prospective study with a much larger sample size of 10,116 community-​dwelling elderly followed for 4 years, Cadet et al. (2020) reported that believing in God and finding strength in religion predicted a greater likelihood of having a mammogram within the past 2 years among Hispanics, but not in Blacks or Whites (analyses controlled for multiple covariates). In the first of two RCTs, Holt et al. (2013) examined the effects of a spiritually based intervention (n =​152) compared to a nonspiritually​based one (n =​133) intended to increase colorectal cancer screening in African Americans age 50–​74 attending 16 churches in Alabama. Both spiritual and nonspiritual interventions involved two 60-​minute educational sessions separated by 1 month, with assessments performed at baseline and 12 months following

Disease Prevention, Detection, and Treatment • 601

the second session. Results indicated no difference between groups on likelihood of having a flexible sigmoidoscopy in the past 5 years, colonoscopy in the past 10 years, or barium enema in the past 5 years; however, having a fecal local blood test in the past 12 months was more common among those in the nonspiritual intervention group (p =​0.03). The second RCT tested the efficacy of a spiritually framed breast cancer screening (BCS) message compared to a traditional screening message in 200 African American women, with 100 randomized to each condition (Best et al., 2016). The traditional BCS message prepared by the CDC was intended to motivate African American women to obtain mammograms. The spiritually framed message focused on the body as the temple of the Holy Spirit, and differed from the traditional message only in its spiritual content. Results indicated an indirect effect of the spiritually framed message on intention to obtain a mammogram through polarity (the ratio of positive to negative thoughts generated by the message) (b =​0.057, p < 0.001). Researchers concluded that spiritual training may improve the efficacy of BCS messages by eliciting more positive thoughts about screening. In summary, the majority of more recent cross-​sectional studies (often small samples) have found a positive association between religiosity and disease screening (primarily cancer), whereas the two more recent prospective studies have reported divergent findings, with one study indicating no evidence for an effect and the other finding evidence for a positive effect in Hispanics but not in other races. Likewise, the two clinical trials (both testing relatively weak spiritual interventions) have reported mixed results. More recent research, then, is mixed in terms of confirming the positive findings from earlier prospective and experimental studies. C O MP L I A N C E TO T RE AT ME NT

Of the 26 recent studies examining the relationship between religiosity and medication adherence, 19 were cross-​sectional, 6 were prospective in design, and 1 was an experimental study (see Appendix). Of the 19 cross-​sectional 602 •  P h y sical H ealth

studies, 12 (63%) found a significant positive correlation between religiosity and medication adherence, 5 (26%) reported worse compliance among the more religious, 1 study reported mixed findings, and 1 study reported complex results. In the first of 6 prospective studies, Peltzer et al. (2011) conducted a 20-​ month follow-​up of 735 HIV-​positive patients in South Africa, finding that mainstream Christians at baseline were more likely than those affiliated with African traditions or no religious affiliation to adhere to antiretroviral treatment (ART) (> 95% adherence) at 12-​month follow-​ up (adjusted OR =​2.32, 95% CI =​1.01–​5.33), with a similar trend present at 20-​ month follow-​up (adjusted OR =​2.32, 95% CI =​0.96–​ 5.63). In contrast, a 6-​month prospective study of 204 HIV-​positive patients in Missouri by Finocchario et al. (2011) found that those with high scores on a God locus of control scale were significantly less compliant with ART (aOR =​ 0.58, 95% CI =​0.40–​0.84). A third prospective study involved a 3-​ month follow-​up of 168 patients with chronic medical illness in Turkey who completed the Hajj pilgrimage to Mecca (Yilmaz et al., 2019). Investigators found significantly less medication compliance immediately following completion of the Hajj pilgrimage (12 reduced or stopped their medication, p =​0.01). However, by 3-​month follow-​up this effect was reduced to a trend level (7 reduced or stopped medication, p =​0.09). When participants were asked why they reduced or stopped their medication, responses indicated this was primarily due to lack of physical health complaints, with 29% indicating that disease-​ specific complaints decreased after the Hajj and 70% reporting that the Hajj pilgrimage had positively affected both their disease status and coping ability. In the fourth prospective study, Assemie et al. (2019) followed 73 HIV-​positive patients in Ethiopia for 16 months, finding that 22% stopped their medication due to spiritual beliefs (although no associations with spirituality or religiosity were examined). In the fifth prospective study, Saffari et al. (2019) followed 793 Iranian patients with type II diabetes for 12 months, finding that religiosity assessed by the 5-​item DUREL at baseline predicted better future medication adherence, acting both

directly and indirectly by increasing religious coping and social support. Finally, Poteat et al. (2019) found that positive religious coping predicted a greater likelihood of medication compliance over 12 months in 167 African American HIV-​positive patients (Poteat et al., 2019). Thus, whether religiosity increases or decreases medication compliance depends on the religion and on the location in the world where this is examined, although the majority of recent cross-​sectional findings and half of prospective studies indicate a positive association between religiosity and medication adherence, consistent with earlier findings. There have also been 13 studies examining the relationship between religiosity and compliance with physician visits, treatment sessions, medical or public health recommendations, or broader adherence to medical/​ psychiatric treatment regimens (diabetes, heart failure). Of those, 6 were cross-​sectional, 5 were retrospective or prospective cohort studies, and 2 were clinical trials. Of the 6 cross-​sectional studies, 5 reported a significant positive association between religiosity and treatment adherence and 1 found no association with intrinsic religiosity. In the first of five prospective studies, Deane et al. (2012) followed 618 psychiatric patients involved in 12-​step residential drug/​ alcohol rehabilitation programs in Australia over 3 months. Results indicated no effect of spiritual beliefs (nonreligious in nature) on dropouts from the program during those 3 months. Gurak et al. (2017) prospectively followed 64 families enrolled in a spiritually integrated family treatment for schizophrenia that targeted religious coping. Researchers examined the effects of baseline religious coping and religious moral values on family session attendance during a 4-​month follow-​up period. Results indicated that higher religious/​ moral values and greater interpersonal religious support both predicted fewer family sessions attended during follow-​up. In the third prospective study, DeFranza and colleagues (2020) examined the relationship between religious involvement and adherence to shelter-​in-​place (SIP) directives in 53 US metropolitan statistical areas over 30 days (1,590 assessment points) between the

end of February and the end of March 2020. Investigators found that religiosity (number of religious congregations per 10,000 residents) predicted less compliance with SIP directives regarding COVID-​19, but only when such directives were in place. No effect was found on compliance when only guidelines (not directives) were in place. Researchers explained the findings as a response to governmental interference with personal and religious freedoms. In the fourth study, using a retrospective cohort design, Shin et al. (2020) reviewed the medical records of 525 participants seen in the emergency room in South Korea for a suicide attempt. Those practicing a religion were over 80% more likely to adhere to a psychiatric follow-​up visit (OR =​1.82, 95% CI =​1.05–​3.15). Finally, in a 3-​month advanced care planning intervention for end-​of-​life treatment preferences in 85 adolescents age 14–​21 with HIV/​ AIDS, researchers found that religiousness/​ spirituality (R/​S; religious attendance, private prayer, feeling God’s presence, identifying as religious and spiritual) moderated the decision to continue treatment in all three end-​of-​life scenarios such that highly R/​S adolescents at baseline had over four times the odds of choosing to continue treatment (OR =​4.39, 95% CI =​ 1.05–​18.35) (Lyon et al., 2020). In the first of two RCTs, Huguelet et al. (2011) randomized 78 patients with schizophrenia in Switzerland to either a group that received a spiritual assessment by their psychiatrist (the R/​S intervention) or to a control group that did not. Results indicated that adherence to clinic appointments was significantly better in the group that received the spiritual assessment. In the second RCT, Moradi et al. (2020) randomized 30 Iranian hemodialysis patients to either a religiously integrated cognitive therapy intervention or an untreated control group, finding that those receiving the intervention improved significantly in their compliance with the hemodialysis treatment regimen compared to those in the control group.

Summary Although the findings vary widely with regard to disease prevention, disease detection, and

Disease Prevention, Detection, and Treatment • 603

treatment compliance, some patterns can be identified. With regard to preventing disease through health behaviors, there is little question from previously reviewed research in other chapters that individuals who are more religious behave in ways that prevent the development and improve the course of many diseases. With regard to healthcare seeking and vaccinations, however, the findings are less clear and are often quite negative depending on religious group. Religious methods of healing may compete with more conventional forms of medical care in certain religious groups, depending on their location in the world. Religious methods (prayer, religious healing) may be used to justify not seeking medical care, sometimes resulting in late presentations of disease at a time when treatment may not be as effective. There is thus evidence for different types of effects in different directions. Experiences and reasons for those experiences given by Mrs. Mercheson in the case vignette above do indeed occur. However, the empirical research suggests that the reasons expressed by Mrs. Mercheson are in fact not the dominant mode by which religiosity affects screening and preventive health behaviors. More often, religion promotes these behaviors. However, with regard to vaccination, religious involvement is either unrelated to obtaining timely vaccinations or related to unfavorable attitudes toward them. Concerning early identification of disease through screening, most studies conducted prior to 2010 (particularly prospective studies) reported that religious individuals were more likely to engage in disease-​ screening behaviors (mammography, Pap smear, colonoscopy, etc.). Likewise, RCTs generally found that faith-​ based religious interventions in religious institutions increased screening behaviors. More recent results from prospective studies and RCTs, while less conclusive than earlier studies, generally support those findings. With regard to compliance with prescribed medications, adherence to treatment regimens, or following directives or guidelines more broadly, the majority of cross-​ sectional and numerous prospective studies indicate greater medication compliance among the more religious, although some recent studies have been 604 •  P h y sical H ealth

less positive. All three RCTs (one early study and two more recent) examining religious interventions on compliance with medication or treatment regimens, however, have reported positive results. Thus, better health behaviors, improved screening that may detect disease earlier at a more treatable stage, and increased compliance with medication and treatment follow-​ up are likely to prevent disease and maintain health in religious individuals. However, conflict between religious and conventional medical forms of healing, religious concerns about vaccination, and evidence indicating religiosity’s negative impact on compliance with public health directives may increase risk of poor health outcomes among the more religious (depending on religion, condition, and geographical location). These findings underscore the importance of educating religious communities about the benefits of disease-​prevention activities, early disease detection, compliance with medical treatments, and timely follow-​up with health professionals. This will be important for preventing illness and maintaining the health of individuals in religious communities. Despite concerns about religiosity’s negative impact on disease prevention practices such as vaccination, reduced disease screening in certain ethnic populations, and difficulties with treatment compliance reported in some studies, religious persons generally experience better mental, social, behavioral, and physical health than those who are less religious.

RECOMMENDATIONS FOR FUTURE RESEARCH There are relatively few well-​designed large prospective studies examining the effects of baseline religiosity on future disease-​ prevention activities (continuity in provider healthcare, regular medical visits, timely vaccinations), recommended disease-​s creening activities (mammography, Pap smear for cervical cancer, colonoscopy, hypertension, diabetes), and level of compliance with medications or adherence to other aspects of treatment, assessed over extended periods of time and controlling for baseline outcomes. Time intervals should ideally be at least 5 years and details on key disease

prevention, detection, and treatment adherence behaviors should be assessed. The closest study to the ideal above was that of Benjamins et al. (2006b), which was a 4-​year prospective study of 4,253 US community dwelling adults age 51–​61 that assessed screening behaviors (mammography, Pap smear, breast self-​exam). Unfortunately, the most recent large 3-​to 12-​ year prospective study by Chen et al. (2020a) examined only a single outcome in this category, preventive healthcare use, without details about the specific preventive healthcare behaviors engaged in. However, with more detailed information on immunizations received, screening activities involved in, and compliance with medical treatments, and more in-​depth measures of baseline religiosity (in addition to religious attendance, the only variable assessed), the Chen et al. study would also have come close to the ideal. Research is also needed to determine what offsets the negative effects on health caused by avoidance of vaccinations, lack of engagement in screening activities, and poor compliance with medication or medical/​psychiatric visits sometimes seen among highly religious persons. How is it that highly religious individuals often have better physical and mental outcomes despite less than optimal vaccinations, delayed disease-​screening procedures, and engagement in religious healing practices instead of traditional medical or psychiatric care? For example, while highly religious African Americans may be more likely to present with late-​stage breast or ovarian cancer, is their mortality rate any different from less religious African Americans or other less religious racial groups more likely to adhere to recommended screening practices? For example, Van Ness and Kasl (2003a) found that African American women with breast cancer who indicated no religious affiliation at baseline were over 10 times more at risk of dying during a 10-​year follow-​up compared to those with a Protestant affiliation (HR =​10.66, 95% CI =​3.32–​34.16). Furthermore, in the overall sample that included Whites, only 45.5% of the group with no religious affiliation had a late stage at diagnosis compared with 60.8% of the entire sample and 83.3% of those with a Pentecostal affiliation; Pentecostals, however, actually had a somewhat lower mortality than

Protestants more generally (HR =​0.82, 95% CI =​0.39–​1.74). Thus, despite presenting at a later stage of disease, survival was actually the same or slightly better. Likewise, are highly religious individuals who meet and worship together in person less likely to acquire infections, or have a more benign disease course once infected, compared to less religious persons who do not attend religious services and are therefore less exposed to contagious viruses? The COVID-​19 pandemic in 2020–​2022 may end up serving as a good testing ground to determine if highly religious individuals have better health outcomes once infected by the coronavirus. While some preliminary research is suggestive in this regard (Rajkumar, 2020), no conclusive results are yet available. Prospective studies are needed to answer questions of this type. Randomized controlled trials (RCTs) are also needed to determine if religious-​based interventions in religious settings are capable of increasing (1) receptivity to life-​saving vaccinations during infancy, childhood, and adulthood; (2) engagement in screening behaviors for detection of cancer, hypertension, diabetes, hypercholesterolemia, and other health conditions common in middle age and later life; (3) compliance with medication or treatment regimens more generally, especially for those with chronic illnesses such as diabetes, hypertension, heart disease, or chronic renal disease on dialysis; and (4) compliance with mental healthcare clinic visits and psychiatric medication by those with psychiatric disorders. Future research could also examine interventions that have a significant religious component, not simply being conducted on church grounds. Studies of this type must take into account cultural influences when conducted in Africa, Asia, South America, and the Middle East, which vary considerably from Western countries in North America, Europe, and Australasia. Interventions delivered in congregation-​based settings of this type have the potential to reach large numbers of individuals in religious countries and in highly religious ethnic groups (e.g., African Americans, Catholic Hispanics, Arab Americans, etc.), where health disparities have been well documented. These disparities may be due at least in part to less regular medical care and vaccinations, failure

Disease Prevention, Detection, and Treatment • 605

to detect diseases early due to lack of screening, and/​or reduced compliance with medical or psychiatric treatments, factors that may be related to religiosity in some cases.

CLINICAL APPLICATIONS Many clinical applications exist for both healthcare professionals and religious professionals that can increase disease-​p revention and health-​promotion activities, thereby enhancing the health of individuals and communities.

Healthcare Professionals As usual, all clinical applications for healthcare professionals begin by taking a spiritual history (SH) in order to find out whether the patient has religious beliefs and how they might be influencing disease prevention, detection, or compliance with proposed treatments. This is particularly important in countries where spiritual-​healing practices are common, such as in Africa, the Middle East, and South and Central America, and in Pentecostal religious groups in Western countries that often rely on faith-​ healing practices. As noted earlier, African Americans, Hispanic Americans, and Arab Americans are ethnic groups in the United States that tend to be highly religious, and religious beliefs frequently affect their healthcare decisions. Although taking an initial SH is important, the SH may need to be repeated throughout the course of care whenever new treatments are proposed or screening activities suggested. As indicated in previous chapters, healthcare professionals can utilize patients’ religious beliefs about the sacred nature of the physical body to help motivate disease-​prevention and health-​promotion activities. As indicated frequently in this Handbook, the physical body is considered by Christians to be the temple of the Holy Spirit based on 1 Corinthians 6:19. For Jews, since the body is created in the image and likeness of God (Genesis 1:27), believers are expected to wash their face, hands, feet, and otherwise care for their physical body every day out of respect for their Maker (Talmud, Shabbath 50b). For Muslims, taking care of one’s health is likewise considered a religious 606 •  P h y sical H ealth

duty (Attum et al., 2018). In Hinduism, as in Christianity, the body is compared to the temple of God, and thus must be treated with respect and care (Jayaram, 2019). In Buddhism, the physical body and mental life are considered interdependent, not separate from one another, and therefore the individual must responsibly care for both body and mind (Wilson, 2004). Thus, all major religious traditions emphasize that individuals must care for their physical bodies as instructed by their sacred scriptures. These beliefs can be utilized by healthcare practitioners to motivate self-​ care activities in those who are highly religious. More than anything else, however, religious patients need education. This must come from both healthcare providers and clergy. Education is needed about the importance of disease-​ prevention activities (vaccination, and consequences of not doing so), disease screening (and risk of cancer and other diseases that are treatable when identified early), and the importance of compliance with medications and other prescribed treatments. Healthcare professionals may volunteer to speak on these topics in faith communities, particularly in their own congregations, in order to promote the health and wellness of the religious community. As when providing care to individual patients, education in faith communities should focus on information about recommended vaccinations (Table 30.2), their safety, and effectiveness; recommended screening procedures at various ages and for different genders (Table 30.3); and the importance of having a primary care physician to coordinate care and of complying with treatments that they prescribe. Health professionals should emphasize that religious healing practices often serve to complement traditional medical treatments, and should not be viewed as competing with them, thus requiring that a choice be made between one or the other.

Religious Professionals Claims by healthcare professionals may have little credibility unless they are supported by congregational leadership (a head pastor, priest, rabbi, imam, and/​ or other respected persons within the faith community). This is necessary to support and engender trust in what is being

said. Religious professionals in such positions should themselves attend educational sessions given by healthcare professionals (either from within the faith community or from without). The congregational leadership should affirm in formal preaching and teaching (and/​or during religious education classes) the information provided by healthcare professionals, expanding on what is being said by providing theological justification and support for behaviors that maintain and enhance health. Such affirmation is particularly important since religious involvement has been associated with increased skepticism and mistrust toward healthcare professionals (López-​Cevallos et  al., 2019), false beliefs that may interfere with compliance to medical guidelines (Freeman et  al., 2022), and vaccine hesitancy (Callaghan et al., 2020; Zaidi & Flores-​ Romo, 2020; and other studies noted earlier). Religious leaders may also support and encourage the development of formal health ministries within the congregation that provide or encourage disease-​prevention activities (such as vaccination), early disease detection (such as screening for cancer, hypertension, or diabetes), and education about the benefits of regular medical care and compliance with prescribed treatments. A parish nurse (also called congregational nurse) with ties to both the religious community and the medical system may be the ideal person to coordinate such activities (Carson & Koenig, 2004). While this may be particularly important for large religious congregations with many older members, several small religious institutions can also band together in order to support a congregational nurse who can serve to establish and coordinate health ministries in all of them. Expending resources to maintain a healthy congregation may be considerably less expensive (in terms of finances and clergy time) than having to visit and minister to sick members in the hospital or at home. While religious institutions throughout history have always been the first to care for the sick and needy in a community, preserving physical and mental health of the faithful within faith communities through disease-​prevention and health-​promotion activities may be just

as important (Koenig, 2005). As noted above, research has shown that when faith-​based and held within faith community settings, educational efforts increase disease-​screening practices, improve health behaviors, and enhance disease self-​management, resulting in significant benefits to members of the congregation (Best et al., 2016; Samuel-​Hodge et al., 2009; Arredondo et al., 2017).

SUMMARY AND CONCLUSIONS Along with good health behaviors, engagement in disease-​ prevention activities, particularly regular medical/​dental visits and vaccinations, early disease detection through screening, and compliance with medical treatments are essential for preserving and improving physical and mental health. The research reviewed in previous chapters indicates that greater religious involvement is consistently related to less cigarette smoking, more exercise, and eating a healthier diet, as well as avoiding heavy alcohol intake and use of illicit drugs. In this chapter we have shown that religiosity is related to disease-​ prevention activities, early disease detection through screening, and compliance with medical and psychiatric treatments, but this is not always so. When this is not so, the reasons are often misunderstandings, false beliefs, conspiracy theories, or exaggerated concerns circulating within faith communities (driving, for example, vaccine hesitancy), and/​ or lack of education about the benefits of such practices in light of their risks. Both healthcare professionals and religious professionals play essential and complementary roles in helping to educate religious persons about the benefits of disease-​ prevention and health-​ promotion activities that will maintain and maximize their health and ability to serve in their community. In the next chapter, we explore the many pathways (including through disease-​ prevention and health-​promotion activities) by which religious involvement may impact physical health through psychological, social, and behavioral mechanisms.

Disease Prevention, Detection, and Treatment • 607

SECTION VII Explanatory Mechanisms: Physical Health THIS SECTION CONTAINS a single comprehensive chapter that examines the psychological, social, and behavioral pathways by which religious involvement could impact physical health (heart disease, hypertension, and other health

conditions covered in Section VI). Again, the effects on physical health are likely to be “indirect” because they occur through religion’s influences on more “proximal” mediators, i.e., mental health, social health, and behavioral health.

31 Understanding the Religion–​Physical Health Relationship I praise You because I am fearfully and wonderfully made. —​Psalm 139:14

PREVIOUS CHAPTERS HAVE documented the health benefits (and sometimes the potentially adverse health risks) of various forms of religious involvement. In each of the Section VI chapters on physical health, we began by laying out a rationale to help explain why religiosity might affect the particular health outcome. In this chapter, however, we bring all this information together, focusing on specific pathways and mechanisms. Having a plausible theory or model is important for many reasons. First, 2 of Hill’s 10 considerations for causality are plausibility and coherence (Hill, 1965). Plausibility means that an association seems to logically follow from or is consistent with currently accepted understandings of pathological processes, i.e., there is a logical connection between the exposure variable (religiosity) and the outcome (physical health). Coherence, closely related to plausibility, means that the association does not

conflict with existing theory and knowledge. For the association between religiosity and physical health to be both plausible and coherent, then, there must exist a rationale for connecting the two. We hypothesize that the relationship bet­ ween religious involvement and physical health can be explained by genetic, physiological, environmental, psychological, social, and behavioral mechanisms, as well as by individual choices and decisions. Because the effects of religion on physical health are likely bidirectional, with religion affecting physical health as well as physical health affecting religion, verifying the theoretical causal models presented in this chapter will be heavily dependent on the findings from prospective studies and randomized controlled trials (RCTs). We begin by examining known determinants of physical health, and then examine how religiosity may influence health through those determinants.

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0031

DETERMINANTS OF PHYSICAL HEALTH Genetic, physiological/​medical, environmental, psychological, social, and behavioral characteristics help to determine a person’s physical health. Many of these factors depend on choices that are under the individual’s control, others are not. Also important are the interactions that occur between these factors. We begin by focusing on each determinant and then provide examples of how they may interact with one another. When discussing determinants of health, the use of the term “determinant” is relative. These factors only have an influence on health; they do not determine it. Rather, physical health is the result of a complex web of causal factors working together, with their total sum resulting in a person’s health at any one point in time.

Genetic Genetic influences based on inherited characteristics set the stage. Genes are known to affect physical and emotional resilience, the risk of developing diseases and mental disorders, and to some extent, longevity. Genetic factors may even have some influence on a person’s level of religiosity and likelihood of engaging in religious practices. Again, genetics influence but do not determine, at least in any absolute sense. In other words, genetic effects involve predispositions only and are not definitive, except in rare cases. Some genetic influences are non-​modifiable (such as sex or race or certain genetic disorders), whereas others are modifiable through actions (choices) by the individual or by their parents or caregivers.

Physiological/​Medical Alterations in cardiovascular, immune, endocrine, and nervous systems are key to the development and maintenance of many physical illnesses. These illnesses include the major causes of morbidity and mortality throughout the world, including heart disease, hypertension, stroke, chronic lung disease, infection, cancer, dementia, and endocrine disorders 612 •  E xplanator y M echanisms

such as diabetes and hypercholesterolemia. These are the 10 most common causes of disease and death in the world (Global Estimates of Health, 2018).

Environmental Environmental factors affecting physical health include exposures during embryonic and fetal development, care provided by parent(s) during infancy and childhood, influences by peers during the preteen and teen years, accidents during childhood and adulthood, workplace injuries, neighborhood safety, exposure to environmental toxins and infectious agents, socioeconomic factors influencing quality of diet, and access to quality healthcare, to name just a few. Many, if not most, of these environmental determinants of health are modifiable in one way or another by individuals or societies/​governments.

Psychological Good mental health, i.e., the regular experience of positive emotions and development of healthy psychological traits, meaning and purpose, and moral/​ethical values, is known to enhance physical health (Park et al., 2016; Trudel-​ Fitzgerald et al., 2019). In contrast, poor mental health (negative emotions, emotional disorders, and psychological distress) has the opposite effect (Chida & Steptoe, 2008; Scott et al., 2016). Positive emotions and psychological states include psychological well-​ being, life satisfaction, happiness, meaning and purpose, optimism, and hope. Positive psychological traits and moral/​ethical values include forgiveness, honesty, courage, self-​ discipline, altruism, humility, gratefulness, patience, and dependability. Negative emotional states include depression, anxiety, fear, addictions to alcohol, drugs, food, or sex, and symptoms of psychological distress that result from loss, trauma, or unwanted change. Psychological factors influence physical health by affecting the central nervous system, autonomic nervous system, and endocrine (cortisol, norepinephrine, and epinephrine stress hormone levels), cardiovascular, and immune systems.

Social As indicated in Chapter 15, the amount and quality of social support are important determinants of physical health. On the one hand, individuals who feel socially isolated or lonely are at greater risk for developing many medical illnesses and dying prematurely. On the other hand, those who report higher levels of social support are more likely to have their health monitored, seek medical care when necessary, and comply with prescribed medical treatments. Social support has been shown to buffer the negative effects of life stressors by helping people to cope better, thereby lowering the risk of significant depression, anxiety, substance use disorders, and other mental health problems that increase risk of physical illness.

Behavioral Health behaviors such as avoiding or stopping cigarette smoking, engaging in regular exercise, consuming a healthy diet, controlling weight, engaging in safe sexual practices, and avoiding activities that increase risk of accidents all have an enormous impact on physical health (see Chapters 17–​19). This applies in particular to the development of chronic illnesses such as cardiovascular disease, cerebrovascular disease, dementia, diabetes, cancer, and other disabling, long-​term, and often painful medical conditions. Because health behaviors are under the individual’s control, they represent one of the most modifiable determinants of physical health.

Interactions between Determinants Each determinant of physical health described above interacts with others in a complex web of causation that results in an individual’s current state of health. For example, environmental influences and health behaviors contribute to the expression of high-​risk genes or genetic disorders. Health behaviors (exercise, diet, cigarette smoking) influence the development and course of many acute and chronic medical conditions. Environmental factors influence psychological and social factors, which affect health behaviors, which in turn affect mental health,

all increasing or decreasing risk of illness. No one factor, then, is responsible for physical health, but rather it is the combination of such factors, each independently and together having effects on the ultimate outcome.

Individual Choice Individual decisions and choices determine the degree to which persons engage in healthy behaviors, seek regular medical care, comply with treatment recommendations, participate in social groups, and mobilize healthy coping behaviors to reduce stress and lower risk of developing psychological problems. Individual choices, then, impact many of the determinants of physical health discussed above. Much, though certainly not all, of physical health, then, is under the individual’s control. This is especially true in economically developed parts of the world where resources are plentiful and accessible, and is also true to some degree in underdeveloped economically deprived regions where resources are more limited, influencing the range of choices available to the person.

RELIGION, RELIGIOSITY, AND DETERMINANTS OF PHYSICAL HEALTH We now briefly review evidence suggesting that religious involvement influences the conditions and choices that people make, which impact physical health by affecting the determinants above.

Genetic Members of certain religious/​ethnic groups are known to be at greater risk for certain illnesses, in ways that have nothing to do with personal choice. For example, Jews are at increased risk of developing breast cancer or Tay-​Sachs disease (Baskovich et al., 2016). Muslims have an increased risk of developing congenital malformations and autosomal recessive disorders due to marrying close relatives, choices that are based on firmly ingrained cultural factors (Younis et al., 2018). Amish Christian groups are likewise at greater risk of developing certain genetic disorders from engaging in The Religion–Physical Health Relationship • 613

consanguineous relationships (Morton et al., 2003). Religiosity may interact with genetic polymorphisms that increase or decrease risk of addiction, thus influencing the development of substance use disorders, which impact physical health (Dew et al., 2017; see also Chapter 10).

Physiological/​Medical Because of effects that religiosity may have on cardiovascular, immune, and endocrine functions (Chapters 20, 24, 25), there is some evidence that those who are more religious tend to experience less heart disease, hypertension, cerebrovascular disease, dementia, infection, and some cancers (Chapters 20–​23, 26). Consequently, religious individuals tend to live longer (Chapter 27). Religious involvement also predicts less physical disability and impaired physical functioning with increasing age (Chapter 28) and may affect the perception of pain and ability to endure it (Chapter 29).

Environmental Religiosity of parent(s) may influence the embryonic and fetal development of offspring by its effects on maternal health behaviors and stress levels (due to improved marital stability), and on the care those offspring receive during infancy and childhood (Chapter 14). Religious involvement may also affect the choice of healthy peer groups during the adolescent and teen years that will reduce the likelihood of delinquent or criminal behavior, alcohol or drug addiction, and premarital teen pregnancy (Chapters 13 and 14). A positive peer group, being raised in a religious home, and receiving religious training within a religious community will help to instill positive character traits that increase the likelihood of completing education, which in turn will determine job quality and likelihood of exposure to workplace accidents (more common with manual labor). Having character traits that foster workplace ethics and positive behavior toward co-​ workers will influence employment stability and productivity, increasing the likelihood that a person can afford to live in a healthy and safe neighborhood. This will limit exposure to environmental toxins or infectious agents, reduce 614 •  E xplanator y M echanisms

the likelihood of physical assault, increase access to healthy foods, and increase the ability to engage in safe recreational activities and physical exercise. Likewise, having employment will increase the likelihood that a person will have health insurance, which will improve the likelihood of regular medical care, the prevention of disease through timely vaccination, the early detection of disease through screening, and access to medical treatments (Chapter 30).

Psychological Religious beliefs and practices may influence the ability to cope with stress (Chapter 4), the risk of depression and speed of depression recovery (Chapter 5), the risk of suicide (Chapter 7), the level of anxiety or fear (Chapter 8), and the likelihood of developing a substance use disorder (Chapter 10). Religious persons also experience more positive emotions such as happiness, life satisfaction, meaning and purpose, optimism, and hope (Chapter 12). Just as negative emotions adversely affect physical health through effects on immune, endocrine, and cardiovascular pathways, the effects on health are the opposite for positive emotions (Chapters 20, 24, and 25). Religious rituals or rites (e.g., the Sacraments) and religious interventions (e.g., religiously integrated psychotherapy) may likewise reduce negative emotions and enhance positive ones that impact physical health.

Social Religious involvement is consistently related to larger social networks, greater social support, higher quality and persistence of support, less social withdrawal, and less loneliness (Chapter 15). Since social support helps to improve physical health and extend longevity in many studies (see Uchino et al., 2018, for an updated review), those who are more religious should have better health through this pathway. Religious persons are also less likely to engage in delinquent or criminal acts, more likely to engage in volunteering and other prosocial altruistic activities, and more likely to participate in community social groups, increasing social capital at the community level (see

Chapter 15 and Appendix). Greater social capital (a shared sense of identity, a shared understanding, shared norms, shared values, trust, cooperation, and reciprocity), in turn, has a positive impact on community health, reduces teenage pregnancy and crime, and is associated with fewer environmental risk factors, thereby improving physical health and wellness (Ehsan et al., 2019).

Behavioral As indicated earlier, up to 40% of premature mortality in the United States is due to unhealthy behaviors (Onge & Krueger, 2017), and a combination of at least four healthy lifestyle factors lowers all-​cause mortality by 66% (Loef & Walach, 2012). Health behaviors are modifiable through the choices that individuals make. Some estimates indicate that more than 80% of chronic health conditions could be eliminated by adopting a healthy lifestyle, i.e., eating healthy foods, engaging in regular exercise, maintaining a healthy weight, making efforts to improve emotional resilience, and avoiding cigarette smoking (Pasupathi et al., 2009; Cunningham et al., 2015; Carter et al., 2015; Bodai et al., 2018). In the majority of studies, religious involvement is associated with and predicts less cigarette smoking, more physical activity, greater emotional resilience, and the eating of a healthier diet (Chapters 17–​19). Furthermore, religious individuals are on average more likely to seek regular medical care, to engage in disease-​screening practices, and to follow the doctor’s recommendations. Positive effects on health behaviors are probably the most important ways that religious involvement affects physical health (see Chapter 27).

Interactions If religious involvement influenced only one or two determinants of health, then the overall impact on physical health would likely be quite modest. However, since religiosity potentially affects many of these determinants, each of which interacts with others, the cumulative effect over a lifetime could be considerable. As noted earlier, such cumulative effects are perhaps best measured by religion’s influence on

longevity. This is true even when accounting for reverse causation due to the turning to religion as physical health worsens and/​or death approaches. Studies have consistently found that religious persons live longer than those who are less religious (see Chapter 27, and reviews by McCullough et al., 2000; Chida et al., 2009; and Lucchetti et al., 2011; as well as more recent individual prospective studies by Li et al., 2016; Kim et al., 2019; Hill et al., 2020; and Zimmer et al., 2020).

Individual Decision-​Making Religious beliefs and commitments influence the choices that people make and ultimately, through repeated choices, the development of healthy habits. All major world religions promote moral and ethical standards with regard to honesty, gratitude, forgiveness, patience, self-​ discipline, altruism, generosity, compassion (empathy), and humility (Chapter 11). These character traits are known to impact mental and social health, thereby affecting physical health as well.

HYPOTHETICAL CAUSAL MODELS Based on the research findings that were summarized in previous chapters, we now present three hypothetical causal models for describing how religious involvement affects physical health. The first model is based on a monotheistic worldview held by the three major monotheistic religious traditions of Judaism, Christianity, and Islam. This model is then adapted to apply to an Eastern religious world­ view and to a secular humanistic worldview. Although based on the evidence and rationale presented earlier, none of these models is proven or established. Rather, each model seeks to provide a framework for discussion and further evaluation. These models will almost certainly require further research to affirm, refine, or refute the hypothesized pathways that each present. Admittedly, there is somewhat more evidence concerning the paths of the monotheistic model simply because most of the existing published religious/​ spiritual (R/​ S) empirical research, and most empirical research more The Religion–Physical Health Relationship • 615

generally, involves Western contexts. However, certain pathways, though certainly not all, may in fact be quite universal. Moreover, even within monotheistic traditions, given the diversity of traditions within Judaism, Christianity, and Islam, the monotheistic model too will likely require modification depending on the specific tradition.

Monotheistic Model In this monotheistic model, the cause or initial “source” that ultimately drives the pathways from religion to physical health is belief in, relationship with, and attachment to God (Figure 31.1). Because there is only one god in the major monotheistic Western religious traditions, we signify this by capitalizing the word God. Western monotheistic belief systems view God as an entity separate from creation itself, a divine being that people can pray to, interact with, and form a relationship with or attachment to. This attachment is sometimes conceived in terms of three theological virtues:

Decisions, Health Behaviors, Health Maintenance, Screening, Compliance Secular Sources

Public prac, rit

Private prac, rit

God

Theological Virtues: faith, hope, love

SOURCE Belief in and attachment to

R commitment

R experiences

Positive Emotions (purpose and meaning optimism, hope, well-being, happiness)

Human Virtues Forgiveness Honesty Self-discipline Altruism Generosity Humility Gratefulness Patience Dependability

Social Connections

Negative Emotions Peer influences, education and training

(depression, anxiety, substance abuse)

R coping

Physical Health and Longevity

Religious community

Nervous System, Immune, Endocrine, and Cardiovascular Functions

Religion/Spirituality

faith in God, hope in God, and love of God. As noted above, these are considered “theological” virtues to distinguish them from the natural “human” virtues. Belief in and attachment to God serve as the basis for specific communal beliefs, rituals, and public religious practices such as attending religious services. Social interactions within the religious community, family, and peer groups play a critical role in reinforcing and shaping attachment to God and the theological virtues that reflect this. Attachment to God also gives rise to private religious practices, religious experiences, and to religious coping behaviors in response to life stressors. Private religious activities include prayer, meditation, scripture reading, listening to religious radio, or watching religious TV. This entire set of practices and beliefs when systematized within a community we call “religion,” although at the individual level it can also be described as “spirituality” (R/​S; see Chapter 1). According to this model, R/​ S influences a set of mediating psychological, social, and

Genetics, Developmental Experiences, Personality

FIGURE 31.1.  Theoretical model of causal pathways to physical health for monotheistic religions (Christianity, Islam, Judaism) (prac, rit =​practice, rituals; R =​Religious). 616 •  E xplanator y M echanisms

behavioral factors, which to some extent also influence R/​ S. We divide psychological and social factors into human virtues, positive and negative emotions, and social connections. Human virtues (or positive psychological traits) include forgiveness, honesty, courage, self-​discipline, altruism, humility, gratefulness, patience, and dependability, as well as dispositions to act with love and kindness. As argued in Chapter 1 on definitions, we view these constructs as separate from the construct of R/​S itself. Instead, we consider them an outcome of R/​S, although not exclusively so, since these virtues clearly have secular sources as well. In common Christian understanding, the human virtues and the positive emotions that result from them are considered the “fruits of the spirit” (Galatians 5:22–​ 23). We emphasize, though, that these fruits are distinct from the Spirit itself, which may be the source of them. R/​ S may also indirectly generate positive emotions, counter negative emotions, and/​or promote stronger social connections through the endorsement of the human virtues. In this model, positive emotions refer to peacefulness, harmony, a sense of existential well-​ being, happiness, hope, optimism, meaning, and purpose. All of these are viewed as indicators of the positive side of mental health. In order to study the effects of positive emotions on health, an entire field has developed over the past two decades called “Positive Psychology.” In contrast to emotions representing the positive side of mental health, negative emotions and emotional disorders reflect the dark side. Examples of negative emotions, as noted earlier, include depression, low self-​esteem, self-​ condemnation, anxiety, fear, restlessness, loss of control, alcohol and drug abuse/​dependence. Besides the indirect influences of R/​S on positive and negative emotions through the human virtues, R/​S may also directly influence mental health (see arrows going directly from R/​S to those constructs in the model in Figure 31.1). In other words, R/​S involvement may itself directly increase well-​being, happiness, meaning and purpose, hope and optimism, as well as reduce depression, anxiety, emotional distress, and substance use/​abuse, rather than doing so indirectly through the human virtues or other positive psychological traits.

Finally, positive social connections at the individual level involve perceptions of social support from relationships with family, friends, and other members of one’s community. Negative social connections, in turn, involve conflicts with family or peer group members, and may include antisocial behaviors such as delinquency and crime. At the community level, positive social connections involve healthy interactions among community members more generally, a level of trust between members, the provision of goods and support to one another, and active participation in prosocial community organizations. The overall level of such involvement often reflects the health of the community and, as noted earlier, is called social capital. Negative social connections at the community level are characterized by the opposite, i.e., low participation in community groups, distrust and fear of other group members, and high levels of conflict in terms of making community-​ level decisions. An example is the 2020–​2022 riots and destruction of community property and businesses in the United States and elsewhere in the name of social justice. Religious groups can directly and indirectly affect positive social connections at both the individual and community level by increasing religious social support and providing community enriching activities (e.g., opportunities to volunteer to help others, operate ministries for the homeless, run soup kitchens, provide jobs). Of course, in some cases, religion may also give rise to negative social interactions at the individual and community levels that have adverse health consequences (e.g., exclusion or persecution of certain groups, terrorism, and the like). Besides acting through psychological and social pathways, R/​S may also influence physical health through personal choices that affect health behaviors and health maintenance activities (medical care seeking, engagement in disease-​ screening activities, compliance with treatments). For example, decisions to engage in risky sexual activities will increase the risk of HIV/​AIDS, genital herpes, gonorrhea, syphilis, and the development of cervical cancer (through transmission of the human papillomavirus). Likewise, the decision to smoke cigarettes increases the risk of developing lung and other cancers, chronic lung disease, The Religion–Physical Health Relationship • 617

hypertension, stroke, coronary artery disease, and a host of other medical conditions (for both the person smoking and others in their environment who are exposed to secondhand smoke). Choices to not exercise, not eat a healthy diet, ignore weight gain, or ignore high cholesterol levels increase the risk of cardiovascular disease, some cancers, and other acute and chronic conditions. Health-​related decisions include choices having to do with getting adequate sleep at night, driving the speed limit, not drinking alcohol or using drugs while driving, and abiding by other rules and laws established by society. Each of these choices has physical health consequences. Individual choices of this type are often influenced by human virtues or character traits, which are themselves often promoted by religion. At the next level in this model, positive emotions, negative emotions, and social connections influence physiological functions (cardiovascular, immune, endocrine, central and autonomic nervous systems) that determine physical health and longevity. As described above and reviewed in Chapters 20–​25, emotional and social factors affect these biological systems in part through the fight-​flight response, which activates the hypothalamic-​ pituitary-​ adrenal (HPA) axis. Activating or calming the cardiovascular immune, endocrine, and nervous system functions is central to how the body protects itself from disease, responds to injury, and recovers from these insults. The causal pathways explaining religiosity’s effects on health described above rest heavily on genetic factors, inherited temperament, and developmental experiences. Genetic predispositions may to some extent influence the development of human virtues and positive psychological traits, such as the ease by which a person forgives, acts in a courageous manner, is self-​ disciplined, or demonstrates patience with others. Developmental factors (experiences during infancy, early childrearing practices, experiences at school, and later events during adult life) contribute to the formation of personality and enduring character traits. Genetic and developmental factors also influence personal choices that affect engagement in health behaviors, disease-​prevention activities, and compliance with recommended 618 •  E xplanator y M echanisms

treatments. Likewise, sociability, positive emotions, and susceptibility to depression, anxiety, or substance abuse disorders are influenced by genetic and developmental factors. Genes also affect nervous system, immune, endocrine, and cardiovascular functions, and thereby contribute to the development of physical disease and influence longevity. Seldom considered, however, is the effect that genes may have on the development of religious beliefs, practices, and commitments themselves through inherited temperament. These include traits such as being social or extroverted (and therefore feeling more comfortable in religious community settings), conscientious (more able to abide by religious ethical and moral standards), or neurotic (anxious and fearful in ways that drive the use of religion to cope) (see Chapter 11). Developmental factors also play a role in making individuals more or less likely to be religious through traumatic life experiences and influences by parents, teachers, and peers in religious and nonreligious settings. Genetic and developmental influences, then, have a considerable influence on each of the causal pathways leading from religion to physical health, thus adding further complexity to the R/​S –​physical health relationship (not to mention the possibility of reverse causation in pathways throughout the model). In considering the health benefits that originate in the “source” (attachment to God), we acknowledge that such attachments may be negative or positive. Negative attachments would be expected to adversely affect health. In other words, a relationship with God that is full of conflict and disharmony, based on judgment and persecution rather than love, mercy, and understanding, could lead to poorer mental, social, and physical health. This is not to ignore the benefits to health that working through religious or spiritual struggles may ultimately produce. Indeed, such struggles are often at the heart of spiritual growth. However, being “stuck” in such struggles has been shown to predict worse outcomes in almost every aspect of health (see Chapter 4, which addresses negative R/​S coping). Finally, the model described above is not a static one, but rather is constantly changing as individuals learn from and respond to life experiences. Age, gender, education, socioeconomic

status, location of residence (inner city vs. rural vs. suburb), access to healthcare, and many other factors also influence physical health and so complicate the relationship between R/​S and health. Thus, it is clear that the ways in which R/​ S influences physical health are complex, intricate, and interrelated, whether considered at one point in time or across time. This makes it impossible for anyone to make judgments, as some are prone to do, about why someone has become sick. Thus, even from a religious perspective, one cannot conclude that a person’s illness is the result of not being religious enough, not having prayed enough, not having gone to religious services enough, or not having developed a strong enough faith or attachment to God. Sometimes, perhaps often, it is the physical illness or disability itself that drives a person into a closer relationship with God or strengthens their faith above and beyond that of the healthy person. Clearly, physical health can also influence religiosity, as well as other psychological and social aspects of life, though,

Eastern Model Figure 31.2 presents a model of R/​S and health based on an Eastern religious worldview. This model is exactly the same as the monotheistic

Decisions, Health Behaviors, Health Maintenance, Screening, Compliance Secular Sources

Public prac, rit

Private prac, rit Dharma Four Noble Truths

SOURCE Brahman/Supreme God, Buddha, Ultimate Reality

R commitment

R experiences

Positive Emotions (purpose and meaning optimism, hope, well-being, happiness)

Human Virtues Forgiveness Honesty Self-discipline Altruism Generosity Humility Gratefulness Patience Dependability

Social Connections

Negative Emotions Peer influences, education and training

R coping

(depression, anxiety, substance abuse)

Physical Health and Longevity

Religious community

Nervous System, Immune, Endocrine, and Cardiovascular Functions

Religion/Spirituality

for simplicity, we have not represented these other influences in the diagram in Figure 31.1. Thus, while R/​S factors may influence physical health and longevity, they do so within a context dominated by factors that have little to do with religion and are not within a person’s control. Perhaps this is why relationships between R/​S and health at the individual level (which appear generally positive) stand in stark contrast to those at the state or country level, where researchers find that the highly religious regions of the world often have the highest rates of physical illness and disease (which may increase religiosity), whereas the least religious populations at the state or country level often have the lowest illness and disease (reflecting less need for religion).

Genetics, Developmental Experiences, Personality

FIGURE 31.2.  Theoretical model of causal pathways to physical health for Eastern monotheistic/​ polytheistic, pantheistic, and non-​theistic religions (Hinduism, Buddhism, Taoism) (prac, rit =​practice, rituals; R =​Religious). The Religion–Physical Health Relationship • 619

model, except that in Hinduism the “source” is Brahman—​the Supreme God—​and other lesser gods that represent aspects of the Supreme God (Koenig, 2017e). Brahma, Vishnu, and Shiva form a triumvirate of the Supreme God responsible for the creation (Brahma), upkeep or preservation of the world (Vishnu), and destroyer and recreator (Shiva) of the world (the “Hindu trinity”). Depending on the particular philosophical school, Brahman may be viewed as transpersonal, personal, or impersonal. Brodd (2003) describes Brahman in pantheistic terms as the eternal, unchanging, infinite, immanent, and transcendent reality, which is the Divine Ground of all matter, energy, time, space, and being (i.e., the universe and everything beyond). In addition to representing aspects of the one Supreme God (e.g., Brahma, Vishnu, and Shiva), lesser gods in Hinduism may sometimes be considered manifestations of experience or being, rather than truly distinct “gods,” although this may vary. As a result, Hinduism has sometimes been referred to as polytheistic monotheism (Chidananda, 2002). In Hinduism, and also in Buddhism to some extent since Buddhism emerged out of Hinduism, there is an end to the spiritual journey that follows several rebirths. This end occurs with realization of the connection between the true self (atman) and the Supreme God, thereby achieving unity with God or reaching Enlightenment/​Nirvana, the true refuge from all suffering (Verma, 2009). In Buddhism, the “source” is the Buddha or the Buddha’s teachings (the Dharma or Dhamma). Ultimate Reality refers to the cause of all existence, ground of being, and foundation of reality (similar to Brahman, the Supreme God in Hinduism). Within Buddhism, variations of the Eastern model might be proposed, depending on the degree to which individuals orient themselves toward the concept of Buddha as a Divine Being to whom they can relate or pray. Certain divisions of Buddhism (Theravada) do not emphasize or even believe in divine beings, while other divisions such as Mahayana Buddhism view the Buddha as an omnipotent divinity with supernatural qualities and as the foundation of all that exists (similar to God in monotheistic traditions or Brahman in Hinduism). In actuality, the lines 620 •  E xplanator y M echanisms

are even more blurred. For example, in Zen Buddhism (very much a part of Mahayana Buddhism), the Buddha would generally not be viewed as the transcendent God, but as a historically revered figure, whereas in Thai Theravada Buddhism, images of the Buddha as God are pervasive, and are worshiped, prayed to, and venerated. In Buddhism there is no creator God, at least in the sense in which Christians, Jews, or Muslims would describe God, i.e., one who created the universe and lies outside of or beyond the created order (Koenig, 2017f). Dharma, a central concept in both Hinduism and Buddhism, replaces faith, hope, and love of God in the model, and instead represents a way of life (some translations define Dharma as “that which upholds or supports” and other translations as “one’s righteous duty”) (Brodd, 2003). Individuals whose lives are guided by the Dharma are thought to progress more rapidly toward nirvana (self-​liberation, or becoming one with Brahman/​ God). In Buddhism (Theravada Buddhism, in particular), the Four Noble Truths provide the philosophical basis for right living and the Eightfold Path. The Four Noble Truths are: (1) there is suffering; (2) there is a cause of suffering (craving or desire); (3) there is the cessation of suffering (nirvana); and (4) the Eightfold Path leads to a cessation of suffering and to nirvana. The Eightfold Path consists of (1) right view, (2) right intention, (3) right speech, (4) right action, (5) right livelihood, (6) right effort, (7) right mindfulness, and (8) right concentration. Nirvana in Buddhism literally means “blowing out,” i.e., blowing out the fires of greed, hatred, and delusion, and thus the attainment of supreme happiness or Enlightenment (Gombrich, 1988). Similar beliefs are present in the Chinese religions, particularly Confucianism and Taoism, where the Tao (the “way” or “path”) precedes and encompasses the universe. The Tao can be known and its principles followed, although the Tao is rarely worshiped and is roughly equivalent to the Hindu concept of Dharma. These Eastern religious beliefs give rise to public and private religious practices, religious commitments, religious experiences (merging with the Supreme God or the universe and beyond), and ways of coping with stress, loss, and suffering. They also promote positive

human virtues or psychological traits and affect health behaviors, thereby indirectly affecting emotional and social health. Eastern religious beliefs and practices also have direct influences on emotional and social health, as do Western religious beliefs. Direct and indirect effects on psychological, social, and behavioral factors, then, lead to healthier physiological functions, better physical health, and greater longevity. Again, genetic, developmental, and background socioeconomic factors influence these relationships, as in monotheistic religions. In both the monotheistic and Eastern models presented here, consistent with our definitions in Chapter 1 and throughout this Handbook, we treat religion and spirituality as closely related terms. Justification for viewing these terms as largely synonymous, however, may not be as strong in Eastern religions as it is in monotheistic traditions. This may be the case in certain forms of Buddhism where some definitions of the transcendent may not involve a divine being. This gives rise to a religion that lies on a continuum with philosophy (especially in theory, although less so in practice),

and may fit better into a broader term such as “spirituality.”

Secular Humanism Finally, we model plausible causal pathways by which secular or atheistic belief systems might impact physical health (Figure 31.3), again largely following the model described earlier for monotheistic and Eastern religions. Secular humanism rejects the supernatural and any R/​S beliefs or practices related to the Divine. However, adherents may believe just as strongly as R/​S people (or more strongly) in humanistic doctrines, so in many ways secular humanism represents a kind of R/​S worldview or at least a firmly held philosophical worldview. This perspective sees the human self and community as the primary “source” of health, thereby taking the place of God in Western religions (and the equivalent of God in Eastern religions). Secular humanism depends on human reason, science, and laws of nature that can be objectively observed, studied, and understood, though such values and pathways

Decisions, Health Behaviors, Health Maintenance, Screening, Compliance

This life

Ethics

Human Virtues Forgiveness Honesty Self-discipline Altruism Generosity Humility Gratefulness Patience Dependability

Social Connections

Negative Emotions Peer influences, education and training

Justice

(depression, anxiety, substance abuse)

Nervous System, Immune, Endocrine, and Cardiovascular Functions

Reason, Science

Self and Community

(purpose and meaning optimism, hope, well-being, happiness)

Physical Health and Longevity

Search for truth

SOURCE

Positive Emotions

Public good

Secular community

Genetics, Developmental Experiences, Personality

FIGURE 31.3.  Theoretical model of causal pathways to physical health for secular humanism. The Religion–Physical Health Relationship • 621

are also operative for religious individuals as well. This gives rise to an emphasis on ethics, justice, the public good, a search for truth, and a focus on life in the here and now. The humanistic worldview likewise both directly and indirectly affects positive emotions and social connections through influences on human virtues or positive psychological traits, individual choices, and health behaviors. Positive emotions and social connections, then, affect physical health and longevity, just as in the models we presented for monotheistic and Eastern religions. Genetic and developmental factors would also be expected to influence these possible causal pathways, again just as they affect those described for monotheistic and Eastern religious traditions. One difference between R/​ S and secular models, however, may be the latter’s even greater emphasis on science and scientific medicine, which could lead to greater disease-​ prevention activities (seeking regular medical care, immunizations, screening, etc.) and perhaps better health behaviors, since the physical body may be all there is from some humanistic perspectives. In some cases, secular humanists may also be better educated, come from a higher socioeconomic class, and therefore have better access to healthcare resources.

Summary We have proposed three theoretical causal models that help to explain how R/​S affects physical health from monotheistic perspectives, Eastern perspectives, and secular humanistic perspectives. Again, these are hypothetical models based on preliminary evidence from R/​S -​health research and other research, and will certainly need refinement (or perhaps be discarded entirely) as more is learned from future research. Nevertheless, these models provide a place to start in describing a reasonably coherent ration­ ale for why R/​S might affect physical health.

IMPORTANCE OF UNDERSTANDING MECHANISMS A better understanding of the pathways through which religion affects health has numerous 622 •  E xplanator y M echanisms

benefits. First, simply having a rational explanation for how religiosity affects health (other than by supernatural explanations for which any potential empirical evidence is both challenging and controversial) will encourage mainstream researchers in the social and behavioral sciences, and perhaps in medicine, nursing, social work, and public health, to study religious involvement alongside more traditional psychological, social, and behavioral influences on health. Furthermore, if a logical argument can be made for how religiosity affects health, then researchers will have more difficulty ignoring an activity in which 80% of the world’s population engages and a large proportion considers very important. In 2015, only 15% of 7.34 billion people were not affiliated with a religion, and even this percentage is projected to decline in future decades (Pew Research Center, 2017). Second, understanding how religion affects health may be useful in developing effective interventions that could help to prevent disease, maintain health, or speed recovery from illness. Interventions at the individual level and at the community level are important here. Bear in mind that from a policy perspective, one can in principle promote participation in religious community for those who already self-​identify with a religious tradition (VanderWeele et al., 2022) without necessarily introducing religion into people’s lives or trying to convert them (the fear of many critics). As noted above, the vast majority of people are already religious (at least in the US, Africa, South America, and the Middle East), report that religion is important in life, and use it to cope with physical and emotional problems (up to 98% in some regions; Scholte et al., 2004). Therefore, it is difficult to justify not developing religious or spiritual interventions compatible with a person’s faith tradition that could prevent disease or improve health. Many individuals might even prefer interventions sensitive to their faith tradition compared to standard treatments that largely ignore or discount R/​S beliefs and needs. However, this is not to say that developing or administering R/​ S interventions is easy. Religion is a sensitive area in most people’s lives, and abuses of such interventions through coercion (rather than gentle persuasion) are possible and must be avoided

in clinical settings, where the balance of power between patient and provider is an issue (Cohen et al., 2000). At the community level, faith-​based interventions in religious congregations may help to maintain member health. These are less controversial than interventions at the individual level. For example, nearly two-​thirds of the US population claim affiliation with a religious tradition, and almost half attend religious services at least monthly (Pew Research Center, 2019d). This is particularly true for minority populations where health disparities are most prominent in relation to disease identification and treatment. Rates of obesity, alcohol and drug abuse, hypertension and diabetes, stroke, and other physical and emotional disorders are now at epidemic levels in these populations. Minority populations often originate from areas of the world where religious and spiritual practices are common methods of healing, and are therefore quite receptive in this regard. Faith-​ based interventions in religious congregations have been shown to increase disease screening, improve immunization rates, increase exercise, improve diet, lower obesity, and increase access to healthcare (see Appendix). Unfortunately, few of these have received a rigorous evaluation of their cost and efficacy, limiting their use more generally. Finally, by better understanding the mechanisms by which religion affects physical health, we may learn something about how psychological, social, and behavioral factors influence health outcomes more generally. Such information might be immensely useful in developing secular interventions that could be applied community-​ wide, regardless of participants’ religiosity or lack thereof, to improve health at the population level. Thus, having a solid rationale for explaining how religion affects health has many practical benefits, including the possibility of improving the health of potentially billions of people and reducing healthcare costs.

RECOMMENDATIONS FOR FUTURE RESEARCH As indicated above, future research is needed to verify and refine the theoretical causal models

presented above, particularly those described for Eastern religions and secular humanism. Some preliminary longitudinal work examining several aspects of the monotheistic model has been carried out in HIV-​positive patients (Kudel et al., 2011). Similar research, potentially integrating evidence from many of the possible pathways, could be carried out in other studies and contexts. Recommendations for future research are divided into information needed and suggested research designs.

Information Needed Future research is needed to test the different pathways in these models to affirm or refute the associations and their causal direction, and also to examine what has been left out. It is possible that completely different frameworks for explaining the religion-​health relationship exist that might be more accurate than those presented here. Perhaps most controversial in the monotheistic models is the claim that the primary source for the effects of religion on physical health is attachment to God. To verify this, measures of attachment to God are needed, and some preliminary progress has been made in this regard. For example, Levin and Kaplan (2010) assess love of God using a 4-​ item subscale of a larger instrument. However, other aspects of this attachment (faith in God and hope in God) also need measuring. Likewise, Rosmarin and colleagues (2011a) have developed a 6-​item trust/​mistrust in God scale that could be used to assess attachment as well. There are also scales that measure anxiety and avoidance in this attachment relationship, including the 14-​item Attachment to God Scale (Rowatt & Kirkpatrick, 2002) and the 9-​item Attachment to God Inventory (Beck & McDonald, 2004). These are just a few initial steps in developing comprehensive measures to assess the quality of a person’s attachment to God, given its central place in the models above. More information is also needed on the roles that genetic factors and personality traits (based on temperament) play in the possible effects of religious involvement on positive character traits or human virtues and the mediating role they play through psychological, social, and behavioral pathways in the The Religion–Physical Health Relationship • 623

relationship between religion and physical health. Could certain personality traits (e.g., conscientiousness, extroversion) or inherited temperaments make religious people more dependable, reliable, compliant, sociable, or conservative in terms of risk-​taking? In that case, religious involvement would not by itself be the cause of greater dependability, sociability, or a healthier lifestyle, but instead would be markers for such traits. In other words, individuals with such inherited predispositions might be that way regardless of whether they are religious or not. If such effects could be explained in part or whole by common genetic influences (which would require further investigation), the next question would be how these genetic connections may have come about. What role did natural processes play in the selection of such genes? Even if genetic effects on temperament are responsible to some degree, religious beliefs and teachings may still help to foster the development of positive character traits, moral/​ ethical standards, and human values, making the sorting out of cause and effect quite challenging. These are difficult questions, and studies to definitively answer them have not yet been carried out. Gene-​environment interactions are also a promising area for study in efforts to explain how religiosity affects physical health, either through parental nurturing during early infancy (possibly through DNA methylation) or through religious experiences later in life that serve to turn genes on and off. Another interesting research direction involves examining the effects of chronic stress on cellular aging that cause changes in chromosomal structure. Such research has examined the effects of stress on the rate of telomere shortening. The telomere is a region of repetitive nucleotide sequences at the end of the chromosome, which protects the chromosome from deterioration when the cell divides. Telomere lengths shorten with aging until they reach a certain minimal length when the cell dies, thus representing a type of intracellular biological clock. Chronic psychological stress is known to increase systemic inflammation that speeds the rate at which telomeres shorten. This is yet another mechanism by which religious involvement, through its stress-​buffering effects, might affect the rate of 624 •  E xplanator y M echanisms

cellular aging and thereby improve health and extend longevity. At least three cross-​sectional studies have now reported a significant association between religiosity and a slower rate of telomere shortening (Koenig et al., 2016b; Hill et al., 2016b; Wang et al., 2020). However, longitudinal studies are lacking that could provide evidence for causation in these relationships (VanderWeele & Shields, 2016c). The opportunities are almost limitless for those wishing to invest their time, talents, and resources in studying these religion-​health mechanisms.

Research Designs Many different approaches are needed to test the theoretical causal models presented in this chapter. Qualitative, cross-​sectional, longitudinal, and experimental studies all have something to contribute. QUAL ITATIVE STUD IES

Qualitative studies can provide important information to confirm, reject, or modify these models since qualitative work provides in-​ depth information about individuals in specific circumstances, information that can then be used to design quantitative studies and interpret their findings. CROSS-​SECTION AL STUD IES

Cross-​ sectional research, while contributing limited evidence for causal inference, can provide information for describing patterns, distributions of religiosity and patterns and distributions of health, and their relationship to one another. P ROSP ECTIVE STUD IES

Large long-​term prospective studies, because of their ability to provide evidence toward causal inference, are greatly needed to assess the theoretical causal models proposed here. Ideally, these studies would comprehensively assess both religiosity and determinants of health at multiple time points, following individuals over long periods—​preferably across their life span. One might design such studies to test the

monotheistic model in countries where monotheism predominates and do likewise for the Eastern model in countries where Hinduism or Buddhism predominates. Also needed are large prospective studies in secular countries (such as northern Europe or China) that comprehensively assess different aspects of secular humanism as a predictor of effects on physical morbidity and mortality. While longitudinal studies often cannot definitively establish causality, they can provide evidence, and sometimes that evidence can be quite strong. When subjects are followed over time and there is information collected at three or more separate time points, then cross-​lagged analyses and other statistical techniques can help determine the order of effects and identify whether a predictor (religion) is having more of an influence on an outcome (health) than vice versa (VanderWeele, 2021b). The problem is that longitudinal studies cannot measure everything that affects the outcome, leaving the possibility that some unmeasured factor related to both the predictor and the outcome is actually responsible for the relationship. Nevertheless, for longitudinal studies where the data are rich (i.e., many subject characteristics are measured), the sample is large, the follow-​up period is sufficiently long, and information is collected at enough time points, new methods of analyzing longitudinal data have been developed that can model relationships over time. One of these newer techniques is inverse-​probability-​of-​treatment weighting and marginal structural modeling (Robins et al., 2000; VanderWeele et al. 2016a). When combined with “sensitivity analyses” (e.g., VanderWeele & Ding, 2017c), which assesses how strong unmeasured confounding would have to be in order to explain away effects, these methods may provide relatively strong evidence for causality. Studies using these approaches that examine numerous outcomes simultaneously (“outcome-​wide studies,” cf. VanderWeele, 2017c; VanderWeele et al., 2020b) can also more rapidly advance knowledge in this field (e.g., see Chen and VanderWeele, 2018; Pawlikowski et al., 2019; Chen et al., 2020a). Prospective studies of this type are likely to be expensive and require multi-​ generational teams of researchers given the length of follow-​ up required in order to assess the effects of

religiosity as an exposure across the life span. Of course, the ideal may or may not be possible given available resources. In the meantime, less definitive smaller-​scale prospective studies may contribute by examining one or more causal pathways described in the models above. When designing such studies, as noted earlier, it is important to assess the effects of a specific religion on physical health in regions where that religion predominates. However, studying the effects of religious involvement on physical health in countries where the religion examined is not the dominant one (e.g., Muslims in the US, Hindus in the Middle East, or secular humanists in Brazil) is also of interest but must be subject to careful interpretation because associations may arise principally from social and cultural pressures affecting health due to being in a minority group. The challenges involved in conducting and interpreting results from observational studies, even prospective studies, cannot be overemphasized. As noted earlier, religious characteristics and factors on the causal pathway between religiosity and physical morbidity/​ mortality almost certainly have bidirectional effects on one another, requiring that reverse-​causation be considered in the design of studies and in the analysis of results. Furthermore, such bidirectional effects are not static in nature, but may be constantly changing over time as individuals develop new experiences and mature across the life span in response to life stressors, including changes in physical health status. Historical and cultural factors will also affect the findings, and these may be difficult to measure. Teams of experienced investigators from various disciplines (anthropology, theology, sociology, psychology, medicine, public health) will likely be needed in order to carry out such research. EXP ERIM EN TAL STUD IES

As we have emphasized previously, the RCT is the strongest study design capable of determining causality, and so will be important for examining the models presented here. Several problems arise, however, when conducting clinical trials. First, they are difficult to conduct as originally designed because of compromises often made between the “ideal” and The Religion–Physical Health Relationship • 625

the “doable.” Second, restrictive inclusion and exclusion criteria for subject participation often limit the generalizability of findings to broader population groups. Third, randomizing certain exposures, such as beliefs, cannot be carried out, and randomizing other exposures may sometimes be considered unethical. Fourth, lack of long-​term follow-​up may be problematic when the effects of an intervention take many months or even years before becoming evident. These and other weaknesses of clinical trials, then, may limit their helpfulness. Longitudinal studies and RCTs may often complement one another. The novel statistical techniques described earlier for examining longitudinal data may assist in the design of both observational and experimental studies with the purpose of determining causality. For example, these methods for handling longitudinal data could help determine how long it might take for an R/​S intervention to reduce depression in order to improve immune or endocrine functions enough to affect a physical health outcome, thus influencing the timeline for the RCT. Many other examples of studies needed could be described (see Koenig, 2011a).

SUMMARY AND CONCLUSIONS This chapter began with a description of genetic, physiological/​medical, environmental,

626 •  E xplanator y M echanisms

psychological, social, and behavioral factors that affect physical health, each dependent to some extent on the individual choices that people make. This was followed by a brief summary of research documenting connections between religious involvement and these health determinants, largely referring to previous chapters in this Handbook. We then presented theoretical causal models based on monotheistic, Eastern, and secular humanistic worldviews in order to explain how religious involvement might affect physical health and longevity, acknowledging that these models are preliminary and will take further work to verify, refine, or refute. Suggestions for future research were then provided, emphasizing the need for large prospective studies that follow individuals for prolonged periods of time (preferably across the life span), examining the effects of religious involvement on physical health acting through the mediators described in these models. In the next and final section of the Handbook, we examine the implications that religion’s effects on health have for public health and health policy in the United States and other countries throughout the world. The challenge that faces all nations is a common one: to maintain the health of populations that are growing older with chronic illnesses that require healthcare at levels that will increasingly consume the economic resources of these countries and thereby affect their stability (economic, military, social, and political).

SECTION VIII Public Health and Health Policy IN THIS SECTION we examine the implications that research findings on religiosity and mental, social, behavioral, and physical health have for public health and health policy. As parts of the world become more secular and increasingly rely on scientific advancements and technology, religion increasingly becomes viewed as outdated and regressive, of little use to individuals and societies as they advance

into the future. The research on religion and health reviewed in this book, however, indicates something quite different. Indeed, the effects of religion on public health may be quite substantial and therefore under-appreciated. Healthcare policymakers must take this into account as they chart the best course for population health and well-​ being in the years ahead.

32 Public Health and Human Flourishing Every man must decide whether he will walk in the light of creative altruism or in the darkness of destructive selfishness. —​Martin Luther King, Jr.

IN THIS CHAPTER we examine the implications that research on religion and health has for public health and well-​being promotion, or, more generally, for human flourishing. In 1920, C. E. Winslow defined public health as “the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and prevention of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health” (Winslow, 1920, p. 30). Public health involves overall population health—​particularly physical health at the community level—​including systematized sanitation, food and water safety, protection from environmental toxins, and

early disease-​prevention and health-​promotion activities (e.g., through vaccinations, screening, public health campaigns). This has recently included support for equity in the social determinants of health such as education, housing, transportation, economic development, and access to healthy foods, with coordination at the local level (DeSalvo et al., 2017). The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-​being and not merely the absence of disease or infirmity” (WHO, 1946) which emphasizes psychological components as well. A proposal was submitted in 1998–​1999 to revise WHO’s definition of health by including spirituality in the preamble of the WHO’s charter. This revision of the definition of health was proposed at the 101st session of the WHO Executive Board by the WHO Regional Office for the Eastern Mediterranean (which included Islamic member countries). The proposed definition was as

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0032

follows: “Health is a dynamic state of complete physical, mental, spiritual, and social well-​ being and not merely the absence of disease or infirmity” (Nagase, 2012). However, this recommendation was never adopted by WHO and the word “spiritual” is not in the current definition. Human flourishing is a concept strongly related to public health, but takes it a step further. VanderWeele (2017a) defined human flourishing or complete human well-​ being as “a state in which all aspects of a person’s life are good,” and argued that, among other things, this requires “doing or being well in the following five broad domains of human life: (i) happiness and life satisfaction; (ii) health, both mental and physical; (iii) meaning and purpose; (iv) character and virtue; and (v) close social relationships” (VanderWeele, 2017a, p. 8149; also see VanderWeele, 2017b; VanderWeele et al., 2019). A sixth (vi) indicator of well-​being is having the financial and material stability that allows well-​being to be sustained over time. Human flourishing exists on both the individual level, i.e., complete well-​being as an individual reflected by the six flourishing indicators above, and on the population level, as a community composed of flourishing individuals, and as the community itself thriving as a community (VanderWeele, 2019b). “Optimal” public health might be conceived as human flourishing at the community level. In reviewing the literature on major determinants of flourishing, VanderWeele (2017a) argued that there was evidence that four major pathways were both (1) common and (2) had large effects on each of the flourishing outcomes. These four pathways were: family, education, work/​ employment, and the religious community. The list was in no way intended to be exhaustive of those factors that shape flourishing. Certain pathways or factors may shape one specific domain but have less effect on others. For example, good health behaviors shape physical and mental health but have less effect on other domains of flourishing. In this chapter we maintain that religious involvement contributes to optimum public health both by directly affecting (and being affected by) the six indicators of human

flourishing and by indirectly doing so through the four pathways described above (see Figure 32.1). First, before examining the impact of religion in these ways, we consider challenges that stand in the way of individual human flourishing and thereby negatively affect public health more generally.

CHALLENGES TO HUMAN FLOURISHING Many challenges exist when trying to maximize the well-​being of individuals and the well-​being of communities that they make up. As noted above, this means more than simply reducing physical illness and disease. The challenges include threats to each of the six human flourishing indicators: decreasing happiness and life satisfaction, loss of meaning and purpose in life, declining moral/​ethical values and behavior, increasing individualism (at the cost of close social relationships and interdependency), declining mental and physical health due in part to poor health behaviors and lack of attention to health promotion and disease detection, and finally, increasing threats to financial and material stability due to skyrocketing costs of healthcare and need for social control to keep people from harming one another. Challenges also include threats to the pathways that lead to human flourishing, such as decreasing marital and family stability, failure to complete education, problems obtaining high-​quality employment due to lack of education/​training and changing job opportunities, and reducing religious community activity due to declines in religious membership, affiliation, and attendance with secularization. We now examine each of these challenges below, first discussing those that impact the indicators of human flourishing themselves.

Happiness and Life Satisfaction There has been a small but steady decline in happiness in the United States, decreasing from 93.3% “rather happy” or “very happy” in 1998 to 91.1% in 2014 (World Values Survey, 2017). By 2017, the percentage of Americans indicating they were “happy” or “very happy” had dropped to 64%, a percentage that was

630 •  P ublic H ealth and H ealth P olic y

Direct Family

Happiness and Life Satisfaction

Meaning and Purpose Religious Involvement Indirect (beliefs, pray or meditate, scripture study, R volunteering, R commitment, and R coping)

Education Virtue and Character Work and Employment

Religious Community

Close Social Relationships

Human Flourishing and Optimal Public Health

Mental and Physical Health

Financial and Material Stability

FIGURE 32.1.  Theoretical model of religion’s effects on human flourishing and public health (R =​Religious).

lower than either India (72%) or even Ethiopia (71%) (Gallup International Poll, 2017). The United States is also ranked 15th among countries in terms of life satisfaction, despite having a gross domestic product (GDP) that is among the highest in the world (World Values Survey, 2017). On December 7, 2020, a new Gallup poll of the US population found that mental health was worse than it had been at any point in the past two decades (Brenan, 2020). In response to the question “How would you describe your own mental health or emotional well-​being at this time? Would you say it is excellent, good, only fair, or poor?” The percentage indicating “excellent” dropped from a high of 51% in 2004 to 34% in 2020, a 9% drop from 2019. When examining changes in subgroups of the population, the study found that Democrats and frequent church attendees showed the least change in mental health (actually a 4% increase among those attending services weekly or more often).

Meaning and Purpose Having meaning and purpose in life is a central component of human flourishing. However, as science and technology have become dominant sources of truth, especially in developed countries where most of the population have basic needs met, identifying the meaning and purpose of life has become difficult for many. From a purely scientific viewpoint, when discarding other sources of understanding, life has no ultimate meaning or purpose. Some view the evolution of the human animal species as merely the result of a random chance event in the universe during the infinity of time, not any kind of divine plan. At the top of Maslow’s hierarchy of needs, after biological, security, relationship, and self-​ esteem needs are met, is self-​actualization (Maslow, 1971). One of the major classes of needs pursued by self-​actualizing people is existential (“being needs”), which include seeking the meaning and purpose of life. Trouble finding meaning and purpose may be a problem both Public Health and Human Flourishing • 631

in the United States and in other developed countries as well, where material resources are plentiful while reasons for living may be in shorter supply. Indeed, research indicates that (in contrast to happiness), levels of meaning and purpose are lower in richer developed countries than in poorer developing countries (Diener et al., 2011).

Virtue and Character Another major challenge to human flourishing has been a decrease in emphasis on virtues and moral values within society, which not only adversely affects mental health and social relationships, but also has led to increasing delinquency and crime. DEC RE A S I N G VIRT UE S /​ MO RA L VA L U E S

There has been a gradual cultural shift in the United States and many other parts of the world, which has been in part due to increasing secularization, with a focus on technology and the sciences (see MacIntyre, 1984, for a historical description of this change from the Middle Ages onward). In a review of the content of American books, Kesebir and Kesebir (2012) found a decline in the use of moral terms such as “virtue,” “decency,” “and conscience,” as well as a 74% decline in virtue words such as “honesty,” “patience,” and “compassion.” Similarly, in an assessment of the cultural salience of morality during the twentieth century and beginning of the twenty-​first, Wheeler et al. (2019) found in a search of Google Book contents that there has been a change in the use of moral language involving harm (vs. compassion, caring, and kindness), fairness (justice, equality), ingroup (group loyalty/​self-​sacrifice vs. betrayal), authority, and purity, with an overall quantitative decrease in terms reflecting authority (r =​−0.37, p < 0.01), purity (r =​−0.88, p < 0.01), and overall morality (r =​−0.92). Similar methodology has been used to document the shift from “us” to “me” word frequencies in English-​language books between 1800 and 2000, reflecting a cultural movement from collectivist values to more individualistic ones (Greenfield, 2013). The

same has been found for Chinese-​ language books (Zeng & Greenfield, 2015). IN CREASIN G D EL IN QUEN CY

A lower emphasis on living a virtuous life, moral values, and character development by educational institutions, social media, and the entertainment industry may result in changes in juvenile delinquency and adult crime. In the United States, the overall juvenile arrest rates increased by 28% from 1970 to 2000 for all age groups, with arrests for serious violence peaking between 1990 and 2000 (Crowell et al., 2001; Lynch et al., 2012). However, rates seem to have fallen again since then. According to the US Office of Juvenile Justice and Delinquency Prevention (OJJDP), overall juvenile arrest rates declined steadily from mid-​1995 to 2015. Likewise, OJJDP reported that juvenile arrests declined from 2014 to 2018 by 8% for aggravated assault, 11% for robbery, and rates for burglary, larceny-​theft, and arson reached historic lows by the end of this period. However, arrests for murder increased by 21% between 2014 and 2018, and arrests for motor vehicle theft increased steadily in each year from 2013 to 2018 (Puzzanchera, 2018). Substantial increases in adolescent antisocial behavior were also observed in many Western countries between 1950 and 2000 during a time of dramatic change in family composition (increased divorce, fewer marriages, more single parent and step-​ parent households), parent work patterns (more mothers working at younger child ages, more dual-​earner families), and economic circumstances (increases in child poverty and income inequality) (Collishaw et al., 2012). The connection between these changing patterns in delinquency, family structure, work, and economic circumstances merits further study. IN CREASIN G AD ULT CRIM E

Rates of robbery, burglary, and motor vehicle theft in 17 large US cities generally rose from the 1960s to a peak in 1980, fell for a few years, and then increased to a second peak in the early 1990s, followed by a fall thereafter, with the national crime rate following a similar

632 •  P ublic H ealth and H ealth P olic y

pattern during this period (Rosenfeld et al., 2019). However, according to the US Bureau of Justice Statistics (2020), the violent crime rate in the United States had a net increase of 2% between 2014 and 2018; the murder rate had a net increase of 16% from 2014 to 2018; the rape rate rose every year from 2014 to 2018 with a net increase of 15%; and the aggravated assault rate increased 7.4% during this same period. During the coronavirus pandemic, from February to June 2020, residential burglary dropped by 20% and larceny and drug offenses decreased by 17%–​57% (reflecting quarantines, business closures, and reduced street activity) (Rosenfeld & Lopez, 2020). However, commercial burglaries rose by 200% during late May and early June 2020, likely due to property damage and looting at the beginning of protests against police, while homicides and aggravated assaults increased by 35%–​37% and robbery increased by 27%. Thus, while delinquency and crime rates have fluctuated in the United States depending on circumstances and societal trends, the rate is generally higher than in the 1960s. Increasing rates of delinquency and crime have in part been driven by school dropout rates, failure to obtain job training, increases in poverty, and likely poor supervision and monitoring due to the growing number of single-​parent households, where the parent must work to support the family.

Close Social Relationships A rise in self-​sufficiency and desire for independence in a number of developed countries has in recent years taken precedence over interdependence and close social relationships. This trend has been less apparent in developing countries where the organization of society has been and continues to be collectivistic, at least partly due to increased need for cooperation due to a lack of material resources. In societies where being independent is highly valued and material resources are plentiful, increasing individual independence may have also given rise to social unrest that has torn some communities apart. These are just general trends, however, since expressions of social unrest in recent years have been occurring in collectivistic societies as well.

IN D IVID UAL ISM VS. COL L ECTIVISM

When individualism reigns, the focus becomes the “I” rather than the “we.” Satisfying one’s own needs becomes a priority over meeting the needs of others, and there is less emphasis on working together in order to achieve common goals and meet common needs. This gives rise to competition over material resources. A priority is placed on fulfilling individual pleasures, needs, and at times neurotic needs for control and dominance over others. In collectivistic societies, as noted above, there is more interdependence that stresses the value of social harmony and importance of emotional support from close others. Free, independent, and individualistic societies represented in countries such as the United States may place less value on close interdependent relationships, thereby lowering the threshold for within-​ community violence and conflict. As an example, in an international study that examined human flourishing across a range of cultural settings (the United States, China, Sri Lanka, Cambodia, and Mexico), researchers found the lowest score on close social relationships were among respondents in the United States, which was explained by the researchers as due to the individualistic culture in the United States that has focused more on personal control and independence and less on social cooperation (Wȩziak-​Białowolska et al., 2019). Note, however, that the samples above were not representative of these countries’ populations and therefore may not be comparable to one another; nevertheless, a similar trend has been reported by others (Kitayama et al., 2010). SOCIAL UN REST

Recently, for good reasons, there has been an increasing demand for social justice, racial equality, and reformation of police policies in the United States. This has occurred concurrently with sharp divides on other social issues along political lines. Consequently, the United States and other developed countries such as the United Kingdom have seen rallies, protests, and demonstrations, which while largely peaceful, have also been associated at times with violence, assault, and destruction of property (Marier & Fridell, Public Health and Human Flourishing • 633

2020; Ives & Lewis, 2020). Social unrest, as noted earlier, has not been limited to individualistic societies, since this has also occurred in countries where societies are more collectivistic, such as in Iran, other countries in the Middle East (the “Arab spring”), and China (e.g., Hong Kong), due to oppressive governments and low standards of living. The decline in close social relationships probably contributes to such unrest. G EOP O L I TI CA L CONFLICTS

War and armed conflict have threated public health and human flourishing since the dawn of civilization and before that as well (Cummins, 2010). Even today, the world is under constant threat as nations arm themselves in a race for dominance and control, spending billions of dollars for this purpose, resources that could be spent on advancing human flourishing. This represents a challenge not only to the achievement of individual and societal well-​being, but to the very existence of the human race itself.

Mental and Physical Health Challenges with regard to mental health include increasing rates of depression, suicide, alcohol and drug use disorders, stress, worry, and feelings of anger and hostility toward others. As populations age in the United States and around the world due to rapid advances in medical care, chronic physical health problems associated with disability and dependency have been rapidly increasing. Mental and physical health problems are often due to inability to cope with life stressors, chronic illness, poor health behaviors, and lack of attending to preventing disease, detecting it early, and complying with recommended treatments. I NC RE A S I N G RAT E S OF DE PRE S S ION

There has been a steady increase during the past several decades in rates of depression in the United States and northern Europe, enough to be called “an epidemic of depression” (Hidaka, 2012). This has been explained by increasing rates of chronic disease, declining social capital, increasing inequality, growing loneliness and social isolation, and changing health behaviors

(e.g., overeating, lack of healthy nutrition, decreased physical activity, sleep deprivation). Increasing rates of depression have been seen not only in adults but also in adolescents and teenagers, particularly young girls (Skovlund et al., 2017; Pew Research Center, 2019c). The Pew Research Center (2019c) recently reported a 59% increase in past-​year major depressive disorders from 2007 to 2017 among teens age 12–​17 in the United States, with a 66% increase in teenage girls based on the 2017 US National Survey on Drug Use and Health. IN CREASIN G RATES OF SUICID E

As indicated in Chapter 7, the suicide rate in the United States has been rapidly increasing. Between 1999 and 2017, rates of completed suicide increased 33% from 10.5/​100,000 to 14.0/​100,000, with the greatest increase coming between 2006 and 2017 (Hedegaard et al., 2018). Age-​adjusted suicide rates grew more rapidly in women than in men, with the incidence in women increasing from 4.0/​100,000 to 6.1/​100,000 (52.5%) from 1999 to 2017, compared to 17.8/​100,000 to 22.4/​100,000 (25.8%) in men. Similar to the increase in depression, age-​cohort-​adjusted suicide rates among young persons age 10–​1 9 increased overall from 4.9/​100,000 to 8.7/​100,000 (78%) from 1999 to 2017, while adjusted rates changed in females from 1.7/​100,000 to 4.2/​100,000 (a 147% increase) during this period (Yu & Chen, 2019). Changes in suicidal thoughts, attempts, and completions in US adolescents have been partly attributed to time spent on social media and electronic devices such as smartphones, compared to time spent by adolescents on non-​screen activities such as in-​person social interaction, sports/​exercise, homework, print media, or attending religious services (Twenge et al., 2018). Suicide rates have also been increasing among young people in United Kingdom (Bould et al., 2019) and Australia (Stefanac et al., 2019). IN CREASIN G SUBSTAN CE USE D ISORD ERS

Alcohol use disorders are now among the most prevalent of all mental disorders worldwide,

634 •  P ublic H ealth and H ealth P olic y

affecting nearly 10% of men and 2% of women, with the highest prevalence in high-​ income and middle-​income countries (Carvalho et al., 2019). Cannabis use and cannabis use disorder increased between 2002 and 2012–​2013 in US adults, especially in men, Blacks, low-​ income groups, never-​ married, urban residents, young adults, and older and non-​W hite adolescents (Hasin et al., 2019). Between 1980 and 2014, mortality rates from drug use disorders climbed nationally in the United States, with increases varying by county from 8% to 8,370% (Dwyer-​Lidgren et al., 2018). In particular, opioid-​related deaths soared more than 4-​fold in the United States between 1999 and 2016 from 2.9/​100,000 to 13.2/​100,000 (Jalal et al., 2018). I N C RE A S I N G S T RE S S AND ANG E R

As noted in Chapter 4, over half of Americans (55%) in 2018 indicated they experienced stress during “a lot of the day” (vs. 44% in 2008), nearly half (45%) said they “worried a lot” (vs. 34% in 2008), and more than one in five (22%) reported they “felt angry a lot” (vs. 16% in 2008) (Gallup Poll, 2019a). I N C RE A S I N G CHRONIC ILLNE S S

A chronic illness is considered to be “a physical or mental health condition that lasts more than one year and causes functional restrictions or requires ongoing monitoring or treatment” (Buttorff et al., 2017, p. 1). In 2014, 60% of Americans had at least one of these conditions (Buttorff et al., 2017). Increasing rates of chronic illness due to poor health behaviors is a particular problem in developed countries such as the United States where only 12% of the population is considered metabolically healthy (Araújo et al., 2019). P O O R H E A LTH B E HAV IORS

As noted in Chapter 31, more than 80% of chronic health conditions could be eliminated by healthy eating habits, engaging in regular exercise, maintaining an ideal body weight, preserving emotional resilience, and avoiding cigarette smoking, which could reduce premature

mortality in the United States by 40% (Onge & Krueger, 2017). In addition to not smoking cigarettes, exercising regularly, eating a healthy diet, controlling weight, and paying attention to mental health, healthy behaviors include safe sexual practices, avoiding alcohol or drug use when driving, obeying driver safety laws, and avoiding high-​risk recreational activities. Cigarette smoking remains a problem in the United States and around the world. As noted in Chapter 17, between 16% and 19% of Americans smoke cigarettes, and there are over 1 billion persons worldwide who smoke. As reviewed in Chapter 18, despite the indisputable health benefits of physical activity and exercise, the United States has one of the highest physical inactivity rates in the world, with nearly 40% of the population having this problem. Many other countries in South America (e.g., Brazil, Columbia, Argentina), the Middle East (e.g., Saudi Arabia, Iraq, United Arab Emirates), and some European countries (e.g., Portugal, Italy, Germany) have physical inactivity rates that exceed 40%. The result of physical inactivity and lack of attention to diet is weight gain. As noted in Chapter 19, there is an epidemic of obesity occurring in the United States and many other developed countries as well. The prevalence of obesity in the United States increased from 33.7% in adults age 20 or older in 2007–​2008 to 39.6% in 2015–​2016, and among Hispanics and African Americans the prevalence reached nearly 50%. P OOR AD H EREN CE TO D ISEASE P REVEN TION /​D ETECTION

The importance of disease prevention and early detection has been a special emphasis of health-​ promotion efforts since the 1960s (Wilson & Jungner, 1968). This has been particularly true for cancer, infections, cardiovascular diseases (hypertension, coronary artery disease, diabetes, hypercholesterolemia), iron deficiency anemia, thyroid disease, visual problems (glaucoma), and hearing problems (Croswell et al., 2010; Adini et al., 2019; Celermajer et al., 2012). Early detection and treatment of illness are crucial for maintaining individual and public health. For example, during the coronavirus pandemic, by the end of July 2022 more Public Health and Human Flourishing • 635

Americans had died from COVID-​19 (over 1 million) than the combined death toll incurred during the past five wars in which the United States was involved (Yan, 2020). Many are not aware of the importance of vaccinations, disease screening tests, and the need for regular medical care in order to maintain health and prevent disease, underscoring the importance of health education.

Financial and Material Stability A major threat to both individual-​and population-​level financial stability is (1) the rising cost of healthcare and (2) the rising costs of social control. R I S I N G C O STS OF HE ALT HCARE

Not counting the effects of the COVID-​19 pandemic, national health spending was projected to increase at an average annual rate of 5.4% from 2019 to 2028, reaching a total of $6.2 trillion in 2028 (CMS, 2020a). The share of the economy (GDP) spent on healthcare is expected to increase from 17.7% in 2018 to 19.7% by 2028. Medicare spending is expected to grow the fastest, at 7.6% per year, with enrollment reaching 75 million by 2028 with cost estimates nearing $1.5 trillion. At the same time, Medicaid spending is expected to reach close to $1.0 trillion per year, private health insurance close to $1.9 trillion, and out-​of-​pocket costs around $0.6 trillion (CMS, 2020b). These healthcare costs are threatening to bankrupt the United States, as well as many other countries worldwide. In 2016, the world spent $7.5 trillion on health, with an average expenditure of $1,000 per person annually (Xu et al., 2018). Half of the world’s countries, however, spend less than $350 per person annually. Based on an analysis conducted nearly a decade ago, the Milken Institute estimated that a modest reduction in risk factors for chronic illness in the United States could lead to a savings of more than $1 trillion annually in labor supply and efficiency (National Prevention Council, 2011). The CDC’s National Center for Chronic Disease Prevention and Health Promotion notes that “90% of the nation’s $3.5 trillion in annual healthcare expenditures are for people with chronic and

mental health conditions” (NCCDPHP, 2020). Many of these are preventable. RISIN G COSTS FOR SOCIAL CON TROL

The costs of maintaining law enforcement (police), courts, jails and prisons, probation and parole, juvenile detention and commitment, juvenile supervision, and criminal justice programs are increasing rapidly due to rising rates of delinquency, crime, and drug abuse as the size of the US populations grows. In 2016, the United States spent $300 billion for this purpose, of which $142.5 billion was spent on law enforcement, $88.5 billion on operating the nation’s prisons, jails, and parole and probation systems, and $64.7 billion on the judicial and legal systems (Hays, 2020). If the costs of incarceration due to lost earnings, adverse health effects, and problems experienced by family members are included, the amount is estimated to approximate $1.2 trillion per year (Hays, 2020), more than 6% of GDP. Other estimates for the average annual cost of law enforcement and its consequences in the United States range from $690 billion to $3.4 trillion (GAO, 2017). Over the past 40 years, the prison population in the United States has grown 7-​fold, and there is no indication of slowing (Pettus-​Davis et al., 2016). Future costs are difficult to estimate, but one thing is sure—​they are not going down.

CHALLENGES TO FLOURISHING PATHWAYS Besides threats to the six main indicators of human flourishing above, there are also many challenges that influence the four major pathways to flourishing (VanderWeele, 2017a).

Family The importance and value of the family is decreasing, especially in developed countries but also in underdeveloped regions as well. D ECREASIN G M ARITAL STABIL ITY

The marriage rate in the United States fell by almost 50% between 1972 and 2018, when it was at its lowest point in recorded history, reflecting

636 •  P ublic H ealth and H ealth P olic y

a similar pattern found in many other countries worldwide (Ortiz-​ Ospina & Roser, 2020). As noted in Chapter 14, the probability of a first marriage ending in divorce in the United States increased from about 20% in 1960 to 45%–​55% in 2016 (Hendi, 2019). The United States is not alone in this regard. In the four decades between 1970 and 2008, the annual divorce rate more than doubled globally, from 2.6 divorces per 1,000 married individuals to 5.5 divorces per 1,000 (DePaulo, 2019). Although divorce rates in the United States in recent years appear to be decreasing, this may be due to the fact that couples now simply live together instead of marrying, and those individuals who do marry are less likely to become divorced (Steverman, 2018). Among US adults age 18–​24, the cohabitation rate between 1968 and 2018 increased over 90-​fold from 0.1% to 9.4% (Gurrentz, 2018). In contrast, the rate of living with a marriage partner for adults age 18–​24 decreased from 39.2% to 7.3% between 1968 and 2018. This means that there are more couples in the United States age 18–​24 now cohabitating together than are living with a marriage partner (9.4% vs. 7.3%). When unmarried cohabitating couples split, this is not included in divorce statistics. I N C RE A S I N G S ING LE -​PARE NT H O U SE H O L D S

As a result of the above trends, more and more children in the United States are being born outside of marriage. The rate of non-​wedlock births increased from about 5% in 1960 to over 40% in 2014 (Ortiz-​Ospina & Roser, 2020), resulting in an increase in single-​parent households from about 5% to nearly 10% in 2010. As a result, more than one-​third of US children in 2018 lived in single-​parent households (Population Reference Bureau, 2020). Children in single-​parent households have worse physical health, emotional health, and school performance compared to those in two-​ parent households (Wilcox, 2011; Anderson, 2014; VanderWeele, 2017a).

Education Completing one’s education (high school minimally, college preferred) is essential for

obtaining a good job in the workforce (Baum et al., 2010). The average US public high school graduation rate improved from 79% in 2010–​ 2011 to 85% in 2017–​2018; however, graduation rates in Hispanics (81%) and Blacks (79%) in 2017–​2018 were lower compared to those in Whites (89%) (NCES, 2020a). In 2017, 67% of high school graduates enrolled in a university or college, a percentage that was not measurably different when compared to 2000 or 2010; again, however, Hispanics (61%) and Blacks (59%) had lower enrollment rates than Whites (69%) in 2017 (NCE2019aS, ). The 6-​ year graduation rate for undergraduate students at 4-​year US universities and colleges for those starting in 2011 and completing by 2017 was 60%, again with significant differences by race: 52% for Hispanics, 40% for Blacks, 63% for Whites, and 71% for Asians (NCE2019bS, ). Thus, there is certainly room for improvement.

Work and Employment With good education comes a greater likelihood of obtaining a high-​quality job that will enable an individual to live in a safe neighborhood and obtain good health insurance. With the recent coronavirus pandemic, the unemployment rate in the United States reached a peak of nearly 15% in May 2020, with some improvement as the economy reopened (9% in August 2020) (Bureau of Labor Statistics, 2020). Prior to that, the unemployment rate hovered around 4% or below during a time of unprecedented economic growth (Bureau of Labor Statistics, 2019). However, as the unemployment rate increases, the competition for jobs also increases, with those having a better education often being more competitive for such positions. Individuals who are more responsible, dependable, and who interact more positively with co-​workers are more likely to keep their jobs, regardless of economic environment. Worldwide for comparison, the unemployment rate in other advanced economies was estimated at 8% for 2020; no estimates were provided for non-​advanced economies (IMF, 2020). Being unemployed will undoubtedly adversely affect an individual’s potential for human flourishing across multiple domains. Public Health and Human Flourishing • 637

Religious Community Church and religious membership has been declining over the past 90 years in the United States as indicated by the Gallup Poll, which began tracking such religious involvement in 1938 (Gallup Poll, 2019b). In 1938, 73% of Americans were members of a church, compared to 50% in 2018. While only 1% indicated no religious affiliation in 1950, by 2019 that percentage had increased to 21% (Gallup Poll, 2020). A similar trend has occurred for attendance at religious services, although not as dramatic, and principally more recent. In 1992, 40% of Americans had attended a church or synagogue in the last seven days, while in 2019, only 34% had done so (Gallup Poll, 2020). These trends reflect a decline in the importance of religion among Americans, with those indicating it was “very important” decreasing from 58% in 1993 to 49% in 2019 (Gallup Poll, 2020). Assuming that the meaning of “religion” to Americans was the same at both time points (and not simply referring to institutional religion), these trends reflect increasing secularization (Voas & Chaves, 2018). In summary, while the pursuit of human flourishing that reflects optimal personal and public health is a worthy goal, the fact is that many challenges stand in the way of achieving it. The question we now address is whether religious involvement can directly enhance indicators of human flourishing and/​ or affect it indirectly through the pathways described above.

religion through the four pathways to flourishing (Figure 32.1).

Direct Effects Religion may directly affect each of the six indicators of human flourishing by its impact on happiness/​ life satisfaction, meaning and purpose, virtue and character, close social relationships, mental and physical health, and financial/​material stability. H AP P IN ESS AN D L IF E SATISFACTION

Religiosity has consistently been associated with more positive emotions, as well as higher psychological well-​being, satisfaction with life, and overall happiness (Chapter 12), which are among the most important indicators of human flourishing. These relationships are not as evident at the country level in certain regions of the world such as northern Europe, which have some of the highest happiness and life satisfaction ratings and yet are also some of the world’s least religious countries. However, in many cases it is economic development that leads to a loss of religiosity, rather than religiosity leading to less happiness. Morever, the social and healthcare systems present in these countries to which this happiness has been linked are based on religious principles that were established at a time in history when these countries were quite religious. Furthermore, as noted previously, care must be taken when generalizing relationships found at the country level to those on the individual level in order to avoid the “ecological fallacy.”

RELIGION AND ADDRESSING THE CHALLENGES

M EAN IN G AN D P URP OSE

In this section we examine the role that religion might play in this regard, based on the research reviewed in this and earlier editions of the Handbook. When discussing the impact of religion on these challenges, rather than citing individual studies, we summarize by referring to Handbook chapters that document such effects. We divide this discussion into two parts, one focusing on the “direct effects” of religion on indicators of human flourishing and the other describing “indirect effects” of

Sigmund Freud said that life had no meaning or purpose other than to find happiness and experience pleasure. In the Foreword of Man’s Search for Meaning by Jewish psychiatrist and concentration camp survivor Victor Frankl, Harold Kushner stated, “Life is not primarily a quest for pleasure, as Freud believed, or a quest for power, as Alfred Adler taught, but a quest for meaning. The greatest task for any person is to find meaning in his or her life” (Frankl, 2006, p. x). Interestingly, Freud wrote that “. . . only

638 •  P ublic H ealth and H ealth P olic y

religion can answer the question of the purpose of life. One can hardly be wrong in concluding that the idea of life having a purpose stands and falls with the religious system” (Freud, 1927, p. 25). Indeed, almost all studies reviewed in Chapter 12 and the Appendix report a significant positive relationship between religiosity and meaning/​purpose in life, including more recent longitudinal studies and at least one randomized controlled trial. V I RTU E A N D CHARACT E R

Religious beliefs and teachings seek to instill virtues and moral values during childhood and adulthood. These include prudence, practical wisdom, justice, fortitude, courage, temperance, moderation, and self-​control, as well as related character traits such as honesty, altruism, generosity, humility, gratitude, patience, and dependability. The current research supports the effectiveness of religion in doing so (see Appendix). Consequently, greater religiosity would be expected to predict a lower likelihood of involvement in delinquent, criminal, and other antisocial acts, as has been found (Chapter 13). By discouraging alcohol and drug use or abuse, providing a community of adults that model prosocial behaviors, and surrounding youth with a prosocial peer group, faith communities can reduce delinquency and later criminal activity. Religion may also help to reduce the interpersonal conflict and violence so common in modern society by teaching forgiveness, reconciliation, and care for the well-​being of others, behaviors that have been emphasized in the original scriptures of all major religious traditions. C L O S E S O C I AL RE LAT IONS HIPS

Religious beliefs encourage close, meaningful social relationships (“love they neighbor”), social harmony more generally, and the building of social capital. Religion builds social capital by encouraging volunteerism, involvement in projects to improve others’ lives, and participation in prosocial community activities that benefit all. When religion does the reverse, this is often within the context of radical fringe religious groups. Because religious beliefs emphasize the importance of family and providing

support to others, it is no surprise that religiosity is strongly related to the amount and quality of social support, both cross-​sectionally and longitudinally (Chapter 15). While religious contexts have sometimes given rise to discrimination, this has often been contrary to religious teachings themselves. Concerning social unrest, those who are more religious may be more likely to advocate for social justice, race equality, and political cooperation. This may involve peaceful protests and demonstrations, as encouraged by Martin Luther King, Jr. (a clergyperson), Mahatma Gandhi (a deeply spiritual person and committed Hindu throughout his life), and Jesus (with rare exceptions, i.e., Matthew 21:12–​13). Religious principles include advocating for disadvantaged groups, treating others as equals, and caring for all those in need. Likewise, religious organizations at the community level contribute to solving social problems by sponsoring soup kitchens, rescue missions for the homeless, and support for marginalized groups in society, all of which reduce social unrest. With regard to geopolitical conflicts, most major world religions, while often originating during circumstances of war, advocate for peaceful coexistence with others, including with those who believe differently (Matthew 22:39; Isaiah 2:4; Qur’an 2:256 and 109:1–​6; Dhammapada 130). The only exception is taking up arms for self-​defense or for the protection of innocents. Religious beliefs also emphasize the importance of treating foreigners well, especially those who are truly helpless and have little power of their own (Leviticus 19:34; Qur’an 4:98–​100). Religion, as a powerful motivator, however, may sometimes be the cause of war or violence (as with discrimination), but in numerous contexts this action opposes the actual religious teachings themselves. M EN TAL AN D P H YSICAL H EALTH

As noted in Chapter 5, religious involvement may help to prevent depression and speed time to remission when depression develops. Furthermore, religious interventions reduce depressive symptoms with relatively large effect sizes (particularly when applied in religious individuals). Religiosity may also enhance Public Health and Human Flourishing • 639

self-​esteem and promote an internal locus of control that can help to counteract depressive symptoms. Likewise, religious beliefs and faith community involvement help to prevent suicidal thoughts, attempts, and completed suicides (Chapter 7), doing so by reducing depression, increasing hope and optimism, and increasing a sense that life has meaning and purpose. Religious involvement can also reduce social isolation, decrease loneliness, and increase social contacts, particularly with those who will provide support when traumatic life events and unwanted loss/​change occurs (Chapter 15). There is also strong evidence that religiosity helps to prevent the development of substance use disorders (Chapter 10). Many of these studies have been conducted in young persons, those who have their entire lives ahead of them. Religion can provide a firm foundation that positively affects human flourishing for decades to come by preventing the development of addictions in early life that enslave individuals and rob them of happiness and meaning. With regard to physical health, religious beliefs and practices can reduce the risk of chronic disease by affecting health behaviors. Religious involvement may help to prevent the initiation of cigarette smoking or help individuals to stop smoking (through group pressure, if not by belief), increase physical activity and exercise, improve diet and weight control, decrease risky sexual activity that leads to sexually transmitted diseases and cervical cancer (Chapters 20, 21, 22, 26), forestall physical disability (Chapter 28), and slow cognitive impairment with aging (Chapters 23). Likewise, by increasing psychological well-​being and reducing mental health problems, religiosity may increase motivation for self-​care that leads to quicker recovery from accidents and illnesses; fewer psychosomatic illnesses; and a reduced likelihood of developing chronic liver disease, hypertension, and other long-​term illnesses due to substance use disorders. Religious involvement during youth may also positively affect physical health by increasing the completion of education (see above and below), which will improve one’s future ability to obtain health insurance, thereby expanding access to healthcare. Religious involvement also has the potential to improve physical health by helping with

health promotion and disease prevention, especially at the community level. From an epidemiological standpoint, the impact of an exposure on health depends on the prevalence of the exposure and the size of the effect. Nearly 85% of the world’s population report a religious affiliation (Pew Research Center, 2012), and within the United States, 89% believe in God or a universal spirit, 79% identify with a religious group, and more than one-​third report having attended a religious services within the past week (Gallup Poll, 2015–​2016). In fact, there is no other cross-​ household social activity engaged in by Americans more frequently than participation in religious groups. Only involvement in family life is more common. Consequently, faith communities have great potential to prevent disease and promote health, and may do so by (1) providing health education during sermons and religious classes, (2) emphasizing the individual’s responsibility to care for their health (including obtaining timely vaccinations and screening), and (3) discouraging negative health behaviors such as smoking, poor eating habits, lack of physical activity, excessive weight gain, and sex outside of marriage, all of which negatively affect emotional and physical health (Chapters 14, 17–​19). F IN AN CIAL AN D M ATERIAL STABIL ITY

If religious individuals have better mental health, are more likely to support and care for one another, live healthier lifestyles, and experience less chronic illness (as suggested by the research reported in this Handbook), then healthcare costs may be lower among those who are more religious. As noted above, religious involvement may reduce the need for costly mental and physical health services by (1) enhancing psychological well-​ being, meaning and purpose, optimism and hope; (2) improving coping with stress and decreasing worry and anxiety; (3) reducing depression, suicidal thoughts and attempts; (4) increasing social and family support; (5) reducing alcohol and drug use, abuse, and addiction; and (6) improving health behaviors. Pastoral care and support by clergy and other members of the congregation can also help to resolve less severe emotional problems that otherwise would require

640 •  P ublic H ealth and H ealth P olic y

formal mental health services. Clergy can also encourage individuals to obtain timely health services so that problems do not progress to a stage where they become resistant to treatment and require expensive long-​term services. As noted earlier, faith communities can partner with healthcare organizations in order to motivate members to obtain regular medical care and improve the early detection of disease through screening. This may be accomplished either informally on the individual level, or through healthcare ministries at the congregation level. Services that may be provided include (1) health education that encourages participation in disease prevention and health maintenance activities; (2) improvement of access to healthcare by arranging transportation to doctor visits; and (3) identification of healthcare advocates to support patients during outpatient visits or inpatient hospitalizations. Health advocates from the faith community may help patients by clarifying treatments prescribed by providers and encouraging compliance with those treatments. These are natural activities for religious institutions, which have always served important roles in healthcare service provision through the building of hospitals and staffing them with religious professionals (Numbers & Amundsen, 1986). Faith-​ based organizations have also long delivered social services, mental health services, and emergency services following disasters, particularly to those at risk of falling through the cracks of government-​funded social, health, and emergency response systems (Koenig, 2005; 2007b). On the individual level, a huge amount of religiously motivated volunteering and financial contributions goes to care for those in need—​ needs which government programs would otherwise have to meet and pay for. Religious commitments may also help to reduce long-​term care costs by effects on marital and family stability (see below), thereby increasing the presence, motivation, and resilience of family members caring for individuals at home, enabling the avoidance of placement in state-​funded nursing homes or mental hospitals. Thus, actions taken by both religious institutions and by religious individuals have the potential to reduce healthcare costs and contribute to the financial and material stability of

communities, thus helping to improve human flourishing and public health. Religion also affects the costs of social control needed to keep people from doing harm to one another. Religious involvement is associated with less delinquency, crime, and other antisocial behaviors (Chapter 13). When internal control is lacking, external control becomes necessary (more police, more jails, more justice system personnel). Religiosity has been shown to produce greater internal control and self-​ regulation, key mechanisms explaining how religiosity influences mental, social, and physical health, in addition to preventing delinquency and crime (McCullough & Willoughby, 2009; Laird et al., 2011; Reisig et al., 2012). Thus, greater religious involvement, and the self-​ control that it generates, should lower costs for external measures to maintain social control.

Indirect Effects Religious beliefs and practices may also indirectly affect human flourishing and public health through their impact on the four major pathways that lead to human flourishing: marital and family stability, completion of education, obtaining high-​quality work and employment, and increasing religious community activity. M ARITAL AN D FAM ILY STABIL ITY

Greater religious involvement is related to less divorce, increased family stability, improved parent-​ child relationships, decreased single-​ parent homes, and less spousal and child abuse (Chapter 14). These positive effects on marriage and the family are a key pathway to flourishing, as children born within marriages and raised in two-​parent homes, as noted earlier, have better mental health, better physical health, are happier in both childhood and adulthood, are less likely to engage in delinquent or criminal acts, have better relationships with their parents, and are less likely to themselves divorce as adults (VanderWeele, 2017a; Li et al., 2018). ED UCATION

As noted previously, religious involvement during youth can increase the likelihood that Public Health and Human Flourishing • 641

young people will complete their education. Religious youth achieve higher academic grades, are more likely to graduate from high school and college; are less likely to be involved in bullying others, school violence, and other delinquent behaviors; are less likely to engage in alcohol and drug use or become addicted; and are less likely to have sex before marriage that results in teen pregnancy and out-​of-​­wedlock births. These effects of religion reduce the likelihood that education will be disrupted due to academic underperformance or school dropout from these causes (Chapters 13 and 14). WORK A N D E M P LOYME NT

Religiosity can also encourage responsible behaviors at work, both the carrying out of one’s duties as required and helping coworkers with their duties. Consequently, religious involvement is related to greater work satisfaction, workplace productivity, and a wide range of positive attitudes toward employment (Jamal & Badawi, 1993; Robert et al., 2006; Osman-​Gani et al., 2013; Carroll et al., 2014; Onyemah et al., 2018). Being happy and productive at work, where many individuals spend a large part of their lives, will no doubt increase their well-​being and quality of life. R EL I GI O U S C O MMUNIT Y

The impact of religiosity on religious community involvement is evident. Individuals who are more religiously committed and consider religion important in their lives are more likely to participate in religious activities with others, such as attending religious services and engaging in religious and nonreligious volunteer activities (Idler et al., 2009; Taniguchi & Thomas, 2011; Guo et al., 2013), both of which are associated with a wide range of mental health benefits and positive physical health consequences.

Summary Religiosity, in one way or another, directly impacts each of the six indicators of human flourishing, and in addition, indirectly influences the four major pathways that lead to

human flourishing. Evidence from recent large prospective studies confirms that religious involvement affects health and human flourishing across the life span from adolescence to young adulthood to later life (Chen & VanderWeele, 2018; Chen et al., 2020a). Positive influences on health reported in these studies include fewer depressive disorders and symptoms, fewer anxiety symptoms, less hopelessness, less loneliness, greater social integration, more positive emotions, greater life satisfaction, greater purpose in life, less cigarette smoking and heavy alcohol use, fewer physical health problems, and lower all-​cause mortality. As noted above, many of these outcomes are central to both individual human flourishing and public health. Interestingly, a relatively recent article published in the journal Social Science & Medicine reviewed the accomplishments of health psychology over the past half-​century (Johnson & Acabchuk, 2018). The authors concluded that “the lessons of health psychology research offer an answer to the secret to successful living: Maintain a sense of purpose, positive social relationships and healthy habits, including a nutritious diet, sufficient exercise and sleep; moderation and optimism are best” (p. 225). Despite the impact that religion has on human flourishing, as documented in hundreds of studies, including many high-​quality prospective observational studies and randomized controlled trials (RCTs), not a single mention was made of the contribution that religious involvement has made to health. The only mention of religion was a comment that fewer people these days were involved in organized religion and that spirituality may have risen to fill this void. Given the potential impact that religion can have on public health and human flourishing, it is remarkable that researchers continue to ignore this psychosocial activity that may profoundly influence virtually every aspect of mental, social, behavioral, and physical health, particularly an activity that is engaged in by more than 80% of the world’s population. The review article above is just one example of the bias against religion that has characterized the medical, psychological, social, and behavioral sciences for more than a century. We hope that the publication of this edition of the Handbook

642 •  P ublic H ealth and H ealth P olic y

will place religion squarely on the radar of these human sciences.

longitudinal studies (VanderWeele et al., 2020d). As one example, the 10-​item Flourishing Index (FI) and 12-​item Secure Flourishing Index (SFI) have demonstrated good psychometric properRECOMMENDATIONS FOR ties in five different cultures, suggesting that FUTURE RESEARCH these instruments may be useful in studying Many areas of future research remain to be contributors to flourishing in a variety of conexplored in order of us to more fully understand texts (Wȩziak-​Białowolska et al., 2019). When the role that religion plays in human flourish- analyzing the data acquired in these studies, we ing. Of particular interest for our purposes would recommend analyzing multiple human here is to identify other aspects of religion, flourishing outcomes simultaneously, rather in addition to religious community activities, than examining only single individual outthat lead to human flourishing. These might comes (VanderWeele, 2017c; VanderWeele et involve various aspects such as the degree of al., 2020b). religious conviction, commitment or devotion; Trends in societal well-​being are also worth level of intrinsic religious motivation; engage- examining. Developed countries such as the ment in private religious activities; and partic- United States and other highly religious counipation in specific religious rituals (which will tries such as those in the Middle East are slowly vary depending on the religious tradition and becoming more and more secular as science culture in which it is practiced). Each of these and technology become the primary sources of religious characteristics should be examined truth and other sources of understanding are separately for their respective contributions to abandoned so that secular humanism becomes human flourishing, rather than combining all the guide for individual decision-​making and in a single statistical model where collinearity self-​restraint. As this occurs, will indicators of (strong relationships between different reli- human flourishing increase or decrease? Thus gious variables) may be an issue. far, it appears that a number of aspects of well-​ For example, a prospective study might being have in fact declined with the erosion recruit a relatively large sample, restricted to of religion in the public life (see “Challenges monotheists, to test the hypothesis that decid- to Flourishing Pathways” above). Thus, future ing to submit or surrender to God’s will (as trends in human flourishing need to be careunderstood by the participant) is a predictor of fully tracked over time, with a particular focus various aspects of human flourishing assessed on how changes are influenced by declines in by an outcome measure such as the Secure religious participation. Flourishing Index (see below). Participants Randomized controlled trials (RCTs) are would need to be followed for a long enough also needed in order to determine how religion period that would allow for changes in the might be utilized to improve human flourishing. human flourishing indicators to occur. The RCTs are needed to identify effective religious length of the follow-​up period is crucial. As interventions at the individual or community noted in Chapter 3, if there is no change in level that positively affect one or more of the measures of human flourishing due to a short six major flourishing domains (happiness/​ follow-​up period, there will be nothing for reli- life satisfaction, meaning/​ purpose, virtue/​ gious variables to predict, resulting in no effect. character, close social relationships, mental/​ If follow-​up is not adequate, such a study might physical health, financial/​material stability) or produce misleading results that discourage fur- the major pathways that lead to them (marither research. tal/​ family stability, education, employment, If possible, longitudinal studies should mea- religious community activity). Numerous sure numerous human flourishing indicators, as religiously integrated psychotherapies have well as the four pathways that lead to flourishing already been shown to improve mental health as described above. One straightforward way to and enhance happiness/​ life satisfaction do so would be to include flourishing or well-​ (Koenig et al., 2015d; Captari et al., 2018), but being indices or inventories in existing or new what about religious interventions for some Public Health and Human Flourishing • 643

of the other flourishing domains or the pathways that affect them? For example, are there religious interventions that can be utilized to improve virtue/​character that result in an increase in prudence (wisdom), fortitude, and/​ or temperance (self-​control), or perhaps religious interventions that might improve marital/​ family stability, leading to downstream effects on mental health? Might forgiveness be one such intervention (VanderWeele, 2018)? Likewise, are there particular demographic groups based on age, race, gender or socioeconomic status, in which these interventions are more or less effective? Truly, the range of different future research projects that are needed is vast.

SUMMARY AND CONCLUSIONS We have focused in this chapter on the impact of religious involvement on public health, and more specifically, on human flourishing—or complete well-​being. The hope is to optimize

health and well-​being at both individual and community levels. We described six central domains of human flourishing (happiness/​life satisfaction, meaning/​purpose, virtue/​character, close social relationships, mental/​physical health, financial/​ material stability) and the four postulated major pathways to achieve this flourishing (family, education, work/​ employment, religious community). We also examined challenges that threaten each of the flourishing domains and the pathways that lead to them, followed by a review of how religious involvement might help to address these challenges based on the research documented in this Handbook. Finally, recommendations for future research were made, emphasizing the importance of longitudinal studies and RCTs to help us better understand how religion contributes to flourishing on the individual and community levels. In the next chapter, we examine the implications that these findings on religious involvement and human flourishing have on public policy in the United States and other countries around the world.

644 •  P ublic H ealth and H ealth P olic y

33 Health Policy Implications You can’t divorce religious belief and public service. . . . I’ve never detected any conflict between God’s will and my political duty. If you violate one, you violate the other. —​James Earl (Jimmy) Carter

HOW SHOULD THE influences of religion on public health and human flourishing shape the health policies made by federal, state, and local governments? The answer to this question is of enormous importance. Although we tread lightly in responding to this sobering question, we are obligated as scientists and clinicians to make a series of recommendations. Admittedly, these are tentative and to some extent dependent on future research. Nevertheless, the research findings on religion and health thus far, as reviewed in this Handbook, have profound implications for how resources are allocated and how societies are regulated. This is true not only for the United States, but also for other countries around the world, given the wide prevalence of religious beliefs/​practices and the increasing challenge of caring for the health needs of aging populations. The goal of all governments, at least those of free societies, is to set up laws, regulations, and rules that allow their societies to thrive.

Societies thrive when their citizens are flourishing in the ways described in the previous chapter (are happy and satisfied with their lives, have meaning and purpose, possess healthy virtues and moral values, have close social relationships, experience mental and physical health, and experience financial stability). If religious involvement can help a significant proportion of the population flourish in one or more of these ways, then government leaders need to consider creating an environment in which religion—​ all religions—​ can thrive.

DEFINITIONS Terms used in this chapter include “public policy” and “health policy,” both having to do with laws, regulations, and rules at all levels of government (local, regional, and national) designed to produce a healthy, productive, and peaceful society.

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0033

Public Policy Public policy has been defined in various ways. Peters (2015) defines it as “the set of activities that governments engage in for the purpose of changing their economy and society” (p. 3). These activities are to be designed to benefit the citizens who make up the population being governed. Others define public policy as “courses of action, regulatory measures, laws, and funding priorities concerning a given topic promulgated by a government entity or its representatives” (Kilpatrick, 2000, p. 1). Such topics may include transportation, public health, education, and defense (Peter, 1998, p. 10). On the federal level in the United States, the government entities involved in determining public policy include Congress which enacts laws, the president who issues executive orders, the Supreme Court which rules on their constitutionality, and various other bureaucratic agencies that issue regulations that affect the public (Wilson, 2006). The actors include politicians, lobbyists, civil servants, domain experts, and industry representatives. Ideally, public policy solves problems effectively, serves and supports government institutions, and encourages active involvement by citizens who are affected by such policies. Most relevant for the current chapter is the definition of public policy as provided by Beauford Longest (2015): “authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, or decisions of others” (p. 9). A common approach to public policy is evidence-​based policy, derived from Rational Choice Theory, which emphasizes the use of existing data, evidence, rational analysis, and information technology to identify problems and determine solutions (Esty & Rushing, 2007). This approach is consistent with the one taken in this chapter when making policy recommendations.

Health Policy An important aspect of public policy is health policy. Health policy involves the “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society” (WHO, 2020, p. 1). According to the US

Centers for Disease Control, health policy is related to public health through policies developed for “the advancement and implementation of public health law, regulations, or voluntary practices that influence systems development, organizational change, and individual behavior to promote improvements in health” (CDC, 2015, p. 1). Health policies are made in both the private sector and in the public or government sector. Examples of policies made in the private healthcare sector include authoritative decisions made by executives of healthcare organizations, or by private organizations such as the Joint Commission (JCAHO) or the National Committee for Quality Assurance (NCQA). Health policies can be further divided into public health policy and health-​in-​all policies. Public health policy, according to De Leeuw and colleagues (2014), “can be conceived either as public sector (government) policy for population health (public health policy), or any policy (including corporate and other civil society approaches) concerned with the public’s health (public health policy)” (p. 3). While such policies are usually executed within the health sector, public health goals can also be achieved by policy developments in other sectors such as education, agriculture, or employment (CDC, 2015). There are two basic types of public health policy: allocative and regulatory. Allocative health policy involves the distribution of income, services, or goods that benefit the health of one group over that of another. Examples of allocative health policy might include funding for Medicaid (the poor) or providing support for Medicare (the elderly). Regulatory health policy involves government standardization applied to specific groups and their behaviors, such as establishing a law that bans smoking in public areas in order to improve public health or a mandate to wear a mask when using public transportation (as during the COVID-​19 pandemic). See Table 33.1 for more examples of allocative and regulatory health policies, those where the effects of religion on health and the effects of religious community programs on community health may intersect. The health-​in-​all policies approach goes beyond the Centers for Disease Control and Prevention’s (CDC’s) viewpoint on public health policy, expanding it to involve “a collaborative

646 •  P ublic H ealth and H ealth P olic y

Table 33.1.  Examples of “Public Health Policy” with Religion-​Health Implications I.  Allocative Policies (allocation of resources) a. Government subsidization of medical education (e.g., for training to integrate spirituality into patient care) and support of medical research (including religion-​health research) * b. Government subsidization of hospitals (e.g., for hiring chaplains, JCAHO requirements to conduct a spiritual assessment) * c. Government subsidization of health insurance coverage (e.g., Affordable Care Act, Consolidated Omnibus Budget Reconciliation Act) d. Government funding of community health centers (including health professional training programs) * e. Medicare program (federal payments to teaching hospitals, hospice programs, long-​term care hospitals, ensuring that health-​related spiritual needs are met) * f. Medicaid program (state and federal payments, to ensure that spiritual needs are assessed and addressed for low-​income individuals and minority groups) * g. Government funding to increase access (Native Americans, veterans, migrants, minorities, mental hospitals) ** h. American Recovery and Reinvestment Act of 2009 (with many health-​related subsidies) i. Government support for community-​based disease-​prevention activities (e.g., immunizations for low-​income children and adults, prevention activities to reduce chronic diseases) *, ** II. Regulatory Policies (federal and state laws that affect actions, behaviors, decisions of others) a. Economic regulation 1. Market-​entry restrictions (e.g., licensing of health-​related practitioners and organizations, including receiving adequate training to identify and address patients’ spiritual needs) * 2. Rate-​setting or price-​setting controls on health services provided (e.g., control of reimbursement rates to physicians and hospitals for Medicare patients) 3. Quality controls on delivery of health services (e.g., ensure acceptable level of quality of services provided (including assessing and addressing spiritual needs) * 4. Market-​preserving controls (e.g., maintain conditions that permit healthcare markets to work fairly in terms of free competition with regard to buyers and sellers) b.  Social regulation (federal and state laws focused on achieving socially desirable outcomes) 1. Ensure workplace safety and fair employment practices * 2. Ensure environmental protection, ban smoking, avoid pollution from medical waste 3. Limit the spread of sexually transmitted diseases (effects of religion on behavior) * 4. Ensure childhood immunizations (dealing with religious exemptions) * 5. Mandatory reporting of communicable diseases ** * Areas where religion-​health relationships may have health policy implications ** Areas where faith community programs and partnerships with healthcare organizations may have health policy implications. Source: Longest, B. B. (2015). Health and health policy (­chapter 1). In Health Policymaking in the United States, 6th ed. Chicago, IL: Health Administration Press, Foundation of the American College of Healthcare Executives, pp. 18–​21.

approach to improving the health of all people by incorporating health considerations into decision-​making across [all] sectors and policy areas” (Rudolph et al., 2013, p. 6). From this perspective, policies that affect health include those involving many other aspects

of public life besides those affecting physical health. The president (Adewale Troutman) and the executive director (Georges Benjamin) of the American Public Health Association emphasized this view when they wrote, “Responsibility for the social determinants of health falls to Health Policy Implications • 647

many non-​ traditional health partners, such as housing, transportation, education, air quality, parks, criminal justice, energy, and employment agencies. Solutions to our complex and urgent problems will require collaborative efforts across many sectors and all levels,

including government agencies, businesses, and community-​based organizations [and may we add, religious communities]” (Troutman & Benjamin, 2013, cited in Rudolph et al., 2013, p. 1). See Table 33.2 for examples of policies governing aspects of public life that impact health.

Table 33.2.  Examples of “Health-​in-​All Policies” with Religion-​Health Implications 1. Data collection by government agencies a. Include indicators of social determinants of health * 2. Direct service provision (by the federal, states, counties, and cities) a. Include healthy home assessments in various programs (including congregational nurse assessments)* b. Promote health screening ** 3. Education a. Educate and inform population on health-​related topics (physical exercise, diet. etc.) *, ** 4. Employment a. Encourage healthy employee behaviors, setting a positive example for private businesses * b. Provide accommodations for healthy behaviors * 5. Funding a. Provide incentives, subsidies, and grants to encourage health-​promoting activities (including payments for health-​promoting services by Medicare, Medicaid) ** b. Include health and health equity criteria in RFPs for funding from agencies outside public health * 6. Guidance and best practices a. Incorporate strategies that promote community health *, ** 7. Permits and licensing for activities or development a. Streamline permitting processes for programs that promote health ** 8. Regulation a. Improve enforcement of bans on smoking, other negative health practices in certain environments ** b. Include health analysis in budgetary and legislative decisions ** 9. Research and evaluation a. Initiate researcher partnerships between universities, research institutions, and communities ** b. Conduct economic research on health outcomes of specific policies *, ** 10. Legislation and ordinances to support access to healthy practices ** 11. Taxes and fees a. Raise taxes on cigarettes and use revenue to pay for health services ** 12. Training and technical assistance a. Provide training and technical assistance to support local health programs ** b. Educate inter-​and intra-​agency staff on how their work relates to health outcomes * * Areas where religion-​health relationships may have health policy implications. ** Areas where faith community programs and partnerships may have health policy implications. Source: Rudolph, L., Caplan, J., Ben-​Moshe, K., Dillon, L. (2013). Health in All Policies: A Guide for State and Local Governments. Washington, DC, and Oakland, CA: American Public Health Association and Public Health Institute, pp. 25–​26 (retrieved on 10-​7-​2020 from https://​www.apha.org/​top​ics-​and-​iss​ues/​hea​lth-​in-​all-​polic​ies).

648 •  P ublic H ealth and H ealth P olic y

When referring to health policy, we do so in a broad way to designate all private-​sector and government actions that are intended to improve individual and population health. When making health policy recommendations, we focus on suggestions for developing, maintaining, or modifying policies in light of religion’s impact on people and on the environments in which they live, work, learn, and play. In effect, this means the influences that religion has on (a) the four pathways to human flourishing and public health reviewed in the previous chapter (family and marital stability, education, employment, religious community activities) and (b) the six indicators of human flourishing and complete well-​being that were considered (happiness/​life satisfaction, meaning and purpose, virtues and character, close social relationships, mental/​ physical health, material/​financial stability).

RELIGION AND PUBLIC POLICY The First Amendment of the US Constitution guarantees that “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof.” The Supreme Court has interpreted this policy as follows (Legal Information Institute, 1992, p. 1): The First Amendment has been interpreted by the Court as applying to the entire federal government even though it is only expressly applicable to Congress. . . . Two clauses in the First Amendment guarantee freedom of religion. The Establishment Clause prohibits the government from passing legislation to establish an official religion or preferring one religion over another. It enforces the “separation of church and state.”. . . The Free Exercise Clause prohibits the government, in most instances, from interfering with a person’s practice of their religion. The Establishment Clause was originally developed to ensure that the government would not establish a particular religion or persecute a person based on their religion (Cooley,

1898), a situation that the founding forefathers of the United States wanted to avoid since this had been an issue in their European countries of origin. However, in Everson v. Board of Education (1947), the Supreme Court ruled that the Establishment Clause forbids not only practices that prefer one religion over another, but also those that “aid all religions” (i.e., a “no aid” policy). Recently, based on original sources, Supreme Court dissenters have returned to the original argument, i.e., that the Establishment Clause was designed to prevent “preferential” promotion of some religions at the cost of others, thus allowing governmental promotion of all religion in general (see Wallace v. Jaffree, 1985; Lee v. Weisman, 1992). Furthermore, the “no aid” policies in state constitutions that have been used to justify discrimination against religious education programs (preventing them from receiving state funds based on the application of the Blaine amendment) have been repeatedly struck down by the Supreme Court on the basis that “[a]‌ State’s interest in achieving greater separation of church and State than is already ensured under the Establishment Clause . . . is limited by the Free Exercise Clause” (Trinity Lutheran Church of Columbia, Inc., v. Comer, 2017; Espinoza v. Montana Department of Revenue, 2020). The 1993 Religious Freedom Restoration Act and 2017 executive order (titled “Promoting Free Speech and Religious Liberty”) have reinforced the notion that allocative public policies cannot discriminate against religious individuals or religious institutions when seeking government financial support in a way that favors secular groups (Religious Freedom Restoration Act, 1993; Executive Order, 2017). Such discrimination is not allowed because it forces a religious institution to choose between “participat[ing] in an otherwise available benefit program or remain[ing] a religious institution,” a violation of the Free Exercise Clause (Trinity v. Comer, 2017, 137 S. Ct. at 2021–​2022). Thus, court decisions on government policies regarding the balance between the Establishment Clause and the Free Exercise Clause have been quite fluid, influenced by various more liberal or conservative interpretations made by those appointed to the courts. These decisions have often arguably been Health Policy Implications • 649

influenced by secular societal trends and political climates, thereby affecting the religious freedoms of those who are religious and those who are not. At least in the United States, the degree of church-​state separation specified in the Establishment Clause is a pressing topic, one that has been and will continue to be hotly debated in the courts for years to come. While the government cannot establish a particular religion in the United States, it can pass laws and adopt policies that support (and sometimes deny) the free exercise of religion as it might apply to public health—​which is at least partly a responsibility of the government. A number of precedents exist for the government’s restriction of religious liberties, particularly when these actions affect the health and well-​being of others. For example, the state of Indiana limited the religious liberty of members of Faith Assembly to have out-​of-​hospital births without prenatal care. This was done by passing a law that required members of this religious tradition to obtain regular prenatal care and medical assistance during delivery (Spence & Danielson, 1987). The goal of this law was to ensure that religious belief did not infringe upon the right to health of mothers and their babies, given the high rate of maternal and infant mortality among Faith Assembly members (Spence et al., 1984). As another example of health policies that affect religious liberties, some states allow religious exemptions from vaccinations and other health practices regarding children, while other states do not allow such exemptions. The same applies to closure of churches or limits placed on the number of people attending religious services imposed by governors in the United States during the recent COVID-​19 pandemic (Brown, 2020). This brief overview helps to frame our health policy recommendations with regard to religion. As noted above, we are fully aware of individual sensitivities with regard to having their religious liberties limited or restricted in any way, including the freedom not to have any religious belief. We understand that any suggestions regarding the regulation of religion will be viewed by many as unduly intrusive. Nevertheless, we will cautiously proceed, as content experts, based on what is known

or suspected from systematic research that has been documented in this Handbook. Furthermore, we emphasize that these recommendations for policymakers are suggestions only, made in light of evidence from research and therefore potentially consistent with evidence-​based policy (see above). The goal is to increase the likelihood of achieving well-​being as characterized by human flourishing at the individual and the public health level—​which, as noted earlier, is at least partly a responsibility of the government—​by affecting public policies made by the government concerning the religious beliefs and practices of people in the population.

HEALTH POLICY RECOMMENDATIONS We begin with the premise, based on the existing research, that a strong religious faith and active involvement in a religious community can affect both individual human flourishing and public health more generally (as summarized in the last chapter). Again, we justify this on the grounds that religious involvement can affect human flourishing indirectly through at least four recognized pathways and affect it directly by impacts on each of the six indicators of human flourishing. In other words, there is growing evidence that religion may enhance marital and family stability; increase the likelihood that young persons will complete their education; improve the likelihood of sustained employment during adulthood; and increase overall community social capital. Likewise, evidence is accumulating that religious activity can directly affect a person’s level of happiness and life satisfaction; serve as an important source of meaning and purpose; help to instill human virtues/​ moral values and promote positive character growth during youth and adulthood; enhance the number and quality of close social relationships; help to prevent or speed recovery from mental health problems (depression, anxiety, substance abuse); promote a wide range of good health behaviors; maintain physical health through health-​ promotion and disease-​prevention activities; and increase the likelihood of achieving financial and material stability. If, as the evidence

650 •  P ublic H ealth and H ealth P olic y

in the previous chapters in this Handbook suggests, some or all of these claims are true, then this demands attention from public policymakers (i.e., those responsible for ensuring the health and flourishing of individuals and communities). We categorize our health policy recommendations into 10 areas: (1) the expression of religion in the public sphere, (2) support for marriage and family life, (3) inclusion of religious literacy in public school education, (4) policies regarding employment and work, (5) media portrayals of religion, (6) providing tax exemptions to religious organizations, (7) providing funding support for research on religion and health, (8) allocating funding support for faith community-​ healthcare system partnerships, (9) identifying and addressing spiritual needs in healthcare settings, and (10) preventing suicide (Table 33.3).

Public Expression of and Participation in Religion Although the free expression of religion is assured by the First Amendment of the Constitu­­tion in the United States, this is not so in many countries where restrictions to religious freedoms have been significantly increasing—​i.e., laws, policies and actions by state officials that restrict religious beliefs and practices (Pew Research Center, 2019a). A number of countries also require religious registration, which has also been strongly linked to religious restrictions and persecution (Finke et al., 2017). As documented in the Handbook, the effects of religious participation on health can be profound, and this arguably has implications for the public expression of and participation in religion. RE C O M M E N DAT ION

If religion enhances health and well-​being, as the research in this Handbook suggests, then health policies of countries throughout the world should be structured in ways that support its citizens’ religious beliefs and practices, as well as preserve the freedom to not engage in such activities. In addition to ensuring religious freedom, efforts could be made to promote

participation in religious communities for those who already positively self-​identify with a religious tradition, and likewise encourage individuals who do not to participate in other forms of community life (VanderWeele et al., 2022). Various materials and outreach efforts could be developed and used to promote different types of community participation, and these could be tailored to each specific religious tradition, describing the research on service attendance, noting the theological understanding of the importance of community within that tradition, listing local communities inviting participation, and ideally also offering resources or contact information for those who have experienced abuse within religious contexts. Such promotional material could be sent to lists of those who have previously indicated a particular religious affiliation. To accommodate those without religious affiliation, other efforts to promote community participation more broadly might also be pursued wherein the health benefits of community participation could be put forward, with a list of local community opportunities provided, including, but not restricted to, religious service attendance. While such efforts in the United States are limited at present, the practice of “social prescribing” saw a dramatic increase in clinical and public health contexts within the United Kingdom over a few short years (NHS England, 2019) and could serve as a model for community promotion activities in other countries. Neglecting community participation and service attendance promotion efforts, when these are appropriate, might well result in adverse effects on the public’s health.

Support for Marriage and Family Life Increasing rates of divorce among married individuals and breakups among cohabitating persons, particularly those with children, have become a threat to traditional family life. This has resulted in a dramatic increase in single-​parent homes, with negative health consequences for both parents and children (see Chapters 14 and 32). The vast majority of research conducted on religion and marital/​ family life has thus far shown that religious Health Policy Implications • 651

Table 33.3.  Public-​and Private-​Sector Health Policy Recommendations 1. Encourage and support religious beliefs and practices of all religions, including their expressions in public, as long as they do not interfere with the rights and freedoms of others (including those with no religious beliefs); stop religious registration, as some countries are doing [I.i, II.b, 6a].a 2. Support marital stability and family life, while (a) acknowledging the important role that religion plays in this regard and (b) providing incentives for religious organizations to provide marriage enrichment programs and for clergy to provide marriage and family counseling [I.i, II.b, 3a, 6a, 12a]. 3. Include education about religious literacy (all major world religions) in public and private schools, including the role that religious beliefs and practices can play in maintaining health and well-​being on the individual and population level [I.i, II.b 2–​3, 3a, 6a, 10]. 4. In the workplace, maintain laws that preserve the rights of employees to practice their religious faith and require employers to provide accommodations for this activity, while also allowing employers not to violate their own religious beliefs when hiring [II.b1, 4a–​b, 10]. 5. Ensure a fair balance of negative and positive portrayals of religion in the media, highlighting the positive contributions of religious individuals and religious leaders to human flourishing, as opposed to only emphasizing the negative effects of religion and abuse by clergy [3a, 6a, 8a]. 6. Maintain the tax exemption status of religious organizations, and ensure that tax laws do not discourage individuals from making tax-​deductible contributions to religious organizations and other religious programs that contribute to public health [I.i, 10, 11a]. 7. Provide more funding support for religion-​health research, particularly longitudinal studies that examine the effects of religious involvement on public health and human flourishing, as well as provide support for RCTs that promote the development and testing of religious interventions to enhance that flourishing [I.a, I.i, 1a, 5b, 8b, 9a–​b]. 8. Provide support for religious community-​health programs to promote the health of congregants, as well as incentives to form faith community-​healthcare organization partnerships that allow for collaboration between these groups to improve community health and build social capital [I.g, I.i, II.b 5, 2b, 3b, 6b, 9a, 10, 12a]. 9. Provide incentives for healthcare organizations to identify and address the spiritual needs of patients in all healthcare settings, and incentives for medical schools and other training programs to teach health professionals how to do this [I.a, I.d, I.e, II.a 1, 5a, 6a, 12b]. 10. Include religious assessments and religious professionals in programs designed to prevent suicide, both in the general population and in specific population subgroups at high risk (e.g., veterans, teenage girls, older males, those with mental illness) [I.g, I.i, 1a, 3a, 6a, 9a, 10, 12a–​b]. a

Related to areas of public health policy (Table 33.1, I–​II) and health-​in-​all policy (Table 33.2, 1–​12).

involvement is associated with greater stability (Chapter 14). R EC O MME N DATION

Policies, laws, and incentives, financial or otherwise, should be directed at supporting

marital/​family stability, while acknowledging the important role that religion may play in this regard and perhaps even utilizing religious approaches for achieving this end. For example, policies could be adopted that reward clergy for providing marital and family counseling (and support the training of clergy to do so). This

652 •  P ublic H ealth and H ealth P olic y

could also be done in conjunction with publicly accessible or even online evidence-​based marital counseling programs (Doss et al., 2016, 2017). Similarly, government incentives could motivate faith communities to develop marital and family enrichment programs for members, and encourage secular organizations to do likewise. As above, policies supporting religious practices and communities that keep parents and families together and, in particular, emphasize prosocial values and moral behaviors may also reduce antisocial behaviors during youth and criminal behaviors during adulthood.

public school curriculum. This trend has often led to an implicit endorsement of anti-​religious beliefs. For an updated review of policies regarding religion in US public schools, including the Supreme Court decisions above, see a recent Pew Research Center (2019b) report. Interestingly, despite the increasingly secular nature of Europe, religious education in public schools remains quite common in many countries (Russell, 2016). Furthermore, the majority of Middle Eastern countries require compulsory religious education in both private and public schools (Faour, 2012).

Private and Public School Education

RECOM M EN DATION

Much can be done to support religious literacy by policies that provide greater latitude for doing so in both private and public school. Religion is a powerful social force in society that students need to know something about, especially from an inter-​religious perspective, even if they themselves do not participate in religious activities. Students who attend public schools frequently come from lower-​income families and minority groups. In 2017, 42% of all students in public elementary or secondary schools in the United States were Black or Hispanic (NCES, 2020b), ethnic groups that are often highly religious. Public schools cannot support a particular religious belief or require others to accept religious or anti-​religious beliefs. More than 55 years ago, the US Supreme Court struck down public school–​sponsored prayer (Everson v. Board of Education of Ewing Township, 1947), and many federal courts have upheld this decision since then. Forbidding religious activities in some jurisdictions has also been applied to expressions of religious devotion such as the wearing of jewelry or clothing with religious symbols. In another Supreme Court ruling, McCollum v. Board of Education (1948), the Court decided against allowing religious instructors from different denominations to enter public schools and offer religious lessons during school hours to students, even though parents had requested these instructors (Vile, 2009). The result of these judicial decisions has been the near total avoidance of religion in

Public policies should continue to support private schools that provide religious education, ensuring that they have adequate resources and well-​trained teachers, and should not discriminate against them based on their religious nature, as supported by the Religious Freedom Restoration Acts (Jipping & Perry, 2021). Policies regarding public schools should encourage educating students at all grade levels about the beliefs of the five major world religions and how those beliefs and practices may contribute (or not) to individual and population health and well-​being, after obtaining approval from parents. Public policies related to school prayer also need to be modified in a way that allows such practices, while also protecting the rights of students and educators who are not religious. For example, schools might allow school time for voluntary prayer arranged by students themselves, while at the same time allowing for secular activities arranged by nonreligious students. This would require the revision of strict policies that discourage all religious practices during school hours. Likewise, we recommend policies that encourage both public and private schools to educate students on the importance of human virtues, moral values, and character development. We recommend this be included as part of the standard curriculum, emphasizing the historical origins of many of these values in religious teachings. The hope is that attention to such matters at school will help to control youth delinquency, alcohol and drug use, teenage pregnancy, and school dropout, factors that Health Policy Implications • 653

will affect the health and well-​being of these youth for the rest of their lives. We also recommend that government health organizations such as the National Institutes of Health (NIH), CDC, and Centers for Medicare and Medicaid Services (CMS) in the United States, as well as national health agencies in other countries, educate the public about the health benefits (and potential risks) of religious participation across a wide range of religious traditions. This might also include educating the media (see below) on the role that religion plays in health and human flourishing, as well as the health risks of religion in terms of seeking exemptions from vaccination and reliance on prayer and other forms of religious healing instead of medical care.

Employment Laws While bringing up religion in the workplace can cause disagreements, conflicts, or even harassment among employers and employees, strong religious beliefs can also provide support for employees as they carry out their jobs and interact with co-​workers (see studies in Chapter 32 that find religiosity related to work satisfaction and productivity). In the United States, the Civil Rights Act of 1964 (Title VII) prohibits employment decisions based on religion and refusal to accommodate a worker’s “sincerely held” religious beliefs/​practices (EEOC, 2014). The only exception is if such an accommodation imposes undue hardship on operation of the business (e.g., violating a seniority system, adversely affecting necessary staffing, jeopardizing the security or health of the worker or co-​workers, or costing the employer more than a minimal amount). By religion, the law specifies not only the five major religious traditions, but also religious beliefs that are uncommon, i.e., those not part of a formal religious organization or only held by a small number of believers. Employers, however, also have rights (e.g., undue hardship, as noted above). Furthermore, in businesses whose purpose is primarily religious in nature, employers may require certain employees to adhere to a particular faith tradition. Courts in the United States, however, will look closely at the employer’s religious requirements for such positions, and court decisions

have varied widely regarding lawsuits over this issue (FindLaw, 2018). RECOM M EN DATION

Laws governing employee hiring or workplace behavior should be maintained, not discriminating against individuals who wish to practice their religious faith and also providing reasonable accommodations for them to do so (e.g., time and space for Muslims to perform their required prayers). Likewise, employers should not be forced by legislation to compromise their religious beliefs while running their businesses, as long as they respect and honor the religious beliefs (or lack) of their employees. For example, Catholic institutions or physicians should not be forced to perform abortions. Welfare policies should also be structured in a way that they do not de-​incentivize work, but rather support employment programs for vulnerable populations. This may be done by incentivizing programs that find jobs in religious organizations or that work with members of congregations to provide employment in their businesses, doing so as an expression of “love for neighbor.” Finally, a great need exists for workplace chaplains who provide spiritual support and counseling to employees. This is particularly important for police and fire departments, as well as ambulance and emergency medical providers, who are under severe emotional stress due to their jobs. Thus, we recommend that state and local government adopt policies that incentivize the hiring of workplace chaplains to provide spiritual support to these first responders when needed. These policies might also be extended to large private-​sector businesses and corporations as a way of enhancing the mental health, morale, and productivity of workers.

Media Portrayals of Religion Since the 1990s, there has been increasing tension between people of faith and the media (Day & Golan, 2010). Many view the media as inherently secular and anti-​religious (Olasky, 1990; Draper & Park, 2010; Engelke, 2010; O’Brien, 2021). This is particularly true for portrayals of Christianity and Islam, where movies and news

654 •  P ublic H ealth and H ealth P olic y

broadcasters frequently depict conservative Christians and their beliefs in a negative light (Hoover, 1998; Kerr, 2003; Bailey, 2010), present Islam as a religion of terrorists (Ahmed & Matthes, 2017), and depict anti-​Semitic views toward Jews (Schoenfeld, 2004). RE C O M M E N DAT ION

Policies pertaining to what is appropriate for the public media, Hollywood movies, and social media should encourage a balanced portrayal of religion, without demeaning the faith of any religious group. Media portrayals of the negative aspects of religion should be counterbalanced by reports on the many positive contributions that religious individuals and institutions make to individuals and the public more generally. The latter include (a) personal contributions (money and time) that religious individuals make to help the needy in a community, and (b) the large amount of social services that religious institutions provide to support families, the poor, the sick, the elderly, those affected by disasters, and those with medical care needs. Furthermore, the rightly needed reporting of child abuse in religious contexts or other forms of religious abuse should be complemented by coverage of the successful efforts made to prevent and reduce such abuse, and by coverage of religiously motivated acts of service and self-​ sacrifice by laypersons and clergy. As but one example, many priests in Italy risked and lost their lives caring for COVID-​19 patients during the recent COVID-​19 pandemic, as clergy have done for thousands of years during disasters and other plagues and pandemics (Horowitz & Povoledo, 2020; Bramstedt, 2020). Both the ill and the good that come out of religious communities should be represented in what the media covers.

Tax Exemptions Tax exemptions for religious bodies have long been under threat (Wood, 1986; Tucker, 2019), as have tax deductions for individuals and corporations that provide charitable contributions to religious organizations. For an example of the latter, the 2017 tax revision called the Tax Cut and Jobs Act (TCJA, 2017) resulted in a higher

standard deduction and limit on deductions for state and local taxes, which caused many individuals to take the standard deduction rather than itemize deductions. Consequently, many persons who previously made charitable contributions to religious organizations no longer claimed this itemized deduction, causing them to reduce or eliminate religious donations (Gravelle et al., 2020). RECOM M EN DATION

Government policy toward the tax-​exempt status of religious organizations and nonprofits should be maintained in order to support the important contributions to public health and human flourishing that such groups make. Likewise, public policies regarding charitable donations should not discourage individuals from making contributions to religious organizations, but rather encourage this practice.

Support for Religion-​Health Research Historically, government funding by the NIH in the United States to support studies on religion, health, and other aspects of human flourishing has been very limited, with few exceptions (e.g., PA-​06-​403, 2006). Most research on religion and health has been conducted either without any funding support or with support from the John Templeton Foundation, other Templeton philanthropies, other smaller private foundations, or individual donors. The National Center for Complementary and Integrative Health (NCCIH, part of NIH), the most natural source of support for such research, has not been “friendly” toward grant proposals that have to do with religion and health. Given the evidence summarized in this Handbook, there is every reason to change the current policy at NIH and at other funding bodies in nations outside of the United States in terms of supporting such research. Executive Order 13798, which prevents discrimination based on the religious nature of institutions seeking government grants (Religious Freedom Restoration Act, 2020), should also apply to grants for conducting scientific studies in this area, which ought to be based on their merit and ability to Health Policy Implications • 655

provide information that will advance public health and human flourishing.

health programs and partnerships with healthcare systems on health-​promotion and disease-​prevention outcomes; and (g) research on how to best address the R EC O MME N DATION healthcare-​related spiritual needs of pat­ Policies with regard to resource allocation ients in acute and long-​term healthcare in each of the institutes at NIH, particularly settings, public and private institutions, NCCIH, should reconsider their bias against and veterans’ hospitals, specifically with research on religion and health. To accomregard to identifying spiritual needs and plish this, NCCIH and other institutes at NIH ensuring that trained chaplains are availshould modify their policies toward religion-​ able to address those needs (see below). health grant applications, as well as put out requests for proposals (RFPs) in this area of Support for Religious Community-​ research. We also recommend that considBased Health Programs eration be given to establishing a separate division at NCCIH or another NIH institute As noted above and throughout this Handbook, with the specific task of reviewing grant appli- participation in religious organizations is cations on religion and health. We make this widespread in the United States and around recommendation based on the general lack of the world, with large segments of the populaexpertise on religion and health among many tion participating in religious services or othsocial and behavioral scientists who serve erwise engaged in religious social activities. on NIH review sections and make decisions Furthermore, while the primary goal of most on these grants. With regard to the areas of religious organizations is to produce spiritual highest priority research, particular emphasis growth, many also have a tradition of meetshould be placed on: ing the emotional, social, and physical health needs of members, as evidenced by the many (a) longitudinal studies examining the impact religion-​affiliated healthcare organizations in of religiosity on pathways to and indica- the United States and worldwide. There is great tors of health and well-​being (as described potential for government and private-​ sector above and in the previous chapter); health programs to partner with religious (b) routine collection of data by the govern- institutions in order to promote health and ment on predictors of human flourishing, prevent disease. This would create an opportuparticularly religious community activity, nity to reach a large segment of the population tracking effects on multiple flourishing with health messages in religious community outcomes; settings where people regularly congregate. (c) longitudinal studies to determine the psy- In the United States, the majority of the popchological, social, behavioral, and biolog- ulation belongs to a religious congregation ical mechanisms that underlie religion’s (Duffin, 2020), thereby offering the possibility positive or negative effects on health; of providing health education to millions of (d) longitudinal studies to identify the par- Americans through such programs. ticular circumstances and individuals in which religious involvement is particularly RECOM M EN DATION healthy or unhealthy; (e) randomized controlled trials (RCTs) that Policies should be developed to support (finanexamine the efficacy of sensitive and cially and otherwise) health programs within sensible religious interventions directed religious institutions, and also to support reliat psychological, social, behavioral, and gious community-​healthcare system partnerbiological pathways that lead to human ships that promote population health. With flourishing; regard to the latter, the White House Office of (f) longitudinal studies and RCTs that exam- Faith-​Based and Community Initiatives, estabine effects of religious community-​based lished in 2001 by President George W. Bush, is 656 •  P ublic H ealth and H ealth P olic y

the government agency at least partly respon- policies could be expanded to further encoursible for such support. This Office, renamed the age and financially support such efforts. Center for Faith and Opportunity Initiatives Another practical example of how govern(CFOI) in 2018 by President Donald Trump ment health policies at the state or local level and renamed again as the White House Office might enhance health is through support of of Faith-​Based and Neighborhood Partnerships faith-​community programs coordinated by a in 2021 by President Joseph Biden, has his- congregational nurse. Government resources torically been poorly funded and inadequately might be allocated to provide partial support staffed. Instead, we recommend that resources for a congregational nurse to serve several relibe allocated to expand this Office so that it can gious communities in an area (churches, syndo a better job of promoting, developing, and agogues, temples, and mosques). This could nurturing such government-​ religious com- be limited to congregations with a high permunity partnerships. The Office established centage of older persons likely to have health Centers for Faith-​ Based and Neighborhood problems. The nurse’s tasks might involve Partnerships (CFNPs) in 14 government agen- running congregational health ministries that cies (CFNP, 2020) including the Partnership provide health education regarding diet, exerCenter at the US Department of Health and cise, weight control, risky sexual activity, and Human Services (DHHS), which seeks to “build importance of vaccinations; screening for disand support partnerships with faith-​based and ease (e.g., identification of hypertension, diacommunity organizations in order to better betes, hypercholesterolemia); and healthcare serve individuals, families and communities counseling concerning medication compliance in need” (Partnership Center, 2020, n.p.). The or rehabilitation following hospitalization. A Partnership Center, and CFNPs in other gov- congregational nurse could also act as a liaiernment agencies, could expand their support son between members of the congregation and of collaborations with religious organizations outpatient medical clinics, acute care hospito improve health and reduce health dispari- tals, and nursing homes, communicating with ties within certain population subgroups, such peers (i.e., other nurses) in these settings to as ethnic minorities, the poor, and those with coordinate healthcare. The goal of such an inimental illness. Such policies can and have been tiative would be to improve health behaviors, developed without violating the Establishment prevent disease, increase the timely seeking Clause (and have been buttressed by the of medical care, increase treatment compliReligious Freedom Restoration Act and Execu­ ance, speed recovery from illness, and prevent tive Order 13798). expensive re-​hospitalizations. A congregational This includes supporting government–​ nurse might also recruit and train volunteers private-​sector partnerships that promote col- from the congregation to, for example, suplaborations with religious communities and port those with health problems, serve as a religious community leaders. For example, healthcare advocate, or provide respite for a partnership between DHHS and Columbia stressed family members caring for those with University Teachers College was formed in dementia. The latter might help caregivers to order to provide a series of webinars for mental continue to care for loved ones at home, rather healthcare providers and clergy on spirituality than place them in a nursing home (for which and mental health (Miller, 2020). A partner- Medicare or Medicaid would have to pay). These ship has also developed between the American are just a few ways that a congregational nurse Psychiatric Association and faith leaders in could reduce healthcare costs and enhance the order to improve the relationship between well-​being of congregants with medical or psymental health professionals and clergy (APA, chiatric problems, and thereby improve public 2014). The latter has involved a joint effort to health. enhance the detection of psychiatric illness at Policies could also be initiated that encourthe religious community level, increase timely age clergy and other members of a congregareferrals, and reduce the stigma of mental tion to visit individuals hospitalized in acute illness in faith communities. Government or long-​ term care settings. Current policies Health Policy Implications • 657

and hospital regulations can make this difficult due to Health Insurance Portability and Accountability Act (HIPPA) laws, even after patient consent has been obtained. Many hospitalized patients, particularly older adults in long-​term care settings with few family members, would benefit from supportive social interactions of this type, which may enhance well-​being and reduce social isolation. The latter has been a particular problem during the recent COVID-​19 pandemic that has required strict limitations on visitors and confinement of patients in long-​term care facilities to their rooms with no close in-​person social contact.

Integrating Spirituality into Healthcare At the end of each chapter in this Handbook we have suggested practical applications of the research findings for healthcare professionals. Given religion’s effects on health and the role that religion plays in coping with illness and healthcare decision-​making, we have emphasized the need to integrate spirituality into patient care, stressing the importance of doing so in a patient-​centered manner. Public-​ and private-​sector healthcare policies could be developed to support such integration, given that the vast majority of physicians and nurses do not regularly take a spiritual history or talk with patients about their health-​related spiritual needs (Curlin et al., 2006; Koenig, 2013; Taylor et al., 2017). The situation is getting worse in this regard. Trained pastoral care providers capable of addressing patients’ spiritual needs cannot address the needs of all patients, stressed family members, and care for the spiritual needs of hospital staff. Furthermore, chaplains are becoming fewer in number due to efforts to control hospital budgets. Because of this, those hospitalized in private-​and public-​sector institutions (as well as those in the military or confined in prisons) may have limited access to religious support that may be essential to the well-​being of those in these institutions. Community clergy may not visit these places, leaving such individuals isolated and unable to freely exercise their religious rights as guaranteed by the Free Exercise Clause. As a

result, it has been the policy of US healthcare institutions, the military, and the prison system to provide pastoral services to support these individuals’ free expression of religion. Consequently, hospitals in the United States have provided pastoral care services since at least the 1920s (Thornton, 1970), the military has done so since the 1700s (Lasson, 1992), and the prison system has included chaplains since prisons were first established (Sundt et al., 2002). Some of these services are supported by taxpayer funding under the Free Exercise Clause. However, a significant shortage of chaplains has been reported in acute care hospitals, where the chaplain-​to-​patient ratio has decreased to 1 to 100 on average (Flannelly et al., 2004) and is far worse in long-​term care settings, especially those that are not religiously affiliated (Schwanke, 1986). These data are old, and with growing limits on hospital expenditures and reduction in pastoral care budgets, the problem has become an urgent one (Timmins et al., 2018; Hall, 2020). RECOM M EN DATION

Governments should consider modifying health­ care policies to incentivize the assessing and addressing of patients’ spiritual needs when seeking outpatient and inpatient healthcare, whether in public or private settings. One example might be the development of a policy requiring such assessment by JCAHO. As noted above, this is a private healthcare organization that monitors hospital practices in both government and private-​sector settings. Prior to 2005, JCAHO required that a spiritual assessment be taken on all patients admitted to acute care hospitals, nursing homes, or home health organizations, and specified what should be included in that assessment (Koenig, 2001b; Warnock, 2009):

658 •  P ublic H ealth and H ealth P olic y

Spiritual assessment should, at a minimum, determine the patient’s denomination, beliefs, and what spiritual practices are important to the patient. This information would assist in determining the impact of spirituality, if any, on the care/​ services being provided and will identify if any further assessment is needed.

The standards require organizations to define the content and scope of spiritual and other assessments and the qualifications of the individual(s) performing the assessment. (Joint Commission website)

issues of religion and spirituality within clinical contexts. Such training could in principle also include approaches to community promotion efforts oriented toward enhancing health and well-​ being. For patients who positively identify with That requirement has changed. JCAHO recom- a religious or spiritual tradition, clinicians could mends, but no longer requires, that a spiritual inquire about and even encourage communal assessment be taken. It now only requires that involvement, when appropriate. For patients all healthcare organizations “respect patients’ without such beliefs and affiliations, other forms cultural and personal values, beliefs, and pref- of community involvement could likewise be erences” (RI.01.01.01 EP6) (Koenig, 2013). encouraged, as noted above. Again, taking a spirJCAHO specifies that the healthcare organiza- itual history can help inform clinicians when tion is responsible for deciding what informa- such discussions are appropriate. Such conversation to collect, which may or may not involve tions within clinical care should also be sensitive a spiritual assessment. How can health pro- to those who may have suffered past negative fessionals respect a patient’s cultural and per- experiences or even abuse from religious comsonal values, spiritual beliefs, and preferences munities, and a spiritual history may help without inquiring about those beliefs? JCAHO uncover such painful past experiences, which now only requires that a spiritual assessment can then prompt empathy, support, and referrals be done on patients receiving end-​of-​life care to appropriate specialists. This more sensitive (PC.01.02.01 EP4), treatment for alcohol or nuanced approach is not a universal prescription, substance abuse (PC.01.02.11 EP5), or treat- but rather respects and encourages other forms ment for emotional/​behavioral disorders (PC of community participation for those who do 01.02.13 EP3), and the extent to which even not self-​identify as religious. This approach also these requirements are in force today remains helps address prior objections about such discusunclear. We recommend that JCAHO con- sions (Sloan et al. 1999, 2000) concerning clinisider requiring that a spiritual assessment be cians and patients having different beliefs, the obtained on admission to acute care hospitals topic being too sensitive, the instrumentalizing (as it had previously done) and have this docu- of religion, lack of clinician training, and conmented in the medical record. cerns about proselytization and abuse of power Once spiritual needs are identified during (VanderWeele et al., 2022). The approach will the spiritual assessment, someone needs to often, however, help uncover spiritual needs and address them. The healthcare chaplain is often simply lead to referrals to religious professionals. the only healthcare professional trained to do Chaplains will of course continue to play so. Further training of clinicians, not only in an important role in the provision of spiritual taking spiritual assessments, but also poten- care. In the United States, hospitals are primartially in providing very basic spiritual care, or in ily responsible for hiring healthcare chaplains. making referrals to chaplains, could assist con- CMS provides some support in this regard. siderably. Lack of clinician training certainly CMS support, however, is limited to costs for does require attention, as prior training in spir- the training of new chaplains to prepare them itual care is one of the strongest predictors of for certification, and does not support regular clinicians providing such care (Balboni et al., pastoral care staff (Warnock, 2009). As noted 2013). While many medical schools now offer above, with hospital budgetary pressures, electives in spiritual care (Koenig et al., 2010b), chaplains are often the first healthcare profesthis is not likely sufficient, as few students par- sional to go. We recommend a national policy of ticipate. As part of the core curriculum, a one-​ subsidizing the salaries of board-​certified prosession training module that reviews neutral fessional chaplains in hospitals and long-​term spiritual-​assessment questions in the context care facilities to ensure adequate staffing, perof existing epidemiologic evidence may more haps doing so through expanding the existing powerfully facilitate an approach to raising support received from CMS. Health Policy Implications • 659

Suicide Prevention Religious involvement has been repeatedly found to predict fewer suicidal thoughts, attempts, and completions in prospective studies conducted both within and outside the United States. As noted in Chapter 7, religious beliefs discourage suicide and improve coping with stress, increase hope, provide meaning and purpose to life, and reduce depression, substance use, and other psychiatric disorders that drive suicide rates up. R EC O MME N DATION

Health policies directed at suicide prevention, both in the general population and in special population subgroups at higher risk for suicide (e.g., youth, older males, veterans suffering from severe trauma), should be designed in a way that bolsters the existing religious resources to which these individuals have access. Likewise, policies should allocate resources to support the hiring of healthcare (and workplace) chaplains and religious counselors to care for religious individuals who may be at risk for suicide. For example, special task forces—​such as that recently developed within the US Veterans Administration to reduce suicide rates in veterans (Rubin, 2019)—​should consider religious approaches to suicide prevention among those who are religious. Again, all efforts in this regard should be implemented in a patient-​centered manner, focused on supporting the person’s existing religious beliefs and practices.

SUMMARY AND CONCLUSIONS The findings on religion, health, and well-​being reported in this third edition of the Handbook have important implications for health policy at the federal, state, and local level in the United States, at the private health sector level, and at government and private health system

levels in other countries. In this chapter, we first defined public policy and health policy, which are generally understood as laws, rules, and regulations affecting environments in which people live, work, learn, and play. Next, we highlighted the sensitive nature and limitations of health policies, particularly those that might be viewed as affecting religious freedoms or interfering with state-​church separation. We then made recommendations in 10 areas for authoritative bodies to consider with regard to policies that affect the health of the public. Specifically, those recommendations have to do with (1) preserving the free expression of religion in the public arena; (2) utilizing religion to support marriage and family life, the basic unit in society that drives public health; (3) expanding the inclusion of religion in public school education; (4) developing business and corporate policies that protect religious rights of employees and employers; (5) encouraging a more balanced portrayal of religion in the media; (6) maintaining tax exemptions for religious organizations and tax deductions for individual donations to religious causes; (7) increasing funding for research on religion and health at the individual and population level; (8) increasing support for partnerships between healthcare organizations and religious communities to meet the health needs of members (the majority of the US population) and the communities in which they live; (9) increasing efforts to identify and address the health-​ related spiritual needs of patients in healthcare settings; and (10) including pastoral care providers in programs designed to prevent suicide. We emphasized that health policies and their accompanying legislation should be religion-​ friendly and religion-​respectful, viewing religion as a resource that promotes health in most cases (with some exceptions that are notable). Again, the purpose of these recommendations is to help governments and private-​sector entities to develop health policies that will promote the health and well-​being of individuals and the public.

660 •  P ublic H ealth and H ealth P olic y

SECTION IX Conclusions IN THIS FINAL section, we review the findings from quantitative research on the relationship between religion and health, examine the rigor of the findings, review the complexity of the relationships, and discuss the implications for clinical practice, public health, and health policy, concluding with a few final comments on the path forward. At the end of this section, we have also included the Appendix, which briefly summarizes the research studies

in this Handbook’s extensive review, including key research summaries, meta-​ analytic reviews, and commentaries on the topic of religion and health. And following this, the Handbook also contains a list of all references cited in the text and in the Appendix and has a detailed index of topics covered, all of which we hope will be valuable resources for understanding the research literature on religion and health.

34 Summary and Conclusions The cardinal error of science lies in shutting the Creator out of His Creation. —​Walter Russell

A GREAT DEAL of research has been covered in the more than one-​half million words contained in this third edition of the Handbook. There is no question that research in this field has exploded, despite the difficulty of obtaining funding to conduct such research. Much research continues to be done without financial support, limiting the quality of the work that can be accomplished. When the first and second editions of the Handbook were published, the goal was to systematically identify and synthesize the published research on religion and health from around the world written in the English language. When reviewing research for the second edition, it became evident that the published research literature had more than tripled in the previous 10 years (2001–​2010), with the number of published quantitative studies on religion/​spirituality (R/​S) and some aspect of health or clinical practice increasing from 1,200 identified in the first edition to nearly 4,000

studies. Over 2,800 original quantitative studies that examined the R/​S -​health relationship had been published in those 10 years. The quality of that research varied enormously (ranging from very low to high), with the overall quality not having changed much in the years that followed the publication of the first edition of the Handbook. This might be attributed to the increasing numbers of new R/​S -​health journals and their acceptance of somewhat lower-​quality studies, which counterbalanced the publication of higher-​quality studies. At the same time, established mainstream journals had become more open than in previous years to publishing the more rigorous R/​S -​health research. In this third edition of the Handbook, any attempt to cover all the published quantitative research on religion and health would have been futile, since the accumulation of research has continued to dramatically increase since 2010, making it almost impossible to identify, review, and summarize all of these studies. Thus, we

Handbook of Religion and Health. Third Edition. Harold G. Koenig, Tyler J. VanderWeele, and John R. Peteet, Oxford University Press. © Oxford University Press 2024. DOI: 10.1093/​oso/​9780190088859.003.0034

have tried to focus in this volume only on the highest-​ quality studies, sometimes examining the findings from cross-​sectional research involving large random samples documenting associations, but especially emphasizing the results from longitudinal cohort studies and randomized controlled trials (RCTs), i.e., studies that provide evidence with regard to causal inference. The question of causal inference has become a particularly important one during the past decade, as more and more research on religion and health has been published, including large prospective cohort studies. Given the often positive associations between religion and health outcomes, researchers have increasingly asked the question “Does religious involvement improve health, or does health affect religious involvement, or both, and to what degree?” We think there is now good evidence from strong studies that religious involvement does in fact affect health in various ways, justifying our recommendations for health policy described in the previous chapter. Much further research, however, is needed to understand how, when, and where religion does so, and how clinicians and public policymakers can best utilize this information to maximize individual flourishing and optimize public health. In some areas of health—​particularly physical health and specific disorders—​the research has been less abundant than in the areas of mental, social, and behavioral health, or on longevity. Therefore, along with high-​quality studies, we have chosen to include in the Appendix of this volume smaller cross-​sectional studies, particularly if conducted in special populations (e.g., non-​ Christian populations, minority groups, or locations in the world where not much research on the topic has been done). These studies we hope will serve as a basis for future longitudinal studies and RCTs. Despite the existing evidence, rationale, and logic that suggest religion affects health, we are only beginning to discover the mechanisms that explain how religious beliefs and practices have such influences. A better understanding of the scientific mechanisms will hopefully help to propel the field of religion and health into the mainstream of the psychological, social, behavioral, and medical sciences. 664 •  C onclusions

In this final chapter, we summarize and comment on the content of previous chapters. This is accomplished by (1) briefly summarizing Section I on research methodology; (2) summarizing the research results reported in Sections II, III, V, and VI on mental, social, behavioral, and physical health; (3) discussing the quality of the research findings thus far reported; (4) reviewing the clinical, public health, and health policy implications of the existing research findings; and (5) describing priorities for future research.

RESEARCH METHODOLOGY Central to the interpretation of past research findings and conducting of future studies are the research methods that investigators employ. Methodology involves definitions and measures, along with research design, data collection, and statistical analysis.

Definitions Definitions of constructs such as religiosity and spirituality are crucial because they determine the content of measures used to assess them, on which the interpretation of the research concerning religion and health rests. The term “spirituality” has evolved over time from its historic grounding in religion to a much broader construct that has expanded to include those who are religious, not religious, and even those who do not acknowledge they are spiritual (i.e., everyone). Attempts to quantify spirituality defined in this broad and nebulous manner have led to an encroachment on mental health, resulting in the inclusion of indicators of good mental health in measures of spirituality, thus sometimes producing meaningless, tautological findings when examining the relationship between spirituality and mental health. Thus, we have focused principally on religion in this Handbook to ensure that the findings from research do not lead to such biased and uninterpretable results, particularly when examining mental health outcomes. These results, however, may also be interpreted as pertaining to one’s spirituality, of which engagement with religion is a part. This approach to measurement and use of language when conducting

research contrasts with that recommended when applying the research findings to clinical practice, where a broad and inclusive term such as “spirituality” fits very well indeed. A nonspecific construct of this type allows patients to define spirituality for themselves, and allows healthcare providers to address spirituality in the way that the patient defines it (i.e., in a patient-​centered manner).

Measurement In Chapter 2 of this Handbook, single and multi​item measures of religious involvement were reviewed, including those that assess religiosity and religious coping in religions other than Christianity (the religion in which most measures have been developed). Some of the best scales for use in future research were suggested, particularly multi-​item measures that comprehensively assess religious activity and commitment. However, we also noted that single-​item measures of religious service attendance seemed to consistently manifest some of the strongest and most robust associations with health. We emphasized that the choice of measure depends on the research question and questionnaire space available, as well as the underlying theory for why a particular aspect of religion might influence the health outcome being studied.

Research Design In Chapter 3 of the Handbook, we reviewed the various types of research design, stressing the importance of understanding the strengths and weaknesses of each research design. We began by emphasizing the specification of a research question, which will determine the research design, the type of sample, and the funding required to carry out the study. Research designs include those that are observational (qualitative, cross-​ sectional, and longitudinal or prospective) and those that are experimental (single group experimental studies, nonrandomized CTs, and RCTs). We emphasized the importance of prospective cohort studies and RCTs in advancing knowledge in this field. For prospective cohort studies, we stressed the length of follow-​up and the

number of follow-​up assessments. We emphasized that participants need to be followed for a long enough period so that changes in the health outcome have a chance to occur, which may be many years. Likewise, we underscored the value of researchers carrying out multiple assessments during follow-​up of both religion and the health outcome. We also devoted some discussion to data collection, use, and analysis. Highlighted was the importance of assessing the degree of exposure to religion over the participant’s lifetime in order to identify the cumulative effect that religion might have on the health outcome (rather than examining the effect of religion assessed only at one time point later in life on future health changes). Finally, the importance of conducting RCTs was repeatedly emphasized, since this is the strongest research design for definitively establishing causal inference.

RESEARCH FINDINGS In our comprehensive review of studies repor­ ted in the second edition of the Handbook, approximately 4% of studies found that highly religious people experienced worse mental health and about 9% reported they had poorer physical health. This is in contrast to the vast majority of studies (roughly two-​ thirds of studies published prior to or during 2010) that reported significant positive relationships between R/​S and health. These studies found that R/​ S people experienced more positive emotions (well-​being, happiness, life satisfaction), fewer emotional disorders (depression, anxiety, suicide, substance abuse), more social connections (social support, marital stability, social capital), lived healthier lifestyles (exercised more, consumed healthier diets, engaged in less risky sexual activity, smoked fewer cigarettes or never smoked), participated in more disease-​screening activities, and were generally more adherent to treatment. Those findings help to explain why the majority of studies have reported that religious people experience better physical health (e.g., less cardiovascular diseases, better immune and endocrine functions, less cancer or better prognosis), and greater overall longevity. As the quality of the studies increased for many health outcomes, Summary and Conclusions • 665

the likelihood of finding a positive relationship between R/​S and health has also increased. The research published in the last 10 years, often using better research methods, has largely confirmed those findings.

addiction, teenage pregnancy), particularly after taking into account socioeconomic factors that adversely affect social capital.

Mental Health

One of the strongest findings both from past and more recent research has been the relationship between religiosity and health behaviors. Greater religiosity has been related to less cigarette smoking, more physical activity and exercise, less extramarital and risky sexual activity, less drinking while driving, and fewer other high-​ risk activities, and recent research has confirmed these reports. We have repeatedly emphasized that poor health behaviors are a major factor in the development of chronic disease, 80% of which could be prevented by behavioral modification. Religious involvement, then, may have its greatest impact on mental and physical health through this pathway.

With regard to the relationship between religiosity and mental disorders, the strongest evidence for a beneficial effect of religiosity is from studies on depression, suicide, and substance use disorders. Recent large prospective studies using state-​of-​the-​art research methods and statistical analyses have now documented this, replicating results from earlier studies that employed less stringent designs and weaker statistical approaches. Moderately strong and consistent relationships continue to be found between religiosity and positive emotions such as psychological well-​ being, life satisfaction, meaning and purpose in life, hope and optimism, gratitude, and generosity. Unfortunately, most of the studies of psychological well-​ being have been cross-​ sectional in design, with only a few prospective studies and RCTs.

Social Health Given the emphasis placed by many religious traditions on gathering together, on family and marital relationships, and on treating others fairly, it is not surprising that greater religiosity is associated with more social support and greater marital and family stability in recent studies. Religious traditions typically stress human virtues and moral values (e.g., forgiveness, honesty, courage, self-​ discipline, altruism, humility, gratitude, patience, dependability), which helps to explain higher-​quality social relationships, and a lower likelihood of delinquency during youth and crime during adulthood among religious persons. Finally, the greater likelihood of prosocial efforts to improve the general community by religious individuals may account for some of the association between religious involvement and greater social capital (e.g., community involvement, trust between members, rate of volunteering, and lower rate of crime, drug 666 •  C onclusions

Behavioral Health

Physical Health Recent studies on religiosity and physical health, although less abundant than for mental health, generally confirm the positive effects reported earlier on cardiovascular diseases, cancer, dementia, disability, and immune and endocrine functions. However, for no physical health outcome are the findings more evident than in studies of religion’s effects on overall mortality. Recent large prospective studies following populations for 15–​ 20 years have found that greater religious involvement, particularly frequent attendance at religious services, is associated with greater longevity and reduced mortality from cardiovascular diseases and cancer, explained in part by improved health behaviors (e.g., less cigarette smoking), greater social support, and better mental health (less mental disorder and more positive emotions). After careful statistical control for confounders, and even mediating factors in many studies, mortality rates during follow-​ up are one-​quarter to one-​third lower among those who frequently attend religious services. Furthermore, physical disability and cognitive impairment with increasing age appear to be less, and physical pain may be more tolerable among those who are more religious.

QUALITY OF THE RESEARCH The strength of these relationships is sometimes strong, but more often is only moderate or weak. Theoretically, R/​S involvement ought to be related to better mental, social, and physical health for many reasons, particularly given its inverse associations with many characteristics and behaviors that lead to the development of disease. Yet for some outcomes we often do not see the strong relationships that might be expected. For certain outcomes, such as longevity, suicide, or substance abuse, the evidence is very consistent and robust. However, for other outcomes such as the incidence of cardiovascular disease or cancer, the evidence is somewhat more varied across studies. Why is this so? Why are these relationships not stronger? One possibility is that the effects of religiosity are simply relatively weak. However, there are other explanations as well. We propose that there are at least four potential additional reasons for sometimes observing only weak to moderate relationships between religiosity and health: (1) measurement issues related to the subjective nature of self-​reports of religiosity and of subjective self-​reports of health, and the potential incongruity of such reports with reality; (2) the complexity of the relationship; (3) researchers not assessing the cumulative nature of these effects over the person’s lifetime; and (4) the poor quality of research, sometimes due to lack of adequate funding support. While these factors influence the relationships reported between religiosity and mental, social, and behavioral health, they are particularly important for studies examining physical health outcomes, which are almost totally dependent on indirect effects conveyed through psychological, social, and behavioral mediators.

Measurement Religiosity and many of the health outcomes to which researchers are trying to relate religiosity, particularly psychological, social, and behavioral outcomes, are often assessed by subjective self-​report. This is also true to some extent for measures of physical disability, general health, and chronic pain. Since measurement in these

cases is based on what individuals report, there is room for error, as such self-​ratings may not be accurate. There is no blood test or x-​ray to objectively determine a person’s level of religiosity, psychological well-​being, social support, or severity of chronic pain. The introduction of such measurement error will often reduce the strength of any true effect that religiosity may have on these outcomes. Relatedly, there may be inconsistency between what people report on questionnaires and how they actually live their lives (Hadaway et al., 1998). Living according to the high moral values and teachings to which religions often espouse may be difficult, even for the most religiously devout individuals. Those who claim they are religious may not “practice what they preach.” Mark Chaves emphasized this in his 2009 presidential address at the Society for the Scientific Study of Religion (Chaves, 2010). Religious beliefs and behaviors are often “context dependent,” such that individuals may be very loving, forgiving, and altruistic in religious settings (i.e., church or synagogue or mosque), but may behave quite differently during the week at work, at home, and during play. It has been said that the spiritual path involves slowly and gradually bringing life into alignment with one’s beliefs, as the person seeks to control the powerful drives for pleasure that involve selfishness, dishonesty, unforgiveness, vengefulness, and greed, all of which are part of the human condition. If individuals do not practice what they say they believe, there is no reason to expect that religion will affect their health. This lack of religious congruency, i.e., the disconnection between religious beliefs and behaviors and their integration into people’s lives as habits of living and behaving, adds measurement error to the relationship between religion and health. In other words, when subjects in a study indicate on a measure of religiosity that they are religious, that religion is important to them, or that they pray or go to church regularly, this may not translate into a lifestyle that reflects those beliefs or practices. If this is true for many self-​described religious people, then it may weaken the relationship between religiosity and health by diluting out the effects that truly lived religion has on health. Summary and Conclusions • 667

Finally, the meaning of various religious beliefs and practices may vary across religions or even within a single religion. For example, weekly church attendance is more important for Catholics than for Protestants, whereas Bible reading is more important for Protestants than Catholics. Likewise, frequency of attendance at the mosque may mean something entirely different for Muslim men (who are obligated to attend for Friday prayers) compared to Muslim women (who do not have that requirement). If different practices mean different things for different religions and for different genders, then the measurement error that this introduces will further weaken relationships between religion and health if participants with different religious views and genders are all lumped together, as is frequently done.

Complexity of the Relationship As if the subjective nature of religious reports, the lack of congruency between what is said and what is done, and the different meaning of religious practices for different groups were not enough, the effects of religion on health are very complex. They are almost certainly bidirectional, with religiosity not only affecting measures of health, but health also affecting aspects of religiosity. Furthermore, these bidirectional effects are changing over time; i.e., they are not static or constant. For example, people often turn to religion for comfort and coping (e.g., praying more, congregating more often with believers for support) when they become physically ill, and may also do so when they are anxious, stressed, or overwhelmed by life circumstances. In contrast, young, healthy, and situationally well-​off individuals may feel they have little or no need for religion, as they are happy exactly the way they are. This dynamic creates a positive association between religiosity and poor health. Alternatively, problems with physical or mental health may reduce religious activity; i.e., people who are sick may not be physically able to attend religious services, and those who are depressed may not want to attend because they lack interest, have low energy, or are socially withdrawn (classic symptoms of depression), or they may be unable to concentrate during 668 •  C onclusions

prayer or scripture study. People may also turn away from religion if stressors continue and prayers remain unanswered, or may reduce or stop their religious involvement if stressors improve. This dynamic might create a positive association between religiosity and good health. These bidirectional effects are also changing over time as individuals cope with their situations or their health or circumstances change. Such changing influences of health on religion and religion on health over time may influence the religion-​ health relationship, sometimes producing an overall weak association, especially if the confounding factors are not adequately controlled for. On top of bidirectional effects that are changing over time, because religiosity tends to bring about greater longevity, this can give rise to selection biases. Because religiosity helps even sick people to live longer, it may then seem that religiosity is related to sickness (or less strongly related to health) because those who were sick but less religious are more likely to die over time. Indeed, there seems to be some evidence of such selection biases with regard to various measures of healthy aging (Li et al., 2018b). The relationship between religion and health may of course also be influenced by many other factors (as illustrated in Chapters 16 and 31). There are genetic factors (the presence of certain genes and/​ or gene-​ environment interactions that influence temperament), developmental factors (rearing practices related to basic needs being met during vulnerable life stages), powerful aging effects (gradual deterioration of the physiological systems that promote healing and resiliency), and environmental factors (accidents, socioeconomic deprivation)—​all of which affect health and often affect religious beliefs and practices as well. Many of these factors may be difficult to measure or may be measured inaccurately, and therefore are difficult to control for, adding unexplained variance to the relationships being studied. Confounders that can be accurately measured include age, gender, race, education, and socioeconomic status. However, accuracy in measurement may be more difficult for genetic effects, childhood experiences, and cultural, societal, or media influences. In addition to

inaccurate measurement and poor control for confounders as described above, there may also be unknown or unmeasured factors that affect both religiosity and the health outcomes being studied. This too may influence the strength of the relationship between religious involvement and health. Finally, associations may be altered and attenuated by controlling for variables that may in fact be mediators (rather than confounders) of the religion-​ health association. Such variables might include, for instance, health behaviors and social support. We have repeatedly emphasized in this Handbook the importance of controlling for such variables in the period prior to the religiosity assessment so as to ensure that such variables are confounders, rather than mediators (VanderWeele, 2015). These concerns are of course particularly worrisome in observational research (cross-​ sectional and prospective longitudinal cohort studies). The fact is that most research on the religion-​ health relationship has been observational in design, since such studies may be less expensive and easier to conduct than high-​ quality RCTs. For a more thorough discussion of how complexity affects the findings from prospective cohort studies on religiosity and mental health, see Koenig et al. (2020b).

Cumulative Effects Another possible explanation for what are sometimes observed as modest associations between religiosity and health, especially for physical disease incidence, may be related to the cumulative nature of the effects of religiosity on health. If religiosity affects disease incidence principally through behavioral, psychological, and social mechanisms, these may take considerable time to accumulate. The total effects of religious participation may only be evident if religiosity, as an exposure, is studied cumulatively over time. Almost all of the religion-​health research, including almost all of the most rigorous studies, examines religiosity at a single point in time and examines its effects on subsequent outcomes. However, if the religiosity assessment is made in mid-​to late life, with control made for prior behavioral, psychological, and social variables, then, while this may be sufficient to assess the effects

of mid-​to late-​life religiosity, it will not adequately reflect the cumulative effects of religiosity over time. It will not, for example, capture early life or young adulthood influences of religiosity on subsequent later-​life physical health. Conversely, if one studies religiosity in early life but the study has a relatively short duration, then there may be inadequate follow-​up time for diseases to have much likelihood of developing. Examining the cumulative effects of religiosity on physical health is challenging, both from a study design perspective and from an analytic perspective. It is challenging from a study design perspective because it requires data collection that begins relatively early in life with a long follow-​up period, and with repeated measures of both religiosity and health and other confounding variables as well. Such studies are time-​ consuming and expensive, and also difficult to implement without having substantial dropout. Furthermore, even with such data, there are analytic challenges. This is because traditional regression methods are not adequate to assess the cumulative effects of a time-​varying exposure if there is the sort of bidirectional relationship and time-​varying confounding described above. In these cases, more sophisticated causal models are needed (VanderWeele et al., 2016a). There is evidence that when examining the cumulative effects of time-​varying religiosity over multiple periods, using such causal models, the effect sizes on mortality are even larger than when considering religiosity at a single point in time (Li et al., 2016b). The same might well be true, and perhaps would be even more pronounced, in examining the effects of religiosity on outcomes like the incidence of cardiovascular disease or cancer over decades.

Research Quality Poorly designed studies are more likely to produce biased or weak results that may lead to inaccurate conclusions. Thus, unless (1) the religious variable is carefully thought out beforehand and chosen for its likely relationship to a health outcome based on a plausible theory; (2) a sensitive, reliable, and accurate measure of that religious variable is used; (3) the right Summary and Conclusions • 669

health outcome is chosen, e.g., one that is likely affected by psychosocial and behavioral factors; (4) a sensitive, reliable, and accurate measure of the health outcome is used, and in longitudinal studies, a sufficient length of follow-​up is allowed for changes in the outcome to occur; (5) the right research design is chosen, one that is capable of detecting a relationship if present; (6) the right sample is chosen and sample size is adequate to avoid type II error, i.e., is powered to detect the effect; (7) the study is managed correctly and carried out as designed; (8) interviewers are well trained so that they ask the questions and record the answers correctly (and those answers are correctly entered into the datafile); (9) statisticians correctly code, re-​ code, and sum variable responses to accurately obtain scale scores; and (10) the right statistical tests are run and correct modeling of relationships is done (potentially also identifying direct and indirect effects through mediators)—​it is unlikely that strong relationships will be found. Failure in any one of these 10 research quality indicators may bias effect estimates. One of the most important factors that influences research quality is having sufficient funding support to carry out a study in the way that it is designed (sufficient funds to pay for the time of experienced primary researchers and consultants, hire sufficient research staff to recruit subjects and conduct the study, reimburse subjects for time and travel, buy equipment, etc.). As noted in the last chapter, funding support for conducting studies on religion and health has been lacking, with the majority of studies conducted with no funding support at all and often on borrowed time. The result is many studies of low quality, reporting weak associations between religion and health.

Summary Given the above concerns about subjective reports of religiosity and health outcomes, congruency between what is reported and what is lived, differences in the meaning of religious beliefs/​practices in different religions and genders, complexity of the dynamics in the religion-​ health relationship and factors affecting it, and the poor quality of many studies sometimes due to inadequate funding 670 •  C onclusions

support, we would expect that only the most robust relationships between religion and health are likely to be consistently detected. The results summarized in this and the previous editions of the Handbook, then, almost certainly represent only an imperfect indication of the actual effects of religiosity. As measures of religiosity improve and greater funding support allows for higher-​quality studies (e.g., more sophisticated study designs, and more accurate ways of analyzing the data that take into consideration complexity), we expect to find even stronger relationships than previously reported.

CLINICAL AND PUBLIC HEALTH IMPLICATIONS Despite the complexity of the religion-​health relationship and limitations in many studies that have examined that relationship thus far, the research findings reported in this Handbook indicate that religious beliefs/​practices often have significant effects on health, usually positive and occasionally negative. We summarize here the implications that these research findings have for clinical practice, public health, and human flourishing more generally.

Clinical Implications Clinical implications have been described at the end of each chapter on specific health outcomes. In summary, the primary implication for healthcare professionals is that the research reported here justifies the routine taking of a spiritual history, i.e., to be willing to discuss these matters with patients rather than ignoring or avoiding them. This is not only because religious and spiritual beliefs are widespread among sick patients, often influence their coping with mental or physical illness, and addressing spiritual needs related to illness can improve well-​being and quality of life, but also because religious beliefs influence medical decision-​making and compliance with the treatments prescribed. A clinician may not be able to optimally practice in their area of expertise without such information, especially in populations that are moderately or highly religious.

Besides taking a spiritual history, we have repeatedly emphasized that identifying and addressing spiritual needs in clinical settings must be patient-​ centered, focusing on the patient’s religious beliefs/​ practices or lack thereof, without proselytizing or any attempt at coercion. However, when treating religious patients, we have emphasized that clinicians can support the religious beliefs and practices that patients find helpful in coping to enhance their health and well-​being. Such support may simply be verbal or may involve simple religious interventions that show respect for the patient’s faith tradition (e.g., providing accommodations allowing the patient to practice their religion, prayer with the patient if requested, and/​or referral to pastoral care providers to address spiritual needs). In patients with depression or anxiety, more advanced interventions may be considered, such as religiously integrated cognitive-​ behavioral psychotherapy or various forms of pastoral counseling. For patients who are not religious, we have recommended that state-​of-​the-​art secular medical and psychological therapies be implemented in a kind and supportive manner: “to cure sometimes, to relieve often, to comfort always” (Siegel, 2018). These recommendations apply to outpatients, home care patients, acutely hospitalized patients, and those in chronic institutional settings such as assisted-​living settings, nursing homes, and state mental hospitals. The addressing of spiritual needs should also, with the patient’s explicit consent, be coordinated with their faith community (clergy, clergy staff, and/​or members of the community as indicated). This must be done in order to comprehensively address the spiritual needs of patients once they return home from medical or rehabilitation settings. Recommendations were also made for community clergy on how to provide health education to congregants through sermons, religious education classes, and the adoption of health ministries that address the health needs of those within and outside the congregation. The goals of health education and on-​the-​ground health ministries at the congregation level are to help members achieve good health and maintain it, enabling them to be active in advancing the mission of the congregation (vs. being

sick and needing to be cared for) and, also, in reducing the time that clergy will need to spend visiting congregants in the hospital or at home when health problems develop.

Public Health and Policy There are numerous public health implications of the impact that religion may have on the mental, social, behavioral, and physical health, and the flourishing of individuals in society. As reviewed in Chapter 32, religious involvement is related (a) indirectly to public health and human flourishing through each of the four major pathways that lead to flourishing, and (b) directly to each of the six indicators of human flourishing considered in that chapter. The effects thus far identified and summarized in this Handbook are sufficient to encourage further research at the population level on the health influences of religious belief and practice. There are also implications for the role of the faith community in health promotion and disease detection, not only at the congregation level but also at the community level, which include the education of youth and adults in terms of human virtues and moral values, the strengthening of marriages and families (the basic communal unit of society), and the building of social capital within the broader society. Collaboration between public health organizations and faith communities may be an important strategy for maintaining or improving the health of the general population. Since public health is affected by healthcare policies implemented by all levels of government and by private-​sector organizations, the research findings on religion and health also have implications for health policy and public policy more generally. In Chapter 33, we made 10 recommendations for instituting or modifying health policies in ways that might address barriers to human flourishing and thereby improve the health of the public. These recommendations pertained to the (1) public expression of and participation in religion, (2) marital and family stability, (3) religious education, (4) expression of religion in the workplace, (5) portrayal of religion in the media, (6) tax exemptions and deductions, (7) funding Summary and Conclusions • 671

support for religion-​health research, (8) funding support for religious community-​ health programs, (9) incentives for healthcare organizations to integrate spirituality into patient care, and (10) inclusion of religion in suicide prevention programs. These policy recommendations were intended for the United States and for other countries as well. More than 80% of the world’s population are affiliated with a religious organization and engage in religious practices of some sort, and these practices often affect health. Therefore, the benefits (and liabilities) of these beliefs/​practices should be relevant to authoritative bodies who are partly responsible for population health, particularly as secularism increases within certain parts of the world.

FUTURE RESEARCH PRIORITIES Each chapter of this Handbook addressing a specific disease outcome has included a section describing recommendations for future research. We have emphasized that much of what can and needs to be done in the future will depend on the availability of research funding. This is why it is so important that national funding bodies, such as the National Institutes of Health and National Science Foundation in the United States, begin to expand their support for research on religion and health. Enough is already known about the religion-​ health relationship based on thousands of quantitative studies, including numerous large high-​ quality prospective studies and RCTs, to warrant investment in research to better understand the effects that religion has on health at the individual and population level and how to leverage such research to promote population health. Cross-​sectional studies can still make a contribution to our understanding of the descriptive associations between religion, health, and demographics, especially with understudied health outcomes, populations, religions, and geographical locations. However, large prospective cohort studies that follow individuals for prolonged time periods (preferably across the life span) must be the focus of future research, along with RCTs and efforts to identify effective religious 672 •  C onclusions

interventions at the individual and population level. With regard to the latter, for example, research is needed to assess the contributions to public health of disease-​prevention/​ health-​ promotion programs implemented in faith communities, as well as the cost-​benefit ratio of providing support for a congregational nurse to lead such programs. Furthermore, the benefits and risks of religious interventions in healthcare settings need to be determined, such as taking a spiritual history, praying with patients, providing religious accommodations, and interventions by pastoral care providers that address spiritual needs. While recommendations for clinical application described above are reasonable, based on the results of observational studies and the experience of seasoned clinicians, there is comparatively little research from RCTs for supporting their adoption.

FINAL COMMENTS The twin healing traditions of religion and medicine have slowly split apart over the past 500 years with the development of modern scientific medicine. Within the past two decades, however, there are signs that the deep rift between these two traditions may be closing. Interest in more integrative and complementary forms of medicine is increasing. Research has shown that medical patients have religious and spiritual needs closely related to their physical health, and the same can be said for psychiatric patients and their mental health. Psychoneuroimmunology and psychosomatic medicine are shedding light on the physiological mechanisms by which psychological, social, and behavioral factors affect physical health. These mechanisms provide us with highly plausible reasons for suspecting that sincerely practiced religion may impact health—​quite apart from supernatural influences that generally lie beyond scientific investigation. What is health? What is religion? What is healing? Returning now to definitions, the American Heritage Dictionary (2020) describes health as “1. The overall condition of an organism at a given time. 2. Soundness, especially of body or mind. . . . 3. The condition of optimal well-​being . . . [our italics].” The word heal comes from the German word heilen, which means “to become whole,”

“to set right,” or “to restore.” While we have focused principally in this book on physical and mental health, and to a certain extent on social health, an all-​encompassing notion of wholeness or flourishing arguably also includes spiritual health as well. This Handbook has provided an extensive review of the empirical research relating participation in religion to physical, mental, and social health. However, many religions of course have as their principal goal not just physical, mental, and social health, but also, and often principally, spiritual health—​a deeper connection with God or the transcendent. The role of religion in bringing about spiritual health is of course the topic of study of many theologies. With the potential introduction of tradition-​ specific measures of spiritual well-​ being, it might also become the topic of empirical research (VanderWeele, 2020a; VanderWeele et al., 2020c). This was not, however, the topic of this Handbook, in which we have focused on physical, mental, and social health as outcomes. In reviewing the literature on religion and physical, mental, and social health, the intent is not to instrumentalize religion for purposes that are not its own, but rather to show the consonance of the ends which religion and medicine promote, and to show the unity of health, or wholeness. Participation in religion and in a religious community can promote health-​related physical, mental, social, and spiritual ends. The word religion itself comes from the Latin word religare, which is composed of two roots:

re and ligare. Re means “back” and ligare means “to bind, to bind together.” Thus, the word religion literally means to bind back together. Religion binds back people into a community that is united around a shared vision of a deeper connection with the divine or transcendent. Religion, through this community and shared vision, has the capacity to bind people back together to God, to the sacred, to the transcendent. That binding of people together creates health; it creates wholeness. It can bring about a physical, mental, social, and spiritual wholeness. True religion has the capacity to bind together and to heal. It can bring healing to those who participate in religious communities; it can bring healing to those who are ill; it may even have the capacity to bring healing to the rift that has been created with scientific medicine. When our patients or we ourselves become physically ill or mentally out of balance, we need to be bound back together. Indeed, health, religion, and healing all have a common goal: making the person whole, sound, transforming him or her into a state of optimal well-​being—​ putting the person, both mind and body, back into order and balance. Understanding how they all work together through research on religion and health, interpretative reflection upon what is found, and multidisciplinary dialogue on what it all means will be key to maximizing human flourishing at the individual and population level.

Summary and Conclusions • 673

Appendix Studies on Religion and Health (Topics arranged in order of chapters)

I. DEFINITION OF CATEGORIES/​ ABBREVIATIONS Investigators: first author/s (year of publication) Type: CS =​cross-​ sectional; PC =​prospective cohort (years); RS =​retrospective; Rco =​retrospective cohort; CT =​clinical trial; Exp =​experimental study (intervention, but without a control group); CC =​case-​control; D =​Descriptive only (no analyses), R =​review, number in parenthesis ( ) indicates years of follow-up in prospective studies or “m” for months Method (Sampling Method): R =​random, probability, or population-​based sample; S =​systematically identified sampling (e.g., consecutive patients); C =​convenience/​purposive sample; R/​C =​unclear whether random or convenience/​ purposive, or random with low response rate; R/​S =​unclear whether random or systematic; Q =​qualitative (see below).

N: number of subjects in sample; in case-​control studies, N =​cases and Cs =​controls Population: C =​children; Ad =​adolescents; HS =​high school students; CS =​college students; CDA =​community-​ dwelling adults (all ages); E =​elderly; MP =​medical patients; PP =​psychiatric patients; NHP =​nursing home patients; CM =​church members; R =​religious/​ clergy; Vets =​veterans; F =​female, M =​male; B =​Black, MA =​Mexican American, W =​White, AAm =​Asian American Location: city, state (abbreviated per usual convention), or country (US =​United States; UK =​United Kingdom; CAN =​Canada) Religious Variables: # = number of religious questions; ORA =​organizational religious activities (religious attendance, church-​related activities, religious giving); NORA =​non-​ organizational religious activities (personal prayer, scripture reading, religious TV/​radio);

 • 675

SR =​subjective religiosity (importance, self-​ rated religiousness, etc.); R =​ religiosity; Sp =​spirituality; SSp =​importance, self-​rated spirituality; RCm =​religious commitment; IR =​intrinsic religiosity; ER =​extrinsic religiosity; Q =​quest; SWB =​spiritual well-​being (RWB religious well-​being and EWB existential well-​being); RC =​religious coping; NRC =​negative religious coping, pleading, religious strain, negative interpersonal religious interactions or negative religious support, spiritual decline, negative relationship with or attachment to God; PRC =​positive religious coping; RB =​ religious belief; RE =​religious experience; CM =​ church membership; D =​denomination or affilia­tion; SDA =​ Seventh-​Day Adventist; SpS =​spiritual support; RSup =​church-​based support, Sp =​spirituality scale (unspecified); R =​religious (general); DSE =​daily spiritual experiences scale; ATG =​attachment to God; WHOQOL-​ SP =​World Health Organization Quality of Life—​Spirituality, Religion, Personal Beliefs (typically excluded from this review due to confounding); BMMRS =​Brief Multi­ dimensional Measure of Religiousness/​Spiritua­lity; FACIT-​ SP =​Functional Assessment of Chronic Illnses Therapy Spiritual Well-​ being (typically excluded from this review due to confounding); DUREL =​Duke University Religion Index (ORA, NORA, IR); BIAC =​Belief into Action Scale; © as used here does not mean “copyright,” but rather indicates scale may be contaminated by indicators of mental health, contain items that are not distinctively spiritual or other psychological constructs Findings: NA =​no association with health outcome; P =​at least one positive association with a better health outcome (p < 0.05) and no negative associations; (P) =​positive association only but significance borderline (0.05 < p < 0.10); NG =​at least one negative association with a better health outcome (p < 0.05) and no positive associations; (NG) =​negative association only but significance borderline (0.05< p ” means better mental or physical health, lower mortality, less depression, better health practices, or greater use of religion or religious activity, compared to other group. 676 •  A ppend i x

Controls: NS =​no statistical analyses; none =​no controls—​analyses not controlled for confounders (i.e., simple correlation or chi-​square analyses); SC =​some controls (but important other variables not controlled); MC =​multiple controls (numerous important variables controlled using regression models); note: religious control variables are excluded. Rating: 1 to 10 (1 =​poor, 10 =​excellent), based on 10 criteria: (1) quality of the peer-​reviewed journal in which study was published, (2) study design: (a) cross-​ sectional studies receive lowest rating, (b) prospective studies receive higher rating, prospective studies with control for baseline outcome receive yet higher rating, especially if follow-​up conducted over many years, (c) randomized controlled trials (RCT) receive higher ratings, depending on how well the RCT was designed and carried out based on standard criteria for RCTs, especially quality of the control group; (3) if cross-​sectional, whether the sample was identified by convenience, systematic, or random sampling; (4) sample size, with larger the sample sizes receiving higher ratings; (5) the type/​quality of sample; (6) quality of the religious/​spiritual measures (absence of tautology); (7) quality of outcome health measure; (8) control for confounders (how many confounders were controlled for and if appropriate); (9) quality and sophistication of the statistical methods; and (10) quality of presentation and interpretation of the findings. In this third edition, only studies rated 8, 9, or 10 are included; “(8)” indicates that rating is lower than 8, but study is included because of its noteworthiness, particular population, or topic on which little information exists. Miscellaneous Abbreviations: exc =​except; MH =​mental health; Parg =​Pargament scale; CA =​cancer; mamo =​mammography; SIDS =​sudden infant death syndrome; prost =​prostate; PAP =​pap smear; chol =​cholesterol; br self =​breast self exam; flu sh =​flu shot; BP =​blood pressure Not Included Here (generally) are dissertations, qualitative studies (except qualitative studies of non-​English-​speaking people/​ countries or non-​ Christian religions about

which there is very little published research), reviews (except classic meta-​analyses or seminal reviews), case reports, case series, studies with very low sample sizes, studies published in book chapters, books, or peer-​reviewed studies not published in the English language; intercessory prayer studies, not considered in the same category of scientific research as other studies

cited here, have been included in a separate section at the end. Unless otherwise specified, search terms used are religion or religiousness or religious or religiosity or spirituality (and) health or medicine. * indicates that study has been reported in a previous section.

Appendix • 677

Commentary

Commentary

Commentary

Commentary

Commentary

Commentary

Commentary

Review

Commentary

Commentary

Salander (2006)

Koenig (2008)

Tsuang & Simpson (2008)

Salander (2012)

Garssen et al. (2012)

Reinert & Koenig (2013)

Puchalski et al. (2014b)

Garssen et al. (2016)

Garssen & Visser (2016)

Koenig (2018a)

P OP UL AT ION

L O C AT ION

R E L IG VA R I ABL E S

FI N DIN G S

R

CS

R

CS

CS

CS

R

R

CS

CS

Glock & Stark (1965)

Allport & Ross (1967)

Hunt & King (1971)

Hoge (1972)

King MB & Hunt (1972)

Discusses and provides definitions for religion and spirituality (Ch 1, pp. 4–​16)

Discusses whether “spiritual well-​being” predicting depression is relevant or interpretable

King MB & Hunt (1975)

Wilson J (1978)

Gorsuch (1984)

*Krause (1993)

Levin et al. (1995b)

309

CM

1990

1356 CM (Presbyt)

CM

CDA

R

R 1978

709

CDA, B

CDA

Reviews ways of measuring religiousness

Reviews ways of measuring religiousness

R

S

93

Review and critique of Allport’s IE scales C

R AT I N G

National US

world-​wide

United States

Texas

New Jersey

MA, NY, TN

#12 ORA,NORA,SR

#18 ORA,SR,RB

#98 scale development

#59 scale development

#10 IR scale

#20 IR-​ER

—​ —​

—​

—​

—​

—​

—​

—​ —​

—​

—​

—​

8

9

8

8

—​

—​

Examines studies examining relationship between spirituality and psychological well-​being, finding 45% contaminated

Discusses definition of spirituality for use in end-​of-​life healthcare settings

Discusses definitions of spirituality for use in nursing research and practice

Review, development, and testing of the renowned Glock & Stark religiosity scales C

C ON T ROL S

Reinforces concern about spirituality measures in nursing research being contaminated with indicators of well-​being

Addresses concerns about spirituality and circular findings

Response to Koenig (2008) above

Concerns about current definitions and measurement of spirituality in research

Discusses the definition and use of the word “spirituality”

“Selling spirituality: The silent takeover of religion”

Discusses the conceptualization and measurement of spirituality

N

Measurement (Chapter 2) (for research purposes) (© indicates possible contamination with mental health items/​other outcomes; R/​V =​Reliability/​Validity)

Commentary

Carrette & King (2004)

M E T HOD

Commentary

T YPE

Hill & Pargament (2003)

Definitions (Chapter 1)

TOPIC / ​I N V E S T IG ATOR S

I. RESEARCH METHODOLOGY

CS

CS

CS

Commentary

Researchers in psychiatry at Harvard comment on Koenig (2008) “Concerns about measuring ‘spirituality’ in research”

Historian and Unitarian minister comments on Koenig (2008) “Concerns about measuring ‘spirituality” in research”

Grulke et al. (2003)

Reitsma et al. (2007)

Francis & Katz (2007)

*Koenig (2008)

*Tsuang & Simpson (2008)

Franch (2008)

CS, Jewish

CDA

CDA (>14 years old)

CDA (Gen Soc Surv)

Israel

Netherlands

Germany

National US

8

R/​V of 9-​item IR, 9-​item ER, 10-​item Quest, 6-​item Glock

C R

CS

CS/​P

R

CS

Commentary

Liu & Koenig (2013)

Migdal & MacDonald (2013)

Chen H et al. (2014)

Koenig et al. (2015a)

Koenig et al. (2015b, c)

576

1,199

Kuwait

MP (cardiac surgery) New Jersey

HS (age 17–​18) (Muslim)

Examines components of religious attendance

Garssen et al. (2016)

C

8

8

8

2,425

247

1,039

(8)

Demonstrates that existential well-​being assoc more w psychol WB than w Sp

Caregivers

NC and Calif

#10   R/​V of Belief into Action Scale (BIAC, original)

(8) Further discussion and documentation of concerns over contamination of spirituality measures with MH indicators

231

8

8

R/​V of modified measures of religiosity

Rural China

CDA in Western China R/​V of DUREL; reliability 0.90, test-​retest 0.87 in 188, 1 factor

CS in Midwest US

CDA, F, ages 13–​34

Addresses concerns about spirituality and circular findings

Reinforces concern about spirituality measures in nursing research being contaminated with indicators of well-​being

MC

Develop, R/​V 23-​item Sahin-​Francis Attitude to Islam Sc

Describes measures of religiosity with psychometrics (chap in Measures of Personality and Social Psychological Constructs)

R

Commentary

CS

*Salander (2012)

CS

Commentary

Rosmarin et al. (2011a)

8

8

R/​V of German 15-​item Systems of Belief Invent (Holland)

R/​V of 24-​item Katz-​Francis Sc of Attitude to Judaism

8

8

R/​V of 33-​item Fetzer BMMRS

R/​V of 10-​item Relig Commitment Inventory (original)

8

R/​V of 22-​item Relig Life Inventory in PP

United Kingdom

8

Generates D-​specific weights for each question

Ohio/​Nation US

8

R/​V of 105-​item RCOPE

N Carolina, Ohio

CS, CDA,PP,counselors Eastern US

PP (schizophrenia)

CDA

CS/​MP,E

9

9

Concern about construct overlap & tautology created by inclusion of positive MH indicators in measures of ‘spirituality’

618

512

1,967

1,445

1,414

155

>2100

540/​551

Describes development of a 6-​item trust/​mistrust in God scale that assesses attachment/​relationship with God

C

C

C

R

R

R

C

S

*Garssen et al. (2012)

CS

CS

Idler et al. (2003)

Idler et al. (2009)

CS

Worthington et al. (2003)

CS

Describes step-​by-​step how to develop and test psychometric properties of a new scale or measure (applicable to religion & health)

Krause (2002a)

Francis et al. (2008a)

CS

Siddle et al. (2002a)

R

C/​S

—​

CS

—​

CS

#60+​ RCOPE

Mockabee et al. (2001)

Ohio & NC

—​

Pargament et al. (2000)

CS/​MP,E

540/​551

Compendium of religious measures with psychometric properties and citations

S

—​

R

#5 ORA,NORA,IR (DUREL original)

CS

North Carolina

Hill PC & Hood (1999)

CDA/​MP

7000/​86

*Pargament et al. (1998)

S

CS, PC

Koenig et al. (1997c), Koenig & Bussing 2010a)

C

427

U.S. Vets/​Active Duty

Southern U.S.

Mainland China #10

#10

R E L IG VA R I A BL E S

C ON T ROL S

Discusses causal inference and longitudinal data analysis, with religion and mental health as an example

(8)

8

R AT IN G

R related to lack of community support for RCT involvement

VanderWeele et al. (2016a)

San Diego, CA

Examines issues related to causal inference (Oxford University Press)

VanderWeele (2015)

CDA, Latina F

CS

Daverio-​Zanetti et al. (2015)

503

Examines effects of asking R questions first (priming) and effects on responses to subsequent health behavior questions (order effects) C

commentary on religious service attendance and major depression—reverse causality (AJE)

Rodriguez et al. (2014)

Describes marginal structural models to estimate direct and indirect effects in longitudinal data

VanderWeele (2009)

VanderWeele (2013)

Directory of wealthy individuals, contact information, kinds of activities they support (book)

Hoover’s (2009)

Describes methods, measurement, statistical approaches, and resources for conducting spirituality & health research

Describes how to use statistical package STATA-​10 to analyze data (not specific to religion-​health research) (book)

Hamilton (2008)

Invited commentary on marginal structural models (American Journal of Epidemiology [AJE])

Directory of private foundations that includes details on the 1000 largest foundations (3,030 pages) (book)

Jacobs (2007)

VanderWeele (2012)

Describes basics of statistical methods; easy to read, humorous, lots of examples (not specific to religion-​health research) (book)

Norman & Streiner (2007)

Koenig (2011a)

Describes public use data sets from the National Center for Health Statistics for religion-​health research

An evidence-​based guide to writing grant proposals for clinical research (Annals of Internal Medicine)

Inouye & Fiellin (2005)

Gillum & Dupree (2007)

Grant Writer’s Handbook provides invaluable information on how to write and structure grants for NIH and private foundations (book)

Reif-​Lehrer (2004)

Describes methods of conducting randomized clinical trials (not specific to religion-​health research) (book)

Describes epidemiological methods in clinical research (not specific to religion-​health research) (book)

Hulley et al. (2001)

Describes state-​of-​the-​art methods in qualitative research (not specific to religion-​health research) (book)

Describes qualitative methods of research (not specific to religion-​health research) (book)

Denzin & Lincoln (2000)

Streubert-​Speziale & Carpenter (2006)

Describes the essentials of designing randomized clinical trials (not specific to religion-​health research) (book)

Piantadosi (2005)

Describes statistical methods verbally rather than numerically; highly recommended (not specific to religion-​health research) (book)

Friedman et al. (1999)

R/​V of Moral Injury Symptom Scale (original)

R/​V of Chinese BIAC

F I N DIN G S

Motulsky (1995)

Research Methods and Design (Chapter 3) (research methods, statistics, grant writing, funding sources; books included in this section)

CS

CS (ave age 21.5)

Edited book whose authors describe different ways of measuring religiosity

Koenig et al. (2018b,c)

1,830

L O C AT ION

Finke et al. (2017)

C

P OP U L AT ION

CS

N

Wang Z et al. (2016a)

ME T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

CS

Discusses sensitivity analysis in observational research (E-​value)

CS

Discusses outcome-​wide longitudinal designs for causal inference (Statistical Science)

Meng et al. (2016)

VanderWeele & Ding (2017c)

Ojukwu et al. (2018)

VanderWeele et al (2020b)

PC (2)

PC (2)

Pargament et al. (2004)

Reynolds et al. (2014b)

S

CS

CS

S

R

C

S

S

a

WTP =​willingness to participate in clinical trials research.

Croog & Levine (1972)

PC,D

PC (10m)

Heart/​Cardiovascular Disorders

CS

Narayanan et al. (2020)

PC (9m)

Ahmadi & Ahmadi (2015)

Cancer

Tix et al. (1998)

Kidney Disease

Adzika et al. (2017)

CS

CS

Koenig et al. (1998d)

Sickle Cell Disease

PC (1)

S

PC(6m) S

Koenig et al. (1998a)

324

117

2,417

174

387

128

268

577

86

202 of 850

188

478/​173

R/​C C

1,024

S

Koenig et al. (1992)

Medical Illness (general/​chronic)

Coping with Stress (Chapter 4)

PC (8)

Hayward & Krause (2016a)

MP, E

MP, E

Durham, NC

Durham, NC

Durham NC

Durham NC

Minnesota

Ghana

MP, M (s/​p MI)

MP, renal cell CA

Massachusetts

Texas

MP, cancer (61% > 59 y)  Sweden

MP, Renal transpl

MP, sickle cell dis

Ad, cystic fibrosis/​diabetes Alabama

MP,E

MP,E

Massachusetts

National US

National US

II. MENTAL HEALTH

CDA,B

W/​B CDA

CDA,E (> 65 yo)

MC

MC

MC

P (Protestants MC only) 

33% reported this coping behavior

P (PRC)

NG

P

MC MC

NA (exc NRC)

#3 R feelings/​views to R 9% incr per yr None

#3 ORA, NORA, RC

Thinking about God, Jesus, etc. (83% small or not at all)

#11 RC,D

#1 Believe (faith) in God

#14 RC (PRC,NRC)

#63 RC

#69 RC, ORA, NORA, SR

P P

#4 D, RC #12 IR, ORA, NORA

8

8

(8)

9

(8)

8

8

8

9

9

B who are more spiritual more likely to participate in research

R activity in W was NG w WTPa in research; in B, it was P

Dropouts were less religious, less educated, more depressed

Discusses whether “spiritual well-​being” predicting depression is relevant or interpretable

Commentary

*Garssen & Visser (2016)

Examines studies examining relationship between spirituality and psychological well-​being, finding 45% contaminated

Review

*Garssen et al. (2016)

CS

Besharat et al. (2018)

Idler et al. (2001) (last yr of life)

PC (12)

PC (4)

Fider et al. (2019)

End-​of-​Life (dying)

CS

Koenig et al. (2016a)

R

S

C

C

C

CS

CS

Hebert et al. (2007)

PC

Winter et al. (2015)

C

CS

C

C

Rabins et al. (1990)

CS

C

Folkman et al. (1994)

Caregiver Stress (CG)

Unterrainer et al. (2016)

Skin Disorder

PC (4)

Kremer et al. (2015)

C

PC (10)

Kremer & Ironson (2014)

C

PC (1.5) C

CS

S

C

C

M E T HOD

Trevino et al. (2010)

HIV/​AIDS

Norenzayan et al. (2012) (autism)

Neurological Disease

Skolarus et al. (2012)

CS

PC (2)

Trevino et al. (2014)

Cerebrovascular Disorder

T Y PE

TOPIC /​IN V E S T IG ATOR S

2,812

585

251

1,227

1,229

62

82

149

177

177

429

327/​706

1,838

327

43

N

CDA, E

Caregivers, Adventists

Stressed caregivers

New Haven, CT

MC

8

8

(8)

(8)

8

8

#3 ORA, SR, RC

# (?) (God image, RSup, IR)

MC

P

While ORA decr, SR and RC stable or incr

MC

P

8

8

(8)

SC

MC

MC

SC

MC

—​

8

8

#41 ORA, IR, etc.

P

P

P (HIV+​)

P

P

(P) (qualitative)

NA (exc NRC) MC

P (less autism)

(8)

(8)

(8)

R AT IN G

8

#3 ORA, NORA, SR

National US

SC

None

C ON T ROL S

#5 ORA, NORA, SR, RC M (P in 4 of 5) MC

Multi-​site US

#10 RB/​Misc

#48+​ R/​Sp well-​being

#1 “Spiritual coping”

#1 “Spiritual coping”

#19 DUREL, NRC, PRC

#1 Belief in personal God

#1 RC

NC & Calif

P

P (QOL)

F I N DI N G S

R/​S very import for meaning in 80% of Latinos, 62% of Ws

#10 RWB

#37 RC, R scale

R E L IG VA R I A BL E S

Baltimore

Alzheimer’s caregivers Multisite US

Caregivers (Alz dis)

CG of Alz D & CA pts

CG HIV+​, 162 HIV-​ San Francisco

Austria

Miami, FL

MP, HIV/​AIDS

MP, severe skin dis

Miami, FL

Multi-​site US

Canada

Corpus Cristi, TX

Iran

New Jersey (?)

L O C AT ION

MP, HIV/​AIDS

MP, HIV/​AIDS

Ad/​adults -​ autism

MP, stroke

MP, coronary artery dis 

MP, 1st time infarction 

P OP U L AT ION

PC (3)

CS

CS

Mohr et al. (2010)

Das et al. (2018)

Serfaty et al. (2020)

R

C

C

C

C

C

C

1,432

CS

PC (56 d) C

CS

CS

CS

CS

CS

Pienaar et al. (2007)

Whitehead & Bergeman (2011)

Shiah et al. (2015)

Frick et al. (2016)

Bussing et al. (2016)

Henderson W et al. (2016)

VanderWeele et al. (2017a)

C

R

C

C

C

R

S

CS

Larson R et al. (2006)

36,613

6304

7,390

8,574

451

244

1,794

2,280

27 /​31

—​

CT

Oman et al. (2006)

93

—​

CT

Bormann et al. (2006)

Orthodox Jews, psychosis

PP, schizo

PP, schizo

PP and 57 clinicians

Inpt alcohol/​drug detox

Florida

CDA, B

National US

National US

Germany

Catholic clergy/​ helpers Young parents

Germany

Clergy and deacons

Taiwan

Indiana

CDA, age 55-​80

#3 ORA (youth groups)

#4 ORA, NORA, RC, SR

#4 R affil, ORA, NORA, SR

#6 DSE©

#15 DSE©, Sp dryness

#20+​RB, R activities

#5 DSE©

#4 RC (COPE)

Illinois

“spiritual mantram” Passage meditation

South Africa

CDA (CS and non-​CS)

#20 Sp coping #7 D, ORA, SR, NORA, RB

Colorado

San Diego, CA

National US

#30 RB, SR, RC, Trust

#4 (faith scale of WHO-​SRPB)

Israel

# many (qual to quant)

India

#10+​ORA, NORA, SSp

#18 SR, RB, RC

Switzerland

Switzerland & Canada

Massachussetts

Police officers

Ad (11th graders)

Health professionals

MP (HIV+​)

CDA (2016 GSS)

165 mothers/​fathers infant death

30

48

115

221

331

Perceived Stress (most often assessed by Cohen’s Perceived Stress Scale)

CS

CS

Hawthorne et al. (2016)

Feigelman et al. (2019)

Bereavement

CS

CS

Borras et al. (2010)

Schizophrenia/​Chronic Psychosis

Medlock et al. (2017)

Addiction MC

None

MC

—​

—​

SC (sex)

SC

None

None

None

None

P

NA

P

None

MC

MC

NA (exc Sp dry) MC

NA

P (moderating) MC

NG

P

P

NA

P (only controlled analysis)

P

NA

P

C (complex)

59%–​69% Sp very important for PP

P (except NRC)

8

8

8

8

(8)

8

8

8

8

8

(8)

(8)

(8)

(8)

(8)

(8)

(8)

CS

CT

Butler-​Barnes et al. (2018)

Alemdar et al. (2018)

-​

R

M E T HOD

62

1161

N

Mothers, NICU

Youth ages 13–​ 17, B

P OP U L AT ION

Turkey

National US

L O C AT ION

Spiritual care intervention

#3 ORA, NORA, SR

R E L IG VA R I A BL E S

P

P (Caribbean B)

F I N DIN G S

PC (2)

PC (1)

PC (2.5)

PC (4)

CS

PC (2)

PC (6m)

CS

PC (4)

Gall et al. (2011)

*Krumrei et al. (2011)

Ai et al. (2012)

Chan & Rhodes (2013)

Tsai et al. (2015)

Tsai et al. (2016)

Trevino et al. (2016)

*Gesselman et al. (2017) (PTSD)

Tsai & Pietrzak (2017)

PC

CS

Williams D et al. (1991)

Mitchell et al. (1993)

Stress Buffering (religiosity as a moderator)

Commentary

Joselph (2011)

R

R

R

C

C

R

R

C

C

C

C

S

CS

Laufer et al. (2010)

R

PC (5)

Greenfield & Marks (2007b)

National US Israel

CDA (over age 35) Ad, grades 7–​10

#14 IR, ER

#1 ORA (not attendance) P

P

SC

MC

—​

MC

C ON T ROL S

868

720

2,718

498

111

1,838

3,157

386

262

89

87

CDA CDA,E

North Carolina

New Haven, CT

National US

Multi-​site US

Breast CA pts +​ spouse dyads Veterans

Boston, Houston

National US

Veterans, E, M, cancer

Veterans

National US

New Orleans

Low-​income mothers Veterans

Michigan

Multisite US

Canada

MP, cardiac surgery

Divorced in past 6 mo

MP, breast cancer

#7 RB (rlg intervention)

#2 D, ORA

#5 DUREL

#10 Sp Persp Sc

#1 R change (increased)

#5 DUREL

#5 DUREL

#16 ORA,SR,RC

NG

P

P

P

P

P

P

P (indirect)

P (PRC)

P (PRC)

#54+​PRC, NRC, R scale #38 ORA, NORA, RC, SSp

M

#51 RC, God image, R sc

MC

MC

MC

SC

MC

MC

MC

MC

MC

SC

S (?)

Draws attention to inclusion of R/​Sp in measures of PTG, potentially leading to confounding in R/​Sp-​PTG relationship

2,999

4,646

Post-​Traumatic Growth or Stress-​Related Growth (note that measures may include items assessing spiritual growth, possibly leading to construct overlap)

T Y PE

TOPIC /​IN V E S T IG ATOR S

8

8

9

(8)

(8)

9

8

8

8

8

8

8

9

(8)

8

R AT IN G

C

CS

PC/​CS

CS

PC (56 d)

CS

CS

Bradshaw & Ellison (2010) (financial)

Button et al. (2010) (genetics)

Rostosky et al. (2010) (sex ID)

*Whitehead & Bergeman (2011)

Momtaz et al. (2011) (social isol)

Momtaz et al. (2012) (chron ill)

CS

PC (2)

Salas-​Wright et al. (2014a) (risk)

Dzivakwe & Guarnaccia (2014) (diab ctrl)

b

LGBT =​lesbian, gay, bisexual, transsexual.

CS

El Ansari et al. (2014) (dep symps)

R

CS

CS

Acevedo et al. (2014)

CS

Kabiru et al. (2014) (adverse events)

Wang T et al. (2014) (poor hlth)

R

CS

Kidwai et al. (2014)

R

R

R

C

R

R

R

CS

CS

Sprung et al. (2012) (job stress)

R

R

C

R

S

Archibald et al. (2013)

Rostosky et al. (2010) (sex ID)

R

CS

Krause (2006c)

R

PC

Chang BH et al. (2003)

R

CS

Chang BH et al. (2001)

2,539

183,912

3,220

5,165

1,504

3,064

1,071

3,570

854

1,415

1,415

244

13,038

2,754

1,140

906

2,375

3,543

P (well-​being) P (well-​being)

#11 IR, ER #11 IR, ER

MP, diabetics, E

Ad & young adults

CS (ave age 25)

CDA (non-​students)

National US

National US

#2 ORA, SR

#4 ORA, SR, IR

#1 SR

#? R belief England/​Wales/​ N. Ireland

#6 ORA, NORA

China

#5 ORA, NORA, SR, RB, RC,

NG (depression)

P (drug selling)

NA (alcohol use)

P (happiness)

P

P (delinquency)

P

NA (stress-​ depression)

#12 SR/​SSp, NORA, ORA #4 ORA, SR, RC

NG

#12 DSE©

Texas

Kenya

Ad, ages 12–​19 CDA

Baltimore

National US

National US

Malaysia

Malaysia

CDA

CDA, B

CDA

CDA, E (age 60 or over)

CDA, E (age 60 or over)

P

P (in heterosexuals)

MC

MC

MC

?

MC

MC

MC

SC

SC

MC

MC

MC

NG (F, LGBT) (heavyalcohol)  MC

#5 DSE©

Indiana

MC

MC

MC

MC

P (ad only) (alcohol use)

P

P (esp F)

P

P

CDA, age 55–​80

#5 SR, ORA, NORA, IR

#4 ORA, NORA, RB

#5 ORA, gratitude to God

#2 ORA, RC

#2 ORA,RC

#3 ORA, SR

Colorado

National US

National US

National US

National US

Ad (LGBTb vs. Hetero) National US

Ad twins, MZ/​DZ

CDA

CDA, E

M veterans (sex assault)

F veterans (sex assault)

9

9

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

CS

CS

CS

Litwin et al. (2017) (chron hlth)

CS

Jung et al. (2017) (depression)

Salas-​Wright et al. (2017)

CS

Doumit et al. (2017)

Kerksieck et al. (2017)

CS

CS

Reinert et al. (2016)

Henderson AK (2016) (child adv)

R

CS

Ikram et al. (2016)

CS

CS

Krause et al. (2016a) (life trauma)

CS

CS

Abu-​R aiya et al. (2016)

Sandhu et al. (2016)

PC (3)

Lechner & Leopold (2015) (unemploy)

Debnam et al. (2016)

C

PC (1)

Helms et al. (2015) (peer victim)

1,637

8,594

R

18,614

R

1,180

949

5,191

5,217

5,340

10,283

11,780

1,589

2,140

5,446

313

1,805

N

C/​S

C

C

R

C

R

R

R

R

C

R

CS

McDougle et al. (2014) (volunteering)

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

CDA,E (age 50 or older)

Catholic clergy/​ pastoral

Ad, age 12–​17

CDA, E (> age 60)

Lebanese CS, F

#1 NORA (freq of pray) P (self-​ realization/​ pleasure)

Israel

P (neuroticism-​SOC)

P (marijuana use) #11 DSE, R trust

#2 ORA, SR

P (suicidal ideation)

P

#15 D, IR, ER (Gorsuch) #5 DUREL

M

NA

NA

#3 ORA, RC, child R socialization

#? Sp measure

#1 SR

P

#15 RC, IR

MC

None

MC

SC

MC

MC

MC

MC

SC

MC

MC

P (C-​reactive protein) P

MC

MC

SC

MC

C ON T ROL S

P

P (life satisf)

P (depresson)

P (self-​rated health)

F I N DIN G S

#1 R practice (yes vs no)

#1 praying for others

#12 Rcm, RC, R hope, R sanc

#1 ORA

#4 ORA, IR

#9 ORA, NORA

R E L IG VA R I A BL E S

Germany

National US

South Korea

Lebanon

National US

Baltimore

CDA, B

National US

C, grades 6–​8

North America

Netherlands

National US

National US

Germany

North Carolina

National US

L O C AT ION

CDA

CDA, 7th Day Adventists

CDA, ethnic minorities

CDA

CDA

CDA

Ad

CDA, age 25–​74

P OP U L AT ION

8

(8)

9

(8)

8

8

8

8

8

8

8

8

9

8

8

R AT I N G

c

ATG =​attachment to God.

PC (1)

CS

Tavares et al. (2019) (stress)

Ironson et al. (2020) (div/​death)

PC (6)

Lee DB & Neblett (2019) (SLE)

CS

PC (6m)

Lorenz et al. (2019) (stress)

PC(10)

CS

Foong et al. (2018) (depression)

Sharif et al. (2019) (BMI)

PC (8)

Bierman et al. (2018) (discrim)

Kim D (2020)

CS

Rosmarin et al. (2018) (sex abuse)

PC (3)

CS

PC (10)

Jung et al. (2018) (child abuse)

Bradshaw & Kent (2018) (ATGc)

CS

R

CS

*Butler-​Barnes et al. (2018)

Vang et al. (2019) (R descrim)

R

CS

Yoon et al. (2018)

Debnam et al. (2018) (stress)

C

CS

Wang L et al. (2017) (apo ε4)

C

R

C

R

R

C

R

R

C

C

R

R

C

R

Krause et al. (2017b) (volunteer) CS

R

CS

Krause et al. (2017a) (finan strain)

S/​R

CS

Talib & Abdollahi (2017) (depress/​hopeless)

157

6,081

1,000

4,734

1,595

348

2,322

7,130

372

27,874

21,890

1,024

1,635

1,161

476

2,410

2,265

2,622

1,376

#5 DUREL

Ireland

Miami, FL

South Korea

MP, HIV/​AIDS

Iran

CDA, age 45+​

National US

#4 RC

#2 R affil, ORA

P (viral load)

P (effect of disability on WB)

P (body image)

P (C-​reactive protein)

#6 ORA, NORA, IR #5 ORA, NORA, IR

P (dimishes w incr age)

#5 D, ORA, NORA, SR

P (depression)

P (cognitive dysfunction)

#6 IR

P (distress)

# D, ORA, IR

Malaysia

P (drug use)

P (sleep probs)

National US

MC

MC

MC

MC

MC

MC

MC

SC?

None

MC

SC

MC

MC

MC

MC

MC

SC

MC

P (life satifaction) MC

P (well-​being)

P (pos emotions)

P

#2 SR, RC

#4 D, ORA, NORA, SR

#7 NORA, ATG

#7 ORA, RB, SR, Sp

#3 ORA, NORA, SR

P (burden)

#6 D, ORA, NORA, IR

P (pulse rate) P (mild cogn impair)

#3 Rcm/​IR #5 DUREL

P (drug use)

P (suicidal behavior)

#3 “religious meaning”

#16 DSE©

#3 D, ORA, SR

National US

Northeast US

Maryland

Canada

National US

National US

National US

South Korea

China

National US

National US

Malaysia

CDA, ave age 41

CDA, E (> age 50)

Ad (B)

PP

CDA, E (age 60 or older)

CDA, E, >age 50

CDA, Jewish

HS students (ave age 16)

CDA

CDA,E (age > 65)

CDA, middle age

Youth age 13–​17, B

Caregivers of dementia

CDA, age 55 or older

CDA

CDA

Ad (ages 13–​18)

8

8

(8)

8

10

8

8

10

(8)

9

9

9

9

8

(8)

(8)

8

8

8

PC

Laffey et al. (2020)

CS

CS,D

CS,D

CS

CS

CS

CS

CS

CS

CS

Pargament et al. (1992)

Ferraro & Koch (1994)

Ellison CG & Taylor (1996)

Pargament et al. (1998)

*Koenig et al. (1998d)

Pargament et al. (1999)

Hank & Schaan (2008)

Baetz & Bowen (2008)

Wachholtz & Sambamthoori (2013)

Hayward & Krause (2015)

General Religious Coping

CS

Feder et al. (2013)

R

R

R

R

S

S CS /​MP,E

CDA

2,889

CDA,B (AA, Carrib)

27,089 in 2002; 20,331 in 2007

37,000

CDA (age 50 or older)

540/​551 14,500

MP, E

577

196/​540/​551, CM/​CS/​MP

CDA,B

1,344

CDA

CM

Veterans with PTSD

Earthquake survivors

CS in Judea & Samaria

CDA in war zone

CDA

HS students, ages 15-​16

CDA

P OP U L AT ION

C/​C/​S

3,417

538

279

200

646

1,011

560

7,365

2,971

N

R

R

S

C

C

C

R

CS

CS

Scholte et al. (2004)

Korn & Zukerman(2011)

Schuster et al. (2001)

S

R

CS

Sigurvinsdottir et al. (2021) (sex ab)

R

M E T HOD

CS

CS

McIntosh et al. (2020)

Natural Disaster/​Terrorism/​War

T Y PE

TOPIC /​IN V E S T IG ATOR S

MC

MC

C ON T ROL S

National US

National US

Canada

Europe

Ohio & NC

Durham, NC

OK, OH, NC

National US

National US

Midwest US

California

Pakistan

P (ORA)

NG

M

M

M

80%

greater in South

M

P

SC

MC

MC

MC

NONE

—​

SC

MC

63% of AA & 54% of Carrib used R to cope w discrimination

Use of prayer stable at 6.9%; gen prayer incr (40% to 46%)

#3 ORA, Sp, prayer cope

#1 prayer frequency

#60+​ RC

#69 RC, ORA, NORA, SR

#14 “brief RCOPE”

#1 prayer (RC)

#1 RC due to SLEs

#30+​IR, ER, Quest

?

91% said “I look to God for strength, support, and guidance”

SC

#5 ORA, SR, RC, NORA

P

98% say Allah main source of emotional support, 81% family

90% coped with Sept 11th by turning to R

P (anger)

C

F I N DIN G S

Israel

#1 RC

#9 Sp, R, R of parents

#1 R/​S, -​R/​S, R/​-​S, -​ R/​-​S

R E L IG VA R I A BL E S

Afghanistan

National US

Iceland

National US

L O C AT ION

8

8

8

9

8

8

8

8

8

8

8

(8)

(8)

8

8

8

(8)

R AT IN G

S

CS

CS

CS

CS

Mitchell et al. (1993)

Koenig et al. (1994b)

Brown D & Gary (1994)

Ellison CG (1995)

R

CS

CT

PC (10)

Kendler et al. (1997)

Toh & Tan (1997)

Miller L et al. (1997)

C

C

C

C

PC (6m)

CS/​PC (2)

Kennedy et al. (1996)

R

R

R

R

R

S

C

R

Blalock et al. (1995)

CS

CS

Brown D et al. (1992)

CS

PC (6m)

*Koenig et al. (1992)

Koenig et al. (1995a)

CT

Propst et al. (1992)

McIntosh & Danigelis (1995)

R

CS

Yeung & Greenwald (1992)

R

R

PC (2)

R

C

PC (3)

CS

Brown D et al. (1990)

*Williams D et al. (1991)

PC (2)

*Rabins et al. (1990)

R

S

C

Idler & Kasl (1992)

CS

CS

Hallstrom & Persson (1984)

Idler (1987)

CC

Fernando (1975,1978) CDA, 100% F CDA, E

CDA

CDA, E

CDA

CDA, B

CDA, E

CDA, B

MP, E

CDA, religious mothers/​child

60/​151

CDA, twins

CDA, E

MP (arthritis), E

CDA, E

MP, E

CDA

CDA, 100% BM

46

1,902

1,855

300

1,644

850

2,956

527

853 vs. 1,826 baby boomers

868

927

850

59 depressed Christian pts

3,640

2,812

720

451

62 caregivers of Alz D & CA pts

2811

800

117 PP vs. Cs

Depression (Chapter 5) (“>” indicates less depression; MDD =​major depressive disorder)

New York

Pasadena, CA

Virginia

Bronx, NY

North Carolina

National US

Durham. NC

North Carolina

Southeast US

Durham NC

North Carolina

Norfolk, VA

Durham, NC

Oregon

New Haven,CT

New Haven, CT

New Haven,CT

Richmond, VA

Baltimore

New Haven, CT

Sweden

London, GB

#4 D,SR

lay counselors in church

#11 RB, ORA, NORA, SR

#2 ORA, D

#1 RC

#1 Relig volunteering

P

P

P

P (CS), NA (PC)

P (neg affect)

P

P

P (ORA), NG (NORA)

#3+​D, ORA, NORA #4 D, RC

P (D only)

P (ORA)

M

NA

P

#12 D, ORA, RCm

#5 D, ORA, SR, NORA

#7 RB (rlg intervention)

#10 RCm

#4 D, RC

P

Jews>non-​J

#1 Jewish vs. non-​J religious CBT

P (men)

P (stress buf)

P

P

P

P

P

#4 ORA, SR, RC

#2 D, ORA

#12 D, ORA, RCm

#1 RC

#4 ORA, SR, RC

#3 ORA, NORA, RB

#2 D, ORA

8

8

—​ MC

9

10

8

8

8

8

8

9

8

8

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

10

10 MC

8 —​

10

8

8

8

9

8

8

MC

MC

MC

MC

MC

MC

MC

—​

C

R

CS

CT

PC (28)

CS

CS

CS

CS

CS

CT

CC/​CS

Braam et al. (1999)

Teasdale et al. (2000)

Strawbridge et al. (2001)

Kalil et al. (2001)

Barber (2001)

Braam et al. (2001)-​study 1

Braam et al. (2001)-​study 2

*Chang BH et al. (2001)

Rye & Pargament (2002)

Schieman et al. (2002)

R

R

R

S

R

R

1,581

58

3,543

17,739

8398

6,923

580

2,676

3051 137

—​

251

2,537

3,497

203

577

86

3,020

177

2,817

4,000

5,772

N

R

R

R

R

C

S

PC (3)

CS

*Koenig et al. (1998d)

S

Musick et al. (1998)

PC (1)

*Koenig et al. (1998a)

R

S

CS

CS

Braam et al. (1998)

Strawbridge et al. (1998)

PC (1)

Braam et al. (1997b)

R

R

CT

CS

Braam et al. (1997a)

CS

CS

Koenig et al. (1997a)

R

Razali et al. (1998)

CS

Levav et al. (1997)

M E T HOD

Ferraro (1998)

T Y PE

TOPIC /​IN V E S T IG ATOR S

CDA (731 disabled)

CS (Christian F), 18–​23 y

F, veterans

CDA, E

CDA, E

HS (98% Muslim)

F, welfare recipients

CDA

PP (with h/​o MDD)

CDA, E

CDA, E, with cancer

E, CDA

CDA

PP

MP, E

MP, E

CDA, E

CDA, E

CDA, E

CDA, E

CDA

P OP U L AT ION

#1 relig psychotherapy

#3 ORA

Rlg vs. sec forgiveness Ontario, Canada

#2 ORA, RC Ohio

#13 D, ORA, RB, SR

#2 ORA, D

#5 ORA, NORA, SR

#1 ORA

#1 ORA

Buddhist mindful med

#1 “religious climate”

#3 ORA, NORA

#5 ORA, NORA, SR

6 D, ORA, NORA, SR, RC

P (not disabled)

NA

P

P (ORA only)

P (ORA only)

P (females)

P

P

P

M

P (Blacks only)

M

M

P

M

P

#12 IR, ORA, NORA #69 RC, ORA, NORA, SR

P

P

P

P (ORA)

Jews > non-​J

F I N DIN G S

#3 D, giving up ORA

#1 SR

#2 ORA

#4 D, ORA, NORA

#1 Jewish vs. non-​J

R E L IG VA R I A BL E S

Natinal US

Europe

Europe

Palestine

Maryland

N. California

UK and Canada

Netherlands

North Carolina

Alameda, Calif

National US

Malaysia

Durham, NC

Durham NC

Netherlands

Netherlands

Netherlands

North Carolina

New Haven & Los Angeles

L O C AT ION

MC

—​

MC

SC

SC

MC

MC

MC

—​

MC

MC

MC

8

8

8

8

8

9

8

10

9

8

10

9

9

8

—​ MC

8

10

8

8

8

9

8

R AT IN G

MC

MC

MC

NONE, but . . .

MC

MC

MC

C ON T ROL S

CT

CS

CS

CT

PC (1)

CS

PC (4)

Rye et al. (2005)

Basoglu et al. (2005)

Jarvis et al. (2005)

Kristeller et al. (2005)

Fenix et al. (2006)

Sujoldzic et al. (2006)

Yeager et al. (2006)

R

R

S

2,930

1,282

175

118

—​

1,358

S/​C 1,485

149

—​

R

158

1,844

22,570

70,884

799

2,375

17,283

1,000

207

1,316

679

C

R

R

R

R

R

C

S

R

993

2,348

16,306

CDA, E (92% non-​Christian)

Ad (mean age 17)

Bereaved caregivers (CA)

MP (cancer)

CDA

CDA, war survivors

d

#2 ORA, SR (scale) #12 D, ORA, RB, R prac

NA

P

P

multi-​item religiousness Bosnia

P

P

P

NA

M

MC

MC

MC

MC

MC

MC

—​

SC

MC

M (ORA-​P, SR-​NG)

Spiritual history

#3 ORA, NORA, D

#10 RB

R vs. secular intervention

#3 ORA, SR, D

#4 ORA, D, SR, RB

MC

MC NGd

M (ORA-​P)

#3 ORA, D, RB

#3 ORA, SR

MC

P (disabled)

#1 RC (read Koran/​ pray)

MC

MC

MC

MC

MC

MC

MC

MC

MC

P

P

P

C

M

P

NA

P (over 65 yo)

P (ORA)

#2 ORA, RC

#4 ORA, CM

#5 DUREL

#2 RC

Taiwan

New Haven, CT

Indiana

Montreal, Canada

Yugoslavia

Midwest US

New York City

Mother-​chld dyads CDA (divorced)

Netherlands

Europe

National Canada

Afghanistan

National US

Netherlands

Alabama

5 centers in US

#3 ORA, NORA, God forgiveness

#5 ORA, NORA, SR, RSsup

Detroit, MI National US

#1 Religious volunteering

#1 Relig volunteering

#4 ORA, NORA

National US

National US

National US

CDA, E

CDA, E

CDA

CDA, Muslim, 13% disab

M veterans

CDA

CDA, E

Mothers of BMT pts

CDA, E, 49% B

CDA, F, B

CDA (over age 60)

CDA

Ad (grades 7–​12)

In European countries with high levels of orthodox belief, the depression-​disability relationship is stronger.

RS (10)

Gur et al. (2005)

CS

Cardozo et al. (2004)

PC (6)

PC (2)

*Chang BH et al. (2003)

Braam et al. (2004b)

R

CS

Meertens et al. (2003)

CS

CS

Parker et al. (2003)

CS

PC (6m)

Manne et al. (2003)

Baetz et al. (2004)

CS

*Krause & Ellison (2003)

Braam et al. (2004a)

R

CS

Van Olphen et al. (2003)

R

R

PC (8)

PC (8)

Musick & Wilson (2003)

R

CS

Morrow-​Howell et al. (2003)

Nonnemaker et al. (2003)

8

8

8

8

8

8

9

8

9

8

8

8

8

9

8

8

8

8

8

9

9

C

R

CS

CT

CS

Norton et al. (2006)

*Bormann et al. (2006)

*Hebert et al. (2007)

PC (6w)

CT

CS

PC (3)

Mann et al. (2008)

Wachholtz & Pargament (2008)

Contrada et al. (2008)

Norton et al. (2008)

PC (5)

*Greenfield & Marks (2007b)

CS

PC (1)

Le et al. (2007)

Bradford et al. (2008)

R

PC (6m)

Koenig (2007a)

PC (1)

CS

Sinha et al. (2007)

CT

CS

Cunningham & Knoester (2007)

Van Voorhees et al. (2008)

PC (2)

Fauth et al. (2007)

Miller WR et al. (2008)-​study 1

R

PC (3)

Braam et al. (2007)-​study 2

740

550 2,989

R/​S

83

—​

S

307

641

60

4,791

4,646

13,317

839

1,690

3,975

1,315

1,346

1,702

S

R

—​

R

S

R

R

R

R/​C

R

CS

CS

Chaaya et al. (2007)

Braam et al. (2007)-​study 1

93

—​ 1,229

4,468

37,000

N

R/​S

R

CS

Baetz et al. (2006)

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S Canada

L O C AT ION

CDA, E, 94% Mormon

MP (cardiac surgery)

MP (vascular HA)

Pregnant F, postpartum

Ad (grades 5–​8)

Substance abusers (outpt)

Ad

CDA (over age 35)

Ad

Utah

New Jersey

Midwest US

South Carolina

Ogden, Utah

New Mexico

National US

National US

National US

North Carolina

National US

Ad (age 11–​18) & parent MP

National US

Chicago

CDA (parents)

Netherlands

Ad (9–​12 yo)

Netherlands

#2 D, ORA

#13 NORA, RB

Sp vs. secular meditation

#13 DUREL, DSE©, SR

#5 ORA, NORA

Spiritual direction

#4 ORA, NORA, SR

#1 ORA (not attendance)

#5 ORA, NORA, SR, D

#17 D, ORA, NORA, IR

#3 ORA, SR

#1 ORA

#1 ORA (“church group”)

#1 prayer (focus)

#1 prayer (focus)

#6 ORA, NORA, SR

#3 ORA, NORA, SR

Beirut, Lebanon

“Spiritual mantram”

Multi-​site US

#2 D,ORA

#2 ORA, Sp values

R E L IG VA R I A BL E S

San Diego, CA

CDA

CDA

CDA, E, poor

Caregivers (Alz dis)

MP (HIV+​)

CDA, 92% Mormon Utah

CDA

P OP U L AT ION

P (exc LDS higher)

NA

P (neg affect)

P

P

NG

P

P

M

P

P

P

NA

NA

NG (in unaffiliated)

P (ORA)

P

(NG)

P (exc LDS higher)

M (P-​ORA, NG-​ Sp values)

F I N DI N G S

MC

MC

—​

SC

MC

—​

MC

MC

SC

MC

MC

MC

MC

MC

MC

MC

SC

—​

MC

MC

C ON T ROL S

8

8

8

8

8

9

10

9

8

8

8

8

8

8

8

8

8

8

8

8

R AT I N G

PC (2)

PC (16m)

PC (1.5)

PC (6m)

CS

CS

PC (2)

CT

CS

PC (3)

CS

CS

Korenromp et al. (2009)

*Trevino et al. (2010)

Dew et al. (2010)

Bailley & Roussiau (2010)

Skarupski et al. (2010)

Payman & Ryburn (2010)

Foley et al. (2010)

Sternthal et al. (2010)

McFarland (2010)

Kudel et al. (2011)

Abdel-​Khalek (2011)

CS

Ellison CG et al. (2009b)

Krause (2009e)

CS

Hill TD et al. (2008a)

PC (4)

CT

*Bay et al. (2008)

CS

CS

Blay et al. (2008a)

Ellison CG et al. (2009c)

CS

Chatters et al. (2008)

Krause (2009a)

PC (1)

King MB et al. (2008)

818

R/​S

C

C

R 2,946

345

919

3,103

115

—​

R

94

6,534

338

145

429

S

C

C

C

147

869

C

607

R/​S

3,012

R/​S

R

2,402

166

—​

R

6,961

837

5,216

R

R

S

Kuwait, Palestine

Multi-​site US HS, ave age 14, Muslim

National US

MP, HIV/​AIDS

Chicago area

Australia

Australia

Chicago

France

CDA, E (> 65 y)

CDA

MP (cancer)

Psychiatr inpts (MDD)

CDA, E (> 65)

CDA, E (age 65 or older)

North Carolina

Multi-​site US

MP, HIV/​AIDS Adolescent PP

Netherlands

National US

National US

National US

F, term of preg, fetal anom

CDA, E

CDA, E

CDA, B

Fresno, Calif

CDA, Mex-​Am (18–​59)

#1 SR (1–​10)

#2 increase in R/​S

#6 ORA, NORA

#17 D, ORA, NORA, etc.

Buddhist Mindful Med

#5 DUREL

#5 DSE©

#6 DSE ©

#13 RC, RB, etc.

#19 DUREL, NRC, PRC

#1 religious vs. not

#4 ORA, NORA, God-​ med ctrl

#4 ORA, NORA, RB

#3 ORA, RB, R sup

#3 ORA, SR, RC

#1 ORA

Multi-​site US

CDA, F, low income

P

P

P (men only)

M

P

P

P

NA

P (exc NRC)

NA (except loss of faith)

NA

P

P

P (RB)

M

P

NA

M

P (ORA)

#3+​ORA, NORA, SR #4 D, R change, SR,ORA

NA

#1+​“hold R/​S beliefs”

Chaplain visits (#5)

Brazil

National US

Europe

Indiana

MP (heart patients)

CDA, E

CDA, E, B

MP, outpatients

None

MC

MC

MC

—​

MC

MC

None

SC

MC

MC

MC

MC

MC

MC

MC

SC

MC

MC

MC

(8)

(8)

8

8

9

9

8

(8)

(8)

8

8

9

8

9

8

8

8

8

8

8

T Y PE

CS

PC (5w)

PC (1)

CS

CS

CS

CS

PC (1)

PC (10)

CS

PC (10)

PC (10)

CC

PC (3m)

CS

PC (3)

PC (4)

CS

TOPIC /​IN V E S T IG ATOR S

Vahia et al. (2011)

Schettino et al. (2011)

Krumrei et al. (2011)

Moxey et al. (2011)

Bjorck & Maslim (2011)

Pirutinsky et al. (2011)

Coleman et al. (2011)-​study 1

Coleman et al. (2011)-​study 2

Rasic et al. (2011a)

Rasic et al. (2011b)

Miller L. et al. (2012)

Kasen et al. (2012)

Hayward et al. (2012a)

Hayward et al. (2012b)

Krause (2012a)

Oates & Goode (2013)

Sun et al. (2012)

Hourani et al. (2012)

R

R

R

R

C

C

C

C

C

R

C

C

C

C

R

C

C

C

ME T HOD

CDA

24,690

1,000

2,780

1,005

380

Active duty military

E, CDA

CDA (874 B, 1,906 W)

E, CDA, Mex-​Americans

E with MDD

National US

Alabama

MC

M (ORA/​NORA-​ P, SR-​NG)

MC

P (IR)

MC

MC

P

MC

MC

P (mod finan strain-​dep)

MC M (ORA-​P, NORA-​NG)

MC

MC

MC

None

MC

P (ORA, SR)

P (SR)

P (via social trust/​subst use)

NA

P

NG (NORA)

#2 SR,IR        P (only in low-​ mod combat exposure)

#5 DUREL

#6 ORA, NORA, SR

#4 religious certainty

Southwest US National US

#6 ORA, NORA, SR, D

#6 ORA, NORA, SR, D

#3 ORA, SR, D

#3 ORA, SR, D

#2 ORA, SR

#2 ORA, RC

#5 SSp

#7 SSp, ORA, NORA

IR moderated physical health-​dep relationship

#3 IR

MC

P (esp God support)

MC

SC

MC

MC

C ON T ROL S

#21 RSup

NA

NA (with R or PRC)

#54+​PRC, NRC, R scale #2 SR, ORA

M (antidepressant response)

NA

F I N DIN G S

#15 RWB, R sc

#5 ORA, NORA, IR

R E L IG VA R I A BL E S

Southeast US

Southeast US

New York City

New York City

Nova Scotia, Canada

CDA

Baltimore, MD

HS, age 15–​19

Bulgaria

Romania & Bulgaria

US & other

CDA

CDA, rural

CDA, rural

CDA, Jews

United States

Australia

CDA, age 55–​85 CDA, F, Muslim

Multisite US

California

San Diego, Calif

L O C AT ION

Divorced in past 6 mo

CDA with MDD

CDA, F, post-​menop

P OP U L AT ION

476 E with MDD vs. 167 ctrls

185

114

1,615

1,091

160

160/​160

212

539

752

89

148

1,973

N

8

9

9

8

9

8

9

9

(8)

9

(8)

(8)

(8)

(8)

(8)

8

8

8

R AT I N G

C

R

PC (1)

CS

CS

Krause (2012b)

Park JI et al. (2012)

Schnall et al. (2012)

PC (7-​12)

CS

Commentary/​critique on reverse causality finding for attendance and depression by Maselko et al. (2012)

PC (1)

PC (2)

CS

CS

PC (14)

PC (8d)

PC (6m)

PC (10)

Maselko et al. (2012)

*Archibald et al. (2013)

VanderWeele (2013)

Leurent et al. (2013)

Rasic et al. (2013)

Thege et al. (2013)

*Liu & Koenig (2013)

Balbuena et al. (2013)

Rosmarin et al. (2013a)

Bekke-​Hansen et al. (2014)

Barton et al. (2013)

47

12,583

1,039

12,643

976

8,318

Canada Northeast US

CDA

Rural China

PP (current/​hx psychosis)

Hungary

CDA, F, age 13–​34

Canada

Europe, Chile

National US

Rhode Island

C

173

Hi/​low risk for MDD

New York City

#2 ORA, D

#5 D, RB, RC, NORA

#18 RB, SR, ORA, NORA, RC

#3 ORA, SR, Sp values

#15 ORA, NORA, IR

#2 ORA, SR

#2 ORA, SR

P

NA

P

P (ORA)

P

NG (SR)

P

NG

P

#12 SR/​SSp, NORA, ORA #3 RB, SR, R affiliation

Dep predicts ORA (F)

NG (more MDD w increased SR) P (more MDD w decreased)

P (mediated race-​depression relationship)

P

P (Asian only)

P

NG

#2 ORA

#2 SR (change in)

Internet (US)

CDA

HS (grade 10)

MP (outpatients)

CDA,B

CDA

CDA with loss after 9/​11

#1 ORA

Baltimore, MD

97 MP hospitalized with acute coronary syndrome in Denmark

C

R

R

R

C

C

3,570

2,097

R

R

608

C

CDA

#1 ORA #5 ORA, SR, IR, RB

RS

1,489

National US National US

Seirmarco et al. (2012)

R

CDA Ad, age 12–​17

CS

17,705

Reese et al. (2012)

R

14,884

#1 ORA

Multisite US

CS

#2 D (atheists vs other), Sp

P

P

#23 D, ORA, IR, ER, God image #5 ORA

M (based on race)

#3 ORA, SR, NORA

South Korea

National US

California

Chicago

CS

CDA, F, post-​menopausal

CDA

CDA, E (> age 65)

Veteran inpts w PTSD

CDA

Robinson et al. (2012)

92,539

6,275

501

449

3,103

Salas-​Wright et al. (2012)

R

C

C

CS

Tran et al. (2012)

R

CS

Sternthal et al. (2012)

MC

MC

SC

MC

None

SC

MC

MC

SC

MC

9

8

(8)

9

(8)

8

8

9

8

9

(8)

8

MC

MC

9

9

8

8

8

(8)

8

MC

MC

MC

SC

MC

MC

MC

T Y PE

CS

CS

PC (39)

CS

CS

CS

PC (3)

PC (2)

RS (12)

PC (2)

PC (2)

CS

P (20)

CS

CT

CS

PC (6m)

PC (6m)

CS

TOPIC /​IN V E S T IG ATOR S

Mota et al. (2013) (MDD)

Chokkanathan (2013)

Thygesen et al. (2013)

Azorin et al. (2013)

Florenzano et al. (2014)

Salgado et al. (2014)

Bradshaw et al. (2015)

*Reynolds et al. (2014b)

Braam et al. (2014)

Ronneberg et al. (2014)

*Dzivakwe & Guarnaccia (2014)

Assari (2014)

Zou et al. (2014)

Vance et al. (2014)

Koenig et al. (2015d)

*Winter et al. (2015)

Cheadle et al. (2015)

Kim NY et al. (2015)

Wang Z et al. (2015)

R

C

C

2,770

232

702 low SES

1,227

132

—​

C

2,621

754

5,899

2,539

7,732

343

128

1,024

650

144

424

9,277

321

8,441

N

C

R

R

R

R

R

C

R

C

S

S

S

R

R

ME T HOD

P

CDA

Western China

South Korea

US inner cities

B,F, post-​partum PP, outpatients

Multisite US

NC, Calif

Virginia

#3 ORA, SR, D

#3 ORA, SR, D

#6 ORA, SR, DSE©

#5 ORA, NORA, SR, RC

RCBT vs. standard CBT

#78 (7 dimensions of R)

#2 RC #1 ORA

National US New York

Alzheimer’s caregivers

MP with MDD

Twins in Virginia registry

Child, teens (age 9–​19)

CDA

National US

#2 ORA, SR

#8 ORA, NORA, SR, IR

MP, diabetics, E

CDA,E (> age 50)

National US

M

#50+​feelings about God,etc.

Netherlands

CDA,E, dep vs. non-​dep

NG

P (treatment response)

P

M (P in 4 of 5)

No difference

NA

P

P (Caribbean B)

P (moderating)

P (PRC)

#14 RC (PRC, NRC)

Alabama

NA

Ad, cystic fibrosis/​ diabetes

#1 Religious music

(P) (F, indirect)

NA

#4+​D, R sc, ORA, SR #1 ORA

NG

M

#5 DUREL

P

#1 D (SDA/​Baptist vs. gen pop)

NG (Sp values)

F I N DIN G S

#5 DUREL

#2 ORA, Sp values

R E L IG VA R I A BL E S

National US

Mexico, US

Santiago, Chile

France

Denmark

Chennai, India

Canada

L O C AT ION

CDA,E (age > 65)

CDA, Mexican migrants

PP, depressed inpts

PP, outpts, MDD spectrum

CDA

CDA, E

Active duty serv member

P OP U L AT ION

MC

MC

MC

MC

R

MC

MC

MC

SC

MC

MC

MC

MC

SC

None

MC

SC

SC

MC (over adjusted)

C ON T ROL S

8

9

9

8

9

8

10

9

8

10

8

8

9

(8)

(8)

8

8

(8)

8

R AT IN G

C

C

CS

CS

PC? [1–​4]

CS

PC (12)

Exp

CS

CS

PC (1)

CS

PC (3.5)

PC (6m)

CS

CS

CS

CS

Rose et al. (2015)

*Frick et al. (2016)

Davis & Kiang (2016)

Naja et al. (2016)

Li et al. (2016a)

Ysseldyk et al. (2016)

*Abu-​R aiya et al. (2016)

Philippus et al. (2016)

Mihaljevic et al. (2016)

*Bussing et al. (2016)

Cohen-​Mansfield et al. (2016)

*Trevino et al. (2016)

Fuller-​Thomson et al. (2016a)

Wyshak (2016)

McClintock et al. (2016)

S

S

C

R

C

C

S

863

3,150

93,676

2,528

111

1,070

7,390

99

2,563

2,140

221

—​

R

48,984

310

C

C

8,574 180

C

12,500

6,082

C

R

R

CS

322

Hudson et al. (2015)

9,068

—​

CT

Greeson et al. (2015)

R

PC (6)

Croezen et al. (2015)

CDA (online Internet)

CDA (online Internet)

CDA, F, 49–​79 yo

CDA, h/​o MDD

Veterans, E, M, cancer

#2 D, RC 54 R & Sp scales 54 R & Sp scales

China India

#1 RC

P

NG

P

P

NG

P (decrease R)

#2 R identity, Δ in R #1 R change (increased)

P

P (IR, before confounds)

#5 ORA, NORA, IR #6 DSE©

P

NA (exc NRC)

M

P

NA

NA

P

P (MDD)

P (lifetime MDD)

P

P

#1 ORA

#12 Rcm, RC, R hope, R sanc

#2 atheist v. Christians, R settings

#1 ORA

#5 ORA, NORA, SR, RC, RB

#10 ORA, R identity (IR)

#15 DSE©, Sp dryness

#4 ORA, SR, IR

#6 ORA, SR

#8 D, DSE©

#1 ORA

National US

Canada

Boston, Houston

Israel

Germany

Catholic clergy/​ helpers CDA, E (over age 75)

Croatia

National US

National US

UK and Canada

National US

Lebanon

North Carolina

PP with dep disorder

MP, traumatic brain inj

CDA

CDA, CS (two studies)

Nurses, F

Syrian refugees (44% MDD)

Asian American ad (13–​18)

Germany

Southern US states

Ad (age 12–​17) Clergy and deacons

National US

North Carolina

Europe

CDA, age 18 or over

Depressed CDA

CDA, E (age >5 0)

SC

SC (age, sex,educ)

MC

MC

MC

None

MC

None

MC

MC

—​

MC

MC

SC

MC

SC

MC

MC

MC

(8)

(8)

9

8

(8)

(8)

8

(8)

8

8

8

10

(8)

(8)

8

8

8

9

10

PC(6m)

CS

CS

CS

CS

PC (9)

CS

CS

CS

CS

CT

CS

PC (3)

CS

Yang et al. (2017)

*VanderWeele et al. (2017a)

Sharma et al. (2017) (MDD)

Rasmussen et al. (2017)

Portnoff et al. (2017)

Ahrenfeldt et al. (2017)

*Sigurvinsdottir et al. (2021)

Henslee et al. (2015) (MDD)

Van de Velde et al. (2017)

Giorgadze et al. (2017)

Ford & Garzon (2017)

Burke et al. (2017)

Lowell et al. (2017) (fragile X)

*Butler-​Barnes et al. (2018)

R

C

1161

83

34,525

78

—​

R

500

R

68,874

810

S/​R

14,255

5,512

7,365

R

Veterans

National US

National US

Taiwan

Ad (age 16–​18) CDA, B

National US

United States

L O C AT ION

CDA with chronic illness

CDA (online Internet)

P OP U L AT ION

Youth age 13–​17, B

Females w genetic risk for mood/​ anxiety do

CDA

CS, Christian

CDA

CDA in 29 countries

CDA hurricane survivors

HS students, age 15–​16

CDA, > age 50

CDA (online survey)

National US

USA

National US

Virginia

Tbilisi, Georgia (Eurasia)

Europe

#3 ORA, NORA, SR

#12 R experience

#1 meditation (vs. not)

Christian mindfulness

#7 misc (RB, PRC, NRC)

#5 ORA, NORA, SR, R context

#2 PRC, NRC

#9 R, R of parents,peers

Iceland Mississippi

#3 ORA, NORA, R educ

#29 DSE©, Sp scale

#1 D

#5 DUREL

#4 ORA, NORA, RC, SR

#4 D, SR, RB, R activities

#8 ORA, NORA, R mean/​hope

54 R & Sp scales

R E L IG VA R I A BL E S

Europe

US, China, India

6,025 SDA/​Bapt vs. 29,817 general population of Denmark

3,151

36,613

2,239

1,696

1,499

N

S

R

C

S

R

C

R

R

C

CS

CS

M E T HOD

T Y PE

Lucette et al. (2016)

TOPIC /​IN V E S T IG ATOR S

P (Caribbean B)

NG (CS), NA (PC)

NG

P (vs. standard mindfulness)

MC

MC

SC

—​

MC

MC

M (P-​ORA, NG-​NORA) P

MC

MC

MC

None

None

MC

None

MC

MC

SC

C ON T ROL S

P (exc NRC)

P

P (except Southern Europe)

P

M (less antidep use in F, more in M)

P

P

NA

P

P

F I N DI N G S

8

8

8

8

(8)

9

8

8

9

(8)

(8)

8

8

9

8

(8)

R AT IN G

R

C

PC (2.5)

CS

PC (4)

PC (6m)

PC (18)

CS

CS

PC (14)

PC (10)

CS

CT

CS

CT

CS

PC (5)

CS

Holt et al. (2018)

Nadal et al. (2018)

Tomita & Ramlall (2018)

Cheadle & Schetter (2018) (post-​partum)

Vittengl (2018)

Chatters et al. (2018)

Lerman et al. (2018)

Chen Y & VanderWeele (2018)

Fancourt & Steptoe (2018)

Drabble et al. (2018)

Pramesona & Taneepanichskul (2018)

Loureiro et al. (2018)

Abdi et al. (2019)

Schnittker (2019)

McClintock et al. (2019)

Moons et al. (2019)

C

C

R

4,028

215

17,602

264 93

—​

60

Non-​ randomized

S

699

2,548

6,950

15,787

2,991

6,295

1,588

15,571

9,495

766

868

160

C

R

S

R

R

R

C

C

R

CS

Moreno & Cardemil (2018)

C

PC (3)

Pirutinsky & Rosmarin (2018)

#2 SR

Multi-​national MP, congenital heart disease

#? SSp, IR, R engagement

New York City

Low-​ & high-​risk MDD

#2 D,SR

NA

P (dep affect R)

P (exc Muslim)

P

NA

#5 ORA, NORA, IR R (Islam/​Shia) intervention vs. controls

P

NG (SSp)

P

(P)

P (older adults)

P (exc neg interact w ch mem)

NG (Sp but not R)

P

P

NA

P (exc NG soc)

P

M (dependent on IR)

Muslim R intervention

#3 D, SR, SSp

#1 R membership

9 countries of Europe

Iran

Brazil

Indonesia

Chicago

England

#2 ORA, NORA

#3 D, ORA, SR

#3 RSup

#4 SR, SSp

#7 D, ORA, SR, DSE©

#2 D, SR

#19 RCm, Sp (categories)

#17 RB, R behaviors, RSup

#1 ORA

#6 IR, R practices

CDA

MP,E, heart failure

MP, hemodialysis

E (age > 60), NH, Muslim

Lesbian, bisexual F

CDA,E (> age 55)

National US

National US

CDA, Hispanic/​ Latino Ad (ave age 15)

National US

National US

Large US cities

South Africa

National US

National US

National US

Massachussetts

CDA, B

CDA

Pregnant F age 18–​40

CDA

CS

CDA, B

Mexican Americans

Jewish pts w mood dis

MC

MC

MC

—​

MC

—​

MC

MC

MC

MC

MC

SC

SC

MC

SC

MC

SC

MC

8

(8)

8

8

(8)

(8)

(8)

10

10

8

8

9

9

9

8

8

8

9

635 92,008

R

R

C/​R

PC (2)

CS

PC (3–​12)

PC (7)

PC (6m)

CT

CS

PC (6m)

Kim ES & VanderWeele (2019)

Fuller-​Thomson & Kotchapaw (2019)

Chen Y et al. (2020a)

Kobayashi et al. (2020)

Carney et al. (2020)

Sanaeinasab et al. (2020)

King KA et al. (2020)

Mosqueiro et al. (2021)

CS

CS

CS

CS

PC (3)

CS

CT

CT

Nimgaonkar et al. (2000)

Hintikka et al. (2000)

*Ellison CG et al. (2001)

Montague et al. (2003) (attachment)

*Caputo (2004)

Maselko & Kubzanski(2006a)

*Oman et al. (2006)

Richards et al. (2006)-​distress

122

58

—​

—​

1,445

1,911

R/​C

R

1,118

1,139

1,642

7,020

111

R

R

R

S

General Mental/​Emotional Health (“>” indicates better)

C

17,399

84

—​

R

163

67,723

5,200

6,759

C

C

R

348

PC (7)

C

PC (6m)

Orr et al. (2019)

N

*Lorenz et al. (2019) (stress)

ME T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

PP (eating disorders)

Health professionals

CDA

Ad (age 12–​16)

CDA (60% B)

CDA

CDA (869 F, 773 M)

Hutterites (CDA) v others

Utah

California

National US

National US

Spiritual group therapy

Meditation (passive)

#9 ORA, NORA, DSE©

#8 R (parent & Ad)

#3 ORA, SR, RC

#4 ORA, prayer, RB

Detroit, MI Brooklyn, NY

#1 ORA

#1 D

#13, including DUREL

#4 ORA, IR, RB

#1 Sp intervention (Islamic)

#2 RB

#1 SR

#1ORA

#1 RC

#1 ORA

#2 ORA, SR

#5 DUREL

R E L IG VA R I A BL E S

Finland

Manitoba, CAN

Brazil

National US

Ad, age 12–​17 Psychiatric outpts

Iran

Cincinnati, OH

Japan

National US

Canada

National US

Ireland

Ireland

L O C AT ION

F, pregnant

MP (CHF)

Medical outpatients

CDA

CDA w chronic pain

Age 50 or over

CDA, over age 50

PP

P OP U L AT ION

MC

MC

MC

C ON T ROL S

MC

M

—​

MC

MC

MC

P

P

P

NA

P

P-​ORA, RB; NG-​prayer

P (F only)

—​

—​

MC

MC

MC

MC

SC

Significantly higher rate of neuroses in Huttterites

P (remission)

P

P

NG (neg affect)

M

P

P (no Cs), NA (with MC)

NG (mediated mortality effect)

NA

P (depression)

F I N DIN G S

8

8

8

9

8

9

8

8

8

8

8

8

9

10

(8)

9

9

8

R AT I N G

R/​C

CS

CS

CS

CS

CS

CS

CS

PC (1)

CS

CS

PC (14)

CS

PC (1)

*Burris et al. (2009)-​distress

Acevedo (2010)

Crammer et al. (2011)

Sasaki et al. (2011)

Ng et al. (2011)

Correa et al. (2011)

Meltzer et al. (2011)

Tsai & Rosenheck (2011)

*Vahia et al. (2011)

Amstadter et al. (2011)

Bert (2011)

Hussain et al. (2011)

*Krumrei et al. (2011)

C

S

C

R

C

C

R

S

R

C

C

R

C

R

CS

—​

PC (8)

CT

Ikedo et al. (2007)

—​

Ellison CE et al. (2008b)-​distress

CT

Jain S et al. (2007)

R/​C

Berry et al. (2007)

CS

Shmueli (2007; 2003)

89

1,180

110

1,368

1,973

582

2,992

1,534

1,092

242

4,139

1,504

353

645

963

78

83

4,504

Australia

Divorced in past 6 mo

Survivors of Asian tsunami

Multisite US

Norway

Oklahoma

Vietnam

Ad (age 11–​18) Ad mothers & offspring

#5 ORA, NORA, IR

San Diego, CA

CDA, F, post-​menopausal

NA NG (with R)

#54+​PRC, NRC, R scale

(P) (offspring)

P

P (resilience)

P (Δ in faith)

NA

P

NG (Muslims vs. none)

SC

MC

MC

MC

MC

SC

SC

MC

MC

M, depending on oxytocin genotype/​culture

#1 RC

#3 ORA, SR, RC

#1 religious affiliation

#2 SR, RC

#3 ORA, SR, RB

United States

Great Britain

Chronically homeless

Ad (age 11–​19)

#1 ORA

#1 R affil

Singapore

NG (peace)

#3 R/​Sp CAM practices

MC

MC

M (P-​ORA, NG-​NORA)

MC

MC

—​

#7 ORA, NORA, SR

M (mostly P)

P

NA

SC

#10 RCm

Brazil

MC

BMM =​relaxation training

NG

P

#11+​R, Sp transcend©

#4 ORA, SR, Ch support

#2 ORA

Prayer during surg (CD)

Buddhist Mindful Med

#1 D (secular to orthodox)

South Korea

National US

Texas

Kentucky

CDA,E, low income

CDA,E (age 60 or over) (57% Buddhist/​Tao)

CDA & CS

MP, cancer survivors

CDA

CS

National US

CDA, age 19–​97 CDA, B

Omaha, NE

Arizona?

Israel

MP

CS, graduate students

CDA, age 45–​75, Jews

8

(8)

8

8

8

8

8

8

8

(8)

8

8

8

8

8

8

8

8

T Y PE

CS

CS

CS

CS

CS

PC (1)

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

PC

TOPIC /​IN V E S T IG ATOR S

Sorensen et al. (2012)

Kim-​Spoon et al. (2012)

Lo et al. (2012)

Yahaya et al. (2012)

Shilo & Savaya (2012)

Tsai et al. (2012)

Morton KR et al. (2012)

Gebauer et al. (2012)

Pirutinsky (2013)

Park NS et al. (2013)

Chiswick & Mirtcheva (2013)

Goeke-​Morey et al. (2013)

McAloney (2013)

Heim & Schaal (2014) (mental stress)

Paiva et al. (2014)

Appel et al. (2014)

Mhaka-​Mutepfa et al. (2015)

*Kidwai et al. (2014)-​distress

R

C

R

S

R

R

R

R

R

R

C

S

C

C

S

R

C

R

M E T HOD

1,071

327

2,095

221

200

17,800

695

2,604

1,431

51,142

187,957

6,753

1,271

461

1,190

34,650

322

2,086

N

CDA

Grandpa fostering orphans

Baltimore

Zimbabwe

National US

Brazil

MP, end-​stage cancer CDA, Asian

Rawanda

Great Britain

#4 ORA, SR, RC

#1(?) “religiosity”

#2 ORA, D

P (ORA)

NA

P

NG

P

#34 IR, RC, emotions toward God #15 R practices sc

P

P (child)

P

M

P (failed to replicate Gabauer)

#1 religious homogeneity

#9 ORA, SR, RB (mother)

#3 ORA, SR, D

National US Northern Ireland

#11 ORA, NORA, RC, DSE

National US

CDA

CDA, married or cohabit

Mother-​child dyads

Child, ad (age 6–​19)

CDA

#1SR

CDA  From 26 European countries

P P (R countries only)

#9 SR, IR, RC #1 SR

National US

P

NG

P

#2 OR, SR

#1 SR (secular-​orthodox)

Israel US cities (large)

#6 RWB

P (exc Hispanics)

MC

MC

MC

None

MC

MC

SC

MC

MC

None

None

MC

MC

SC

MC

MC

C (dep on parent attach)  MC

None

C ON T ROL S

#4 ORA, SR, IR, share RB

NA

F I N DI N G S

#6 ORA, SR

#1 “seeking God’s help”

R E L IG VA R I A BL E S

Malaysia

National US

Virginia

Norway

L O C AT ION

Online dating site, 11 European countries

CDA (Adventists)

Homeless veterans

LGB youth

Malay ad (16 yo)

CDA, age 12 or over

Ad-​parent dyads

Cancer patients

P OP U L AT ION

9

(8)

8

(8)

(8)

8

8

8

8

8

8

8

8

(8)

8

9

(8)

(8)

R AT IN G

C

CS

CS

PC/​CS

CS

CS

CS

CS

CS

CS

CS

PC (7d)

CS

PC (2)

Buzdar et al. (2015)

Warren et al. (2015)

Mosqueiro et al. (2015)

Waters et al. (2015)

*Wang Z et al. (2015)

Moore et al. (2016)

Fuller-​Thomson et al. (2016b)

*Henderson AK (2016)

Wang Z et al. (2016b)

Hope et al. (2017)

Currier et al. (2017)

Ford et al. (2017)

Isaacs et al. (2017)

e

ADHD =​attention deficit hyperactivity disorder.

C

P (3)

Semplonius et al. (2015)

R

R

C

R

C

R

R

C

R

R

R

C

C

CS

R/​S

Meta-​analysis

CS

Superville et al. (2014)

R

Salsman et al. (2015)

CS

*McDougle et al. (2014)

R

Al Zaben et al. (2015)

CS

*Acevedo et al. (2014)-​distress

2,157

2,053

231

1,170

1,812

5,191

Worldwide

Young adults (ave 27 yo)

Veterans

CDA, Muslim, age 18–​59

National US

#5 DUREL

#2 R pract, Islam educ

#4 RSup

Thailand

National US

Ad, B (age 13–​17)

#10 Rcm (Worthington) #2 God imagery (neg/​ pos)

China

CS (2/​3 with no R affil)

#3 ORA, RC, child R social ization

#1 S/​R coping

Michigan

National US

Canada

CDA, B

Psychiatric inpatients

#3 ORA, SR, D

#2 ORA, D

#3 IR (from DUREL)

NA

P (R prac), NG (Is. educ)

M (NG w neg, P w pos)

P

M (dep on modeling)

P (mastery)

P

P (although atheists =​R)

NG

P

P (resilience)

NA (exc NRC)

P

#15 IR, ER #7 RC, PRC, NRC

P (but not Sp)

P

#11 ORA, NORA, Sp

P

#13 ORA, NORA, IR

P

M (P-​ORA, NG-​NORA)

NG (NORA)

Any R/​S measure

#1 Sabbath keeping

#9 ORA, NORA

#6 ORA, NORA

Online (Facebook/​ #5 religiosity Reddit)

Western China

Australia

CDA age 16–​59 CDA

Brazil

South Carolina

Pakistan

Ontario, Can

Saudi Arabia

PP, inpts, depressed

PP (psychiatric disabilities)

CS, 4th yr of college, F

CS

MP, renal dialysis,Muslim

107/​3801, F with ADHDe (20–​39 y)

4,667

2,770

7,653

143

533

502

1,132

310

National US

National US

CDA, age 25–​74 CDA, Seventh-​Day Adventists

Texas

CDA

129 studies in cancer patients

5,411

1,805

1,504

MC

MC

MC

MC

MC

MC

None

MC

MC

None (?)

MC

MC

None

MC

MC

—​

MC

MC

MC

9

8

8

8

8

8

(8)

8

8

8

(8)

(8)

(8)

9

(8)

8

8

8

8

CS

CS

CS

CS

CS

CS

CS

Meta-​analysis

CS

CS

PC (6)

*Cheadle & Schetter (2018)

Yeung (2018)

Sithey et al. (2018)

Baker et al. (2018)

Jang M et al. (2018)

Brammli-​Greenberg et al. (2018)

Fuller-​Thomson & West (2019)

Captari et al. (2018)

Lassiter et al. (2019)

Winzer & Gray (2019)

Pawlikowski et al. (2019)

C

C

CS

CS

CS/​RS

Cruz et al. (2010)

Dervic et al. (2011)

R

R

R

C

R

R

C

R

R

R

C

R

*Baetz et al. (2006)

Bipolar Disorder (Chapter 6)

CS

Dilmaghani (2018a)

C

PC (3)

Hui et al. (2017)

ME T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

CDA

149

334

37,000

6,400

32,198

1,071

PP, depressed with BPD

Bipolar do, veterans

CDA

Age 16 or older

Buddhists

CDA, gay/​bisexual, M

Pittsburgh

Pittsburgh

Canada

National Poland

Thailand

National US

Worldwide

Canada

Israel

Nepal

C, age 10–​18 CDA, Israeli Jews

National US

CDA (25% response rate)

Bhutan

CDA (age 15–​65+​)

#5 R affil, R obj to suicide

#5 DUREL

#2 ORA, Sp values

#1 ORA

#5 Buddhist practices

#9 R, RC; #9 Sp©

R/​S integrated therapy

#1 RC

#1 R categories (Haredi, etc., vs. secular)

#2+​SR, NORA

MC

SC

C ON T ROL S

P

P

MC

?

10

MC

P (suicide attempt)

NG (euth, mixed)

MC

MC

(8)

(8)

8

9

(8)

9

9

8

(8)

8

9

8

8

9

8

R AT IN G

MC

MC

—​

M (P-​ORA, NG-​Sp values)      MC

NA (with PHQ-​15)

P

M (NG-​R , P-​Sp)

P

P (excluding those w cancer)         MC

M

M

MC

MC

MC

P (mastery, self-​ SC esteem, optimism)

M (non-​linear)

P

F I N DIN G S

#3 D (atheists vs. other),ORA P (but atheist > other D)

#3 D, SSp, RB (Buddhist)

#6 ORA, NORA

#7 D, ORA, SR, DSE©

Texas

#1 SR

Large US cities

#1 D (Christian convert)

R E L IG VA R I A BL E S

Canada

Hong Kong

L O C AT ION

CDA

Pregnant F age 18–​40

CDA

CS (ave age 24)

P OP U L AT ION

97 studies, 102 samples

10,891

4,057

200

1,714

7,041

1,504

1,604

20,868

455

N

C

C

CS

D

CS

CS

PC (2)

CS

CS/​D

*Caribe et al. (2015a)

Grover et al. (2016)

*Mizuno et al. (2018)

Gawad et al. (2018)

Stroppa et al. (2018)

Ouwehand et al. (2019)

Ouwehand et al. (2020)

R

R

CS

CS

CS

CS

RS

CS

CS

CS

CS

Ward (1980)

Singh et al. (1986)

Stack & Wasserman (1992)

Truett et al. (1992)

Krull & Trovato (1994)

Stack et al. (1994)

Stack & Wasserman (1995)

Siegrist (1996)

Resnick et al. (1997)

R

R

S

C

R

R

R

S

CS

Singh (1979)

R

CS

Paykel et al. (1974)

PP (bipolar)

PP, outpts, bipolar do

PP, outpts, MDD spectrum

Psychiatric outpts with BPD

196

196

158

668

Suicide rates

12,118

2,034 Ad

age 15–​30 yo

1,197 B, 8,204 W, CDA

4,946 F, 4,475 M, CDA

CDA (twins)

—​

CDA

CDA

CDA

CDA

CDA

7,620

5,726

6,521

1,530

1,292

720

PP (bipolar)

PP (bipolar)

PP (bipolar)

PP inpts (64% bipolar)

112 schizo, 120 bipolar, 137 ctrls

185

164

424

168

Suicide (Chapter 7) (P =​less of or negative attitudes toward)

C

C

C

C

C

S

CS

*Azorin et al. (2013)

S

CS

Stroppa & Moreira‐Almeida (2013)

#3 D, ORA, SR

Austria/​Japan

National US

Gemany

National US

National US

Quebec, Can

Australia

National US

National US

National US

National US

Connecticut

Netherlands

Netherlands

Brazil

#1 SR

#2 D, ORA

#1 ORA

#1 ORA

#1 D (% None)

#2 D, ORA

#2 D, ORA

#? ORA, Misc

#1 SR

#3 D, ORA, SR

#3 ORA, NORA, CM

NA

P

P

P

P

P

P

P (attitude)

P

P

P

—​

NG

#2+​R affil, SR, others #18 D, SR, DUREL, RC

P (exc NRC)

NG (psychotic symp)

NG (manic symp)

C

P

NG

P (depress symp)

#22 D, RC, DUREL, others

#5 DUREL

#3+​ RB

India Texas

#5 DUREL

#5 DUREL

#19 DUREL, RC

Brazil

France

Brazil

MC

MC

MC

MC

MC

SC (factor)

MC

MC

MC

MC

MC

None

None

MC

MC

SC

None

MC

MC

MC

8

8

8

8

8

9

8

9

8

8

8

(8)

(8)

8

(8)

(8)

(8)

(8)

8

(8)

RS

CS

CS

RS

CS

RS

CS

RS

CS

PC (10)

RS

CS

CS

CS

CS

CS

CS

CS

PC (7)

Ellison CG et al. (1997)

Neeleman et al. (1997)

Neeleman et al. (1998)

Neeleman (1998)

Stack (1998)

Neeleman & Lewis (1999)

Stack (2000)

Nisbet et al. (2000)

DeCesare (2000)

Lubin et al. (2001)

Hilton et al. (2002)

Stack (2002)

Greening & Stoppelbein (2002)

Cook JM et al. (2002)

*Nonnemaker et al. (2003)

Perkins DF & Jones (2004)

Bearman & Moody (2004)

Kessler et al. (2006)

Thompson MP et al. (2007)

f

Standard Metropolitan Statistical Areas.

T YPE

TOPIC / ​IN V E S T IG ATOR S

R

R

R

R/​S

R

S

S

R

R

R

R

CDA

Entire population

CDA

Deceased (relative intervention) #1 D

Israel

15,034

1,043

13,465

3,012

16,306

621

1,098

845

National US

National US New Orleans National US

Ad CDA (post-​Katrina) Ad (age 12–​17)

Michigan

Ad (grades 7–​12) Ad, physically abused

Baltimore, MD

Southeast US

National US

CDA, E, B (abused)

HS

CDA

P

P

P

P

#4 ORA, NORA, SR

#1 SR (1–​3 rating)

#1 “bec more S/​R” (67%)

#1 ORA

#3 ORA, SR

P

NA

P (males)

NA

P (NORA)

P

P (RB)

#33 ORA, IR, ER, RB #1 RC

P

#1 ORA

P

Jewish males higher suicide vs. non-​Jew M

#2 D (Mormon, active)

#3 D, ORA, SR

#1 ORA

#1 ORA

#25 D, ORA, Misc

P

P

#3+​ religiousness #1+​ religiosity

P

P

P

F IN DI N G S

#17 ORA, NORA, SR, RB

#26 D, ORA, RB

#1 D homogeneity

R E L IG VA R I A BL E S

National US

National US

National US

Europe/​America

National US

Netherlands

National US

Death records in the state of Utah from 1991–​1995

5.4 mil

1,714

961 22,957

R

Suicide rates

CDA

26 countries

1,500+​

CDA

E.Europe, US, Can

National US

Suicide rates CDA

L O C AT ION

P OP U L AT ION

Suicide rates

f

11 provinces

1,729

23,085

296 SMSA

N

S/​R

S

R

S

R

R

R

M E T HOD

MC

MC

MC

SC

MC

MC

MC

MC

None

None

MC

MC

MC

MC

MC

MC

MC

MC

MC

C ON T ROL S

10

8

9

8

9

8

8

8

9

8

8

10

8

8

8

8

8

10

8

R AT IN G

CS

CS

CS

CS

CC

PC (5)

PC (10)

CS

CC

CS

CS

CS

CS

PC (13)

CS

RS

CS

CS

CS

PC (15)

*Pienaar et al. (2007)

Cohen CI et al. (2008)

Blackmore et al. (2008)

Rasic et al. (2009)

Sisask et al. (2010)

Spoerri et al. (2010)

*Rasic et al. (2011a)

*Rasic et al. (2011b)

Zhang et al. (2011)

Spencer et al. (2012)

*Robinson et al. (2012)

Assari et al. (2012)

*Hourani et al. (2012)

Nkansah-​Amankra (2013)

*Liu & Koenig (2013)

Panczak et al. (2013)

*Mota et al. (2013)

*Florenzano et al. (2014)

Hoffman & Marsiglia (2014)

Kleiman & Liu (2014)

R

C

S

R

S

R

R

R

R

R

C

R

C

R

R

20,014

702

144

8,441

3.7 m

1,039

9,421

24,690

5,181

14,884

700

392

1,615

1,091

3.6 mil

#2–​4 RC (COPE)

National US

National US

National US

Central Mexico

HS (age 14–​24) CDA

Santiago, Chile

PP, depressed inpts

Active duty military Canada

Switzerland

Rural China

CDA, F, age 13–​34 CDA (6,909 suicides)

National US

Ad (Add Health study)

Active duty military National US

CDA, B

CDA

MP with advanced cancer Multisite US

P

#1 ORA

P

P (esp killing self)

NA

#4+​D, R sc, ORA, SR #2 ORA, SR

NA

P

P

#2 ORA,Sp values

#1D (R affiliation vs. not)

#15 ORA, NORA, IR

P (CS), NA (PC)

NG (only in non-​ deployed group) #3 ORA, NORA, SR

P #2 SR, IR

P

P

NG (mediated)

P (via social trust)

P

P (higher in none)

M (depending on country)  

P

P (esp SR)

P

#1 SR

#1 ORA

#13 DSE

#4 ORA, RB, D

China (rural)

Suicides (age 15–​34)

#2 ORA, SR

Nova Scotia, Canada

#2 ORA, RC

Baltimore, MD

#1D (Prot vs. none)

#3 D, ORA, SR

#2 ORA, Sp values

#3 ORA, SR, SpR

#3 ORA, SR, RC

HS, age 15–​19

Switzerland

Multi-​national

Canada

Canada

Brooklyn, NY

South Africa

CDA

CDA

2,819 suicide attempt vs. 5,484 ctrls

C/​R

CDA (age 15 & older)

CDA (age 15 & older)

CDA, E

Police officers

36,984

36,984

1,074

1,794

R

R

R

R

MC

MC

MC

None

MC (over adjust)

MC

None

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

8

10

(8)

(8)

8

9

(8)

9

8

8

9

8

8

(8)

9

9

8

9

9

8

T Y PE

CS

CS

CS

PC (8)

CS

CS

CS

CC

CS

CS

CS

PC (25)

CS

CS

CS

CS

TOPIC /​IN V E S T IG ATOR S

Trevino et al. (2014)

Amit et al. (2014)

Kopacz (2014)

O’Reilly & Rosato (2015)

Toussaint et al. (2015a)

*Caribe et al. (2015a)

Assari (2015)

Akbari et al. (2015)

Kress et al. (2015)

Langille et al. (2015)

Kopacz et al. (2016)

Burshtein et al. (2016)

Cosco et al. (2016)

*McClintock et al. (2016)

*McClintock et al. (2016)

*McClintock et al. (2016)

MP, Veterans

Adol, Jewish

MP, cancer (life exp < 6 months)

C

C

C

R

R

S

1,499

863

3,150

4,741

4,914

472

CDA (online Internet)

CDA (online Internet)

CDA (online Internet)

CDA

CDA, ave age 29.4

Vets, PTSD residential rx

Ad grd 10,12

2,147 F/​ 2,218 M

S

CS

14,385

R/​S

CDA, B

PP, outpts, bipolar do

Ad, young adults

300 w suicide attempt vs. 300 ctrls

5,191

164

4,448

1,106,104 CDA (age 16–​74)

5,378

620

603

P OP U L AT ION

C

R

C

R

S

S

R

C

M E T HOD N

54 R & Sp scales

India

54 R & Sp scales

54 R & Sp scales

China

United States

#2 ORA, SR

#1 Secular to ultra-​R

Israel National US

#15 ORA, NORA, DSE©, RC

#1 ORA

California

Canada

#2 SR,RB

#5 DUREL

Iran Multi-​site US

#2 SR

National US

#5 DUREL

#7 ORA, NORA, SR, D

Trinidad/​Tobago Brazil

#1 D

#3 SSp, RC, Sp health

#1 SR

#16 RC, SR, SSup

R E L IG VA R I A BL E S

N. Ireland

Ashville, NC

Israel

Multi-​site US

L O C AT ION

P

P

NG

NA (?)

P

P (ORA) (exc NRC)

NA

P (non-​suicide self-​injury)

P (IR)

P (AA men only)

P

P

P (only for Catholics, age 55–​74)

P

P

P (exc NRC)

F I N DI N G S

SC

SC

SC (age,sex,educ)

MC

MC

MC

MC (mediators?)

MC

MC

MC

MC

MC

MC

None

MC

MC

C ON T ROL S

(8)

(8)

(8)

8

9

(8)

8

8

(8)

8

(8)

8

9

(8)

8

8

R AT IN G

CS

CT

PC (30)

PC (6m)

CS

CS

CS

CS

Ramos et al. (2018)

Svob et al. (2018)

Currier et al. (2018b)

*Loureiro et al. (2018)

*Gawad et al. (2018)

Jongkind et al. (2019)

Boyas et al. (2019)

CS

Kopacz et al. (2017)

Kim M & Lee (2018)

C

CS

*Portnoff et al. (2017)

CS

CS

Nishi et al. (2017)

CS

CS

AbdelGwad et al. (2017)

Lew et al. (2018)

CS

Hsieh (2017)

Kralovec et al. (2018)

C

CS

*Sharma et al. (2017) (PTSD)

R

C

C

S

C

3,115

155

668

264

303

326

132

—​

C

4,322

753

2,074

772

5,512

260,816

175

1,703

3,151

89,708

321

R

S

C

R

C

S

R

S

PC (14)

VanderWeele et al. (2016b)

C

CS

Lawrence et al. (2016)

CS

China

Netherlands National US

Latina/​o ad, age 12–​17

Texas

Brazil

Alabama

New York City

N. Carolina, California

South Korea

Austria

PP with MDD

PP inpts (64% bipolar)

MP, hemodialysis

US Veterans

Offspring suicide risk

MDD & chronic med ill

MP, stroke survivors

PP (inpatients)

P (IR)

#3 SR, IR, RB

#4 ORA, NORA, SR, God image

P (IR)

SC

MC

MC MC

P

#5 ORA, NORA, IR

P exc neg God image

MC

NRC predicted SI (not vice versa) #22 NRC

#5 DUREL

MC

P (esp girls)

#2 ORA, SR

Religious CBT intervention

MC

None

None

MC

None

MC

MC

MC

MC

MC

MC

No diff from std CBT

P

#14 D, ORA, IR

NA

P (exc ER-​P)

#14 IR, ER #1 Religious activities

NA (exc NRC)

New York

Iraq/​Afghan US Veterans

M

P

NA

P (overall, but . . .)

NA

P

NG (after ctrl meaning)

#5 RC

#29 DSE©, Sp scale

US, China, India

CDA (online survey)

#5 DUREL

#1 ORA

#5 DUREL

#1 ORA

#3 ORA, SR, D

#2 ORA,SR

Texas

Worldwide

National US

National US

New York

National US

CDA

Psychiatric inpatients

Suicides in 42 countries

Veterans

Nurses, F

PP, depressed

(8)

(8)

(8)

(8)

8

10

8

8

(8)

(8)

(8)

(8)

9

(8)

8

8

10

(8)

CS

PC (6)

PC (26)

CS

PC (2)

RS

CS

CC

PC (11)

CS

Jacob et al. (2019)

*Pawlikowski et al. (2019)

Chen Y et al. (2020b)

Fitzpatrick et al. (2020)

Lyu et al. (2020)

Shin et al. (2020)

Kim YJ et al. (2020)

Huang et al. (2020)

Erlangsen et al. (2021)

*Mosqueiro et al. (2021)

C

R

C

R

C

R

C

S

R

R

111

266,324 Psychiatric outpts

Adults age > 45 Brazil

CS

CS

CS

CS

CS

CS

CS

CS

*DeCesare (2000)

Burdette et al. (2005)

Cohen J et al. (2006)

Curlin et al. (2008)

Cohen J et al. (2008)

Verbakel & Jaspers (2010)

Bulow et al. (2012)

Dany et al. (2015)

C

C

R

R

R

R

R

R

413

Europe

National US

Europe (33 countries)

National US

National US

Palliat care MDs, interns

France

Europe & Israel

CDA, 33 countries (31 from Europe)

Physicians in EOL care

Physicians

CDA

CDA

CDA

248 ICU pts, 330 fam, 386 nurses, 304 MDs

37,393

8,631

1,144

41,125

1,111

1,714

#1 Belief in God (51%)

#2 D, RB

#9 D, SR, RB, RC

NG

P

P

P (attitude/​ action)

P

#4 D, IR, R infl medicine #1 D (relig vs. non-​relig)

P

P

P

P

#4 D, ORA, RB

#3 D, ORA, strength of aff

#3 D, ORA, SR

NG

P (via parent monitor)

P (adherence psych f/​u)

NA

P

P

P (weekly attendance)

P

F I N DIN G S

P (R or social grp combined)

#13, including DUREL

#1 ORA

#1 Buddhist vs. none

Wuhan, China Australia

#4 ORA, SR, RB

National US

Adol age 12–​17

#1 R vs. not

#1 Have religion vs. No

#1 SR

#1 ORA

#1 ORA

#1 (do you have a R?)

R E L IG VA R I A BL E S

South Korea

South Korea

National US

National US

National Poland

England

L O C AT ION

ER for suicide attempt

CDA, age > 65

CDA

Health professionals

Age 16 or older

CDA

P OP U L AT ION

61 vs. 425 (Buddhist addicts vs. non-​addicts)

14,272

525

926

10,368

109,633

6,400

7,403

M E T HOD N

Assisted Suicide/​Euthanasia (where P indicates less favorable attitudes toward desire for hastened death beyond natural)

T Y PE

TOPIC /​IN V E S T IG ATOR S

MC

?

MC

NONE

MC

MC

MC

MC

MC

MC

MC

(8)

8

9

8

9

9

8

8

(8)

8

(8)

8

(8) SC

8 MC

8

10

10

8

R AT IN G

MC

MC

MC

MC

MC

C ON T ROL S

CS

Balboni et al. (2018)

R

R 1,005

1,648 US clergy

CDA

CS

CS

CS

PC (2)

CS

*Baetz et al. (2006) (panic do)

*Baetz et al. (2006) (soc phob)

*Fauth et al. (2007)

*Chatters et al. (2008)

R

R

R

R

R

837

1,315

37,000

37,000

1,282

93

*Sujoldzic et al. (2006)

161

PC (1)

CT

*Zehnder et al. (2006)

*Bormann et al. (2006)

—​

*Basoglu et al. (2005)

S

PC (40+​)

Wink & Scott (2005) (death anxiety) 1,358

CT

Chen YY (2005)

1,316

S/​C

CS

*Cardozo et al. (2004)

S

CS

CS

*Krause & Ellison (2003)

58

—​

155

CT

*Rye & Pargament (2002)

203

62

C

C

177

CT

*Razali et al. (1998)

2,969

1,299

S

CT

Azhar et al. (1994)

R

R

—​

CS

Koenig et al. (1993b)

720

799

CS

Koenig et al. (1993a)

R

R

PC (2)

*Williams D et al. (1991)

National US

Chicago

Ad (9–​12 yo) CDA, E ,B

Canada

Canada

Bosnia

San Diego, CA

Switzerland

Yugoslavia

California

New Jersey

Afghanistan

National US

Ohio

Malaysia

Malaysia

North Carolina

North Carolina

New Haven, CT

National US

National US

CDA

CDA

Ad (mean age 17)

MP (HIV+​)

MP, C (age 6–​15)

CDA, war survivors

CDA

CS

CDA, Muslim, 13% disab

CDA, E, 49% B

CS (Christian F), 18–​23 yo

PP

Muslims

CDA

CDA, E

CDA

Anxiety (Chapter 8) (including fear, generalized anxiety disorder, i.e., GAD, and PTSD)

CS

Bulmer et al. (2017)

P

MC

NA NA

#3+​ ORA,NORA,SR

MC

MC

MC

MC MC

—​

MC

MC

MC

—​

MC

MC

8

8

8

8

8

8

8

8

8

8

8

8

8

8

–​ –​

8

–​

9

8 9

P M (P-​ORA, NG-​ Sp values)

8 8

MC

MC

MC

P (P-​ORA)

NA

P

NA (PTSD)

C

#1 ORA (“church group”)

#2 ORA, Sp values

#2 ORA, Sp values

#2 ORA,SR (scale)

“spiritual mantram”

#2 RC

#10 RB

#5 SR, RB

P (hi trauma, F)

P (non-​disabled)

#1 RC (read Koran/​ pray) “Religious writing”

P

NA

P

P

P

NA

P

#3 ORA, NORA, God forgiveness

Rlg vs. secular forgiveness

#1 relig psychotherapy

religious therapy

#5 ORA, NORA, SR

#5 ORA, NORA, SR

#2 D, ORA

28% said physician aide in dying was morally acceptable

#2 D, SR

PC (16m)

CT

PC (3)

CS

CT

CS

CS

CT

CS

PC (1)

PC (10)

CT

CS

*Korenromp et al. (2009)

*Foley et al. (2010)

*McFarland (2010) (death anxiety)

Lavric & Flere (2010)

Rosmarin et al. (2010)

*Sternthal et al. (2010)

Laufer & Solomon (2011) (PTSD)

Harris JI et al. (2011) (PTSD)

*Hussain et al. (2011) (PTSD)

Cannon et al. (2011) (worries)

*Rasic et al. (2011a)

Akuchekian et al. (2011)

Rosmarin et al. (2011b)-​study 1

166

—​

CT

CS

*Bay et al. (2008)

CS

*Contrada et al. (2008)

Ellison CG et al. (2009a)

550

S

CT

323

50

C

1,091

—​

551

1,180

54

1,972

3,103

126

1,386

R

C

S

—​

C

R

C

C

919

115

—​

R

147

921

83

C

R

—​

60

*Wachholtz & Pargament (2008)

—​

CT

N

*Miller WR et al. (2008)-​study 1

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

CDA

PP with OCD

CDA

MP (cancer survivors)

Survivors of Asian tsunami

Internet –​US

Iran

Baltimore, MD

Nebraska

Norway

Minnesota

Israel

HS, non-​secular Veterans with PTSD

Chicago area

Northeast US

Bosnia, Serbia, Slovenia, US

National US

Australia

Netherlands

National US

Indiana

New Jersey

Midwest US

New Mexico

L O C AT ION

CDA

CDA, Jewish

CS

CDA,E (> 65 yo)

MP (cancer)

F, term of preg, fetal anomaly

CDA

MP (heart patients)

MP (cardiac surgery)

MP (vascular HA)

Substance abusers (outpt)

P OP U L AT ION

#20 Trust/​Mistrust in God

Spiritual CBT

#2 ORA, RC

#? hi vs. low spirituality

#1 RC

Spiritual intervention

#14 IR, ER

#17 D, ORA, NORA, etc.

P (trust in God)

P

NA

P

(NG)

P

P (exc ER)

M

None

—​

MC

?

MC

—​

MC

MC

—​

P

Spiritual psychotherapy (Internet)

SC

P (exc for Quest, ER)

#27 IR, ER, Quest, ORA

MC

—​

MC

MC

SC

MC

—​

—​

C ON T ROL S

M (women only)

P

NG (PTSD)

P

NA

NA

P

NG

F I N DIN G S

#6 ORA, NORA

Buddhist Mindful Med

#1 religious vs. not

#3 ORA, NORA, RB

Chaplain visits (#5)

#13 NORA, RB

Sp vs. secular meditation

Spiritual direction

R E L IG VA R I A BL E S

(8)

(8)

9

8

(8)

8

8

8

8

(8)

8

9

8

8

8

(8)

8

8

R AT IN G

PC (14d)

PC (3)

CS

CS

CS

CS

CS

CS

RS

CS

CS

CS

CS

CS

CS

CS

Rosmarin et al. (2011b)-​study 2

McIntosh et al. (2011)

*Sorensen et al. (2012)

Krause & Bastida (2012)

Clements & Ermakova (2012)

*Robinson et al. (2012)

*Park JI et al. (2012)

*Hourani et al. (2012) (PTSD)

*Seirmarco et al. (2012)

*Salas-​Wright et al. (2012)

*Tran et al. (2012) (PTSD)

*Sternthal et al. (2012)

*Mota et al. (2013) (panic att)

*Thege et al. (2013)

Ellis L et al. (2013)

*Liu & Koenig (2013)

R

C

R

R

R

C

R

C

R

R

R

C

R

R

R

—​

1039

3,950

12,643

8,441

3,103

449

17,705

608

24,690

6,275

NA (except for mistrust)

Malaysia, Turkey, US Rural China

CDA, F, age 13–​34

Hungary

Canada

Chicago

California

National US

#2 SR (change in SR)

Internet (US)

#15 ORA, NORA, IR

#7 D, RB, SR, R act, R hx

#2 ORA, SR

#2 ORA, Sp values

P

None

None

SC

M (P-​ORA, NG-​SR) NG (fear of death)

MC (over adjust)

MC

MC

MC

MC

MC

SC

MC

MC

MC

None

MC

None

NG (Sp values)

M (based on race)

P-​ERs only

#23 D, ORA, IR, ER, God image ORA, SR, NORA

P

#5 ORA, SR, IR, RB

P (PTSD worse with decrease)

P (only in low-​ mod combat exposure)

#2 SR, IR

National US

P

P

P

NG

NG (Protestants)

#1 ORA

#12 Surrender to God scale

#5 ORA, gratitude to God

#1 “seeking God’s help”

#3 ORA, IR       P (ORA) (cogn                 intrusions)              C (IR) (cogn              intrusions)

#20 Trust/​Mistrust in God

#2 D (atheists vs, other), Sp

South Korea

National US

Tennessee

Southwest US

Norway

National US

New York City

CS, CDA

CDA

Active duty serv member

CDA

Veteran inpts w PTSD

Ad, age 12–​17

CDA with loss after 9/​11

Active duty military

CDA

CDA

CS/​pregnant F

460/​230 14,884

CDA, Hispanic, E

Cancer patients

CDA (after Sept 11th)

Rlg Jews with subclinical anxiety

1,005

2,086

890

39

(8)

8

8

8

(8)

(8)

9

(8)

8

8

9

(8)

8

(8)

9

(8)

PC (4)

PC (60–​ C 90 d)

Peterman et al. (2014)

Currier et al. (2015)

CS

CT

Beiranvand et al. (2014)

Breslin & Lewis (2015a)

CS

*Vance et al. (2014) (phobia)

CT

CS

*Ellison CG et al. (2014)

Oman & Bormann (2015)

PC (3)

*Bradshaw et al. (2015)

P (1)

CS

*Appel et al. (2014)

Bryant-​Davis et al. (2015)

CT

Koszycki et al. (2014)

CS

CS

Oginska-​Bulik (2013)

*Shiah et al. (2015)

CT

Hosseini et al. (2013)

CT

PC (4)

*Chan & Rhodes (2013)

Elham et al. (2015)

PC (8d)

*Rosmarin et al. (2013a)

839

S/​R

371

132

—​ C

252

451

66

C

C

—​

160

—​

532

2,621

1,511

1,024

2,095

23

C

R

R

R

—​

116

66

—​ C

386

47

7,403

N

C

—​

R

CS

King MB et al. (2013a)

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

CDA

Veterans with PTSD

CDA, B, F, sexual assault

CDA (CS and non-​CS)

MP, E, admitted to CCU

Veterans, PTSD, inpt prgm

Ad, age 11–​15

Muslim women C-​section

Twins in Virginia registry

CDA

CDA,E (age > 65)

CDA, Asian

PP with GAD

Emergency service workers

Sp mantram repetition #16 NORA (freq/​type)

San Diego, CA Ireland

#2 RC (brief COPE)

#20+​RB, R activities

Tairwan Chicago

Need-​based Sp/​R intervn

NG (dissociation)

P (PTSD symptoms)

NA

NA

P

P

NG

#6 RCm scale, Δ in RCm #17+​ BMMRS

P (relaxation)

NA (explained by genetic factors)

P (if attached to God)

P (death anxiety)

P

P

NA (PTSD)

P

NA (PTSD)

P

NG (Sp view)

F I N DIN G S

Recited prayer meditation

#78 (7 dimensions of R)

#10 prayer, attach God

#1 Religious music

#2 ORA, D

Sp-​based interv vs. sup

#7 R practices

Sp/​R interven vs. controls

Iran

California

Multisite US

Iran

Virginia

National US

National US

National US

Canada

Poland

Iran (Shia Muslim)

#16 ORA, SR, RC

New Orleans

Low-​income mothers CABG patients pre-​op

#18 RB, SR, ORA, NORA, RC

#5 Royal Free Interview

R E L IG VA R I A B L E S

Northeast US

United Kingdom

L O C AT ION

PP (current/​hx psychosis)

CDA

P OP U L AT ION

SC

—​

MC

None

—​

MC

SC

—​

MC

MC

MC

MC

—​

SC

—​

MC

SC

MC

C ON T ROL S

(8)

9

(8)

(8)

8

9

8

8

8

8

9

8

8

(8)

8

8

(8)

8

RATING

CS

CS

CS

CS

CS

CS

CS

CS

CS

PC (6m)

CS

CS

CS

PC (3)

CS

CS

CS

PC (14)

Maideen et al. (2015)

Galek et al. (2015)

*Wang Z et al. (2015)

*Frick et al. (2016)

*Ganocy et al. (2016) (PTSD)

*McClintock et al. (2016) (GAD

*McClintock et al. (2016) (GAD

*McClintock et al. (2016) (GAD

Meanley et al. (2016)

*Trevino et al. (2016)

*Philippus et al. (2016)

*Sharma et al. (2017) (PTSD)

*Henslee et al. (2015) (PTSD)

*Lowell et al. (2017)

Gesselman et al. (2017) (PTSD)

*Moreno & Cardemil (2018)

*Lerman et al. (2018)

*Chen Y & VanderWeele (2018)

S

R

R

C

6,950

15,787

868

498

83

810

S/​R C

3,151

1,257

111

351

1,499

863

R

S

C

C

C

C

3,150

418

C

8,574

S/​C

2,770

1,453

1,556

C

R

C

R/​S

#5 ORA, SR, RC

Detroit, MI

National US

National US

CDA, Hispanic/​ Latino Ad (ave age 15)

National US

Mexican Americans

Multi-​site US

Breast CA pts +​ spouse dyads

#2 ORA, NORA

#3 D, ORA, SR

#1 ORA

#10 Sp Persp Sc

#12 R experience

US

F w genetic risk for mood/​anxiety disorder

#5 DUREL

#1 ORA

#2 PRC, NRC

National US

National US

#1 R change (increased)

54 R & Sp scales

United States

Boston, Houston

54 R & Sp scales

54 R & Sp scales

China India

#20 SWB

#15 DSE©, Sp dryness

#3 ORA, SR, D

#2 Rcm

#5 DUREL

Ohio

Germany

Western China

National US

Malaysia

Mississippi

CDA hurricane survivors

Veterans

MP, traumatic brain injury

Veterans, E, M, cancer

Gay, bisexual, M (age 18–​29)

CDA (online Internet)

CDA (online Internet)

CDA (online Internet)

Army National Guard

Clergy and deacons

CDA

CDA

CDA

P (PTSD)

P (older adults)

P

P (intrusive thoughts)

NA

P (PRC)

P

P

NG

NG (homophobia)

P

P

NG

NA with RWB

P

NG

P (exc in those lacking meaning)

NG

MC

MC

SC

SC

MC

MC

MC

MC

MC

MC

SC

SC

SC (age, sex,educ)

MC

MC

MC

MC

MC

10

8

8

(8)

8

8

8

8

(8)

(8)

(8)

(8)

(8)

(8)

8

8

8

8

PC (4m)

CS

CT

CT

PC(7)

CS

CS

PC (2)

PC (3–​12) C/​R

CS

PC (?)

CT

Zimpel et al. (2018)

*Loureiro et al. (2018)

Harris JI et al. (2018) (PTSD)

Nikfarjam et al. (2018)

Mota et al. (2019) (PTSD)

MacLeod et al. (2019)

*Moons et al. (2019)

*Kim ES et al. (2019b)

*Chen Y et al. (2020a)

Stroope et al. (2020)

Kimhi et al. (2020)

Samsudin et al. (2019)

Amini et al. (2020)

145

—​ —​

CT

Exp/​CT

CT

CT

Lang et al. (2020)

Amjadian et al. (2020)

*Sanaeinasab et al. (2021)

g

PCGT =​Present Centered Group Therapy.

63

60

84

—​

—​

75

561

—​

933

92,008

5,200

4,028

1,001

R (?)

C

R

C

R

2,307

72

—​ R

138

264

101

544

N

—​

S

C

C

CS

Ramirez et al. (2018)

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

F, pregnant

MP, CABG (heart surg)

Marathi Hindu CDA

MP with GI cancer

Surgical pts (Muslim)

CDA, Jews

CDA, South Asians

CDA

Age 50 or over

MP, congenital heart disease

CDA

Trauma-​exposed Veterans

Patients with anxiety

Veterans with PTSD

MP, hemodialysis

Outpt w panic do in RCT

CDA, age 18–​59

P OP U L AT ION

Iran

Iran

Mauritius

Iran

NG

M

P (CS), NA (PC)

P

#1 Sp intervention (Islamic)

Islamic R intervention

Hindu ritual in temple

R/​Sp care intervention

P

M (R > ctrls, R =​breathing techniques)

P

P

P

—​

—​

—​

—​

—​

None

MC

P (slight/​mod v. hi) P

MC

MC

MC

None

MC

—​

—​

MC

MC

MC

C ON T ROL S

P

NG (mediated mortality effect)

R intervention (Dzikr)

#1 “religiosity”

Israel Malaysia

#1SR

#1ORA

#1 ORA

US cities

National US

National US

#2 SR, SSp #2 SR

New Zealand

#5 DUREL

Religious intervention vs. drug Rx

Equivalent to PCGTg

NA

#5 ORA, NORA, IR Spiritual intervention

NA (panic symp)

P

F I N DI N G S

#49 RC (PRC,NRC)

#1 SR

R E L IG VA R I A B L E S

Multi-​national

National US

Iran

Minnesota

Brazil

Brazil

Bogota, Columbia

L O C AT ION

8

(8)

(8)

8

8

(8)

(8)

10

9

8

(8)

9

8

9

(8)

8

(8)

R AT IN G

CS

Evans et al. (2018)

C

C

C

373

155

120

US Veterans

US Veterans

US Veterans

C

Exp/​PC

PC (2)

CS

CS

CS

PC (8d)

PC (39)

CS

CS

PC (5)

CS

Raguram et al. (2002)

Benda (2002a,b)

Lewis-​Fernandez et al. (2009)

Danbolt et al. (2011)

Mohr et al. (2012)

*Rosmarin et al. (2013a)

*Thygesen et al. (2013)

*Caqueo-​Urizar et al. (2016)

Kéri & Kelemen (2020)

Steenhuis et al. (2016)

*AbdelGwad et al. (2017)

C

C

C

C

Psychiatric inpatients

C with/​wo hallucinations

337/​337 175

PP with/​without schizophrenia

PP with schizophrenia

CDA

PP (current/​hx psychosis)

PP (outpts w schizophren)

PP with schizophrenia

CDA, Latinos

Homeless vets, with substance abuse

PP active psychotic symps

PP (schizophrenia, inpts)

Hutterites (CDA)

120/​120

253

9,277

47

—​ S

276

50

2,554

600

31

193

7,020

C

C

R

S

S

CS

Siddle et al. (2002a)

S

CS

*Nimgaonkar et al. (2000)

Schizophrenia and Other Psychoses (Chapter 9) (NG =​more psychotic symptoms)

CS

CS

Koenig et al. (2018d)

Youssef et al. (2018)

Moral Injury (MI) in Setting of PTSD (P indicates religiosity inversely related to MI)

Texas

Netherlands

Hungary

South America

Denmark

Northeast US

Switzerland, Canada, US

Norway

National US

Midwest US

India

United Kingdom

Manitoba, CAN

M

#5 DUREL

#5 Sp & R questionnaire

#31 BMMRS, #4 Christian Sp

M

NA

NA, exc NG w RC

P

P

#1 D (SDA/​Baptist vs. gen pop) #4 D, SR, ORA, NORA, RC

NA

#18 RB, SR, ORA, NORA, RC

M

NG

P

P (20% improve)

NG (R delusions)

None

None

None

MC

SC

SC

SC

None

MC

MC

None

MC

Significantly lower rate of psychoses in Huttterites

NRC mediated MI-​distress relationship

#20+​RB, ORA, NORA, DSE #5 centrality of R

MC

Moderated MI-​PTSD relationship in subgroup

P

#1 RC

#5 ORA, NORA, RB

#1 stayed at temple 6 wk

#3 SR, RB

#1 D

#26 NRC

Houston, TX

#10 BIAC #10 BIAC

Multi-​site US Augusta, GA

(8)

8

(8)

(8)

8

(8)

(8)

(8)

8

9

(8)

8

8

(8)

(8)

(8)

C

CT

CS

CS

CS

PC (1m)

CS/​CC

CS

CS

CS

CS

CS

Ofori-​Atta et al. (2018)

*Gawad et al. (2018)

Mizuno et al. (2018)

Oh et al. (2018)

Mishra et al. (2018)

Severaid et al. (2019)

Loch et al. (2019)

Oh et al. (2019) (psych exp)

Anderson-​Schmidt et al. (2019)

Kos et al. (2019)

*Serfaty et al. (2020) (Rx expect)

h

SSD =​schizophrenia spectrum disorder.

C

CS

Kovess-​Masfety et al. (2018)

C

S

C

R

R

R

C

C

—​

R

C

CS

Peltier et al. (2017)

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

PP inpts (64% bipolar)

PP, 80% schizophrenia

CDA from 18 countries

Blacks with hallucinations

P OP U L AT ION

30

50

262

3,570

226

71 vs. 72

67

1,666–​ 4,795

Orthodox Jews, psychosis

PP with schizophrenia

PP (schizophr, schizo-​affect)

CDA, B

CDA, high prodromal symps

Ad, high-​risk psychosis

PP with schizophrenia

CDA, racially diverse

112 schizo, 120 bipolar, 137 ctrls

668

139

22,542

471

N

P (ORA)

#29 DUREL, RC, R/​S

#30 RB, SR, RC, Trust/​ P (trust), NG Mistrust (mistrust)

Croatia Israel

NG

M

NA (NG w depression)

      CS-​NG (R delusions)      PC-​NG (R delusion outcome)

     NG (psychotic exp’s)

     NA (resilience)

    NG (psychotic symp)

NG (R delusions)

#7 ORA, RSup

#5 DUREL

MC

None

C ON T ROL S

None

MC

MC

MC

SC

None

None

MC

SC

MC

NG (did better with medication)

NG (psychotic symp)

P (less likely to have SSDh)

F I N DIN G S

#1 D, active vs. non-​active

Germany

National US

Brazil

#5 DUREL

#5 NORA

India

Illinois

#7 SR, ORA, NORA, IR, RC

#3 D, ORA, SR

Austria/​Japan National US

#5 DUREL

Prayer camp active (PCA) vs. PCA +​meds

#6 D, ORA, SR, IR, RC

#1 Sp hallucinations

R E L IG VA R I A B L E S

Texas

Ghana

Worldwide

Louisiana

L O C AT ION

(8)

(8)

(8)

8

(8)

(8)

(8)

8

(8)

(8)

8

9

(8)

R AT IN G

CS

CC

Exp

Noort et al. (2020)

*Kéri & Kelemen (2020)

Dwidiyanti et al. (2020)

C

C

C

C

45

#1 Sp mindfulness

Indonesia

CS

CS

CS

CS

CS

CS

CS

Perkins (1987)

Bock et al. (1987)

Cochran et al. (1988)

Cochran & Akers (1989); Cochran (1991 & 1993)

Benson & Donahue (1989)

Beeghley et al. (1990)

Krause (1991)

R

CS

CS

Hays et al. (1986)

13,878

S/​R

CS

Amoateng & Bahr (1986)

835

S

CS

Lorch & Hughes (1985)

R

R

R

R

R

R

S

R

2,746

1,607

8,652

> 12,000

3,065

7,581

4,289

860

17,000

1,121

4,000

Hasin et al. (1985)

R R

CS

CS

Cisin & Calahan (1968)

National US

CDA, E

CDA

HS seniors

Ad

CDA

CDA

CS

National US

National US

National US

Midwest US

National US

National US

New York

National US

National US

Ad (13–​18) HS seniors

Colorado Springs

Five US cities

Norway

HS students

PP with depression

CDA

CDA

#4 ORA, NORA, SR

#5 ORA, SR, CM, RB

#2 ORA, SR

#4 ORA, SR, D

#4 ORA, RB, SR, CM

P

P

P

P

P

P

P

#3+​SR, D, misc #4 D, ORA, SR, CM

P

P

P (SR)

P

P

P

P (drug-​taking)

#2 ORA, SR

#5 religiousness scale

#6+​CM, ORA, SR

#1 D (some vs none)

#4 ORA, NORA

#5+​ORA, RC, RB

Description of early natural history of alcoholism (and consequences of religious conversion)

Wallace (1972)

R, O

Lemere (1953)

Discussion of therapeutic role of Alcoholics Anonymous

PP w schizophrenia

NA –​Christian R NG –​Spirituality

NG

#25+​D, RB, SR, ORA, RC #26 Christian R, others

NG-​pos symps P-​neg symps

#25 R scale

Hungary

Netherlands

Spain

Bales (1944)

Alcohol Use/​Abuse/​Dependence

PP, E (ave age 77)

PP vs. controls

120 schizo vs. 120 nl ctrls

155

81 vs. 95

Substance Use/​Addiction (Chapter 10) (SA =​substance abuse)

CS/​CC

Duñó et al. (2020)

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC-​grade, sex

MC

MC

MC?

—​

None

SC (gender)

SC

9

9

9

8

9

9

8

9

9

8

9

9

9

(8)

(8)

(8)

(8)

R R

CS

CS

CS

PC (2)

CS

CS

CS

CS

CS

CS

CS

Forster et al. (1993)

*Brown D & Gary (1994)

Koenig et al. (1994a)

Foshee & Hollinger (1996)

Goldfarb et al. (1996)

Idler & Kasl (1997a)

*Kendler et al. (1997)

*Levav et al. (1997)

*Resnick et al. (1997)

Wallace & Forman (1998)

Trinkoff et al. (2000)

CS

PC (2)

CS

PC (1)

PC(7)

Winter et al. (2002)

*Benda (2002a,b)

Assanangkornchai et al. (2002)

Regnerus & Elder (2003)

Gotham et al. (2003)

R

CS

PC (1)

Szaflarski (2001)

CS

Brown TN et al. (2001)

Tonigan et al. (2002)

R

PC (28)

*Strawbridge et al. (2001)

C

R

C

S

R

C

R

S

CS

CS

Miller L et al. (2000)

Sutherland & Shepherd (2001)

R

R

R

C

R

S

R

R

S

R

R

CS

Cochran et al. (1992)

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

United Kingdom

Ad (age 11–​16)

Homeless vets, subst abuse

Twins, age 16, & parents

Alcoholics (MATCH pgm)

CDA

HS

424

7,789

National US Midwest US

Ad/​parents CS (age 18–​20)

Thailand

Midwest US

#1 ORA

#4 ORA, SR, R change

#5 SR, R activities

#5 ORA, NORA, RB

P

P

P

P

MC

MC

MC

MC

SC

P

#12 REL scale (MMPI) Finland

MC NONE

P #2+​God blf, AA attend P

MC

SC

MC

MC

MC

MC

MC

#2 ORA, NORA

P

P (women)

P

P

P

P

P

MC

MC

MC

—​

MC

MC

MC

MC?

MC

C ON T ROL S

Multi-​site US

#1 (?) RCm

#1 ORA

#2 RB, ORA

#7 ORA, SR, RC, RB

#4 NORA, RB, RC

#3 D, ORA, SR

#1 SR

Lower in Jews

#1 D (Jews vs. non-​J)

P (ORA) P

#11 RB, ORA, NORA, SR

#2 ORA,SR

PP > MS

P

#12 scale

P

#4+​ORA, RB, SR, D

P (ORA)

P

P

F I N DIN G S

#5 ORA, NORA, SR

#12 relig scale, ORA, D

#1 D (None vs other)

#3+​R homogamy, SR, D

R E L IG VA R I A B L E S

Poland (national)

National US

California

National US

Ad (age 15–​19) CDA

National US

National US

National US

New Haven & Los Angeles

Virginia

New Haven, CT

New York

Southeast US

North Carolina

Southeast US

New York state

National US

L O C AT ION

Nurses

HS students

Ad

CDA

CDA, twins

CDA, E

PP/​Medical students

Ad & mothers

CDA

CDA,B,M

CDA,E

CDA Protestant

P OP U L AT ION

91 dependent /​77 hazardous /​ 144 non-​drinkers

600

2,262

1,697

1,518

188,000

2,676

4,516

676

3,600

5,000

12,118

5,772

1,902

2,812

101/​119

2,102

2,969

537

667

3,772

N

9

10

8

9

8

8

8

9

9

8

8

8

9

8

8

9

9

8

9

9

8

8

9

R AT IN G

PC (3)

CS

PC (10)

CS

CS

CS

CS

PC(3 m)

PC (6 mo)

CS

CT

PC (2)

CS

CS

Caputo (2004)

Chen CY et al. (2004a,b)

Windle et al. (2005)

Harris AH et al. (2006)

Viner et al. (2006)

Pirkle & Richter (2006)

Jeynes (2006)

Gordon et al. (2006)

White et al. (2006)

Hill TD et al. (2006a)

Margolin et al. (2006)

Jessor et al. (2006)

*Baetz et al. (2006)

Kliewer & Murrelle (2007)

R

PC(2)

CS

Booth et al. (2004)

Beyers et al. (2004)

C

PC(4)

Steinman & Zimmerman(2004)

R

R 17,215

37,000

975

72

C

1,504

—​

319

130

18,726

929

2,789

3,032

760

R

S

C

R

R

R

S

C

12,797

1,911

R/​C R

40,845

664

705

1,182

56,004

S

CS

PC(3)

Wills et al. (2003)

R

CS

Wallace et al. (2003)

US & Australia

Ad (grades 6–​12)

HS

Central America

Canada Central America

CDA

Colorado

Connecticut

Texas

Northwest US

Pennsylvania

National US

HS (age 12–​20)

CS, freshmen

Methad-​maintain addicts

CDA

HS transitioning to CS

Adult inpt alcoholics

HS (12th grade)

National US

London (UK)

Ad (age 11–​14)

F (5th grade to college)

National US

New York

Substance abusers, inpt,M

Age 16 to 25

National US

Southern US

At-​risk drinkers

Ad (age 12–​16)

Midwest US

New York

National US

HS, B

Ad (7th to 10th grade)

Ad (10th grade) (5% B)

#9 RB, parent religiosity

#2 ORA, Sp values

#2 SR, ORA

Sp-​focused Rx (Buddhist)

#1 ORA

#2 ORA, SR

#16 DSE©

#3 SR, ORA

#1 SR

#2 D, observance

#2 RB, ORA, NORA

#2 ORA, SR

#1 religious practices

#8 R (parent & Ad)

#? “particip in R activity”

#5 ORA, SR, NORA

#1 ORA

#4 SR

#3 D, ORA, SR

P (both)

P

P

P

P

P

NA (sobriety)

P

P

P (Muslim/​ other vs. None)

P

P

P

P

P

P

P

P

P

MC

MC

MC

—​

MC

MC

SC

SC

MC

MC

MC

MC

MC

MC

MC

MC

MC (?)

SC

SC

9

8

8

8

8

8

6

8

8

8

8

9

8

9

9

9

8

8

8

PC (5)

CS

Haber & Jacob (2007)

Bartkowski & Xu (2007)

CS

CS

Degenhardt et al. (2007)

*Baetz & Bowen (2008)

CS

O’Malley & Johnson (2007)

CT

PC (5)

Petts & Kenoester (2007)

*Miller WR et al. (2008)-​study 1

PC (1)

Zemore (2007)

PC (2)

PC (2)

Carrico et al. (2007)

Benjamins & Buck (2008)

R

CS

Joutsenniemi et al. (2007)

PC (8)

CS

Atkins & Hawdon (2007)

CS

CS

Stockdale et al. (2007)

Jackson et al. (2008)

CS

Michalak et al. (2007)

Steinman et al. (2008)

R

CS

*Sinha et al. (2007)

R

—​

R

R

S

R

R

R

C

S

R

C

R

R

R

R

CS

Wallace et al. (2007)

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

37,000

60

10,399

33,007

32,087

1,493

3,582

9,282

5,791

890

733

2,805

4,589

822

12,716

7,370

1,690

16,595

N

CDA

Polydrug addicts (inpts)

Canada

New Mexico

Mexico (natl)

Columbus, OH

CDA, E (> 50 yo)

National US

AD (6th–​12th grades)

National US

Missouri

National US

National US

National US

HS

HS seniors

Ad, F

CDA

HS seniors

Parents

#3 ORA, Sp, prayer cope

Spiritual direction

#3 ORA, SR

#1 ORA

#2 ORA, SR

#5 D, SR, ORA, RC

#7 D, ORA, RB

#2 D, SR

#1 RCm

#3 ORA, R homogamy

P

#7 R belief/​behav change

Substance abusers

California

P (12-​step involv)

#22 IR, misc R

Multi-​site US

Veterans inpt SA prgms

P (ORA)

NA

NA

P

P

P (exc Denom)

P

P (exc Catholics)

P (driving alc)

NA (R homogamy)

P

#1 ORA (6% of sample)

Finland

CDA (age 30–​54)

M

P

#1 churches/​1,000 $15 SR, RB

P (exc Denom)

P

P

F I N DIN G S

#2 D, SR, RB

#3 ORA, SR

#2 SR, ORA

R E L IG VA R I A B L E S

National US

National US

National US

National US

National US

L O C AT ION

Sub abus in support grps

CDA

CDA

Ad (age 11–​18) & parent

Ad (12th graders)

P OP U L AT ION

MC

—​

MC

SC

MC?

MC

SC

MC

MC

MC

MC

MC

SC (age)

MC

MC

MC

MC

MC

C ON T ROL S

8

8

9

9

10

8

8

9

8

9

8

8

8

8

8

8

8

8

R AT IN G

C C

PC (6)

PC (15m)

PC/​CS

PC (2m)

PC (6m)

CS

CS

CS

CS

PC (2)

Krentzman et al. (2010)

*Button et al. (2010)

Kelly et al. (2011a)

Kelly et al. (2011b)

*Rasic et al. (2011b)

Kovacs et al. (2011)

*Good & Willoughby(2011)

Vaughan et al. (2011)

Hodge et al. (2011)

C

R

R

S

C

C

C

R/​S

S

R

C

R

PC (10)

CS

Edlund et al. (2010)

C

Stevens-​Watkins & Rostosky (2010)

PC (15m)

Pagano et al. (2009) (AA helping)

R

S

Green K et al. (2010)

CS

Page RL et al. (2009)

CS

CS

Pence et al. (2008)

R

CS

CS

*Blay et al. (2008)

R

Chamratrithirong et al. (2010)

CS

Ellison CG et al. (2008a)

R

Allen & Lo (2010)

PC(2)

Hill TD & McCullough (2008)

804

14,297

3,993

881

1,615

1,726

195

2,754

414

1,599

725

2,812

420

36,370

1,593

1,031

611

6,961

15,424

2,402

National US

Pregnant, post-​ partum F

Thailand

Southwest US

National US

Adol (age 12–​17) Latino students (ave age 11)

#1 ORA

#3 R affil, ORA, SR

#3 SR, IR

#3 D, ORA, SR Ontario, Can

#2 ORA, SR Hungary

HS students

Nova Scotia, Can

HS, age 15–​19

#14 R behaviors, AA attend

#14 ORA, NORA, RB

#5 SR, ORA, NORA, IR

#13 R behavior

#3 ORA, SR, NORA

#1 ORA

#14 ORA, SR, RB, Sp

M

P

P

P (girls only)

P

P

P

P (prob alcohol use)

(P) for PC, P for CS

NA

NA

NA (R or Sp)

NA

P

#3 ORA, SR, IR #7 RB, SR, NORA

P

P

P

#13 R behaviors

#3 D, ORA, SR

#2 RC (COPE)

M

P

#2 D hetero/​homo, ORA #4 D, R change, SR, ORA

P

#1 ORA

HS students, grades 9–​12

Multisite US

Ohio

Colorado

Multisite US

National US

Chicago

Alcoholics in MATCH

Ad in SA program

Adol twins, MZ/​DZ

Alcoholics in MATCH

Ad, M, B

CDA, B

National US

Teen-​parent dyads CDA

National US

CDA

National US

Southeast US

MP (HIV+​)

PP (alcoholics) (MATCH)

Brazil

National US

Multi-​site US

CDA, E

CDA

CDA, F, low income

MC

MC

MC

None (?)

MC

MC

MC

SC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

8

8

8

(8)

(8)

9

8

8

8

9

9

8

(8)

9

9

8

8

8

9

9

S R

PC (6m)

CS

CS

CS

CS

Kelly et al. (2012)

Pitel et al. (2012)

Piko et al. (2012)

*Park JI et al. (2012)

Haber et al. (2012)

R S

CS

CS

CS

Sebena et al. (2012)

Lucchetti et al. (2012)

Ford & Hill (2012)

R C

CS

CS

PC (4)

PC (1)

CS/​PC (3)

PC (5)

*King MB et al. (2013a)

*Kagimu et al. (2013)

Aalsma et al. (2013)

Desmond et al. (2013)

Borders & Boothc (2013)

Haber et al. (2013)

S

C

C

R

C

CS

CS

Pokhrel et al. (2012a)

Pokhrel et al. (2012b)

R

C

R

CS

CS

*Salas-​Wright et al. (2012)

Gryczynski & Ward (2012)

R

?

R

C

C

CS

Salmoirago et al. (2011)

M E T HOD

T Y PE

TOPIC /​IN V E S T IG ATOR S

4,002

710

9,568

328

1,224

7,403

362

354

17,727

383

2,529

14,556

17,705

4,002

6,275

592

3,674

1,726

56,372

N

Russia

HS (age 15–​16)

AR, OH, KY Missouri

Ad/​young adults (F)

National US

Recent stimulant users

Ad (Add Health study)

Indianapolis, IN

Uganda

CDA, age 15–​24, Muslim Ad, F (age 14–​17)

United Kingdom

CDA

Russia

National US

Adol (age 12–​17) HS (10th grade)

Brazil

CDA living in slums

Europe (5 countries)

National US

CS (freshmen; ave age 20)

National US

Ad, age 12–​17

Missouri

Ad, age 12–​17

Ad/​young adults (F)

CDA

South Korea

#6 RCm, ORA, D

#3 ORA, SR

#9 parent and adol R

NA

P

P

P (females only)

P (heavy use)

P

P

P

P

P

P (mediator)

P

F I N DIN G S

P

P (CS), NA (PC)

P (adol R)

P

P

P (Relig view)

P (ethnic non-​ Russians only)

#4 RB, RC, IR, NORA

#30+​ BMMRS

#5 Royal Free Interview

#5 Sp scale

#5 Sp scale

#4 ORA, SR, IR

#7 DUREL, RB

#1 SR

#4 SR, IR, ORA

#5 ORA, SR, IR, RB

#9 ORA, IR, RB

#2 D (atheists vs. other), Sp

#? “religiousness”

Hungary

HS students (age 14–​17)

#2 ORA,SR

Slovakia

Ad, grades 9–​10

#7 RB, R activity sc

#1 ORA

R E L IG VA R I A B L E S

United States

National US

L O C AT ION

Alcoholics in AA

CDA,F

P OP U L AT ION

MC

MC

MC

MC

None

MC

?

MC

MC

MC

MC

MC

MC

MC

SC

?

SC/​MC

MC

MC

C ON T ROL S

10

8

9

9

(8)

8

(8)

(8)

9

8

8

9

9

8

8

(8)

8

9

9

R AT IN G

R

CS

CS

CS

CS

Donovan (2013)

Holt et al. (2014)

Michaelson et al. (2014)

*Vance et al. (2014)

Mohammadpoorasl et al. (2014)

CS

CS

Gmel et al. (2013)

*El Ansari et al. (2014)

PC (1)

Strobbe et al. (2013)

CS

CS

Tumwesigye et al. (2013)

Burke et al. (2014)

PC (9m)

Tonigan et al. (2013)

CS

PC (39)

*Thygesen et al. (2013)

CS

CS

Gomes et al. (2013)

Fletcher & Kumar (2014)

CS

Galanter et al. (2013a)

Moscati & Mezuk (2014)

CS

CS

Garcia et al. (2013)

*Mota et al. (2013)

CS

Neighbors et al. (2013)

5,387

118

475

130

9,277

12,595

144

8,441

1,504

1,124 Texas

Military recruits, M

AA members

CDA, fishing villages

AA members (early on)

CDA

CS

MDs attending AA conf

Switzerland

Poland

Uganda

New Mexico

Denmark

Brazil

Worldwide

Canada

CDA, Mex-​Am Active duty serv member

Northwest US

CS

#2 D, SR

#1 Spiritual awakening

#2 D, ORA

P

P

P (ORA)

P

P

#1 D (SDA/​Baptist vs. gen pop) #13 R/​Sp change, AA attendance

P

#1 ORA

P

NA

P

P (modifies perceived norms)

#4 RB, SR, ORA, DSE

#2 ORA, Sp values

#2 ORA, D

#4 R values

MC

MC

MC

MC

SC

MC

None

MC (over adjust)

MC

None

(8)

(8)

(8)

9

8

8

(8)

8

8

(8)

C

C

R

R

R

C

R

R

3,220

2,312

6,203

12,000

1,837

2,621

26,078

2,370

CS (ave age 25)

CS

CDA

Ad (Add Health)

CS (ave age 22)

#1 SR

England/​Wales/​ N. Ireland

P

P

#2 ORA, self-​ID as R, Sp, secular San Francisco

p P (except change, M)

#3 ORA, NORA, SR

P

NA (explained by genetic factors)

P

P (R behaviors)

#2 D, ORA, SR, change

National US

National US

#28 strength of RB

Iran

#1 ORA #78 (7 dimensions of R)

Canada

#15 ORA, NORA, RC

Virginia

Ad (age 11–​15) Twins in Virginia registry

National US

CDA, B, w/​o cancer

MC

MC

MC

MC

MC

MC

MC

8

(8)

9

8

8

8

9

(8)

Summary of research on 12-​step programs; found that active participation in these groups was associated with longer periods of abstinence or reduced substance use, improved social functioning, and greater self-​confidence in ability to cope with addiction

C

C

C

C

S

R

C

R

R

C

T Y PE

CS

P/​CS

PC (15m)

Rco (1-​5 y)

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

TOPIC /​IN V E S T IG ATOR S

Escobar & Vaughan (2014)

Martin et al. (2015)

Tran et al. (2015)

Kobayashi et al. (2015)

*Rose et al. (2015)

*Salas-​Wright et al. (2015)

Holt et al. (2015b)

Drabble et al. (2016)

*Debnam et al. (2016)

*McClintock et al. (2016)

*McClintock et al. (2016)

*McClintock et al. (2016)

Ransome & Gilman (2016)

*Ganocy et al. (2016)

He et al. (2016)

Kelly et al. (2017)

R

25,229

977

418

S/​C

1,499

863

3,150

5,217

26,784

R

CDA,B age 21 or older

C, grades 6–​8

54 R & Sp scales 54 R & Sp scales

India United States

National US

China

CDA age 12–​35 CDA with alcohol/​ drug problems

Ohio

P (indirect)

NA with RWB

P

P

P

NG

P

P (both groups)

P

P

P (binge drinking)

P

P

P (mediated by general coping)

P

F I N DI N G S

MC

MC

MC

SC

SC

SC (age, sex, educ)

MC

MC

SC

MC

SC

MC

MC

SC

MC

C ON T ROL S

Most common reported recovery pathway was mutual-​ help groups at 45% (made up primarily of 12-​step programs, e.g., AA)

#1 RB (yes vs. no)

#20 SWB

#4 ORA, SR,S p

54 R & Sp scales

National US

#? Sp measure

China

#1 SR

#17 ORA, SR, Sp locus of control

#4 ORA, SR, IR

#4 ORA, SR, IR

#1 SR

#1 ORA

#40 RC

#6 ORA, SR, IR

R E L IG VA R I A BL E S

Baltimore

Army National Guard

CDA, B & W

CDA (online Internet)

CDA (online Internet)

CDA (online Internet)

National US

National US

National US

Southern US states

Ad (age 12–​17) CDA (age 12–​25)

Japan

Australia

Rhode Island

National US

L O C AT ION

MP, outpts seen at single hospital

Before & after pregnancy

Alcoholics in treatment

Young Latino adults

P OP U L AT ION

10,723 heterosex vs. 446 sexual minority, F

2,370

19,312 /​ 2,721

R

C

C

C

C

R

R

R

12,500

29,215

S R

6,597

116

2,442

N

S

C

R

M E T HOD

9

8

(8)

9

(8)

(8)

(8)

8

8

8

9

8

9

9

(8)

8

R AT IN G

CS

CS

CS

CS

PC (14)

*Nadal et al. (2018)

*Kim DH et al. (2018)

Krause et al. (2018b)

Malinakova et al. (2019a)

*Chen Y & VanderWeele (2018)

PC (5)

Nordfjaern (2018)

CS

CS

Henderson (2017)

*Moreno & Cardemil (2018)

CS

*Salas-​Wright et al. (2017)

CS

CS

*Burke et al. (2017)

PC (5)

CS

Nedelec et al. (2017)

Isralowitz et al. (2018)

CS

*Henslee et al. (2015)

*Holt et al. (2018)

CS

Tuck et al. (2017)

R

CS

CS

*Sharma et al. (2017)

*Medlock et al. (2017)

C

CS

*VanderWeele et al. (2017a)

R

21,965

S

R

R

C

C

R

C

C

S

R

R

R

6,950

4,566

2,142

638

9,495

868

766

758

2,671

1,692

18,614

34,525

217

810

S/​R S

16,596

331

3,151

36,613

320

R

C

C

CS

CS

Meyers et al. (2017)

Churakova et al. (2017)

CDA

National US

National US

National US

National US

Mississippi

Ad (ave age 15)

National US

Czech Republic

Ad (age 13–​15)

Chicago National US

At-​risk B adol CDA

National US

National US

National US

Southern Israel

Norway

CS

Mexican Americans

CDA, B

CS, F, Jewish

CDA, age 40 and older

CDA, B (employed/​ National US recent)

Ad, age 12–​17

CDA

Monozygotic twins

CDA hurricane survivors

Ontario, Canada

Massachussetts

CDA

National US

Inpt alcohol/​drug detox

National US

Ukraine

Veterans

CDA, B

CDA

#3 ORA, SR

P

#2 ORA, NORA

#8 R (ORA), Sp (SWB)

#18 D, ORA, NORA, NRC

#4 ORA, NORA, etc.

#19 RCm, Sp (categories)

#1 ORA

#17 RB, R behaviors, RSup

#1 Religious activity

#3 SR, CM

#3 D, ORA, NORA

#2 ORA, SR

#1 meditation (vs. not)

#5 ORA, NORA, RC, SR

NA (binge drinking)

P (with hi R and hi Sp)

P (exc NRC)

P

P

P

P (exc NG soc)

P

P

P (except Baptist, NG)

P

NG

P

P (PRC)

P

#1 R affil vs. atheist/​ none #2 PRC, NRC

P (exc NRC)

P

P

P

#18 SR, RB, RC

#5 DUREL

#4 ORA, NORA, RC, SR

#16 DSES©

MC

MC

SC

MC

MC

SC

SC

MC

MC

MC

MC

MC

SC

MC (incl shared env/​ gene)

MC

MC

MC

MC

None

MC

9

10

8

8

(8)

8

8

8

(8)

8

8

9

8

(8)

8

8

(8)

8

8

(8)

CS

PC (10)

PC (6)

PC (7)

PC (3–​12)

Review

Ransome et al. (2019a)

Guo & Metcalfe (2019)

*Pawlikowski et al. (2019)

Jang SJ (2019)

*Chen Y et al. (2020a)

Kelly et al. (2020)

CS

PC (12)

CS

*Cochran & Akers (1989); Cochran (1991)

Newcomb (1992)

Amey et al. (1996)

R

S?

R

R

R

CS

CS

*Hays et al. (1986)

13,878

S/​R

*Amoateng & Bahr (1986)

835

S

CS

CS

*Hasin et al. (1985)

11,728

614

3,065

17,000

1,121

13,58

*Lorch & Hughes (1985)

27,175

R

CS

R

CS

McIntosh et al. (1981)

National US

HS

Ad

Ad

National US

Los Angeles

Midwest US

National US

Ad (13–​18) HS seniors

Colorado Springs

Five US cities

Texas

Pennsylvania

HS

PP with depress

age 12–​19

grades 7–​12

#3 OR, SR, D

#1 SR

#4 ORA, SR, D

#2 SR, ORA

#5 religiousness scale

#6+​CM, ORA, SR

#1 D (some vs None)

#3 D, ORA, SR

#2 D, ORA

#1 ORA

P

P

P

P

P

P (SR)

P

P

P

P

P

8 10

—​ MC

8

9

9

8

9

8

8

9

10

9

10

10

8

9

8

(8)

(8)

8

8

R AT IN G

MC

MC

MC

SC-​grade, sex

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC

None

MC

MC

MC

C ON T ROL S

Cochrane review of benefits of Alcoholics Anonymous and other 12-​step programs for alcohol use disorder

National US

#5 ORA, SR, RC

Arizona & Pennsylvania

P

P

NA

P

P

P

NA

P

P (R behaviors)

F I N DI N G S

—​

CDA

Ad offenders (age 14–​17)

#1 ORA #1 ORA

National US National Poland

Ad (age 17–​21) Age 16 or older

#2 ORA,SR (contextual)

#2 ORA, R faith

#2 R affil, ORA

#7 D, SR, IR, NORA

#3 D, SR, SSp

#2 D, ORA

#11 RB, R behavior

R E L IG VA R I A BL E S

92,008

1,289

6,400

6,787

National US

CDA

National US

34,653

26 countries

Madrid, Spain

CDA

Chicago

Ad (age 12–​18)

Delaware

Uganda

L O C AT ION

Lesbian, bisexual F

Adol (8th & 11th grades)

MP, HIV-​infected

P OP U L AT ION

666–1 ​ ,045 CDA, substance abusers

thousands

2,890

699

11,530

447

N

C/​R

C

R

R

R

R

R

R

C

S

C

M E T HOD

McLuckie et al. (1975)

Drug Use/​Abuse/​Dependence

CS

PC (7)

*Marshall (2019)

Mak (2019)

CS

CS

CS

*DeCamp & Smith (2019)

*Drabble et al. (2018)

PC (1)

Adong et al. (2018)

Baena et al. (2019)

T Y PE

TOPIC /​IN V E S T IG ATOR S

R

S R

CS

CS

CS

CS

PC (2)

*Miller L et al. (2000)

*Brown TN et al. (2001)

*Sutherland & Shepherd (2001)

Strote et al. (2002)

*Benda (2002a,b)

R —​

PC (1)

CS

PC(3)

CS

PC (18)

PC (10)

PC (4)

CS

PC (3)

CS

CT/​PC

*Regnerus & Elder (2003)

*Nonnemaker et al. (2003)

*Wills et al. (2003)

*Beyers et al. (2004)

Hamil-​Luker et al. (2004)

Brown TL et al. (2004)

*Steinman & Zimmerman (2004)

*Chen CY et al. (2004a,b)

*Caputo (2004)

Steinman (2005)(drug sell)

Stahler et al. (2005)

1,911

R/​C 111

38,999

12,797

705

964

2,791

40,845

1,182

16,306

7,787

56,004

8,656

600

> 14,000

4,516

188,000

676

3,600

R

C

C

R

S

CS

R

R

R

CS

CS

Chien et al. (2002)

*Wallace et al. (2003)

R

S

R

R

R

589

CS

5,000

R/​C

*Trinkoff et al. (2000)

17,952 12,118

R

CS

PC (19)

*Wallace & Forman (1998)

R

Kandel & Chen (2000)

CS

CS

Bell et al. (1997)

*Resnick et al. (1997)

CS

National US

Midwest US

#2 SR

#1 ORA

#8 R (parent & ad)

#1 religious practices

#1 ORA

#2 ORA

#1 “R upbringing”

#? “particip in R activ”

#4 SR

#4 ORA, NORA

#4 ORA, SR, R change

#3 D, ORA, SR

#1 SR

#5 ORA, NORA, RB

#1 SR

#2 RB,ORA

#1 (?) RCm

#7 ORA, SR, RC, RB

#4 NORA, RB, RC

#1 ORA

#3 D, ORA,S R

#1 SR

Philadelphia, PA Faith-​based recov prg

Ohio Homeles,B, F, cocaine use

National US HS (grades 9-​12)

Central America

Ad (age 12–​16)

HS

Midwest US

Ad (age 10–​20) HS, B

National US

Ad (age 15–​17 at base)

US & Australia

Ad (grades 6–​12)

National US

Ad (grades 7–​12) New York

National US

Ad/​parents Ad (7th to 10th grade)

National US

Canada

Midwest US

Ad (10th grade) (5% B)

CDA

Homeless vets, subst abusers

National US

United Kingdom

CS

Ad (age 11–​16)

National US National US

Ad (age 15–​19) HS

National US

New York

National US

National US

Nurses

Marijuana users (young)

HS

Ad

P

P

P

P

P

P (in males)

P

P (in delinquents)

P

P

P

P

P

P

P

P

P

P

P

P

NA

P

P

MC

—​

MC

MC

MC

MC (?)

NONE

MC

MC

SC

MC

MC

SC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

9

8

9

9

8

8

8

8

9

8

9

10

8

8

9

9

8

10

8

8

8

9

8

CS

CS

PC (2)

*Bartkowski & Xu (2007)

*Carrico et al. (2007)

CS

*Kliewer & Murrell (2007)

*Stockdale et al. (2007)

CS

*Degenhardt et al. (2007)

CS

CS

*Atkins & Hawdon (2007)

CS

CS

*O’Malley & Johnson (2007)

Herman-​Stahl et al. (2007)

PC (2)

*Fauth et al. (2007)

Benjet et al. (2007a,b)

CS

PC (1)

*Zemore (2007)

CS

CS

*Baetz et al. (2006)

*Wallace et al. (2007)

CS

*Viner et al. (2006)

*Sinha et al. (2007)

CS

PC (1)

Herman-​Stahl et al. (2006)

*Harris AH et al. (2006)

CS

CS

Yanovitzky (2005)

*Jeynes (2006)

T Y PE

TOPIC /​IN V E S T IG ATOR S

S

R

R

R

R

R

R

C

R

R

R

R

C

R

R

S

R

R

R

M E T HOD

2,805

1,493

12,716

3005

23,645

17,215

9,282

822

5,791

1,315

1,690

16,595

733

37,000

2,789

3,032

17,709

18,726

5,007

N

London (UK)

Ad (age 11–​14)

Chicago

Ad (9–​12 yo)

Veterans inpt SA prgms

HS seniors

CDA

Ad (age 12–​17)

#22 IR, misc R

Multi-​site US

P (12-​step involv)

P (exc Denom)

P

#1 churches/​1000 #5 D, SR, ORA, RC

M (NG in users)

NG

P (RB), M (PR)

P

M

P (driving drgs)

P (low violence)

P

#5 D, ORA, SR

#1 SR

#9 RB, parent relig (PR)

#2 D, SR

#15 SR, RB

#1 RCm

#1 ORA (“church group”)

#3 ORA, SR

P

P

#7 R belief/​behav change #2 SR, ORA

P

NA

P (contin care)

P

P

P

F I N DI N G S

#2 ORA, Sp values

#2 D, observance

#3+​RB & behaviors

#1 SR

#3 SR, ORA

#2 ORA, SR

R E L IG VA R I A BL E S

National US

National US

Mexico City

National US

Central America

HS (age 12–​20) CDA (age 18–​25)

National US

National US

CDA

Sub abus in support grps

National US

National US

HS seniors

National US

Ad (age 11–​18) & parent

California

Ad (12th graders)

Substance abusers

Canada

National US

CDA

National US

Inpts in VA subs ab prgm

National US

National US

L O C AT ION

Ad (age 12–​17)

HS (12th grade)

Ad (age 9–​18)

P OP U L AT ION

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC

MC

C ON T ROL S

8

8

8

8

9

9

9

8

8

8

8

8

8

8

8

8

9

8

8

R AT IN G

R R

CS

*Page RL et al. (2009)

S

C/​S C

CS/​RS

CS/​PC/​ CT

PC (10)

CS

CS

CS

PC (2)

CS

CS

CS

PC (2 mo)

Chu & Sung (2009)

Lambert et al. (2010)

*Green K et al. (2010)

*Edlund et al. (2010)

*Allen & Lo (2010

Moro et al. (2011)

*Hodge et al. (2011)

*Kovacs et al. (2011)

*Rasic et al. (2011b)

*Good & Willoughby (2011)

*Kelly et al. (2011a)

C

R

C

S

C

C

R

R

S

R

CS

PC (7)

Agrawal & Lynskey (2009)

Harrell & Broman (2009) (Rx dg use)

S

CS

CS

Saint-​Jean et al. (2008)

R

*Pence et al. (2008)

CS

*Steinman et al. (2008)

R

R

CS

PC (21)

*Wallace et al. (2007)

R

PC (5)

*Jackson et al. (2008)

*Petts & Kenoester (2007)

195

3,993

1,615

881

804

589

2,812

36,370

725

1,758

2,977

4,882

27,467

1031

611

60,345

33,007

32,087

16,595

890

CDA

National US

#2 ORA, SR

P

Ad in SA program

#14 ORA,NORA,RB

#1 ORA

Ontario, Can Ohio

#2 ORA, SR

Nova Scotia, Can

HS, age 15–​19 HS students, grades 9–​12

#3 D, ORA, SR

#3 R affil, ORA,SR

#6 Sp scale

P

P

P

P (girls only)

P

NG

P (R), NG (Sp)

#3 ORA, SR, IR

P

P (B only)

P (B only)

P

P

P

P #14 ORA, SR, RB, Sp

SC

NONE (?)

MC

MC

MC

MC

MC

None (?)

MC

None

MC

MC

MC

MC

MC

MC

MC

MC

MC

NA (indirect?) MC

P

P

P

P (R homogamy)

#1 ORA

#1 NORA

#1 ORA

#3 ORA, SR, NORA

Hungary

Southwest US

Finland

National US

National US

Chicago

Florida

Multi-​site US

National US

#3 D, ORA, SR

#2 RC (COPE)

#1 ORA

HS students

Latino students (ave age 11)

Psychedelic drug users

CDA

CDA

CDA,B

CS (4 separate studies)

Drug abusers (inner city)

Ad (Ad Health)

National US

Southeast US

Pregnant, post-​ partum F

Florida

MP (HIV+​)

#1 ORA

Columbus, OH

Ad (6th–​12th grades) Ad (age 10–​18)

#2 ORA, SR

#2 ORA, SR

#3 ORA, R homogamy

National US

National US

National US

HS

HS (12th grade)

Parents/​families

8

8

(8)

(8)

8

(8)

8

9

9

8

8

8

8

8

8

8

9

10

8

9

CS

PC (39)

CS

CS

PC (1)

CS

CS

CS

CS

CS

CS

CS

*Thygesen et al. (2013)

Galanter et al. (2013b)

*Gmel et al. (2013)

*Desmond et al. (2013)

*Gomes et al. (2013)

*Burke et al. (2014)

*Moscati & Mezuk (2014)

*Michaelson et al. (2014)

*Fletcher & Kumar (2014)

Billioux et al. (2014)

*Escobar & Vaughan (2014)

CT

*Miller WR et al. (2008)-​study 1

CS

CS

*Ford & Hill (2012)

*Salas-​Wright et al. (2012)

CS

*Pitel et al. (2012)

*King MB et al. (2013a)

CS

CS

*Robinson et al. (2012)

*Lo et al. (2012)

T Y PE

TOPIC /​IN V E S T IG ATOR S

R

C

R

R

R

C

R

R

C

C

S

R

R

—​

R

R

R

R

M E T HOD

2,442

838

12,000

26,078

6,203

2,312

12,595

9,441

5,387

527

9,277

7,403

17,705

60

17,727

1,784

34,650

14,884

N

National US

Ad (age 12–​17)

Ad, age 12–​17

National US

Canada

Young Latino adults

CDA, hi drug use area

National US

Baltimore

National US

Ad (age 11–​15) Ad (Add Health)

National US

San Francisco

Brazil

National US

Switzerland

CA, FL, PA

Denmark

United Kingdom

CDA

CS

CS

Ad (Add Health study)

Military recruits, M

Narcotics anony members

CDA

CDA

New Mexico

Slovakia

Ad, grades 9–​10 Polydrug addicts (inpts)

National US

National US

L O C AT ION

CDA, age 12 or over

CDA

P OP U L AT ION

#1 ORA

P P P

#6 ORA, SR, IR

p #9 ORA, RB, RSup

#3 ORA, NORA, SR

P (exc change, M)

P

#2 ORA, self-​ID as R, Sp, secular #2 D, ORA, SR, change

P

P (adol R)

P

#1 ORA

#9 parent and adol R

#2 D, SR

P

P

#1 D (SDA/​Baptist vs. gen pop) #3 ORA, Sp experiences

MC

MC

MC

MC

MC

MC

None

MC

MC

MC

None

SC

MC

M (Rlg-​P, Sp-​N)

—​

MC

SC/​MC

MC

MC

C ON T ROL S

P

#5 ORA, SR, IR, RB

NA

P

P

P

P

F I N DI N G S

#5 Royal Free Interview

Spiritual direction

#4 ORA, SR, IR

#2 ORA, SR

#4 ORA, SR, IR, share RB

#1 ORA

R E L IG VA R I A BL E S

8

(8)

8

9

9

(8)

8

9

(8)

(8)

8

8

9

8

9

8

9

9

R AT IN G

CS

CS

*McClintock et al. (2016)

*Drabble et al. (2016)

CS

CS

CS

CS

CS

PC (32)

CS

CS

Acheampong et al. (2017)

*AbdelGwad et al. (2017)

*Medlock et al. (2017)

*Nedelec et al. (2017)

*Salas-​Wright et al. (2017)

Terry-​McElrath et al. (2017)

*Isralowitz et al. (2018)

Rezende-​Pinto et al. (2018)

CS

CS

*McClintock et al. (2016)

*Sharma et al. (2017)

CS

*McClintock et al. (2016)

PC (3)

CS

*Salas-​Wright et al. (2015)

CS

CS

*Rose et al. (2015)

Cucciare et al. (2016)

PC (15 m)

Haug et al. (2014)

Carrico et al. (2017)

CS

*Mohammadpoorasl et al. (2014)

S

C

R

R

S

C

C

C

R

C

C

R

C

C

C

R

R

C

R

CDA (online Internet)

CDA (online Internet)

CDA (online Internet)

710

531

758

9,831

18,614

217

331

175

319

3,151

1,565

Stimulant users

Adult crack cocaine users

CS, F, Jewish

12th graders

Ad, age 12–​17

Monozygotic twins

Inpt alcohol/​ drug detox

Psychiatric inpatients

Women prisoners

Veterans

Young gay men (18–​29 y)

54 R & Sp scales 54 R & Sp scales

India United States

Florida

Brazil

Southern Israel

National US

National US

National US

Massachussetts

Texas

#11 DUREL+​R history

#1 Religious activity

#2 ORA, SR

#2 ORA, SR

#5 ORA, NORA, RC, SR

#18 SR, RB, RC

#5 DUREL

#3 ORA, SR

#5 DUREL

#14 Sp act, coping, God ctrl

Dallas/​Houston National US

#3 ORA, SR

Ark, Tex, Ohio

#1 SR

54 R & Sp scales

China

National US

#4 ORA, SR, IR

P

P

P

P

NA

P (except NRC)

NA

P

NA

M

P (cocaine)

P (both groups)

NG P

NG NA

NG

P

P

P

#1 R belief/​practice #4 ORA, SR, IR

P

#28 strength of RB

National US

Southern US states

Ad (age 12–​17) CDA (age 12–​25)

Switzerland

Iran

Young men, army recruits

CS (ave age 22)

10,723 heterosex vs. 446 sex minority, F

1,499

863

3,150

19,312 /​ 2,721

12,500

2,774

1,837

MC

None

MC

MC

MC (incl shared env/​ gene)

MC

None

MC

MC

MC

MC

MC

SC

SC

SC (age,sex,educ)

MC

SC

MC

MC

(8)

(8)

10

9

(8)

(8)

(8)

(8)

8

(8)

8

8

(8)

(8)

(8)

9

8

8

8

PC (7)

*Jang SJ (2019)

C

C

R

S

1,289

1,354

6,787

318

1,354

11,530

699

6,950

4566

638

27,874

868

N

Czech Republic

Ad (age 13–​15)

Ad offenders (age 14–​17)

CS

CT

CS

CS

Perkins et al. (2002)

*Richards et al. (2006)

Boisvert & Harrell (2012)

Boisvert & Harrell (2013)

R

591

603

122

—​ R

18,592

R

CDA, F

CDA, M

PP (w eating disorders)

Ad, F, abused (age 12–​18)

Alberta, Can

Alberta, Can

Utah

#1 SR

#1 SR

Spiritual group therapy

#3 ORA, SR

#5 ORA, SR, RC

Arizona & Pennsylvania

National US

#1 SR

#1 ORA

#3 ORA, SR

#3 ORA, SR, RC

#2 D,ORA

#3 D, SR, SSp

#2 ORA, NORA

#8 R (ORA), Sp (SWB)

#4 ORA, NORA, etc.

#2 SR,RC

#1 ORA

R E L IG VA R I A BL E S

Arizona & Pennsylvania

National US

Ad offenders (age 14–​17)

Missouri

Ad (age 17–​21)

Arizona & Pennsylvania

Delaware

Chicago

Women prisoners

Serious juvenile offenders

Adol (8th & 11th grades)

Lesbian, bisexual F

National US

Chicago

At-​risk B adol

Ad (ave age 15)

Maryland

National US

L O C AT ION

HS students (ave age 16)

Mexican Americans

P OP U L AT ION

Eating Disorders (“>” means better than, i.e., less likely to have disordered eating)

PC (7)

Crank & Teasdale (2019)

C

CS

PC (10)

Jones et al. (2018)

PC (7)

Stansfield (2018)

*Guo & Metcalfe (2019)

C

CS

*DeCamp & Smith (2019)

S C

PC (14)

R

CS

CS

*Malinakova et al. (2019a)

C

*Chen Y & VanderWeele (2018)

CS

*Kim DH et al. (2018)

C

R

M E T HOD

*Drabble et al. (2018)

CS

CS

*Moreno & Cardemil (2018)

*Debnam et al. (2018)

T Y PE

TOPIC /​IN V E S T IG ATOR S

NA (symptoms)

NA (symptoms)

P

NA

P

P (F only)

P

P

P (only cognitively unimpaired)

P

NA

P

P (with hi R and hi Sp)

P

P

P

F I N DI N G S

MC

MC

—​

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC

MC

MC

SC

C ON T ROL S

(8)

(8)

8

9

9

9

10

(8)

9

8

(8)

10

8

(8)

9

8

R AT IN G

CS

CS

PC (10) S

CS

CS

CS

*Debnam et al. (2016)

*Doumit et al. (2017)

Sipilä et al. (2017)

Audette et al. (2018)

Thomas et al. (2018)

Ramón-​Jarne et al. (2019)

CS

CS

PC (5)

PC (3)

Ghandour & El Sayed (2013)

Mutti-​Packer et al. (2017)

Bormann et al. (2019)

CS

Casey et al. (2011)

Lee GP et al. (2014)

CS

CS

Eitle (2011)

Ellison CG & McFarland (2011)

Gambling

CS

Feinson & Hornik-​Lurie (2016) (body image)

C

R

C

163

4,121

570

570

436

S/​R C

2,207

9,320

556

1,069

5,104

2,825

949

5,217

498

115

7,403

R

R

R

C

C

C

C

S

C

CS

Phillips et al. (2014)

R

CS

*King MB et al. (2013a)

Pathological gamblers

CDA (prob gamblers oversample)

CS

CS

Adol (age 13–​16)

CDA

CDA (age 18–​27)

Adol (ave age 14.8)

CS, F, Muslim

CS

F, from age 16 to 22–​27

#9 D, ORA, R sc #5 DUREL

Iowa

#2 D (Muslims vs. Christ), R prac

#2 R practice, SR

#8 R scale

#3 D, ORA, NORA, RB

#7 D, ORA, R scale

#1 R affil

Canada

Lebanon

Lebanon

Alberta, Can

National US

National US

Ceuta, Spain

United Arab Emirates

#10 RC

P

P (CS), NA (PC)

C

P

P

P (exc Catholics)

C

Christian> Muslim

NG

P/​C

# 40 ORA, SR, IR, ER, Quest

Multisite US

NA

#12 R fundamentalism sc

Finland

P (buffering)

P

P

P

NG (Sp view)

#15 D,IR,ER (Gorsuch)

#? Sp measure

#1 Secular vs ultra-​orthodox

#10 RWB

#5 Royal Free Interview

Lebanon

Baltimore

C, grades 6–​8 Lebanese CS, F

Israel

Eastern U.S.

United Kingdom

CDA (primary care clinics)

Undergrad nursing student

CDA

MC

MC

MC

MC

MC

MC

MC

MC

None

SC

None (?)

MC

MC

None

None

MC

8

9

(8)

(8)

(8)

8

8

8

(8)

(8)

8

8

8

(8)

(8)

8

T Y PE

M E T HOD N

P OP U L AT ION

C

350

4,182

4,990

1,596

Muslim CS

Adol (mean age 14)

Army recruits, M

Adol (mean age 16) #21 ORA, SWB #39 Religiosity

Israel/​Palestine

#2 D, RB and practice

#5 RB, NORA

R E L IG VA R I A BL E S

Czech Republic

Switzerland

Malaysia

L O C AT ION

CS

R

33,982

HS, grades 9 and 10 England/​Wales

#5 R affil, ORA, RB

PC (53)i

CS

CS

CS

CS

CS

CS

PC (3)

McCullough et al. (2005)

*Abdel-​Khalek (2010)

*Francis (2013)

*Aghababaei et al. (2015)

*Wilt et al. (2017)

*Kerksieck et al. (2017)

Afhami et al. (2017)

Hui et al. (2018)

C

C 375

228

Iran Hong Kong

94% CS (age 18–​36) Prot Christians, ave age 23

Germany

8,594

C/​S

#14 IR, ER

Iran & Poland

NA NA

#6 DUREL, SR

P

P (SR), NG (NRC)

M

P

P

NA

NA

#1 Δ in D to non-​believer

#11 DSE, R trust

#4 SR,#26 NRC

#5 R affil, ORA, RB

England/​Wales

National US

#2 SR

#1 Overall religiosity

#4 SR, NORA, RB, ORA

Kuwait

California

California

Catholic clergy/​ pastoral

CDA/​CS

1,047/​ 3083

C

HS, grades 9 and 10 CS and CDA (7 samples)

33,982

CS

Intellectually gifted C

Ad (age 12–​18), gifted

1,530

C

R

487

1151

C C

492

C

P

P

P

P

P (F)

F I N DI N G S

i

In McCullough et al. (2003), personality in adolescence predicting future R; in McCullough et al. (2005), personality in mid-​life (27–​40) predicting R across life span.

PC(19)i

McCullough et al. (2003)-​stdy 2

Neuroticism/​Emotional Instability (i.e., anxious, uptight) (NEO-​5, Eysenck, or Cattell PF) (P indicates less of it; NG more of it)

*Francis (2013)

Psychoticism (i.e., lack of responsibility, risk taking) (Eysenck Personality Questionnaire) (P indicates less of it; NG more of it)

Personality Traits

Personality Traits and Disorders (Chapter 11)

CS

Agbaria & Bdier (2019)

R

S

CS

CS

Braun et al. (2016)

S

CS

*Malinakova et al. (2018)

Charlton et al. (2013)

Online Gaming/​Internet Use (P means less online or console gaming or time on the Internet)

TOPIC /​IN V E S T IG ATOR S

None

None

None

MC (NRC)

SC

SC (age, sex)

None

SC

MC

SC (age, sex)

None

SC

SC

SC

C ON T ROL S

8

(8)

(8)

8

(8)

9

(8)

8

8

9

(8)

8

8

(8)

R AT IN G

CS

CS

CS

CS

CS

Sultan et al. (2020)

Inozu et al. (2020)

Saroglou et al. (2020)

Entringer et al. (2021)

Lace et al. (2020)

C

C

C

C

C

C

C

844

1,037

2,277,240

404

273

372

350

PC (53)j

CS

CS

CS

CS

CS

PC (3)

CS

CS

*McCullough et al. (2005)

*Francis (2013)

*Aghababaei et al. (2015)

*Kerksieck et al. (2017)

*Afhami et al. (2017)

*Wilt et al. (2017)

*Hui et al. (2018)

*Carlson et al. (2019)

*Agbaria & Bdier (2019)

C

C

C

C

C

350

844

375

Muslim CS

CDA (Internet)

Protestant Christians, ave age 23

CDA/​CS

1,047/​ 3,083

#39 Religiosity

Israel/​Palestine

NG

P

NA

#1 Δ in D to non-​believer #37 IR, ER, RCm

P (SR), NA (NRC)

NA

P

P

P

NA

NA

P (IR)

NG

P

NA

P

P

P

#4 SR, #26 NRC

#6 DUREL, SR

United States

Hong Kong

National US

Iran

94% CS (age 18-​36)

228

#11 DSE, R trust

#14 IR, ER

#5 R affil, ORA, RB

England/​Wales Iran & Poland

#1 Overall religiosity

#4 SR, NORA, RB, ORA

#4 IR, SR

#1 SR

California

California

Germany

8,594

C/​S

CS and CDA (7 samples)

HS, grades 9 and 10

Intellectually gifted C

Ad (age 12–​18), gifted

United States

World

CDA (Internet) CDA (Internet)

#3 SR, NORA

Belgium

CDA > 50% atheists/​agnost

#19 RB and R practice #2 RCm

Pakistan

#39 Religiosity

Israel/​Palestine Turkey

Muslim CS

Muslim CS

#37 IR, ER, RCm

United States

Catholic clergy/​ pastoral

1,530

C

33,982

1,151

C R

492

C

CDA (Internet) Muslim CS

j

In McCullough et al. (2003), personality in adolescence (1920s) predicting future R; in McCullough et al. (2005), personality in mid-​life (1940s) predicting R across life span.

PC(19)j

*McCullough et al. (2003)-​stdy 2

Extraversion (i.e., sociable, talkativeness) (NEO-​5, Eysenck, or Cattell PF)

CS

CS

Carlson et al. (2019)

*Agbaria & Bdier (2019)

None

None

None

MC (NRC)

None

None

SC

SC (age, sex)

SC

MC

None

?

SC

MC

None

None

None

(8)

(8)

8

8

(8)

(8)

(8)

9

8

8

(8)

8

(8)

(8)

(8)

(8)

(8)

CS

*Lace et al. (2020)

C

C 1,037

2,277,240

404

372

N Belgium World United States

CDA (Internet) CDA (Internet)

Pakistan

L O C AT ION

CDA > 50% atheists/​agnost

Muslim CS

P OP U L AT ION

#4 IR, SR

#1 SR

#3 SR,NORA

#19 RB and R practice

R E L IG VA R I A BL E S

CS

CS

*Entringer et al. (2021)

*Lace et al. (2020)

C

C

C

C

C

1,037

2,277,240

404

350

372

844

375

228

8,594

C/​S C

CDA/​CS

1,047 /​ 3,083

C

World United States

CDA (Internet) CDA (Internet)

#4 IR, SR

#1 SR

#3 SR, NORA

#39 Religiosity Belgium

#19 RB and R practice Israel/​Palestine

#37 IR, ER, RCm Pakistan

CDA > 50% atheists/​agnost

Muslim CS

Muslim CS

United States

CDA (Internet)

NG (IR)

M

NA

NG

P

NG

NA

#1 Δ in D to non-​believer

Hong Kong

NG

#6 DUREL, SR

Iran

P

#11 DSE, R trust

P (SR), P (NRC)

P

M

P, no ctrls; NA, multiple ctrls

Germany

#4 SR, #26 NRC

#14 IR, ER

Iran & Poland National US

#3 D, RB, Sp

#4 SR, NORA, RB, ORA

Australia

California

Protestant Christians, ave age 23

94% CS (age 18–​36)

Catholic clergy/​ pastoral

CS and CDA (7 samples)

CDA (ave age 55)

Ad (age 12–​18), gifted

1,530

C

1,093

492

P (IR)

M

NA

NG

F I N DI N G S

k

In McCullough et al. (2003), personality in adolescence (1920s) predicting future R; in McCullough et al. (2005), personality in mid-​life (1940s) predicting R across life span.

CS

CS

*Carlson et al. (2019)

*Saroglou et al. (2020)

C

PC (3)

*Hui et al. (2018)

CS

CS

Afhami et al. (2017)

CS

CS

*Kerksieck et al. (2017)

*Sultan et al. (2020)

CS

*Wilt et al. (2017)

*Agbaria & Bdier (2019)

C

CS

*Aghababaei et al. (2015)

R

CS

Browne et al. (2014)

C

PC(19)k

*McCullough et al. (2003)-​stdy 2

Openness to Experience (i.e., preference for variety, intellectual curiosity; opposite of conservatism) (NEO-​5 and other measures)

CS

*Entringer et al. (2021)

C

C

CS

CS

*Sultan et al. (2020)

M E T HOD

T Y PE

*Saroglou et al. (2020)

TOPIC /​IN V E S T IG ATOR S

None

?

SC

None

None

None

None

None

None

MC (NRC)

SC

MC

None

?

SC

None

C ON T ROL S

(8)

8

(8)

(8)

(8)

(8)

8

(8)

(8)

8

(8)

8

8

(8)

8

(8)

(8)

R AT IN G

CS

*Lace et al. (2020)

C

C

C

C

C

C

C/​S

C

PC(19)m

C

492

1,037

2,277,240

404

372

350

844

375

228

#37 IR, ER, RCm #39 Religiosity

Israel/​Palestine

United States

CDA (Internet)

California

World

CDA (Internet)

Ad (age 12–​18), gifted

#3 SR, NORA

Belgium

#4 SR, NORA, RB, ORA

#4 IR, SR

#1 SR

#19 RB and R practice

Pakistan

Muslim CS CDA > 50% atheists/​agnost

Muslim CS

United States

P, no ctrls; NA, multiple ctrls

P (IR)

P

NA

P

P

P

#1 Δ in D to non-​believer

CDA (Internet)

NA

#6 DUREL, SR

Iran Hong Kong

P

#11 DSE, R trust

P

P (SR), NG (NRC)

P

NA

P

Germany

#4 SR, #26 NRC

#14 IR, ER

Iran & Poland National US

#1 Overall religiosity

#4 SR, NORA, RB, ORA

California

California

Prot Christians, ave age 23

94% CS (age 18–​36)

Catholic clergy/​ pastoral

CDA/​CS

1,047 /​ 3,083 8,594

CS and CDA (7 samples)

1,530

Intellectually gifted C

Ad (age 12–​18), gifted

m

l

In McCullough et al. (2003), personality in adolescence (1920s) predicting future R; in McCullough et al. (2005), personality in mid-​life (1940s) predicting R across life span. In McCullough et al. (2003), personality in adolescence (1920s) predicting future R; in McCullough et al. (2005), personality in mid-​life (1940s) predicting R across life span.

*McCullough et al. (2003)-​stdy 2

Agreeableness (i.e., soft-​hearted, sympathetic) (NEO-​5)

CS

CS

*Agbaria & Bdier (2019)

*Entringer et al. (2021)

C

CS

*Carlson et al. (2019)

CS

PC (3)

*Hui et al. (2018)

CS

CS

*Afhami et al. (2017)

*Sultan et al. (2020)

CS

*Kerksieck et al. (2017)

*Saroglou et al. (2020)

C

CS

*Wilt et al. (2017)

C

CS

*Aghababaei et al. (2015)

1,151

C

PC (53)l

*McCullough et al. (2005)

492

C

PC(19)l

*McCullough et al. (2003)-​stdy 2

Conscientiousness (i.e., conscientious, reliable) (NEO-​5 or Cattell PF)

None

?

SC

None

None

None

None

None

None

MC (NRC)

SC

SC

MC

8

(8)

8

(8)

(8)

(8)

(8)

8

(8)

(8)

8

(8)

8

8

CS

CS

CS

CS

PC (3)

CS

CS

CS

CS

CS

CS

*Aghababaei et al. (2015)

*Kerksieck et al. (2017)

*Afhami et al. (2017)

*Wilt et al. (2017)

*Hui et al. (2018)

*Carlson et al. (2019)

*Agbaria & Bdier (2019)

*Sultan et al. (2020)

*Saroglou et al. (2020)

*Entringer et al. (2021)

*Lace et al. (2020)

Exp

Exp

Rounding et al. (2012)

Watterson & Giesler (2012)

Self-​discipline, Self-​control, Less Impulsive

Virtues (positive aspects of character)

PC (53)

*McCullough et al. (2005)

m

T Y PE

TOPIC /​IN V E S T IG ATOR S

C

C

C

C

C

C

C

C

C

C

75

48 /​60 /​ 60 /​97

1,037

2,277,240

404

372

350

844 #39 Religiosity

Israel/​Palestine

World United States

CDA (Internet) CDA (Internet)

CS

CS

#3 SR, NORA

Belgium

CDA > 50% atheists/​agnost

?# (various) 14+​ORA, NORA, IR, SR

Canada Indiana

#4 IR, SR

#1 SR

#19 RB and R practice

Pakistan

Muslim CS

Muslim CS

#37 IR, ER, RCm

United States

CDA (Internet)

P

P

P (IR)

P

NA

P

NG

P

NA

Hong Kong

#1 Δ in D to non-​believer

P P (SR), NG (NRC)

#6 DUREL, SR

Iran

P

P

P

F I N DI N G S

#4 SR, #26 NRC

#11 DSE, R trust

Germany

National US

#14 IR, ER

#1 Overall religiosity

R E L IG VA R I A BL E S

Iran & Poland

California

L O C AT ION

Prot Christians, ave age 23

CDA/​CS

1,047 /​ 3,083 375

94% CS (age 18–​36)

Catholic clergy/​ pastoral

CS and CDA (7 samples)

Intellectually gifted C

P OP U L AT ION

228

8,594

C/​S C

1,530

1,151

C C

N

M E T HOD

—​

—​

None

?

SC

None

None

None

None

MC (NRC)

None

None

SC

SC

C ON T ROL S

8

8

(8)

8

(8)

(8)

(8)

(8)

8

8

(8)

(8)

(8)

8

R AT IN G

CS

CS

Caribe et al. (2015b)

Pascoe et al. (2016)

CS

PC (3)

CS

PC (3)

Krause & Hayward (2015)

*Hui et al. (2018)

Chan SW et al. (2020)

Chan SW et al. (2020)

Guilt-​prone

Miscellaneous Negative Traits

CS

Jordan et al. (2014)

Compassionate/​Warm/​Empathetic

S

CS

CS

*Koenig et al. (1998d)

Brennan & London (2001)

C

C

C

R

C

R

R

R

C

R

CS

Ellison CG (1992)

Cooperativeness

PC (3)

Oates (2013)

695

3,248

375

1,535

642

4,527

577

2,107

444

154

2,780

Young adults

Young adults (ave age 25)

Protestant Christians, ave age 23

CDA (ave age 63)

CS from Utah, 152 CDA from overall

CDA

MP, E

CDA, B

CDA

91 PP & 61 CDA controls

CDA

China

Hong Kong

National US

USA

National US

Durham, NC

National US

Florida

Brazil

National US

NA

P

NA

#1 Δ in D to non-​believer #7 D (Christian vs. none), Faith maturity

P

P (religiosity)

P

P

P

SC

SC

None

MC

SC

MC

MC

MC

MC

SC

P (IR) in PP P

MC

M (P in B, NG in W)

#3 RCm

#Many

#3 ORA, NORA, SR

#69 RC, ORA, NORA, SR

#5+​RB, NORA, SR

#6 ORA, NORA, RC, SR

#5 DUREL

#4 ORA, SR

8

8

8

(8)

9

8

8

8

(8)

9

CS

*Fontana & Rosenheck (2004)

S

M E T HOD

CS

CT

CS

CS

CS

CS

CS

CS

*Kark et al. (1996a)

*Bormann et al. (2006)

Ai et al. (2010)

*Schnall et al. (2012)

*Lutjen et al. (2012)

Salas-​Wright et al. (2014b)

*Salas-​Wright et al. (2015)

Shorey et al. (2016)

C

R

R

R

398

19,312/​ 2,721

90,202

1,629

92,539

156

CS/​PC

437 93

C

CDA, veterans w PTSD

P OP U L AT ION National US (?)

L O C AT ION #1 RC change (incr)

R E L IG VA R I A BL E S P (less guilt)

F I N DI N G S MC

C ON T ROL S

PP, substance abusers

CDA (age 12–​25)

Ad (ave age 14.6)

CDA (19% resp rate)

CDA, F, post-​menopausal

MP (cardiac surgery)

MP (HIV+​)

CDA

Southeast US

National US

National US

#16 DSES©

#4 ORA, SR, IR

#4 ORA, SR, IR

#4 D, SR, ORA, NORA

#1 ORA

Multisite US National US

#20+​R sc, NRC, PRC

“Spiritual mantram”

relig vs. secul kibbutz

Michigan

San Diego, CA

Israel

P (aggression)

P (violent attack)

P (violent aggression)

(P) (thru forgiveness)

M

P

P

P

SC

MC

MC

SC

MC

MC

—​

SC

Describes how scales measuring authoritarianism are heavily confounded by R content, introducing anti-​R bias

1,385

N

—​

S

Commentary

Hostility/​A ggression/​Anger (P =​less of it)

Mavor et al. (2011)

Authoritarianism (scales confounded by anti-​religious bias)

T Y PE

TOPIC /​IN V E S T IG ATOR S

(8)

9

9

(8)

8

(8)

8

8

8

R AT IN G

CS

CS

Goncalves et al. (2020)

Haney & Rollock (2020)

C

C

R

C

S

CS

CS

CS

CS

CS

CS

Breslin & Lewis (2015b)

Horton et al. (2016a)

Horton et al. (2016b)

Crespi et al. (2019)

Hanel et al. (2019)

Carvalho et al. (2020)

C

C

C

C

C

C

Paranoid/​Schizoid/​Schizotypal/​Personality Disorder (or Traits)

Cluster A (eccentric, odd)

Personality Disorders

Koenig et al. (1990)

CS/​RS

CS

*Stroope et al. (2020)

Miscellaneous Traits

CS

*Sigurvinsdottir et al. (2021)

751

189

1,194

305

252

371

100

509

4,607

933

7,365

Florida

PP/​substance abuse

CDA

CS

Brazil

E. Germany

Canada

Florida

PP/​substance abuse CS

Ireland

North Carolina

Midwest US

Brazil

US cities

Iceland

CDA

CDA, age 55–​80

CS

CDA age 14 and over

CDA, South Asians

HS students, age 15–​16

#36 General R, ATG

#15 RB, RE, ORA, NORA

#4 RB

#10 RWB

#10 RWB

#16 NORA (freq/​type)

P (exc paranor­ mality)

P (impulsive non-​conf)

NG (magical thinking)

NA

(8) (8) (8)

SC SC

(8)

(8)

(8)

(8)

(8)

8

(8)

8

SC

None (?)

None

None

P (paranoid ideation) NA

SC

None

MC

MC

MC

MC

NG (magical thinking)

P

P (except Q)

#40 IR, ER, Quest

#1 RC

P

P (no affil vs. Hindu)

P

#2 D, SR

#2 D, SR

#9 Sp, R, R of parents

T Y PE

C

PC (1)

CS

CS

Good et al. (2017) (self-injury)

Hosack (2019)

*Carvalho et al. (2020)

CS

*Horton et al. (2016b)

C

C

C

C

C R

CS

CS

CS

*Horton et al. (2016b)

Buzdar et al. (2019)

Daghigh et al. (2019)

C

388

618

305

252

117

305

252

751

466

1,132

305

252

429

N

CS

CS

CS

*Horton et al. (2016a)

*Horton et al. (2016b)

*Nadal et al. (2018)

C

C

C

9,495

305

252

Antisocial Personality Disorder (or Traits) (also see Delinquency/​Crime)

C

C

PC (35)

CS

Wink & Dillon (2003)

*Horton et al. (2016a)

Narcissistic Personality Disorder (or Traits, i.e., narcissism)

CS

*Horton et al. (2016a)

Histrionic Personality Disorder (or Traits)

C

CS

*Horton et al. (2016b)

C

CS

CS

*Horton et al. (2016a)

C

M E T HOD

Hafizi et al. (2014)

Borderline Personality Disorder (or Traits)

Cluster B (erratic, dramatic)

TOPIC /​I N V E S T IG ATOR S

CS

Pakistan

National US

Florida CS

Florida

PP/​substance abuse

Iran

PP/​drug addicts

CS

Florida

Florida

PP/​substance abuse

Berkeley, CA

PP/​drug addicts

Florida

Florida

Brazil

Midwest US

Canada

Florida

Florida

Tehran, Iran

L O C AT ION

CDA

PP/​substance abuse

PP/​drug addicts

CDA

CS

CS

PP/substance abuse

PP/drug addicts

Medical students

P OP U L AT ION

#19 RCm, Sp (categories)

#10 RWB

NG

NA

NA

NG (generally)

#10 RWB

NG #4+​RB, etc.

NG

NA (after ctrls)

NA

NA

NA

P (generally)

NA exc Quest

NA exc Doubt/Quest

NA

NA

P

F I N DI N G S

#26 IR, ER, Quest

#10 RWB

#10 RWB

#2 Rlg and Sp ratings

#10 RWB

#10 RWB

#36 General R, ATG

#? R engage, Quest

#10 ORA, Sp Tran Index

#10 RWB

#10 RWB

#5 DUREL

R E L IG VA R I A BL E S

SC

None (?)

SC

SC (?)

SC

None (?)

SC

MC

None (?)

SC

SC

None

MC

None (?)

SC

None

C ON T ROL S

8

(8)

(8)

(8)

(8)

(8)

(8)

8

(8)

(8)

(8)

(8)

8

(8)

(8)

(8)

R AT I N G

CS

*Horton et al. (2016b)

C

C

C

C

252

305

252

305

PP/​substance abuse

Florida

Florida

Florida

PP/​substance abuse

PP/​drug addicts

Florida

PP/​drug addicts

CS

CS

Van der Hooft et al. (2018)

*Inozu et al. (2020)

C

C

C

C

252

273

377

200 Netherlands

PP/​OCD

CS

PC

CS

CT

PC (37)

CS

Lee G & Ishii-​Kuntz (1987)

Markides et al. (1987)

Levin & Markides (1988)

Beutler et al. (1988)

Willits & Crider (1988)

Pollner (1989)

R

C

C

R

R

R

R

R

CS

CS

Ortega et al. (1983)

St. George & McNamara (1984)

R R

CS

CS

Hadaway & Roof (1978)

Singh & Williams (1982)

R R

CS

CS

Edwards & Klemmack (1973)

Spreitzer & Snyder (1974)

507

3,072

1,650

120

750

230

2,872

3,362

4,522

1,459

2,164

1,547

CDA, E

Virginia

CDA

CDA

National US

Pennsylvania

Netherlands

Texas

CDA, E, Mex-​Am (40 ea), CDA

Texas

CDA, 70%Mex

Washington St

National US

CDA

N. Alabama

CDA (25–​52 yo)

National US

US National

National US

CDA

CDA,E

CDA

CDA

Turkey

Pakistan

PP/​OCD Muslim CS

Florida

PP/​drug addicts

Psychological Well-​being, Life Satisfaction, and Happiness (PWB =​psychological well-​being)

Positive Emotions (Chapter 12)

CS

CS

*Horton et al. (2016a)

Ghafoor et al. (2018)

Obsessive-​Compulsive Personality Disorder (or Traits) (including scrupulosity, thought-action fusion)

CS

*Horton et al. (2016a)

Dependent Personality Disorder (or Traits)

CS

CS

*Horton et al. (2016a)

*Horton et al. (2016b)

Avoidant Personality Disorder (or Traits)

Cluster C (fearful, anxious)

#7 ORA, NORA, RE

#9 ORA, RB

laying hands

#1 ORA

#3 ORA, NORA, SR

#1 ORA

#2 ORA, SR

#2 ORA

#1 ORA

#3 D, ORA, SR

#1 ORA

#1 ORA

#2 RCm

#3 D, ORA, RCm

#19 R activity sc

#10 RWB

#10 RWB

#10 RWB

#10 RWB

#10 RWB

P

P

P

P (women only)

NA

P (men only)

P

P

P

P

P (< 65 y)

P

NG

NA (exc Cath)

P (r =​–​.20)

NA

NA

NA

NA

NA

9 MC

8

10

—​ MC

8

8

8

8

8

9

8

8

8

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC

None

SC

None (?)

SC

None (?)

SC

R R

CS

Krause (1993)

R

R S

PC

Levin et al. (1996a)

R R

CS

Ellison CG et al. (2001

R C

CT

CS

CS

*Rye & Pargament (2002)

Krause & Ellison (2003)

Krause (2003)

27,000 118

R R —​

CS

CS

CS

CT

Suhail & Chaudhry (2004)

Greene & Yoon (2004)

*Kristeller et al. (2005)

R

181

521

973

119,769

Krause (2004a)

R

PC (30)

CS

*Wink & Dillon (2003)

1,247

1,316

58

53,658

34,706

1,139

1,985

239

624

253

1,848

709

448

5,629

> 20,000

997

2,107

1,500

N

Helliwell & Putnam (2004)

R

C

R

CS

CS

Ferriss (2002)

Diener & Clifton (2002)

R

PC

CS

*Tix & Frazier (1998)

Hintikka et al. (2001)

S

CS

PC

Levin et al. (1995a)

Ringdal et al. (1995); Ringdal (1996)

R

CS

CS

Thomas & Holmes (1992)

Krause (1992)

R

R

CS

CS

Ellison CG (1991)

R R

CS

CS

Ellison CG et al. (1989)

Ellison CG & Gay (1990)

Feigelman et al. (1992)

M E T HOD

T YPE

TOPIC/​I N V E S T IG ATOR S

MP (cancer)

CDA

CDA, E, B

CDA

CDA

CDA

CDA,E, 49% B

CDA,E, 49% B

CS (Christian F), 18–​23 yo

CDA

CDA

CDA

CDA

Indiana

Europe

National US

Spiritual history

#2 ORA, D

#7 ORA, R sup, RC

#18 Muslim Rlg Sc

#2 ORA, SR Lahore, Pakistan

#2 Rlg and Sp ratings Multi-​national

#8 Rlg meaning, ORA, NORA

#3 ORA, NORA, God forgiveness

P (functional WB)

P (ORA)

P

P

P

P

P

P

NA

P Rlg vs. sec forgiveness

P #2/​#4 RB, misc R

MC

MC

MC

MC

MC

MC

MC

MC

—​

None

None

MC

M (P-​ora,rb; NG-​p)

MC MC

P

P

MC

SC P (young)

MC

(P) (p=​.06)

MC

MC

MC

MC

MC

MC

MC

C ON T ROL S

P

P

P

P

NA

P

P

P

F I N DI N G S

#3 ORA, RB, D

#4 ORA, prayer, RB

#1 ORA

#11 RC, D

#1 ORA

#2 RB

Berkeley, CA

National US

National US

Ohio

Worldwide

National US

Detroit, MI

Finland

Minnesota

Texas

CDA, Mex-​Am Renal transpl

Norway

#12 ORA, NORA, SR

#18 ORA, SR, RB

world-​wide National US

#4 ORA, NORA, SR

#2 ORA, SR

#2 D (dissaffiliates)

#7 D, ORA, NORA, SR

#4 D, ORA, NORA,SR

#6 D, ORA, NORA, SR

R E L IG VA R I A BL E S

National US

National US

National US

National US

National US

National US

L O C AT ION

MP cancer

CDA, B

CDA

CDA,E,B

CDA

CDA

CDA

CDA, B

CDA

P OP U L AT ION

8

9

9

8

9

8

9

8

8

8

8

9

8

9

10

8

10

9

9

9

8

9

9

9

R AT I N G

CS

PC (23)

CS

CS

CS

*Hill TD et al. (2008a)

Koenig LB & Vaillant (2009)

Gallup Poll (2009)

*Bailley & Roussiau (2010)

Momtaz et al. (2010)

R

C

R

C

R

R

1,367

338

143,000

456

2,402

2,679

37,000

R

CS

CS

*Baetz & Bowen (2008)

Ellison CG et al. (2008a)

8,665

R/​C

CS

Yamaoka (2008)

890

3032

R R

CS

PC (5)

Greenfield (2007a)

*Petts & Kenoester (2007)

73

—​

CT

Goldstein (2007)

128

CT

Moadel et al. (2007)

122

—​

—​

CS

Abdel-​Khalek (2007)

24,036

R

6,339

CT

*Richards et al. (2006)

9,167 14,557

R

CS

Uppal (2006)

R

R

CS

CS

Lelkes (2006)

58

—​

Benjamins (2006a)

1,445

R

CS

CT

*Maselko & Kubzansky (2006a)

*Oman et al. (2006)

852

R/​S

PC (3)

Krause (2006d)

1,252

R

CS

Krause (2005)

National US

Inner-​city US

CDA,E (age 60–​110)

CDA,E (age 65 or older)

#1 ORA #6 DSE© #14 IR, ER

Malaysia

#1 SR

P

P

P

P

P

P #1 ORA

P (ORA) #8–​#18 DSE©,ORA,NORA

NA

NA (R homogamy)

P

NA (=​ control)

NA (exc SocWB)

P

P (incr EWB)

P

P (satisfac w hlth care)

P

NA

P

P (less educated)

P

#3 ORA,Sp,prayer cope

#1 Rlg faith (yes vs. no)

#3 ORA, R homogamy

#2 ORA, SR

“Cultivating sacred moments”

Yoga Intervention

#1 SR (0–​10 rating)

Spiritual group therapy

#1 ORA

#1 SR

#3 D, SR, RB

Meditation (passive)

#9 ORA, NORA, DSE©

#5 Religious doubt

#5 God-​mediated ctrl, ORA

France

Worldwide

CDA, M, age 47–​70 CDA

Multi-​site US

National US

Canada

East Asia

CDA, F, low income

CDA

CDA

CDA

National US

CDA (mid-​life) Parents

California

New York City

Kuwait

Utah

Canada

National US

Hungary

California

National US

National US

National US

CDA

MP (breast CA)

Ad (age 14–​18), Muslim

PP (eating disorders)

MP (disabilities)

CDA, E

CDA

Health professionals

CDA

CDA, E

CDA, E

MC

None

SC

MC

MC

MC

SC

MC

MC

MC

—​

—​

SC

—​

MC

MC

MC

—​

MC

MC

MC

8

(8)

10

10

8

8

8

8

9

8

8

8

8

8

9

9

9

8

8

8

8

PC (14 d)

Kashdan & Nezlec (2012)

CS

*Hussain et al. (2011)

CS

CS

Lewis et al. (2011)

Abdel-​Khalik (2012b)

CS

*Bjorck & Maslim (2011)

CS

CS

Chlan et al. (2011)

Abdel-​Khalik (2012a)

CS

*Abdel-​Khalek & Eid (2011)

CS

CS

*Momtaz et al. (2011)

CS

PC (3)

*McIntosh et al. (2011)

Levin (2012a, analysis #1)

PC (1)

Lim & Putnam (2010)

Levin (2012a, analysis #2)

CS

Okulicz-​Kozaryn (2010)

C

C

C

R

R

S

R

C

C

C

R

R

R

R

R

C

CS

CS

Abdel-​Khalek (2010)

Green M & Elliott (2010)

R

CS

Williams E et al. (2010)

M E T HOD

T YPE

TOPIC/​I N V E S T IG ATOR S

87

1,420

1,251

859

1,023

1,180

4,281

539

298

2,946

1,415

890

1,915

74,117

1,000

487

20,388

N

CS (ave age 21)

Adol, young, middle-​age

CS

CDA, Jews, outside Israel

CDA, Jews in Israel

Survivors of Asian tsunami

CDA

CDA, F, Muslim

Spinal cord inj (as child)

HS, ave age 14, Muslim

CDA,E (age 60 or over)

CDA (after Sept 11th)

CDA

CDA (79 countries)

CDA

CS

CDA (Europ Values Surv)

P OP U L AT ION

Virginia

Kuwait

Egypt, Kuwait

Worldwide

Israel

Norway

Northern Ireland

United States

Multisite US

Kuwait, Palestine

Malaysia

National US

National US

Worldwide

National US

Kuwait

Europe

L O C AT ION

#2 daily Sp x 1,239 days

#1 SR

#1 SR

#6 ORA, SR, others

#6 ORA, SR, others

#1 RC

#2 D, ORA

#21 RSup

#3 SR, RC

#1 SR (1–​10)

#11 IR, ER

#3 ORA, IR

#6 D, ORA, NORA, SR

#8 ORA, SR, RB

#11 D, RB, IR, ORA, NORA

#2 SR

#2 Raffil, ORA

R E L IG VA R I A BL E S

P

P

P

P

P

NA

P (esp Catholics)

P (esp God support)

P (RC)

P

P

P

P (religious identity)

P (depend on R of country)

P

P

P

F I N DI N G S

MC

None

None

MC

MC

MC

None

MC

MC

None

MC

MC

MC

MD

MC

None

MC

C ON T ROL S

8

(8)

(8)

8

8

(8)

(8)

(8)

(8)

(8)

8

9

8

9

8

(8)

8

R AT I N G

R R

CS

CS

CS

Patterson & Price (2012)

Assari (2013)

*Park NS et al. (2013)

R R

PC (8d)

CS

*Rosmarin et al. (2013a)

Levin (2013)

Rco (3)

CS

CS

Janz et al. (2014)

Levin (2014)

Wen (2014)

R

PC (3)

CS

*Bradshaw et al. (2015)

Johnson JR et al. (2014)

R

CS

Hayward & Elliott (2014)

R

R

C

S

C

Northeast US

PP (current/​hx psychosis)

CDA (57 countries)

CDA, E (66% B)

CDA, E (ave age 84)

38,898

991

772

275

1,024

317,109

Parents & children (6–​17)

Jewish CDA

MP, breast CA

Family of deceased ICU pts

CDA,E (age > 65)

CDA

#8 ORA, SR, RB, NORA #1 Parent ORA

National US

#8 Sp Beliefs Index at Time 2

Los Angeles/​ Detroit Israel

#14 Sp care activ, chap

#1 Religious music

#3 ORA, SR

#1 Atheists vs. Christians

#6 ORA, DSES©

#10 Sp Persp Sc

#9 ORA, NORA, SR, RB

#2 ORA, NORA

#18 RB, SR, ORA, NORA, RC

#15 ORA, NORA, IR

#2 ORA, SR

#11 ORA, NORA, RC, DSE

#7 ORA, RSup

#2 D, ORA

#3 ORA, NORA, SR

#1 “seeking God’s help”

Seattle, WA

National US

Worldwide

Worldwide

Chicago

Australia

Worldwide

Israel

Rural China

CDA, age 15 or older

Hungary

CDA, F, age 13–​34

National US

National US

CDA

CDA

CDA, B

National US

Pakistan

CDA, age 18–​60, Muslim CDA

Norway

Cancer patients

2 million text messages on Twitter

6,864

CS

Ritter et al. (2014)

R/​S

CS

Skarupski et al. (2013)

324

49,943

1,849

47

1,039

12,643

1,431

6,082

29,424

150

2,086

R

CS

PC (4)

Lun & Bond (2013)

Cowlishaw et al. (2013)

C

R

CS

CS

*Thege et al. (2013)

*Liu & Koenig (2013)

R

R

C

CS

Ismail & Desmukh (2012)

R

CS

*Sorensen et al. (2012)

SC

MC

P

MC

P (child well-​being)

P

NG (Δ in WB)

MC

MC

MC

P (satisfaction) MC

9

8

8

(8)

9

8

(8)

8

9 8

MC

8

(8)

(8)

8

8

9

9

(8)

8

SC

MC

SC

None

SC

MC

MC

MC

None

MC

P (but interact MC w govt restrict)

P (Christian)

P

P (indirectly thru meaning)

P

P

P

P

P

P

P

NG in pornography users

P (r =​0.76)

NA

PC? (1–​4)

CS

CS

CS

CS

CS

CS

Hayward et al. (2016b)

Biccheri et al. (2016)

Fenelon & Danielsen (2016)

*Henderson W et al. (2016)

*Philippus et al. (2016)

*Abu-​R aiya et al. (2016)

CS

*Warren et al. (2015)

*Davis & Kiang (2016)

CS

*Aghababaei et al. (2015)

CS

CS

Kvande et al. (2015a)

CS

PC (3)

*Lechner & Leopold (2015) (unemploy)

Rakrachakarn et al. (2015)

CS

Achour et al. (2015)

Roh et al. (2015)

CS

CS

Battle & DeFreece (2014)

Mollidor et al. (2015)

T YPE

TOPIC/​I N V E S T IG ATOR S

R

S

R

R

C

2,140

2,558

6,304

34,565

590

3,010

180

C R

223

1,025

533

1,530

528

5,446

315

1,848

717

N

C

C

C

C

R

R

C

C

C

M E T HOD

CDA

MP, traumatic brain inj

Young parents

CDA

MP with fibromyalgia

CDA

Asian Am adol (13–​18)

CDA, American Indians, E

CDA

PP (psychiatric disabilities)

CS and CDA (7 samples)

CDA

CDA

Muslim academicians

Church attenders (ave age 53)

Black, Lesbian F

P OP U L AT ION

National US

National US

National US

National US

France

National US

North Carolina

North Plains, US

Malaysia

South Carolina

Iran & Poland

Norway

Germany

Malaysia

Australia

National US

L O C AT ION

#12 Rcm, RC, R hope, R sanc

#1 ORA

#4 R affil, ORA, NORA, SR

#1 R disaffiliation

#? Sp scale (French)

#1D (R vs. nonreligious)

#10 ORA ,R identity (IR)

#5 DUREL

#8 R scale

#7 RC, PRC, NRC

#14 IR, ER

#15 ORA, R exp

#1 ORA

#11 R from Islamic persp

#4 ORA, NORA, RB, SR

#7 D, ORA, Sp scale

R E L IG VA R I A BL E S

? SC

MC

SC

MC

SC

MC

SC

SC

MC

None

MC

MC

P (moderating)

P

P

MC

MC

MC

MC

C ON T ROL S

P (NG for disaffiliation)

P (indirect)

P

P

P

P

P (exc NRC)

P

P (exc neg R exp)

P (buffering)

P

P

P

F I N DI N G S

8

8

8

8

(8)

8

(8)

(8)

(8)

(8)

(8)

(8)

9

(8)

8

(8)

R AT I N G

CS

CS

PC (7m)

CS

PC (10)

PC (3)

CS

*Litwin et al. (2017)

Porter et al. (2017)

Kaliampos & Roussi (2017)

Dilmaghani (2018b)

*Jung, Jong Hyun (2018) (pos affect)

*Bradshaw & Kent (2018)

Abdel-​Khalek & Lester (2018)

CS

Krause & Pargament (2017)

CS

CS

Steffen et al. (2017)

CS

CS

Wilt et al. (2017)

Speed & Fowler (2017)

CT

Rouholamini et al. (2017)

Speed (2017)

CT

Moeini et al. (2016)

C

R

R

R

C

C

R

R

R

R

C

C

220/​205

1,024

1,635

41,695

86

914

1,637

2,670

3,620

2,798

855

Canada

Egyptian/​British CS

CDA,E (age > 65)

Egypt/​UK

National US

National US

CDA (age 15–​65) CDA, middle age

Greece

New York City

MP (HIV/​AIDS), > 50 yrs MP with cancer

Israel

National US

Canada

National US

Midwest US

National US

Iran

Iran

Brazil

CDA, E (age 50 or older)

CDA

CDA

CDA

CS

Ad, orphanage CDA/​CS

1,047 /​ 3,083

E with hypertension

Psychiatrists

C and ad (age 7–​19) Zambia

Multi-​site US

National US

CDA, F, 49–​79 yo CS/​CDA

Germany

Catholic clergy/​ helpers

40

52

—​ —​

104

1,293

3,083/​ 1,047

93,676

7,390

C

C

CS

CS

Holder et al. (2016)

S C

CS

CS

*Wyshak (2016)

Wilt et al. (2016)

Machado et al. (2016)

C

CS

*Bussing et al. (2016)

NA

#1 SR

#7 NORA, attach to God

#7 ORA, RB, SR, Sp

#4 D, SR, ORA, NORA

#6 RB, RC

#28 Sp Assess Sc©

#1 NORA (freq of pray)

#4 ORA, NORA, SR, RB

#3 ORA, NORA, SR

#4 Loss of faith, ORA, NORA

#15 IR, ER, ORA

#4 SR ,#26 NRC

R/​Sp training

MC

MC

—​

(8)

P (both samples)

P

P (moderating)

P

P (with RC)

P

None

MC

MC

MC

MC

MC

(8)

9

9

9

8

(8)

8

MC

P (self-​ realization/​ pleasure)

8

8

(8)

8

8

MC

MC

SC

MC

(8)

(8)

8

8

9

8

P (only for MC gnostic theists)

M

P (indirect)

P

P (exc NRC)

P

P (existential well-​being)

P

#2 ORA, SR Religious intervention

MC

MC

M MC (benevolent-​P, non-b ​ enev-N ​ G)

P

P

#2 prac R, ORA (n =​64)

#10 RB about suffering

#2 D, RC

#6 DSE©

R R

PC (3)

Kent et al. (2018)

—​

CS

CS

CS

CS

PC (6)

*Vang et al. (2019)

*Moons et al. (2019)

Marshall (2019)

*Pawlikowski et al. (2019)

CS

*Winzer & Gray (2019)

Yu et al. (2019)

CS

CT

CS

Desmond et al. (2018)

Ozmen et al. (2018)

CS

Krause et al. (2018b)

Abdi et al. (2019)

PC?

*Khambati et al. (2018)

C

CS

CS

Yaden et al. (2018)

Ngamaba & Soni (2018)

R

PC (10)

*Fancourt & Steptoe (2018)

R

R

R

C

R

6,400

thousands

4,028

74,042

21,890

32,198

93

R

3,966

—​

2,358

3,010

1,493

330,319

12,815

2,548

6,950

1,504

1,024

9,495

42

N

C

R

R

C

R

S

CS

PC (14)

*Yeung (2018)

*Chen Y & VanderWeele(2018)

C

CT

CS

Sajadi et al. (2018)

M E T HOD

T YPE

*Nadal et al. (2018)

TOPIC/​I N V E S T IG ATOR S

Age 16 or older

CDA

MP, congenital heart disease

CDA (World Values Survey)

CDA

Buddhists

MP, E, heart failure

CS (ave age 20)

Young adults (age 17–​24)

CDA

Maltreated children (outcomes)

CDA from 100 countries

Facebook users

CDA, E (> age 55)

Ad (ave age 15)

CDA

CDA, E (age > 65)

CS

F cancer patients

P OP U L AT ION

National Poland

#1 ORA

#2 R affil, ORA

#2 SR

Multi-​national 26 countries

#12 misc R, secular values

#4 D, ORA, NORA, SR

#5 Buddhist practices

R (Islam/​Shia) inter vs. controls

World

Canada

Thailand

Itran

#7 BMMRS

#? ORS, SR, NORA

National US National US

#4 ORA, Rcm

#1 “R engagement”

#3D, ORA, SR

#1 R affiliation

#1 R membership

#2 ORA, NORA

#6 ORA, NORA

#9 Forgiv by God, attach to G

#19 RCm, Sp (categories)

#1 Spiritual counseling

R E L IG VA R I A BL E S

National US

US

Worldwide

US and UK

England

National US

Texas

National US

National US

Iran

L O C AT ION

P (multiple indicators)

P

P

P (NG w sec val)

P

P

P

P

P (exc Sp but not R)

P

NA

P

P

P

P

P

P (only in hi attach G)

P

P (exist WB)

F I N DI N G S

MC

SC

MC

None (?)

MC

MC

—​

None

MC

MC

MC

MC

SC

MC

MC

MC

MC

SC

—​

C ON T ROL S

10

8

8

8

9

9

8

(8)

8

8

(8)

9

8

10

10

8

9

8

8

R AT I N G

CS

CS

CS

CS

PC (7)

PC (18m)

PC (6m)

Bodogai et al. (2020)

Pandya (2020)

Amissah & Nyarko (2020) (unemploy)

Rose et al. (2020)

Long et al. (2020b)

*Schnitker et al. (2020)

Carney et al. (2020)

CS

PC (3-​12)

*Chen Y et al. (2020a)

Makridis et al. (2021)

R

CS

Domínguez & López-​Noval (2021)

CS

CS

Bomhoff & Siah (2019)

CS

CS

Rainville & Mehegan (2019)

Pöhls et al. (2020)

C

Exp

Haushofer & Reisinger (2019)

Zheng et al. (2020)

C

CS/​PC (14m)

Kor et al. (2019)

R

R

C

C

R

C

2,386,405

348,532

33,879

191

227

51,661

1,170

362

1,764

1,243

R/​C C

92,008

101

~55,000

1,525

316

1,352

398

C/​R

—​

R

R

C

R

CS

Schuurmans-​Stekhoven (2019)

CDA

CDA

CDA

MP, congestive heart failure

National US

100 countries

24 countries

Connecticut

United States

Athletes age 12–​22

National US

Ad, B, age 13–​17

National US

Ghana

Youth age 18–​35

Nurses

Large US cities

Eastern Europe

National US

Worldwide

Indian Am guru followers

CDA,E (World Values Survey)

CDA

Countries

55 countries

National US

CDA

Kenya

CDA, age > 40

Israel

Japan

CS, 84% Christian

Ad, age 13–​17 (85% J)

CDA, E (age 50–​85)

#3 Raffil, ORA, SR

#2 ORA, SR

#2 SR

#4 RB, ORA

#3 IR

#1 Divine forgiveness

#6 D, ORA, NORA

#15 centrality of R scale

#38 faith maturity scale

#5 D, ORA, NORA, RB, R

#1ORA

P (relationship w God)

Reduced PWB

P

P

P

NA

NA

P

P (NORA)

P

P

NA (exc Cath > Prot)

P

C

P (indiv level), NA (country level)

#4 country-​level relig

#1 SR

#1 Sources of purpose

#1 Atheist primes

P

P (before personality mediators)

#24 ORA, NORA, Sp

#6 SR, RB, NORA

MC

MC

MC

SC

MC

MC

MC

None

MC

SC

MC

MC

MC

MC

—​

None (?)

MC

9

8

8

8

8

9

(8)

(8)

(8)

(8)

10

(8)

8

(8)

8

8

(8)

CS

CS

Carroll et al. (2014)

Pandey & Singh (2019)

1,011

R/​S

PC (2)

PC

CS

CS

CS

PC? (1–​4)

CS

CT

PC (14)

CS

Krause & Hayward (2012c)

*Kashdan & Nezlec (2012)

Francis (2013)

*Steffen et al. (2015)

*Shiah et al. (2015)

*Davis & Kiang (2016)

*Meanley et al. (2016)

Daher et al. (2016)

*Chen Y & VanderWeele (2018)

Pedersen et al. (2018)

1,011

C

554

6,950

132

—​

S

351

180

C C

451

425

33,982

87

C

R

R

C

S

1361

S

CS

CS

Krause (2009e)

Krause (2010d)

12,640

R

CS

Skrabski et al. (2005)

25,888

151

827

854

N

CS

?R

C

C

R

M E T HOD

Francis (2000)

Meaning/​Purpose in Life

CS

T Y PE

*Sprung et al. (2012)

Job Satisfaction

TOPIC /​I N V E S T IG ATOR S

CDA (ave age 32)

Adol (ave age 15)

CDA with MDD

Gay, bisexual,M (age 18–​29)

Asian Am ad (13–​18)

CDA (CS and non-​CS)

CDA

HS, grades 9 and 10

CS (ave age 21)

CDA,E

CDA,E

CDA, E

CDA

C, age 13–​15, Christian

Social health activists

Employees of Catholic Church

CDA

P OP U L AT ION

Denmark

National US

NC and Calif

Detroit, MI

North Carolina

#5 ORA, NORA, RB, SR

#2 ORA, NORA

Religious vs. Secular CBT

#5 ORA, SR, RC

#10 ORA, R identity (IR)

#20+​RB, R activities

Taiwan

#5 R affil, ORA, RB #21 IR, ER

England/​Wales National US

#2 daily Sp x 1,239 days

#4 ORA, relat w God

#4 ORA, God med ctrl

#1 ORA

#2 ORA, SR

#3 ORA, NORA, RB

? RC

#26 SOW sc, DUREL

#12 DSE©

R E L IG VA R I A BL E S

Virginia

National US

National US

National US

Hungary

United Kingdom

India

Multisite US

National US

L O C AT ION

P

P

equal effects, except in highly R

M (R-​NG,Sp-​P)

P

P

P (IR) w intrinsic aspirations

P

P

P

P (both)

P

P

P (all three)

P

P

NG (moderating)

F I N DI N G S

None

MC

—

MC

SC

None

SC

None

MC

MC

MC

None

MC

MC

?

MC

SC

C ON T ROL S

(8)

10

8

(8)

(8)

(8)

(8)

9

8

9

8

8

9

9

(8)

(8)

8

R AT I N G

PC (3)

CS

PC (3)

CS

Krause & Hayward (2014b)

Rao et al. (2016)

*Kent et al. (2018)

*Ozmen et al. (2018)

PC

CT

CT

*Ringdal et al. (1995); Ringdal (1996)

*Rye et al. (2005)

Bay et al. (2008)

Hope

CS

*Schnall et al. (2012)

801

253 149 166

—​ —​

3,966

1,024

8,180

918

92,539

1,005

S

C

R

R

S

C

R

R

PC (3)

CS

*McFarland (2010)

Krause & Bastida (2011)

852

R/​S

PC (3)

*Krause (2006d)

1,252

226

1,126

2812

92,008

398

881

R

CS

*Krause (2005)

S

S

CS

PC

Krause (2002b)

*Ai et al. (2002)

Idler & Kasl (1997a)

C/​R

R

PC (3–​12)

*Chen Y et al. (2020a)

R

C

CS

CS

*Schuurmans-​Stekhoven (2019)

Optimism

CS

Abeyta & Routledge (2018)

MP (heart patients)

CDA (divorced)

MP cancer

CS (ave age 20)

CDA, E (age > 65)

Indiana

Midwest US

Norway

National US

National US

Australia

CDA, F, age 31–​36

#1 ORA

Multisite US

Chaplain visits (#5)

R vs. secular intervention

#2 RB

#7 BMMRS

#12 D, ORA, NORA, RB

#1 Prayer/​Sp healing

#5 ORA, religious music

#2 ORA, RE

National US

#6 ORA, NORA

Southwest US

MC

MC

MC

MC

MC

MC

None

NA

NA

(P) (p =​.06)

P

P

P

P

P

P

P (men only)

SC

—​

SC

None

MC

MC

MC

MC

MC

MC

P (less doubt) MC

M (P-​GMC, NG-​NORA)

#5 God-​med ctrl, NORA #5 Religious doubt

P (RC)

P

P (disabled)

P

P

P (meaning/​ need for meaning)

#11 NORA, ORA, SR, RC

#2 ORA, SR

#4 ORA, SR

#1 ORA

#6 SR, RB, NORA

#10+​RCm, DUREL

National US

National US

National US

Michigan

National US

New Haven, CT

National US

Japan

Internet (US)

CDA, E (age > 65)

CDA, F, post-​menopausal

CDA, E, retired, Mex-​Am

CDA, E (age > 65)

CDA, E

CDA, E

MP (cardiac surgery)

CDA, E, 54%B

CDA, E

CDA

CDA, E (age 50–​85)

CS

8

8

8

(8)

9

8

8

8

8

8

8

8

8

8

9

10

(8)

(8)

CS

PC (2–​10)

PC (3–​12)

PC (4)

Tirrell et al. (2019)

Opsahl et al. (2019)

*Chen Y et al. (2020a)

Long et al. (2020a)

PC (2)

PC/​Exp

CS

*Krause (2009d)

Schnitker et al. (2014)

Sharma & Singh (2019)

PC

CS

Russo & Dabul (1997)

*Krause (2003)

R

R

R

R

CS

CS

Krause (1995)

R R

CS

CS

*Krause (1992)

Ellison CG (1993)

*Ellison CG & Taylor (1996)

R

C

1,247

4,150

1,344

1,005

1,933

448

2,107

220

45

839

R/​S C

674 /​780 /​832 /​104

13,771

C

R

92,008

23,864

S C/​R

888

1,774

7,653

39

N

C

R

R

—​

M E T HOD

CS

Krause & Tran (1989)

Self-​Esteem

PC/​RCT

Lambert et al. (2009)

Gratitude

CS

CS

*Waters et al. (2015)

CT

Nedderman et al. (2010)

Krause et al. (2015)

T Y PE

TOPIC /​I N V E S T IG ATOR S

CDA, E (748 W, 752 B)

CDA, F

CDA, B

CDA, E

CDA, B

CDA, E, B

CDA, B

CDA

Adol

CDA,E

CS

CDA, E

CDA

National US

National US

National US

National US

National US

National US

National US

India

Western Europe

National US

Southeastern US

National US

National US

Europe

El Salvador

Youth (age 9–​15) CDA (age 50 or older)

National US

Australia

Gatesville, TX

L O C AT ION

CDA

CDA age 16–​59

F prisoners (20 vs. 19)

P OP U L AT ION

P

#6+​DSES, R

#4 ORA, NORA, SR

#8 Rlg meaning, ORA, NORA

#2 D (aff vs. no aff), ORA

#1 prayer (RC)

#8 ORA, NORA, RC

#5 ORA, NORA

P

NA

NG

P (RC)

P

P

P

P

#18 Δ in Rcm, Sp transcendence

#6 ORA, NORA

P

P

NA

P

P

#4 ORA, NORA, God-​med ctrl

#3 prayer frequency

#1 ORA

#1 ORA

#3 ORA, NORA, R ed

P

P (grateful to God)

#11 Sp scale

P

#10 RB, ORA, SSup,+​

(P) overall, P for factor 1

F I N DI N G S

#2 ORA, D

Christian group therapy

R E L IG VA R I A BL E S

9

8

SC–​educ, inc MC

8

9

9

9

9

(8)

(8)

9

8

10

10

10

(8)

8

8

(8)

R AT I N G

MC

MC

MC

MC

MC

SC

SC

MC

None

MC

MC

MC

None

MC

None (?)

C ON T ROL S

PC (3)

CS

PC (3)

PC (2)

PC? (1–​4)

CS

CT

Krause & Hayward (2012a)

*Gebauer et al. (2012)

*Bradshaw et al. (2015)

Krause & Hayward (2014c)

*Davis & Kiang (2016)

*Meanley et al. (2016)

*Ysseldyk et al. (2016)

C

PC (1)

PC (3)

P (14)

*Bert (2011)

*Krause (2012b)

PC (3)

*Kashdan & Nezlec (2012)

C

PC(1.5)

*McFarland (2010)

221

—​

180

C 351

1,011

S/​R

C

1,024

187,957

364

87

501

110

894

429

2,402

1,000

13,317

800

R

C

C

C

R

C

R

R

R

*Trevino et al. (2010)

PC (1)

*Le et al. (2007)

R

852

R/​S

CS

CS

Krause & Ellison (2007)

890

CS

PC (3)

*Krause (2006d)

1,195 1,252

R

Carlton-​Ford et al. (2008)

PC (5)

*Petts & Kenoester (2007)

R R

*Hill TD et al. (2008a)

CS

CS

Krause (2004b)

*Krause (2005)

CDA, E

National US

Virginia

National US

Oklahoma

CS (two studies)

Gay, bisexual,M (age 18–​29)

Asian Am adol (13–​18)

CDA,E (age 65 or older)

CDA,E (age > 65)

#2 atheist v. R, religious settings

#5 ORA, SR, RC

Detroit, MI UK and Canada

#10 ORA, R identity (IR)

#4 ORA, God control

#1 Religious music

#1 SR

#9 SSup, ORA, role B church

#2 daily Sp x 1,239 days

#5 ORA

#3 ORA, SR, RC

North Carolina

National US

National US

CDA, online dating site, 11 European countries

CDA, E, B

CS (ave age 21)

CDA, E (age > 65)

Ad mothers & offspring

#6 ORA, NORA

#19 DUREL, NRC, PRC

Multi-​site US

MP, HIV/​AIDS National US

#1 ORA

CDA, E (age > 65)

#2 D,SR

#5 ORA, NORA, SR, D

#9 R socialization, others

#5 Religious doubt

#3 ORA, R homogamy

MC

MC

MC

MC

MC

None

MC

MC

SC

MC

MC

MC

MC

MC

M

M (R-​NG,Sp-​P)

P

P (thru mediators)

P

-​

MC

SC

MC

MC

P (R countries None only)

NA (exc CS anal)

P

P

P (mothers)

P (men only)

P (exc NRC)

P

P (SR)

P

P

P (less doubt)

NA (R homogamy)

P

#3 God-​mediated control

Multi-​site US

National US

National US

National US

National US

P

#4 ORA, NORA, RB

Baghdad, Iraq

Ad (age 12–​17)

National US National US

CDA, F, low income

Ad

CDA, E (Christian)

CDA, E

Parents

CDA, E

8

(8)

(8)

9

9

8

8

8

8

8

8

8

8

8

8

8

9

9

8

8

PC?

CS

CS

*Khambati et al. (2018)

*Ghafoor et al. (2018)

*Rose et al. (2020)

C R

PC(1.5)

CT

PC (4m)

CS

CS

CT

CS

PC (1m)

*Trevino et al. (2010)

*Foley et al. (2010)

Balboni et al. (2010)

Atef-​Vahid et al. (2011)

*Sorensen et al. (2012)

Jafari et al. (2013)

Preau et al. (2013)

Basinski et al. (2013)

115

C

R

C

92

4,270

65

2,086

384

343

—​ C

429

C

128

—​

CT

*Moadel et al. (2007)

450

C

PC

Mrus et al. (2006)

93

CT

118

CT

*Bormann et al. (2006)

—​

1,170

200

1,493

1,614

6,950

1,024

5,191

N

—​

R

C

C

C

S

R

R

M E T HOD

*Kristeller et al. (2005)

Quality of Life

PC (14)

CS

PC (3)

*Kent et al. (2018)

*Chen Y & VanderWeele (2018)

CS

*Henderson AK (2016)

Drewelies et al. (2018)

T Y PE

TOPIC /​I N V E S T IG ATOR S

National US

Adol, B, age 13–​17

MP w chron pancreatitis

MP after cancer dx

MP with breast cancer

MP (cancer)

Poland

France

Iran

Norway

Iran

Multi-​site US

MP (cancer)

Australia

MP (end-​stage cancer)

Multi-​site US

MP, HIV/​AIDS MP (cancer)

New York City

Multi-​site

San Diego, CA

MP (breast CA)

MP (HIV-​AIDS)

MP (HIV+​)

Indiana

Pakistan

PP/​OCD

MP (cancer)

US

Netherlands

Maltreated child (outcomes)

National US

CDA, E, age 55–​65

National US

National US

L O C AT ION

Ad (ave age 15)

CDA,E (age > 65)

CDA, B

P OP U L AT ION

#2 ORA, SR

#1 RC

Religious intervention

#1 “seeking God’s help”

#1 R attitudes scale

Sp sup from med team/​pastoral care

Buddhist Mindful Med

#19 DUREL, NRC,PRC

Yoga Intervention

#42 FACIT-​Sp©, DUREL, RC

“Spiritual mantram”

Spiritual history

#6 D, ORA, NORA

#19 R activity sc

#1 “R engagement”

#1 SR

#2 ORA, NORA

#9 Forgiven by God, attach to God

#3 ORA, RC, child R social ization

R E L IG VA R I A BL E S

P

M

P

NA

P

P

(P)

NA (exc NRC)

NA (exc SocWB)

M

NG

P

P (NORA)

P (r =​ –​.20)

NA

NA

(P)

(P)

P

F I N DI N G S

None

(8)

8

8

—​ MC

8

(8)

9

9

8

8

8

8

8

(8)

(8)

(8)

(8)

10

9

8

R AT I N G

MC

MC

MC

—​

MC

—​

MC

—​

MC

MC

None

MC

None

MC

MC

MC

C ON T ROL S

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

PC (4m)

CS

Kehyayan et al. (2016)

Currier et al. (2016)

Caqueo-​Urizar et al. (2016)

*Wyshak (2016)

Kim HJ et al. (2017)

*Henslee et al. (2015)

Cruz et al. (2017)

Dorji et al. (2017)

Gallardo-​Peralta (2017)

*Zimpel et al. (2018)

*Rezende-​Pinto et al. (2018)

CT

Chung et al. (2016)

Maheri et al. (2016)

CS

CS

PC (6m)

Rohani et al. (2015)

Dong & Zhang (2015)

PC (1)

Lanfredi et al. (2014)

Hamren et al. (2015)

CS

*Paiva et al. (2014)

S

C

S

C

531

101

777

337

168

810

S/​R C

2,288

93,676

253

678

389

C

S

C

S

R

928

256

—​ C

214

3,159

162

139

221

R

C

C

C

S

Adult crack cocaine users

Outpt with panic disorder in RCT

CDA, E (age > 60)

CDA, E (90% Buddhist)

MP hemodialysis

CDA hurricane survivors

Brazil

Brazil

Chile (north)

Bhutan

Saudi Arabia

Mississippi

#11 DUREL+​R history

#49 RC (PRC, NRC)

#38 BMMRS

#4 SSp, NORA, RB

#13 Muslim R scale

#2 PRC,NRC

#4 IR, RB, RC

Multi-​site US

CDA, LGBT, age > 50

#2 D, RC

National US

CDA, F, 49–​79 yo

#4 D, SR, ORA/​NORA, RC

MC

MC

MC

MC

MC

SC

MC

None

SC

MC

None

P

NA

M (P-​DSE©, NG-​RC)

NG

P

P (exc NRC)

MC

MC

MC

MC

SC (age)

MC

P MC (psychological HRQOL)

P

P

P (mediated)

#15+​ (BMMRS)

South America

P (strongest predictor)

P

#9 Spiritual growth

#2 ORA, RC

P (pre-​post)

P

“Praise Dance” (Christian)

P

#? BMMRS+​

NA (exc NRC)

NA

NA

#3 ORA, NORA, SR

#24 RC, Sp Persp Sc

#20 SWB

#15 R practices sc

PP with schizophrenia

California

Iran

Vets, PTSD residential rx

Canada

NH (43% > age 85)

Hong Kong

Ethiopia

Chicago

Iran

Italy

Brazil

MP, β-​thalassemia

CDA, Chinese F

CDA,E (age > 55)

CDA, E, Chinese

MP with new breast CA

Schizophrenia (resident)

MP, end-​stage cancer

(8)

8

(8)

(8)

(8)

8

8

9

(8)

(8)

(8)

8

8

(8)

8

(8)

8

(8)

CT (non-​ rand)

CS

PC (6m)

*Pramesona & Taneepanichskul (2018)

*Moons et al. (2019)

Abu et al. (2019a)

C

C

M E T HOD

1,039

4,028

60

N

MP, admitted for ACS

MP, congenital heart disease

E (age > 60), NH, Muslim

P OP U L AT ION

Mass & Georgia

Multi-​national

Indoneisa

L O C AT ION

PC (3)

CS

*Bradshaw et al. (2015)

*Pascoe et al. (2016)

S

R

R

S

R

S

1,051

444

1,024

583

1,495

224

CS

CS

CS

Chadwick & Top (1993)

CS

Sloane & Potvin (1986)

*Benson P & Donahue (1989)

CS

Freeman (1986)

Grasmick et al. (1991)

PC (1–​3) —​

R

R

R

R

R/​R?

R

CS

Stark et al. (1982)

Peek et al. (1985)

R

CS

Rhodes & Reiss (1970)

Delinquency and Crime

2,143

304

> 12,000

1,121

2,358/​4,961

817

1799

21720

Delinquency, Crime, and Academic Performance (Chapter 13)

PC (7)

PC (3)

Hayward & Krause (2013a)

Krause & Hayward (2014a)

CS

PC

Wolinsky & Stump (1996)

*Ai et al. (2005a,b)

young BM /​WM

HS,M

Ad Mormons

CDA

HS

HS

Indiana

Florida

National US

National US

National US

Michigan

Eastern US

Oklahoma city

National US

National US

Boston, Chi, Phi

National US

National US

Tennessee

III. SOCIAL HEALTH

White boys

HS

CDA

CDA,E (age > 65)

CDA, E (age > 65)

CDA, E (age > 65)

MP (cardiac surgery)

MP

Locus of Control/​Sense of Control (P indicates positive relationship with internal locus of control or sense of control)

T Y PE

TOPIC /​I N V E S T IG ATOR S

relig values/​practices

#6 D, ORA, SR

#1 SR

#2 ORA, SR

#1+​ ORA

#1+​ religiosity

#6 RB, SR, ORA

#4 ORA, D, misc

#6 ORA, NORA, RC, SR

#1 Religious music

#7 RSup (Sp & emotional)

#6 God control, RCm

#5 NORA, SR

#3+​D, SR, RB

#3 RC, NORA

#2 SR

Muslim R intervention

R E L IG VA R I A BL E S

MC

SC P

MC P/​NA

MC

MC

MC

NONE

MC

MC

MC

MC

MC

MC

MC

MC

MC

—​

C ON T ROL S

P

P

P

M

P

P

P

P

P (Sp sup only)

P (RCm)

M

P

P

P

P

F I N DI N G S

8

8

9

9

9

8

8

9

8

9

9

10

8

9

8

8

(8)

R AT I N G

CS

CS

CS

Lee MR (2006)

Torgler (2006)-​cheat tax

Branco & Braam (2006)

PC (3)

*Caputo (2004)

CS

CS

Lee MR & Bartowski (2004)

Jang SJ & Johnson (2005)

PC (1)

Pearce & Haynie (2004)

PC (8)

PC (5)

Benda et al. (2003)

CS

PC (1)

*Regnerus & Elder (2003)

Johnson BR (2004)

PC (1)

Regnerus (2003b)

*Yanovitzky (2005)

CS

PC (1)

Jang SJ & Johnson (2003)

CS

*Nonnemaker et al. (2003)

Regnerus (2003a)

CS

Benda & Corwyn (2002)

S

CS

PC (2)

*Barber BK (2001)

2,358

R/​S

Johnson BR et al. (2001)

5,000

R

CS

CS

*Wallace& Forman (1998) 6,923 Multi-​site US

Ad (age 13–​18)

National US National US

Ad/​parents Ad/​parents

R

R

S

1,701

34,265

902

659

R/​C

201 5,007

C R

NH, E

Multi-​site US

Worldwide

National US

counties (county-​ level data) CDA (World Values Surv)

National US

National US

Ad (age 9–​18) CDA, B

New York

Prisoners

National US

1,911

R/​C

Ad (age 12–​16)

National US

County level data–​juvenile homicide

R

Southern US

National US

Ad /​ county-​level data

Prisoners, M

National US

CDA, B

National US

National US

Ad (grades 7–​12)

Palestine

Ad (age 11–​17)

Major US cities

National US

HS (98% Muslim)

B, M (age 16–​24)

HS

National US National US

National US

10,444

572

7,767

11,046

9,401

2,107

14,801

1,031

1,725

Adolescents Adolescents

Ad (and their mothers)

R

R

R

R

R

R

R

R

R

11,955 12,118

Johnson BR et al. (2000)

R R

CS

CS

Stark (1996)

*Resnick et al. (1997)

#2 D, ORA

#2 ORA, RC

#8 D, ORA, SR, RB

#1 churches/​1,000

#8 ORA, NORA, SR

#2 ORA, SR

Prison fellowship pgm

#8 R (parent & Ad)

#1 % civic engaged R den

#2 ORA, SR (child & m)

#6 ORA, NORA, SR

#4 ORA, SR, R change

#4 Ad, #3 parents

#3 D,ORA,RB

#12 ORA,NORA,SR

#4 ORA, NORA

#5 ORA, NORA, SR

#4 ORA, SR

#5 ORA, NORA, SR

#2 ORA, SR

#3 D, ORA, SR

#1 SR

P

M

P (exc Denom)

P

P

NA (indirect?)

P

NA

P (rural areas)

P (M interact)

P (recitivism)

P

P-​Ad, M-​Parents

P

P

P (NORA)

P

P

P

P

P

NA (violence)

SC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

9

8

9

8

8

8

8

9

8

9

9

10

10

10

8

9

8

9

9

8

9

8

CS

CS

CS

CS

CS

CS

CS

CS

Salas-​Wright et al. (2014b)

*Salas-​Wright et al. (2014a)

Salas-​Wright et al. (2015)

Conover-​Williams & Chang (2016)

DeCamp & Smith (2019)

Kim DH et al. (2018)

*Rezende-​Pinto et al. (2018)

P (14)

*Bert (2011)

*Kabiru et al. (2014)

CS

*Meltzer et al. (2011)

CS

PC (7)

Glanville et al. (2008)

*Michaelson et al. (2014)

CS

*Jackson et al. (2008)

CS

CS

*Bradford et al. (2008)

CS

CS

*Sinha et al. (2007)

*Salas-​Wright et al. (2012)

PC (2)

*Fauth et al. (2007)

*Pitel et al. (2012)

CS

CS

Stack & Kposowa (2006)

*Stockdale et al. (2007)

T Y PE

TOPIC /​I N V E S T IG ATOR S

C

C

S

R

R

R

R

R

R

R

R

C

R

R

R

R

R

R

R

R

M E T HOD

531

638

11,530

8,362–​ 12,940

19,312 /​ 2,721

183,912

90,202

3,064

26,078

3,674

17,705

110

2,992

15,197

31,855

641

1,690

1,315

12,716

45,728

N

Kenya

Ad, age 12–​19

Brazil

Chicago

At-​risk B ad Heavy cocaine-​ using adults

Delaware

National US

National US

National US

Adol (8th & 11th grades)

Ad (Add Health)

CDA (age 12–​25)

Ad & young adults

National US

Canada

Ad (age 11–​15)

Ad (ave age 14.6)

Slovakia

National US

Ad, grades 9–​10

Ad, age 12–​17

Oklahoma

Great Britain

Ad mothers & offspring

National US

Ad (age 11–​19)

Ogden, Utah

Ad (grades 5–​8) Ad, grades 7–​12

National US

Ad (age 11–​18) & parent National US

Chicago

Ad (9–​12 yo)

HS

National US

36 nations

L O C AT ION

CDA

CDA

P OP U L AT ION NA

P (except D)

F I N DI N G S

#7 DUREL, ORA (childhood)

#4 ORA, NORA, etc.

#2 D, ORA

#3 ORA, NORA, SR

#4 ORA, SR, IR

#4 ORA, SR, IR

#4 ORA, SR, IR

#5 ORA, NORA, SR, RB, RC

#1 ORA

#2 ORA, SR

#5 ORA, SR, IR, RB

#3 ORA, SR, RC

#3 ORA, SR, RB

#2 ORA

#2 ORA, SR

#5 ORA, NORA

#3 ORA, SR

P (crime)

P

P

P (weaker in sexual minorities)

P

P (drug selling)

P (violent aggression)

P

NA (fighting)

P

P (theft)

P (offspring)

P (ORA)

P (dropout)

P

P

P

#1 ORA (“church group”) NA

#1 churches/​1,000

#4 D, ORA, RC, SR

R E L IG VA R I A BL E S

MC

MC

MC

SC

MC

MC

MC

MC

MC

SC/​MC

MC

MC

SC

MC

NONE

MC

MC

MC

NONE

MC

C ON T ROL S

(8)

(8)

8

8

9

9

9

8

9

8

9

8

8

10

8

8

8

8

8

9

R AT I N G

PC (11m)

CS

CS

Exp/​PC (10)

PC (10)

PC (7)

CS

Bhutta et al. (2019)

Massarwi et al. (2019)

Mendolia et al. (2019)

Stansfield et al. (2020)

Pardini et al. (2021)

Guo (2021)

Sahin & Unlu (2021)

Conduct disorder.

C

PC (5)

Lensch et al. (2021)

n

R

PC (1)

Pitt & DeMaris (2019)

S

C

C

R

R

R

R

C

C

C

PC (8)

PC(1)

Schuster & Krahé (2019)

C

CS

PC (7)

*Jang SJ (2019)

C

R

R

R

Stansfield et al. (2019)

PC (10)

Jang SJ (2018)

C C

Andreesc (2019)

PC (12)

PC (7)

Miller T & Vuolo (2018)

PC (1.5)

Watts (2018)

Atherton et al. (2018)

CS

PC (12m)

Schroeder et al. (2018)

Tomaszewska & Krahe (2018)

603

31,272

1,354

1,170

684

38,568

2,811

506

1,111

14,091

811

571

2,903

1,289

1,354

674

13,796

4,053

318

CS

Midwest US

#5 ORA, SR, Sp

Arizona/​Pennsyl Turkey

Ad offenders (age 14–​19) Ad, age 14–​18

#7 ORA, NORA

#3 SR, RC

Arizona/​ Pennsylvania

Ad offenders, M

Sp/​R programs in prison

#1 SR

England

Ad (age 13–​18)

Oregon

#15 R scale

Israel

Arab Muslim ad (13–​18) Adult prisoners

#14 ORA, R activities

#2 SR, R use of time

Pakistan

Midwestern US

Ad (age 12–​17)

#1 ORA #5 SR, NORA, RB

#24 D, SR, IR, ER

Calif & Florida

#2 SR, R education

#5 ORA, SR, RC

Oregon

Chile & Turkey

Arizona/​ Pennsylvania

#5 ORA, SR, Sp

Arizona/​ Pennsylvania

#4 ORA, SR, NORA, RB

#5 ORA, RB

#6 religiosity

National US

Adult probation (Muslim)

#4 RB, ORA, NORA, SR #2 ORA, SR

California

National US

National US

Poland

Ad (Add Health)

Cuban descent, age 22–​27

Adult prisoners

CS

Ad offenders (age 14–​17)

Ad offenders (age 14–​19)

Mex Am children grade 5

Ad (Add Health)

Ad, M (Add Health)

CS (67% F)

P (RB)

M (delinquency)

P

P (gun violence)

P (those w prior sex off)

P (fighting)

P (buffering phys viol)

P (recidivism)

P (first arrest)

P (violence)

P (F only)

P

M (sex aggression)

P

P

NA (PC)n P (CS)

M

P (only in certain genotype)

NA (sexual aggression)

MC

(8)

SC

MC

MC

MC

MC

MC

SC

MC

MC

MC

MC

MC

MC

8

9

9

8

8

8

8

9

9

(8)

9

8

9

9

8 MC

9

SC (?)

8

(8)

MC

MC

MC

15,197 50 states

R R -​

PC (5)

S R

CS

CS

PC (6)

PC (14)

CS

CS

CS

PC?

CS

CS

PC(13)

CS

Good & Willoughby (2011)

Sutantoputri & Watt (2012)

Gottfried & Polikoff (2012)

Maslow et al. (2012)

Hallfors et al. (2013)

Azagba et al. (2014)

Wen (2014)

Khambati et al. (2018)

*Isralowitz et al. (2018)

Moffat & Yoo (2020)

Horwitz et al. (2020)

Goncalves et al. (2020)

R

C

C

R

R

C

R

R

C

R

PC (7)

CS

*Glanville et al. (2008)

Reeve & Basalik (2011)

4,607

11,829

?

758

1,493

38,898

9,229

328

10,925

12,237

1,006

3,993

890

7,261

*Petts & Kenoester (2007)

R

CS

4,434

N

PC (1)

R

M E T HOD

Regnerus (2000)

T Y PE

*Regnerus & Elder (2003)

School Performance

TOPIC /​I N V E S T IG ATOR S

CDA age 14 or over

Ad (Add Health)

HS

CS, F, Jewish

Maltreated children (outcomes)

Brazil

National US

England

Southern Israel

US

#2 R affil, SR

P (violence)

P

P

#4+​R affil, ORA, SR, R educ #3 SR, ORA, NORA

NA

(P) (p =​0.058)

P (child school engage)

P (school connected­ ness)

P (school dropout)

P (college grad w/​ o chron illness)

#1 Religious activity

#1 “R engagement”

#1 Parent ORA

National US

Parents & children (6–​17)

#2 ORA, SR

E. Canada

Ad, grades 7–​12

#3 D, ORA, NORA

#1 ORA

P (F, non-​ sexual minority)

#10 R student/​ parent/​peer

Zimbabwe

National US

National US

P (IR)

NA (mediated?)

NG

P

P (R homogamy)

P

P

F I N DI N G S

#5 ORA, NORA, IR

#1 ORA

Ontario, Can Indonesia

#7 RB, ORA, SR, NORA

#2 ORA

#3 ORA, R homogamy

#4 ORA, SR, R change

#2 D, ORA

R E L IG VA R I A BL E S

US

National US

National US

National US

National US

L O C AT ION

Orphan girls (ave age 15)

Ad (chronic ill vs. not)

Ad (Add Health)

CS (65% Muslim)

HS students, grades 9–​12

(state averages for IQ)

Ad (Add Health)

Parents

Ad and parents

Ad (10th graders)

P OP U L AT ION

MC

MC

MC

8

9

(8)

(8)

(8)

MC None

9

9

MC

MC

(8)

10

MC

MC

8

(8)

8

(8)

10

9

10

8

R AT I N G

MC

SC

MC

None (including SES/​race)

MC

MC

MC

MC

C ON T ROL S

R R

CS

Glenn (1982)

CS

CT

CS

CT

CS

Laurenceau et al. (2004)

Mullins et al. (2004)

*Rye et al. (2005)

Martin & Levy (2006)

CS

CS

Wineberg (1994)

Wilson J & Musick (1996)

Curtis & Ellison (2002)

R

CS

CS

Lehrer & Chiswick (1993)

Ellison CG (1997)

CS

CS

*Truett et al. (1992)

PC (28)

CS

Heaton & Pratt (1990)

Call & Heaton (1997)

R R

CS

Shehan et al. (1990)

*Strawbridge et al. (2001)

R

CS

*Pollner (1989)

R

4,999

National US

CDA, F, age 25–​39

National US Ohio

149

Denver, CO

National US

California

National US

National US

National US

National US

National US

Australia

National US

National U.S.

National U.S.

Edmonton, Can

National US

National US

National US

National US

CDA (divorced)

County-​level divorce data (n =​621)

Newlywed couples

—​

217

—​

1st time married couples

CDA

CDA (couples)

CDA

F, W, CDA

CDA, B

first marriages

CDA (twins)

CDA

CDA

CDA

CDA (married couples)

R

2,945

2,676

4,587

5,648

506

1,975

3,060

7,620

12,000

1,753

3,072

179

CDA

CDA

1,552–​ 5,433 8,952

CDA

CDA,F

7,029

5,442

R

R

R

C

R

R

R

R

CS

CS

Glenn (1984)

Larson L & Goltz (1989)

R

CS

Shrum (1980)

R

CS

Bumpass & Sweet (1972)

Marital Stability and Satisfaction (religiosity, marriage, divorce, satisfaction, adjustment)

Marital and Family Stability (Chapter 14)

#2 D, ORA

Relig forgive vs. secular

#1 R homogamy

Clergy-​admin marital Rx

#4 D, ORA, RB (R homog)

#1 ORA

P

NA

P

P

P (M attend, RH)

P

P

P #3 D, ORA, RB

P #2+​ORA, D

P

#2+​ ORA #2 ORA, R homogamy

P

#1 R homogamy

P

P

#2+​ ORA, R-​homogamy #2 D, ORA

P (esp Catholics)

P

P

P

P (males)

P

P (heter less stable than hom)

#2 ORA, D

#7 ORA, NORA, RE

#3 ORA, D, R homogam

#2 D, ORA

#1 D,ORA

#2 ORA, D

#1 D (heterog v homog)

MC

—​

MC

—​

MC

SC

MC

MC

MC

MC

MC

SC (factor)

SC

MC

MC

MC

MC

MC

MC

MC

8

9

8

9

8

9

10

9

9

8

8

9

8

8

8

8

8

8

9

8

R R

PC (1)

Wilcox W & Wolfinger (2007)

CS

CS

CS

Cirhinlioglu et al. (2018)

Henderson et al. (2018)

McDonald et al. (2018)

C

PC (14)

CS

Li et al. (2018a)

PC (4)

Rose et al. (2018)

Dilmaghani (2018c)

C

CS

Holland et al. (2016)

R

R

R

CS

R

R

R

PC (9)

CS

C

Tuttle & Davis (2015)

CS

David & Stafford (2015)

R

R

S

Olson et al. (2015)

PC (13)

Lyons & Smith (2014)

C

CS

CS

Fincham et al. (2011)

PC (7)

Uecker (2008)

McFarland et al. (2011) (sex)

R

PC (7)

Brown E et al. (2008)

R?

CS

PC (6)

Burdette et al. (2007)

Collins RL et al. (2007)

C

PC (5)

Rhoades et al. (2006)

M E T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

829

468

510

18,239

66,444

331

5,720

1,513

763

342

7,367

2,029

487

2,079

373

454

7,791

3,069

197

N Colorado

L O C AT ION

National US

Married couples

Cohab or dating couples

Married couples

CDA

US nurses, married

Married couples

Married SDA (Adventists)

CDA married

CDA

Married couples

Arkansas

National US

Turkey

Canada

National US

Midwest US

#6 ORA, trust in God

#5 ORA, RB, R affil

#13 Religiousness

#1 R affil vs. secular

#1 ORA

#10 Santa Clara R sc

#32 IR, RC, NORA, RC

#3 R homogamy, spouse prayer

National US

#7 ORA, NORA, SR

Multi-​site US

#7 relate w God, joint R sc

#5 ORA, SR, NORA, RB

#2 ORA, IR

#17 DSE©, R activity

#3 D, ORA ,SR

#4 D, ORA, SR, joint ORA

#2 SR, IR

#3 D, ORA, RB

#3 D, ORA, RB

#1 SR

R E L IG VA R I A BL E S

National US

Midwest US

National US

National US

CDA, F, adol (Add Health)

Southeast US

CDA, E (age 57–​85)

National US

Michigan

West coast US

Couples, B

Married young adults

Couples just married

Married young adlts (23)

CDA

CDA, parents, wed/​ National US unwed

Engaged couples

P OP U L AT ION

MC

MC

MC

P (marital adjust)

P (relat quality)

P (marital quality)

P

P

M

MC

MC

MC

MC

MC

MC

P (mediated by MC Sp meaning)

P

P

P (satisfac­tion)

8

8

(8)

8

10

8

8

8

9

(8)

9

P (non-​marital MC parity)

(8)

10

9

8

9

9

8

R AT I N G

8

SC

MC

MC

MC

MC

MC

MC

C ON T ROL S

MC

M

P

P (exc Denom)

P (wife only)

P

P

P (getting married)

P (dedication)

F I N DI N G S

PC (34)

CS

CS

CS

PC (10)

CS

CS

PC(17)

PC (5)

PC (1)

Hwang et al. (2019)

Chen Y et al. (2019a)

Aman et al. (2019)

White et al. (2020)

King V et al. (2022)

Dew JP et al. (2020)

Perveen & Malik (2020)

Hwang et al. (2021)

Kogan & Weißmann (2020)

Rose et al. (2021)

CS

Hajihasani & Sim (2019)

CS

CS

Khodadadi et al. (2018)

PC (7)

CT

Shamsipour et al. (2018)

Sadeghi et al. (2019)

CS

Rahman & Ali (2018)

King V et al. (2019)

CS

Dew J et al. (2018)

C

R

C

C

R

R

R

C

S

C

R

C

C

R

—​

C

R

331

11,146

173

600

1,368

371

1,562

254

3,929

193

2,085

200

194

2,860

40

82

1,362

Married couples

Ad migrants and non-​m

Married couples

Married w family violence

#4 NORA, IR, SR

#2 D, SR

Europe NW US city

#2 SR, D homogamy

#15 RCm (Huber)

#3 RB, NORA, ORA

#2 Couples’ religiosity

#4 ORA, NORA, SR

#14 RCm, R prac

#1 Family religiousness

S. California

Pakistan

National US

Iowa

Long-​term married CDA Married couples

National US

Pakistan

National US

#3 ORA, SR, D homog

#1 ORA w parents

S. California

#21 IR, ER

National US

#21 IR, ER

#26 R attitudes

R-​focused couples ther

#1 SR

#3 RB, NORA, ORA

Iran

Iran

Iran

Newlyweds in therapy

Married couples, Muslim

CDA (ave age 47)

Married couples

Adolescents in step-​fam

Married F, CS

Married F < age 18

Married F

Iran

Pakistan

Dual-​career married CDA Couples refer for therapy

National US

Married couples

P (marital satisf)

P (cohabita­ tion)

C (marital satisf)

P (marital quality)

P (sexual satisf)

P (activities together)

P (help & change therapy)

P (marital satisf)

P (parental warmth)

P (D homog)

P

P

NA (marital satisf)

P (couple intimacy)

P

P (marital satisf)

P (marital commit)

SC

MC

MC

SC

MC

SC

MC

None

MC

MC

MC

None

None

None

—​

None

MC

8

9

9

(8)

8

9

8

(8)

8

9

9

(8)

(8)

8

(8)

(8)

8

T Y PE

M E T HOD

CS

CS

PC (20)

CS

CS

CS

CS

CS

CS

CS

PC (45)

CS

CS

CS

*Kim-​Spoon et al. (2012)

*Morton KR et al. (2012)

Spilman et al. (2013)

*Goeke-​Morey et al. (2013)

King V et al. (2013)

*Kabiru et al. (2014)

Poorsheikhali & Alavi (2015)

Nelson & Uecker (2018)

Faro et al. (2018)

Brand et al. (2018)

Silverstein et al. (2019)

*King V et al. (2019)

Chen Y et al. (2019b)

Malinakova et al. (2019b)

R

S

R

S

C

C

R

R

R

R

R

C

S

C

Family Functioning (parental religiosity, family functioning)

TOPIC /​I N V E S T IG ATOR S

4,182

3,929

1,523

220

70

193

1,096

309

3,064

9,002

695

451

6,753

322

N

Adol (average age 14)

CDA

Adolescents in step-​fam

Adult children

Parents of deaf children

Czech Republic

#5 ORA, RWB

#1 Family religiousness

#1 ORA w parents

National US National US

#1 R activities w mother

#1 Affil (S, T, R, O, UO)

#4 ORA, SR, NORA

#4 ORA, NORA, SR, RB

#9 R behavior scale

#5 ORA, NORA, SR, RB, RC

#2 ORA, changed R

#9 ORA, SR, RB (mother)

#3 ORA, SR

#9 SR, IR, RC

#6 ORA, SR

R E L IG VA R I A BL E S

S. California

Israel

Southeast US

B, parent-​adol dyads

Iran

Student-​parent dyads National US

Kenya

Ad, age 12–​19

CDA with children

National US

CDA with 1 living parent

Northern Ireland

Iowa

2-​parent families Mother-​child dyads

National US

Virginia

L O C AT ION

CDA (Adventists)

Adol-​parent dyads

P OP U L AT ION

MC

None

P (authorita­ tive) M (parent monitor, support)

MC

MC

MC

None

MC

None

None

MC

SC

P

P (help provided to M)

NG (involved in interv pgm)

NA (maternal warmth)

P (parenting satisf)

P (family relations)

P (parental monitoring)

P (exc change of R)

P (multiple indicators)

MC

MC

P (non-​risky family) P (family functioning)

MC

C ON T ROL S

NA (parent attachment)

F I N DI N G S

8

8

8

10

(8)

(8)

8

(8)

(8)

9

8

10

8

(8)

R AT I N G

CS

CS

CS

CS

CS

CS

*Boyas et al. (2019)

Shafer et al. (2019)

Stearns & McKinney (2020)

Kliewer et al. (2020)

Stier & Kaplan (2020)

Shorter & Elledge (2020)

PC (5)

PC (7)

CS

Ellison et al. (2011) (spanking)

Watts (2017)

Wolf & Kepple (2019)

CS

CS

CS

PC (3m)

Ellison CG et al. (1999)

Ellison CG & Anderson (2001)

Ellison CG et al. (2007)

Katerndahl et al. (2015)

Domestic Violence

PC (14)

*Bert (2011)

Child Abuse (P =​less abuse)

CS

Sharma et al. (2019)

C

R

R

R

C

R

R

C

C

?R

C

C

R

R

C

200

6,800

6,800

4,662

3,023

9,002

456

110

367

30,000

326

417

2,297

3,115

576

Virginia

Mississippi

Texas

National US

CDA, married/​ cohab F, physical abuse by spouse

National US

National US

California

#3 RC, Sp symp, Sp counsel visits

#1 ORA

#1 ORA

#3 D, RB, ORA

#2 ORA, indiv & county

#4 ORA, NORA, SR

#3 D, RB

National US

National US

#3 ORA, SR, RC

M

P

P

M

NA

P

P (for conserv Prot denoms)

P (mothers)

P (↑cohesion, ↓conflict)

#9(?) Moral-​religious sc

Oklahoma

E. Tennessee

CDA married or cohab

CDA

Parents of child < 13

Adol (Add Health)

Mother, child (age 2–​4)

Adol mothers & offspring

Adol, ave age 16

None

P (positive​ emotional environm)

MC

MC

MC

MC

MC

MC

MC

MC

None

MC

None

P (parent-​ child conflict)

P (value of children)

MC

None

None

P (father involvement) NG (harsh discipline)

P (parental monitoring)

P (parental monitoring)

#1 ORA

#12 mother ORA, RCm, RC

#53 R traits scale

#15 RCm (Huber)

#3 SR, IR

National US National US

#2 ORA, SR

Alabama

CDA in 24 OECD countries worldwide

B adol and mothers

CS

Fathers of child age 2–​17

Ad, Hispanic, age 12–​17

CDA, low-​income areas

8

8

8

9

8

9

8

8

(8)

8

(8)

(8)

8

8

(8)

CS

*Goncalves et al. (2020)

R

R

R

R

C

M E T HOD

PC

PC(3)

CS

PC(1.5)

*Contrada et al. (2008)

Krause & Bastida (2009)

*Skarupski et al. (2010)

*Trevino et al. (2010)

R

CS

R

CS

R

CS

PC (28)

*Koenig et al. (1997a)

*Strawbridge et al. (2001)

Szaflarski (2001)

2,676

S R

CS

CS

Kark et al. (1996a)

*Idler & Kasl (1997a)

*Hill TD et al. (2008)

4,000

R

CS

CS

Ellison CG & George (1994)

2,956

C

854

R/​S 429

6,534

550

2,402

1,518

2,812

437

3,597

S

R

R

2,107 1,439

Bradley (1995)

R R

CS

CS

4,522

Taylor RJ & Chatters (1988)

R

4,607

1,401

1,523

55,523

260

N

Hatch L (1991)

CS

*Ortega et al. (1983)

Social Support

Social Support and Other Social Factors (Chapter 15)

CS

CS

CS

Jung JH & Olson (2017)

Kposowa & Aly Ezzat (2019)

CS

Renzetti et al. (2017)

Daoud et al. (2020)

T Y PE

TOPIC /​I N V E S T IG ATOR S

Multi-​site US

MP, HIV/​AIDS

National US Chicago

#15 R affil, NRC, PRC

#5 DSE©

#4 ORA, Sp connected

#13 NORA, RB

#1 ORA New Jersey

#2 ORA, NORA Multi-​site US

#1 ORA

#3 ORA, NORA

#2 ORA, SR

relig vs. secul kibbutz

#1 ORA

#1 ORA

#2 ORA

#4 D, ORA, CM, SR

#2 ORA

#2 D,SR

#1 SR (R, trad, sec)

#1 ORA

#2 ORA, SR

#22 RCm, R self-​regulat

R E L IG VA R I A BL E S

Poland (national)

California

Durham NC

New Haven, CT

Israel

National US

North Carolina

National US

National US

N. Alabama

Brazil

Isreal

Egypt

Worldwide

National US

L O C AT ION

CDA, E (age > 65)

CDA, E

MP (cardiac surgery)

CDA, F, low income

CDA

CDA

E, CDA

CDA, E

CDA

CDA

CDA (ECA)

CDA, E, F

CDA, B

CDA

CDA age 14 and over

CDA, F, Jews & Arabs

CDA, Muslim

CDA from 49 countries

CDA, M (80% Christian)

P OP U L AT ION

P (exc NRC)

P

P

P

P

P

P (women)

P

P (ORA, SR)

P

P

P

P

P

P

P (explained by alc depend)

NG (Arabs)

P

P

NG

F I N DI N G S

NONE

MC

SC

MC

MC

MC

SC

MC

MC

SC

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC

C ON T ROL S

8

8

8

8

8

8

9

9

9

8

8

8

9

8

8

8

8

8

8

(8)

R AT I N G

CS

CS

CS

PC (2)

CS

CS

*Rao et al. (2016)

*Philippus et al. (2016)

*Wyshak (2016)

Thompson et al. (2017)

Bailly et al. (2018)

*Ramirez et al. (2018)

o

LGB =​lesbian, gay, bisexual.

CS

CS

*Al Zaben et al. (2015)

Sowa et al. (2016)

CS

Kvande et al. (2015b)

P (2.5)

CS

*Krause & Hayward (2012b)

Le et al. (2016)

CS

*Shilo & Savaya (2012)

P (3)

CS

*Schnall et al. (2012)

CS

CS

*Correa et al. (2011)

*Semplonius et al. (2015)

CS

*Moxey et al. (2011)

*Hayward et al. (2016b)

CS

CS

Al-​Kandari (2011)

*Kudel et al. (2011)

S

C

C

C

S

S

R

R

C

R

C

C

R

R

C

C

S

R

C

1,472

544

567

218

93,676

2,574

8,180

57,391

1,251

3,010

1,132

310

470

1,005

461

92,539

1,538

752

345

National US

France Bogota, Columbia

CDA, E (ave age 76) CDA, age 18–​59

St. Louis, MO

CDA, F, 49–​79 yo MP, B, breast CA

National US

Australia

CDA, F, age 31–​36 MP, traumatic brain inj

Europe

National US

National US

Ontario, Can

Saudi Arabia

Norway

CDA, E, age > 50

CDA, B

CDA

CS

MP, renal dialysis, Muslim

CDA

Southwest US

Israel

LGBo youth (ave age 18) CDA,Hispanic,E

#1 ORA

Multisite US

CDA,F, post-​menopausal

#1 SR

#6 DSE©

#15 R/​Sp beliefs

#2 D, RC

#1 ORA

#1 Prayer/​Sp healing

#1 R organizational activ

#9 ORA, NORA, RB

#1D (R vs. nonreligious)

#11 ORA, NORA, Sp

#13 ORA, NORA, IR

#5 ORA, NORA, SR, RC

#5 ORA, gratitude to God

#1 SR (secular-​orthodox)

#1 ORA

#2 SR, ORA

#2 increase in R/​S

#1 SR

Brazil

CDA,E, low income

Australia

Multi-​site US

MP, HIV/​AIDS CDA, age 55–​85

Kuwait

NH (ave age 77)

P

P

P (CS), NA (PC)

P

P

NG (social functioning)

P

NA

P

P (indirect)

P

M

P (connected to others)

NG

P

P

P

P

P

MC

MC

MC

MC

MC

MC

SC

MC

MC

MC

MC

SC

MC

SC

MC

None

MC

MC

None

(8)

(8)

8

9

8

8

8

8

8

8

(8)

(8)

8

(8)

8

(8)

(8)

(8)

(8)

PC (3–​12)

*Chen Y et al. (2020a)

PC (1)

PC (7)

French et al. (2020)

Long K et al. (2020a)

CT

CS

PC

CT

Exp

Exp

*Rye & Pargament (2002)

*Krause & Ellison (2003)

Tsang et al. (2005)

*Rye et al. (2005)

Williamson & Gonzales (2007)

Witvliet et al. (2008)

Forgiveness (“>” indicates greater forgiveness)

PC (6)

PC (3-​12)

PC (3.5)

*Cohen-​Mansfield et al. (2016)

*Pawlikowski et al. (2019)

CS

Rote et al. (2012)

*Chen Y et al. (2020a)

CS

*Lee G & Ishii-​Kuntz (1987)

Loneliness

CS

PC (17)

*Winzer & Gray (2019)

PC (7)

*Orr et al. (2019)

Hill TD et al. (2019)

CS

CS

Krause (2018a)

Ju et al. (2018)

T Y PE

TOPIC /​I N V E S T IG ATOR S

C

57

169

149

–​ C

60

1,316

58

54,703

C

S

C

C

564

92,008

C

6,400

C/​R

1,170

2,169

2,872

92,008

2,479

32,198

6,759

738

1,744

N

R

R

R

R

C/​R

R

R

R

C

R

M E T HOD

National US

CS

CS

CDA

CS

CDA,E, 49% B

CS (Christian F), 18–​23 y

Nurses

Muslim adol

CDA

Age 16 or older

Michigan

Midwest US

Midwest US

Southern US

National US

Ohio

National US

Indonesia

National US

National Poland

Israel

CDA (age 57–​85) CDA,E (over age 75)

Washington State

CDA

National US

Southwest US

CDA

Thailand

CDA, age 65+​

Ireland

China

National US

L O C AT ION

Buddhists

CDA, over age 50

Tibetan Buddhist adol

CDA

P OP U L AT ION

#10 R commitment

#1 SR

R vs. secular intervention

#9 IR (Allport)

#3 ORA, NORA, God forg

P

P

NA

P

P

NA

P

#2 self/​divine forgiveness

Rlg vs. sec forgiveness

P

P

P

#20 RC, R behaviors

#1ORA

#1 ORA

P (mediated) P (decrease R)

#1 ORA

NA

P

P

P

NA

NG

P

F I N DI N G S

#2 R identity, Δ in R

#1 ORA

#1 ORA

#2 D, ORA

#5 Buddhist practices

#2 ORA, SR

#15 RCm (Huber)

#4 ORA, RSup

R E L IG VA R I A BL E S

None

SC

–​

None

MC

–​

MC

MC

MC

MC

None

MC

MC

MC

MC

MC

MC

SC

MC

C ON T ROL S

(8)

(8)

9

(8)

8

8

10

8

10

10

(8)

8

8

10

10

9

9

(8)

8

R AT I N G

PC (14)

PC (7w)

Exp

*Chen Y & VanderWeele (2018)

Fincham et al. (2020)

C

S

R

R

365

91

393

6,950

1,535

200

1,629

696

1,004

1,087

CS

CS

CS

Ad (ave age 15)

CDA (ave age 63)

CDA

CDA (19% response rate)

CDA, E

CDA, E

CDA

Texas

Florida

Florida

National US

National US

Kigali, Rawanda

National US

National US

National US

National US

#42 IR, ER, Q, RB, R prime

#1 R priming

#2 ORA, SR

#2 ORA, NORA

#3 RCm

#34 IR, RC, emotions toward God

#4 D, SR, ORA, NORA

#6 ORA, NORA, R sup

#6 ORA, NORA, R sup

#5 D, ORA, NORA, SR

C

NA except angry God (NG)

P

P

P

P (exc NRC)

P

P (R sup)

P (R sup)

M (P =​9, NG =​1)

(8)

—​

S R

CS

CS

CS

CS

CS

*Larson R et al. (2006)

Warburton & Stirling (2007)-​volun

Ecklund & Park (2007)-​volun

*Berry et al. (2007)

Kim J et al. (2007)-​volun

R

R

R

R

CS

Kim D & Kawachi (2006)

R

CS

Wuthnow (2002)

15,506

963

711

4,792

2,280

24,835

5,603

Korea (national)

Australia

CDA, age 19–​97 CDA

National US

CDA, Asian American

Australia

Illinois

Ad (11th graders) CDA, E (age > 54)

#6 ORA

Multi-​site US

CDA

P (exc Buddhist)

P

P

P

P

MC

MC

MC

NONE

MC

#1D

P (any afil greater than None)

MC

Development of a 28-​item social capital scale (incl R participation)

#7 D, ORA

#1 ORA

#3 ORA (youth groups)

#5 D, ORA, CM, lead role

National US

CDA

8

8

8

8

8

8

8

8

(8)

SC

10 Cross-​lagged R→F

8

(8)

(8)

9

8

8

MC

MC

MC

SC

MC

MC

MC

Social Capital (community participation, volunteerism (volun), engagement in community-​based, civic, or political/​social-​justice organizations, social trust, reciprocity)

Exp

C

CS

*Krause & Hayward (2015)

Tsang et al. (2020)

C

CS

*Heim & Schaal (2014)

R/​S R

PC(3)

CS

R/​S

Krause (2010a)-​study 2

CS

Krause (2010a)-​study 1

R

Lutjen et al. (2012)

CS

Toussaint & Williams (2008)

R R

CS

CS

CS

CS

PC (6)

Kim-​Yeary et al. (2012)

Lewis et al. (2013)

Holt et al. (2015a)

*Marshall (2019)

*Pawlikowski et al. (2019)

6,400

thousands

803

2,610

10,828

15,197

N

CS

CS

Gillum & Masters (2010) (blood don)

Almeida et al. (2013)

CS

*Kim J et al. (2007)

CS

CS

*Ecklund & Park (2007)

Krause & Hayward (2012b)

CS

*Warburton & Sterling (2007)

CS

CS

Saroglou et al. (2005)-​study 4

CS

CS

Saroglou et al. (2005)-​study 3

Najafizadeh et al. (2010)

CS

Harris AH et al. (2005)

Ahn et al. (2011)

CS

Nelson LD & Dynes (1976)

C

R

R

S

R

R

R

R

C

C

R

R

National US

CDA, age 18–​44

281

1,005

525

Brazil

Southwest US

E, Mex-​Am (age > 65) Graduate students

Texas

CDA, E (age > 60)

Tehran, Iran

Korea (national)

National US

Australia

Belgium

Belgium

National US

Soutwest US

National Poland

26 countries

National US

National US

National US

National US

L O C AT ION

CDA

CDA, Asian American

CDA, E (age > 54)

CDA

HS

CDA, E (over 70)

CDA

Age 16 or older

CDA

CDA, B

CDA (ethnically diverse)

CDA

Ad, grades 7–​12

P OP U L AT ION

Donation cards during Ramadan

10,976

15,506

711

4,792

274

315

7,496

663

Altruistic, Generosity, Volunteering, and Giving (“>” indicates greater)

R

R

R

R

PC (7)

*Glanville et al. (2008)

M E T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

#2 R affil, ORA

#10 RWB

#9 ORA, RSup, RCm

#1 ORA

#1 Ramadan

#3 D, ORA, SR

#1 D

#7 D,ORA

#1 ORA

#8 Self, others’ R/​S ratings

#4 Self, others’ R/​S ratings

#1 ORA

#5 ORA, NORA, SR

#1 ORA

NA (blood don)

P

P

P

P (though weak)

P (any afil > None)

P (except Buddhist)

P

P

P

P

P

NA (trusting people)

P

P (R behaviors)

P

#10+​ORA, RB, RSup #9 ORA, NORA, RB

P

P

F I N DI N G S

#5 ORA, SR, NORA

#2 ORA

R E L IG VA R I A BL E S

None

MC

MC

None

MC

MC

MC

MC

SC

SC

NONE

MC

MC

SC

MC

MC

MC

MC

C ON T ROL S

(8)

8

8

(8)

8

8

8

8

8

8

8

8

10

8

(8)

8

8

10

R AT I N G

C C

CS

CS

Yen & Zampelli (2014)

*Mollidor et al. (2015)

PC (?)

CS

CS

PC (18m)

PC (5)

Petrovic et al. (2021)

Damian (2019)

Schnitker et al. (2020)

Neugebauer et al. (2020)

CS

*Krause et al. (2018b)

Kim Y & Dew (2019)

PC (9m)

Shepherd et al. (2018)

R

CS

PC (14)

*Yeung (2018)

CS

Fiorillo & Nappo (2017)

*Chen Y & VanderWeele (2018)

R

CS

*Sowa et al. (2016)

C

C

R

C

R

R

C

S

R

R

PC (3)

CS

Krause (2015)

Okun et al. (2015)

R

R

CS

*Wen (2014)

R

CS

*Lewis et al. (2013)

230

227

116,380

1,368

8,163

3,010

492

6,950

1,504

17,000

57,391

8,148

1,154

1,848

2,610

38,898

2,610

New York

United States

Athletes age 12–​22 CDA

Europe

National US

Australia

National US

National US

National US

Texas

United Kingdom

Europe

Wisconsin

National US

Australia

#2 ORA, SR

#3 IR

#3 D, ORA, SR

#3 ORA, NORA, SR

#2 ORA, SR

#4 ORA, Rcm

#2 SR

#2 ORA,NORA

#6 ORA, NORA

#1 R participation

P

P

P

M (country vs indiv level)

P

MC

MC

MC

MC

MC

MC

SC

P (compass­ ion/​ generosity; Sp only) P (helping others)

MC

MC

MC

SC

MC

MC

None

MC

MC

MC

P

P

P

P

NG (Sp)

P (ORA)

#1 R organizational activity

P

#5 ORA, Sp (self-​rated)

P

P

NA (parent-​ rated child health)

P

#9 ORA, RCm, SSup

#4 ORA, NORA, RB, SR

#4 D, ORA, SR

#1 Parent ORA

National US

National US

#10+​ORA, RB, RSup

National US

CDA

Couples

CDA

CDA

Medical students

Adol (ave age 15)

CDA

CDA

CDA,E, age > 50

CDA, E

CDA, E, age > 50

Church attenders (ave age 53)

CDA

Parents & children (6–​17)

CDA (ethnically diverse)

8

8

8

(8)

8

8

8

10

8

8

8

9

8

(8)

8

9

8

L O C AT ION

R E L IG VA R I A BL E S

F I N DI N G S

C ON T ROL S

R R R R

CS

PC (6)

CS

*Resnick et al. (1997)

Koenig et al. (1998f)

*Wallace& Forman (1998)

CS

PC (3)

CS

PC(3)

Kaufman et al. (2002)

Whooley et al. (2002)

*Nonnemaker et al. (2003)

*Wills et al. (2003)

R

CS

CS

*Brown TN et al. (2001)

*Sutherland & Shepherd (2001)

C

PC (3)

Sperber et al. (2001)

CS

R

C

R

S

R

CS

PC (29)

*Szaflarski (2001)

*Strawbridge et al. (2001)

C

CS

CS

*Idler & Kasl (1997a)

*Kendler et al. (1997)

R

S S

CS

CS

Goldbourt & Medalie (1975)

*Brown D & Gary (1994)

Cigarette Smoking (Chapter 17)

C

1,182

16,306

4,569

17,287

4,516

188,000

312

2,676

1,518

5,000

4,000

12,118

1,902

2,812

537

10,000

84

Iran

Israel

National US Multi-​site US National US

Ad, age 13–​19 CDA (20–​32 yo) Ad (grades 7–​12)

New York

United Kingdom

Ad (7th to 10th grade)

National US

Ad (age 11–​16)

Israel

California

Poland (national)

National US

North Carolina

National US

Virginia

New Haven, CT

Norfolk, VA

HS

Ad, Jewish, 9th grade

CDA

CDA

HS

CDA, E

Ad

CDA, twins

CDA, E

CDA, B, M

CDA, M

V. HEALTH BEHAVIORS

Pregnant women

#4 SR

#4 ORA, NORA

#w D, ORA

#1 ORA

#2 RB, ORA

P

P

P

P

NA (indirect?)

P

NA

#1 D (Orth/​Trad v Sec) #1 (?) RCm

P

P

P

P

P

P

P (ORA, SR)

P (ORA)

P

P (head circum­ference)

#1 ORA

#2 ORA, NORA

#3 D,ORA,SR

#4 ORA, NORA, D

#1 SR

#11 RB, ORA, NORA, SR

#2 ORA, SR

#12 relig scale, ORA, D

#3 ORA, SR

R educ intervention

SC

MC

MC

MC

MC

MC

MC

SC

MC

MC

MC

MC

MC

MC

MC

NONE

—​

CT

P OP U L AT ION

Review and description of theoretical model describing religion’s effects on mental health across the life span (Ch 7, pp. 153–​176)

N

Gilani et al. (2019)

M E T HOD

*Koenig (2018a)

T Y PE

Tests the model presented in the 2012 edition of Handbook describing mechanism by which R influences health in 345 HIV+​patients

*Kudel et al. (2011)

TOPIC /​I N V E S T IG ATOR S

IV. UNDERSTANDING THE RELIGION, MENTAL, AND SOCIAL HEALTH RELATIONSHIP (Chapter 16)

8

9

9

8

8

10

(8)

9

8

9

10

8

9

9

8

8

(8)

R AT I N G

CS

CS

*Sinha et al. (2007)

Gillum & Sullins (2008b)

CS

*Kliewer & Murrell (2007)

CS

PC (1)

Hoving et al. (2007)

*Steinman et al. (2008)

CS

*Pirkle & Richter (2006)

CS

CS

*Hill TD et al. (2006a)

CS

PC (1)

Nonnemaker et al. (2006)

*Degenhardt et al. (2007)

CS

Brown TT et al. (2006)

*Wallace et al. (2007)

CS

Timberlake et al. (2006)

R

CS

Gillum (2005a)

CS

PC(4)

*Steinman & Zimmerman (2004)

CS

PC (1)

Van Den et al.Bree (2004)

Gillum (2005b)

CS

*Beyers et al. (2004)

*Viner et al. (2006)

R

CS

Baron-​Epel et al. (2004)

R

R

R

R

R

2,395

33,007

16,595

9,282

1,690

17,215

4,055

R/​S R

929

1,504

13,750

R

R

R

39,369

1,564

R/​S R

2,789

18,774

14,475

705

14,133

40,845

12,862

12,797

56,004

R

C

R

S

R/​C

R

CS

*Chen et al. (2004a,b)

R

CS

*Wallace et al. (2003)

National US

Ad (age 12–​18)

National US

National US

Columbus, OH

AD (6th–​12th grades) CDA, F, hx preg in 20

CDA

Midwest US

US & Australia

Ad (grades 6–​12) HS, B

Israel

Central America

National US

CDA

HS

Ad (10th grade) (5% B)

#5 D, ORA, SR, NORA

#3 D, ORA, SR

#1 ORA

#2 SR, ORA

#2 D, SR

#3 ORA, SR

#9 RB, parent religiosity

#1 Religious vs. not R

#1 SR

#1 ORA

P (in females)

P

P

P

P

P

P

P

P

P

P

P (both)

NA

P

P

P

P

P

P (observance)

P

No under-​reporting of smoking by R

#1 Social cap from R gps

#5 D, SR, ORA

#2 D, observance

#1 ORA

#1 ORA

#1 ORA

#1 “religion”

#? “particip in R activ”

#2 D, relig (sec to orth)

#1 religious practices

#3 D, ORA, SR

MC

SC

MC

MC

MC

MC

MC

MC

MC

MC

?

SC?

MC

MC

MC (?)

SC

MC

MC

MC

SC

8

9

8

9

8

9

(8)

8

8

10

8

8

8

8

8

8

8

9

8

8

8

CS

CS

CS

CS

*Pokhrel et al. (2012)

*Pitel et al. (2012)

CS

*Lucchetti et al. (2012)

*Salas-​Wright et al. (2012)

CS

*Kovacs et al. (2011)

*Ford & Hill (2012)

CS

Gryczynski & Ward (2011)

CS

*Chamratrithirong et al. (2010)

PC (2)

CS

Feinstein et al. (2010)

*Hodge et al. (2011)

PC (6)

Yong et al. (2009)

CS

CS

Gillum & Williams (2009)

CS

CS

Gillum et al. (2009)

*Salmoirago et al. (2011)

CS

*Page RL et al. (2009)

Gillum (2011)

CS

*Blay et al. (2008)

R

S

R

R

R

S

R

C

R (?)

C

C

C

R

R

R

R

R

R

R

PC (8)

PC (2)

*Jackson et al. (2008)

*Benjamins & Buck (2008)

R

CS

Pampel (2008)

M E T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

3,674

354

17,727

17,705

383

881

14,695

804

5,088

56,372

420

5,474

2,232

3,766

9,374

1031

6,961

10,399

32,087

200,000

N

#2 ORA, SR

Thailand

Teen-​parent dyads

National US

Russia

HS (age 15–​16)

Slovakia

National US

Ad, grades 9–​10

National US

Ad (age 12–​17)

Brazil

Ad, age 12–​17

CDA living in slums

Hungary

Ad, age 12–​17 HS students

Southwest US

National US

Latino students (ave age 11)

CDA, Mexican Am

National US

Multi-​site US

CDA (age 45–​84) CDA, F

#1 SR

#2 ORA, SR

#5 Sp scale

#4 ORA, SR, IR

#5 ORA, SR, IR, RB

#7 DUREL, RB

#3 D, ORA, SR

#2 ORA, IR

#3 R affil, ORA, SR

#1 ORA

#1 ORA

#7 RB, SR, NORA

#7 ORA, NORA,Sp Exp

#3 D, ORA, SR

Malaysia/​ Thailand

#1 ORA

#3 D, ORA, SR

#4 D, R change, SR, ORA

#3 ORA, SR

National US

F, age 30–​44

F I N DI N G S

P

NA

P

NA

P

P

P

P

P

P

P

P

NA (quit)

P

P

P

P

P

P

#1 D Prot, Cath, P Muslim vs. None, Other

R E L IG VA R I A BL E S

Smokers (31% Muslim, 69% Buddhist)

National US

National US

Pregnant, post-​ partum F CDA, M (NHANES-​III)

Brazil

Mexico (national)

National US

sub-​Sahara Africa

L O C AT ION

CDA, E

CDA, E (> 50 y)

HS

CDA

P OP U L AT ION

SC/​MC

MC

MC

MC

MC

None (?)

MC

MC

?

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC

SC

C ON T ROL S

8

(8)

9

9

8

(8)

9

8

8

9

(8)

8

9

8

8

8

8

9

10

8

R AT I N G

CS

CS

*Rao et al. (2016)

Kalter-​Leibovici et al. (2016)

C

CS

PC (6)

CS

Gillum & West (2015)

Almutairi (2016)

CS

*Salas-​Wright et al. (2015)

Mumford & Liu (2016)

R

CS

*Holt et al. (2015b)

R

R

R

R

R

7,524

8,180

9,050

715

7,036

19,312 /​ 2,721

2,370

1,837

4,496

R R

PC (10)

CS

Bailey et al. (2015)

Allahverdipour et al. (2015)

29,215

S

6,203

12,000

2,621

2,370

13,278

26,078

Rco (1-​5 y)

*Kobayashi et al. (2015)

12,595 852

310

CS

*Al Zaben et al. (2015)

R

R

C

R

R

R

1,504 5,387

C

CS

CS

*Vance et al. (2014)

CS

CS

*Holt et al. (2014)

*Fletcher & Kumar (2014)

CS

Ward et al. (2014)

*Moscati & Mezuk (2014)

CS

*Michaelson et al. (2014)

R

R

CS

CS

*Gomes et al. (2013)

Primack et al. (2014)

R C

CS

CS

*Garcia et al. (2013)

*Gmel et al. (2013)

CDA, Mex-​Am

National US

Ad (Add Health)

National US

Australia

CDA, F, age 31–​36

Israel

National US CDA

Saudi Arabia

Mothers (pre-​preg)

National US

National US

National US

Tabriz, Iran

National US

Japan

Saudi Arabia

National US

CS, M

CDA, age > 40

CDA (age 12–​25)

CDA, B age 21 or older

CS

CDA (middle age)

MP, outpts

MP, renal dialysis, Muslim

CDA

Virginia

National US

CDA, B, w/​o cancer Twins in Virginia registry

National US

Canada

Ad (age 11–​15) Ad (age 12 or older)

Florida

Brazil

Switzerland

CS

CS

Military recruits, M

#2 ORA, D

#2 D, SR

#1 Prayer/​Sp healing

#1 ORA

#6 ORA, NORA, other

#1 ORA

#4 ORA, SR, IR

#17 ORA, SR, Sp locus of control

#28 R scale

#5 ORA, SR, RC, IR

#1 SR

#13 ORA, NORA, IR

#2 D, ORA, SR, change

#3 ORA, NORA, SR

#78 (7 dimensions of R)

#15 ORA, NORA,RC

#4 SR, IR, ORA

#1 ORA

#3 D, SR, SSp

#1 ORA

#2 D, SR

P

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC

MC

MC

MC

MC

MC

P

P

P

P

MC

MC

MC

MC

NA (menthol MC cig)

P

P

P

P

P

P

P

p

NA (explained by genetic factors)

P (R behaviors)

P

P

P (waterpipe smoking)

P

P

8

8

8

9

(8)

8

9

8

8

10

9

(8)

9

8

8

(8)

8

9

(8)

8

(8)

3,151 810

R S/​R

CS

CS

CS

PC (29)

Hussain et al. (2019)

Freeman (2021)

Cartwright (2021)

Zhang C et al. (2021)

S

PC (2)

PC (4)

Moutinho et al. (2019)

Martin et al. (2019) (quitting)

C

PC (6)

PC(22)

*Pawlikowski et al. (2019)

Lee JY et al. (2020)

C

R

R

R

R

R

R

R

CS

R

CS

PC (11)

Ahrenfeldt et al. (2018)

S

*Isralowitz et al. (2018)

PC (14)

*Chen Y & VanderWeele (2018)

R

R

R

*Marshall (2019)

CS

CS

*Salas-​Wright et al. (2017)

Malinakova et al. (2019a)

CS

CS

*Sharma et al. (2017)

CS

Martinez et al. (2017)

*Henslee et al. (2015)

S

CS

20,222

548

7,586

Ad to midlife

CDA, new immigrants

Ad & young adulthood

age >20 /​16–​20

39,836 /​ 2,355 9,080

CDA, F (ave age 58)

New York

National US

National US

England

United Kingdom

Brazil

Harlem, NY

Medical students

National Poland

Age 14–​36

26 countries

Southern Israel

Europe

Age 16 or older

CDA

CS, F, Jewish

Age 50 or older

National US

Czech Republic

Ad (ave age 15)

National US

Ad (age 13–​15)

Mississippi

National US

Brazil

National US

National US

Worldwide

L O C AT ION

Ad (age 12–​17)

CDA hurricane survivors

Veterans

CDA at primary care health centers

CDA

CDA, B

CS in 26 countries

P OP U L AT ION

53,650

327

674

6,400

thousands

758

23,864

6,950

4566

18,614

1,055

34,525

36,613

Burke et al. (2017)

C C

CS

CS

N

Peltzer et al. (2016)

M E T HOD

T Y PE

*VanderWeele et al. (2017a)

TOPIC /​I N V E S T IG ATOR S

#1 ORA

#2 D, ORA

#5 D, ORA, NORA

#1 D

#1 “R group activities”

#5 ORA, NORA, IR

#1 ORA (family)

#1 ORA

#2 R affil, ORA

#1 Religious activity

#3 ORA, NORA, R educ

#2 ORA, NORA

#8 R (ORA), Sp (SWB)

#2 ORA, SR

#2 PRC, NRC

#5 DUREL

#5 DUREL

#1 meditation (vs. not)

#4 ORA, NORA, RC, SR

#5 DUREL

R E L IG VA R I A BL E S

MC

MC

MC

SC

None

MC

MC

SC

MC

MC

MC

SC

SC

None

SC

C ON T ROL S

P

P

P

MC

MC

MC

P (Christians/​ MC Other < None)

P (unadjusted) None NA (adjusted)

P (NORA)

P

P

P

P

P

P

P (with hi R and hi Sp)

P

NA

NA

P

NG

P

M

F I N DI N G S

9

8

8

(8)

9

8

9

10

8

(8)

9

10

8

9

8

8

(8)

8

8

8

R AT I N G

CS

PC (6)

PC (6–​14)

PC (7)

Varella et al. (2020)

Sartor et al. (2020)

Upenieks & Schafer (2020)

Ross et al. (2020)

CS

Exp

CS

Kahan & Nicaise (2012)

Debnam et al. (2012)

CT

Duru et al. (2010)

*Pitel et al. (2012)

CS

*Baetz & Bowen (2008)

CS

CS

*Hill TD et al. (2006a)

CS

CS

Gillum (2006b)

*Salmoirago et al. (2011)

CS

Baron-​Epel et al. (2005)

Dodor (2012)

PC (29)

CS

*Strawbridge et al. (2001)

Kraut et al. (2003)

CS

*Idler & Kasl (1997a)

Exercise/​Physical Activity (Chapter 18)

PC (3–​12)

*Chen Y et al. (2020a)

2,370

45

—​ R

3,674

3,620

R

R

56,372

62

-​ C

37,000

1,504

11,820

9,133

3,687

2,676

2,438

R

R

R

R

S

R

R

1,960

3,609

C C

2,172

8,881

92,008

R

C

C/​R

California

Southern CA National US

CDA, B, w/​o cancer

Slovakia

Ad, grades 9–​10 Muslim youth, ave age 12

National US

National US

Los Angeles

Canada

Texas

National US

Israel

Israel

#13 Sp hlth LOC (passive & active)

Muslim pedometer intervention

#2 ORA, SR

#4 OA, SR, NORA, RC

#1 ORA

Faith-​based physical activity intervention

#3 ORA, Sp, prayer cope

#1 ORA

#1 ORA

#2 D, SR

#1 SR

#1 ORA

#3 ORA, SR

#1 ORA

N. Carolina/​Virg

New Haven, CT

#1 ORA

#4 ORA, NORA,S R

#1 ORA

#1 ORA

National US

CDA, B (ave age 32)

CDA, F

Sedentary B, E, F

CDA

CDA

CDA (age > 20)

CDA (20% Arab)

M, industrial workers, Jew

CDA

CDA, E

CS

CDA, middle aged

Pittsburgh

Brazil

CDA, age 35–​74 C, F, age 5–​8

National US

CDA

NA

P

NA

M

P

P

P

P

P (F age > 59)

NG-​Jews, NA-​Arab

NG

P (women)

P

P (cigar use)

P

P (White girls)

P

P

SC

—​

SC/​MC

SC

MC

SC

MC

MC

MC

MC

SC

MC

MC

MC

MC

None

MC

(8)

(8)

8

8

9

9

8

8

8

8

8

9

9

8

8

8

(8)

10

29,215 20,222

Rco (1–​ S 5 y)

R R

PC (6m)

CT

CS

PC (2)

Ansari et al. (2017)

Arredondo et al. (2017)

Malinakova et al. (2018)

*Kim ES et al. (2019b)

PC(10)

CS

PC (7)

Svensson et al. (2020)

*Long et al. (2020a)

92,008

C/​R

Herold et al. (2022)

44,281

S

CS

PC (3–​12)

Spence et al. (2020)

PC (12m)

Zhang J et al. (2019)

*Chen Y et al. (2020a)

C

CS

C

S

C

R

23,864

51,661

1,024

1,596

595

1,271

6,400

Mohammad et al. (2019)

R

PC (11)

PC (6)

*Ahrenfeldt et al. (2018)

*Pawlikowski et al. (2019)

5,200

4,182

436

—​ R

132

C

44

—​

CT

Webb & Bopp (2017)

36,613

C C

CS

CS

*Peltzer et al. (2016)

*VanderWeele et al. (2017a)

26,078 549

*Kobayashi et al. (2015)

R C

CS

144

CS

—​

N

*Michaelson et al. (2014)

Exp

Martinez et al. (2013)

M E T HOD

Karvinen & Carr (2014)

T Y PE

TOPIC /​I N V E S T IG ATOR S

Canada

San Diego, CA

L O C AT ION

Nurses

CDA

CDA,E

CDA

F, nurses

M, B, homosexual

CDA, age 14 or older

CDA, age 16 or older

CDA, age 50 or older

CDA, age 50 or over

Ad (mean age 14)

National US

Denmark

Europe

National US

National US

Philadelphia

Iran

National Poland

Europe

National US

Czech Republic

San Diego, CA

Texas

CDA, F, B/​Hispanic F from 16 Cath churches

Pennsylvania

National US

Worldwide

Japan

Clergy (Christian)

CDA, B

CS in 26 countries

MP, outpts

Users of Craiglist website (ave age 37)

Ad (age 11–​15)

Church-​going Latinas

P OP U L AT ION

#2 R motivated forgive

#2 ORA, NORA

#4 ORA, NORA, other

#1ORA

#1 ORA, RC

#3 ORA, NORA

#33 R scale

#1 ORA

#3 ORA, NORA, R educ

#1 ORA

#21 ORA, SWB

Faith-​based exercise program

#30 BMMRS

Faith-​based phys active program

#4 ORA, NORA, RC, SR

#5 DUREL

#1 SR

#7 God control, SR

#1 ORA

Faith-​based exercise program

R E L IG VA R I A BL E S

SC

—​

MC

SC

None

SC

MC

SC

MC

—​

P

NA

P unadj, NA adj

P

NA

NG (ORA)

NA

P

P (> weekly attend)

MC

MC

MC

MC

MC

None

MC

None

MC

MC

C ON T ROL S

P (exerc mediated mortality effect)

P

P

NA

P

M

M

P

NG

P

P

F I N DI N G S

9

(8)

9

10

(8)

8

(8)

10

9

9

8

9

8

(8)

8

8

9

(8)

9

(8)

R AT I N G

Diet and Weight (Chapter 19)

R R

CS

Locher et al. (2005) (nut def)

R

Exp

CS

Acosta-​Enriquez et al. (2019)

CS

*Rao et al. (2016) (vitamins)

Hermstad et al. (2018)

CS

Tan et al. (2016)

CS

CS

*Michaelson et al. (2014)

*Burke et al. (2017)

C

CS

*Holt et al. (2014)

CS

CS

*Pitel et al. (2012)

CS

CS

*Dodor (2012)

*Peltzer et al. (2016)

CS

*Debnam et al. (2012)

*VanderWeele et al. (2017a)

R

CS

*Salmoirago et al. (2011)

C

C

R

C

CS

R

R

R

R

R

C

363

258

34,525

36,613

20,222

8,180

574

26,078

2,370

3,674

3,620

2,370

56,372

1,071

—​

CT

1,504

1,000 14,192

Winett et al. (2007)

5000 3,878

R

CS

CS

*Hill TD et al. (2006a)

Obisesan et al. (2006) (fish)

S

CS

PC (0.5)

*Wallace & Forman (1998)

Lytle et al. (2003)

Diet (high fat intake =​NG, high fish intake =​P, “>” indicates better) HS

National US

Ad (age 13–​19)

Church members

CDA

CDA, B

CS in 26 countries

Mexico

Atlanta

National US

National US

Worldwide

Australia

Canada

Ad (age 11–​15)

CDA, F, age 31–​36

National US

CDA, B, w/​o cancer

W. Malaysia

Slovakia

Adol, grades 9–​10

CDA, Adventists

National US

National US

CDA, B, w/​o cancer CDA, B (ave age 32)

National US

CDA, F

Virginia

National US

CDA, CM

Texas

CDA (NHANES-​III)

Birmingham, AL

Minnesota

CDA

CDA, E

Ad, 7th graders

#5 DUREL

M

SDA > non-​SDA

P

Faith-​based environmental change #1 SDA vs. non-​SDA

P (vegetarian)

NG #1 meditation (vs. not)

#4 ORA, NORA, RC, SR

P

P #1 Prayer/​Sp healing

P #6 DUREL +​Sabbath keeping

P (R behaviors)

P

M (fast foods)

M

P (fiber intake)

NA

P

M

#1 ORA

#15 ORA, NORA, RC

#2 ORA, SR

#4 OA, SR, NORA, RC

#13 Sp hlth LOC (passive & active)

#1 ORA

Church-​based nutrition program

#1 ORA

#1 ORA

P (B, M)

P

#6 Sp/​R influence #1 ORA

P

#3 D, ORA, SR

MC

None

SC

None

SC

MC

MC

MC

MC

SC/​MC

SC

SC

MC

—​

MC

MC

MC

SC

MC

(8)

(8)

8

8

8

8

(8)

9

(8)

8

8

(8)

9

8

8

8

8

8

9

PC (7)

*Long et al. (2020b)

S

R R

CS

*Idler & Kasl (1997a)

S C

PC (6)

Exp/​PC

CS

PC (1)

PC (8)

CS

CS

CS

Van Lenthe et al. (2000)

Perk et al. (2001)

Kim KH et al. (2003)

Sarri et al (2003)

Cline & Ferraro (2006)

Gillum (2006a)

Kim KH (2007)-​wt percep

Bruce MA et al. (2007)

R

R

R

R

C

R

R

CS

PC (28)

*Oman & Reed (1998)

*Strawbridge et al. (1997)

R

Exp/​PC

CS

Kumanyika & Charleston (1992)

C

C

S

*Ferraro (1998)

Weight (weight, BMI, or waist-​hip ratio)

CS

CS

*Svensson et al. (2020)

Kang et al. (2020)

S

C

CS

CS

Wen et al. (2019)

*Spence et al. (2020)

C

PC(20)

Kunto & Mandemakers (2019) (stature)

M E T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

3,497

3,032

16,657

3,617

120

3,032

17

767

5,286

1,931

2,812

3,497

188

51,661

973

1,024

44,281

82,510

21,723 /​ 9,771

N

CDA, 34% B (over-sampled)

National US

National US

National US

CDA, age 25–​74

CDA (NHANES-​III)

#3 ORA, NORA

#12 D, ORA, RC, IR, SR

#1 ORA

#5 D, ORA, SR, NORA, RC

#1 Fasting for R reasons

Greece National US

#12 D, ORA, RC, IR, SR

Ramadan fast

#1 D (None vs. Cath vs. other)

#1 ORA

#1 ORA

#2 ORA, SR

#6 ORA, NORA, SR, RC

NG (only B,F)

M

MC

MC

MC

MC

M (P-​ORA, NG-​NORA) (NG)

MC

MC

NONE

MC

MC

MC

MC

MC

—​

MC

MC

MC

None

MC

MC

C ON T ROL S

P

NG (Men)

P

NA

NG (CS)

NA (PC)

NG

NG (SR)

NG

P

NA

#2 R-​motivated forgiveness

Church-​based wt loss

NA

P

NA

P

M

F I N DI N G S

#1 religion (yes, no)

#2 ORA, NORA

#1 ORA, RC

#3 ORA, SR, RC

#1 Ramadan fast during pregnancy

R E L IG VA R I A BL E S

National US

CDA

60 fasting vs. 60 non-​fast

CDA, age 25–​74

Israel (Muslim)

Netherlands

CDA, age 20–​49 CDA, treated hypertens

Alameda, Calif

Marin, Calif

New Haven, CT

National US

Baltimore

National US

South Korea

Denmark

National US

Southeastern US

Indonesia

L O C AT ION

CDA

CDA,E

CDA,E

CDA

CM, 100% B, F

Nurses

MP (outpatients)

CDA

F, nurses

Low income CDA

Child/​mothers

P OP U L AT ION

8

8

8

9

(8)

8

(8)

8

10

9

9

9

(8)

9

(8)

(8)

(8)

8

9

R AT I N G

CS

PC (9)

*VanderWeele et al. (2017a)

Hill TD et al. (2017b)

S

C

R

772

36,613

1497

3010

R

CS

CS

*Hayward et al. (2016b)

Krause & Hayward (2016)

23

Gainey et al. (2016)

7,414

—​

CS

Ruiz & Acevedo (2015) (wt perception)

R

36,965

S

CT

CS

Lycett (2015)

CDA, E

CDA, age 50 or over

CDA, B

CDA

CDA

MP, diabetes

CDA

CDA

MP

CDA, Asian Indians

1,450–​ 2,934

CDA, F, B, obese

CDA

CDA, B

CDA, B (ave age 32)

Overweight Catholics

Mexico

National US

National US

National US

Thailand

Texas

United Kingdom

Japan

National US

California

South Carolina

Australia

Jackson, MS

National US

Arkansas

Multi-​site US

CDA (age 45–​84)

NG

NA

P

NA

NG

#1 ORA

#4 ORA, NORA, RC, SR

P

P

NA (RSup moderating)

#1 D (R vs. atheists/​agn) #6 Attach to God, RSup

NA

M

NG

NG (CS) NA (Rco)

P

NG

P

M

NA

NG

Buddhist walking meditat

#5 D, ORA, NORA, RB, SR

#1 R affiliation

#1 SR

#1 ORA

#3 ORA, SR, IR

Sp-​based weight program vs. non-​Sp

#3 ORA, SR, D

#8 ORA, NORA, DSE©

#4 OA, SR, NORA, RC

Catholic-​tailored wt loss prog vs. standard

#7 ORA, NORA, Sp Exp

#1 Spiritual counseling

#2 R educ, R orthodoxy

Israel Detroit, MI

#6 Spirituality

Minnesota

Obese B,F, breast CA

3,228

R

C/​Ad (grades 7–​8) CDA, M (age 40–​65)

R

48

—​

2,378 9,408

R

1504

Rco (1–​5 y)

*Kobayashi et al. (2015)

34

—​

3,620

5,474

31

C

C

3,010 1,890

R

CS

CS

Bharmal et al. (2013)

*Hill TD et al. (2014)

CT

Nam (2013a)

R

CS

CS

*Dodor (2012)

CS

CT

Krukowski et al. (2010)

Reeves et al. (2012)

CS

*Feinstein et al. (2010)

Kortt & Dollery (2014)

R

CT

Djuric et al. (2009)

S S

PC(1.5)

PC (?)

Pasch et al. (2008)

*Beeri et al. (2008)

MC

None

MC

MC

—​

MC

MC

MC

MC

MC

—​

MC

MC

SC

No dif, except for treat satisfaction

MC

—​

SC

MC

9

8

8

8

8

8

8

9

8

8

8

8

8

8

8

8

(8)

(8)

9

CS

CS

*Kobayashi et al. (2020)

Doolittle et al. (2021)

CS

*Svensson et al. (2020)

CS

PC (56d)

Whitehead & Bergeman (2020)

Varella et al. (2020)

PC (10)

Chen Y et al. (2019b)

PC (7)

92,008

C/​R

PC (4)

Suh et al. (2019)

*Long et al. (2020b)

44,281

S

CS

*Sharif et al. (2019)

PC(2)

CS/​ PC(4)

Nie (2019)

PC (3–​12)

S

PC (2)

*Kim ES et al. (2019b)

*Spence et al. (2020)

R

CS

Bentley-​Edwards et al. (2020)

*Chen Y et al. (2020a)

R

CS

C

C

C

C

C

S

R

C

R

R

6,950

3,685

67,723

8,881

51,661

1,024

267

3,929

2,912

1,000

2,513

5,200

4,344

thousands

23,864

*Marshall (2019)

S R

PC (14)

11,457

PC (11)

R

N

*Chen Y & VanderWeele (2018)

CS

Godbolt et al. (2017)

M E T HOD

*Ahrenfeldt et al. (2018)

T Y PE

TOPIC /​I N V E S T IG ATOR S

Japan Large US cities

HIV+​US Veterans

Brazil

National US

National US

National US

Denmark

Indiana

National US

National US

Iran

National US

National US

National US

26 countries

Europe

National US

National US

L O C AT ION

Med outpatients

CDA, age 35–​74

Nurses

CDA

F, nurses

CDA

CDA, E (55 or older)

CDA (ave age 47)

CDA, E (age > 50)

CDA, ave age 41

Youth (age 18–​22)

CDA (age 50 or over)

CDA, B

CDA

Age 50 or older

Adol (ave age 15)

CDA, E (age > 50)

P OP U L AT ION

#1 ORA

#1 SR

NG

NG

NG

NG (divine)

#2 R-​motivated forgiveness

P

P unadj, NA adj

P (via neg affect)

NA

NA

NA

#1 ORA

MC

MC

MC

SC

MC

MC

MC

C ON T ROL S

None

None

None

MC

MC

MC

MC

SC

MC

MC

Buffers BMI-​ SC body image

P (? CS)

(P)

NG (males only)

NG

P (R educ only)

NA

NG (in Black F only)

F I N DI N G S

#1 ORA

#2 ORA, RC

#2 ORA, NORA

#9 RC

#1 Family religiousness

#1 ORA

#5 ORA, NORA, IR

#5 D, ORA, NORA, SR

#1 ORA

#2 R affil, ORA

#2 R affil, ORA

#3 ORA, NORA, R educ

#2 ORA, NORA

#1 ORA

R E L IG VA R I A BL E S

(8)

8

(8)

9

10

9

(8)

8

10

9

(8)

8

10

8

8

9

10

8

R AT I N G

R R

CS

CS

CS

Cochran & Beeghley (1991)

Goldscheider & Mosher (1991)

Seidman et al. (1992)

R

CS

PC (1)

PC(4)

CS

PC (1)

CS

CS

PC (1)

CS

*Nonnemaker et al. (2003)

Rostosky et al. (2003)

*Steinman & Zimmerman (2004)

Jones RK et al. (2005)

Lehrer et al. (2006)

Halpern et al. (2006)

Trinitapoli & Regnerus (2006)

Adamczyk & Felson (2006)

de Visser et al. (2007)

R

CS

CS

Atkins et al. (2001)

CS

Lammers et al. (2000)

Miller L & Gur (2002)

R

PC (5)

Paul et al. (2000a, b)

R

R

R

R

R

R

C

R

R

R

S

R

CS

PC (18)

*Resnick et al. (1997)

Thornton & Camburn (1989)

R

R

R

CS

PC (4)

Kandel D (1990)

R R

CS

CS

Brown S (1985)

Rosenbaum & Kandel (1990)

Beck et al. (1991)

R

CS

Miller PY & Simon (1974)

19,307

1,468

960

1,434

4,152

2,914

705

3,691

16,306

3,356

4,118

26,023

1,037

888

12,118

7,011

8,450

14,979

thousands

2,711

2,711

702

2,064

CDA, F

National US

National US National US Australia

Ad CDA (age 16–​59)

Malawi (Africa)

Age 18–​26 CDA, M

National US

National US

F (age 15–​44) HS

Midwest US

National US

HS, B

National US

Ad (age 15–​21)

National US

Ad (grades7–​12)

National US

Minnesota

Ad (grades 7–​12) Ad, F (age 12–​21)

New Zealand

Age 11–​16 CDA, married

Detroit

National US

National US

Ad (age 18)

Ad

CDA, F

National US

National US

CDA

National US

youth, age 14–​22

National US

young adults

National US

CDA, age 19–​20

Illinois

Ad, B, F

Ad, W

#2 D, ORA

#9 D, R of self & friends

#2 D, ORA

#1 ORA

#1 ORA

#2 D, ORA (age 14)

#1 ORA

#3 ORA, SR

#4 ORA, NORA

#7 D, ORA, NORA, SR

#1 ORA

#1 “religious feelings”

#3 ORA

#3 D, ORA, SR

#1 SR

#2 ORA, D

#4 ORA, D

#5 ORA, SR, RB, CM, D

#2 D, ORA

#2 ORA, D

#1 ORA

#1 ORA

#1 SR

Risky Sexual Activity (P means less high-​risk activity, less sexual activity outside of marriage, more negative attitudes toward)

Miscellaneous Health Behaviors (no chapter)

P

P

P

P

P (males)

P (incl more contracep)

P (in females)

P (coital debut)

P

P

P

P

P (males)

P

P

P

P (ORA)

P

P

P (ORA)

P

P

P

MC

MC

MC

MC

MC

MC

MC (?)

MC

MC

SC

MC

MC

MC

MC

MC

MC

SC

MC

MC

MC

MC

MC

SC –​sex, age

9

8

8

8

8

8

8

9

9

8

9

9

8

8

8

10

8

10

8

8

8

8

8

CS

CS

CS

CS

Stulhofer et al. (2011)

Edwards et al. (2011)

Ogland et al. (2011)

Adamczyk & Hayes (2012)

PC (1)

Hull et al. (2011)

CS

Haglund & Fehring (2010)

CS

CS

*Chamratrithirong et al. (2010)

*McFarland et al. (2011)

CS

Trinitapoli (2009)

CS

CS

Kabiru & Orpinus (2009)

CS

PC (3)

Burdette & Hill (2009)

Ahrold & Meston (2010)

PC (7)

*Uecker (2008)

Gyimah et al. (2010)

CS

*Sinha et al. (2007)

R

R

R

C

C

R

R

C

R

C

R

#2 ORA, SR

National US

418,140

2,364

973

1,355

369

791

3,848

1,415

3,168

#2 ORA, IR

National US Northeast US

CDA, unmarried, E (age 57–​85) Ad, age 14–​16 CS (ave age 19)

CDA from 31 countries

Ad (unmarried, age 15–​19)

Adol, F, Latinas, never married

Worldwide

#1 D

MC

Muslims/​Hindus 50

Prot Christians, ave age 23

CDA

Active duty military

CDA

Southwest US

National US

National US

Indonesia

National Poland

Europe

National US

Hong Kong

Province in China

National US

National US

Norway

CDA, age 55–​85 Cancer patients

National US

C, age 6–​11, Ad (12–​19)

National US Texas

HS CDA

#3 D, ORA, SR

P

#1 ORA

#1 ORA

#1 ORA

? Religiosity

#1 ORA

#3 ORA, NORA, R educ

P

NA

NA

P

NA (sleeping well)

P

NA (but P for buffering)

NG

#1 Δ in D to non-​believer #3 D, ORA, SR

P

P

P (through hope)

NG

NA

M

P

#1 “follower of a R”

#2 ORA, IR

#7 ORA, RSup, God ctrl

#1 “seeking God’s help”

#2 SR, ORA

#1 religious activities

#1 ORA

MC

MC

MC

MC

MC

MC

MC

MC

None

None

MC

MC

None

MC

MC

MC

9

8

10

8

8

10

9

10

8

(8)

9

8

(8)

(8)

8

8

T Y PE

M E T HOD N

P OP U L AT ION

CS

PC (1)

CS

PC (5)

CS

CS

Linardakis et al. (2015)

Cattelino et al. (2014)

*Hayward et al. (2016b)

Holt et al. (2017)

Shen (2019)

*Moons et al. (2019)

C

R

C

R

C

R

R

#2 SR

Multi-​national

CC

CT

PC (23)

CT

CT

CS

PC (10)

PC (31)

Friedlander et al. (1986)

Thoresen (1990)

Goldbourt et al. (1993)

Burell (1996)

Zamarra et al. (1996)

Gupta et al. (1997)

Eng et al. (2002)

Oman et al. (2002)

R

C

R

C

S

R

-​

-​

6,545

28,369

3,148

21

128

10,059

?

539

CDA

Health professionals, M

CDA

N. California

National US

Rural India

Buffalo, NY

Sweden

MP –​CABG vs. Cs MP with CAD

Israel

California

Israel

CDA, M

CDA

MP with 1st MI vs. Ctrls

#1 ORA

#1 ORA

#1 prayer & yoga

#1 Transcendental Med

#1 “reflect on spirit issues”

#3 religiosity

Spiritual intervention

#1 orthodox vs. secular Js

#1 ORA

#15 RB, R behaviors, RC

#1D (R vs. non-​religious)

#4 RC, RB, IR, NORA

#3 NORA, R educ, D

#6 ORA, NORA

R E L IG VA R I A BL E S

National US

National US

VI. PHYSICAL HEALTH

MP, congenital heart dz

CDA, E, age 49–​64

8,726/​ 4,392 4,028

CDA, B

National US

N. Italy

Ad (age 14–​16) CDA

Europe

Texas

CDA,E (age > 50)

CDA

565

3,010

908

16,557

1,369

L O C AT ION

Heart Disease (Chapter 20) (P means less heart disease; “>” indicates worse cardiac outcome than . . .)

CS

Hill TD et al. (2007)

General Health Behaviors (P means positive health behaviors or fewer negative ones)

TOPIC /​I N V E S T IG ATOR S

NA (CHD mortality)

NA (CVD mortality)

P

P

P

P (MI death)

P

P

P

P

(8)

MC

MC

9

9

9

-​ MC

9

10

(8)

8

8

8

8

8

9

8

8

R AT I N G

-​

MC

-​

MC

MC

MC

MC

MC

P NA

MC

MC

MC

C ON T ROL S

P

P (mult behav risk factors)

P

F I N DI N G S

R C

PC (18m)

PC (5)

CC

CS

PC (8)

PC (4)

PC (7)

CS

PC (9)

PC (18)

CS

PC (12)

CC

PC (23)

PC (13)

PC (2)

Blumenthal et al. (2007)

O’Reilly & Rosato (2008)

Burazeri et al. (2008)

Horne et al. (2008)-​study 1

Schnall et al. (2010)

Feinstein et al. (2010)

Salmoirago et al. (2013)

Banerjee et al. (2014)

Floud et al. (2016)

Li et al. (2016b)

*VanderWeele et al. (2017a)

Saeed et al. (2018)

Hemmati et al. (2019)

Eilat-​Adar & Goldbourt (2019)

Wen et al. (2019)

Abu et al. (2019b)

C

C

C

C

C

R

R

C

C

C

S

2,068

82,510

9,245

190

80,805

36,613

74,534

735,159

5,442

43,708

5,474

92,395

4,629

National US

CDA, F (age 50–​79)

MP, hospitalized ACS

CDA, underserved

CDA, M, middle age

Mass. & Georgia

Southeast US

Israel

Iran

National US

CDA, F, age 50–​79 CAD vs. 324 MP controls

National US

National US

United Kingdom

CDA, B

Nurses (Nurses Hlth Study)

CDA, F, ave age 60

Canada (national)

National US

CDA (age 45–​84)

CDA

National US

Utah

Albania

N Ireland

CDA, F (age 50–​79)

MP (coronary angio)

MP (acute coron syn) vs. ctrls

467/​737

S

CDA

932,634

R/​S

Multi-​site US

New Haven, CT

MP, post-​MI

MP (cardiac, s/​ p MI)

Saudi Arabia

MP (cardiac outpts)

503

62

86

C

C

PC (6m)

Martin & Levy (2006) (func recov)

C

Exp

Chamsi-​Pasha & Ahmed (2004)

#3 RC, NORA

#3 ORA, SR, RC

#1 religiosity

#97 Muslim R sc

#1 D

NG

NA

NG

Others > Mormons

P

NA

NA

P

P

Prot =​Cath =​ Jews

NG

P NA

P NG

P (explained by health behaviors)

#4 ORA, NORA, RC, SR

#1 ORA

#1 ORA

#1 ORA

#1 NORA

#7 ORA, NORA, Sp Exp

#3 D, ORA, RC

NA

M (P-​ ORA,NG-​ SR)

NA

Cath =​Prot =​other/​ none (M) Church of Ireland > Cath (F)

#1 Mormon vs. Other

#3 ORA,NORA

#1 D (v Cath)

#18 ORA, NORA, Sp

#3 D, ORA, SR

#1 Ramadan fast

MC

MC

MC

MC

MC

8

9

9

(8)

8

8

10

(age-​adjusted) MC None

9

8

9

9

9

8

8

8

(8)

(8)

(8)

SC (age, region) MC

MC

MC

MC

NONE

MC

MC

MC

None

MC

-​

CS

CS

PC (11)

PC (3-​12)

Abu et al. (2019c)

Alghalayini et al. (2019)

Ahrenfeldt et al. (2019)

*Chen Y et al. (2020a)

23,864 92,008

C/​R

80

2,067

N

R

C

C

M E T HOD

CDA

CDA (10 countries)

MP with heart failure

MP, hospitalized ACS

P OP U L AT ION

National US

Europe

Saudi Arabia

Mass. & Georgia

L O C AT ION

#1ORA

#3 ORA, NORA, R educ

#13 Muslim R scale

#3 RC, NORA

R E L IG VA R I A BL E S

Exp

CT

Exp

Exp

Exp

Masters et al. (2005)

Paul-​Labrador et al. (2006)

Masters & Knestel (2011)

Ayazi et al. (2018)

Masters et al. (2022)

C

C

C

—​

C

C

CS

CT

Exp

CT

Berntson et al. (2008)

Kurita et al. (2011)

Gao et al. (2019)

*Amjadian et al. (2020)

CT

*Paul-​Labrador et al. (2006)

21 60

—​

59

—​

229

—​

103

85

74

131

103

75

178

R

—​

Heart Rate Variability (P =​increased HRV, which is good)

Exp

Masters et al. (2004)

MP, CABG (heart surg)

Exper Buddhist meditate

NH with CVD

CDA, E, minorities

MP with stable CAD

Iran

Hong Kong

Japan

Chicago

S. California

New York

Durham, NC

CDA, B, age 23–​47 Christian CS

#14 IR, ER (Gorsuch)

Colorado/​Utah?

CDA (mean age 50)

Islamic R intervention

#1 Buddhist chanting

Chaplain sermon intervention

#12 ORA, RWB

Transcendental Med

Devotional prayer, IR

#3 ORA, NORA,I R

Transcendental Med

#20 IR, ER (Allport)

#20 IR, ER (Allport)

S. California

Utah

CDA (age 60–​80) MP with stable CAD

Utah

CDA (18–​24, 60–​80)

Cardiovascular Reactivity (includes brachial artery vasoreactivity [BAR]; “>” indicates greater cardiovascular reactivity)

T Y PE

TOPIC /​I N V E S T IG ATOR S

C

P

P

P

(P)

P

M (anger recall)

ER/​IR> Pro-​religious

NA (with BAR)

ER > IR in elderly

ER > IR in elderly

NA

NG (praying)

NA

M (activation)

F I N DI N G S

—​

—​

—​

MC

(8)

(8)

8

8

8

8

-​

—​

8

8

8

8

8

10

9

(8)

(8)

R AT I N G

—​

—​

—​

SC

SC

MC

MC

MC

MC

C ON T ROL S

CS

Al-​Jobouri et al. (2019)

C

5,474

S

R 186

2,912

772

23

—​ S

8,180

45

R

C

PC (?)

Bagheri et al. (2019)

C

S ?

177

550

78

—​ S

142

232

C

S

CDA, age 50 or over

MP (CABG surgery)

MP (cardiac surgery)

MP (cardiac surgery)

MP (cardiac surgery)

MP (cardiac surgery)

MP (cardiac surgery)

MP, suspected CHD

CDA, age 50 or over

Iran

Michigan

New Jersey

Omaha, NE

New Jersey

New Hampshire

Iraq

National US

Mexico

Thailand

Australia

CDA, F, age 31–​36 MP, diabetes

Thailand

Multi-​site US

CDA, E, mild/​mod depression

CDA (age 45–​84)

#47 Hall & Edwards scale

#16 Misc R

#13 NORA, RB

Prayer during surg (on CD)

#7 ORA, NORA, RB

#3 ORA, SR, RC

#2 NORA

#1 ORA

#1 ORA

Buddhist walk meditation

#1 Prayer/​Sp healing

Buddhist walk meditation

#7 ORA, NORA, Sp Exp

CS

PC (20)

CT

CS

Stavig et al. (1984)

Timio et al. (1988)

*Beutler et al. (1988)

Livingston et al. (1991)

CT

Patel & North (1975)

R

C

S

R

C

1420

120 (40 ea),

144

1,757

34

California

CDA, B

CDA

Maryland

Netherlands

Italy

CDA, Asians/​Pc Cath nuns vs. CDA, F

England

MP

#1 church affiliation

laying hands, thought projection

#1 Ca nuns vs. other

#1 (affiliation v None)

#1 Yoga

Hypertension/​Blood Pressure (Chapter 21) (HTN; P indicates lower BP or less HTN; “>” indicates higher BP or increased HTN)

PC (8d)

PC (9d)

CT

*Ikedo et al. (2007)

*Contrada et al. (2008)

PC (7d)

Contrada et al. (2004)

Ai et al. (2009a)

PC (6m)

Oxman et al. (1995)

Cardiac Surgery (including survival and surgical complications)

PC (9)

PC (4)

CT

*Gainey et al. (2016)

*Hill TD et al. (2017b)

CS

*Rao et al. (2016)

*Suh et al. (2019)

CS

CT

*Feinstein et al. (2010)

Prakhinkit et al. (2014)

Miscellaneous Indicators of Cardiovascular Disease

MC MC

P

NA

P

P

P

P

P

NA

NA

P (RB)

P (RC)

8

9

—​ MC

10

8

8

(8)

(8)

8

8

8

9

MC

MC

—​

?

MC

MC

—​

MC

MC

(8)

8

8

8

8

MC —​

8

8

—​

MC

P (pericardial MC fat volume)

P (pulse rate)

P (pulse rate)

P (vascular activity)

NG (palpita­ tions)

P

NA

R R C R

CS

PC (3–​6)

PC (32)

Koenig et al. (1998e)

Timio et al. (2001)

PC (3)

CS

Fitchett & Powell (2009)

*Feinstein et al. (2010)

CS

CS

Buck et al. (2009)

Bell et al. (2012)

S

CS

Gorman & Sivaganesan (2007)

CS

CS

Maselko et al. (2007)

CS

PC (1)

*Yeager et al. (2006)

*Al-​Kandari (2011)

CT

Sorensen et al. (2011)

C

CS

*Paul-​Labrador et al. (2006)

R

R

R

R

12,488

36,000

1,472

5,474

1,439

2,860

29,816

853

S/​C R

944

103

14,475

R

—​

R

150

Gillum & Ingram (2006)

100

—​

CT

Schneider et al. (2005)

—​

CT

Barnes et al. (2004)

1,723 679

R

PC (3)

CS

Krause et al. (2002a)

*Van Olphen et al. (2003)

144 /​138

4,000

5,145

National US

Oakland, CA

Augusta, GA

Detroit, MI

Japan

Italy

North Carolina

Rhode Island

National US Multi-​site US

CDA, F, age 42–​52 CDA (age 45–​84)

Norway National US

CDA CDA (NHANES-​III)

Kuwait

Chicago, IL

CDA (age 43, 2/​3 minorities)

NH (ave age 77)

National US

Multi-​site US

Taiwan

CDA

CDA, E (McArthur aging)

CDA, E (92% non-​Christian)

MP with stable CAD S. California

CDA (NHANES-​III)

CDA,B

Ad, B with high BP

CDA, F, B

CDA, E

Nuns vs. F in community

CDA, E

CDA

Norfolk, VA Oakland, CA

CT (analysis by gender of Schneider et al. (1995) study above)

CDA, B, M CDA, B, E

Lapane et al. (1997)

537 111

Alexander et al. (1996)

C

S

L O C AT ION

CS

P OP U L AT ION

CT

N

*Brown D & Gary (1994)

M E T HOD

Schneider et al. (1995)

T Y PE

TOPIC /​I N V E S T IG ATOR S

#1 ORA

#1 ORA

#1 SR

#7 ORA, NORA, Sp Exp

#8 Daily Sp Experiences

#4 ORA, NORA, Sp

#1 ORA

#1 ORA (for HTN anal)

#12 D, ORA, RB, R prac

Transcendental Med

#1 ORA

Transcend Med x 12 mo

Transcend Med x 4 mo

#5 ORA, NORA, SR, CM

#8 NORA, RB, RC

Nuns v. F in community

#4 D, ORA, NORA

#1 church membership

#1 Transcendental Med

#1 Transcendental Med

#12 relig scale, ORA,D

R E L IG VA R I A BL E S

P

P

P

NA

NG

NG (Sp, pray)

NA (? mediated)

NG (men)

(P)

P

P

P

P

NG (CM)

M

P

P

P

P

P

NA

F I N DI N G S

10

MC

MC

None

MC

MC

MC

MC

MC

MC

—​

MC

—​

—​

MC

MC

NONE

MC

9

9

(8)

8

9

8

8

8

8

8

8

9

8

8

9

8

9

8

—​ MC

10

8

R AT I N G

—​

MC

C ON T ROL S

CS

CS

CT

Rco (1-​5 y)

CS

PC (4)

CT

PC (9)

CS

CS

CS

Exp

CC

*Banerjee et al. (2014)

Hill TD et al. (2014)

*Beiranvand et al. (2014)

*Kobayashi et al. (2015)

Charlemagne-​Badal & Lee (2016a)

Charlemagne-​Badal & Lee (2016b)

*Gainey et al. (2016)

Hill TD et al. (2017b)

Krause et al. (2017)

Bruce et al. (2017b)

Liu et al. (2019)

Ayazi et al. (2018)

Meng et al. (2018)

C

C

C

CS

R

1,384 vs. 798 controls

74

594

212

1,919

772

23

—​ S

5,720

9,581

C

C

29,215

S

p

Buddh monks/​ nuns

CDA, B, M, age 23–​47

Buddhist monks

Ad (ave age 15), B

CDA

CDA, age 50 or over

MP, diabetes

CDA (7th-​Day Adventists)

CDA (7th-​Day Adventists)

MP, outpts

Muslim women C-​section

CDA, E

1,450–​ 2,934 160

CDA

CDA, Buddhist, E

CDA (ave age 67)

CDA (age 18–​30)

5,442

160

195

2,433

—​

R

R

C

C

C

GMC =​God-​mediated control (e.g., “I rely on God to help me control my life”).

CS

CS

Anyfantakis et al. (2013)

Stewart et al. (2014)

PC (18)

Feinstein et al. (2012)

#1 D (Buddhist vs. other)

#5 DUREL

North Carolina Tibet

#1 hours spent R activities

#6 DSES

#3 ORA, NORA, GMC

#1 ORA

Buddhist walking meditation

#13 ORA, RSup

#4 ORA, IR

#1 SR

Recited prayer meditation

#1 ORA

#2 ORA, D

#5 ORA, NORA (Buddhist)

#6 ORA, NORA, SR

#1 R activities

Tibet

Mississippi

National US

Mexico

Thailand

North America

North America

Japan

Iran

National US

Canada

Thailand (rural)

Greece

Multi-​site US

p

NA

MC MC

P

P (interaction)

P

MC

SC

MC

MC

MC

P (modera­tion) P (SBP in F only)

MC

—​

MC

MC

MC

—​

MC

MC

None

P (DBP only)

P

P (RSup; mediated by BMI)

P (IR)

NA

NA

P (diastolic)

P

P

P

NG (uncontrolled)

8

(8)

8

(8)

8

9

8

9

8

9

8

8

8

(8)

(8)

9

CT

CS/​Exp

CS

CS

CS

Schnell et al. (2020)

Lamb et al. (2020)

Robbins et al. (2021)

Fiório et al. (2020)

CS

Yunanto et al. (2020)

*Sanaeinasab et al. (2021)

CS

*Varella et al. (2020)

CS

CS

Al-​Jobouri et al. (2019)

*McIntosh et al. (2020)

CS

Desormais et al. (2019)

PC (3–​12)

PC (11)

*Ahrenfeldt et al. (2019)

*Chen Y et al. (2020a)

PC (4)

*Suh et al. (2019)

PC(12)

CT

Asmand et al. (2019)

CS

CS

Lamb et al. (2018)

*Spence et al. (2020)

PC (8)

Cozier et al. (2018)

Teteh et al. (2020)

T Y PE

TOPIC /​I N V E S T IG ATOR S

34

R

R

R

3,184

1,932

4,835

50

84

—​ —​

2,971

92,008

C/​R R

9,308

44,281

46

8,881

186

1,777

23,864

C

S

C

C

C

S

R

2,912

—​ R

4,874

43,179

N

R

R

M E T HOD

CDA

Young adults, B

Young adults (ave age 29)

CS

F, pregnant

CDA

Sao Paulo, Brazil

National US

National US

Austria

Iran

National US

National US

National US

CDA

National US

CDA, Seventh-​Day Adv

Indonesia

Brazil

Iraq

Benin, W. Africa

Europe

National US

Iran

National US

National US

L O C AT ION

F, nurses

NHP

CDA

MP suspected CAD

CDA

CDA (10 countries)

CDA, E (age > 50)

Women with HTN

Young CDA (ave age 29)

CDA, B, age 21–​69

P OP U L AT ION M

F I N DI N G S

NG (lowest in -​R/​-​S)

#1 R/​S, -​R/​S, R/​-​S, -​R/​-​S

#1 Have a religion

#3 D, ORA, RC

#5 OR, SR, NORA ,RC

#15 RC (Huber)

NG

M in women

C, M

P

P

NA (indirect?)

P (PRC)

P

P (systolic)

#1 ORA

#1 Sp intervent (Islamic)

8

MC

MC

MC

None

SC

—​

None

MC

MC

MC

MC

8

8

(8)

(8)

8

(8)

10

8

10

(8)

(8)

8

9

9

(8)

8

10

R AT I N G

None

MC

MC

MC

—​

MC

MC

C ON T ROL S

(higher educ-​NG)

M (lower educ -​P)

P

Animists > Christians

NA

NA

NA

M (P in heterosex, NG in sex minor)

#10 RC (PRC & NRC)

#2 ORA, RC

#16 DSES

#1ORA

#2 NORA

#1 D

#3 ORA, NORA, R educ

#1 ORA

Qur’anic teachings

#2 ORA

#4 ORA, NORA, RC, SR

R E L IG VA R I A BL E S

CS

CS

Abel & Greer (2017)

Fikriana et al. (2019)

R

C

C

225

80

400 North Carolina Indonesia

MP w grade 2-​3 hypertens

Ghana

CDA, B, F w hypertension

Outpts with hypertension

#2-​4 RC (brief COPE)

#9 ORA, NORA, SR

#12 ORA, NORA, Sp

CS

PC (3)

PC (5)

CS

PC (8)

PC (1–​5)

PC (18)

CS

PC (18)

PC (12)

*O’Reilly & Rosato (2008)

*Feinstein et al. (2010)

Schnall et al. (2010)

Morgenstern et al. (2011)

*Feinstein et al. (2012)

*Anyfantakis et al. (2013)

*Li S et al. (2016b)

Saeed et al. (2018)

CT

Castillo-​Richmond et al. (2000)

*Obisesan et al. (2006)

RCo

Doody et al. (2000)

Berges et al. (2007)

PC (6)

Colantonio et al. (1992)

C

C

C

80,805

74,534

195

2,433

669

S C

92,395

C

5,474

932,634

R/​S C

3,050

14,192

60

1,103

2812

R

R

—​

S

R

National US

Multi-​site US

Multi-​site US

CDA, F (50 or over)

Nurses (Nurses Hlth Study)

National US

National US

Greece

CDA (age 18–​30) CDA (ave age 67)

Texas

MP with new stroke

National US

CDA (age 45–​84) CDA, F (50 or over)

N Ireland

CDA

Southwest US

CDA (NHANES-​III) CDA, E (65 or over)

Iowa

National US

New Haven, CT

CDA w HTN, B

Catholic nuns vs. radiology techs vs. gen pop

CDA, E

#1 D (Prot v Cath vs Jew)

#1 ORA

#6 ORA, NORA, SR

#1 R activities

#2 SR (68% w 8 on 2–​8 sc)

#3 R affil, ORA, RC

#7 ORA,NORA,Sp Exp

#1 D (any D vs. none/​oth

#1 ORA

#1 ORA

Transcendental med

Nuns v. techs v. gen pop

#3 ORA, SR, RC

Cerebrovascular Disease (Chapter 22) (cerebrovascular disease [CBVD], stroke, carotid artery intima-​media thickness [CA-​IMT])

CS

Kretchy et al. (2013)

Hypertension Medication Adherence

MC

MC

MC

SC

None

None MC

MC

None

SC

J less than Ca/​P

10

9

MC

(8)

9

8

8

8

8

8

8

8

(8)

9

(8)

(8)

(8)

Age adjusted MC MC

None P (stroke) NA (stroke) P (CBVD mortality)

MC P (CA-​IMT)

MC

None

P (CA-​IMT)

NA

NA

NG (CA-​IMT) MC

NA

P (disability)

P (in B, F)

P (CA-​IMT)

NA (techs) P (gen pop)

P NA

P

(P) (ORA)

NG (Sp)

PC (11)

PC (3-​12)

*Ahrenfeldt et al. (2019)

*Chen Y et al. (2020a)

C/​R

R

M E T HOD

92,008

23,864

N

CDA

CDA (10 countries)

P OP U L AT ION

National US

Europe

L O C AT ION

#1 ORA

#3 ORA, NORA, R educ

R E L IG VA R I A BL E S

CS

Sowa et al. (2016)

C

CS

PC (1)

RS

Coin et al. (2010)

Inzelberg et al. (2013)

CS

C C

CS

Zhang (2010)

Fung & Lamb (2013)

R

PC (3)

*Al Zaben et al. (2015)

Editorial: discusses results for R involve & healthy cognitive aging, explanations for findings, and future directions for research

Corsentino et al. (2009)

R

C

R

57,391

310

380

778

64

8,703

2,938

1,890

CDA, E, over age 50

MP, renal dialysis, Muslim

CDE, E (ave age 70)

Europe

Saudi Arabia

Hong Kong

CDE, E (over age 65) Israel

Italy

China

CDE, E, age 80–​105 CDE, E

Southeast US

CDA, E

Israel

CDA, M (age 40–​65)

#1 R organizational activ

#13 ORA, NORA, IR

#6 ORA, NORA

#2 Prayer during midlife

#4 ORA, NORA

#1 R participation

#1 ORA

#2 R educ, R orthodoxy

#1 prayer intervention

P

P

P

P (women)

P

P

P (esp F, dep)

NG

P (quality of life)

SC

MC

SC

SC

SC

MC

MC

MC

?

MC

MC

MC

Hill TD (2008)

S

New Mexico

Mod-​late stage dementia

P (esp if depressed)

P

P

PC (36)

?

#1 ORA

#7 SR, ORA, NORA, SR

Beeri et al. (2008)

C

Southwest US

CDA, E, Mex-​Am

Toronto, CAN

Mild-​Mod Alzheim dis

Exp

2,759

Southwest US

CDA, E (Mex-​Am)

Smith LG (2008)

R

70

#1 ORA

MC

PC (11)

C

3,050

M (P-​ORA)

MC

Reyes-​Ortiz et al. (2008)

R

#12 D, ORA, RB, R prac

Taiwan

P (ORA)

PC (7)

CDA, E (92% non-​Christian)

#3 ORA, SR, RC

New Haven, CT

PC (1)

2,930

CDA ,E

MC

MC

C ON T ROL S

Hill TD et al. (2006b)

PC (4)

*Yeager et al. (2006)

2,812

NA (indirect?)

P (CS) NA (PC)

F I N DI N G S

Kaufman et al. (2007)

R

PC (3–​6)

Van Ness & Kasl (2003a)

R

Alzheimer’s Disease and Other Dementias (Chapter 23) (including level of cognitive function in general populations)

T Y PE

TOPIC /​I N V E S T IG ATOR S

8

(8)

(8)

(8)

8

8

8

8

?

8

8

9

8

8

10

9

R AT I N G

CS

CS

PC(12)

CT

Jung J et al. (2019)

Kim DH et al. (2019) (same as Jung et al. ?)

Lekhak et al. (2020)

Marciniak et al. (2020)

CS

CS/​PC (6)

Kraal et al. (2019)

te Nijenhuis et al. (2021)

CS

Drozdowska et al. (2019)

PC (3)

CS

*Foong et al. (2018)

Mao et al. (2020)

CS

*Drewelies et al. (2018)

RS

CS

Sun et al. (2018)

CS

CS

Su et al. (2018)

Hill TD et al. (2020c)

R

P (8)

Hwang et al. (2018)

Tedrus et al. (2020)

C

CS

Despoina et al. (2018)

C

R

C

1,967

10,741

169

516

20

-​ S

1,135

325

325

16,069

8,776

2,322

1,614

1,347

557

5,948

404

2,410

1,170

R

C

C

R

C

S

C

R

C

C

CS

*Wang L et al. (2017) (apo ε4)

R

PC (3.5)

*Cohen-​Mansfield et al. (2016)

China Netherlands

CDA (age > 55), Muslim CDA, E (age 55–​65)

CDA, E

CDA, E, healthy

CDA, E (age 80 or older)

CDA with epilepsy

South Korea

China

Brazil

National US

Czech Republic

National US

CDA, E (age > 50) CDA with MCI (age 55+​)

South Korea

South Korea

National US

United Kingdom

MP w Alzheimer’s disease

MP w Alzheimer’s disease

CDA, E (age > 51)

CDA stroke survivors

Malaysia

China

CDA, E (age > 60 years)

South Korea

CDA, E (age > 60)

Greece

CDA (age > 45)

China

CDA, E (age 55–​90)

Israel

CDA (age > 55)

CDA, E (over age 75)

#1 R affil vs. none

#1 ORA

#10 IR

#5 ORA, Raffil

Buddhist Mindfulness Med

#2 NORA

#5 DUREL

#5 DUREL

#6 ORA, NORA, RB

#1 R group participation

#6 IR

#1 SR

#5 DUREL

#1 R activity

#1 ORA

#15 (SBI-​15R)

#5 DUREL

#2 R identity, Δ in R

NA (IQ score)

NA

P (verbal fluency)

M

P

P

P

P

M (CS) NA (PC)

NG (reaction time)

P

NA

P

P

NA

NG

P (buffering)

(P) (decrease R)

None

MC

None

MC

—​

MC

MC

MC

MC

MC

MC

None

MC

MC

MC

SC (age)

MC

SC

(8)

9

(8)

8

(8)

9

(8)

(8)

8

8

8

(8)

(8)

(8)

9

(8)

8

(8)

CS

Wallack et al. (2016)

PC

Otaiku (2022)

R

C

S

Q

S

M E T HOD

CS

CT

Exp

PC (4)

PC (10)

CS

Wuerfel et al. (2004)

Granqvist et al. (2005)

Grant et al. (2010)

Owen et al. (2011) (MRI)

Tenke et al. (2013)

Miller L et al. (2014)

35

—​

C

C

CDA, hi & low risk for MDD

E, 57% with MDD

Zen meditators vs. ctrls

CS

Refractory partial seizures

New York City

New York City

Southeast US

Montreal, CAN

Sweden

United Kingdom

England & U.S.

Boston, MA

CDA

22 US states

Mid-​stage PD vs. 75 controls

Canada

National US

L O C AT ION

Deaths due to PD

E with MS

CDA, Mormon

P OP U L AT ION

103 offspring of MDD/​ non-​MDD

52

268

89

—​

C

33

9,796

71

33,678

683

60,871

N

C

Brain Structure and Nervous System Functions

RS (7)

CC

Park RM et al. (2005)

Butler et al. (2011)

Parkinson’s Disease (PD)

PC (6)

T Y PE

Hawkes et al. (2007)

Multiple Sclerosis

Other Neurological Disorders

TOPIC /​I N V E S T IG ATOR S

C ON T ROL S

58% (CI 41%–​71%) lower in Mormons

F I N DI N G S

#2 ORA, SR

#1 SR

Life change R exp

Zen meditation

Transcr mag stim (TMS) vs. sham

MC

NG (hippo­ campal vol)

P (cortical brain thickness)

SC

P (EEG alpha None rhythm)

—​

—​

None

MC

MC

MC

P (cortical brain thickness)

NA (TMS =​ sham)

R assoc with smaller R hippocampal vol

P (R not important, OR=​9.99, 95% CI=​ 3.28-​30.4)

#4 D, SR/​SSp, ORA, NORA

#5 R convictions

PD patients lower on R/​S

NG (both)

#27 BMMRS

#2 Clergy, R workers

7 themes related to “healthy aging with MS”; one was R (6%)

#1 D (Mormon v other)

R E L IG VA R I A BL E S

10

8

8

8

9

(8)

10

(8)

8

(8)

8

R AT I N G

CS

PC (20)

CS

CS

CS

Hougaard et al. (2015)

Tenke et al. (2017)

Liu J et al. (2017)

Xu J et al. (2018)

Pozueta et al. (2019)

S

C

C

C

C

S

CS

Kim JH et al. (2015)

R

C

C

C

229

16

23

15

87

24

106

73

10/​10

CDA, E, minorities

CDA

PP with MDD

CDA

CDA with different dementias

Chicago

South Korea

Finland

Sweden

Spain

New Haven, CT

PC (6)

PC (1)

CT

Lutgendorf et al. (2004)

*Yeager et al. (2006)

McCain et al. (2008)

CS,PC

CT

Koenig et al. (1997b)

Jones BM (2001)

252

—​

557 944

R/​S R

19

1,718

—​

R

MP (HIV)

CDA, E (92% non-​Christian)

CDA, E

CDA, healthy

CDA,E

#12 ORA, RWB

#13 Spiritual acceptance

#13 Spiritual acceptance

#13 Spiritual acceptance

#12 D, ORA, RB, R prac Spiritual growth group

#1 ORA

Qigong intervention

#1 ORA

(8)

NA with 5-​HT1A receptors

NA

NA

P

NG

P

P

—​

MC

MC

—​

MC

MC

9

8

8

(8)

8

8

Related to serotonin transporter (8) availability in brainstem raphe subnuclei by PET-​MRI

(8)

(8)

(8)

(8)

8

(8)

(8)

Lower 5-​HT1A receptor binding

NA with FTD or AD

#1 Hyper-​relig

Taiwan Virginia

None

M (pial surface area, cortical thickness)

P (post EEG alpha rhythm)

C (examines diffusion tensor imaging)

Iowa

Hong Kong

North Carolina

MC

#12 Quest Scale

#1 SR

Offspring of MDD/​ New York City non-​MDD Healthy volunteers

NG (abnormal EEG activ)

fMRI study of “Christmas spirit” in the brain (cortical areas)

#6 SR, IR, NORA

#2 D, SR

Denmark

Sao Paulo, Brazil

Offspring of MDD/​ New York City non-​MDD

CDA, healthy

196 w epilepsy vs. 66 ctrls

Interleukin-​6 (IL-​6) (pro-​inflammatory cytokine; higher in stress, depression, impaired immunity; P indicates reduced levels)

Immune Function (Chapter 24)

*Berntson et al. (2008)

CS

CS

Karlsson et al. (2011)

Autonomic Nervous System Activity

Exp

Borg et al. (2003)

Brain Neurotransmitters (serotonin [5-​HT1A], dopamine)

CS

Tedrus et al. (2014)

CS

CT

CT

CS

CT

Ai et al. (2009b)

Pace et al. (2009)

*Kurita et al. (2011)

Bellinger et al. (2014)

Berk et al. (2015)

132 132

59

—​

—​

61

—​

C

235

8,450

66

N

S

R

—​

M E T HOD

CS

CT

*Bellinger et al. (2014)

*Berk et al. (2015)

132 132

—​

195

C

C

MP, depressed

MP, depressed

CDA, E (ave age 67)

MP, depressed

MP, depressed

NH with CVD

CS (ave age 18.5)

MP (cardiac surgery)

CDA, age 40 or older

MP (breast CA)

P OP U L AT ION

NC and Calif

NC and Calif

Greece

NC and Calif

NC and Calif

Japan

Atlanta, GA

Michigan

National US

Chicago

L O C AT ION

Conventional vs. RCBT

#29 ORA, NORA, IR

#6 (strength of R/​S belief)

Conventional vs. RCBT

#29 ORA, NORA, IR

Chaplain sermon intervention

Buddhist compassion med

#14 PRC, NRC

#1 ORA

Buddhist mindful med

R E L IG VA R I A BL E S

NA

(NG)

NA

NA

NA

P (IL-​10/​IL-​ 6 ratio)

P (freq of prac)

NA (except NRC)

(P) (p =​0.057)

P

F I N DI N G S

CT

PC, part of CT

*Berk et al. (2015)

*Berk et al. (2015)

132 132 132

C —​ —​

66

252

—​ —​

19

—​

MP, depressed

MP, depressed

MP, depressed

MP (breast CA)

MP (HIV), 40% F

CDA, healthy

NC and Calif

NC and Calif

NC and Calif

Chicago

Virginia

Hong Kong

#29 RCm

Conventional vs. RCBT

#29 ORA, NORA, IR

Buddhist mindful med

Spiritual growth group

Qigong intervention

CT

CS

*McCain et al. (2008)

*Bellinger et al. (2014)

C

—​ 132

252

MP, depressed

MP (HIV)

NC and Calif

Virginia

#29 ORA,NORA,IR

Spiritual growth group

Interleukin 12-​p70 (IL-​12-​p70), TNF-​α, IL-​2 (proinflammatory cytokines) (P indicates lower levels; NG indicates higher levels)

CT

CS

*Witek-​Janusek et al. (2008)

*Bellinger et al. (2014)

CT

CT

*Jones BM (2001)

*McCain et al. (2008)

NA

NA

Increased

NA

Increased

Increased

Increased

Increased

Interferon Gamma (IFN-​γ) (pro-​inflammatory cytokine with with anti-​inflammatory properties as well, known to be increased or decreased in depression)

CS

*Anyfantakis et al. (2013)

Interleukin 1β (pro-​inflammatory cytokine; P indicates reduced levels)

CT

CS

Witek-​Janusek et al. (2008)

Gillum et al. (2008a)

T Y PE

TOPIC /​I N V E S T IG ATOR S

MC

—​

—​

—​

MC

—​

—​

—​

—​

MC

None

—​

MC

—​

—​

MC

None

—​

C ON T ROL S

(8)

9

8

8

(8)

(8)

9

(8)

8

(8)

(8)

8

(8)

(8)

(8)

(8)

(8)

(8)

R AT I N G

132 132

—​ —​

MP, depressed

MP, depressed NC and Calif

NC and Calif #29 RCm

Conventional vs. RCBT

CT

*Berk et al. (2015)

132

—​

Exp

CS

Paiva et al. (2014)

R

CS

PC (5)

*Hill TD et al. (2014)

CS

Holt-​Lunstad et al. (2011)

Ferraro & Kim (2014)

CS

CS

Nelson B et al. (2009)

C

Yilmaz et al. (2008)

S

R

C

C

PC/​CC

CC

*Aksungar et al. (2007)

C

Exp/​PC

*Sivasankaran et al. (2006)

R R

CS

CS

King DE et al. (2002)

R

—​

Ford ES et al. (2006)

CS

King DE et al. (2001)

C-​reactive Protein (P indicates lower levels)

Mehr et al. (2020a)

221

1,124

1,939

100

1,023

46/​40

40/​28

33

14,818

556

10,059

45

132

C

66

252

—​ —​

19

—​

Miscellaneous Cytokines (IL-​1b, IL-​6, IL-​8, TNF alpha)

CT

CS

Witek-​Janusek et al. (2008)

*Bellinger et al. (2014)

CT

CT

*Jones BM (2001

*McCain et al. (2008)

NC and Calif

NC and Calif

Chicago

Virginia

Hong Kong

National US National US Brazil

CDA, E CDA, E (age 57–​85) MP, end-​stage cancer

Utah

S. California

CDA (age 18–​89) CDA, married, healthy

Turkey

Turkey

CDA, 46 pray v 40 ctrls

40 fasting, 28 ctrls

Connecticut

National US

CDA w & wo CAD

National US

CDA (NHANES-​III)

National US

CDA (diabetics)

CDA (NHANES-​III)

Stage 1-​2 breast CA Iran

MP, depressed

MP, depressed

MP (breast CA)

MP (HIV)

CDA, healthy

#15 R practices scale

#3 ORA, D, clergy confidant

#1 ORA

#12 FACIT-​SP©

#1 ORA

#1 prayer (Muslim)

#1 Ramadan fast

Yoga & meditation

#1 ORA

#1 ORA

#1 ORA

Religious intervention

Conventional vs. RCBT

#29 ORA, NORA, IR

Buddhist mindful med

Spiritual growth group

Qigong intervention

Interleukin 4 and Interleukin 10 (IL-​4 and IL-​10) (anti-​inflammatory cytokines) (P indicates increase in levels or higher levels)

CT

PC, part of CT

*Berk et al. (2015)

*Berk et al. (2015)

P

P (ORA) in B

P

P

P

NA

P

NA

(P? mediated)

P

P (via smoking)

Increased

NG

M

NG

NA

NG (IL-​10)

NG

NA

None

MC

MC

MC

SC

None

None

None

MC

MC

MC

—​

—​

MC

—​

—​

—​

—​

—​

(8)

9

8

(8)

(8)

(8)

(8)

(8)

8

8

8

(8)

8

(8)

(8)

9

(8)

8

8

—​ R

C

R 118

4,734

2,912

643

772

1,589

132

132

N

AA, healthy, ave age 32

CDA, E (age > 50)

CDA, E (age > 50)

CDA, E, stressed

CDA, age 50 or over

CDA

MP, depressed

MP, depressed

P OP U L AT ION

Detroit, MI

National US

National US

National US

Mexico

National US

NC and Calif

NC and Calif

L O C AT ION

#2 SR, SSp

#6 ORA, NORA, IR

#1 ORA

#4 ORA, NORA, R meaning/​hope

#1 ORA

#1 praying for others

Conventional vs. RCBT

#29 ORA, NORA, IR

R E L IG VA R I A BL E S

R

PC (4)

CS

*Suh et al. (2019) (Cystatin-​C)

Simons et al. (2019) (gene exp)

413

2,912

1,423

S C

CS

CS

CS

PC (4)

PC (4)

Meredith et al. (2001)

Chang BL et al. (2003)

Messina et al. (2003)

Ironson et al. (2006a)

Ironson et al. (2006b)

C

C

C

C

C

CS

CS

Woods et al. (1999)

Sephton et al. (2001)

100

100

40

182

202

112

106

CD-​4 Cells (reduced in HIV+​, AIDS, and some cancers; P =​higher count)

C

R

CS

Hybels et al. (2014) (D-​dim, VCAM)

MP (HIV)

MP (HIV)

MP (misc cancer)

MP (HIV)

MP (HIV)

MP (metas breast CA)

HIV+​gay M

CDA, B (ave age 29)

CDA, E (age > 50)

CDA, E (age > 65)

Miami, FL

Miami, FL

Italy

Los Angeles

St. Louis

N. California

P (exc NRC) P

#2 ORA, R/​S change

P

#1 Rorschach sex/​ sp exp #12 View of God

NA

MC

MC

NONE

NONE

None

SC NA

SC P (CD4/​CD3)

MC

MC

None

None

MC

P

P

P

P

P (hi racism, centrality)

P (IR, moderator)

MC

MC

P (ORA) (P)

MC

MC

—​

MC

C ON T ROL S

P

P (buffers)

NA

NA

F I N DI N G S

#3 ORA,NORA

#1 Prayer (66% very imp)

#2 ORA, SR

#4 ORA, NORA

#5 ORA, NORA, SR

Florida

#1 ORA

Georgia/​Iowa

#1 ORA

National US

North Carolina

Other Indicators of Inflammation (D-​dimer, s-​VCAM, Cystatin-​C, inflammatory gene expression; P indicates lower levels)

CS

Drolet & Lucas (2020)

R

PC (4)

CS

*Suh et al. (2019)

*Tavares et al. (2019)

S

CS

Ironson et al. (2018)

S

CS

PC (9)

*Krause et al. (2016a)

*Hill TD et al. (2017b)

C

CS

CT

*Bellinger et al. (2014)

*Berk et al. (2015)

M E T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

8

8

(8)

(8)

(8)

8

(8)

(8)

9

(8)

(8)

8

9

8

8

8

8

(8)

R AT I N G

PC (4)

*Kremer et al. (2015)

C

C

C

129

177

101

429

Miami, FL

MP, HIV/​AIDS

CT

CT

*McCain et al. (2008)

*Witek-​Janusek et al. (2008)

66

252

—​ —​

112

C

MP (breast CA)

MP (HIV)

MP (metas breast CA)

S

221

50

30

112

CT

CC

PC (1m)

Li Q et al. (2005)

Latifynia et al. (2007)

Neutrophil/​Leukocyte Functioning (P =​higher)

*McCain et al. (2008)

C

C

—​

24

12

252

Lymphocyte Proliferation and Function (P =​higher, which is better)

CS

*Paiva et al. (2014)

S

S

CS

PC (3)

Lissoni et al. (2008a)

C

CS

Lissoni et al. (2008b)

*Sephton et al. (2001)

CDA, M (Muslim)

6 Qigong, 6 controls

MP (HIV)

MP (metas CA)

Lung CA

Lung CA

MP (metas breast CA)

Total Lymphocytes (lymphocyte count, lymphocyte/​WBC ratio) (P indicates more lymphocytes)

CS

*Sephton et al. (2001)

Iran

Texas

Virginia

Brazil

Italy

Italy

N. California

Chicago

Virginia

N. California

Miami, FL

Multi-​site US

MP (HIV)

Georgia

MP (HIV/​AIDS)

Virginia

MP, F (HIV), 90% B

MP (HIV)

Multi-​site US

S. California

MP (HIV/​AIDS) MP (HIV/​AIDS)

South India

MP (HIV)

Natural Killer Cells (numbers or function) (P indicates more NKC or better function)

PC (4)

Ironson et al. (2011)

C

CS

PC(1.5)

Dalmida et al. (2009)

252

—​

CT

*Trevino et al. (2010)

450

C

CS

*McCain et al. (2008)

82 420

Cotton et al. (2006)

C C

CS

CS

Chandra et al. (2006)

Ramer et al. (2006)

Ramadan fasting

Qigong practitioners

Spiritual growth group

#15 ORA, NORA

#5 Faith score©

#10 Spirituality©

#2 ORA, SR

Buddhist mindful med

Spiritual growth group

#2 ORA, SR

#1 “Spiritual coping”

#12 View of God

#19 DUREL, NRC, PRC

#20 EWB©, RWB

Spiritual growth group

#42 Durel, Facit-​Sp©, RC

?# Spirituality©

#6 “spirituality”©

NA (no change)

P

P (vs. ctrl only)

P

P (post-​chemo)

NA

P

P

NA

(P)

P

P (positive view)

NA (exc NRC)

P

NA

NA

NA

NA

None

—​

—​

None

None

None

SC

—​

—​

SC

MC

MC

MC

MC

—​

None

None

None

(8)

(8)

9

(8)

(8)

(8)

8

(8)

9

8

8

8

8

7

9

(8)

(8)

(8)

T Y PE

M E T HOD N

P OP U L AT ION

CS

C

C

—​

C

S

CDA, young

F, orofacial pain

MP (metastatic breast CA)

41

25 intervention, 16 ctrl

44 bereaved, 44 controls

1,319

24

112

Wisconsin

Texas

Israel

Brazil

N. California

L O C AT ION

Buddhist mindful med

144 /​144 78

R R —​

CS

PC/​CC

CT

PC (1)

CS

CS

CC

Tully et al. (2006)

*Ikedo et al. (2007)

Pereira et al. (2010)

Gillum & Holt (2010)

Callen et al. (2011)

Kagimu et al. (2012)

S

C

R

C

Uganda

106 HIV+​/​424 HIV-​(age 15–​24)

National US

Florida

Omaha, NE

United Kingdom

Malawi (Africa)

National US

National US

Florida

CDA

MP (stem cell transplants)

MP

Ad w meningitis v ctrls

CDA, M

Ad (beginning of study)

Hlth prof (58% dentists)

CDA, E

82

11,507

85

960

11,594

*Trinitapoli & Regnerus (2006)

R

PC (6)

42,523

Ford CA et al. (2005)

C

PC (4)

Merchant et al. (2003)

?# DSE©, ORA, SR, others

#38 BMMRS

#1 ORA

?# “spiritual absence”

Prayer during surg (CD)

#1 ORA

#2 D,ORA

#3 D, SR, NORA

#1 ORA

MC

None

None

SC

C ON T ROL S

MC

MC

MC

MC

MC

P

P (flu symptoms)

MC

None

NG for H. pylori in Mexican Am

P for STI (mediated)

P

NA (sternal infection)

P

P (STI)

NA (STI by urine)

P (periodon­ titis)

P (incr antibodies to influenza)

P (CMV titer)

NG (CMV titer)

#1 ORA

P

#3 family/​personal R

NG (ORA)

F I N DI N G S

#10 Sp Persp Sc

#2 ORA, SR

R E L IG VA R I A BL E S

Infection (susceptibility and recovery, as an indicator of immune function); STI =​sexually transmitted infection; “>” =​more infection

Davidson RJ et al. (2003)

CT

CC

*Garcini et al. (2019) (IgG)

Antibody Response to Vaccination

CS

CS

Lago-​Rizzardi et al. (2014) (IgE)

Lawrence GM et al. (2017) (IgG)

Antibody Levels (P indicates lower levels, which is good)

*Sephton et al. (2001)

Cell-​Mediated Immunity (cutaneous response to antigens; P =​better response)

TOPIC /​I N V E S T IG ATOR S

8

(8)

8

(8)

8

9

8

10

9

8

(8)

(8)

(8)

8

R AT I N G

CC

CS

CS

CS

*Garcini et al. (2019) (IgG)

Pirutinsky et al. (2020)

Shaw et al. (2020)

Rozenfeld et al. (2020)

PC (4)

PC (4)

CS

CS

PC(1.5)

PC (4)

PC (4)

*Ironson et al. (2006a)

*Ironson et al. (2006b)

*Ramer et al. (2006)

*Chandra et al. (2006)

*Trevino et al. (2010)

*Ironson et al. (2011)

*Kremer et al. (2015)

Viral Load

CS

PC (14)

*Chen Y & VanderWeele (2018)

Krause (2019)

CS

Krause & Ironson (2017b) (EBV)

PC

CS

*Hill TD et al. (2014) (EBV)

PC (1)

P (4)

Raghavan et al. (2013) (HCV)

* Bagheri et al. (2019)

CS

Muula et al. (2012)

*Watson et al. (2019)

CS

*Puzek et al. (2012)

C

C

C

C

C

C

C

C

C

C

C

S

C

C

S

R

R

C

R (?)

R

CDA

CDA, B, M, bisexual

MP (CABG surgery)

Ad (ave age 15)

CDA

177

101

429

82

420

100

100

34,503

1,342

419

Miami, FL

MP (HIV/​AIDS)

Miami, FL

Multi-​site US

MP, HIV/​AIDS

MP,HIV/​AIDS

South India

S. California

Miami, FL

Miami, FL

Rhode Island

Kazakhstan

NY, NJ area

Texas

National US

Atlanta

Iran

National US

National US

National US

MP (HIV)

MP (HIV/​AIDS)

MP (HIV)

MP (HIV)

CDA tested for COVID19

M, market vendors

CDA, Am Orthodox Jews

44 bereaved, 44 controls

852

225

?

6,950

1,745

CDA, E

1,450–​ 2,934

Texas

Malawi

CDA, F (age 15–​49) MP with Hepatitis C

Croatia

CDA, age 18–​25

87

2,609

1,005

#1 “Spiritual coping”

#12 View of God

#19 DUREL, NRC, PRC

#6 “spirituality”©

P

P (positive view)

NA

(P)

NA

P ?# Spirituality©

P (exc NRC) #2 ORA, R/​S change

Christians>Agnostics

MC

MC

None

None

None

MC

MC

MC

MC

None

NG (COVID-​19) NA with self-​report STI

MC

MC

MC

?

MC

MC

MC

SC

MC

MC

P (less react for herpes)

P (Hispanics)

#12 View of God

#1 R affiliation

#3 ORA, IR

#25 IR, RC, Trust-​Mistrust

#1 ORA

#3 R sup

P

P (HIV/​chlamydia/​ gonor tested)

? Disappoint with God #3 ORA, SR

P

M (NG for GMC, P for ORA)

#5 God-​med ctrl, ORA, NORA #2 ORA, NORA

P (mod vs. low)

P (men)

No differ in HIV across R denom

NA (chlamydia)

#1 ORA

#2 ORA, RC

#1 D

#8 ORA, SR, R upbring

8

8

8

(8)

(8)

8

8

8

8

(8)

(8)

(8)

8

(8)

10

8

8

8

8

8

PC (1)

PC (1)

Van Wagoner et al. (2016)

*Ironson et al. (2020)

C

C

M E T HOD 157

382

N

CS

CT

Exp

CC

CS

CT

PC, part of CT

*Anyfantakis et al. (2013)

Carvalho et al. (2014)

Zangeneh et al. (2014)

*Bellinger et al. (2014)

*Berk et al. (2015)

*Berk et al. (2015)

CS

Merritt & McCallum (2013)

Sahmeddini et al. (2014)

PC (6m)

CS

Turner-​Cobb et al. (2010)

CS

Lynn et al. (2010)

Mihaljevic et al. (2011)

—​

CT/​PC

—​

15

132

132

—​ —​

132

40

C

C

20

60

—​

195

—​

78

17

C

C

C

52

71

61

Bormann et al. (2009)

252

—​

CT

Pace et al. (2009)

—​

CT

*McCain et al. (2008)

853

944

S/​C

CS

*Maselko et al. (2007)

R

PC (1)

*Yeager et al. (2006)

Cortisol (cortisol, cortisol diurnal curve) (P =​decreased or lower levels)

Stress Hormones (Chapter 25)

T Y PE

TOPIC /​I N V E S T IG ATOR S

MP, depressed

MP with depression

MP with depression

F, polycystic ovary dis

MP (cancer)

F, preg, during labor

CDA (ave age 67)

B caregivers & non-​careg

PTSD veterans

MP, brain injury

CDA, Pentecostals

MP (HIV)

CS (ave age 18.5)

MP (HIV)

CDA, E (McArthur aging)

CDA,E (92% non-​Christian)

MP, HIV/​AIDS

MP, HIV/​AIDS

P OP U L AT ION

NC and Calif

NC and Calif

NC and Calif

Iran

Brazil

Iran

#29 RCm

Conventional vs. RCBT

#29 RCm

Ramadan fasting

Christian prayer (listen)

Listening to Qur’an

#6 ORA, NORA, SR

#34 RC

Ohio Greece

#20 SWB©

#2 RC

#8 religisity (Rohrbaugh)

Sp-​mantram /​#4 Faith

Buddhist compassion med

Spiritual growth group

#3 D, ORA, SR

P

F I N DI N G S

(NG)

NA

NA

P

NA

P

P

NG

P

P

P

P (PC)

NA

NA

NA

NA

P (incr in RC buffered div/​death)

#12 D, ORA, RB,R prac

#4 RC

#1 ORA

R E L IG VA R I A BL E S

Croatia

United Kingdom

New York

San Diego

Atlanta, GA

Virginia

Multi-​site US

Taiwan

Miami, FL

Alabama

L O C AT ION

—​

—​

MC

None

—​

—​

None

SC

None

None

None

None

—​

—​

MC

MC

None

MC

C ON T ROL S

8

8

(8)

(8)

(8)

8

(8)

(8)

(8)

(8)

(8)

8

(8)

9

8

8

(8)

8

R AT I N G

100 7 studies (116 interv vs. 96 ctrls) 30 (15 interv vs. 15 ctrls)

CS

Meta-​analysis

Meta-​analysis

CT (non-​ randomized)

Akbari et al. (2017)

Pascoe et al. (2017a)

Pascoe et al. (2017b)

Soetrisno et al. (2017)

C C

C C S —​

CS

CS

CS

CT/​CS

CS

CS

Exp

Exp

CT/​Exp

CS

CS/​Exp

CT

Hulett et al. (2018)

Akbari et al. (2017)

Lee DB et al. (2021)

Campbell (2018)

Tønnesen et al. (2019)

Sladek et al. (2019)

Grossi et al. (2019)

Gamaiunova et al. (2019)

Farias & Newheiser (2019)

Allen et al. (2020)

*Schnell et al. (2020)

Erisna et al. (2020)

74

CDA age 18–​81

Ad, Latino

CS, F, healthy

CS at a Christian university

CDA, B (ave age 21)

Nursing students

F with breast cancer

MP undergoing CABG

40

50

700

100

National US F, primip, 3rd sem, Muslim

Indonesia

Austria

CDA, age 35–​85 CS

United Kingdom

Switzerland

Italy

Arizona

California

Northwest US

Michigan

Iran

Missouri

India

Indonesia

Worldwide

Worldwide

Iran

Worldwide

Thailand

National US

Flint, Michigan

Post-​grad sci (50% R)

29 exp meditators vs. 26 controls

—​

60

48

188

100

41

147

209

—​

CS (nursing)

12 studies (312 interv vs. 302 ctrls)

C

C

R

C

CT

Kiran et al. (2017)

—​

C

5 studies (86 interv vs. 104 ctrls)

MP, diabetes

CDA

Meta-​analysis

23

—​

Sanada et al. (2016)

1470

S

PC (10)

Hi-​risk B youth

CT

201

Tobin & Slatcher (2016)

C

*Gainey et al. (2016)

PC (6)

Assari et al. (2015)

R intervention (Maryam exercise)

#15 RC (Huber)

#6 RC

Reflecting on R belief

Buddhist meditation

Religious cathedral

#7 “religiosity”

#10 RCm (Worthington)

Christian prayer

#2 ORA

#10 RWB

#38 DSE©, RC, RSup, etc.

Hindu Rajyoga med

R logotherapy

Buddhist/​Hindu med

Hindu yoga/​med

#10 religiosity

Buddhist mindfulness med

Buddhist walking med

#2 ORA

#1 Participation in R activ

None

None

—​

—​

—​

—​

None

—​

—​

MC

MC

(8)

?

—​

—​

P

NA

—​

—​

P (white men) MC

NA

P (cortisol recovery)

8

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

9

(8)

9

9

(8)

8

8

8

8

None

None

P (60% reduction in cathedral)

(P) mod stress-​cortisol

NA

NA (RCT), P (CS)

P moderating discrim-​cortisol relationship

NA

NG (DSE)

M

P

P

P (but weak)

NA

P (but weak)

P

P

P

T Y PE

M E T HOD N

P OP U L AT ION

L O C AT ION

R E L IG VA R I A BL E S

CS

CC

CS

CT

PC part of CT

Meta-​analysis

Imamura et al. (2015)

Zangeneh et al. (2014)

*Bellinger et al. (2014)

*Berk et al. (2015)

*Berk et al. (2015)

*Pascoe et al. (2017b)

132

—​

CS

CS

Exp

CS

CS

CT

CS

*Sasaki (2011)

Kelsch et al. (2013)

Sasaki et al. (2015)

Holbrook et al. (2015)

Fisher et al. (2015)

Van Cappellen et al. (2016)

Imamura et al. (2017)

Oxytocin (OT) (P =​higher)

317

83

—​ C

34,831

34

110

79

242

C

C

C

C

C

Other Hormones and Related Neuropeptides

132

—​ MP, depressed

MP with depression

MP with depression

F, polycystic ovary dis

CDA, E

Experienced TM med

CDA, E (McArthur aging)

CDA, E, rural

CDA, M (ave age 45)

CDA internet dating sites

CS (ave age 23)

Japan

#4 Blf in life after death

#19 SSp, Sp Trans Sc

#1 R vs. non-​R

US/​World

Religious priming

#23 SSp, Ironson-​ Woods sc #2 SSp, ORA

North Carolina

NA (norepi)

NA

(P) (epi)

P (norepi)

P

NA (sMHPG)

P (after TM)

P (women)

F I N DI N G S

None (?)

None

—​

—​

—​

MC

None

None

MC

NG

MC

Incr Sp© with intranasal Oxyt

P (estrogen/​ OT pers trait)

P

(8)

8

(8)

(8)

(8)

(8)

(8)

8

8

8

(8)

(8)

(8)

(8)

—​ MC

8

R AT I N G

MC

C ON T ROL S

Related to self-​control in GG

P

#10 RCm (Worthington) NA with OXTR gene

Hindu meditation

#29 RCm

Conventional vs. RCBT

#29 RCm

Ramadan fasting

#6 RB (life after death)

Hindu transcend med

#3 D, ORA, SR

Utah

S. California

Florida

MP, HIV+​ CS (ave age 19)

S. Korea/​Calif

Worldwide

NC and Calif

NC and Calif

NC and Calif

Iran

Japan (rural)

Granada, Spain

Multi-​site US

CDA, CS (ave age 25)

2 studies (19 interv vs. 16 ctrls)

132

40

346

5

853

C

C

C

C

Exp

Infante et al. (2010)

S/​C

CS

*Maselko et al. (2007)

Epinephrine [epi], Norepinephrine [norepi], MHPG [metabolite of norepi], and Catecholamines (P =​decreased or lower levels)

TOPIC /​I N V E S T IG ATOR S

CT

Exp

CS

CT

Cortes et al. (2018)

Machida et al. (2018)

*Tønnesen et al. (2019)

Mehr et al. (2020b)

116

60 15

C —​

32

—​ C

334

C

F, Breast CA

CS, F, healthy

CDA, healthy (ave age 46)

CDA (ave age 27)

CDA

Iran

California

Japan

Sweden

New York

Spiritual/​religious intervention

CS

C

60

CS, F, healthy

CS

CS

PC (2)

Rco (1-​5 y)

CT

CS

*Banerjee et al. (2014)

* Dzivakwe & Guarnaccia (2014)

*Kobayashi et al. (2015)

*Gainey et al. (2016)

Rivera-​Hernandez (2016)

CS

*Anyfantakis et al. (2013)

*Hill TD et al. (2014)

CS

*Feinstein et al. (2010)

23

—​ 364

29,215

CDA, E

CDA, Mexican, w diabetes

MP, diabetes

MP, outpts

MP, diabetes, E

CDA

S

R

Multi-​site US

Mexico

Thailand

Japan

National US

National US

Canada

Greece

CDA (age 45–​84) CDA (ave age 67)

Multi-​site US

CDA, E (McArthur aging)

1,450–​ 2,934 2,539

13 Muslim countries

Detroit, MI

California

MP with stable CAD S. California

MP (diabetes)

CDA, F, B

5,442

195

5,474

R

R

R

C

C

853

CS

*Maselko et al. (2007)

S/​C

CT

*Paul-​Labrador et al. (2006)

12,243

679

103

R/​S

RS/​CS —​

R

CS

*Van Olphen et al. (2003)

Salti et al. (2004)

Diabetes (includes fasting blood sugar [FBS], insulin levels, HbA1c, development of diabetes)

Metabolic Disorders (no chapter)

*Tønnesen et al. (2019)

P

NA

#3 ORA, SR

Buddhist walking meditation

#1 SR

#2 ORA,SR

#1 ORA

#2 ORA, D

#6 ORA, NORA, SR

#7 ORA, NORA, Sp Exp

#3 D, ORA, SR

Transcendental Med

Ramadan fast

MC

MC

MC

MC

MC

—​

None

MC

None

—​

None

—​

P (diab care & control)

P (HbA1c)

P

MC

—​

MC

P (moderating) SC

NA (HbA1c)

P

P

NA

NA (HbA1c)

P

NG (hypo­ glycemia)

NG (CM)

#10 RCm (Worthington) P

#5 ORA, NORA, SR, CM

SC

No incr Sp w intranasal Oxyt

Related with OXTR gene

#10 RCm (Worthington) P

Arigato-​Zen Buddhist meditation

#18 Sp Trans Sc

#1 SR/​SS

Neuropeptide Y (neuropeptide in CNS promoting general well-​being, anxiety regulation, and stress resilience; P =​higher levels)

CS

Anderson et al. (2017)

8

8

9

8

8

8

(8)

8

8

8

(8)

8

(8)

(8)

(8)

(8)

8

(8)

PC(1)

CS

PC (56d)

PC (3–​12)

PC (8)

Saffari et al. (2019)

*Bentley-​Edwards et al. (2020)

*Whitehead & Bergeman (2020)

*Chen Y et al. (2020a)

Walker R et al. (2020)

C S

CT

CS

CS

Rco (1-​ 5 y)

PC (9)

PC (4)

*Paul-​Labrador et al. (2006)

*Maselko et al. (2007)

*Feinstein et al. (2010)

*Kobayashi et al. (2015)

*Hill TD et al. (2017b)

*Suh et al. (2019)

S

853

S/​C

CDA, age 50 or over CDA, E (age > 50)

National US

Mexico

Japan

Multi-​site US

CDA (age 45–​84) MP, outpts

Multi-​site US

S. California

New York

CDA, E (McArthur aging)

MP with stable CAD

Israel

National US

National US

Indiana

National US

Iran

L O C AT ION

CS

CS

CS

*Maselko et al. (2007)

*Hill TD et al. (2014)

Brintz et al. (2017)

R

R

S/​C

CDA, age > 45, Latino

CDA, E

1,450–​ 2,934 3,278

CDA,E (McArthur aging)

853

Large US cities

National US

Multi-​site US

Allostatic Load/​Metabolic Syndrome (combination of cholesterol, blood pressure, glycosylated hemoglobin, weight)

2,912

772

29,215

5,474

103

R

Ad

CDA, E with diabetes

CDA

CDA, E (55 or older)

CDA, B

MP,E, type II diabetes

P OP U L AT ION

223 Mennonites vs. 12,275 Cs

673

—​

S

CC

Glick et al. (1998)

R

CS

Friedlander et al. (1987)

2,662

92,008

C/​R R

267

4,344

793

N

C

R

C

M E T HOD

Cholesterol or Hypercholesterolemia (> =​higher cholesterol)

T Y PE

TOPIC /​I N V E S T IG ATOR S

#2 ORA, NORA

#1 ORA

#3 D, ORA, SR

#1 ORA

#1 ORA

#1 SR

#7 ORA, NORA, Sp Exp

#3 D, ORA,SR

Transcendental Med

#1 D (Mennon vs. other)

#7 D,SR

#4 RB, IR, RC

#1 ORA

#9 RC

#2 R affil, ORA

#25 ORA, NORA, IR, RC

R E L IG VA R I A BL E S

MC

MC

MC

SC

MC

MC

C ON T ROL S

NA

P

P (ORA, in F)

(P) (bad chol)

P (total chol)

NA

P

NA

NA

MC

MC

MC

MC

MC

MC

MC

MC

—​

Others > Mennon (men only)

P

NG

NA (indirect?)

P (A1c, via neg affect)

NG (but P in Presby & Cath)

P (med adhere)

F I N DI N G S

8

8

8

9

9

9

8

8

8

8

8

9

10

8

8

8

R AT I N G

PC (7)

CS

PC (4)

Allshouse et al. (2018)

Morales-​Jinez et al. (2018)

*Suh et al. (2019)

R

R

C

R

S

5,449

2,912

131

2,371

772

CDA, E (age > 50)

National US

Mexico

National US

CDA, E (average age 74)

Hisp F, age 42–​52

National US Mexico

CDA, age 40–​65 CDA, age 50 or over

#1 ORA

#1 ORA

#1 ORA

#3 RC, NORA

#1 ORA

PC

PC,CC

CC

CC

PC (6)

RS

CS

CS

PC (14)

CS

RS (1)

CC

Reynolds & Kaplan (1990)

Lyon et al. (1994)

Egan et al. (1996)

Kinney AY et al. (2003)

Kroenke et al. (2006)

Gebregziabher et al. (2006)

*Gillum & Williams (2009)

*VanderWeele et al. (2017a)

*Chen Y & VanderWeele (2018)

Polite et al. (2018)

Orlewska et al. (2018)

Jafri et al. (2019)

C

R

C

S

C

R

S

S

R

R

S

R

120 cases vs. 240 ctrls

> 20,000

389

6,950

36,613

3,766

2,433

2,835

637 vs. 1,043 ctrls

6,611

49,182

6,848

Alameda, Calif

MP, lung CA

CDA

MP, newly diag cancer

Ad (ave age 15)

Texas, Louisiana

Poland

Chicago

National US

National US

National US

F, age 30–​44 CDA, B

S. California

National US

North Carolina

National US

Utah

Multiple myeloma

F nurses w breast CA

MP, colon CA

Breast CA vs. Ctrls

CA risk

CDA

None

#3 RB, ORA

#2 ORA, RB

#18 RC, God LOC

#2 ORA, NORA

#4 ORA, NORA, RC, SR

#3 D, ORA, SR

#1 D

#1 ORA

MC

MC

MC

None

MC

NA

P (lung and breast CA)

None

SC

NG (late stage MC present)

P (abnormal Pap)

NG

P (risk factors)

Jew have marginal higher risk (11%) vs. Prot/​Cath

NA (? mediated)

P (Whites)

J > non-​J

#1 D (Jewish v non-​J) #2 CM, ORA

SC —​

MC

MC

MC

non-​M > Morm

P

P

P (moderates) MC

MC

NA

#2 ORA, CM

P P

#1 D (Mormon v non-​M)

Cancer Development/​Prognosis (CIN =​cervical intraepithelial neoplasia; “>” indicates worse risk, outcome, or more cancer)

Cancer (Chapter 26)

CS

PC (9)

Bruce et al. (2017a)

*Hill TD et al. (2017b)

(8)

(8)

8

(8)

10

8

8

8

8

8

8

8

9

9

(8)

9

9

PC (11)

PC (27)

PC (30)

CS

PC (3–​12)

PC (10m)

Ahrenfeldt et al. (2019)

Saeaib et al. (2019)

Hamada et al. (2019)

*Simons et al. (2019)

*Chen Y et al. (2020a)

*Narayanan et al. (2020)

PC (31)

PC (6)

*Oman et al. (2002)

*Kroenke et al. (2006)

R

CS

PC

CC

Enstrom (1989)

Dwyer et al. (1990)

PC

Zollinger et al. (1984)

*Ringdal et al. (1995); Ringdal ( 1996)

R

CC

Enstrom (1980)

S

R

S

S

R

R

CC

Enstrom (1978)

R

PC/​CC

Lemon & Walden (1966) Utah & Calif Utah & Calif California

CDA-​Mormons CDA-​Mormons MP-​with CA

2,835

6,545

F nurses w breast CA

CDA

MP cancer

3,063 counties,CDA 253

National US

N. California

Norway

National US

California

California

Texas

#1 ORA

#1 ORA

#2 RB

#2 D, CM

#2 ORA, Mor v non-​M)

#1 D (SDA vs. non-​SDA)

#1 D Act (Mor vs. non-​M)

#1 D Act (Mor vs. non-​M)

#1 D (SDA vs. non-​SDA)

#3 ORA, NORA, RC

#1 ORA

#5 ORA, NORA, SR

Georgia/​Iowa National US

#1 D

#1 D

#3 ORA, NORA, R educ

R E L IG VA R I A BL E S

National US

Thailand

Europe

L O C AT ION

CDA, 100% M

MP, renal cell CA

CDA

CDA, B (ave age 29)

Health professionals, M

MP, uterine cancer

CDA (10 countries)

P OP U L AT ION

9,844 active Mormans /​3,199 others

2,304

4 large samples

55,000 vs. Ctrls

11,071

117

92,008

C/​R CS

413

49,410

742

23,864

N

C

C

R

R

M E T HOD

Cancer Mortality (“>” means greater mortality)

T Y PE

TOPIC /​I N V E S T IG ATOR S

MC

None

MC

C ON T ROL S

NA (? mediated)

MC

MC

SC NA (? mediated)

MC

P

SC

MC

SC-​age, sex

SC-​age, sex

SC-​age

MC

MC

(P) (p =​.06)

P

SDA =​non-​ SDA

non-​M > Morm

non-​M > Morm

non-​SDA > SDA

P (fewer CA symptoms)

(P)

P (cancer MC supressor gene)

Ashkenazi Jews > others

Buddhists > Muslims

P

F I N DI N G S

8

9

8

8

9

8

8

8

8

8

10

(8)

8

8

9

R AT I N G

PC (< 1m)

PC (6)

PC (15)

PC (6m)

PC (4)

Shin et al. (2018)

Thompson et al. (2018)

Alcaraz et al. (2019)

Saxena et al. (2019)

Hunt et al. (2019)

R

C

C

C

C

C

C

C

C

CT/​PC

PC (6–​13)

Ali et al. (2018)

Nair et al. (2020)

Kidney Disease (including renal function)

Head & neck CA

CDA, 30 years or older

Aggressive lymphoma

Advanced CA (19.5d survival)

F, surgery for breast CA

CDA

F, breast cancer

Nurses (Nurses Hlth Study)

Nurses (Nurses Hlth Study)

Terminally ill w CA

Terminally ill w CA

CDA, F (age 50–​79)

CDA

180 76,443

C

CDA, low SES

MP, kidney stones

47 largest cities

177

580,182

701

204

6,901

3.4 mil

206

121,700

74,534

170

481

92,395

932,634

C

Miscellaneous Medical Disorders (no chapter)

PC (3)

Virani et al. (2018)

C

PC (10)

RS (34)

PC (20)

Sarma et al. (2018)

Mai et al. (2018)

PC (18)

*Li et al. (2016b)

Noon et al. (2018)

C

PC (3)

King MB et al. (2013b)

C C

PC (8)

PC (4m)

*Schnall et al. (2010)

R/​S

Yun et al. (2012)

PC (5)

*O’Reilly & Rosato (2008)

Southeast US

Pakistan

National US

India

National US

Minnesota

#3 ORA, RC, Sp

P

P

P

#1 Congregations/​ population

Sp motivated intervention

Christians > Hindus

P

NA (after ctrls)

#1 D

#1 ORA

#1 Sp quality of life

NA

#12 FACIT-​SP©

South Korea

Muslims > Buddhists

#1 D

Thailand

P

(NG)

NA (colorectal)

P

P (through 6 mo)

#1 Religious workers

#1 religion vs. no

#1 ORA

#1 ORA

#20 Sp beliefs

(NG) (prayer)

P

MC w/​o clincal correlates

None

MC

None

MC

SC

MC

MC

SC

None

MC

MC

MC

SC

None

Catholics > MC Fundamentalists Catholics > Presbyterian (F only) Catholics > Other/​None (F only)

#2 R affil, prayer

#3 D, ORA,RC

#1 D (vs. Catholics)

Finland

South Korea

National US

National US

United Kingdom

South Korea

Multi-​site US

N Ireland

9

(8)

8

(8)

10

(8)

(8)

(8)

8

(8)

10

10

8

8

8

8

TOPIC /​I N V E S T IG ATOR S

T Y PE

PC (5)

Reynolds et al. (2014a)

PC (4)

CS

CS

CS

Zini et al. (2012a)

Zini et al. (2012b)

*Peltzer et al. (2016)

PC

*Merchant et al. (2003)

Dental Problems

Braga et al. (2019)

Infertility

Chliaoutakis et al. (2005)

CS

PC (5)

Maselko et al. (2006b)

Accidents (non-​fatal)

CS

CS

*Van Olphen et al. (2003)

Pulmonary Disease and Function

*Van Olphen et al. (2003)

Osteoarthritis/Rheumatoid Arthritis

C

C

C

C

C

R

20,222

254

246

42,523

877

324

46

1,174

R/​S C

679

679

N

R

R

M E T HOD

CS in 26 countries

Jewish adults (age 35–​44)

Jewish adults (age 35–​44)

Hlth prof (58% dentists)

Infertile F (receiving Rx)

CDA

Adol with cystic fibrosis

CDA, E (McArthur study)

CDA, F, B (asthma)

CDA, F, B

P OP U L AT ION

#2+​SR, ?Sp

Israel

#5 DUREL

#2+​SR, ?Sp

Israel

Worldwide

#1 ORA

#5 D, ORA, NORA

#4 R/​trad lifestyle

#14 RC

#1 ORA

#5 ORA, NORA, SR, RSup

#5 ORA, NORA, SR, RSup

R E L IG VA R I A BL E S

National US

Brazil

Crete

Alabama

Multi-​site US

Detroit, MI

Detroit, MI

L O C AT ION

None

MC

MC

MC

MC

MC

C ON T ROL S

M

P (dental caries)

SC

MC

P SC (periodon­titis)

MC P (periodont­itis)

P

P (accident prone behavior)

P (PRC)

P

P (SR)

P

F I N DI N G S

8

(8)

(8)

9

(8)

(8)

8

9

8

8

R AT I N G

PC

PC

PC

CC

PC

PC

PC

Idler & Kasl (1991)

*Idler & Kasl (1992)

Bryant & Rakowski (1992)

Acheson (1994)

Goldman et al. (1995)

*Oxman et al. (1995)

Rasanen et al. (1996)

PC

CC

Simpson WF (1989)

Kark et al. (1996b)

R

CT

Alexander et al. (1989)

PC

PC

Seeman et al. (1987)

CC

PC

Schoenbach et al. (1986)

Rogers (1996)

R

CC

Spence et al. (1984)

Goldstein (1996)

C

PC

Janoff-​Bulman & Marshall (1982)

S

R

S

R

S

R

R

R

S

C

R

R

R

R

PC

Wingard (1982)

R

PC

House et al. (1982)

3,900

15,520 vs. ctrls

15,938

1,624 deaths

232

7,500

6,623

473

2,812

2,812

5,568

73

4,175

2,059

26,618

30

4,725

2,754

All-​Cause Mortality (P =​lower mortality; “>” =​greater mortality than)

Mortality (Chapter 27)

CDA, E

rlg vs sec kib

CDA

Israel

Rhode Island

National US

Finland

New Hampshire

MP-​open-​heart surg CDA,M

National US

Ohio

National US

New Haven, CT

New Haven, CT

Illinois

Massachusetts

Alameda, Calif

Georgia

Indiana

Massachusetts

CDA, E

births, perinatal

CDA, E, B

CDA, E

CDA, E

CDA

E

CDA, age > 38

CDA

Faith Assembly vs. others

NH, E

Tecumseh, MI Alameda, Calif

CDA CDA, age 30–​69

#1 ORA

P

#1 relg v secular kibutzim

P

P non-​J > Jew (M) Jew > non-​J (F)

#1 D (Jewish vs non-​J)

E. Orth > Luth

P (RC)

P

#1 ORA

#1 D (E. Orthdox, Luth)

#3 ORA, SR, RC

#1 ORA

P non-​A > Amish

#1 D (Amish vs non-​A)

C

NA

Christ Sc > other

P

P

P

Faith As > other

NG

C

#1 ORA

#4 ORA, SR, RC

#4 ORA, NORA

#1 D Christ Sc v other)

#1 Transcendental Med

#1 CM

#1 ORA

#1 D (Faith As vs. other)

#2 SR

#1 CM

MC

9

8

SC-​age, sex

MC

SC-​age, sex

MC

MC

MC

MC

-​

MC

MC

10

8

9

8

9

10

8

9

10

8

8

-​

MC

10

MC

10

(8)

SC-​age MC

(8)

8

SC

MC

PC (12)

PC (8)

PC (12)

PC (8)

PC (10)

PC (6)

PC (8)

Kraut et al. (2004)

Musick et al. (2004)

Heuch et al. (2005)

*Harris AH & Thoresen (2005)

Walter-​Ginzburg et al. (2005)

Bagiella et al. (2005)

Hill TD et al. (2005)

PC (2)

Pargament et al. (2001)

PC (12)

PC (32)

*Timio et al. (2001)

*Lutgendorf et al. (2004)

PC (6)

Helm et al. (2000)

PC (31)

PC (8)

Ellison CG et al. (2000)

PC (10)

PC

Hummer et al. (1999)

*Oman et al. (2002)

PC

Koenig et al. (1999)

*Eng et al. (2002)

PC

Oman et al. (1999)

R

PC

PC

Krause (1998a)

Oman & Reed (1998)

S

PC

Koenig et al. (1998b)

R

R

R 3,050

14,456

960

7,496

29,871

R/​S R

3,617

R

3,638

557

R/​S

6,545

Marin, Calif.

National US

Durham NC

Alameda, Calif

L O C AT ION

Multi-​site US Southwest US

CDA, E

Israel

National US

California

National US

Israel

Iowa

National US

N. California

North Carolina

Italy

North Carolina

National US

National US

North Carolina

CDA,E, Mex-​Am

CDA, E

CDA, E (over 70)

CDA, Seventh-​Day Adventists

CDA

CDA, M, industrial workers

CDA, E

Health professionals, M

CDA

MP, E

Nuns vs. F in community

144 /​138 444

CDA,E

CDA,B

CDA

CDA,E

3,851

3,002

21,204

3,968

28,369

S

CDA, E

CDA, E

MP

CDA

P OP U L AT ION

#1 ORA

#8 ORA, NORA, RC

#3 RC

#1 ORA

R E L IG VA R I A B L E S

#1 ORA

#1 ORA

#1 ORA

#1 ORA

#1 Length church member

#6 ORA, SR, NORA

#1 SR

#1 ORA

#1 ORA

#1 ORA

#17 RC, ORA, NORA, SR

Nuns v. F in com

#1 NORA

#1 ORA

#1 ORA

#1 ORA

MC

M (P-​ORA)

P

P

(M)

P

MC

M

SC

MC

M (P-​males, NA/​NG-​females)

MC

MC

MC

MC

MC

NONE

M (P in < 55, NG in > 55)

P

P

P

P (exc NRC)

P

MC

P (non-​ disabled)

9

9

8

9

8

9

9

9

9

9

8

8

8

9

10

—​ MC

9

9

9

9

9

10

R AT I N G

MC

P

P

P

MC

MC

P/​M P

MC

MC

NA

P

F I N DI N G S C ON T ROL S

same cohort as above; found that volunteering associated with lower mortality, but primarily only in the religiously active

1,931

819

1,010

5,286

N

C

R

S

C

R

R

R

R

S

R

PC

Strawbridge et al. (1997)

M E T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

PC (2)

PC (24)

PC (9)

PC (23)

Enstrom & Breslow (2008)-​ study 1

Enstrom & Breslow (2008)-​ study 2

*Koenig LB & Vaillant (2009)

PC (2)

Gu et al. (2007)

Zhang W (2008)

PC (10)

Dupre et al. (2006)

PC (8.5)

PC (3)

Krause (2006a)

Gillum et al. (2008a)

PC (4)

*Yeager et al. (2006)

PC (7)

PC (10)

La Cour et al. (2006)

Litwin (2007)

PC (11)

Resnick (2006)

PC (6)

PC (7)

Ostbye et al. (2006)

PC (7)

RS (7)

Park R et al. (2005)

Ayalon & Covinsky (2007)

PC (12)

Teinonen et al. (2005)

Hsu (2007)

RS (10)

Jaffe et al. (2005)

C

R

S

R

R

R

R

R

R (?)

R

R

R

C

R

S

S

R

R

381

15,832

9,815

6,757

8,450

1,811

4,179

2,825

13,297

4,136

1,500

3,800

734

6,874

3,413

71,157

1,080

141,683

CDA, M, (age 47–​70)

CDA,W (age 25–​99)

CDA, Mormon, R active

CDA,E (age 80–​105)

CDA (> age 40)

CDA, E, Jewish (age > 70)

CDA, E, Jewish (age > 60)

CDA, E

CDA, E (over age 80)

CDA, E

CDA, E (Christians only)

CDA, E (92% non-​Christian)

CDA, E (over age 70)

CDA

CDA

Deaths due to Dementia

CDA,E

CDA, Jews

Inner city US

National US

#1 ORA

#1 ORA

#1 D

#1 Freq of R practices

China California

#1 ORA

#1 ORA

#1 ORA

#1 ORA

#1 Freq of R activity

#1 ORA

National US

Israel

Israel

Taiwan

China

North Carolina

#11 ORA, NORA, Ch sup

#12 D, ORA, RB, R prac

Taiwan National US

#3 SR, ORA, NORA

#1 ORA

#6 ORA, NORA, RE, etc

#2 Clergy, R workers

#1 ORA

#1 % R-​aff neighborhood

Denmark

Wisconsin

Utah

22 US states

Finland

Israel

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

NA

P

MC

SC?

Similar to R active white US non-​Morm

P (F, poor health)

P (exc mediators)

P

P

P (F only)

NA

P

M

P (ORA only)

P

P

P (exc R visits)

NG (clergy)

P (F only)

P

9

9

9

9

8

8

8

8

9

10

8

8

8

8

8

8

8

8

R S

PC (15)

PC (4)

PC (3)

PC (1–​5)

D

PC (5–​10)

PC (19)

Lerch et al. (2010)

Bonaguidi et al. (2010)

Zeng et al. (2011)

*Morgenstern et al. (2011)

Rajpathak et al. (2011)

Cohen L et al. (2012)

Moulton & Sherkat (2012)

R

C

R

C

R

R

C

S

R

PC (5)

Sullivan (2010)

R

O’Reilly & Rosato (2008)

PC (14)

Hummer et al. (2010)

C

PC (17)

PC (8)

*Schnall et al. (2010)

C

PC (1)

PC (8)

McCullough & Willoughby (2009)

C

S

Beasley et al. (2010)

PC (65)

Ironson & Kremer (2009)

M E T HOD

Pereira et al. (2010)

PC

PC (3–​5)

Smith KR et al. (2009)

T Y PE

TOPIC /​I N V E S T IG ATOR S

22,080

217

477

669

15,973

179

6.9 million

894,131

85

4,589

18,129

9,423

92,395

1,343

147

24,262

N

MP,F, breast CA

CDA

National US

Texas

National US

CDA age 95–​109 MP, metastatic renal CA

Texas

China

Italy

Switzerland

Northern Ireland

NA (stroke mort)

P

P

MC

MC

#1 ORA

#3+​ORA, NORA, IR

P (except in hi edu)

NA

MC

MC

9

8

8

8

9

8

8

MC P (age 25–​44) P (age 45–​64) NG (age 65+​) MC

8

8

MC Catholics > Prot fundamen­ talists

7% of women, 2.5% of men attrib longevity to R, Sp, or God

#2 SR,RC (68% with 8 on 2–​8 sc)

#1 R participation

#10 RC (search for God)

#1 D None vs. Catholic

#1D

MC

9

10

10

9

9

8

8

P

? “Sp absence/​faith” scale

MC

MC

MC

MC

MC

MC

R AT I N G

SC

P

#1 ORA

P (ORA)

P

Multi-​site US Florida

MP with new stroke

CDA over age 65

MP (liver transplant)

CDA

CDA

MP (stem cell transplants)

#1 ORA (controlled for D)

P

P (F, mediated)

P

P

F I N DI N G S C ON T ROL S

#2 D, ORA

National US

CDA (age 51–​61)

#3 D, ORA, RC

#1 relig trajectories

“Spirit transformation”

#2 D, RCm, Mormon

R E L IG VA R I A BL E S

National US

Multi-​site US

CDA, F (age 50–​79)

CDA, over age 50

California

Miami

Utah

L O C AT ION

CDA (geniuses) (Terman)

MP (HIV)

CDA

P OP U L AT ION

29,236 32,830

R

PC (14)

PC (5m)

PC (8)

PC (6–​30)

PC (8-​28) R

PC (30)

PC (22)

PC (18)

Rco(11)

PC (5)

PC (17)

PC (5)

PC (8)

PC (18)

PC (10)

PC (10)

PC (10)

*Paiva et al. (2014)

Headey et al. (2014)

Stavrova (2015)-​study 2

Kim J et al. (2015)

Lawrence et al. (2015)

Geulayov et al. (2015)

*Li S et al. (2016b)

Darviri et al. (2016)

McDougle et al. (2016)

Ironson et al. (2016)

Park et al. (2016)

*VanderWeele et al. (2017a)

*Bruce et al. (2017a)

Ralston et al. (2017)

Tzeng & Lee (2017)

Idler et al. (2017)

R

R

R

R

C

C

C

R

S

C

R

R

R (?)

C

R

18,370

3,155

295,621

5,449

36,613

191

177

3,146

1,519

74,534

585

31,481

12,541

221

16,849

177

Pantell et al. (2013)

C

PC (4)

1,232

*Caplan et al. (2013)

R

PC (3)

Toussaint et al. (2012)

National US

Taiwan CDA, age 41 or older

United Kingdom CDA, E, age 60+​

National US

CDA age 40–​65 (NHANES) CDA

National US

CDA, B

Connecticut

Miami, FL

HIV+​ patients MP, E, CHF

Wisconsin

Greece

National US

Israel

National US

National US

National US

CDA, E

CDA

Nurses (Nurses Hlth Study)

CDA, M

CDA

CDA

CDA

Germany

#3 D, ORA, SR

#1 R activity

#1D (any vs. none)

#1 ORA

#4 ORA, NORA, RC, SR

#2 ORA, Sp peace©

#17 Spiritual coping

#3 ORA, NORA, SR

#2 ORA, NORA

#1 ORA

#1D (secular to orthodox)

#1 ORA

#6 D, RB, ORA, NORA, +​

#1 ORA

#1 ORA

#15 R practices sc

Brazil

CDA, ≥ age 16

#1 ORA

National US

#5 DUREL

#4 God’s forgiveness

MP, end-​stage cancer

Alabama

National US

CDA

CDA with cancer

CDA, age > 65

MC MC

M (ORA-​P, SR-​NG)

MC

MC

MC

MC

P

NA

P

P (ORA only)

P (Sp peace)

MC

MC

M (P-​ORA, NG-​NORA) P

MC

MC

None

MC

MC

MC

MC

MC

MC

MC

MC

P (moderate R vs. low)

P

NA

P (< 1/​wk vs. > 1/​wk)

P (ORA only)

P (only in R regions)

P

P

P

P (IR only)

(NG) (uncondi­ tional)

9

8

9

9

10

(8)

9

9

8

10

(8)

9

9

9

8

8

10

8

8

R R

RCo (4)

RS

PC (15)

PC (16)

PC (4–​8)

PC (16) PC (10)

PC (6)

PC (inhosp)

PC (8)

PC (2)

RS

PC (13)

PC (12)

PC (18)

PC (inhosp)

Knighton et al. (2018)

Wallace LE et al. (2019)

Lawrence EM et al. (2019)

Li ZH (2020a)

Zimmer et al. (2019)

Ofstedal et al. (2019)

*Kim ES & VanderWeele (2019)

*Bagheri et al. (2019)

Fraser et al. (2020)

*Abu et al. (2019b)

Ebert et al. (2020)

Wen et al. (2019)

Hill TD et al. (2020b)

Zimmer et al. (2020)

Farzanegan et al. (2020)

C

R

R

C

S

C

C

C

R

R R

R

S

S

C

PC (5)

Morton et al. (2017)

M E T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

MP (CABG surgery)

CDA (age 50 or over)

CDA,E (age > 50) CDA,E (age > 50)

CDA, E (80% Buddhists /​Tao)

CDA, E (80 years or older)

CDA

4,200

3,849

14,743

82,510

6,400

2,068

ICU patients

CDA, E (80% Buddh/​Tao)

CDA, E

Low income CDA

Gravestone analysis (Christian)

MP, hospitalized Acute Coronary Synd

#5 R practices (Muslim)

#1 R worship, pray, read

Taiwan Iran

#1 ORA

#3 ORA, SR, RC

#5 Gravestone R index

#3 RC, NORA

#1D (SDA vs. non-​SDA)

? Knowledgeable about God

#1 ORA

#1 SR #1 ORA

#4 D, ORA, NORA, SR

#1 R activities

#1 ORA

#1 D (R affiliation)

#1 Faith identification

#18 RC, SR, ORA, RSup

R E L IG VA R I A BL E S

Mexico

Southeastern US

National US

Mass. & Georgia

National US

Iran

National US

National US National US

Taiwan

China

National US

Utah 43 US cities

MP, heart failure

National US

L O C AT ION

Obituaries, city-​ level R

CDA, Adventists

P OP U L AT ION

87,000 SDA vs. 384,000 CDA

?

5,200

19,649 18,818

3,891

30,070

20,410

1,601

4,737

6,531

N

NG (hi delirium group)

P

P

P

M

SC

MC

MC

MC

SC

MC

MC

non-​SDA > SDA NA

?

MC

MC MC

MC

MC

MC

SC

MC

MC

P

P

P P

P

P

P

P (only in R cities)

P

P

F I N DI N G S C ON T ROL S

8

9

10

9

8

8

8

(8)

10

9 9

8

9

10

8

8

8

R AT I N G

PC(11)

PC (10)

PC (7)

PC (19)

Rco (20)

Idler (2020)

Long et al. (2020c)

Upenieks et al. (2021)

Pinchas-​Mizrachi et al. (2021)

PC (31)

PC (10)

PC (5)

*Oman et al. (2002)

*Eng et al. (2002)

*O’Reilly & Rosato (2008)

Accident Mortality

*Oman et al. (2002)

PC (31)

PC (21 mo)

Bonaguidi et al. (2010)

Respiratory Mortality

PC (31)

*Oman et al. (2002)

Gastrointestinal Mortality

Kim HJ et al. (2018)

RS (16)

PC(22)

Trudel-​Fitzgerald et al. (2020)

*Doolittle et al. (2021)

Chronic Kidney Disease Mortality

PC (8)

Løkken et al. (2020)

28,369 932,634

R/​S

6,545

6,545

179

6,545

3,639

1,230,636

CDA

Health professionals, M

CDA

N Ireland

National US

N. California

N. California

Italy

MP, s/​p liver transplant

CDA

N. California

South Korea

Israel (national)

CDA

MP, Buddhist priests

CDA Jewish citizens

National US

CDA, age 25–​74

3,032

National US

Nurses

National US

CDA, E

Large US cities

51,661–​ 54,703

National US

Nurses, ave age 58

Norway

HIV+​US Veterans

CDA (ave age 54)

18,346

3,685

72,322

35,902

?

R

R

C

R

S

R

R

S

R

C

C

R

#1 D (vs. Cath)

#1 ORA

#1 ORA

#1 ORA

#11 RC

#1 ORA

#1 Priests vs. gen pop

#1 Haredi vs. non-​Haredi

#4 R childhood home, ORA, SR

#2 R-​motivated forgiveness

#1 ORA

#4 ORA, RB, NORA, SR

#1 ORA

#1 ORA

Catholics > Methodists (M only) Catholics > Fundament (F only)

NA

NA

P

P (search for God)

P

P

P

M

NG

P

P (explained by smoking)

P

P

MC

MC

MC

MC

MC

MC

MC (?)

MC

MC

MC

MC

MC

MC

MC

8

9

9

9

9

9

8

8

9

10

9

9

10

10

RS

Cau et al. (2013)

RS (7)

RS (16)

*Park RM et al. (2005)

*Kim HJ et al. (2018)

S

S

C

S

R

—​

ME T HOD

3,639

71,157 MP, Buddhist priests

Deaths due to Dementia

R (monks) Nuns vs. F in community

South Korea

22 US states

Italy

Netherlands

Mozambique

CDA, F, age 18–​50

144/​138

US

L O C AT ION

(average infant mortality)

P OP U L AT ION

1,523

2,019

50 states

N

CS

PC

PC (3)

CS

CS

PC (5)

PC (2)

PC (4)

*Idler & Kasl (1997a)

Idler & Kasl (1997b)

Kelley-​Moore & Ferraro (2001)

Benjamins et al. (2003)

Hendershot (2003)

Benjamins (2004)

Reyes-​Ortiz et al. (2006)

*Yeager et al. (2006)

R

R

R

R

R

R

R

R

R

R

CS

PC

Idler (1995)

*Musick (1996)

R

PC

R

CS

*Idler (1987)

*Idler & Kasl (1992)

2,930

1,341

4,071

35,000?

2,958

1,282

2,812

2,812

2,623

146

2,812

2,811

CDA, E (92% non-​Christian)

CDA, E, age > 70, Hispanic

CDA, E (over 72 y)

CDA

CDA, E

CDA, E

CDA, E

CDA, E

#1 ORA #12 D, ORA, RB, R prac

Taiwan

#2 ORA, SR

#1 prayer as CAM

#2 ORA, NORA

#1 ORA

#4 ORA, SR, D

#4 ORA, SR, D

#2 ORA, NORA

#4 RC, SR, D

#4 ORA, SR, D

#4 ORA, SR, D

#1 Priests vs. gen pop

#2 Clergy, R workers

Nuns v. F in com

#1 monks vs. others

#1 D (affiliated vs. not)

#7 RB, ORA, SR, NORA

R E L IG VA R I A BL E S

Southwest US

National US?

National US

Durham, NC

National US

New Haven, CT

New Haven, CT

North Carolina

New Haven, CT

CDA, E

MP-​rehab clin

New Haven, CT New Haven, CT

CDA, E

CDA, E

Physical Disability (Chapter 28) (physical functioning, ability to perform activities of daily living)

RS

PC (32)

De Gouw et al. (1995)

*Timio et al. (2001)

Clergy Mortality

CS

T Y PE

*Reeve & Basalik (2011)

Infant/​Child/​A dolescent Mortality

TOPIC /​I N V E S T IG ATOR S

NA

NA

MC

MC

MC P (fear of fall)

MC M (ORA-​P, SR-​NG)

MC

MC NG

P (ORA)

MC

MC

M:ORA-​p, SR-​n P (ORA)

MC

P for subj hlth

MC

MC NG (RC)

MC M-​ORA-​p, SR-​n

MC (?)

MC

None

SC

MC

None

C ON T ROL S

P (ORA)

P

NG (clergy)

P

P

P (mortality 0–​5 y)

NG

F I N DI N G S

8

8

9

9

8

8

10

9

9

8

10

9

8

8

8

8

8

(8)

R AT I N G

CS

PC (4)

CS

CS

PC (17)

CS

CS

*Thege et al. (2013)-​work perf

Caplan et al. (2013)

Hybels et al. (2014)

*Al Zaben et al. (2015)

Hill TD et al. (2016a)

*Hayward et al. (2016b) (chronic hlth)

*Sowa et al. (2016)

PC (10)

Son & Wilson (2011)

CS

CS

Levin (2011)

*Levin (2013)

CS

*Vahia et al. (2011)

PC (2)

CS

Coleman et al. (2011)

CS

CS

*Kudel et al. (2011)

*Krause & Hayward (2012c)

PC (?)

Giaquinto et al. (2010)

Levin (2012b)

PC (5)

CT

CS

Reyes-​Ortiz et al. (2007)

Park NS et al. (2008)

CS

Tekur et al. (2008)

PC

*Ai et al. (2006a)

*Shmueli (2003; 2007)

R

R

R

R

C

R

C

R

R

R

S

R

R

C

C

C

S

C

57,391

3010

2,482

310

1,423

177

12,643

1,849

1,287

1,011

3,257

4,484

1,973

160

345

112

80

784

10,587

4,504

R/​C

R

335

S

CDA,E, > age 50

CDA

CDA,E (age > 65)

MP, renal dialysis, Muslim

CDA, E (survivors)

CDA with cancer

CDA

CDA, age 15 or older

CDA, Jewish, age>50

CDA, E

Europe

National US

Southwest US

Saudi Arabia

North Carolina

Alabama

Hungary

Israel

Israel

National US

National US

CDA, age 25–​74

San Diego, CA

CDA, F, post-​menop National US

Romania/​ Bulgaria

CDA, age 60+​

CDA, Jews

Multi-​site US

Italy

MP (post-​stroke) MP, HIV/​AIDS

India

Alabama

Latin America

Israel

Michigan

MP (chr low back pain)

CDA, E

CDA, E

CDA, age 45–​75, Jews

MP (cardiac)

NG

NG

#1D (R vs. atheists/​ agn) #1 R organizational activity

P

P

P

P

M (ORA-​P, SR-​NG)

SC

MC

MC

MC

MC

MC

SC

MC

MC P

MC M (ORA-​P, NORA-​NG)

MC

MC

MC

None

MC

MC

—​

MC

MC

MC

MC

P (? total effect)

NA

M

NA (SF-​36)

M

P

#1 ORA

#13 ORA,NORA,IR

#1 ORA

#5 DUREL

#2 ORA, SR

#2 ORA, NORA

#3 ORA, NORA, R educ

#4 ORA, relat w God

#1 R upbringing

#21 SR, Jewish activ, etc.

#5 ORA, NORA, IR

#7 NORA, ORA, SR, RC

#2 increase in R/​S

NA (functional recovery)

P

#14 Royal Free Interv

P

Hindu Yoga med/​exerc

NA

NG

P (PRC)

#5 DUREL

#2 R affil, SR

#1 SR (secular to orthod)

#14 RC

8

8

10

(8)

8

8

8

8

8

9

9

8

8

(8)

(8)

(8)

9

8

8

8

8

R

CS

PC(17)

CT/PC

PC(2)

CS

CS

CS

PC(10)

Choi (2020)

Allen et al. (2019)

*Kim ES et al. (2019b)

Hong et al. (2020)

Travers et al. (2020)

Avelar-​Gonzalez et al. (2020)

Orr et al. (2020)

6,383

R

S

C

R

6,122

128

470

20,518

5,200

248

-​

R

1,946

10,055

2,067

3,104

R

R

R

24

—​

Monserud (2019)

Exp

Aberer et al. (2018)

34,807

34,525

14,255

1,170

8,405

5,340

N

C

R

C

PC(16)

Li S et al. (2018b)

CS

CS

*Burke et al. (2017)

R (?)

*Abu et al. (2019c)

PC (9)

*Ahrenfeldt et al. (2017)

R

CS

PC (3.5)

*Cohen-​Mansfield et al. (2016)

C

PC (2)

CS

Canada et al. (2016)

S

Latham-​Mintus & Aman (2019)

CS

Sandhu et al. (2016)

ME T HOD

Latham & Clarke (2018)

T Y PE

TOPIC /​I N V E S T IG ATOR S

#1 meditation (vs. not)

Mexico Ireland

CDA, age 50+​

NY, NJ, Pennsylvania

National US & S. Korea

National US

North Carolina

Southwest US

#2 D, ORA

#4 ORA,NORA

#1 SR

#1 ORA

#1 ORA

#5 DUREL

#1 ORA

#1 R activities

#3 NORA, RC

Mass/​Georgia South Korea

#4 RB, RC

#1 ORA

#1 R/​S exercises

#1 ORA

None

MC

MC

MC

?

MC

None

None

MC

MC

—​

MC

SC

MC

None

MC

MC

C ON T ROL S

P (ORA in F MC Catholics); NG (D)

P

P (perc worse health)

P

P (mediated mortality effect)

P (IR moderated)

P

P

NA

NA

P

NA

NA (healthy aging)

NG

P (except W. Europe)

NA

#23 R identity, Δ in R #3 ORA, NORA, R educ

P (thru meaning/​peace)

NA (moderates dysthymia-​ADL relation)

F I N DI N G S

#4 “faith” (FACIT-​SP)

#1 SR

R E L IG VA R I A BL E S

National US

National US

Austria

National US

National US

Europe

Israel

National US

National US

L O C AT ION

MP, E, ave age 80

NHP, E

CDA, E

CDA, E

B, MP with osteoarthritis

Hispanic CDA, E

CDA, E

MP (acute coronary syn)

CDA, E (ave age 71)

CDA, E

MP w SLE, S. Sclerosis, melanoma

F, CDA, Nurses Hlth Study

CDA

CDA, age > 50

CDA, E (over age 75)

Cancer patients

CDA

P OP U L AT ION

9

(8)

(8)

8

10

8

9

8

(8)

8

8

(8)

10

8

9

(8)

8

8

R AT I N G

CS

Bruce et al. (2021)

1,126 429

679 1,911

S

R/​C

R

R

R

R/​C

CS

CS

CS

PC (2)

PC (8)

CS

CS

*Szaflarski (2001)

Hyyppa & Maki (2001; 2003)

*Krause (2002b)

Krause et al. (2002b)

*Morrow-​Howell et al. (2003)

Finch & Vega (2003)

*Van Olphen et al. (2003)

CS

*Sujoldzic et al. (2006)

625

R/​S

PC (1)

Musick (1996)

PC (3)

CS

*Krause (2006c)

CS

CS

Krause (2006b)

Krause (2006e)

CS

*Ostbye et al. (2006)

*Kim D & Kawachi (2006)

2,623

R

PC (59)

R

R

S

S

S

C

1,282

24,835

906

Ad (mean age 17)

CDA

CDA, E

E, CDA

CDA, E

CDA CDA, E

3,413

Intellectually gifted C

CDA

Ad (age 12–​16)

Utah

#2 ORA,SR (scale)

#12 ORA,NORA,R sup #6 ORA

#2 ORA, NORA Multi-​site US Bosnia

NA

P (F only)

P

P

M

P

#5 ORA, gratitude to God P (esp F) National US

North Carolina

National US

NG M (P-​ora, NG-​sr)

#9 ORA, SR, Ch-​base sup P

#6 ORA, NORA, RE

#4 SR, NORA, RB, ORA

#8 R (parent & Ad) #2 ORA, SR

National US

P

NA

#5 ORA, NORA, SR, RSup P (ORA)

#1 R support seeking

#1 Relig volunteering

Multi-​national California

P

P

NA

P

P

P

NA

P

P (age 80–​89)

#4 ORA, NORA, Ch sup M (M-​P, F-​Ng)

#2 ORA, SR, church sup

#3 ORA

#2 ORA,NORA

#2 ORA,SR

#8 ORA, NORA, RC

#1 ORA

#2 ORA, SR

#1 ORA

#1 ORA

National US

Detroit, MI

Fresno, Calif.

CDA, Mex-​Am CDA, F, B

National US

National US

National US

Finland

Poland (national)

National US

National US

Washington

Texas

North Carolina

China

CDA (over age 60)

CDA, Presbyterians

CDA, E, 54% B

CDA (50% Swedish)

CDA

CDA

CDA, E

CDA, E

CDA, Mex-​Am

MP with prostate cancer

Oldest old (ave age 90)

548/​238

1,119

119,769

*McCullough & Laurenceau (2005)

R

PC (3)

CS

*Caputo (2004)

3,012

993

2,000

1,518

10,930

*Helliwell & Putnam (2004)

R

R

R

CS

Drevenstedt (1998)

3410 511

R

R

CS

PC/​CS

1125

804

12,331

Krause (1998b)

R

?

?

Broyles & Drenovsky (1992)

CS

Levin & Markides (1986)

Self-​R ated Health

PC (3)

Li ZH et al. (2020b)

MC

None

MC

MC

MC

MC

MC

SC

MC

MC

MC

MC

MC

MC

MC

MC

MC

SC

MC

MC

MC

MC

MC

8

8

8

9

8

8

8

9

9

9

8

8

8

8

8

8

8

8

8

8

8

(8)

8

PC (2)

CS

CS

CS

CS

CS

CS

CS

*Green & Elliott (2010)

Scheitle & Adamczyk (2010)

Nicholson et al. (2010)

*Bailley & Roussiau (2010)

*Skarupski et al. (2010)

Gillum & Griffith (2010)

Kodzi et al. (2011)

CS

Krause (2009c)

PC (1)

PC(6)

Krause (2009b)

*Krause (2010d)

PC (23)

*Koenig LB & Vaillant (2009)

Krause (2010c)

CS

Ross et al. (2008)

PC (3)

CS

*Shmueli (2003; 2007)

CS

CS

*Reyes-​Ortiz et al. (2007)

Krause & Ellison (2009)

PC (4)

*Yeager et al. (2006)

Krause (2010b)

T Y PE

TOPIC/​I N V E S T IG ATOR S

537 208 508 450 1,011

R/​S

R/​S

R/​S

R/​S

R/​S

R (?)

R

C

R

R

2,606

22,929

6,534

338

39,334

30,523

1,000

680

R/​S

R

456

C

2,262

4,504

R

10,587

R/​C

2,930

N

R

R

M E T HOD

Slum residents (age > 50)

CDA

CDA, E (age > 65)

CDA, E (age 65 or older)

CDA from 22 countries

CDA (GSS 1972–​2006)

CDA

CDA, E

CDA, E

CDA, E

CDA, E

CDA, E

CDA, E

CDA, M, age 47 to 70

CDA cancer survivors

CDA, age 45–​75, Jews

CDA,E

CDA,E (92% non-​Christian)

P OP U L AT ION

Nairobi, Kenya

National US

Chicago

France

#2 D, ORA

#4 Prayer for health

#5 DSE©

#6 DSE©

#3 ORA, NORA, SR

#2 D, D switching

National US

#4 ORA, God med ctrl

#3 ORA, NORA, R sup

#4 ORA, Sp

#11 D, RB, IR, ORA, NORA

Europe

P

P

P (mediated)

NG

NA

P (SR)

NA

F I N DI N G S

NG (ORA)

NG

P

P

P

NG (Mormons/​ Jehovah Wit)

P

P (ORA only)

P (oldest old)

P (ORA only)

#2 Suppressing R doubt predicts worse SRH

#8 ORA, R sup, grat to God

#8 R volunt, RSup, RCm

#1 ORA

#1 prayed for own health

#1 D (secular to orthodox)

#2 R affil, SR

#12 D, ORA, RB, R prac

R E L IG VA R I A BL E S

National US

National US

National US

National US

National US

National US

National US

Inner city US

National US

Israel

Latin America

Taiwan

L O C AT ION

MC

MC

MC

None

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

C ON T ROL S

8

8

8

(8)

9

9

8

9

8

8

8

8

8

9

8

8

8

8

R AT I N G

R

R

CS

*Levin (2011)

CS

CS

CS

CS

CS

CS

PC (7)

CS

CS

CS

CS

*Levin (2012b)

*Levin (2013)

*Chiswick & Mirtcheva (2013)

*Assari (2013)

*Thege et al. (2013)

* Park NS et al. (2013)

Hayward & Krause (2013b)

Nam (2013b)

*Hayward & Elliott (2014)

*Battle & DeFreece (2014)

*McDougle et al. (2014)

S

CS

CS

Darviri et al. (2012)

CS

*Morton KR et al. (2012)

*Kim-​Yeary et al. (2012)

S

CS

*Lutjen et al. (2012)

R

C

R

R

R

R

R

R

R

R

R

R

R

R

PC (10)

CS

*Son & Wilson (2011)

*Krause & Bastida (2011)

R

CS

Huijts & Kraaykamp (2011)

S

CS

*Al-​Kandari (2011)

1,805

717

317,109

2,390

1,192

1,431

12,643

6,082

2,604

1,849

1,287

10,828

1,519

6,753

1,629

1,005

3,257

4,484

127,257

1,472

P

National US

CDA, age 25–​74

#9 ORA, NORA

#7 D, ORA, Sp scale

US, multi-​site

CDA, F, B, lesbian

M (P-​ORA, NG-​NORA)

M

P (but interact w govt restrict)

P (Whites)

P (RSup given, B only)

#16+​RSup, others

P (ORA)

P

P

P

NG (NORA)

P

P

P

NA

P (indirect thru optimism)

P

M

NA

#1 ORA

None

MC

MC

MC

MC

MC

MC

SC

MC

MC

MC

MC

MC

MC

MC

SC

MC

MC

MC

M (P-​ORA, NG-​SR) MC

#11 ORA, NORA, RC, DSE

#2 ORA, SR

#3 ORA, SR

National US

National US

National US

Hungary

#7 ORA, RSup

#3 ORA, SR, D

National US National US

#2 ORA, NORA

#3 ORA, NORA, R educ

#5 ORA, SR, NORA

#2 ORA, NORA

#9 SR, IR, RC

#4 D, SR, ORA, NORA

Israel

Israel

National US

Rural Greece

National US

National US

#2 ORA,RE

#1 R upbringing

#21 SR, Jewish activ, etc.

#3 D, ORA, SR

#1 SR

Worldwide

CDA

CDA

CDA, E (age > 65)

CDA

CDA

CDA, B

Child, ad (age 6–​19)

CDA, age 15 or older

CDA, Jewish (age > 50)

CDA

CDA

CDA (Adventists)

CDA (19% resp rate)

Southwest US

National US

CDA, age 25–​74 CDA, E, retired, Mexican

National US

Europe

Kuwait

CDA, Jews

CDA

NH (ave age 77)

(8)

8

(8)

8

8

10

8

8

9

8

8

8

8

8

8

(8)

8

9

8

9

T Y PE

PC (3)

CS

CS

CS

CS

CS

CS

CS

CS

CS

PC (3.5)

CS

CS

CS

CS

CS

PC (9)

CS

TOPIC/​I N V E S T IG ATOR S

*Krause & Hayward (2014b)

*Headey et al. (2014)

*Krause et al. (2015)

*Dong & Zhang (2015)

Stavrova (2015)-​study 1

Stavrova (2015)-​study 2

Speed & Fowler (2016)

*Hayward et al. (2016b)

*Fenelon & Danielsen (2016)

*Wyshak (2016)

*Cohen-​Mansfield et al. (2016)

*Rivera-​Hernandez (2016)

*Speed & Fowler (2017)

*Speed (2017)

*Burke et al. (2017)

Hvidt et al. (2017)

*Ahrenfeldt et al. (2017)

Brooks et al. (2018)

R

R (?)

C

R

R

R

R

R

S

R

R

R

R

R

C

R

R (?)

R (?)

M E T HOD

26,701

14,255

3,000

34,525

2,670

3,620

364

1,070

93,676

34,565

3,010

3,427

20,773

85,748

3,159

1,774

257,000 person-​ years

918

N

Europe UK, Scotland,Can

Youth, age 11–​15

Denmark

National US

National US

Canada

Mexico

CDA, age > 50

Young twins

CDA

CDA

CDA

CDA, Mexican, w diabetes

Israel

National US

CDA, F, 49–​79 yo CDA, E (over age 75)

National US

National US

National US

National US

Worldwide

Chicago

National US

Germany

National US

L O C AT ION

CDA

CDA

CDA

CDA

CDA

CDA, E, Chinese

CDA

CDA

CDA, E (age > 65)

P OP U L AT ION

#1 Connection to Transcendent

#3 ORA, NORA, R educ

#5 ORA, NORA, RC, RB

#1 meditation (vs. not)

#4 ORA, NORA, SR, RB

#3 ORA, NORA, SR

P

P (except S. Europe)

NG

NA

NA

P affil, NG non-​affiliated

NA

(P) (decrease R)

#3 R identity, Δ in R #3 ORA, SR

NG

P (i.e., NG for disaffil)

#2 D, RC

#1 R disaffiliation

NG in atheists NA

#3 ORA, NORA, SR

P (only in R regions)

P (only in R countries)

SC

MC

MC

SC

9

9

8

8

8

8

MC MC

8

(8)

9

8

8

8

9

9

8

8

8

8

R AT I N G

MC

None

MC

MC

MC

MC

MC

MC

None

MC

P (indirect) NA

MC

MC

C ON T ROL S

P

P (indirect thru hope)

F I N DI N G S

#1 religious vs. non-​R

#1 ORA

#4 ORA, SR

#3 ORA, NORA, SR

#10 ORA,God image, SpSup,+​

#1 ORA

#4 religious music

R E L IG VA R I A BL E S

CS

CS

CS

CS

CS

CS

CS

CS

?

*Yeung (2018)

Stroope & Baker (2018)

*Brammli-​Greenberg et al. (2018)

Mukerjee & Venugopal (2018)

*Lawrence EM (2019)

*Shen (2019)

*Marshall (2019)

*Stroope et al. (2020)

Berggren & Ljunge (2020)

PC (23)

CS

PC (3)

PC (10)

CS

CS

CS

*Koenig LB & Vaillant (2009)

*Moxey et al. (2011)

*McIntosh et al. (2011)

*Son & Wilson (2011)

*Levin (2012b)

*Chiswick & Mirtcheva

*Headey et al. (2014)

General Physical Health (more objective)

CS

*Krause (2018a)

R (?)

R

R

R

R

R

C

C

C

R

R

R

R

257K person-​ years

2,604

1,287

3,257

890

752

456

5,364

933

thousands

National US Germany

Youth age 6–​19 CDA

Israel

National US

CDA, age 25–​74 CDA, Jewish, age > 50

National US

Australia

CDA, age 55–​85 CDA (after Sept 11th)

Inner city US

Europe

US cities

26 countries

National US

National US

National US

Israel

National US

Texas

National US

CDA,M, age 47–​70

CDA

CDA, South Asians

CDA

CDA CDA, E, age 49–​64

15,442

CDA

CDA, Israeli Jews

CDA (and county level)

CDA

CDA

8,726/​ 4,392

23,353

4,057

25,862

C/​S

R

1,504

1,744

R

R

#1 ORA

#3 ORA, SR, D

#3 ORA, NORA, R educ

#1 R upbringing

#3 ORA, IR

#2 SR, ORA

#1 ORA

#1 SR

#1 SR

#2 R affil, ORA

#1 ORA

#1 ORA

#3 D, ORA, SR

#1 R categories (Haredi, etc., vs. secular)

#2 ORA, RS

#6 ORA, NORA

#4 ORA, RSup

P

MC

MC

MC

M (ORA-​P, NORA-​NG) P

MC

MC

MC

MC

MC

P (physical symptoms)

P

NG (comorbidity)

P (mediated)

NG

SC MC

M

MC

MC

MC

MC

MC

MC

MC

P (slight/​mod v. hi)

P

P

P (M > F)

M

P, but only in R counties

NA

P (indirect effect)

8

8

8

9

9

(8)

9

8

(8)

8

8

9

9

8

9

8

8

CS

CS

CS

PC (9)

CS

PC (14)

CS

PC (11)

CS

CS

CS

*Krause et al. (2015) (symps)

*Hayward et al. (2016b) (chronic hlth)

Sotodehasl et al. (2016)

*Ahrenfeldt et al. (2017)

*Hvidt et al. (2017)

*Chen Y & VanderWeele (2018)

*Baker et al. (2018)

*Ahrenfeldt et al. (2019)

*Brammli-​Greenberg et al. (2018)

Agadjanian & Jansen (2018) (child malnutrition)

*Moons et al. (2019)

R

C

R

R

R (?)

R

S

C

R (?)

R

R

R

R/​S

M E T HOD

3,583

4,028

1,255

4,057

23,864

1,714

6,950

3,000

14,255

470

3010

1,774

5,411

N

Mothers giving birth

MP, congenital heart disease

Mothers of child 0–​5

CDA, Israeli Jews

CDA (10 countries)

CDA (25% response rate)

Ad (ave age 15)

Young twins

CDA, age > 50

CDA, M

CDA

CDA

CDA, Seventh-​Day Adventists

P OP U L AT ION

CS

CS

Grzywacz & Keyes (2004)

Ng T et al. (2009)

R

R 1,281

3,032

CDA,E

CDA

Health Broadly Defined (including physical, emotional, and social elements)

Burdette et al. (2012)

CS

CS

*Superville et al. (2014)

Low Birthweight

T Y PE

TOPIC/​I N V E S T IG ATOR S

#2 SR

Multi-​national

Singapore

National US

P (compl hlth) P (sucess aging)

#1 RC (R/​S sup/​ comfort)

P

NG

P (esp Protestant)

P

M

P (but atheist > other D)

NG (no. of PH problems)

NG (obj hlth)

P (except S. Europe)

#1 ORA

#1 ORA

#1 Churched vs. not churched

Mozambique

National US

#1 R categories (Haredi, etc., vs. secular)

#3 ORA, NORA, R educ

#3 D (atheists vs. other), ORA

#2 ORA, NORA

#5 ORA, NORA, RC, RB

#3 ORA, NORA, R educ

P

NG

#1D (R vs. atheists/​ agn) #1 Prayer frequency

P (indirect)

P

FI N DI N G S

#10 ORA,God image, SpSup,+​

#1 Sabbath keeping

R E L IG VA R I A BL E S

Israel

Europe

National US

National US

Denmark

Europe

Iran

National US

National US

National US

L O C AT ION

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

C ON T ROL S

8

8

8

8

8

8

9

8

10

8

9

(8)

8

8

8

R AT I N G

CS

CS

PC (1m)

PC (11)

CT

*Al-​Kandari (2011)

Dezutter et al. (2011)

*Basinski et al. (2013)

Tronvik et al. (2014)

*Beiranvand et al. (2014)

24,610 160

—​

92

202

1,472

S

C

C

S

C

PC(3-​7 mo)

*Andersson (2008)

118

83

—​

*Wachholtz & Pargament (2008)

CT

CT

*Tekur et al. (2008)

37,000

80

Exp

Wiech et al. (2008)

R

—​

CS

*Baetz & Bowen (2008)

72

—​

24

CT

John PJ et al. (2007)

122

68

C

—​

C

CT

PC (4 wk)

Wachholtz & Pargament (2005)

Cohen L et al. (2005)

188

382

74

C

R

CS,D

PC (?)

Cronan et al. (1989)

C

PC (8 wk)

Hodges et al. (2002)

Turner & Clancy (1986)

Iran

Norway

CDA (age 20+​) Muslim women C-​section

Poland

Belgium

Kuwait

Sweden

Midwest US

India

Oxford, England

Canada

India

Toronto, CAN

Ohio

Tennessee

San Diego

Seattle, WA

MP w chron pancreatitis

Chronic pain pts

NH (ave age 77)

MP w chronic pain

MP (vascular HA)

MP (chr low back pain)

12 religious, 12 athiest

CDA

MP (migraine w/​ o aura)

MP, F (pre to post-​surg)

CS

MP (spinal surgery)

CDA MS compl

MP-​low back

Chronic Pain (less pain or greater tolerability of pain =​P, unless otherwise specified)

Chronic Pain (Chapter 29) and Somatic Symptoms

Recited prayer meditation

#1 ORA

#2 ORA, SR

#2 R affil, SR

#1 SR

#3 prayer

Sp vs. secular meditation

Hindu Yoga med/​exerc

View R vs. Sec painting

#3 ORA, Sp, prayer cope

Hindu Yoga

#2 RC (brief COPE)

Spiritual meditation

—​

P

Headache predicted ORA

NA

P (pain endurance)

P

—​

MC

None

None

None

8

9

(8)

(8)

(8)

(8)

9

9

8

—​ —​

8

8

(8)

8

(8)

8

(8)

SC

—​

MC

—​

None

NA (PC), NG (CS) ? SC

P (Sp)

P

P

M

P

NG

P (cold pressor)

NA

#1 most common, #2 most helpful

#7 INSPIRIT (79% hi)

#2 (R use/​helpful)

SC

P

#1 “praying or hoping”

T Y PE

CT

CT

CS

CS

CT

CS

CS

CS

CT

CT

CS

CS

CS

CS

CS

CS

CS

TOPIC/​I N V E S T IG ATOR S

Nasiri et al. (2014)

Feuille & Pargament (2015)

*Burke et al. (2017)

*Liu X et al. (2018)

Sollgruber et al. (2018)

*Brammli-​Greenberg et al. (2018)

Harris JI et al. (2018b)

Goudarzian et al. (2018)

Meints & Edwards (2018)

Keivan et al. (2019)

Xu et al. (2019)

Hatefi et al. (2019)

Tafazoli et al. (2019)

Lea et al. (2019)

Nunes-​Reis et al. (2020)

Major & Adam (2020)

Grossoehme et al. (2020)

68

—​

522 127

—​

100

585

200

300

R

C

C

C

C

156

208

—​

C

380

436

S

C

4,057

113

—​

R

2,052

34,525

107

80

N

R

R

—​

—​

ME T HOD

Ad with cancer

Ad (grades 5–​12)

Middle US

Hungary

Brazil

Multi-​site US

Veterans/​Active Duty F, chron pelvic pain

Iran Iran

F, post-​C-​sec pain

China

Iran

Indiana

Iran

Minnesota

Israel

Austria

Province in China

National US

Ohio

Iran

L O C AT ION

E, chron back pain

CA pts w chron pain

Burn patients

Pain-​free CS

Hospitalized cancer pts

Veterans w chron pain

CDA, Israeli Jews

Meditators (exper & novices)

CDA

CDA

MP with migraine

Muslims, heart surgery

P OP U L AT ION

F I N DI N G S

#5 BMMRS

#1 ORA

#5 DUREL

#10 RCm

#10 RWB

#30 RC, attach to God

#1 R faith (96% none)

#1 Sp care intervention

#1 Prayer (act, pass, none)

#14 RC (Brief RCOPE)

#26 Sp struggles only

#1 R categories (Haredi, etc., vs. secular)

Taoist meditation

#1 “follower of a R”

#1 Sp meditation

Standard mindfulness vs. Sp mindful vs. relax MC

—​

—​

C ON T ROL S

NA (pain interference)

NAq

NA

NG

NA

P

NA (pain acceptance)

P

P (pain tolerance)

P (exc NRC)

Pain catastrophe/​ interfere

P

P

None

None

None

MC

None

(8)

(8)

(8)

(8)

(8)

(8)

(8)

—​ None

8

8 —​

—​

(8)

(8)

SC

MC

8

8

8

8

8

8

R AT I N G

MC

—​

P (bivar only, NA in multivar)

NG (back pain)

NA

Reciting prayer (praise) P

R E L IG VA R I A BL E S

CS

Asadi-​Piri et al. (2020)

C

C

CS

CS

CS

CS

CS

CS

CS

PC (6)

CS

CS

*Shmueli (2007; 2003)

*Yamaoka (2008)

Pimenta et al. (2014)

*Frick et al. (2016)

*Bussing et al. (2016)

*Jang M et al. (2018)

O’Donnell et al. (2018)

*Pawlikowski et al. (2019)

Hamdan & Peterseil-​Yaul (2020)

Zidkova et al. (2020)

With functional abdominal pain disorder.

PC

*Ai et al. (2006b) (physical fatigue)

q

CS

*Krause & Ellison (2003)

R

C

R

C

C

C

C

C

4,182

321

6,458

155

200

7,390

8,574

710

8,665

4,504

R/​C

R/​C

335

1,316

?

150

S

S

Somatic Symptoms (somatization) (less somatization =​P)

CS

Vasigh et al. (2020)

Israel Czech Republic

CDA, age 18–​36 Ad, age 11–​15

National Poland

Ireland

F, post-​abortion Age 16 or older

Nepal

Germany

Catholic clergy/​ helpers C, earthquake survivors

Germany

Lisbon, Portugal

Peri-​/​post-​ menopausal F Clergy and deacons

East Asia

CDA

Israel

Michigan

MP-​cardiac surgery CDA, age 45–​75, Jews

National US

Iran

Iran

CDA, E, 49% B

Chronic pain pts, E

Chronic pain pts

#8 ORA, RWB, EWB

#2 SR, R practices

#1 ORA

M

NA

NA (with PHQ-​15) (NG for > weekly vs. weekly)

NA

P

#2 SR, Δ in prayer freq #1 R affil vs. no

NG, although . . .

P

P

NG

NG

M (P-​PC, NG-​CS)

M (Ora-​P, Nora-​NG)

P (pain self-​efficacy)

P (pain self-​efficacy)

#6 DSE©

#15 DSE©, Sp dryness

#20 SWB scale©

#1 Rlg faith (yes vs. no)

#1 SR (secular to orthodox)

#19 NORA, PRC, NRC

#3 ORA, NORA, God forg

“Spirituality”

#20 SWB©

SC

8

(8)

10

MC

None

(8)

(8)

8

8

(8)

8

8

8

8

(8)

(8)

MC

None

MC

MC

MC

MC

MC

MC

MC

None

None

T Y PE

M E T HOD N

P OP U L AT ION

L O C AT ION

R E L IG VA R I A BL E S

F I N DI N G S

CS

CS

CS

CS

CC

PC (3–​12)

King DE & Pearson (2003)

Vu et al. (2016) (delayed care)

Rogers-​Sirin et al. (2017)

Onyigbuo et al. (2018)

Moorman et al. (2019)

*Chen Y et al. (2020a)

599 92,008

C/​R

297

496

254

18,162

260

C

C

C

C

R

C

CDA

MP, B, ovarian CA

CDA, Nigerians

Professors and CS

CDA, F, Muslim

CDA

CM,R

#1 ORA

#4 ORA, NORA, RC, SR

Multi-​site US National US

#5 RC, RB, R behavior

#6 ORA, NORA, RC

#12 SR, IR, RC

#1 ORA

#2+​ ORA

United Kingdom

Turkey

Chicago

National US

Midwest US

R

CS

Litton et al. (2011) (vac intent)

—​

S

CS

*Reeve & Basalik (2011) (immuniza)

R

R

R

R

Ruijs et al. (2011) (vac coverage) CS

CS

CS

Stupiansky et al. (2010) (HPV)

CS

Antai (2009) (child vacs)

Reiter et al. (2010) (HPV)

PC (2)

*Benjamins & Brown (2004) (flu)

403

432

50 states

406

1,323

3,725

6,055

CDA, F, w dau 10–​14

Cities

State averages

#1 D (Orthod Prot Den) #1 ORA

Netherlands Alabama

#7 RB, ORA, SR, NORA

#1 SR

National US US

#1 “religiosity”

National US

CDA, F, w sons age 9–​18

CDA, F, age 27–​55

#1 D (59% Muslim)

#2 D, SR

Nigeria

National US

CDA, F w child age ≥ 1

CDA, E

Vaccination/​Immunization (P =​positive attitudes toward vaccination; NG =​negative attitudes; “>” indicates more likely vaccination)

CS

Apel (1986)

Healthcare Seeking, Knowledge about Prevention

Disease Prevention

MC

MC

SC

MC

MC

NONE

C ON T ROL S

NA w intention to vac

Lowest in OPD

NA

NG (accept)

NG (accept)

Christian > Muslim

P, esp Jewish

MC

SC

None

MC

?

MC

MC

NA (prevent hlth MC care use)

NG (late stage at diag)

NA (other than Christian)

NG (seeking pychol serv)

NG (delay due to no F physician)

P (continuity w provider)

P

Disease Prevention, Detection, and Compliance (Chapter 30) (“>” indicates greater activity, greater screening, more positive prevention activity)

TOPIC/​I N V E S T IG ATOR S

(8)

(8)

(8)

(8)

(8)

8

9

10

(8)

(8)

(8)

(8)

8

(8)

R AT I N G

CS

CS

CS

CS

CS

Taylor S et al. (2017) (polio)

Motta et al. (2018) (anti-​vac)

Krok-​Schoen et al. (2018) (vac ref)

Sarathchandra et al. (2018)

CS

Repalust et al. (2017) (child vac)

CS

CS

Larson HJ et al. (2016) (vac blfs)

Bodson et al. (2017) (HPV)

Discusses view of Jews, Hindus, Catholic Christians, Protestant Christians, Amish, Jehovah’s Witnesses, and Muslims to measles vac

Wombwell et al. (2015)

Moran et al. (2017) (flu)

CS

Watkins et al. (2015) (HPV)

C

C

C

S

C

C

R

R

C

C

246

337

1,310

3,306

1,565

326

1,000

65,819

759

408

CDA (Internet)

CDA, parents of girls 9–​17

CDA

CDA, w child < 5 y

National US

Ohio

National US

#? “religiosity”

#4 D, SR, RB, ORA

#1 ORA

#1 intensity of R observ

#1 ORA

Los Angeles Nigeria

#2 ORA,RB

Utah

#1 SR

CDA, F, age 18–​26 CDA, Hispanic, age 21–​50

NA (with willingness to vaccinate)

NA (with intention to vaccinate)

NA (receive vaccine)

NA

NG

NA for vac, NG for intent

MC

MC

MC

MC

MC

2% to 50% range

None

MC

None

None

SC

MC

NA w vaccine acceptance

MC

NG (bivariate), NA (multivariate)

NG

NA (refuse OPV)

P

NG

NG (vaccine refusal)

#1 Vaccine incompatible with RB

#1 Rely on God for health

Croatia

67 countries

Houston, TX

#10 R scale

CDA (68% parents)

CDA

CDA, F, B

F, age 18–​26, no HPV vac

CDA with son 11–​17 Utah

#1 ORA

CS

779

National US

Krakow et al. (2015) (HPV vac)

C

#21 IR, ER (Allport)

Brooklyn

CS

323

CDA with dau 9–​18

Taylor J et al. (2014) (HPV)

C

#2 D, ORA

National US

CS

476

CDA with dau age 9–​17

Reynolds (2014) (HPV)

C

#1 SR

National US

CDA, mothers, dau 9–​18

MC

None

CS

444

NG (intent to vac)

NA with vac dau

Shelton et al. (2013) (HPV)

R

#1 R orthodoxy

Israel

CDA, F, w dau < 18

#3 “spirituality”

CS

103

St Louis

Sadigh et al. (2012) (HPV)

C

CDA, B, w dau 9–​17

CS

200

Natan et al. (2011) (vac intent)

C

CS

Thompson et al. (2011) (vac)

(8)

(8)

(8)

8

8

(8)

8

8

(8)

(8)

(8)

(8)

(8)

8

(8)

(8)

C

R

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

Elran et al. (2018) (child vac)

Athanasakis et al. (2018) (flu)

Makarić et al. (2018) (child vac)

Ganczak et al. (2018) (HPV)

Birmingham et al. (2019) (HPV)

Franco et al. (2019) (HPV)

Best et al. (2019) (HPV)

Bryden et al. (2019) (vac at 5 y)

Padilla et al. (2020) (flu)

Hennebery et al. (2020) (HPV)

Callaghan et al. (2020) (COVID-​19)

Olagoke et al. (2021) (COVID)

Cadeddu et al. (2020) (anti-​vac)

Galor et al. (2020) (HAV vac)

Quinn & Lewin (2020) (vac)

Stecula et al. (2020) (anti-​vac)

Smith DT et al. (2020)

C

R

C

R

R

C

C

R

C

R

C

C

R

R

C

C

CS

Grandahl et al. (2018) (HPV)

ME T HOD

T Y PE

TOPIC/​I N V E S T IG ATOR S

1,037

1,680

608

634

2,626

502

4,613

254

173

897

307

20,495

1,631

450

542

1,268

1,504

301

N

CDA

CDA

CS

Israeli Defence Force recruits

CDA, age 15 or over

CDA

Australia

National US

Pennsylvania

Israel

Italy

National US

National US

New Orleans

F (18–​26), parent (dau 12–​17) CDA

Texas

Australia

CDA, Hispanic

Major city postcodes

Florida

National US

Ad, age 13–​17 CS, F

Utah

Poland

Croatia

Greece

Israel

Thailand

L O C AT ION

CS

Parents of 17 yo’s

Parents of C age 6

CDA > 60 yo

CDA with child 2–​30 m

CDA, parents of dau 9–​12

P OP U L AT ION

#1 SR

#1 SR

#1 Family religiosity

#1 R orthodoxy

#1 religion (yes, no)

#5 Durel (ORA, NORA, IR)

#1 “religiosity”

#1 SR

#5 Durel (ORA, NORA, IR)

#1 R affil (any vs. none)

#1 RB (affecting sex)

#1 SR (state level)

#10 Rcm

#1 SR

#1 SR

#1 SR

#1 R orthodoxy

#1 SR

R E L IG VA R I A BL E S

M

NG

NG

NA

NA

NG

NG (vaccine hesitancy)

NA

NA

P

NG (mediated by sex activity)

NG

NG (vaccine adhere)

NA (willing to vaccinate)

NA

P (vaccinated in past yr)

NA

P (benefit)

F I N DI N G S

MC

MC

?

None

None

MC

None

None

None

MC

MC

MC

None (?)

None

MC

None (?)

MC

MC

C ON T ROL S

(8)

8

(8)

(8)

(8)

(8)

(8)

(8)

(8)

8

(8)

8

(8)

(8)

(8)

(8)

(8)

(8)

R AT I N G

R

CS

Engin & Vezzoni (2020) (anti-​vac)

CS

CS

Azaiza et al. (2010) (Br screening)

*Reeve & Basalik (2011) (mamo)

397 50 states

—​

320

9890

9890

9890

1,504

4,253

4,253

4,253

853

7,866

6,055

6,055

6,055

6,055

6,055

2,626

977

R

C

R

R

CS

R

R

PC (2)

PC (4)

*Benjamins (2006b)-​breast self

Hatefnia et al. (2010) (mamo)

PC (4)

*Benjamins (2006b)-​pap

R

*Benjamins (2007)-​diabet

PC (4)

Benjamins (2006b)-​mamo

R

R

R

CS

Altpeter et al. (2005) (mamo intent)

PC (2)

PC (4)

Benjamins (2005)(chol)

R

PC (2)

PC (2)

*Benjamins & Brown (2004b) (breast self)

R

*Benjamins (2007)-​BP

PC (2)

*Benjamins & Brown (2004b) (mamo)

R

*Benjamins (2007)-​chol

PC (2)

*Benjamins & Brown (2004b) (prost)

R

R

PC (2)

*Benjamins & Brown (2004b) (Pap)

R

*Hill TD et al. (2006a)-​physical/​ CS dental

PC (2)

Benjamins & Brown (2004) (chol)

Disease Detection (Screening; “>” means more screening)

R

CS

Włodarska et al. (2021) (child)

State averages

US

Israel

Iran

CDA, F, Palestinian

Mexico

CDA, F, age > 35

Mexico

Mexico

Texas

National US

National US

National US

North Carolina

National US

National US

National US

National US

National US

National US

Italy

Poland

CDA, E

CDA, E

CDA, E

CDA

CDA, F, age 51–​61

CDA, F, age 51–​61

CDA, F, age 51–​61

CDA, F, rural

CDA, E

CDA, E

CDA, E

CDA, E

CDA, E

CDA, E

CDA

CDA

P

P

P

M

P

P

P

P

NG

P

P (Jew > None)

P (Jew > None)

P, esp Jewish

P (Jew > None)

P, esp Jewish

NA

NG

#7 RB, ORA, SR, NORA

NG

#2 D, SR      NG (CBE, SBE, Mamo)

#2 RB

#3 ORA, SR

#3 ORA, SR

#3 ORA, SR

#1 ORA

#3 D, ORA, SR

#3 D, ORA, SR

#3 D, ORA, SR

#2 RB about breast lump

#3 D, ORA, SR

#2 D, SR

#2 D, SR

#2 D, SR

#2 D, SR

#2 D, SR

#3 SR, ORA, NORA

#1 SR

None

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

MC

(8)

8

(8)

8

8

8

8

9

9

9

8

9

9

9

9

9

9

8

8

R

C

CS

CS

CS

CT

CS

CS

CS

CS

CS

CS

CS

CS

CS

CT

CS

*Salmoirago et al. (2011)

Nguyen et al. (2012) (Pap, CBE)

Ochoa-​Frongia et al. (2012)

Holt et al. (2013) (colorec scrn)

O’Reilly et al. (2013) (Breast CA screening)

Allen et al. (2014) (mamo, Pap, colo)

Conway-​Phillips & Janusek (2014)

Padela et al. (2015) (mamo)

Brittain & Murphy (2015) (colorectal)

Leyva et al. (2015) (mamo,pap,colo)

Moore E et al. (2016) (multi-​screen)

Melvin et al. (2016) (mamo)

Sen & Kumkale (2016) (mamo)

Best et al. (2016)

Plantinga et al. (2016) (genetic test)

504

200

—​

C

474

550

602

5,102

129

240

134

78

37,211

C

R

C

C

C

C

R

CDA, age 18–​40 w partn

CDA, F, B

CDA, F

CDA, F

CDA, B, church v comm

CDA

CDA, B

CDA, Muslim

CDA, F, B

CDA, F, Hispanic

CDA, F

16 chuches, 285 members

—​

CDA, F, B, underserved

CDA, F, Vietnamese

CDA, F

CDA, Presbyterians

P OP U L AT ION

900+​

111

56,372

1,076

N

C

C

C

C

CS

Benjamins et al. (2011)

ME T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

Netherlands

Multi-​site US

Turkey

National US

Kansas City

National US

Michigan

Chicago

Illinois

Massachusetts

Northern Ireland

Alabama

New York City

Richmond, VA

National US

National US

L O C AT ION

#1 “religion”

Sp framing of mammography screening message

NG

P

NA

NG

#? R/​Sp value #? “religiousness”

NA

P (mamo, colo) #6+​ORA, NORA,SR

#1 ORA

P (colonoscopy)

NG (past 2 y)

#4+​SR, IR, RC #? “religiosity”

P (Breast CA screen)

P (positive RC)

P (br screen low in no R affil)

NG for fecal blood test

NA w Br/​Cerv CA scr

M (dep on acculturation)

P (more screening)

P (more screening)

F I N DI N G S

#10 Sp Persp Sc

#16 ORA, RB, RC

#2 R affiliation

Sp vs. non-​Sp intervention

#? “religious beliefs”

#21 IR, ER

#1 ORA

#5 ORA, RB, R support

R E L IG VA R I A BL E S

None

MC

?

MC

MC

MC

MC

MC

MC

SC

MC

—​

?

MC

MC

MC

C ON T ROL S

(8)

8

(8)

8

(8)

8

(8)

(8)

(8)

(8)

8

8

(8)

(8)

9

8

R AT I N G

CS

CS

Freund et al. (2019) (mamo,CBE)

Kretzler et al. (2020) (cancer)

R

R

R

C

R

S

R

C

R

PC (20m)

CT

CS

PC (6m)

CS

Peltzer et al. (2011) (med adhere)

Huguelet et al. (2011) (appt attend)

Leone (2011) (provider Rx recs)

Finocchario et al. (2011) (med adhere)

Grossoehme et al. (2012)

C

C 28

204

48

78

—​

C

735

1,170

861,303

10,116

7,043

799

Ohio

Missouri

HIV+​ patients Parents of child w cystic fibrosis

South Carolina

Switzerland

South Africa

Diabetic outpatients

PP (schizophrenia)

HIV+​ patients

National US

F, age 15–​20

National US Israel

CDA, F (88% J, 12% Arab)

CDA, E

Germany

Israel

CDA age 40 or over

Kansas City

CDA, F, ultra-​ orthod, Arab

Canada

Toronto, Can

#12 RC, RB

#? RC, RB, ORA, NORA

#? NORA, provider Sp

Psychiatrist Sp assessment vs. no

#2 Sp prac & prayer, D

#1 SR

#1 SR

#4 RB, IR, RC

#1 ORA

#1(?) RB

#9 ORA, NORA,CM

#3 D, ORA, SR

#1 R affil

#17 RB, RSup

#14 Sp act, coping, God ctrl

Dallas/​Houston National US

#1 meditation (vs. not)

#38 BMMRS

#4 ORA, NORA, RC, SR

National US

National US

National US

CDA, B

CDA, F

1,202–​ 2,670 274

Outpatients

CDA,B

Young gay men (18–​29 y)

CDA

CDA, Hispanic

CDA, B

5,311

766

1,565

34,525

2,316,218

36,613

S

Compliance with Treatment (ART =​antiretroviral therapy)

CS

CS

Bauer et al. (2018) (blood sugar)

Mason et al. (2020) (PAP, pelvic)

R

CS

Speed (2018) (Pap, mamo)

PC(4)

CS

Lofters et al. (2018) (Breast screening)

CS

PC (2.5)

Holt et al. (2018) (mam, PSA, col)

Cadet et al. (2021) (Br CA)

CS

*Carrico et al. (2017) (HIV screen)

Pinchas-​Mizrachi, Solnica, et al. (2021)

R

CS

*Burke et al. (2017) (chol check)

R

CS

Cadet et al. (2021) (Pap)

C

CS

*VanderWeele et al. (2017a)

P (adhere self-​efficacy)

NG (God LOC)

P

P

P (Christian v other)

NA

P (Arabs), NG (Jews)

P (Hispanics)

P

NG

P (yrs of CM)

P (mamo-​ORA)

P

NA

P

P

P

P (physical exam)

(8) (8)

None

(8)

8

9

(8)

8

8

8

(8)

(8)

8

(8)

8

(8)

8

9

8

MC

None

—​

MC

MC

MC

MC

MC

MC

MC (?)

MC

None

MC

MC

SC

MC

None

T Y PE

PC (3m)

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

CS

PC(4m)

CS

TOPIC /​I N V E S T IG ATOR S

Deane et al. (2012) (dropouts)

Kisenyi et al. (2013) (med adhere)

Amr et al. (2013) (med adhere)

*Kretchy et al. (2013) (med adhere)

Watkins et al. (2013) (self-​care)

Grossoehme et al. (2015) (med adhere)

Pecoraro et al. (2016) (med adhere)

Alvarez et al. (2016) (CHF tx adhere)

Silva et al. (2016) (med adhere)

Mutumba et al. (2016) (ART adh)

Papailou & Kiani (2016) (adhere to tx)

Abdel Aziz et al. (2016) (med adhere)

Dalmida et al. (2017) (med adhere)

Gurak et al. (2017)

Freire de Medeiros et al. (2017)

C

C

C

C

C

C

C

C

C

C

C

C

C

C

C

M E T HOD

202

64

292

121

101

464

88

130

120

142

132

400

92

220

618

N

MP, on renal dialysis

Brazil

Florida

Southeast US

MP, HIV+​ Families in treatment for schizophrenia

United Arab Emirates

PP, schizophrenia

Iran

Uganda

Ad, HIV+​ MP, Ad, Type I diabetes

Brazil

Brazil

Russia

Ohio

Illinois

Ghana

Egypt

Uganda

Australia

L O C AT ION

MP, kidney transplant

MP, congest heart fail

dropouts vs. engaged in treat

Parents of child w cystic fibrosis

Diabetics, B

MP, hypertension

PP with schizophrenia

MP with HIV/​AIDS

PP, 12-​step inpt drug/​alc

P OP U L AT ION

#5 DUREL

#29 RC

#33 BMMRS

#1 Saw faith healer after DC

#21 ER, IR

#9 ORA, NORA,RC

#5 ORA, NORA, IR

#9 ORA, NORA, IR, Faith

#12 View of God Inventory

Many # RC, RB

#15 Syst Blfs Invent (SBI)

#12 ORA, NORA, Sp

#16 DSES

#5 D, ORA, NORA

#8 Sp beliefs scale©

R E L IG VA R I A BL E S

P (dialysis session adher)

NG (fewer fam sessions attend)

P (prayer only)

SC

MC

MC

MC

SC

NA-​IR, NG-​ER NG

MC

MC

MC

None

None

SC

SC

MC

None

MC

C ON T ROL S

NG (prayer)

P (IR)

P

P (HIV tx)

C

P

NG (Sp)

P

P

NA

F I N DI N G S

(8)

8

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

(8)

8

R AT I N G

CS

PC (3m)

PC(16m) C

CS

CS

CS

CS

PC(1)

CS

CS

PC (1)

CT

Ransome et al. (2019b) (med adhere)

Yilmaz et al. (2019) (med adhere)

Assemie et al. (2019) (med adhere)

*Fikriana et al. (2019) (med adhere)

Movahedizadeh et al. (2019) (med adhere)

Helvaci et al. (2020) (med adhere)

Akinnawo et al. (2019) (med adhere)

*Saffari et al. (2019) (med adhere)

Berner et al. (2019) (med adhere)

Seyedfatemi et al. (2019) (med adhere)

Poteat & Lassiter (2019) (med adhere)

Moradi et al. (2020)

167 30

—​

400

120

793

227

112

164

225

73

168

647

92

760

C

C

CS

C

C

C

C

R

S

C

C

CS

El-​Masry et al. (2018) (med adere)

C

CS

Lin CY et al. (2018) (med adhere)

Iran

Southeastern US

MP, B, HIV+​ MP, hemodialysis (HD)

Iran

Vienna, Austria

Iran

Nigeria

Turkey

Iran

MP, heart failure

MP, rheum arthritis

MP, E, type II diabetes

PP, outpatients

MP, COPD

PP

Indonesia

Ethiopia

MP, HIV+​, stopped ART MP, hypertension

Turkey

Brazil, Thailand, Zamiba

Egypt

Iran

MP, chronic illness

MP, HIV+​

MP, cancer

MP, epilepsy

Sp-​integrated cognitive therapy

#14 PRC, NRC

#2 RC

#5 RC

#25 ORA, NORA, IR, RC

P (compliance w HD)

P (exc NRC)

P

NA

P

P

P

#12 FACIT-​Sp© #6 IR, ER

P

P

—​

SC

None

MC

MC

None

None

SC

MC

22% stopped ART due to Sp beliefs

None

NG (post-​Hajj), NA (3m)

(8)

(8)

(8)

(8)

8

(8)

(8)

(8)

8

(8)

(8)

8

MC

NG (worsens alcohol-​adhere relation)

(8) (8)

MC MC

P (analgesics)

P

#24 R faith, RC

#2 RC (COPE)

#1 Sp beliefs

R pilgrimage (Hajj)

#1 ORA

#10 RCm

#17 DUREL, RC

PC(30d)

Rco

PC (3m)

Exp

CS

DeFranza et al. (2021) (COVID-​19)

*Shin J. et al. (2020)

Lyon et al. (2020) (Rx contin)

*Dwidiyanti et al. (2020) (med adhere)

Amadi et al. (2020) (med adhere)

C

C

C

C

R

M E T HOD

140

45

85

525

1,590

N

Nigeria

MP, HIV+​

CS

C

339

Advance cancer pts

Sp needs met (vs. not)

P

NA with IR

P

Sp/​R mindfulness #14 IR,ER

P (moderating effect)

P (adherence psych f/​u)

NA overall follow of guidelines NG if directives in place

F I N DI N G S

#4 ORA, NORA,SR

#1 R vs. not

#1 R congreg/​10,000

R E L IG VA R I A BL E S

CS

CT

CS,PC

PC (3)

RS

PC (2)

CS

CT

*Yeung & Greenwald (1992)

*Burell (1996)

Koenig et al. (1998c)

Reuben et al. (2002)

Rohrer et al. (2003)

Koenig et al. (2004)

Thind (2005)

*Ikedo et al. (2007)

2,468 78

–​

811

5,006

6,567

542

128 vs. Cs

3,640

R

S

R

R

S

S

R

Omaha, NE

Indonesia

C (age 0–​5) MP

North Carolina

West Texas

Prayer during surg (CD)

#1 D (Muslim vs. non-​M)

#37 NORA, SR, DSE©, Sp

#1 SR

#2 ORA,D #1 ORA

Durham NC

MP, inpts, E

CDA, E

CDA, E

#1 “reflect spirit issues”

#1 Jewish vs. non-​J

Multi-​site US

Sweden

MP -​CABG MP, E

New Haven,CT

CDA

NA (LOS)

non-​M > Muslim

P (LTC use)

P (MD visits)

P (LOS)

P

P

Jews > Non-​J

Use of General Medical Services (P indicates less services used; “>” indicates more services used; LTC =​long-​term care; LOS =​length of hospital stay)

Balboni et al. (2011)

Healthcare Costs Northeast US

Indonesia

Washington DC

MP, Ad, B, HIV+​ PP, schizophrenia

South Korea

National US

L O C AT ION

PP, ER for suicide attemp

53 MSA, 30 days (1,590)

P OP U L AT ION

Healthcare Costs and Use of Health Services (no chapter in this edition)

T Y PE

TOPIC/​I N V E S T IG ATOR S

–​

MC

MC

MC

MC

MC

-​

MC

MC

SC

—​

MC

MC

MC

C ON T ROL S

8

8

8

8

9

9

9

8

8

(8)

(8)

(8)

(8)

9

R AT I N G

PC

CS

PC (1)

PC (1)

CS

PC (8d)

PC (4m)

CS

CS

CS

CS

CS

PC

*Contrada et al. (2008)

Wilkinson et al. (2008)

*Krause (2010c)

*Cannon et al. (2011)

Bediako et al. (2011)

Ai et al. (2011)

Balboni TA et al. (2013)

*Headey et al. (2014)

Williams et al. (2015)

Solanke et al. (2015)

*Burke et al. (2017)

* Bagheri et al. (2019)

Oh A et al. (2019)

R

C

R

S

C

R (?)

C

C

C

4,712

?

34,525

19,087

563

257,000 person-​ years

343

443

93

551

450

R/​S

C

31,044

550

R

S

CDA, E (65 or over)

MP (CABG surgery)

CDA

Women giving live birth

National US

Iran

National US

Nigeria

National US

Germany

CDA

CDA, B

Northeast US

#1 ORA

? Disappoint with God

#1 meditation (vs. not)

#1 D

#3 ORA,SR

#1 ORA

Sp needs supported by R comm

#23 D, R scale, DSE

#6 RC (PRC, NRC)

Mid-​Atlantic US

Michigan

#? hi vs. low spirituality

#3 ORA, NORA, R sup

Prayer for health

#13 NORA, RB

Nebraska

National US

National US

New Jersey

Advanced cancer pts

MP (cardiac surgery)

MP (sickle cell disease)

MP (cancer survivors)

CDA, E

CDA

MP (cardiac surgery)

MC

NA (time to NH placement)

P

NG (office visits)

Christians > Muslims (maternal hlth services)

P (health ins; F, age 51–​64, only)

NA

NG

NA

P (PRC) (hosp admit)

NA

M (outpt visits)

MC

?

SC

9

(8)

8

(8)

(8)

MC MC

8

9

8

(8)

8

8

8

8

MC

MC

MC

MC

?

MC

NG (more likely to see PCP)

NA (LOS)

T Y PE

M E T HOD N

P OP U L AT ION

PC

CS

CS

RS (10)

CS

Rosmarin et al. (2013b)

Lukachko et al. (2015)

Williams SL & Cabrera-​Nguyen (2016)

Banta & McKinney (2016)

*Rao et al. (2016)

CS

CS

*Ng et al. (2011)

Vicente et al. (2018)

R

CS

Fontana & Rosenheck (2004)

CS

PC (2)

*Benda (2002a,b)

CS

PC (2)

Benda (2001)

Hays & Lincoln (2017)

PC

*Kennedy et al. (1996)

*AbdelGwad et al. (2017)

R

CS

*Koenig et al. (1994b)

S

C

S

R

R

S

R

S

S

S

R

R

R

CS

*Yeung & Greenwald (1992)

R

CS, D

Larson DB et al. (1988)

Youths, B (age 18–​29)

CDA, B

Psychiatric pts (day-​treatment)

CDA, E (age 60 or over)

CDA,veterans w PTSD

Homeless vets, subst abu

Homeless vets, substance abusers

CDA, E

Baby boomers

CDA

CDA

1,606

175

1,315

8,180

CDA, E (age > 60)

Psychiatric inpatients

CDA, B

CDA, F, age 31–​36

1,976,893 psychiatr hosp discharges

806

3,570

159

1,092

1,385

600

600

1,855

853 vs. 1,826

3,640

18,000+​

Use of Mental Health Services (P indicates less services used; “>” indicates more services used)

TOPIC /​I N V E S T IG ATOR S

Bambui, Brazil

Texas

National US

Australia

California

National US

National US

#1 ORA

#5 DUREL

#11 ORA, NORA, SR

#1 Prayer/​Sp healing

MC

P (anti-​ depressant use)

SC MC

NA (LOS)

M

P

MC

MC

P (LOS)

#1 faith-​based hosp vs. other

MC MC

(P) (more approp use)

SC

MC

MC

MC

MC

None

MC

MC

#1 consulted R/​Sp advisor > MH services

#13 ORA,NORA,SR

#3 RB, RSup

Northeast US

P (faster treatment response)

P (Christians vs. none)

#1 R affil (57% Bud/​ Tao)

Singapore

P (readmit)

P (readmit)

Jews > others

C (D)

P (outpt)

#5 ORA, NORA, RB, SR

#5 ORA, NORA, RB, SR

#1 Jews vs. others

#5 D, ORA, SR, NORA

Jews > Non-​J

8

(8)

8

8

8

8

8

8

8

8

8

8

8

9

8

R AT I N G

#1 Jewish vs. non-​J

C ON T ROL S 9

F I N DI N G S

#1 seeking clergy for psychiatric problems (most often)

R E L IG VA R I A BL E S

#1 RC change

National US (?)

Midwest US

Midwest US

Bronx, NY

Durham NC

New Haven,CT

5 US cities

L O C AT ION

PC (6)

R

CS

CS

Harris KM et al. (2006)

Turner et al. (2019)

CS

C

R

R

R

79

5,191

64,450

2,825

6,400

Exp/​PC

CS

CT

CT

CT

CT

CT

PC (1)

*Stahler et al. (2005)

Trinitapoli (2005)

Resnicow et al. (2005) (HB)

*Winett et al. (2007)

Samuel-​Hodge et al. (2009)

*Duru et al. (2010)

*Holt et al. (2012)

*Tsai et al. (2012)

1,071

—​

C

—​

906

—​

Sedentary B, E, F

Churches (117 vs. 84 subj)

CDA, CM

CDA, CM, B

Congregations

Homeless, B, F, cocaine use

MP w advanced cancer

CDA,B (AA & Caribbean)

CDA, moderate & sev MI

CDA, American Indian

Age 16 or older

40 inpt pgrms for homeless vets

16 chuches, 285 members

62

24

1,236

111

R

C

Faith-​Based Health Collaborations/​Programs (“>” indicates better than)

Delgado-​Guay et al. (2015)

Advanced Directives/​End-​of-​Life Planning

CS

Beals et al. (2006)

Timeliness in Seeking Care (seeking care when appropriate)

*Pawlikowski et al. (2019)

US cities (large)

Alabama

Los Angeles

North Carolina

Virginia

Atlanta, GA

National US

Philadelphia, PA,

Texas

National US

National US

North & SW US

National Poland

MC

MC

MC

P

—​

NA with resuscitation decision

P (more likely SC to seek MH care)

M (P in 8 of 10)

P-​Sp (MH care)

P (visits)

No difference M/​NA

Faith-​based vs. secular

P (vs. controls)

Faith-​based physical activity intervention Sp intervention incr colorectal CA screen

P

P

P

Faith-​based self-​ management for diabetes

Church-​based nutrition, exercise program

Sp enhanced intervention

MC

—​

—​

—​

—​

—​

57% sponsored soc service pgrms; 6% for senior citizens

Faith-​based recov prg

#5 ORA, NORA, IR

#2 SR

#3 ORA, SR, IR

#2+​D, Sp

#1 ORA

8

8

9

8

8

9

8

8

(8)

8

9

8

10

—​ 604 436

CT

CT

CT

Exp/​PC

Opinion —​ —​

CT

Condrasky et al. (2013)

Wingood et al. (2013)

Martinez et al. (2013)

Gutierrez et al. (2014)

Griffith et al. (2016)

144

—​

C

CT

Exp/​PC

*Arredondo et al. (2017)

Tettey et al. (2017)

R

R

R

R

R

PC (18m)

Levin & Schiller (1987)

Krause (1997)

Levin (1994)

Levin (1996)

Levin et al. (1996b)

Kudel et al. (2011)

199

Bronx/​Harlem

San Diego, CA

F I N DI N G S

B

F Latinas from 16 Cath ch

CDA, B, overweight

Bible-​based diabetes prevention program

Faith-​based exercise program

Faith-​based HIV prevention prgm

#3 ORA, RSup (predictors in FAN)

P

P

P (wks abstinent)

New York

San Diego, Calif

Georgia

Effects of Bible-​based intervention provided by lay educators for BP, weight, BMI

Faith-​based exercise program

Faith-​based pgrm to prevent diabetes

P

P

P

MP (HIV+​)

US cities

#9 SR, SS, RC

Reviews literature on religion-​health relationship and discusses mechanisms Testing Koenig model (confirmed)

Examines how natural history, salutogenesis, and host resistance may explain religion’s effects on health

Provides theoretical foundation for epidemiology of religion

345

—​

—​

—​

P (fruit/​veg intake)

Faith-​based (scripture P (physical activity) motivated) prgm (FAN)

Examines directions for the scientific study of religion, aging, and health

Comprehensive review of religion and health

C

C ON T ROL S

Half (55%) or less had any action-​oriented activities re health

R E L IG VA R I A BL E S

MC

—​

—​

Examines what religious institutions can do to aid recovery of those with psychotic disorders

B, Latino

Church-​going Latinas

Atlanta, GA

South Carolina

South Carolina

National US

L O C AT ION

VII. Understanding the Religion–​Physical Health Relationship (Chapter 31)

—​

CT

183

134

—​

C

1,257 members in 74 B churches

—​ B, F, age 18–​34, sex active

1,257 members in 74 B churches

—​

Sattin et al. (2016)

General Mechanisms

P OP U L AT ION

844  Faith community leaders

Wilcox et al. (2013)

C

CS

N

Bopp & Fallon (2013)

M E T HOD

T Y PE

TOPIC /​I N V E S T IG ATOR S

8

8

9

8

8

(8)

8

8

8

(8)

R AT I N G

CS

Dew & Koenig (2014)

CT

Akbari et al. (2016)

CS

PC (4)

CS

CS

CS

Hill TD et al. (2016b)

Hill TD et al. (2017a)

Muhsen et al. (2019)

Wang L et al. (2020)

Isehunwa et al. (2022)

2,288

C/​R

R

R

*VanderWeele & Koenig (2017)

VanderWeele et al. (2019)

R

R

R

*VanderWeele (2017a)

Oman (2018)

Alturki et al. (2020)

Health Policy Implications (Chapter 33)

R

VanderWeele (2017a)

CDA

CDA (age 55 or older)

CDA, Arabs

CDA (age 50 or older)

CDA

Stressed caregivers

National US

China

Israel

National US

Tennessee

NC and Calif

Tehran, Iran

(NG)

#7 ORA, NORA, RC

MC

MC

MC

MC

MC

8

8

(8)

9

8

(8)

8

8

8

8

Examines health policy implications of Islamic beliefs with regard to cigarette smoking

Reviews theories and empirical evidence on relations between religion/​spirituality and health policy and management

Discusses religious determinants of human flourishing & health policy implications (Proceedings National Academy of Sciences)

Discusses determinants of human flourishing (Journal of the American Medical Association)

Describes a course on Sp and health at the Harvard School of Public Health (American Journal of Public Health)

Discusses determinants of human flourishing (Proceedings for the National Academy of Sciences)

NA (buffer MC dep-​T assson)

P

#1 R vs. trad/​secular #5 (DUREL)

NA (? indirect effects)

P

P (except in non-​R)

P (spiritual Rx decr expression of dopamine genes, D1-​D5)

P (decr expression of pro-​ inflammatory genes)

SS/​SL genotype less in R

Interaction found w 5-​HTTLPR

#1 ORA

#3 ORA, NORA, SR

#41 ORA, NORA, DSE©, IR

#7 ORA, SR, NORA, R exp

#1 ORA

VIII. PUBLIC HEALTH AND HEALTH POLICY

1,742

934

4,514

1,252

251

C

R

R

R

C

60 breast CA, 30 healthy ctrls

—​

National US

Youth (age 18–​26)

Wisconsin (?)

National US

Youth (age 18–​26)

19 Buddhist meditators vs. ctrls

2,537

1,434

C

R

R

Public Health and Human Flourishing (Chapter 32)

CS

Koenig et al. (2016b)

Telomere Length

Exp

Kaliman et al. (2014)

Gene Expression

CS

*Halpern et al. (2006)

Serotonin Transporter Polymorphisms (5-​HTTLPR, i.e., SS, SL, LL, with SS and SL conferring vulnerability to drug use/​depression)

T Y PE

M E T HOD N

P OP U L AT ION

L O C AT ION

R E L IG VA R I A BL E S

F I N DI N G S

CS

CS

CS

CS

Curlin et al. (2007)

*Cohen J et al. (2008)

Ramondetta et al. (2011)

Duivenbode et al. (2019)

R

C

C

R

R

S

C

2,183

255

273

8,631

1,144

3,086

8,308

CDA, infertile F

Muslim physicians

Physicians, gynecologists

Physicians in EOL care

Physicians (all specialties)

Phys admitting to ICU

Inpatients

National US

National US

National US

Europe

National US

Europe

Chicago

Examines R effects on help-​seeking for infertility

CS

CS

PC (4m)

Williams et al. (2011)

Karches et al. (2012)

Maciejewski et al. (2012)

Medical Patients

C

S

S

345

8,308

2,768

Chicago Multisite US

MP, end-​stage cancer

Chicago

Medical inpts (73% B)

Hospitalized patients

C ON T ROL S

#7 D, ORA, NORA

#12 IR, ORA, NORA

#1 D

#3 D, ORA, IR

#1 D

#14 PRC, NRC

#3 ORA, IR, SSp

Decreased living will (PRC) Increased life-​prolong care (PRC)

M (re EOL planning)

MC

MC

41% wish to discuss spiritual concerns while in hospital; of those, 51% had such discussions; of those not wishing such discussions, 19% had them anyway

R significantly influenced EOL decisions

8

8

8

(8)

(8)

9

R signif relat to EOL att/​act all 6 countries R beliefs influenced MD decisions

9

9

8

8

R AT I N G

R signif related to med dec, pt care prac

R signif related to EOL dec /​ outcomes

Freq attendees 50% more likely to prefer to leave medical decisions to the physician

Patients’ Attitudes Toward Spiritual Integration (published since 2010, see 2nd edition of Handbook (OUP) for earlier studies)

PC

Sprung et al. (2007)

Physicians (published after 2000)

CS

CS

Greil et al. (2010)

Chung et al. (2012)

Patients (published since 2010, see 2nd edition for earlier studies)

Medical Decision-​Making (includes EOL =​end of life attitudes/​decisions such as extending life, refusing treatment, active shortening of dying process)

(no chapters in this edition of the Handbook; see Spirituality in Patient Care, 3rd edition, Templeton Press, 2013)

Clinical Applications

TOPIC /​I N V E S T IG ATOR S

C

CS

CS

CS

CS

CS

CS

CS

CS/​Q

CS

CS

CS

Banin et al. (2014)

Edman et al. (2014)

Hodge & Wolosin (2015a)

Hodge & Wolosin (2015b)

Hodge et al. (2016)

Kumar et al. (2016)

Park & Sacco (2017)

Bowie et al. (2017)

Arutyunyan et al. (2018)

Coats et al. (2018)

Astrow et al. (2018)

CS

CT

Rakhawy & Hamdi (2010)

*Huguelet et al. (2011)

Psychiatric Patients

C

CS

Ellis MR et al. (2013)

5,191 78

—​

727

537

162

877

111

1,117

4,112

2,227

1,281

3,587

300

326

3,443

8,308

R

C

S

C

S

S

S

C

C

S

C

C

PC (10)

McFarland et al. (2013)

S

CS

Chung et al. (2012)

Cancer pts who chose intern med clinic to address spirituality had greater perceived stress, more depression, & more pain

Multi-​site US

PP (schizophrenia)

CDA w/​wo psych illness

MP, cancer outpatients

MP, severe illness

Parents of child in ICU

MP prostate cancer

MP (outpts), CHF

MP, cancer, radiotherapy

Switzerland

Upper Egypt

Brooklyn, NY

Seattle, WA

Michigan

Maryland

Connecticutt

India

P (quality of communica­ tion)

MC

(8)

Receive Sp assessment vs. no

Well tolerated by pts

8

7.6% of M, 10.5% of F sought Faith Healer for mental dis (8)

48% OK if MD asked Sp needs; 23% had unmet Sp needs

#1 IR

(8)

(8)

Want MD to ask about R/​S: 34% yes, 30% not sure, 36% no R/​S influenced decisions about child’s medical care: 49%

(8)

(8)

(8)

8

8

(8)

Religious beliefs about prostate CA influenced treatment decisions

54% “not at all” wanted MD or staff to address Sp needs

Examines opinions of pts regarding importance of Sp health

P associated w address Sp needs

Identifies predictors of dissatisfaction with meeting Sp needs

Multi-​site US

Overall satisf w care

Examines the spiritual needs related to med illness

National US

8

(8)

Examines predictors of wanting MDs to address Sp/​R issues

Midwest US Brazil

9

8

(8)

MC

P (re leav med MC decisions to MD)

Diagnosis of cancer predicts increased religiosity

#3 ORA, IR, SSp

30% indicated R/​Sp struggles/​concerns; 1/​3 received Sp sup

National US

Chicago

MP, hosp DC, age > 65 Multi-​site US

MP, hosp DC, B, age > 65

MP, American Indians

MP, cancer vs. others

Medical outpatients

MP (hospitalized)

CDA, age 25–​74

Medical inpts (73% B)

CS

CS

Rosmarin et al. (2015)

Rosmarin et al. (2016)

C

C

C

R

M E T HOD

1,123

253

253

6,616

N

US Veterans

PP, acutely hospitalized

PP, acutely hospitalized

CDA w/​wo psych illness

P OP U L AT ION

Alabama, other

Boston, MA

Boston, MA

Singapore

L O C AT ION

CS

CS

CS

CS

CS

CS

CS

R

CS

CS

CS

Donohue et al. (2010)

Stern et al. (2011)

Rasinski et al. (2011)

Rasinski et al. (2012)

Phelps et al. (2012)

Balboni MJ et al. (2013)

Balboni MJ et al. (2014)

Kim D et al. (2014)

Lawrence et al. (2014)

Ford et al. (2014)

Rodin et al. (2015)

Physicians (Medical Practice)

S

C

S

S

C

C

S

S

S

C

Neonatologists

Primary care MDs

Physicians (all types)

15%–​20% said incorp Sp into counseling very import (esp non-​W hites)

37% of those without a R affiliation wanted to include Sp

Oncology nurses/​ MDs

Boston, MA

Boston, MA

Boston, MA

National US

National US

National US

National US

(8)

8

Explores why spiritual care is infrequent at end-​of-​life (EOL) Examines 11 reasons for not providing spiritual care at EOL

8

Attitudes toward addressing spiritual issues in oncology

(8)

8

23% had received formal training in R/​Sp & medicine “Sense of calling” assoc with MD satisf treat smoking, alc, obesity

8

(8)

Examines beliefs/​practices concerning address Sp in clinic

Influence of R/​S on treat decisions re hi-​risk infants

(8)

(8)

(8)

8

R AT I N G

Boston, MA

Oncology nurses/​ MDs

322

South Carolina

MPs and their MDs

181/​541

National US

Prim care MD/​ psychiatrists

896/​312

Examines clinicians’ perceived role in providing spiritual care

Compares Sp assess reported by MDs with reports by their pts

36%–​37% PC MD’s/​48%–​51% psych unlikely to refer to R provider

(8)

(8)

(8)

Describes rise/​fall of AMA’s Committee on Medicine and Religion and the Depart of Medicine and Religion 1961–​1974

339

75 pts, 204 oncologists, 118 nurses

68 pts, 204 oncologists, 114 nurses

896

1,144

181 Jewish MDs vs. 849 non-​Jew

298

C ON T ROL S

1.5% overall, 6.6% if mental ill

F I N DI N G S

58% wanted their clinician to include Sp in their care

#1 Seeing R/​Sp advisor

R E L IG VA R I A BL E S

Healthcare Professionals’ Attitudes toward Spiritual Integration (published since 2010, see 2nd edition of Handbook (OUP) for earlier studies)

Currier et al. (2018b)

CS

CS

Picco et al. (2013)

Veterans

T Y PE

TOPIC /​I N V E S T IG ATOR S

CT

CS

CS

CS

CS

CS

Exp

Exp

R

CS

PC

CS

CS

Cagle et al. (2016)

Franzen (2016)

Salmoirago-​Blotcher et al. (2016)

Lee-​Poy et al. (2016)

Koenig et al. (2017a)

Koenig et al. (2017b)

Koenig et al. (2017c)

VanderWeele et al. (2017b)

Robinson et al. (2017)

Woods & Hensel (2018)

Jirásek & Hurych (2018)

Smyre et al. (2018)

520

—​

S

R

C

National US

Sense of “calling” by 46% Muslim, 45% Cath, 60% of evang Prot

MD brought up Sp issues in 5.6% of 249 meetings

Canada

Massachusetts

National US

North Carolina

Belgium

(8)

52% “sometimes” asked pts about (8) R/​S beliefs; MD comfort level, train

NA with MC burnout P (reduced maladaptive behaviors, malpractice)

8

8

Physicians (Mayo Clinic)

Minnesota

Physicians

National US

Czech Republic

8

(8)

MDs’ opinions on engaging pts’ R/​Sp concerns; 55% said would pray

None

8

P on communica­ tion

8

Asked if ‘spiritual health’ exists: 26% CDA yes, 47% MDs

#6 D, DUREL

Described R characteristics of MDs (e.g., 24% atheist/​ agnostic)

Discusses importance of addressing R/​S issues in medical care (Journal of the American Medical Association)

Intervention to improve MD/​nurse attitudes and behavior toward taking a Spiritual History

Intervention to improve MD/​nurse attitudes and behavior toward integrating Sp into outpt clinical practice

1,800 CDA, 1,210 physicians 1,156

#7 ORA, NORA, IR, R rest

MDs’ attitudes toward religious discussions with patients

8

8

MC

#1 SR Preference for hospice care

P (W), NG (B)

(8)

Taking “sp history” (no/​min R faith) no effect on any outcome

(8)

8

(8)

Physicians, nurses, staff (outpatient setting) -​describes attitudes & practices related to integrating (8) Sp

Family physicians

ER physicians

Physicians

CDA,E (AARP)

MP w life threat dis

Tested an intervention to increase Sp assessments and chaplain referrals on palliative care service

46 peds residents, 364 pts cared for by them in Colorado

2,097

520

—​

139

138

1,144

3,586

49

31

737

S

Physicians

Content of family meetings with MD in ICU

Discusses the lack of religion/​spirituality in the intensive care unit (JAMA Internal Medicine)

1,208

249

Discusses whether religion deserves a place in secular medicine (“con” view) published in J Medical Ethics

Discusses whether religion deserves a place in secular medicine (“pro” view) published in J Medical Ethics

C

C

S

S

R

—​

C

Vermandere et al. (2016)

S

Exp

CS

Yoon et al. (2015)

C

Commentary

CS

Ernecoff et al. (2015)

Gomez-​Castillo et al. (2015)

R

Earp (2015)

Balboni et al. (2015)

R

Biggar (2015)

CS

CS

CS

CS

Thompson et al. (2019)

Bowman et al. (2018)

Van Randwijk et al. (2019)

Fradelos et al. (2020)

CS

Taylor D et al. (2011)

Commentary

Commentary

Commentary

Commentary

Commentary

CS

CS

R

CS

Dein et al. (2010)

Poole & Higgo (2010)

Poole & Cook (2011)

Poole & Higgo (2011)

Stanley et al. (2011)

Hofmann & Walach (2011)

Worthington et al. (2011)

Besterman-​Dahan et al. (2012)

S

R

C

R

King MB & Leavey (2010)

S

S

C

S

C

S

M E T HOD

Hook et al. (2010)

Mental Health Professionals

CS

Siatkowski et al. (2008)

Physicians (Surgical Practice)

T Y PE

TOPIC /​I N V E S T IG ATOR S

Surgery pts (general/​ortho)

Ophthalmology pts

Nurses

Physicians

MDs, nurses, HCP

Physicians

P OP U L AT ION

F I N DI N G S

C ON T ROL S

No differ in discussion, training in adv care planning

83% agreed surgeon be aware of RB, 63% should take Sp hx

Alabama

P –​relig prac, NG-​R beliefs/​exp

99.3% accepted prayer when offered prayer; 96% felt free to reject the prayer; 1% felt uncomfortable when offered

#15 Huber centrality sc

6% addressed R/​S issues once/​week or more; 21% once/​ mo

#1D

MDs’ opinions regarding addressing pts R/​Sp concerns at end-​of-​life

R E L IG VA R I A BL E S

Oklahoma

Greece

Denmark

Dayton, OH

National US

L O C AT ION

German psychotherapists

E (> 65) patients w dep/​anx

Germany

Texas

22% of pts bring up spirituality, 81% not trained to address

77%–​83% preferred inclusion of R/​S in therapy

447

Active duty US military seek MH services

United States

44% from MH, 31% from chap, 25% both (not much diff)

Review and meta-​analysis of religious accommodative therapies and non-​religious spiritual psychotherapies

895

66

Argues that spirituality represents a threat to therapeutic boundaries in psychiatric practice

(8)

8

(8)

(8)

(8)

(8)

8

(8)

8

R AT I N G

Argues that praying with patient constitutes breach of professional boundaries in psychiatric prac (Br J Psychiatry)

Critiques the incorporation of spirituality into psychiatric care (The Psychiatrist, UK)

Discusses need for British psychiatrists to address spiritual issues in mental health care (The Psychiatrist, UK)

Supports the principle that psychiatrists cannot ignore a patient’s spiritual issues (The Psychiatrist, UK)

Reviews empirically supported religious and spiritually integrated psychotherapies

361

300

378

911

704

1,156

N

R

CS

Commentary

R

CS

Commentary

R

Commentary

CS

CS

CS

Commentary

Commentary

Commentary

Commentary

Commentary

CS

Commentary

Cook & Powell (2013b)

Rosmarin et al. (2013c)

Yamada et al. (2014)

Cummings et al. (2014)

Mohr & Huguelet (2014)

Pearce et al. (2015)

Anderson et al. (2015)

Prusak (2016)

Ho et al. (2016)

Menegatti-​Chequini et al. (2016)

Peteet et al. (2016)

Moreira‐Almeida et al. (2016)

Peteet et al. (2019)

Peteet (2018)

Pearce et al. (2018)

Dein (2018)

Payman & Lim (2018)

Poole et al. (2019)

R

C

C

C

S

C

Commentary

Cook (2013a)

S

CS

Lawrence et al. (2012)

Primary care/​Psych MDs

National US

Attitudes toward treatments for alcoholism

8

Cognitive-​behavioral US therapists

47% no belief in personal God, only 15% said S/​R often/​always relevant

(8)

Psychiatric outpatients

Switzerland

25% wished to address R/​Sp issues in their psychiatric care

Therapists in Massachusetts Psychol Assn

Brazilian psychiatrists

Healthcare workers in mental rehab

Massachusetts

Brazil

Hong Kong

P (burnout & MC depression)

R history was taken in 50%; only 30% were detailed

Debate with Christopher Cook about role of religion/​spirituality in psychiatry (British Journal of Psychiatry)

Australia

Argues for the inclusion of R/​S in psychiatric care of persons of all ages (British Journal of Psychiatry Bulletin)

Describes spiritually integrated cognitive processing therapy for moral injury in the setting of PTSD

Discusses the next generation of psychotherapies that focus on well-​being, including Sp integrated therapies

Discusses role of mental health professionals in assessing and addressing spiritual needs of geriatric patients

Audit of 66 psychiatric records

(8)

(8)

(8)

(8)

Discusses influence of therapists’ worldview on treat- (8) ment of patients; 56% with R affiliation, 63% said worldview would infl clin practice

56% did not usually inquire about patients’ R/​S (not role, no training)

#16 DSES

Position statement on inclusion of religion and spirituality in psychiatric practice (World Psychiatric Association)

50

484

312

Discusses new diagnosis of “Religious or Spiritual Problem” under V-​code 62.89 in DSM-​5

Review and meta-​analysis of faith-​adapted therapies for depression and anxiety

Describes religious cognitive behavioral therapy (RCBT) for depression in the medically ill

147

Review of 29 studies finds that therapist R/​S and client-​therapist R/​S similarity are not consistently better outcomes

Describes efforts by Los Angeles County Dept Mental Health to address Sp in mental health, indiv & group treatments

262

Argues that spirituality is not bad for mental health (as some have claimed) (British Journal of Psychiatry)

Position statement on incorporation of religion/​spirituality into psychiatric practice (Royal College of Psychiatrists, UK)

896/​312

S C

CS

R

CS

Exp/​PC

CS

CS

CS

PC (4)

CS

Abu-​El-​Noor & Abu-​El-​Noor (2014)

Timmins et al. (2015)

Sahin & Kardaş Özdemir (2016)

Cooper & Zimmerman (2017)

Musa (2017)

Taylor EJ et al. (2017)

Taylor EJ et al. (2018)

Ross et al. (2018)

Mamier et al. (2019)

CS

R

CS

CS

CS

CS

Oxhandler et al. (2015)

Francoeur et al. (2016)

Kvarfordt et al. (2017)

Oxhandler et al. (2017)

Oxhandler & Giardina (2017)

Oxhandler & Parrish (2018)

Social Workers

Commentary

*Reinert & Koenig (2013)

C

R

R

C

R

C

C

C

C

C

C

C

CS

*Phelps et al. (2012)

C

M E T HOD

CS

T Y PE

Ozbasaran et al. (2011)

Nurses

TOPIC /​I N V E S T IG ATOR S Nurses, attitude to sp care

P OP U L AT ION

Boston, MA

Turkey

L O C AT ION

MP admitted to CCU Gaza Strip, Israel

Nurses

Assess Sp needs (70%) & provide Sp care (78%) very import

S. Calif

S. Calif

Jordan

Social workers

Nurses, SDA hospitals

National US

S. Calif

Nursing students, 8 countires of Europe

Nurses

Nurses, SDA hospitals

Nurses

Maryland

Turkey

550

329

482

190

Health professionals, incl SW

Social workers

Social workers

Social work educators

Texas

National US

National US

Canada

9

#7 R/​Sp +​#40 RSIPAS

Examines attitudes to Sp integrate 8

80% never/​rarely document Sp care in chart; 73% never/​ 8 rarely arranged for chaplain visit (faith-​based health system)

Examines Sp care competencies & change over 4 yrs of study

(8)

(8)

Nurses at faith-​based hosps more likely to pray, Sp discuss

None

8

P (with providing Sp care)

(8)

(8)

(8)

8

8

R AT I N G

Frequency of taking a Sp history (17% never, 10% regularly)

#20 SWB

P (improved BP and lifestyles in 6 of 7 areas)

Explores attitudes of general hospital nurses to Sp care

#40 R/​S Integrated Prac Assess

Compared R & Sp integration

8

8

8

#7 R/​Sp

Examines R/​S of SW compared to gen pop Examines what helps/​hinders SW re integrating Sp into prac

(8)

Examines Sp content in SW curriculum and attitudes to Sp inclusion

Discusses role of social workers in providing spiritual care to patients with chronic disease and at the end-​of-​life

442

554

2,193

445

1,030

355

39 parish nurses check BP on 109 CDA

193

C ON T ROL S

Attitudes toward addressing spiritual issues in oncology

Examines guidance regarding spiritual care competency provided in current nursing textbooks

275

F I N DI N G S

29% support pts sp prac; 60% ignored, 11% did not allow

R E L IG VA R I A BL E S

Discusses definitions of spirituality for use in nursing research and practice

68 pts, 204 oncologists, 114 nurses

319

N

R

R

Levin (2016b)

VanderWeele & Koenig (2017)

CS

CS

Jacob et al. (2017)

Purnell et al. (2019)

CS

CS

R

RS

CT

CS

Nieuwsma & Rhodes (2013)

Nieuwsma et al. (2014)

Koyn (2015)

Choi et al. (2015)

Piderman et al. (2017)

Aslakson et al. (2017)

Chaplains

CS

Davidson et al. (2010)

Pharmacists

R

Taylor BD et al. (2011)

Public Health Specialists

CS

CS

Turner & Cook (2016)

Rezapour et al. (2016)

Rehabilitation Therapists C

C

—​

S

S

S

C

C

S

C

274

Physical therapists Speech and OT therapists

Scottland Iran

P w job satisfaction

SC(?)

Examines opinions regarding addressing Sp issues in PT #64 Islamic R sc

Maryland

Final-​year pharm students

Chaplains (VA, DOD)

National US

National US

Georgia

1st-​year pharm students

Chaplains (VA, DOD)

Nevada

Pharmacists in Nevada

Adult ICU admissions

Rochester, MN

Durham, NC

144 ICU MP & fam at Johns Hopkins, Baltimore

24 cancer pt-​support person dyads

4,169

Chaplains’ notes in EMR cursory & without detail

Chaplain-​led spiritual legacy intervention, improved QOL

6% visit by chaplain, 46% no F/​U visit, 4% referred by MD

(8)

8

9

8

Chaplains’ current/​potential roles in mental health care 70% never made referrals to mental health professionals

(8)

(8)

8

8

19% indicate important to conduct a spiritual assessment

Exam R/​S of students and attitudes to address Sp in coursework & clin prac

R affil assoc w willinghess to dispense meds

(8) (8)

Examines barriers to integrating chaplains in mental health

#6 SSp,DUREL +​ others

#21 DSE©, DUREL

#1 R affil

Reviews research on religion and relevance to resiliency in the U.S. Army

2,163

2,163

141

580

668

Describes a course on spirituality and health at the Harvard School of Public Health

Describes partnerships between faith-​based organizations and medical organizations relevant to public health

Describes faith-​based Morehouse School of Medicine public health/​preventive medicine residency program

163

CS

CS

D

CS

Snowden et al. (2017)

Jeuland et al. (2017)

Nieuwsma et al. (2017)

Damen et al. (2019)

CS

Q

*Balboni MJ et al. (2018)

Koss et al. (2018)

531

2,092

N

Chaplains working in palliative care

Chaplains (23 countries)

P OP U L AT ION

United States

Worldwide

L O C AT ION

C

R

R

C

CS

CS

Lucchetti et al. (2013)

Wachholtz & Rogoff (2013)

CS

CS

Stuck et al. (2012)

Talley & Magie (2014)

CS

Schafer et al. (2011)

CS

CS

Costa W et al. (2010)

CS

Commentary

Anandarajah et al. (2010)

Doolittle et al. (2013)

CS

Koenig et al. (2010b)

C

C

C

C

C

C

S

S

S

S

CS

Grabovac & Ganesan (2003)

S

CS

Sansome et al. (1990)

Berg et al. (2013)

F I N DI N G S

C ON T ROL S

Examines what they do and who they are

Attitudes to research; 81% indicated “definitely important”

R E L IG VA R I A BL E S

35

1,005

1,005

110

US clergy

US clergy

US clergy

Palliative care MDs, nurses, SWs

(8)

8

R AT I N G

28% said physician aid in dying was morally acceptable

Medical students

250 medical students

38 of 143 physician assistant prgs

108 internal medicine residents

259

Kansas

National US

New Havn, CT

Massachussetts

3,630 medical students from 12 schools in Brazil

P (burnout)

P (burnout)

MC

MC

58% wanted to address S/​R issues

Describes “spirituality in medicine” curriculum & evaluation

68% said students desire train on Sp/​R; 37% offer no training; 69% would consider add course, but 92.3% said would not add curriculum to discuss religion during patient encounters

#26 Hatch SIBS©

#16 DSE

#10 DUREL, Sp scale

(8)

(8)

(8)

(8)

8

(8)

(8)

89 psychology PhD/​PsyD programs (41% response); 84% addressed R/​Sp in supervision; 75% no course on R/​Sp Describes a combined training program involving psychiatry residents, psychology interns, and seminar students

8

8

8

8

301 psychology courses (85% of courses in Brazil); 13%–​16% addressed R/​Sp in course; 84% had nothing on R/​Sp

Provides competencies for family medicine resident eduction in the area of patient-​centered spiritual care

104 of 122 US med schools, Sp in curriculum: 7% dedicated course, 34% elective, 73% content in existing course

14 of 16 psychiatry residency programs in Canada: 29% nothing, 29% required, 64% elective teaching on Sp

276 directors of psychiatric training programs; 12% of programs have a course on religion

(8)

8

Examines clergy religious values regard EOL med decisions 8

Describes views of these professionals on what chaplains do (8)

Describes development of curriculum for clergy regarding EOL care

National US

National US

United States

Describes efforts to integrate chaplaincy services with MH care across the Veterans Adm & Department of Defense

C

C

M E T HOD

Education of Healthcare Professionals (published since 2010, see 2nd edition of Handbook (OUP) for earlier studies)

CS

Balboni MJ et al. (2017)

Non-​Chaplain Clergy

T Y PE

TOPIC /​I N V E S T IG ATOR S

CS

CS

D

D

CS

CS

CS

Culatto & Sumerton (2015)

Rassoulian et al. (2016)

Mitchell et al. (2016)

McGovern et al. (2017)

Gatell et al. (2017) (underserved)

Bator et al. (2017)

Saleem & Saleem (2017)

CS

CS

CS

CS

CS

CS

*Gillum & Griffith (2010)

Taylor RJ et al. (2011)

Barber (2013)

Pew Research (2014)

Carter EW et al. (2015)

CS

Taylor RJ & Chatters (2010)

Flannelly et al. (2010)

CS

Upchurch et al. (2010)

Community-​Dwelling Adults

CS

Lucchetti et al. (2014)

?

R

S

R

R

R

R

R

C

C

C

C

S

C

National US

CDA

12,706 intellect/​develop disabilities

35,000

114 countries

Multi-​site US

National US

Worldwide

National US

National US

CDA (1972–​2006 GSS)

National US

National US

Pakistan

Canada

Chicago

CDA

CDA

3,570 Afric-​Am B/​1,621 Carib B

45,463

22,929

6,010

CDA, F, age 40–​59

Med students/​non-​ med CS

120/​120

5,849

Medical students

Medical students

405

393

P (Sp, calling)

MC

Decr in R affil & attend over time

MC

—​

—​

MC

48% attend R services/​month; 35% more than 3x/​mo

D, ORA, NORA, SR

Religiosity declined as economic security increased

Describes in detail the religious characteristics of these pops

#3 D, ORA, SR

#4 Prayer for health in 12 mo: 63% B, 50% H, 42% W (any)

MC

(8)

10

8

8

8

8

9

(8)

#2 SR, SSp, R/​Sp great in B than W

None

9

P (well-​being, combined sample)

(8)

(8)

#1 prayer: the most common CAM practice in US for women

#14 IR, ER

Assisted suicide; 38% would personally give lethal medicine

#6 IR, ORA, D, Sp, “calling”

Describes a 3-​year spirituality curriculum for psychiatry residents; interviews examining perceptions of 12 residents

Describes development of a medical school curriculum for moral and spiritual wellness of students at Harvard

Austrian med students

(8)

1,400

(8)

8

55% said it was role of MD to talk about R/​S; 14% should be incl in med rec

MS more support of controv ethical issues were less R

34 of 59 UK med schools, Sp in curriculum: 6% dedicated course, 21% elective, 63% content in existing course

3,630 med students (MS) from 12 schools in Brazil

CS

CS

PC (1)

CS

PC (13)

PC (3.5)

CS

CS

RS

CS

CS

PC (14)

King SD et al. (2017)

Twenge et al. (2015)

Hui et al. (2015)

Levin (2016a)

Uecker et al. (2016)

*Cohen-​Mansfield et al. (2016)

Gallup Poll (2017)

*Burke et al. (2017)

Silverstein & Bengtson (2018)

Palmer et al. (2018)

Pew Research (2018)

Min et al. (2018)

CS

CS

R

McLaughlin et al. (2010)

Haghighi et al. (2015)

*Koyn (2015)

Military Personnel

T Y PE

TOPIC /​I N V E S T IG ATOR S

R

C

S

R

S

C

R

R

R

R

R

C

R

S

M E T HOD

P OP U L AT ION

National US

Military staff

Tehran, Iran

Portsmouth, VA

S. California

53% act duty mil outpts

Europe

Parent-​child dyads

Multi-​site US

CDA, E, w/​o cog impair CDA in 34 countries

National US

National US

National US

Israel

National US

National US

China

CDA, baby boomers

CDA

CDA

CDA, E (over age 75)

Ad (Add Health)

CDA

Chinese Christian CS

Northwest US

L O C AT ION

C ON T ROL S

27% with some R/​S struggle

F I N DI N G S

9

Married child more likely to return to R

#86 SWB, R

P (SWB and R orientation)

None

34% desire to discuss RB with health professional

87% Christian, 91% believe in God, 53% attend serv > monthly

#6 ORA,SR,RB

#5+​SR, ORA, NORA, RB, R as part of national identity

93% stated their spiritual needs were met

#9 RΔ, ORA, NORA, SR, RB Predictors of RΔ over 10 yrs

(8)

(8)

9

9

(8)

(8)

9

—​

#4 meditation [4%] and type (mantra, mindfulness, spiritual)

—​

(8)

#2 D, SR

10

Not much change with aging

8

#2 R identity, Δ in R

32% often prayed for self; 51% for others

8

9

(8)

R AT I N G

#2 D, ORA Ad of married parents likely to return to R

#5 healing prayer

Examined change in religious involvement

Examined change in ORA and R affiliation from 1966–​2014

#7 NRC

R E L IG VA R I A BL E S

Reviews research on religion and relevance to resiliency in the U.S. Army

503

670

1,084

56,000

4,077

599

34,525

126,965

1,070

11,479

1,714

932

11.2 million adol/​teens

1,449 stem cell transplant survivors

N

References

Aalgaard, R. A., Bolen, R. M., & Nugent, W. R. (2016). A literature review of forgiveness as a beneficial intervention to increase relationship satisfaction in couples’ therapy. Journal of Human Behavior in the Social Environment, 26(1), 46–​55. Aalsma, M. C., Woodrome, S. E., Downs, S. M., Hensel, D. J., Zimet, G. D., Orr, D. P., & Fortenberry, J. D. (2013). Developmental trajectories of religiosity, sexual conservatism and sexual behavior among female adolescents. Journal of Adolescence, 36(6), 1193–​1204. Aaltonen, K. I., Isometsä, E., Sund, R., & Pirkola, S. (2019). Risk factors for suicide in depression in Finland: first-​hospitalized patients followed up to 24 years. Acta Psychiatrica Scandinavica, 139(2), 154–​163. Abarca-​Gómez, L., Abdeen, Z. A., Hamid, Z. A., Abu-​Rmeileh, N. M., Acosta-​Cazares, B., Acuin, C., et al. (2017). Worldwide trends in body-​ mass index, underweight, overweight, and obesity from 1975 to 2016. Lancet, 390(10113), 2627–​2642.

Abdel Aziz, K., Elamin, M. H., El-​Saadouni, N. M., El-​Gabry, D. A., Barakat, M., Alhayyas, F., et al. (2016). Schizophrenia: impact of psychopathology, faith healers and psycho-​ education on adherence to medications. International Journal of Social Psychiatry, 62(8), 719–​725. AbdelGawad, N., Chotalia, J., Parsaik, A., Pigott, T., & Allen, M. (2017). Religiosity in acute psychiatric inpatients: relationship with demographics, clinical features, and length of stay. Journal of Nervous and Mental Disease, 205(6), 448–​452. Abdel-​Khalek, A. M. (2007). Religiosity, happiness, health, and psychopathology in a probability sample of Muslim adolescents. Mental Health, Religion & Culture, 10(6), 571–​583. Abdel-​Khalek, A. M. (2010). Religiosity, subjective well-​being, and neuroticism. Mental Health, Religion and Culture, 13(1), 67–​79. Abdel-​Khalek, A. M. (2012a). Associations between religiosity, mental health, and subjective well-​ being among Arabic samples from Egypt and

 • 863

Kuwait. Mental Health, Religion & Culture, 15(8), 741–​758. Abdel-​Khalek, A. M. (2012b). Subjective well-​being and religiosity. Mental Health, Religion & Culture, 15(1), 39–​52. Abdel-​Khalek, A. M., & Eid, G. K. (2011). Religiosity and its association with subjective well-​being and depression among Kuwaiti and Palestinian Muslim children and adolescents. Mental Health, Religion & Culture, 14(2), 117–​127. Abdel-​Khalek, A. M., & Lester, D. (2018). Subjective well-​being and religiosity: significant associations among college students from Egypt and the United Kingdom. International Journal of Culture and Mental Health, 11(3), 332–​337. Abdi, A., Soufinia, A., Borji, M., & Tarjoman, A. (2019). The effect of religion intervention on life satisfaction and depression in elderly with heart failure. Journal of Religion and Health, 58(3), 823–​832. Abdul-​Hakim, R., Abdul-​R azak, N. A., & Ismail, R. (2010). Does social capital reduce poverty? A case study of rural households in Terengganu, Malaysia. European Journal of Social Sciences, 14(4), 556–​566. Abdul-​R ahman, A. K., Card, T. R., Grainge, M. J., & Fleming, K. M. (2018). All-​cause and cause-​ specific mortality rates of patients treated for alcohol use disorders: a meta-​analysis. Substance Abuse, 39(4), 509–​517. Abel, E. (2004). Paternal contribution to fetal alcohol syndrome. Addiction Biology, 9(2), 127–​133. Abel, W. M., & Greer, D. B. (2017). Spiritual/​ religious beliefs & medication adherence in Black women with hypertension. Journal of Christian Nursing, 34(3), 164–​169. Aberer, E., Alexander, A., Martin, L., Michaela, P., Sabina, S., Regina, F. P., et al. (2018). The influence of religious/​spiritual exercises on well-​being and quality of life in dermatological patients: a quasi-​experimental study. Cogent Medicine, 5(1), 1499593. Abeyta, A. A., & Routledge, C. (2018). The need for meaning and religiosity: An individual differences approach to assessing existential needs and the relation with religious commitment, beliefs, and experiences. Personality and Individual Differences, 123, 6–​13. Abondio, P., Sazzini, M., Garagnani, P., Boattini, A., Monti, D., Franceschi, C., et al. (2019). The genetic variability of APOE in different human populations and its implications for longevity. Genes, 10(3), 222.

864 •  R eferences

Abou El Azayem, G., & Hedayat-​Diba, Z. (1994). The psychological aspects of Islam: basic principles of Islam and their psychological corollary. International Journal for the Psychology of Religion, 4, 41–​50. Abrahamson, A. C., Baker, L. A., & Caspi, A. (2002). Rebellious teens? Genetic and environmental influences on the social attitudes of adolescents. Journal of Personality & Social Psychology, 83(6), 1392–​1408. Abrams, J. Z. (Ed.). (1999). Illness and Health in the Jewish Tradition. Philadelphia, PA: Jewish Publication Society. Abu Raiya, H., Pargament, K. I., Mahoney, A., & Stein, C. (2008). A psychological measure of Islamic religiousness: development and evidence for reliability and validity. International Journal for the Psychology of Religion, 18(4), 291–​315. Abu, H. O., McManus, D. D., Lessard, D. M., Kiefe, C. I., & Goldberg, R. J. (2019a). Religious practices and changes in health-​related quality of life after hospital discharge for an acute coronary syndrome. Health and Quality of Life Outcomes, 17(1), 149. Abu, H. O., Lapane, K. L., Waring, M. E., Ulbricht, C. M., Devereaux, R. S., McManus, D. D., et al. (2019b). Religious practices and long-​ term survival after hospital discharge for an acute coronary syndrome. PloS One, 14(10), e0223442. Abu, H. O., McManus, D. D., Kiefe, C. I., & Goldberg, R. J. (2019c). Religiosity and patient activation among hospital survivors of an acute coronary syndrome. Journal of General Internal Medicine, 35, 762–​769. Abu-​El-​Noor, M. K., & Abu-​El-​Noor, N. I. (2014). Importance of spiritual care for cardiac patients admitted to coronary care units in the Gaza Strip: patients’ perception. Journal of Holistic Nursing, 32(2), 104–​115. Abu-​R aiya, H., Pargament, K. I., & Krause, N. (2016). Religion as problem, religion as solution: Religious buffers of the links between religious/​spiritual struggles and well-​being/​ mental health. Quality of Life Research, 25(5), 1265–​1274. Abu-​Zeid, H. A. H., Choi, N. W., Maini, K. K., & Nelson, N. A. (1975). Incidence and epidemiologic features of cerebrovascular disease (stroke) in Manitoba, Canada. Preventive Medicine, 4, 567–​578. Acevedo, G. A. (2010). Collective rituals or private practice in Texas? Assessing the impact of religious factors on mental health. Review of Religious Research, 52(2), 188–​206.

Acevedo, G. A., Ellison, C. G., & Xu, X. (2014). Is it really religion? Comparing the main and stress-​ buffering effects of religious and secular civic engagement on psychological distress. Society and Mental Health, 4(2), 111–​128. Acheampong, A., Vidot, D. C., Striley, C. W., & Cottler, L. (2017). The association between religion/​spirituality and 30 day crack/​cocaine and marijuana use among female offenders. Drug & Alcohol Dependence, 171, e2–​e3. Acheson, L. S. (1994). Perinatal, infant, and child death rates among the old order Amish. American Journal of Epidemiology, 139, 173–​183. Achour, M., Grine, F., Nor, M. R. M., & MohdYusoff, M. Y. Z. (2015). Measuring religiosity and its effects on personal well-​being: a case study of Muslim female academicians in Malaysia. Journal of Religion and Health, 54(3), 984–​997. ACS (2019). Tobacco and cancer fact sheet. American Cancer Society. Retrieved on 12-​20-​2019 from https://​www.can​cer.org/​cont​ent/​dam/​can​cer-​ org/​can​cer-​cont​rol/​en/​bookl​ets-​fly​ers/​toba​cco-​ and-​can​cer-​factsh​eet.pdf. Adam, E. K., Snell, E. K., & Pendry, P. (2007). Sleep timing and quantity in ecological and family context: a nationally representative time-​diary study. Journal of Family Psychology, 21(1), 4–​19. Adamczyk, A. (2013). The effect of personal religiosity on attitudes toward abortion, divorce, and gender equality—​does cultural context make a difference? EurAmerica, 43(1), 213–​253. Adamczyk, A., & Felson, J. (2006). Friends’ religiosity and first sex. Social Science Research, 35(4), 924–​947. Adamczyk, A., & Hayes, B. E. (2012). Religion and sexual behaviors understanding the influence of Islamic cultures and religious affiliation for explaining sex outside of marriage. American Sociological Review, 77(5), 723–​746. Adams, H. P., Jr., Bendixen, B. H., Kappelle, L. J., Biller, J., Love, B. B., Gordon, D. L., & Marsh, E. E., III (1993). Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. Stroke, 24(1), 35–​41. Adams, M. L., Grandpre, J., Katz, D. L., & Shenson, D. (2019). The impact of key modifiable risk factors on leading chronic conditions. Preventive Medicine, 120, 113–​118. Addo, J., Ayerbe, L., Mohan, K. M., Crichton, S., Sheldenkar, A., Chen, R., . . . McKevitt, C. (2012). Socioeconomic status and stroke: an updated review. Stroke, 43(4), 1186–​1191. Address, R. F. (2018). What does Jewish tradition say about health and wellness? ReformJudaism. org. Retrieved on 12-​26-​2019 from https://​

reform​juda​ism.org/​blog/​2018/​09/​20/​what-​ does-​jew​ish-​tradit​ion-​say-​about-​hea​lth-​and-​ welln​ess. Adekeye, O. B., & Sheikh, T. L. (2009). Self-​efficacy and religiosity as determinants of cognitive behavioural therapy treatment outcome in substance use disorders. African Journal of Drug and Alcohol Studies, 8(1) (https://​www.ajol.info/​ index.php/​ajdas/​arti​cle/​view/​47411). Adini, B., Singer, S. R., Ringel, R., & Dickmann, P. (2019). Earlier detection of public health risks–​ Health policy lessons for better compliance with the International Health Regulations (IHR 2005): insights from low-​, mid-​and high-​income countries. Health Policy, 123(10), 941–​946. Adong, J., Lindan, C., Fatch, R., Emenyonu, N. I., Muyindike, W. R., Ngabirano, C., et al. (2018). The relationship between spirituality/​ religiousness and unhealthy alcohol use among HIV-​infected adults in southwestern Uganda. AIDS and Behavior, 22(6), 1802–​1813. Adzika, V. A., Glozah, F. N., Ayim-​Aboagye, D., & Ahorlu, C. S. (2017). Socio-​demographic characteristics and psychosocial consequences of sickle cell disease: the case of patients in a public hospital in Ghana. Journal of Health, Population and Nutrition, 36(1), 4. Afhami, R., Mohammadi-​Zarghan, S., & Atari, M. (2017). Self-​rating of religiosity (SRR) in Iran: validity, reliability, and associations with the Big Five. Mental Health, Religion & Culture, 20(9), 879–​887. Afshar, M., Richards, S., Mann, D., Cross, A., Smith, G. B., Netzer, G., et al. (2015). Acute immunomodulatory effects of binge alcohol ingestion. Alcohol, 49(1), 57–​64. Agadjanian, V., & Jansen, N. A. (2018). Historical legacies, social capital, and women’s decision-​ making power: religion and child nutrition in Mozambique. Journal of Religion and Health, 57(4), 1458–​1472. Agbaria, Q., & Bdier, D. (2019). The association of Big Five personality traits and religiosity on Internet addiction among Israeli-​Palestinian Muslim college students in Israel. Mental Health, Religion & Culture, 22(9), 956–​971. Agerbo, E., Sullivan, P. F., Vilhjalmsson, B. J., Pedersen, C. B., Mors, O., Børglum, A. D., et al. (2015). Polygenic risk score, parental socioeconomic status, family history of psychiatric disorders, and the risk for schizophrenia. JAMA Psychiatry, 72(7), 635–​641. Aggacitta, B., & Kumara, B. (2013). Cankama Sutta: Walking (AN 5.29), translated from the Pali Canon. Access to Insight (BCBS Edition).

References • 865

Retrieved on 12-​26-​2019 from http://​www.acce​ ssto​insi​ght.org/​tipit​aka/​an/​an05/​an05.029. agku.html. Aghababaei, N., Błachnio, A., Arji, M., Chiniforoushan, M., & Mohammadtabar, S. (2015). The relations among well-​being outcomes, religiosity, and personality. Polish Psychological Bulletin, 46(3), 460–​468. Agnew, R. (2015). Strain, economic status, and crime (Ch. 11). In Piquero, A. R. (ed.), The Handbook of Criminological Theory, Hoboken, NJ: Wiley-​Blackwell, pp. 209–​229. Agnew, R. (2016). Race and youth crime: why isn’t the relationship stronger? Race and Justice, 6(3), 195–​221. Agrawal, A., & Lynskey, M. T. (2008). Are there genetic influences on addiction? Evidence from family, adoption and twin studies. Addiction, 103, 1069–​1081. Agrawal, A., & Lynskey, M. T. (2009). Correlates of later-​onset cannabis use in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Drug and Alcohol Dependence, 105, 71–​75. Ahmadi, F., & Ahmadi, N. (2015). Nature as the most important coping strategy among cancer patients: a Swedish survey. Journal of Religion and Health, 54(4), 1177–​1190. Ahmed, S., & Matthes, J. (2017). Media representation of Muslims and Islam from 2000 to 2015: a meta-​analysis. International Communication Gazette, 79(3), 219–​244. Ahn, S., Phillips, K. L., Smith, M. L., & Ory, M. G. (2011). Correlates of volunteering among aging Texans: the roles of health indicators, spirituality, and social engagement. Maturitas, 69(3), 257–​262. Ahrenfeldt, L. J., Möller, S., Andersen-​R anberg, K., Vitved, A. R., Lindahl-​Jacobsen, R., & Hvidt, N. C. (2017). Religiousness and health in Europe. European Journal of Epidemiology, 32(10), 921–​929. Ahrenfeldt, L. J., Möller, S., Hvidt, N. C., & Lindahl-​ Jacobsen, R. (2018). Religiousness and lifestyle among Europeans in SHARE. Public Health, 165, 74–​81. Ahrenfeldt, L. J., Hvidt, N. C., Kjøller, S. T., Möller, S., & Lindahl-​Jacobsen, R. (2019). Religiousness and diseases in Europe: findings from SHARE. Journal of Religion and Health, 58(6), 1925–​1937. Ahrold, T. K., & Meston, C. M. (2010). Ethnic differences in sexual attitudes of US college students gender, acculturation, and religiosity factors. Archives of Sexual Behavior, 39(1), 190–​202.

866 •  R eferences

Ai, A. L., Peterson, C., Bolling, S. F., & Koenig, H. G. (2002). Private prayer and optimism in middle-​ aged and older patients awaiting cardiac surgery. Gerontologist, 42(1), 70–​81. Ai, A. L., Peterson, C., Rodgers, W. L., & Tice, T. N. (2005a). Effects of faith and secular factors on locus of control in middle-​aged and older cardiac patients. Aging & Mental Health, 9(5), 470–​481. Ai, A. L., Peterson, C., Rodgers, W. L., & Tice, T. N. (2005b). Faith factors and internal health locus of control in patients prior to open-​heart surgery. Journal of Health Psychology, 10(5), 669–​676. Ai, A. L., Peterson, C., Bolling, S. F., & Rodgers, W. (2006a). Depression, faith-​based coping, and short-​term postoperative global functioning in adult and older patients undergoing cardiac surgery. Journal of Psychosomatic Research, 60(1), 21–​28. Ai, A. L., Peterson, C., Tice, T. N., Rodgers, W. L., Seymour, E. M., Bolling, S. F., et al. (2006b). Differential effects of faith-​based coping on physical and mental fatigue in middle-​aged and older cardiac patients. International Journal of Psychiatry in Medicine, 36(3), 351–​365. Ai, A. L., Wink, P., Tice, T. N., Bolling, S. F., & Shearer, M. (2009a). Prayer and reverence in naturalistic, aesthetic, and socio-​moral contexts predicted fewer complications following coronary artery bypass. Journal of Behavioral Medicine, 32, 570–​581. Ai, A. L., Seymour, E. M., Tice, N., Kronfol, Z., Appel, H., & Bolling, S. F. (2009b). Spiritual struggle related to plasma interleukin-​6 prior to cardiac surgery. Psychology of Religion and Spirituality, 1(2), 112–​128. Ai, A. L., Pargament, K., Kronfol, Z., Tice, T. N., & Appel, H. (2010). Pathways to postoperative hostility in cardiac patients: Mediation of coping, spiritual struggle and interleukin-​6. Journal of Health Psychology, 15(2), 186–​195. Ai, A. L., Wink, P., & Shearer, M. (2011). Secular reverence predicts shorter hospital length of stay among middle-​aged and older patients following open-​heart surgery. Journal of Behavioral Medicine, 34(6), 532–​541. Ai, A. L., Hall, D., Pargament, K., & Tice, T. N. (2013). Posttraumatic growth in patients who survived cardiac surgery: the predictive and mediating roles of faith-​based factors. Journal of Behavioral Medicine, 36(2), 186–​198. Aiken, C. B., Weisler, R. H., & Sachs, G. S. (2015). The Bipolarity Index: a clinician-​rated measure of diagnostic confidence. Journal of Affective Disorders, 177, 59–​64.

Akanbi, M. O., Carroll, A. J., Achenbach, C., O’Dwyer, L. C., Jordan, N., Hitsman, B., et al. (2019). The efficacy of smoking cessation interventions in low‐and middle‐income countries: A systematic review and meta‐ analysis. Addiction, 114(4), 620–​635. Akbari, B., Azari, M. G., & Mousavi, S. M. (2017). The relationship between spiritual wellbeing and depression, stress, anxiety with cortisol level among nursing students. Researcher Bulletin of Medical Sciences, 22(1), 16. Akbari, M. E., Haghdoost, A. A., Nakhaee, N., Bahramnejad, A., Baneshi, M. R., & Zolala, F. (2015). Risk and protective factor for suicide attempt in Iran: a matched case-​controlled study. Archives of Iranian Medicine, 18(11), 747–​752. Akbari, M. E., Kashani, F. L., Ahangari, G., Pornour, M., Hejazi, H., Nooshinfar, E., et al. (2016). The effects of spiritual intervention and changes in dopamine receptor gene expression in breast cancer patients. Breast Cancer, 23(6), 893–​900. Akinnawo, O. E., Kumuyi, D. O., & Akpunne, B. C. (2019). Psychosocial determinants of medication adherence among psychiatric outpatients. Journal of Health, Medicine and Nursing, 69, 57–​64. Akrawi, D., Bartrop, R., Potter, U., & Touyz, S. (2015). Religiosity, spirituality in relation to disordered eating and body image concerns: a systematic review. Journal of Eating Disorders, 3(1), 1–​24. Aksungar, F. B., Topkaya, A. E., & Akyildiz, M. (2007). Interleukin-​6, C-​reactive protein and biochemical parameters during prolonged intermittent fasting. Annals of Nutrition & Metabolism, 51(1), 88–​95. Akuchekian, S., Jamshidian, Z., Maracy, M. R., Almasi, A., & Jazi, A. H. D. (2011). Effectiveness of religious-​cognitive-​behavioral therapy on religious oriented obsessive compulsive disorder and its co-​morbidity. Journal of Isfahan Medical School, 28(114), 1–​11. Al Aboud, N. M., & Jialal, I. (2018). Genetics, epigenetic mechanism. StatPearls. Retrieved on 12-​5-​2019 from https://​www.ncbi.nlm.nih.gov/​ books/​NBK532​999/​. Alghalayini, K. W., Al-​Zaben, F. N., Sehlo, M. G., & Koenig, H. G. (2019). Effects of a structured heart failure program on quality of life and frequency of hospital admission in Saudi Arabia. Saudi Medical Journal, 40(6), 582–​589. Al Zaben, F., Khalifa, D. A., Sehlo, M. G., Al Shohaib, S., Binzaqr, S. A., Badreg, A. M., et al. (2015a). Religious involvement and health in dialysis

patients in Saudi Arabia. Journal of Religion and Health, 54(2), 713–​730. Al Zaben, F., Sehlo, M., Khalifa, D., & Koenig, H. G. (2015b). Test-​retest reliability of the Muslim Religiosity Scale: follow-​up to “Religious involvement and health among dialysis patients in Saudi Arabia.” Journal of Religion and Health, 54(3), 1144–​1147. Alacreu-​Crespo, A., Olié, E., Guillaume, S., Girod, C., Cazals, A., Chaudieu, I., & Courtet, P. (2020). Dexamethasone suppression test may predict more severe/​violent suicidal behavior. Frontiers in Psychiatry, 11, 97. Alahmad, G., & Dekkers, W. (2012). Bodily integrity and male circumcision: an Islamic perspective. Journal of the Islamic Medical Association, 44(1), 1–​9. Alakhdhair, S., Sheets, V., Geib, R., Alkhuwaildi, A., & Koenig, H. G. (2016). Psychometric properties of the Arabic version of the Belief into Action Scale. Mental Health, Religion & Culture, 19(8), 846–​857. Alam, I., Gul, R., Chong, J., Tan, C. T. Y., Chin, H. X., Wong, G., et al. (2019). Recurrent circadian fasting (RCF) improves blood pressure, biomarkers of cardiometabolic risk and regulates inflammation in men. Journal of Translational Medicine, 17(1), 272. Alcántara, C., Peacock, J., Davidson, K. W., Hiti, D., & Edmondson, D. (2014). The association of short sleep after acute coronary syndrome with recurrent cardiac events and mortality. International Journal of Cardiology, 171(2), e11–​e12. Alcaraz, K. I., Eddens, K. S., Blase, J. L., Diver, W. R., Patel, A. V., Teras, L. R., et al. (2019). Social isolation and mortality in US black and white men and women. American Journal of Epidemiology, 188(1), 102–​109. Alcoholics Anonymous (2001). Alcoholics Anonymous, 4th ed. New York, NY: Alcoholics Anonymous World Services. Al-​Dhahabi, M. I. (1961). Al-​Tibb al-​Nabawi (Prophetic Medicine). Cairo: Mutafā al-​Halabī. Aldinger, F., & Schulze, T. G. (2017). Environmental factors, life events, and trauma in the course of BPD. Psychiatry and Clinical Neurosciences, 71(1), 6–​17. Alemdar, D. K., Kardaş Özdemir, F., & Güdücü Tüfekci, F. (2018). The effect of spiritual care on stress levels of mothers in NICU. Western Journal of Nursing Research, 40(7), 997–​1011. Alexander, C. N., Langer, E. J., Newman, R. I., Chandler, H. M., & Davies, J. L. (1989). Transcendental meditation, mindfulness,

References • 867

and longevity: an experimental study with the elderly. Journal of Personality and Social Psychology, 57(6), 950–​964. Alexander, C. N., Schneider, R. H., Staggers, F., Sheppard, W., Clayborne, B. M., Rainforth, M., et al. (1996). Trial of stress reduction for hypertension in older African Americans. II. Sex and risk subgroup analysis. Hypertension, 28(2), 228–​237. Al-​Hazzaa, H. M. (2018). Physical inactivity in Saudi Arabia revisited: a systematic review of inactivity prevalence and perceived barriers to active living. International Journal of Health Sciences, 12(6), 50–​64. Ali, F., Agaku, I., Sharapova, S., Reimels, E., & Homa, D. (2020). Peer reviewed: onset of regular smoking before age 21 and subsequent nicotine dependence and cessation behavior among US adult smokers. Preventing Chronic Disease, 17, E06. Ali, L., Ali, S., Hussain, S. A., Haider, F., & Ali, S. (2018). Role of spiritual sentiments in improving the compliance of water intake in patients with urolithiasis. Journal of Religion and Health, 57(1), 26–​32. Ali, M. M. (1990). The Religion of Islam, 6th ed. Columbus, OH: The Ahmadiyya Anjuman Isha’at Islam. Alicandro, G., Malvezzi, M., Gallus, S., La Vecchia, C., Negri, E., & Bertuccio, P. (2019). Worldwide trends in suicide mortality from 1990 to 2015 with a focus on the global recession time frame. International Journal of Public Health, 64(5), 785–​795. Al-​Jobouri, H. J., Nafakhi, H., Rokan, K. J., & Al-​ Basri, A. M. (2019). The relationship between religious practices and markers of subclinical coronary atherosclerosis. Journal of Madenat Alelem University College, 11(2), 67–​75. Al-​Kandari, S., Alsalem, A., Abohaimed, S., Al-​Orf, F., Al-​Zoubi, M., Al-​Sabah, R., et al. (2017). Brief report: social support and coping strategies of mothers of children suffering from ASD in Kuwait. Journal of Autism and Developmental Disorders, 47(10), 3311–​3319. Al-​Kandari, Y. Y. (2011). Religiosity, social support, and health among the elderly in Kuwait. Journal of Muslim Mental Health, 6(1), 81–​98. Allahverdipour, H., Abbasi-​Ghahramanloo, A., Mohammadpoorasl, A., & Nowzari, P. (2015). Cigarette smoking and its relationship with perceived familial support and religiosity of university students in Tabriz. Iranian Journal of Psychiatry, 10(3), 136–​143. Allen, J. D., Pérez, J. E., Pischke, C. R., Tom, L. S., Juarez, A., Ospino, H., & Gonzalez-​Suarez,

868 •  R eferences

E. (2014). Dimensions of religiousness and cancer screening behaviors among church-​going Latinas. Journal of Religion and Health, 53(1), 190–​203. Allen, J. O., Watkins, D. C., Chatters, L., & Johnson-​ Lawrence, V. (2020). Mechanisms of racial health disparities: evidence on coping and cortisol from MIDUS II. Journal of Racial and Ethnic Health Disparities, 7(2), 207–​216. Allen, K. D., Arbeeva, L., Campbell, L., Cené, C., Keefe, F. J., Oddone, E., et al. (2019). Identifying subgroups of African American patients with differential improvement following a pain coping skills training program for osteoarthritis. Osteoarthritis and Cartilage, 27, S489. Allen, M. S., & Laborde, S. (2017). Five factor personality traits and inflammatory biomarkers in the English longitudinal study of aging. Personality and Individual Differences, 111, 205–​210. Allik, J., Laidra, K., Realo, A., & Pullmann, H. (2004). Personality development from 12 to 18 years of age: changes in mean levels and structure of traits. European Journal of Personality, 18(6), 445–​462. Allison, P. J., Guichard, C., Fung, K., & Gilain, L. (2003). Dispositional optimism predicts survival status 1 year after diagnosis in head and neck cancer patients. Journal of Clinical Oncology, 21, 543–​548. Allport, G. W. (1937). Personality: A Psychological Interpretation. Oxford, UK: Holt. Allport, G. W., & Ross, J. M. (1967). Personal religious orientation and prejudice. Journal of Personality & Social Psychology, 5, 432–​443. Allshouse, A. A., Santoro, N., Green, R., Wong, J. Y., Upchurch, D. M., Neal-​Perry, G., et al. (2018). Religiosity and faith in relation to time to metabolic syndrome for Hispanic women in a multiethnic cohort of women: findings from the Study of Women’s Health across the Nation (SWAN). Maturitas, 112, 18–​23. Almeida, R. G., Martinez, E. Z., Mazzo, A., Trevizan, M. A., & Mendes, I. A. (2013). Spirituality and post-​graduate students’ attitudes towards blood donation. Nursing Ethics, 20(4), 392–​400. Almela, M., Hidalgo, V., Villada, C., van der Meij, L., Espín, L., Gómez-​Amor, J., et al. (2011). Salivary alpha-​amylase response to acute psychosocial stress: the impact of age. Biological Psychology, 87(3), 421–​429. Almutairi, K. M. (2016). Predicting relationship of smoking behavior among male Saudi Arabian college students related to their religious

practice. Journal of Religion and Health, 55(2), 469–​479. Alonso‐Pedrero, L., Bes‐Rastrollo, M., & Marti, A. (2019). Effects of antidepressant and antipsychotic use on weight gain: a systematic review. Obesity Reviews, 20(12), 1680–​1690. Al-​Qaradawi, Y. (1992). The Status of Women in Islam. Cairo: Islamic Home Publishing. Al-​Qaradawi, Y. (1999). The Lawful and the Prohibited in Islam. Drive Oak Brook, IL: American Trust Publications. Alrouji, M., Manouchehrinia, A., Gran, B., & Constantinescu, C. S. (2019). Effects of cigarette smoke on immunity, neuroinflammation and multiple sclerosis. Journal of Neuroimmunology, 329, 24–​34. Altemeyer, B. (1988). Enemies of Freedom: Understanding Right-​Wing Authoritarianism. San Francisco, CA: Jossey-​Bass. Altpeter, M., Mitchell, J., & Pennell, J. (2005). Advancing social workers’ responsiveness to health disparities: the case of breast cancer screening. Health & Social Work, 30(3), 221–​232. Alturki, K., Hamza, A., & Walton, P. (2020). Islam and motivation to quit smoking: public health policy implications. Journal of Religion and Health, 59(3), 1175–​1188. Alvarez, J. S., Goldraich, L. A., Nunes, A. H., Zandavalli, M. C. B., Zandavalli, R. B., Belli, K. C., et al. (2016). Association between spirituality and adherence to management in outpatients with heart failure. Arquivos Brasileiros de Cardiologia, 106(6), 491–​501. Alzheimer’s Disease Association (2019). 2019 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 15(3), 321–​387. Amadi, K. U., Nduanya, U. C., Odinka, J. I., Onu, J. U., Muomah, C. R., Odinka, P. C., et al. (2020). Religion and adherence to antiretroviral medication. American Journal of Humanities and Social Sciences Research, 4(12), 425–​433. Aman, J., Abbas, J., Nurunnabi, M., & Bano, S. (2019). The relationship of religiosity and marital satisfaction. Behavioral Sciences, 9(3), 30. Amato, P. R. (2000). The consequences of divorce for adults and children. Journal of Marriage and Family, 62(4), 1269–​1287. Amato, P. R. (2001). Children of divorce in the 1990s. Journal of Family Psychology, 15(3), 355. Amato, P. R., & Keith, B. (1991). Parental divorce and the well-​being of children. Psychological Bulletin, 110(1), 26–​46. Amato, P. R., & Rogers, S. J. (1997). A longitudinal study of marital problems and subsequent

divorce. Journal of Marriage and Family, 59, 612–​624. Amato, P. R., Loomis, L. S., & Booth, A. (1995). Parental divorce, marital conflict, and offspring well-​being during early adulthood. Social Forces, 73(3), 895–​915. Amen, D. G., Darmal, B., Raji, C. A., Bao, W., Jorandby, L., Meysami, S., et al. (2017). Discriminative properties of hippocampal hypoperfusion in marijuana users compared to healthy controls. Journal of Alzheimer’s Disease, 56(1), 261–​273. American Cancer Society (2019). Cancer facts and ­figures 2019. Retrieved on 6-​23-​2020 from https://​www.can​cer.org/​cont​ent/​dam/​can​cer-​ org/​resea​rch/​can​cer-​facts-​and-​sta​tist​ics/​ann​ ual-​can​cer-​facts-​and-​figu​res/​2019/​can​cer-​facts-​ and-​figu​res-​2019.pdf. American Diabetes Association (2013). Economic costs of diabetes in the US in 2012. Diabetes Care, 36(4), 1033–​1046. American Heart Association (2019a). What kind of diet helps heart health? Retrieved on 1-​4-​2020 from https://​www.heart.org/​en/​news/​2019/​03/​ 25/​what-​kind-​of-​diet-​helps-​heart-​hea​lth. American Heart Association (2019b). Prevalence of obesity in the United States among persons 2–​19 years and 20+​years: NHANES. Retrieved on 1-​5-​2020 from https://​health​metr​ics.heart. org/​pre​vale​nce-​of-​obes​ity-​in-​the-​uni​ted-​sta​ tes-​among-​pers​ons-​2-​19-​years-​and-​20-​years-​ nha​nes/​. American Heart Association (2020a). What is cardiovascular disease? Retrieved on 3-​16-​2020 from https://​www.heart.org/​en/​hea​lth-​top​ics/​ consu​mer-​hea​lthc​are/​what-​is-​car​diov​ascu​lar-​ dise​ase. American Heart Association (2020b). 2020 heart disease and stroke statistical update fact sheet at-​a-​glance. Retrieved on 3-​16-​2020 from https://​www.heart.org/​en/​about-​us/​heart-​and-​ str​oke-​asso​ciat​ion-​sta​tist​ics. American Heart Association (2020c). 2020 heart disease and stroke statistical updates fact sheet at-​a-​glance. Retrieved on 3-​3-​2020 from https://​ profe​ssio​nal.heart.org/​idc/​gro​ups/​aha​mah-​pub​ lic/​@wcm/​@sop/​@smd/​docume​nts/​downl​oada​ ble/​ucm​_​505​473.pdf. American Heritage Dictionary (2020). Health. American Heritage Dictionary. Boston, MA: Houghton Mifflin Harcourt. Retrieved on 10-​12-​2020 from https://​www.ahdic​tion​ary. com/​word/​sea​rch.html?q=​Hea​lth. American Psychiatric Association Committee on Religion and Psychiatry (1990). Guidelines

References • 869

regarding possible conflict between psychiatrists’ religious commitments and psychiatric practice. American Journal of Psychiatry, 147, 542. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM- 5®). Washington, DC: American Psychiatric Publishing. Ames, D., Haynes, K., Adamson, S. F., Bruce, L. E., Chacko, B. K., Button, L., et al. (2018). A Structured Chaplain Intervention for Veterans with Moral Injury in the Setting of PTSD. Durham, NC: Duke University Center for Spirituality, Theology and Health (Christian, Buddhist, Hindu, Jewish, and Muslim versions available). Ames, D., & Koenig, H. G. (2019). Randomized Controlled Trial Comparing Conventional Cognitive Processing Therapy (CPT) with Spiritually-​ Integrated CPT and Structured Chaplain-​ Administered Pastoral Care in U.S. Veterans with Moral Injury and PTSD Symptoms. Los Angeles, CA: Greater Los Angeles Veterans Healthcare System. Amey, C. H., Albrecht, S. L., & Miller, M. K. (1996). Racial differences in adolescent drug use: the impact of religion. Substance Use and Misuse, 31, 1311–​1332. Amini, K., Tahrekhani, M., Abbas-​Alamdari, Z., & Faghihzadeh, S. (2020). The effect of spiritual care on anxiety about death in patients with gastrointestinal cancer undergoing chemotherapy: a randomized controlled trial. European Journal of Integrative Medicine, 19, 46. Amiri, S., & Behnezhad, S. (2019). Systematic review and meta-​analysis of the association between smoking and the incidence of frailty. Neuropsychiatrie, 33, 198–​206. Amit, B. H., Krivoy, A., Mansbach-​Kleinfeld, I., Zalsman, G., Ponizovsky, A. M., Hoshen, M., et al. (2014). Religiosity is a protective factor against self-​injurious thoughts and behaviors in Jewish adolescents: findings from a nationally representative survey. European Psychiatry, 29(8), 509–​513. Amitai, M., & Apter, A. (2012). Social aspects of suicidal behavior and prevention in early life: a review. International Journal of Environmental Research and Public Health, 9(3), 985–​994. Amjadian, M., Bahrami Ehsan, H., Saboni, K., Vahedi, S., Rostami, R., & Roshani, D. (2020). A pilot randomized controlled trial to assess the effect of Islamic spiritual intervention and of breathing technique with heart rate variability feedback on anxiety, depression and psycho-​physiologic coherence in patients after

870 •  R eferences

coronary artery bypass surgery. Annals of General Psychiatry, 19(1), 1–​10. Amoateng, A. Y., & Bahr, S. J. (1986). Religion, family, and adolescent drug use. Sociological Perspectives, 29, 53–​76. Amr, M., El-​Mogy, A., & El-​Masry, R. (2013). Adherence in Egyptian patients with schizophrenia: the role of insight, medication beliefs and spirituality. Arab Journal of Psychiatry, 24, 60–​68. Amstadter, A. B., Richardson, L., Meyer, A., Sawyer, G., Kilpatrick, D. G., Tran, T. L., et al. (2011). Prevalence and correlates of probable adolescent mental health problems reported by parents in Vietnam. Social Psychiatry & Psychiatric Epidemiology, 46(2), 95–​100. Anandacoomarasamy, A., Caterson, I., Sambrook, P., Fransen, M., & March, L. (2008). The impact of obesity on the musculoskeletal system. International Journal of Obesity, 32(2), 211. Anandarajah, G., Craigie, F., Jr., Hatch, R., Kliewer, S., Marchand, L., King, D., et al. (2010). Toward competency-​based curricula in patient-​centered spiritual care: recommended competencies for family medicine resident education. Academic Medicine, 85(12), 1897–​1904. Anderson, A. (2002). Pentecostal approaches to faith and healing. International Review of Mission, 91(363), 523. Anderson, J. (2014). The impact of family structure on the health of children: effects of divorce. Linacre Quarterly, 81(4), 378–​387. Anderson, M. R., Miller, L., Wickramaratne, P., Svob, C., Odgerel, Z., Zhao, R., et al. (2017). Genetic correlates of spirituality/​religion and depression: a study in offspring and grandchildren at high and low familial risk for depression. Spirituality in Clinical Practice, 4(1), 43–​63. Anderson, N., Heywood-​Everett, S., Siddiqi, N., Wright, J., Meredith, J., & McMillan, D. (2015). Faith-​adapted psychological therapies for depression and anxiety: systematic review and meta-​analysis. Journal of Affective Disorders, 176, 183–​196. Anderson, R. J., Hurley, R. W., Staud, R., & Robinson, M. E. (2016). Cognitive-​motivational influences on health behavior change in adults with chronic pain. Pain Medicine, 17(6), 1079–​1093. Anderson, W. L., Wiener, J. M., Finkelstein, E. A., & Armour, B. S. (2011). Estimates of national health care expenditures associated with disability. Journal of Disability Policy Studies, 21(4), 230–​240.

Anderson-​Schmidt, H., Gade, K., Malzahn, D., Papiol, S., Budde, M., Heilbronner, U., et al. (2019). The influence of religious activity and polygenic schizophrenia risk on religious delusions in schizophrenia. Schizophrenia Research, 210, 255–​261. Andrasfay, T., & Goldman, N. (2020). Physical functioning and survival: is the link weaker among Latino and Black older adults? Social Science & Medicine, 255, 112983. Andreassi, M. G., & Della Corte, A. (2016). Genetics of bicuspid aortic valve aortopathy. Current Opinion in Cardiology, 31(6), 585–​592. Andreescu, V. (2019). Gender differences and patterns of arrest across two generations of Cuban immigrants in the United States. Journal of Ethnicity in Criminal Justice, 17(2), 133–​168. Andrews, F. M., & Withey, S. B. (1976). Social Indicators of Well-​being. New York, NY: Plenum Press. Andruszkiewicz, A., Basińska, M. A., Felsmann, M., Banaszkiewicz, M., Marzec, A., & Kędziora-​ Kornatowska, K. (2017). The determinants of coping with pain in chronically ill geriatric patients: the role of a sense of coherence. Clinical Interventions in Aging, 12, 315. Angel, J. L. (1947). The length of life in ancient Greece. Journal of Gerontology, 2(1), 18–​24. Angele, M. K., Pratschke, S., Hubbard, W. J., & Chaudry, I. H. (2014). Gender differences in sepsis: cardiovascular and immunological aspects. Virulence, 5(1), 12–​19. Angelica, M. (2017). What is redemptive suffering? Catholic Exchange. Retrieved on 8/​8/​2020 from https://​catho​lice​xcha​nge.com/​what-​is-​red​empt​ ive-​suffer​ing. Anonymous (1991). Outbreaks of rubella among the Amish: United States, 1991. Morbidity & Mortality Weekly Report, 40, 264–​265. Anonymous (2005). A brief history of nicotine anonymous. Retrieved on 12-​21-​2019 from https://​nicot​ine-​anonym​ous.org/​files/​DOCS_​s​ even​minu​tes/​SM_​200​5_​Se​ptem​ber.pdf. Ansari, S., Munir, K., & Gregg, T. (2012). Impact at the “bottom of the pyramid”: the role of social capital in capability development and community empowerment. Journal of Management Studies, 49(4), 813–​842. Ansari, S., Soltero, E. G., Lorenzo, E., & Lee, R. E. (2017). The impact of religiosity on dietary habits and physical activity in minority women participating in the Health is Power (HIP) study. Preventive Medicine Reports, 5, 210–​213. Anstey, K. J., Cherbuin, N., Budge, M., & Young, J. (2011). Body mass index in midlife and late‐life

as a risk factor for dementia: a meta‐analysis of prospective studies. Obesity Reviews, 12(5), e426–​e437. Antai, D. (2009). Faith and child survival: the role of religion in childhood immunization in Nigeria. Journal of Biosocial Science, 41, 57–​76. Anthony, I. C., Norrby, K. E., Dingwall, T., Carnie, F. W., Millar, T., Arango, J. C., et al. (2010). Predisposition to accelerated Alzheimer-​ related changes in the brains of human immunodeficiency virus negative opiate abusers. Brain, 133(12), 3685–​3698. Antoni, M. H., & Dhabhar, F. S. (2019). The impact of psychosocial stress and stress management on immune responses in patients with cancer. Cancer, 125(9), 1417–​1431. Anyfantakis, D., Symvoulakis, E. K., Panagiotakos, D. B., Tsetis, D., Castanas, E., Shea, S., et al. (2013). Impact of religiosity/​spirituality on biological and preclinical markers related to cardiovascular disease. Hormones, 12(3), 386–​396. APA (2014). Psychiatry and faith community leaders kick off collaboration aimed at reducing stigma and improving mental health care. American Psychiatric Association. Retrieved on 10-​3-​2020 from https://​www.psy​chia​try.org/​ newsr​oom/​news-​relea​ses/​psy​chia​try-​and-​faith-​ commun​ity-​lead​ers-​kick-​off-​collab​orat​ion. Apel, M. D. (1986). The attitude and knowledge of church members and pastors related to older adults and retirement. Journal of Religion & Aging, (293), 31–​43. Appel, H. B., Ai, A. L., Huang, B., & Nicdao, E. (2014). Detrimental effects of discrimination on mental health in Asian Americans: counteracting roles of religious involvement. International Journal for the Psychology of Religion, 24(1), 28–​46. Aquinas, T. ([1274] 1948). Summa Theologica: Complete English Translation in Five Volumes. Notre Dame, IN: Ave Maria Press. Arabin, B., & Baschat, A. A. (2017). Pregnancy: an underutilized window of opportunity to improve long-​term maternal and infant health—​ An appeal for continuous family care and interdisciplinary communication. Frontiers in Pediatrics, 5, 69. Araújo, J., Cai, J., & Stevens, J. (2019). Prevalence of optimal metabolic health in American adults: national health and nutrition examination survey 2009–​2016. Metabolic Syndrome and Related Disorders, 17(1), 46–​52. Archibald, P. C., Dobson Sydnor, K., Daniels, K., & Bronner, Y. (2013). Explaining

References • 871

African-​Americans’ depressive symptoms: a stress-​distress and coping perspective. Journal of Health Psychology, 18(3), 321–​331. Ardito, C., Leombruni, R., Mosca, M., Giraudo, M., & d’Errico, A. (2017). Scar on my heart: effects of unemployment experiences on coronary heart disease. International Journal of Manpower, 38(1), 62–​92. Arem, H., Moore, S. C., Patel, A., Hartge, P., De Gonzalez, A. B., Visvanathan, K., et al. (2015). Leisure time physical activity and mortality: a detailed pooled analysis of the dose-​response relationship. JAMA Internal Medicine, 175(6), 959–​967. Argue, A., Johnson, D. R., & White, L. K. (1999). Age and religiosity: evidence from a three-​wave panel analysis. Journal for the Scientific Study of Religion, 423–​435. Arias, E., & Xu, J. (2019). United States Life Tables, 2017. National Vital Statistics Reports 68 (7), 1–​66. Retrieved on 7-​3-​2020 from https://​www. cdc.gov/​nchs/​fast​ats/​life-​exp​ecta​ncy.htm. Arit, J., Jahn, H., Kellner, M., Strohle, A., & Yassouridis, A. (2003). Modulation of sympathetic activity by corticotropin-​releasing hormone and atrial natriuretic peptide. Neuropeptides, 37, 362–​368. Arnetz, B. B., Theorell, T., Levi, L., Kallner, A., & Eneroth, P. (1983). An experimental study of social isolation of elderly people: psychoendocrine and metabolic effects. Psychosomatic Medicine 45(5), 395–​406. Arredondo, E. M., Elder, J. P., Haughton, J., Slymen, D. J., Sallis, J. F., Perez, L. G., et al. (2017). Fe en Acción: promoting physical activity among churchgoing Latinas. American Journal of Public Health, 107(7), 1109–​1115. Arroyo-​Johnson, C., & Mincey, K. D. (2016). Obesity epidemiology worldwide. Gastroenterology Clinics, 45(4), 571–​579. Arsenault, B. J., Rana, J. S., Lemieux, I., Despres, J. P., Kastelein, J. J. P., Boekholdt, S. M., et al. (2010). Physical inactivity, abdominal obesity and risk of coronary heart disease in apparently healthy men and women. International Journal of Obesity, 34(2), 340–​347. Arston, B. (2020). Judaism and the human body: commentary on Parashat Ki Teitzei. Retrieved on 7-​22-​2020 from https://​www. myjew​ishl​earn​ing.com/​arti​cle/​lets-​get-​ physi​cal/​. Artaud, F., Sabia, S., Dugravot, A., Kivimaki, M., Singh-​Manoux, A., & Elbaz, A. (2016). Trajectories of unhealthy behaviors in midlife and risk of disability at older ages in

872 •  R eferences

the Whitehall II Cohort Study. Journals of Gerontology, 71A(11), M1500–​1506. Artress, L. (1996). Walking a Sacred Path: Rediscovering the Labyrinth as a Spiritual Practice. New York, NY: Penguin. Artyukhov, I. P., Arshukova, I. L., Dobretsova, E. A., & Shulmin, A. V. (2016). Mortality and economic burden of Krasnoyarsk region, Russia, caused by regular tobacco usage. International Journal of Chronic Obstructive Pulmonary Disease, 11, 351–​355. Arutyunyan, T., Odetola, F., Swieringa, R., & Niedner, M. (2018). Religion and spiritual care in pediatric intensive care unit: parental attitudes regarding physician spiritual and religious inquiry. American Journal of Hospice and Palliative Medicine, 35(1), 28–​33. Aryanpur, M., Yousefifard, M., Oraii, A., Heydari, G., Kazempour-​Dizaji, M., Sharifi, H., et al. (2019). Effect of passive exposure to cigarette smoke on blood pressure in children and adolescents: a meta-​analysis of epidemiologic studies. BMC Pediatrics, 19(1), 161. Asadi-​Piri, Z., Harvey, I. S., Imani-​Nasab, M. H., Zare, S., Nouraei Motlagh, S., & Cheraghi, N. (2021). Spirituality and pain self-​efficacy in older adults with chronic pain. Journal of Religion, Spirituality & Aging, 33(3), 298–​310. Aseltine, R. H., Jr., & Kessler, R. C. (1993). Marital disruption and depression in a community sample. Journal of Health and Social Behavior, 34(3), 237–​251. Ashley, L. L., & Boehlke, K. K. (2012). Pathological gambling. Journal of Psychoactive Drugs, 44(1), 27–​37. Asiamah, N. (2016). Socio-​demographic determinants of physical activity (PA). Cogent Medicine, 3(1), 1276037. Aslakson, R. A., Kweku, J., Kinnison, M., Singh, S., Crowe, T. Y., II, Ast, K., et al. (2017). Operationalizing the measuring what matters spirituality quality metric in a population of hospitalized, critically ill patients and their family members. Journal of Pain and Symptom Management, 53(3), 650–​655. Asmand, P., Mardani, S., Kheiri, S., Jazayeri, S. R., & Solati, K. (2019). Investigating the effectiveness of practicing teachings of the Qur’an on anxiety and blood pressure in Iranian women with primary blood pressure. Journal of Qur’an and Medicine, 3(3), 30–​37. Assanangkornchai, S., Conigrave, K. M., & Sauders, J. B. (2002). Religious beliefs and practice, and alcohol use in Thai men. Alcohol & Alcoholism 37 (2), 193–​197.

Assari, S. (2013). Race and ethnicity, religion involvement, church-​based social support and subjective health in United States. International Journal of Preventive Medicine, 4(2), 208. Assari, S. (2014). Chronic medical conditions and major depressive disorder: differential role of positive religious coping among African Americans, Caribbean blacks and non-​Hispanic whites. International Journal of Preventive Medicine, 5(4), 405–​413. Assari, S. (2015). Ethnic and gender differences in additive effects of socio-​economics, psychiatric disorders, and subjective religiosity on suicidal ideation among blacks. International Journal of Preventive Medicine, 6(1), 53. Assari, S., Lankarani, M. M., Caldwell, C., Zimmerman, M., Malekahmadi, M. R. (2015). Baseline religion involvement predicts subsequent salivary cortisol levels among male but not female Black youth. International Journal of Endocrinology & Metabolism 13(4), e31790. Assari, S., Larkarani, M. M., & Moazen, B. (2012). Religious beliefs may reduce the negative effect of psychiatric disorders on age of onset of suicidal ideation among Blacks in the United States. International Journal of Preventative Medicine, 3(5), 358–​364. Assemie, M. A., Leshargie, C. T., & Petrucka, P. (2019). Outcomes and factors affecting mortality and successful tracing among patients lost to follow-​up from antiretroviral therapy in Pawi Hospital, Northwest Ethiopia. Tropical Medicine and Health, 47(1), 52. Assiri, H. M., Almazarigeh, S. D., Moshibah, A. M., Al-​Shahrani, S. F., Al-​Qarni, N. S., & Hadadi, A. M. (2015). Risk factors for physical inactivity in Saudi Arabia. AL-​A zhar Assiut Medical Journal, 13, 132–​138. Astrow, A. B., Kwok, G., Sharma, R. K., Fromer, N., & Sulmasy, D. P. (2018). Spiritual needs and perception of quality of care and satisfaction with care in hematology/​medical oncology patients: a multicultural assessment. Journal of Pain and Symptom Management, 55(1), 56–​64. Asubiaro, O. Y., & Fatusi, A. O. (2014). Differential effects of religiosity on sexual initiation among Nigerian in-​school adolescents. International Journal of Adolescent Medicine and Health, 26(1), 93–​100. Athanasakis, K., Kyriopoulos, I., & Kyriopoulos, J. (2018). PHP331—​Is it enough to have it in the vaccination programme? An empirical analysis of the factors that affect influenza vaccination uptake in adults in Greece. Value in Health, 21, S207.

Atherton, O. E., Ferrer, E., & Robins, R. W. (2018). The development of externalizing symptoms from late childhood through adolescence. Developmental Psychology, 54(6), 1135–​1147. Atkin, N., Vickerstaff, V., & Candy, B. (2017). “Worried to death”: the assessment and management of anxiety in patients with advanced life-​limiting disease, a national survey of palliative medicine physicians. BMC Palliative Care, 16(1), 69. Atkins, D. C., Baucom, D. H., & Jacobson, N. S. (2001). Understanding infidelity. Journal of Family Psychology, 15(4), 735–​749. Atkins, R. G., Jr., & Hawdon, J. E. (2007). Religiosity and participation in mutual-​aid support groups for addiction. Journal of Substance Abuse Treatment, 33(3), 321–​331. Attum, B., Waheed, A., & Shamoon, Z. (2018). Cultural competence in the care of Muslim patients and their families. StatPearls Publishing. Retrieved on 9-​1-​2020 from https://​www.ncbi. nlm.nih.gov/​books/​NBK499​933/​. Attwood, M. (2004). Suicide as a response to suffering. Western Buddhist Review, 4, online. Retrieved on 6-​10-​2019 from http://​www.wester​ nbud​dhis​trev​iew.com/​vol4/​suicide​_​as_​a_​re​spon​ se_​t​o_​su​ffer​ing.html. Audette, L. M., Barry, C. M., Carlucci, M. E., & Hardy, S. (2018). Associations among body dissatisfaction, gender, and three latent profiles of religiosity. Mental Health, Religion & Culture, 21(4), 380–​394. Aune, D., Sen, A., Prasad, M., Norat, T., Janszky, I., Tonstad, S., et al. (2016). BMI and all cause mortality: a systematic review and non-​linear dose-​response meta-​analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants. British Medical Journal, 353, i2156. Avelar-​González, A. K., Bureau-​Chávez, M., Durón-​ Reyes, D., Mondragón-​Cervantes, M. I., del Carmen Jiménez-​Acosta, Y., Leal-​Mora, D., et al. (2020). Spirituality and religious practices and its association with geriatric syndromes in older adults attending to a geriatric’s clinic in a university hospital. Journal of Religion and Health, 59(6), 2794–​2806. Avgerinos, K. I., Spyrou, N., Mantzoros, C. S., & Dalamaga, M. (2019). Obesity and cancer risk: emerging biological mechanisms and perspectives. Metabolism, 92, 121–​135. Ayalon, L., & Covinsky, K. E. (2007). Late-​life mortality in older Jews exposed to the Nazi regime. Journal of the American Geriatrics Society, 55(9), 1380–​1386.

References • 873

Ayazi, M., Johnson, K. T., Merritt, M. M., Di Paolo, M. R., Edwards, C. L., Koenig, H. G., et al. (2018). Religiosity, education, John Henryism active coping, and cardiovascular responses to anger recall for African American men. Journal of Black Psychology, 44(4), 295–​321. Ayling, K., Sunger, K., & Vedhara, K. (2020). Effects of brief mood-​improving interventions on immunity: a systematic review and meta-​analysis. Psychosomatic Medicine, 82(1), 10–​28. Azagba, S., Asbridge, M., & Langille, D. B. (2014). Is religiosity positively associated with school connectedness?: evidence from high school students in Atlantic Canada. Journal of Primary Prevention, 35(6), 417–​427. Azaiza, F., Cohen, M., Awad, M., & Daoud, F. (2010). Factors associated with low screening for breast cancer in the Palestinian authority. Cancer, 116(19), 4646–​4655. Azale, T., Fekadu, A., Medhin, G., & Hanlon, C. (2018). Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-​sectional community study. BMC Psychiatry, 18(1), 41. Azhar, M. Z., Varma, S. L., & Dharap, A. S. (1994). Religious psychotherapy in anxiety disorder patients. Acta Psychiatrica Scandinavica, 90, 1–​3. Azofeifa, A. (2016). National estimates of marijuana use and related indicators: National Survey on Drug Use and Health, United States, 2002–​2014. MMWR. Surveillance Summaries, 65(11), 1–​25. Azorin, J. M., Kaladjian, A., Fakra, E., Adida, M., Belzeaux, R., Hantouche, E., et al. (2013). Religious involvement in major depression: protective or risky behavior. The relevance of bipolar spectrum. Journal of Affective Disorders, 150(3), 753–​759. Baćak a, V., & Štulhofer, A. (2011). Masturbation among sexually active young women in Croatia: associations with religiosity and pornography use. International Journal of Sexual Health, 23(4), 248–​257. Bachhuber, M. A., Hennessy, S., Cunningham, C. O., & Starrels, J. L. (2016). Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996–​2013. American Journal of Public Health, 106(4), 686–​688. Backholer, K., Peters, S. A., Bots, S. H., Peeters, A., Huxley, R. R., & Woodward, M. (2017). Sex differences in the relationship between socioeconomic status and cardiovascular disease: a systematic review and meta-​analysis.

874 •  R eferences

Journal of Epidemiology and Community Health, 71(6), 550–​557. Badran, M., & Laher, I. (2011). Obesity in Arabic-​ speaking countries. Journal of Obesity, Article ID 686430, 1–​9. Badrasawi, M. M., Shahar, S., Manaf, Z. A., Haron, H. (2013). Effect of Talbinah food consumption on depressive symptoms among elderly individuals in long term care facilities, randomized clinical trial. Clinical Interventions in Aging, 8, 279–​285. Baena, B. C., Meneses, C., Caperos, J. M., Prieto, M., & Uroz, J. (2019). The role of religion and religiosity in alcohol consumption in adolescents in Spain. Journal of Religion and Health, 58(5), 1477–​1487. Baetz, M., & Bowen, R. (2008). Chronic pain and fatigue: associations with religion and spirituality. Pain Research & Management, 13, 383–​388. Baetz, M., Griffin, R., Bowen, R., Koenig, H. G., & Marcoux, E. (2004). The association between spiritual and religious involvement and depressive symptoms in a Canadian population. Journal of Nervous & Mental Disease, 192(12), 818–​822. Baetz, M., Bowen, R., Jones, G., & Koru-​Sengul, T. (2006). How spiritual values and worship attendance relate to psychiatric disorders in the Canadian population. Canadian Journal of Psychiatry, 51(10), 654–​661. Bagheri, J., Shayan, N., Bagheri, M. M., & Heidari, M. (2019). Relationship of spirituality with morbidity and mortality in patients with coronary artery disease undergoing CABG surgery at Shariati Hospital. Journal of Pizhūhish dar dīn va Salāmat, 5(1), 76–​86. Bagiella, E., Hong, V., & Sloan, R. P. (2005). Religious attendance as a predictor of survival in the EPESE cohorts. International Journal of Epidemiology, 34(2), 443–​451. Bahri, N., Najafi, T. F., Shandiz, F. H., Tohidinik, H. R., & Khajavi, A. (2019). The relation between stressful life events and breast cancer. Breast Cancer Research and Treatment, 176, 53–​61. Baider, L., Russak, S. M., Perry, S., Kash, K., Gronert, M., Fox, B., et al. (1999). The role of religious and spiritual beliefs in coping with malignant melanoma. Psycho‐Oncology, 8(1), 27–​35. Bailey, M. (2010). Media, religion and culture: an interview with Michael Wakelin. Journal of Media Practice, 11(2), 185–​189. Bailey, Z. D., Slopen, N., Albert, M., Williams, D. R. (2015). Multidimensional religious involvement

and tobacco smoking patterns over 9–​10 years: a prospective study of middle-​aged adults in the United States. Social Science & Medicine, 138, 128–​135. Bailly, N., & Roussiau, N. (2010). The Daily Spiritual Experience Scale (DSES): validation of the short form in an elderly French population. Canadian Journal on Aging, 29(2), 223–​231. Bailly, N., Martinent, G., Ferrand, C., Agli, O., Giraudeau, C., Gana, K., et al. (2018). Spirituality, social support, and flexibility among older adults: a five-​year longitudinal study. International Psychogeriatrics, 30(12), 1745–​1752. Bajelan, M., Roodi, N. E., Daloee, M. H., Farhangnia, M., & Kuchaksaraei, A. S. (2019). The effect of low testosterone and estrogen levels on progressive coronary artery disease in men. Reports of Biochemistry & Molecular Biology, 8(2), 168. Baker, D. W. (2017). History of the Joint Commission’s pain standards: lessons for today’s prescription opioid epidemic. Journal of the American Medical Association, 317(11), 1117–​1118. Baker, J. L., Olsen, L. W., & Sørensen, T. I. (2007). Childhood body-​mass index and the risk of coronary heart disease in adulthood. New England Journal of Medicine, 357(23), 2329–​2337. Baker, J. O., Stroope, S., & Walker, M. H. (2018). Secularity, religiosity, and health: physical and mental health differences between atheists, agnostics, and nonaffiliated theists compared to religiously affiliated individuals. Social Science Research, 75, 44–​57. Balboni, M. J., Sullivan, A., Amobi, A., Phelps, A. C., Gorman, D. P., Zollfrank, A., et al. (2013). Why is spiritual care infrequent at the end of life? Spiritual care perceptions among patients, nurses, and physicians and the role of training. Journal of Clinical Oncology 31(4):461–​467. Balboni, M. J., Sullivan, A., Enzinger, A. C., Epstein-​ Peterson, Z. D., Tseng, Y. D., Mitchell, C., et al. (2014). Nurse and physician barriers to spiritual care provision at the end of life. Journal of Pain and Symptom Management 48(3), 400–​410. Balboni, M. J., Sullivan, A., Enzinger, A. C., Smith, P. T., Mitchell, C., Peteet, J. R., et al. (2017). US clergy religious values and relationships to end-​ of-​life discussions and care. Journal of Pain and Symptom Management, 53(6), 999–​1009. Balboni, M. J., Sullivan, A., Smith, P. T., Zaidi, D., Mitchell, C., Tulsky, J. A., et al. (2018). The views of clergy regarding ethical controversies in care

at the end of life. Journal of Pain and Symptom Management, 55(1), 65–​74. Balboni, T. A., Paulk, M. E., Balboni, M. J., Phelps, A. C., Loggers, E. T., Wright, A. A., et al. (2010). Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. Journal of Clinical Oncology, 28(3), 445. Balboni, T. A., Balboni, M., Paulk, M. E., Phelps, A., Wright, A., Peteet, J. R., et al. (2011). Support of cancer patients’ spiritual needs and associations with medical care costs at the end of life. Cancer, 117(23), 5383–​5391. Balboni, T. A., Balboni, M., Enzinger, A. C., Gallivan, K., Paulk, M. E., Wright, A., et al. (2013). Provision of spiritual support to patients with advanced cancer by religious communities and associations with medical care at the end of life. JAMA Internal Medicine, 173(12), 1109–​1117. Balboni, T. A., Balboni, M. J., & Fitchett, G. (2015). Religion, spirituality, and the intensive care unit: the sound of silence. JAMA Internal Medicine, 175(10), 1669–​1670. Balboni, T. A., VanderWeele, T. J., Doan-​Soares, S. D., Long, K. N., Ferrell, B. R., Fitchett, G., et al. (2022). Spirituality in serious illness and health. Journal of the American Medical Association, 328(2), 184–​197. Balbuena, L., Baetz, M., & Bowen, R. (2013). Religious attendance, spirituality, and major depression in Canada: a 14-​year follow-​up study. Canadian Journal of Psychiatry, 58(4), 225–​232. Baldessarini, R. J., Tondo, L., & Vázquez, G. H. (2019). Pharmacological treatment of adult bipolar disorder. Molecular Psychiatry, 24(2), 198–​217. Bales, R. F. (1944). The therapeutic role of alcoholics anonymous as seen by a sociologist. Quarterly Journal of Studies on Alcohol, 5, 267–​278. Bandelow, B., & Domschke, K. (2015). Panic disorder. In Stein, D., & Vythilingum, B. (eds.), Anxiety Disorders and Gender. Cham, Switzerland: Springer, pp. 31–​48. Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience, 17(3), 327–​335. Banerjee, A. T., Boyle, M. H., Anand, S. S., Strachan, P. H., & Oremus, M. (2014). The relationship between religious service attendance and coronary heart disease and related risk factors in Saskatchewan, Canada. Journal of Religion and Health, 53(1), 141–​156.

References • 875

Banin, L. B., Suzart, N. B., Guimarães, F. A. G., Lucchetti, A. L., de Jesus, M. A. S., & Lucchetti, G. (2014). Religious beliefs or physicians’ behavior: what makes a patient more prone to accept a physician to address his/​her spiritual issues? Journal of Religion and Health, 53(3), 917–​928. Banta, J. E., McKinney, O. (2016). Faith-​based hospitals and variation in psychiatric inpatient length of stay in California, 2002–​2011. Journal of Religion and Health, 55, 787–​802. Barber, B. K. (2001). Political violence, social integration, and youth functioning: Palestinian youth from the Intifada. Journal of Community Psychology, 29(3), 259–​280. Barber, N. (2013). Country religiosity declines as material security increases. Cross-​Cultural Research, 47(1), 42–​50. Barber, N. (2018). Cross-​national variation in attitudes to premarital sex: economic development, disease risk, and marriage strength. Cross-​Cultural Research, 52(3), 259–​273. Barbour, K. E., Helmick, C. G., Boring, M., & Brady, T. J. (2017). Vital signs: prevalence of doctor-​ diagnosed arthritis and arthritis-​attributable activity limitation—​United States, 2013–​ 2015. Morbidity and Mortality Weekly Report, 66(9), 246. Barichello, T., Badawy, M., Pitcher, M. R., Saigal, P., Generoso, J. S., Goularte, J. A., et al. (2016). Exposure to perinatal infections and bipolar disorder: a systematic review. Current Molecular Medicine, 16(2), 106–​118. Barnes, D. E., Haight, T. J., Mehta, K. M., Carlson, M. C., Kuller, L. H., & Tager, I. B. (2010). Secondhand smoke, vascular disease, and dementia incidence: findings from the cardiovascular health cognition study. American Journal of Epidemiology, 171(3), 292–​302. Barnes, J. C., & Jacobs, B. A. (2013). Genetic risk for violent behavior and environmental exposure to disadvantage and violent crime: the case for gene-​environment interaction. Journal of Interpersonal Violence, 18, 92–​120. Barnes, J. C., Liu, H., Motz, R. T., Tanksley, P. T., Kail, R., Beckley, A. L., et al. (2019). The propensity for aggressive behavior and lifetime incarceration risk: a test for gene-​ environment interaction (GxE) using whole-​ genome data. Aggression and Violent Behavior, 49, 101307. Barnes, V. A., Treiber, F. A., Johnson, M. H. (2004). Impact of Transcendental Meditation on ambulatory blood pressure in African-​American

876 •  R eferences

adolescents. American Journal of Hypertension, 17(4), 366–​369. Baron, J., & Brown, R. V. (2012). Teaching Decision Making to Adolescents. Abington, UK: Routledge. Baron-​Epel, O., Haviv, A., Garty, N., Tamir, D., & Green, M. S. (2005). Who are the sedentary people in Israel? A public health indicator. Israel Medical Association Journal, 7(11), 694–​699. Baron-​Epel, O., Haviv-​Messika, A., Tamir, D., Nitzan-​Kaluski, D., & Green, M. (2004). Multiethnic differences in smoking in Israel: pooled analysis from three national surveys. European Journal of Public Health, 14(4), 384–​389. Barr, T., Helms, C., Grant, K., & Messaoudi, I. (2016). Opposing effects of alcohol on the immune system. Progress in Neuro-​ Psychopharmacology and Biological Psychiatry, 65, 242–​251. Barry, L. C., Kerns, R. D., Guo, Z., Duong, B. D., Iannone, L. P., & Carrington Reid, M. (2004). Identification of strategies used to cope with chronic pain in older persons receiving primary care from a Veterans Affairs Medical Center. Journal of the American Geriatrics Society, 52(6), 950–​956. Bartkowski, J. P., & Xu, X. (2007). Religiosity and teen drug use reconsidered: a social capital perspective. American Journal of Preventive Medicine, 32(6 Suppl), S182–​194. Bartkowski, J. P., Xu, X., & Levin, M. L. (2008). Religion and child development: evidence from the early childhood longitudinal study. Social Science Research, 37(1), 18–​36. Bartlett, J., & Kaplan, J. (eds.) (2002). Bartlett’s Familiar Quotations, 17th ed. Boston, MA: Little, Brown. Barton, Y. A., Miller, L., Wickramaratne, P., Gameroff, M. J., Weissman, M. M. (2013). Religious attendance and social adjustment as protective against depression: a 10-​year prospective study. Journal of Affective Disorders, 146, 53–​57. Barton-​Bellessa, S. M., Lee, J., & Shon, P. (2015). Correcting misconceptions about Alfred Adler’s psychological theory of crime in introductory criminology textbooks: moving Adler’s theory of crime forward. Journal of Individual Psychology, 71(1), 34–​57. Basiński, A., Stefaniak, T., Stadnyk, M., Sheikh, A., & Vingerhoets, A. J. (2013). Influence of religiosity on the quality of life and on pain intensity in chronic pancreatitis patients after neurolytic celiac plexus block: case-​controlled

study. Journal of Religion and Health, 52(1), 276–​284. Baskovich, B., Hiraki, S., Upadhyay, K., Meyer, P., Carmi, S., Barzilai, N., et al. (2016). Expanded genetic screening panel for the Ashkenazi Jewish population. Genetics in Medicine, 18(5), 522–​528. Basoglu, M., Livanou, M., Crnobaric, C., Franciskovic, T., Suljic, E., Duric, D., et al. (2005). Psychiatric and cognitive effects of war in former Yugoslavia: association of lack of redress for trauma and posttraumatic stress reactions. Journal of the American Medical Association, 294(5), 580–​590. Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & Laudet, A. (2016). Peer-​delivered recovery support services for addictions in the United States: a systematic review. Journal of Substance Abuse Treatment, 63, 1–​9. Batelaan, N. M., Seldenrijk, A., Bot, M., van Balkom, A. J., & Penninx, B. W. (2016). Anxiety and new onset of cardiovascular disease: critical review and meta-​analysis. British Journal of Psychiatry, 208(3), 223–​231. Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. Lancet, 385(9969), 735–​743. Bator, E. X., Philpott, B., & Costa, A. P. (2017). This moral coil: a cross-​sectional survey of Canadian medical student attitudes toward medical assistance in dying. BMC Medical Ethics, 18(1), 1–​7. Batson, C. D. (1976). Religion as prosocial agent or double agent? Journal for the Scientific Study of Religion, 15, 29–​45. Batson, C. D., & Schoenrade, P. (1991a). Measuring religion as quest: 1. Validity concerns. Journal for the Scientific Study of Religion, 30, 416–​429. Batson, C. D., & Schoenrade, P. (1991b). Measuring religion as quest: 2. Reliability concerns. Journal for the Scientific Study of Religion, 30, 430–​447. Battle, J., & DeFreece, A. (2014). The impact of community involvement, religion, and spirituality on happiness and health among a national sample of Black lesbians. Women, Gender, and Families of Color, 2(1), 1–​31. Batty, G. D., Shipley, M. J., Kvaavik, E., Russ, T., Hamer, M., Stamatakis, E., et al. (2018). Biomarker assessment of tobacco smoking exposure and risk of dementia death: pooling of individual participant data from 14 cohort studies. Journal of Epidemiology and Community Health, 72(6), 513–​515. Batz, C., & Tay, L. (2018). Gender differences in subjective well-​being. In E. Diener, S. Oishi, & L.

Tay (eds.), Handbook of Well-​Being. Salt Lake City, UT: DEF, pp. 1–​15. Baudouin, C., Charveron, M., Tarroux, R., & Gall, Y. (2002). Environmental pollutants and skin cancer. Cell Biology and Toxicology, 18(5), 341–​348. Bauer, A. G., Berkley-​Patton, J., Bowe Thompson, C., & Christensen, K. (2018). Predictors and missed opportunities for blood glucose screening among African Americans: implications for church-​ based populations. Journal of Health Disparities Research and Practice, 12(2), 4. Bauer, U. E., Briss, P. A., Goodman, R. A., & Bowman, B. A. (2014). Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet, 384(9937), 45–​52. Baum, S., Ma, J., & Payea, K. (2010). Education Pays, 2010: The Benefits of Higher Education for Individuals and Society. Trends in Higher Education Series. New York, NY: College Board Advocacy & Policy Center. Retrieved on 9-​25-​ 2020 from https://​eric.ed.gov/​?id=​ED526​357. Baxter, A. J., Scott, K. M., Vos, T., & Whiteford, H. A. (2013). Global prevalence of anxiety disorders. Psychological Medicine, 43(5), 897–​910. Baxter, A. J., Vos, T., Scott, K. M., Ferrari, A. J., & Whiteford, H. A. (2014). The global burden of anxiety disorders in 2010. Psychological Medicine, 44(11), 2363–​2374. Bayarri Fernàndez, E., Ezpeleta, L., Granero, R., de la Osa, N., & Domènech, J. M. (2011). Degree of exposure to domestic violence, psychopathology, and functional impairment in children and adolescents. Journal of Interpersonal Violence, 26(6), 1215–​1231. Bazzano, L. A., Gu, D., Whelton, M. R., Wu, X., Chen, C. S., Duan, X., et al. (2010). Body mass index and risk of stroke among Chinese men and women. Annals of Neurology, 67(1), 11–​20. BBC (2019). Buddhist attitudes to family life. British Broadcasting Corporation. Retrieved on 10-​21-​2019 from https://​www.bbc.co.uk/​bites​ ize/​gui​des/​z7d7​sbk/​revis​ion/​3. Beach, S. R., Lei, M. K., Brody, G. H., Dogan, M. V., & Philibert, R. A. (2015). Higher levels of protective parenting are associated with better young adult health: exploration of mediation through epigenetic influences on pro-​ inflammatory processes. Frontiers in Psychology, 6, 676. Beals, J., Novins, D. K., Spicer, P., Whitesell, N. R., Mitchell, C. M., Manson, S. M., et al. (2006).

References • 877

Help seeking for substance use problems in two American Indian reservation populations. Psychiatric Services, 57(4), 512–​520. Bear, U. R., Garroutte, E. M., Beals, J., Kaufman, C. E., & Manson, S. M. (2018). Spirituality and mental health status among Northern Plain tribes. Mental health, Religion & Culture, 21(3), 274–​287. Bearman, P. S., & Moody, J. (2004). Suicide and friendships among American adolescents. American Journal of Public Health, 94(1), 89–​95. Beasley, J. M., Newcomb, P. A., Trentham-​Dietz, A., Hampton, J. M., Ceballos, R. M., Titus-​Ernstoff, L., et al. (2010). Social networks and survival after breast cancer diagnosis. Journal of Cancer Survivorship, 4(4), 372–​380. Beaver, K. M., Gibson, C. L., Jennings, W. G., & Ward, J. T. (2009). A gene X environment interaction between DRD2 and religiosity in the prediction of adolescent delinquent involvement in a sample of males. Biodemography and Social Biology, 55(1), 71–​81. Beck, R., & McDonald, A. (2004). Attachment to God: The Attachment to God Inventory, tests of working model correspondence, and an exploration of faith group differences. Journal of Psychology and Theology, 32(2), 92–​103. Beck, S. H., Cole, B. S., & Hammond, J. A. (1991). Religious heritage and premarital sex: evidence from a national sample of young adults. Journal for the Scientific Study of Religion, 30, 173–​180. Becker, E. R., & Granzotti, A. M. (2019). Trends in in-​hospital coronary artery bypass surgery mortality by gender and race/​ethnicity: 1998–​ 2015. Journal of the National Medical Association, 111(5), 527–​539. Becoña, E., Martínez, Ú., Calafat, A., Juan, M., Fernández-​Hermida, J. R., & Secades-​Villa, R. (2012). Parental styles and drug use. Drugs, 19(1), 1–​10. Bediako, S. M., Lattimer, L., Haywood, C., Ratanawongsa, N., Lanzkron, S., & Beach, M. C. (2011). Religious coping and hospital admissions among adults with sickle cell disease. Journal of Behavioral Medicine, 34(2), 120–​127. Beeghley, L., Bock, E. W., & Cochran, J. K. (1990). Religious change and alcohol use. Sociological Forum, 5, 261–​278. Beeghly, M., Perry, B. D., & Tronick, E. (2016). Self-​regulatory processes in early development. In Maltzman, S. (ed.), Oxford Handbook of Treatment Processes and Outcomes in Psychology: A Multidisciplinary, Biopsychosocial Approach. New York, NY: Oxford University Press, pp. 42–​54.

878 •  R eferences

Beeri, M. S., Davidson, M., Silverman, J. M., Schmeidler, J., Springer, R. R., Noy, S., et al. (2008). Religious education and midlife observance are associated with dementia three decades later in Israeli men. Journal of Clinical Epidemiology, 61(11), 1161–​1168. Begley, C. E., Annegers, J. F., Swann, A. C., Lewis, C., Coan, S., Schnapp, W. B., et al. (2001). The lifetime cost of bipolar disorder in the US. Pharmacoeconomics, 19(5), 483–​495. Begley, T. M., Lee, C., & Czajka, J. M. (2000). The relationships of type A behavior and optimism with job performance and blood pressure. Journal of Business and Psychology, 15(2), 215–​227. Beiranvand, S., Noparast, M., Eslamizade, N., & Saeedikia, S. (2014). The effects of religion and spirituality on postoperative pain, hemodynamic functioning and anxiety after cesarean section. Acta Medica Iranica, 52(12), 909–​915. Bekke-​Hansen, S., Pedersen, C. G., Thygesen, K., Christensen, S., Waelde, L. C., et al. (2014). The role of religious faith, spirituality and existential considerations among heart patients in a secular society. Journal of Health Psychology, 19(6), 740–​753. Bell, C. N., Bowie, J. V., & Thorpe, R. J. (2012). The interrelationship between hypertension and blood pressure, attendance at religious services, and race/​ethnicity. Journal of Religion and Health, 51(2), 310–​322. Bell, R., Wechsler, H., & Johnston, L. D. (1997). Correlates of college student marijuana use. Addiction, 92, 571–​581. Bellinger, D. L., Berk, L. S., Koenig, H. G., Daher, N., Pearce, M. J., Robins, C. J., et al. (2014). Religious involvement, inflammatory markers and stress hormones in major depression and chronic medical illness. Open Journal of Psychiatry, 4(04), 335–​352. Beltrán-​Sánchez, H., Crimmins, E. M., & Finch, C. E. (2012). Early cohort mortality predicts the cohort rate of aging. Journal of Developmental Origins of Health and Disease, 3(5), 380–​386. Benda, B. B. (2001). Predictors of rehospitalization of military veterans who abuse substances. Social Work Research, 25(4), 199–​212. Benda, B. B. (2002a). Factors associated with rehospitalization among veterans in a substance abuse treatment program. Psychiatric Services, 53(9), 1176–​1178. Benda, B. B. (2002b). A survival analysis of dimensions of religion among homeless substance abusers: going into the remotest regions. Marriage & Family, 5(1), 99–​114.

Benda, B. B., & Corwyn, R. F. (2002). The effect of abuse in childhood and in adolescence on violence among adolescents. Youth & Society, 33(3), 339–​365. Benda, B. B., Toombs, N. J., & Peacock, M. (2003). Discriminators of types of recidivism among boot camp graduates in a five-​year follow-​up study. Journal of Criminal Justice, 31(6), 539–​551. Beneitez, I., & Nieto, R. (2017). Do we understand pain from a biopsychosocial perspective? A review and discussion of the usefulness of some pain terms. Pain Management, 7(1), 41–​48. Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., et al. (2019). Heart disease and stroke statistics: 2019 update. Circulation, 139(10), e56–​528. Benjamins, M. R. (2004). Religion and functional health among the elderly. Journal of Aging & Health, 16(3), 355–​374. Benjamins, M. R. (2005). Social determinants of preventive service utilization: how religion influences the use of cholesterol screening in older adults. Research on Aging, 27(4), 475–​497. Benjamins, M. R. (2006a). Does religion influence patient satisfaction? American Journal of Health Behavior, 30(1), 85–​91. Benjamins, M. R. (2006b). Religious influences on preventive health care use in a nationally representative sample of middle-​age women. Journal of Behavioral Medicine, 29(1), 1–​16. Benjamins, M. R. (2007). Predictors of preventive health care use among middle-​aged and older adults in Mexico: the role of religion. Journal of Cross-​Cultural Gerontology, 22(2), 221–​234. Benjamins, M. R., & Brown, C. (2004). Religion and preventative health care utilization among the elderly. Social Science & Medicine, 58(1), 109–​118. Benjamins, M. R., & Buck, A. C. (2008). Religion: a sociocultural predictor of health behaviors in Mexico. Journal of Aging & Health, 20(3), 290–​305. Benjamins, M. R., Musick, M. A., Gold, D. T., & George, L. K. (2003). Age-​related declines in activity level: the relationship between chronic illness and religious activities. Journals of Gerontology, 58(6), S377–​385. Benjamins, M. R., Ellison, C. G., Krause, N. M., & Marcum, J. P. (2011). Religion and preventive service use: do congregational support and religious beliefs explain the relationship between attendance and utilization? Journal of Behavioral Medicine, 34(6), 462–​476. Benjamins, M. R., Hunt, B. R., Raleigh, S. M., Hirschtick, J. L., & Hughes, M. M. (2016). Racial

disparities in prostate cancer mortality in the 50 largest US cities. Cancer Epidemiology, 44, 125–​131. Benjet, C., Borges, G., Medina-​Mora, M. E., Blanco, J., Zambrano, J., Orozco, R., et al. (2007a). Drug use opportunities and the transition to drug use among adolescents from the Mexico City Metropolitan Area. Drug & Alcohol Dependence, 90(2–​3), 128–​134. Benjet, C., Borges, G., Medina-​Mora, M. E., Fleiz, C., Blanco, J., Zambrano, J., et al. (2007b). Prevalence and socio-​demographic correlates of drug use among adolescents: results from the Mexican Adolescent Mental Health Survey. Addiction, 102(8), 1261–​1268. Ben-​Meir, Y., & Kedem, P. (1979). Index of religiosity of the Jewish population of Israel. Megamot, 24, 353–​362. Bennett, D. A. (2017). Mixed pathologies and neural reserve: implications of complexity for Alzheimer’s disease drug discovery. PLoS Medicine, 14(3), e1002256. Benowitz, N. L. (2010). Nicotine addiction. New England Journal of Medicine, 362(24), 2295–​2303. Ben-​Shaanan, T. L., Azulay-​Debby, H., Dubovik, T., Starosvetsky, E., Korin, B., Schiller, M., et al. (2016). Activation of the reward system boosts innate and adaptive immunity. Nature Medicine, 22(8), 940. Benson, J., Maldari, T., Williams, M. J., & Hanifi, M. H. (2010). The impact of culture and ethnicity on women’s perceived role in society and their attendant health beliefs. InnovAiT, 6, 358–​365. Benson, P. L., & Donahue, M. J. (1989). Ten-​year trends in at-​risk behaviors: a national study of black adolescents. Journal of Adolescent Research, 4, 125–​139. Bentley-​Edwards, K. L., Carr, L. T. B., Robbins, P. A., Conde, E., Zaw, K., & Darity, W. A. (2019). Investigating denominational and church attendance differences in obesity and diabetes in black Christian men and women. Journal of Religion and Health, 59(6), 3055–​3070. Benvenuti, A., Miniati, M., Callari, A., Mariani, M. G., Mauri, M., & Dell’Osso, L. (2015). Mood Spectrum Model: evidence reconsidered in the light of DSM-​5. World Journal of Psychiatry, 5(1), 126–​137. Benzies, K., & Mychasiuk, R. (2009). Fostering family resiliency: a review of the key protective factors. Child & Family Social Work, 14(1), 103–​114. Berg, G. M., Whitney, M. P., Wentling, C. J., Hervey, A. M., & Nyberg, S. (2013). Physician assistant

References • 879

program education on spirituality and religion in patient encounters. Journal of Physician Assistant Education, 24(2), 24–​27. Bergantin, L. B. (2020). Depression rises the risk of hypertension incidence: discussing the link through the Ca2+​/​cAMP signaling. Current Hypertension Reviews, 16(1), 73–​78. Berges, I. M., Kuo, Y. F., Markides, K. S., & Ottenbacher, K. (2007). Attendance at religious services and physical functioning after stroke among older Mexican Americans. Experimental Aging Research, 33(1), 1–​11. Berggren, N., & Ljunge, M. (2021). Good faith and bad health: self-​assessed religiosity and self-​assessed health of women and men in Europe. Social Indicators Research, 153(1), 323–​344. Berk, L. S., Bellinger, D. L., Koenig, H. G., Daher, N., Pearce, M. J., Robins, C. J., et al. (2015). Effects of religious vs. conventional cognitive-​behavioral therapy on inflammatory markers and stress hormones in major depression and chronic medical illness: a randomized clinical trial. Open Journal of Psychiatry, 5(03), 238–​259. Berkel, J., & deWaard, F. (1983). Morality pattern and life expectancy of Seventh-​Day Adventists in the Netherlands. International Journal of Epidemiology, 12, 455–​459. Berkman, L. F., Kawachi, I., & Glymour, M. M. (Eds.). (2014). Social Epidemiology. New York, NY: Oxford University Press. Berkman, L. F., & Syme, S. L. (1979). Social networks, host resistance, and mortality: a nine-​year follow-​up study of Alameda County residents. American Journal of Epidemiology, 109(2), 186–​204. Bernardi, L., Sleight, P., Bandinelli, G., Cencetti, S., Fattorini, L., Wdowczyc-​Szulc, J., et al. (2001). Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms. British Medical Journal, 323(7327), 1446–​1449. Berner, C., Erlacher, L., Fenzl, K. H., & Dorner, T. E. (2019). Medication adherence and coping strategies in patients with rheumatoid arthritis. International Journal of Rheumatology, article ID 4709645. Berntson, G. G., Norman, G. J., Hawkley, L. C., & Cacioppo, J. T. (2008). Spirituality and autonomic cardiac control. Annals of Behavioral Medicine, 35(2), 198–​208. Berry, H. L., Rodgers, B., & Dear, K. B. (2007). Preliminary development and validation of an Australian community participation questionnaire. Social Science & Medicine, 64(8), 1719–​1737.

880 •  R eferences

Berscheid, E., & Regan, P. (2005). The Psychology of Interpersonal Relationships. Mahwah, NJ: Pearson. Bert, S. C. (2011). The influence of religiosity and spirituality on adolescent mothers and their teenage children. Journal of Youth and Adolescence, 40(1), 72–​84. Besharat, M. A., Ramesh, S., & Moghimi, E. (2018). Spiritual health mediates the relationship between ego-​strength and adjustment to heart disease. Health Psychology Open, 5(1), 1–​8. Best, A. L., Spencer, S. M., Friedman, D. B., Hall, I. J., & Billings, D. (2016). The influence of spiritual framing on African American women’s mammography intentions. Journal of Health Communication, 21(6), 620–​628. Best, A. L., Thompson, E. L., Adamu, A. M., Logan, R., Delva, J., Thomas, M., et al. (2019). Examining the influence of religious and spiritual beliefs on HPV vaccine uptake among college women. Journal of Religion and Health, 58(6), 2196–​2207. Best, J. B., & Kirk, W. G. (1982). Religiosity and self-​destruction. The Psychological Record, 32(1), 35–​39. Bettger, J. P., Zhao, X., Bushnell, C., Zimmer, L., Pan, W., Williams, L. S., et al. (2014). The association between socioeconomic status and disability after stroke. BMC Public Health, 14(1), 281. Betzig, L. (1989). Causes of conjugal dissolution. Current Anthropology, 30, 654–​676. Beutler, J. J., Attevelt, J. T., Schouten, S. A., Faber, J. A., Mees, E. J. D., & Geijskes, G. G. (1988). Paranormal healing and hypertension. British Medical Journal, 296, 1491–​1494. Beyers, J. M., Toumbourou, J. W., Catalano, R. F., Arthur, M. W., & Hawkins, J. D. (2004). A cross-​ national comparison of risk and protective factors for adolescent substance use. Journal of Adolescent Health, 35(1), 3–​16. Bharmal, N., Kaplan, R. M., Shapiro, M. F., Kagawa-​ Singer M., Wong, M. D., Mangione, C. M., et al. (2013). The association of religiosity with overweight/​obese body mass index among Asian Indian immigrants in California. Preventive Medicine, 57, 315–​321. Bhatia, A., & Kumar, Y. (2014). Cellular and molecular mechanisms in cancer immune escape. Expert Review of Clinical Immunology, 10(1), 41–​62. Bhutta, M. H., Wormith, J. S., & Zidenberg, A. M. (2019). Assessing the relationship between religiosity and recidivism among adult probationers in Pakistan. International Journal

of Offender Therapy and Comparative Criminology, 63(5), 752–​780. Biccheri, E., Roussiau, N., & Mambet-​Doué, C. (2016). Fibromyalgia, spirituality, coping and quality of life. Journal of Religion and Health, 55(4), 1189–​1197. Bicknese, A. (1999). The Teen Challenge drug treatment program in comparative perspective (Ph.D. dissertation). Evanston, IL: Northwestern University. Bierman, A. (2006). Does religion buffer the effects of discrimination on mental health? Differing effects by race. Journal for the Scientific Study of Religion, 45(4), 551–​565. Bierman, A., Lee, Y., & Schieman, S. (2018). Chronic discrimination and sleep problems in late life: religious involvement as buffer. Research on Aging, 40(10), 933–​955. Bigand, T., Wilson, M., Bindler, R., & Daratha, K. (2018). Examining risk for persistent pain among adults with overweight status. Pain Management Nursing, 19(5), 549–​556. Biggar, N. (2015). Why religion deserves a place in secular medicine. Journal of Medical Ethics, 41, 229–​233. Billioux, V. G., Sherman, S. G., & Latkin, C. (2014). Religiosity and HIV-​related drug risk behavior: a multidimensional assessment of individuals from communities with high rates of drug use. Journal of Religion and Health, 53, 37–​45. Birmingham, W. C., Macintosh, J. L., Vaughn, A. A., & Graff, T. C. (2019). Strength of belief: religious commitment, knowledge, and HPV vaccination adherence. Psycho‐oncology, 28(6), 1227–​1233. Bishop, G. D., Tong, E. M., Diong, S. M., Enkelmann, H. C., Why, Y. P., Khader, M., et al. (2001). The relationship between coping and personality among police officers in Singapore. Journal of Research in Personality, 35(3), 353–​374. Bitton, A., Choudhry, N. K., Matlin, O. S., Swanton, K., & Shrank, W. H. (2013). The impact of medication adherence on coronary artery disease costs and outcomes: a systematic review. American Journal of Medicine, 126(4), 357.e7–​ 357.e27. Bjorck, J. P., & Maslim, A. A. (2011). The multi-​faith religious support scale: validation with a sample of Muslim women. Journal of Muslim Mental Health, 6(1), 62–​80. Black, N., Stockings, E., Campbell, G., Tran, L. T., Zagic, D., Hall, W. D., et al. (2019). Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-​analysis. Lancet Psychiatry, 6(12), 995–​1010.

Blackmore, E. R., Munce, S., Weller, I., Zagorski, B., Stansfeld, S. A., Stewart, D. E., et al. (2008). Psychosocial and clinical correlates of suicidal acts: results from a national population survey. British Journal of Psychiatry, 192(4), 279–​284. Blaine, S. K., Nautiyal, N., Hart, R., Guarnaccia, J. B., & Sinha, R. (2019). Craving, cortisol and behavioral alcohol motivation responses to stress and alcohol cue contexts and discrete cues in binge and non‐binge drinkers. Addiction Biology, 24(5), 1096–​1108. Blair, S. N. (2009). Physical inactivity: the biggest public health problem of the 21st century. British Journal of Sports Medicine, 43(1), 1–​7. Blalock, S. J., DeVellis, B. M., & Giorgino, K. B. (1995). The relationship between coping and psychological well-​being among people with osteoarthritis: a problem-​specific approach. Annals of Behavioral Medicine, 17, 107–​115. Blanchflower, D. G., & Oswald, A. J. (2008). Is well-​ being U-​shaped over the life cycle? Social Science & Medicine, 66(8), 1733–​1749. Blanco, C., Compton, W. M., Saha, T. D., Goldstein, B. I., Ruan, W. J., Huang, B., et al. (2017). Epidemiology of DSM-​5 bipolar I disorder. Journal of Psychiatric Research, 84, 310–​317. Blay, S. L., Batista, A. D., Andreoli, S. B., & Gastal, F. L. (2008). The relationship between religiosity and tobacco, alcohol use, and depression in an elderly community population. American Journal of Geriatric Psychiatry, 16, 934–​943. Blazer, D. G. (1982). Social support and mortality in an elderly community population. American Journal of Epidemiology, 115(5), 684–​694. Blazer, D. G. (2011). Spirituality and depression: A background for the development of DSM-​5. In Peteet, J. R., Narrow, W., & Lu, F. (eds). Religious and Spiritual Issues in Psychiatric Diagnosis: A Research Agenda for DSM-​5. Washington, DC: American Psychiatric Publishing, pp. 1–​21. Blazer, D. G. (2016). Empirical studies about attendance at religious services and health. JAMA Internal Medicine, 176(6), 785–​786. Blazer, D., Hughes, D., & George, L. K. (1987). Stressful life events and the onset of a generalized anxiety syndrome. American Journal of Psychiatry, 144(9), 1178–​1183. Blazer, D. G., & Palmore, E. (1976). Religion and aging in a longitudinal panel. The Gerontologist, 16, 82–​85. Bleuler, E. ([1911] 1960). Dementia Praecox Oder Gruppe der Schizophrenien. Leipzig, Germany: Deuticke. Bleys, D., Luyten, P., Soenens, B., & Claes, S. (2018). Gene-​environment interactions between stress

References • 881

and 5-​HTTLPR in depression: a meta-​analytic update. Journal of Affective Disorders, 226, 339–​345. Blomberg, B. B., Alvarez, J. P., Diaz, A., Romero, M. G., Lechner, S. C., Carver, C. S., et al. (2009). Psychosocial adaptation and cellular immunity in breast cancer patients in the weeks after surgery. Journal of Psychosomatic Research, 67(5), 369–​376. Bloom, B. L., Asher, S. J., & White, S. W. (1978). Marital disruption as a stressor: a review and analysis. Psychological Bulletin, 85, 867–​894. Bluethmann, S. M., Mariotto, A. B., & Rowland, J. H. (2016). Anticipating the “silver tsunami”: prevalence trajectories and comorbidity burden among older cancer survivors in the United States. Cancer Epidemiology, Biomarkers & Prevention, 25(7), 1029–​1036. Blum, R. W. (1998). Healthy youth development as a model for youth health promotion: a review. Journal of Adolescent Health, 22(5), 368–​375. Blumenthal, J. A., Babyak, M. A., Ironson, G., Thoresen, C., Powell, L., Czajkowski, S., et al. (2007). Spirituality, religion, and clinical outcomes in patients recovering from an acute myocardial infarction. Psychosomatic Medicine, 69(6), 501–​508. Blyth, F. M., March, L. M., Nicholas, M. K., & Cousins, M. J. (2005). Self-​management of chronic pain: a population-​based study. Pain, 113(3), 285–​292. Boateng, G. O., Neilands, T. B., Frongillo, E. A., Melgar-​Quiñonez, H. R., & Young, S. L. (2018). Best practices for developing and validating scales for health, social, and behavioral research: a primer. Frontiers in Public Health, 6, 149. Bock, E. W., Cochran, J. K., & Beehgley, L. (1987). Moral messages: the relative influence of denomination on the religiosity-​alcohol relationship. Sociological Quarterly, 28, 89–​103. Bodai, B. I., Nakata, T. E., Wong, W. T., Clark, D. R., Lawenda, S., Tsou, C., et al. (2018). Lifestyle medicine: a brief review of its dramatic impact on health and survival. Permanente Journal, 22, 17–​25. Bodai, B. I., & Tuso, P. (2015). Breast cancer survivorship: a comprehensive review of long-​term medical issues and lifestyle recommendations. Permanente Journal, 19(2), 48–​79. Bodhi, B. (2010). The Noble Eightfold Path: Way to the End of Suffering. Kandy, Sri Lanka: Buddhist Publication Society.

882 •  R eferences

Bodogai, S. I., Olah, Ş., & Roşeanu, G. (2020). Religiosity and subjective well-​being of the central and eastern European’s elderly population. Journal of Religion and Health, 59(2), 784–​795. Bodson, J., Wilson, A., Warner, E. L., & Kepka, D. (2017). Religion and HPV vaccine-​related awareness, knowledge, and receipt among insured women aged 18-​26 in Utah. PloS One, 12(8), e0183725. Boduszek, D., Debowska, A., Sherretts, N., Willmott, D., Boulton, M., Kielkiewicz, K., et al. (2021). Are prisoners more psychopathic than non-​forensic populations? Profiling psychopathic traits among prisoners, community adults, university students, and adolescents. Deviant Behavior, 42(2), 232–​244. Boelens, P. A., Reeves, R. R., Replogle, W. H., & Koenig, H. G. (2009). A randomized trial of the effect of prayer on depression and anxiety. International Journal of Psychiatry in Medicine, 39, 377–​392. Boffetta, P. (2006). Human cancer from environmental pollutants: the epidemiological evidence. Mutation Research/​Genetic Toxicology and Environmental Mutagenesis, 608(2), 157–​162. Bogenschutz, M. P., Rice, S. L., Tonigan, J. S., Vogel, H. S., Nowinski, J., Hume, D., & Arenella, P. B. (2014). 12-​step facilitation for the dually diagnosed: a randomized clinical trial. Journal of Substance Abuse Treatment, 46(4), 403–​411. Bogner, H. R., & Wittink, M. N. (2004). Depression as a risk factor for underuse of mammography. Journal of Women’s Health, 13(6), 739–​742. Boissoneault, J., Lewis, B., & Nixon, S. J. (2016). Acute behavioral and long-​term health effects of moderate alcohol use in older adults. Current Addiction Reports, 3(1), 62–​74. Boisvert, J. A., & Harrell, W. A. (2012). Ethnicity and spirituality as risk factors for eating disorder symptomatology in men. International Journal of Men’s Health, 11(1), 36–​62. Boisvert, J. A., & Harrell, W. A. (2013). The impact of spirituality on eating disorder symptomatology in ethnically diverse Canadian women. International Journal of Social Psychiatry, 59(8), 729–​738. Bomhoff, E. J., & Siah, A. K. L. (2019). The relationship between income, religiosity and health: Their effects on life satisfaction. Personality and Individual Differences, 144, 168–​173. Bonaccio, M., Di Castelnuovo, A., Costanzo, S., Gialluisi, A., Persichillo, M., Cerletti, C., et al. (2018). Mediterranean diet and mortality in the elderly: a prospective cohort study and

a meta-​analysis. British Journal of Nutrition, 120(8), 841–​854. Bonaguidi, F., Michelassi, C., Filipponi, F., & Rovai, D. (2010). Religiosity associated with prolonged survival in liver transplant recipients. Liver Transplantation, 16(10), 1158–​1163. Booker, S. (2019). Spirituality in chronic pain self-​ management: lower use but equal importance in older African Americans. Innovation in Aging, 3(Suppl 1), S394. Boone, D., & Kim, S. Y. (2019). Family strain, depression, and somatic amplification in adults with chronic pain. International Journal of Behavioral Medicine, 26(4), 427–​436. Booth, B. M., Curran, G. M., Han, X. (2004). Predictors of short-​term course of drinking in untreated rural and urban at-​risk drinkers: effects of gender, illegal drug use and psychiatric comorbidity. Journal of Studies on Alcohol, 65(1), 63–​73. Booth, J., Connelly, L., Lawrence, M., Chalmers, C., Joice, S., Becker, C., et al. (2015). Evidence of perceived psychosocial stress as a risk factor for stroke in adults: a meta-​analysis. BMC Neurology, 15(1), 233. Bopp, M., & Fallon, E. A. (2013). Health and wellness programming in faith-​based organizations: a description of a nationwide sample. Health Promotion Practice, 14(1), 122–​131. Borders, T. F., & Boothc, B. M. (2013). Stimulant use, religiosity, and the odds of developing or maintaining an alcohol use disorder over time. Journal of Studies on Alcohol and Drugs, 74(3), 369–​377. Börjesson, M., Onerup, A., Lundqvist, S., & Dahlöf, B. (2016). Physical activity and exercise lower blood pressure in individuals with hypertension: narrative review of 27 RCTs. British Journal of Sports Medicine, 50(6), 356–​361. Bormann, J. E., Gifford, A. L., Shively, M., Smith, T. L., Redwine, L., Kelly, A., et al. (2006). Effects of spiritual mantram repetition on HIV outcomes: a randomized controlled trial. Journal of Behavioral Medicine, 29(4), 359–​376. Bormann, J. E., Aschbacher, K., Wetherell, J. L., Roesch, S., & Redwine, L. (2009). Effects of faith/​assurance on cortisol levels are enhanced by a spiritual mantram intervention in adults with HIV: a randomized trial. Journal of Psychosomatic Research 66, 161–​171. Bormann, N. L., Allen, J., Shaw, M., & Black, D. W. (2019). Religiosity and chance beliefs in persons with DSM-​IV pathological gambling enrolled in a

longitudinal follow-​up study. Journal of Gambling Studies, 35, 849–​860. Bornovalova, M. A., Gratz, K. L., Delany-​Brumsey, A., Paulson, A., & Lejuez, C. W. (2006). Temperamental and environmental risk factors for borderline personality disorder among inner-​ city substance users in residential treatment. Journal of Personality Disorders, 20(3), 218–​231. Borras, L., Mohr, S., Gillieron, C., Brandt, P. Y., Rieben, I., Leclerc, C., et al. (2010). Religion and spirituality: how clinicians in Quebec and Geneva cope with the issue when faced with patients suffering from chronic psychosis. Community Mental Health Journal, 46(1), 77–​86. Borsook, D., Youssef, A. M., Simons, L., Elman, I., & Eccleston, C. (2018). When pain gets stuck: the evolution of pain chronification and treatment resistance. Pain, 159(12), 2421. Bortolato, B., Köhler, C. A., Evangelou, E., León‐ Caballero, J., Solmi, M., Stubbs, B., et al. (2017). Systematic assessment of environmental risk factors for bipolar disorder: an umbrella review of systematic reviews and meta-​analyses. Bipolar Disorders, 19(2), 84–​96. Boss, L., Kang, D. H., & Branson, S. (2015). Loneliness and cognitive function in the older adult: a systematic review. International Psychogeriatrics, 27(4), 541–​553. Bottaccioli, A. G., Bottaccioli, F., & Minelli, A. (2019). Stress and the psyche-​brain-​immune network in psychiatric diseases based on psychoneuroendocrineimmunology: a concise review. Annals of the New York Academy of Sciences, 1437(1), 31–​42. Botvin, G. J., & Griffin, K. W. (2016). Prevention of substance abuse. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, & R. Krishnamurthy (eds.), APA Handbook of Clinical Psychology: Applications and methods. American Psychological Association, pp. 485–​509. Botwin, M. D., Buss, D. M., & Shackelford, T. K. (1997). Personality and mate preferences: five factors in mate selection and marital satisfaction. Journal of Personality, 65(1), 107–​136. Bould, H., Mars, B., Moran, P., Biddle, L., & Gunnell, D. (2019). Rising suicide rates among adolescents in England and Wales. Lancet, 394(10193), 116–​117. Boule, L. A., & Kovacs, E. J. (2017). Alcohol, aging, and innate immunity. Journal of Leukocyte Biology, 102(1), 41–​55. Bovero, A., Leombruni, P., Miniotti, M., Rocca, G., & Torta, R. (2016). Spirituality, quality of life,

References • 883

psychological adjustment in terminal cancer patients in hospice. European Journal of Cancer Care, 25(6), 961–​969. Bowen, D. J., Beresford, S. A., Christensen, C. L., Kuniyuki, A. A., McLerran, D., Feng, Z., et al. (2009). Effects of a multilevel dietary intervention in religious organizations. American Journal of Health Promotion, 24, 15–​22. Bowen, S. E., Howard, M. O., & Garland, E. L. (2016). Inhalant use disorders in the United States. In Reedy, V. R. (ed.), Neuropathology of Drug Addictions and Substance Misuse. San Diego: Academic Press, pp. 931–​942. Bowie, J. V., Bell, C. N., Ewing, A., Kinlock, B., Ezema, A., Thorpe, R. J., Jr., et al. (2017). Religious coping and types and sources of information used in making prostate cancer treatment decisions. American Journal of Men’s Health, 11(4):1237–​1246. Bowlby, R. (2018). Fifty Years of Attachment Theory. Abington, UK: Routledge. Bowman, M., St. Cyr, S., & Stolf, I. A. (2018). Health-​care provider personal religious preferences and their perspectives on advance care planning with patients. American Journal of Hospice and Palliative Medicine, 35(12), 1565–​1571. Bowman, T. S., Gaziano, J. M., Buring, J. E., & Sesso, H. D. (2007). A prospective study of cigarette smoking and risk of incident hypertension in women. Journal of the American College of Cardiology, 50(21), 2085–​2092. Boyas, J. F., Kim, Y. J., Villarreal-​Otálora, T., & Sink, J. K. (2019). Suicide ideation among Latinx adolescents. Children and Youth Services Review, 102, 177–​185. Boyle, P. A., Buchman, A. S., Barnes, L. L., & Bennett, D. A. (2010). Effect of a purpose in life on risk of incident Alzheimer disease and mild cognitive impairment in community-​dwelling older persons. Archives of General Psychiatry, 67(3), 304–​310. Braam, A. W., Beekman, A. T. F., van Tilburg, T. G., Deeg, D. J. H., & van Tilburg, W. (1997a). Religious involvement and depression in older Dutch citizens. Social Psychiatry and Psychiatric Epidemiology, 32, 284–​291. Braam, A. W., Beekman, A. T. F., Deeg, D. J. H., Smith, J. H., & van Tilburg, W. (1997b). Religiosity as a protective or prognostic factor of depression in later life. Acta Psychiatrica Scandinavia 96:199–​205. Braam, A. W., Beekman, A. T. F., Eeden P., Deeg, D. J. H., Knipscheer, K. P. M., & Tilburg, W. (1998). Religious denomination and depression in the

884 •  R eferences

older Dutch citizens. Journal of Aging and Health, 10, 483–​503. Braam, A. W., Beekman, A. T., van den Eeden, P., Deeg, D. J., Knipscheer, K. P., & van Tilburg, W. (1999). Religious climate and geographical distribution of depressive symptoms in older Dutch citizens. Journal of Affective Disorders, 54(1–​2), 149–​159. Braam, A., van den Eeden, P., Prince, M., Beekman, A., Kivela, S., Lawlor, B., et al. (2001). Religion as a cross-​cultural determinant of depression in elderly Europeans: results from the EURODEP collaboration. Psychological Medicine, 31(5), 803–​814. Braam, A. W., Delespaul, P., Beekman, A. T., Deeg, D. J., Peres, K., Dewey, M., et al. (2004a). National context of healthcare, economy and religion, and the association between disability and depressive symptoms in older Europeans: results from the EURODEP concerted action. European Journal of Ageing, 1(1), 26–​36. Braam, A. W., Hein, E., Deeg, D. J., Twisk, J. W., Beekman, A. T., & Van Tilburg, W. (2004b). Religious involvement and 6-​year course of depressive symptoms in older Dutch citizens: results from the Longitudinal Aging Study Amsterdam. Journal of Aging and Health, 16(4), 467–​489. Braam, A. W., Deeg, D. J., Poppelaars, J. L., Beekman, A. T., & van Tilburg, W. (2007). Prayer and depressive symptoms in a period of secularization: patterns among older adults in the Netherlands. American Journal of Geriatric Psychiatry, 15(4), 273–​281. Braam, A. W., Schaap-​Jonker, H., van der Horst, M. H., Steunenberg, B., Beekman, A. T., van Tilburg, W., et al. (2014). Twelve-​year history of late-​life depression and subsequent feelings to God. American Journal of Geriatric Psychiatry, 22(11), 1272–​1281. Braam, A. W., & Koenig, H. G. (2019). Religion, spirituality and depression in prospective studies: a systematic review. Journal of Affective Disorders, 257, 428–​438. Bradford, K., Vaughn, L. B., & Barber, B. K. (2008). When there is conflict: interparental conflict, parent–​child conflict, and youth problem behaviors. Journal of Family Issues, 29(6), 780–​805. Bradley, D. E. (1995). Religious involvement and social resources: evidence from the data set, “Americans Changing Lives.” Journal for the Scientific Study of Religion, 34, 259–​267. Bradley, K. (2017). The vows in an Islamic ceremony. Retrieved on 7-​25-​22 from https://​classr​oom. syno​nym.com/​

Bradshaw, M., & Ellison, C. G. (2010). Financial hardship and psychological distress: exploring the buffering effects of religion. Social Science & Medicine, 71(1), 196–​204. Bradshaw, M., Ellison, C. G., Fang, Q., & Mueller, C. (2015). Listening to religious music and mental health in later life. The Gerontologist, 55(6), 961–​971. Bradshaw, M., & Kent, B. V. (2018). Prayer, attachment to God, and changes in psychological well-​being in later life. Journal of Aging and Health, 30(5), 667–​691. Braga, D., Melamed, R. M. M., Setti, A. S., Zanetti, B. F., Figueira, R. D., Iaconelli, A., Jr., et al. (2019). Role of religion, spirituality, and faith in assisted reproduction. Journal of Psychosomatic Obstetrics & Gynecology, 40(3), 195–​201. Brain, K., Burrows, T. L., Rollo, M. E., Chai, L. K., Clarke, E. D., Hayes, C., et al. (2019). A systematic review and meta‐analysis of nutrition interventions for chronic noncancer pain. Journal of Human Nutrition and Dietetics, 32(2), 198–​225. Braithwaite, S. R., Coulson, G. L., Spjut, K., Dickerson, W., Beck, A. R., Dougal, K., et al. (2013). The influence of religion on partner selection strategies of emerging adults. Journal of Family Issues, 34, 295–​332. Bramlett, M. D., & Blumberg, S. J. (2007). Family structure and children’s physical and mental health. Health Affairs, 26(2), 549–​558. Brammli-​Greenberg, S., Glazer, J., & Shapiro, E. (2018). The inverse u-​shaped religion–​health connection among Israeli Jews. Journal of Religion and Health, 57(2), 738–​750. Bramstedt, K. A. (2020). COVID-​19 as a cause of death for Catholic priests in Italy: an ethical and occupational health crisis. Health and Social Care Chaplaincy, 8(2), 180–​190. Branco, K. J., & Braam, A. W. (2006). The effects of church attendance, strength of faith, and cognitive impairment on socially inappropriate and abusive behavior among nursing home residents. Journal of Religion, Spirituality & Aging, 19(1), 17–​36. Brand, D., Zaidman-​Zait, A., & Most, T. (2018). Parent couples’ coping resources and involvement in their children’s intervention program. Journal of Deaf Studies and Deaf Education, 23(3), 189–​199. Brandt, M. J., & Henry, P. J. (2012). Psychological defensiveness as a mechanism explaining the relationship between low socioeconomic status and religiosity. International Journal for the Psychology of Religion, 22(4), 321–​332.

Braun, B., Kornhuber, J., & Lenz, B. (2016). Gaming and religion. Journal of Religion and Health, 55(4), 1464–​1471. Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2018). Global cancer statistics 2018. CA: A Cancer Journal for Clinicians, 68(6), 394–​424. Breault, K. D., & Barkey, K. (1982). A comparative analysis of Durkheim’s theory of egoistic suicide. Sociological Quarterly, 23, 321–​331. Brenan, M. (2020). Americans’ mental health ratings sink to new low. The Gallup Poll. Retrieved on 12-​21-​2020 from https://​news.gal​ lup.com/​poll/​327​311/​americ​ans-​men​tal-​hea​lth-​ rati​ngs-​sink-​new-​low.aspx. Brenes, G. A., Rapp, S. R., Rejeski, W. J., & Miller, M. E. (2002). Do optimism and pessimism predict physical functioning? Journal of Behavioral Medicine, 25(3), 219–​231. Brennan, K. M., & London, A. S. (2001). Are religious people nice people? Religiosity, race, interview dynamics, and perceived cooperativeness. Sociological Inquiry, 71(2), 129–​144. Brenowitz, W. D., Hubbard, R. A., Keene, C. D., Hawes, S. E., Longstreth, W. T., Jr., Woltjer, R. L., et al. (2017). Mixed neuropathologies and estimated rates of clinical progression in a large autopsy sample. Alzheimer’s & Dementia, 13(6), 654–​662. Brent, D. A., & Mann, J. J. (2005). Family genetic studies, suicide, and suicidal behavior. American Journal of Medical Genetics, 133C, 13–​24. Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Schweers, J., & Balach, L. (1994). Familial risk factors for adolescent suicide: a case-​ control study. Acta Psychatrica Scandinavica, 89(1), 52–​58. Breslin, M. J., & Lewis, C. A. (2015a). Dissociation and religiosity: the role of religious experience. Journal of Spirituality in Mental Health, 17(1), 26–​33. Breslin, M. J., & Lewis, C. A. (2015b). Schizotypy and religiosity: the magic of prayer. Archive for the Psychology of Religion, 37(1), 84–​97. Breslow, R. A., Dong, C., & White, A. (2015). Prevalence of alcohol‐interactive prescription medication use among current drinkers: United States, 1999 to 2010. Alcoholism, 39(2), 371–​379. Brewster, M. E., Velez, B. L., Foster, A., Esposito, J., & Robinson, M. A. (2016). Minority stress and the moderating role of religious coping among religious and spiritual sexual minority individuals. Journal of Counseling Psychology, 63(1), 119.

References • 885

Brezina, T., Tekin, E., & Topalli, V. (2009). “Might not be a tomorrow”: a multimethods approach to anticipated early death and youth crime. Criminology, 47(4), 1091–​1129. Brintz, C. E., Birnbaum-​Weitzman, O., Llabre, M. M., Castañeda, S. F., Daviglus, M. L., Gallo, L. C., et al. (2017). Spiritual well-​ being, religious activity, and the metabolic syndrome. Journal of Behavioral Medicine, 40(6), 902–​9 12. Brittain, K., & Murphy, V. P. (2015). Sociocultural and health correlates related to colorectal cancer screening adherence among urban African Americans. Cancer Nursing, 38(2), 118. Britten, N., & Fisher, B. (1993). Qualitative research and general practice. British Journal of General Practice, 43, 270–​271. Brock, B., & Swinton, J. (eds.). (2012). Disability in the Christian Tradition: A Reader. Grand Rapids, MI: William B. Eerdmans. Brodd, J. (2003). World Religions. Winona, MN: Saint Mary’s Press. Brodin, P., & Davis, M. M. (2017). Human immune system variation. Nature Reviews Immunology, 17(1), 21. Brooks, F., Michaelson, V., King, N., Inchley, J., & Pickett, W. (2018). Spirituality as a protective health asset for young people: an international comparative analysis from three countries. International Journal of Public Health, 63(3), 387–​395. Brown, C. A., Cardoso, C., & Ellenbogen, M. A. (2016). A meta-​analytic review of the correlation between peripheral oxytocin and cortisol concentrations. Frontiers in Neuroendocrinology, 43, 19–​27. Brown, D. R., & Gary, L. E. (1994). Religious involvement and health status among African-​ American males. Journal of the National Medical Association, 86, 825–​831. Brown, D. R., Ndubuisi, S. C., & Gary, L. E. (1990). Religiosity and psychological distress among Blacks. Journal of Religion and Health, 29(1), 55–​68. Brown, D. R., Gary, L. E., Greene, A. D., & Mulburn, N. G. (1992). Patterns of social affiliation as predictors of depressive symptoms among urban Blacks. Journal of Health and Social Behavior, 33, 242–​253. Brown, E., Orbuch, T. L., & Bauermeister, J. A. (2008). Religiosity and marital stability among Black American and White American couples. Family Relations, 57(2), 186–​197. Brown, E. G., Gallagher, S., & Creaven, A. M. (2018). Loneliness and acute stress reactivity: A

886 •  R eferences

systematic review of psychophysiological studies. Psychophysiology, 55(5), e13031. Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R. (2000). Risk factors for suicide in psychiatric outpatients: a 20-​year prospective study. Journal of Consulting and Clinical Psychology, 68(3), 371–​377. Brown, M. (2020). Coronavirus and church closures: will the COVID-​19 gathering bans survive free exercise challenges? Social Sciences Research Network (SSRN). Retrieved on 8-​4-​2022 from https://​pap​ers.ssrn.com/​sol3/​Pap​ers. cfm?abst​ract​_​id=​3580​135. Brown, N. N., Burd, L., Grant, T., Edwards, W., Adler, R., & Streissguth, A. (2015). Prenatal alcohol exposure: an assessment strategy for the legal context. International Journal of Law and Psychiatry, 42, 144–​148. Brown Jr, R. D., Ransom, J., Hass, S., Petty, G. W., O’Fallon, W. M., Whisnant, J. P., & Leibson, C. L. (1999). Use of nursing home after stroke and dependence on stroke severity: a populationbased analysis. Stroke, 30(5), 924–929. Brown, S. L., Nesse, R. M., Vinokur, A. D., & Smith, D. M. (2003). Providing social support may be more beneficial than receiving it: results from a prospective study of mortality. Psychological Science, 14(4), 320–​327. Brown, S. V. (1985). Premarital sexual permissiveness among black adolescent females. Social Psychology Quarterly, 48, 381–​387. Brown, T. L., Flory, K., Lynam, D. R., Leukefeld, C., & Clayton, R. R. (2004). Comparing the developmental trajectories of marijuana use of African American and Caucasian adolescents: patterns, antecedents, and consequences. Experimental & Clinical Psychopharmacology, 12(1), 47–​56. Brown, T. N., Schulenberg, J., Bachman, J. G., O’Malley, P. M., & Johnston, L. D. (2001). Are risk and protective factors for substance use consistent across historical time? Prevention Science, 2(1), 29–​43. Brown, T. T., Scheffler, R. M., Seo, S., & Reed, M. (2006). The empirical relationship between community social capital and the demand for cigarettes. Health Economics, 15(11), 1159–​1172. Brown, W. M., Consedine, N. S., & Magai, C. (2005). Altruism relates to health in and ethnically diverse sample of older adults. Journal of Gerontology, 60B, P143–​P152. Browne, M., Pennycook, G., Goodwin, B., & McHenry, M. (2014). Reflective minds and open hearts: cognitive style and personality predict religiosity and spiritual thinking in a community

sample. European Journal of Social Psychology, 44(7), 736–​742. Broyles, P. A., & Drenovsky, C. K. (1992). Religious attendance and the subjective health of the elderly. Review of Religious Research, 34, 152–​160. Bruce, J., & Quinlan, J. (2011). Chronic post surgical pain. Reviews in Pain, 5(3), 23–​29. Bruce, M. A., Sims, M., Miller, S., Elliott, V., Ladipo, M. (2007). One size fits all? Race, gender and body mass index among U.S. adults. Journal of the National Medical Association, 99(10), 1152–​1158. Bruce, M. A., Martins, D., Duru, K., Beech, B. M., Sims, M., Harawa, N., et al. (2017a). Church attendance, allostatic load and mortality in middle aged adults. PloS One, 12(5), e0177618. Bruce, M. A., Beech, B. M., Norris, K. C., Griffith, D. M., Sims, M., & Thorpe Jr, R. J. (2017b). Sex, obesity, and blood pressure among African American adolescents. American Journal of Hypertension, 30(9), 892–​898. Bruce, M. A., Bowie, J. V., Beech, B. M., Norris, K. C., LaVeist, T. A., Howard, D. L., et al. (2021). Church attendance and mobility limitation among black and white men with prostate cancer. American Journal of Men’s Health, 15(1), 1557988321993560. Bruininks, P., & Malle, B. F. (2005). Distinguishing hope from optimism and related affective states. Motivation and Emotion, 29(4), 324–​352. Brummett, B. H., Boyle, S. H., Kuhn, C. M., Siegler, I. C., & Williams, R. B. (2009). Positive affect is associated with cardiovascular reactivity, norepinephrine level, and morning rise in salivary cortisol. Psychophysiology, 46(4), 862–​869. Bryant, S., & Rakowski, W. (1992). Predictors of mortality among elderly African Americans. Research on Aging, 14, 50–​67. Bryant-​Davis, T., Ullman, S., Tsong, Y., Anderson, G., Counts, P., Tillman, S., et al. (2015). Healing pathways: longitudinal effects of religious coping and social support on PTSD symptoms in African American sexual assault survivors. Journal of Trauma & Dissociation, 16(1), 114–​128. Bryden, G. M., Browne, M., Rockloff, M., & Unsworth, C. (2019). The privilege paradox: geographic areas with highest socio-​ economic advantage have the lowest rates of vaccination. Vaccine, 37(32), 4525–​4532. Buchheit, T., Van de Ven, T., & Shaw, A. (2012). Epigenetics and the transition from acute to chronic pain. Pain Medicine, 13(11), 1474–​1490.

Buck, A. C., Williams, D. R., Musick, M. A., & Sternthal, M. J. (2009). An examination of the relationship between multiple dimensions of religiosity, blood pressure, and hypertension. Social Science & Medicine, 68(2), 314–​322. Bücker, S., Nuraydin, S., Simonsmeier, B. A., Schneider, M., & Luhmann, M. (2018). Subjective well-​being and academic achievement. Journal of Research in Personality, 74, 83–​94. Budge, S. L., Moore, J. T., Del Re, A. C., Wampold, B. E., Baardseth, T. P., & Nienhuis, J. B. (2013). The effectiveness of evidence-​based treatments for personality disorders when comparing treatment-​as-​usual and bona fide treatments. Clinical Psychology Review, 33(8), 1057–​1066. Buffenstein, R., Karklin, A., & Driver, H. S. (2000). Beneficial physiological and performance responses to a month of restricted energy intake in healthy overweight women. Physiology & Behavior, 68(4), 439–​444. Bullard, K. M., Cowie, C. C., Lessem, S. E., Saydah, S. H., Menke, A., Geiss, L. S., et al. (2018). Prevalence of diagnosed diabetes in adults by diabetes type: United States, 2016. Morbidity and Mortality Weekly Report, 67(12), 359. Bulmer, M., Bӧhnke, J. R., & Lewis, G. J. (2017). Predicting moral sentiment towards physician-​assisted suicide: the role of religion, conservatism, authoritarianism, and Big Five personality. Personality and Individual Differences, 105, 244–​251. Bulow, H. H., Sprung, C. L., Baras, M., Carmel, S., Svantesson, M., Benbenishty, J., et al. (2012). Are religion and religiosity important to end-​of-​ life decision and patient autonomy in the ICU? The Ethicatt study. Intensive Care Medicine, 38, 1126–​1133. Bumpass, L. L., & Sweet, J. A. (1972). Differentials in marital instability: 1972. American Sociological Review, 37, 754–​767. Bundy, J. D., Bazzano, L. A., Xie, D., Cohan, J., Dolata, J., Fink, J. C., et al. (2018). Self-​reported tobacco, alcohol, and illicit drug use and progression of chronic kidney disease. Clinical Journal of the American Society of Nephrology, 13(7), 993–​1001. Buonanno, P., Montolio, D., & Vanin, P. (2009). Does social capital reduce crime? Journal of Law and Economics, 52(1), 145–​170. Burazeri, G., Goda, A., & Kark, J. D. (2008). Religious observance and acute coronary syndrome in predominantly Muslim Albania. Annals of Epidemiology, 18(12), 937–​945. Burdette, A. M., Hill, T. D., & Moulton, B. E. (2005). Religion and attitudes toward

References • 887

physician-​assisted suicide and terminal palliative care. Journal for the Scientific Study of Religion, 44(1), 79–​93. Burdette, A. M., Ellison, C. G., Sherkat, D. E., & Gore, K. A. (2007). Are there religious variations in marital infidelity? Journal of Family Issues, 28(12), 1553–​1581. Burdette, A. M., & Hill T. D. (2009). Religious involvement and transitions into adolescent sexual activities. Sociology of Religion 70 (1), 28–​48.Burdette, A. M., Ellison C., Hill, T, Glenn, N. (2009). Hooking up at college: does religion make a difference? Journal for the Scientific Study of Religion, 48, 535–​551. Bureau of Labor Statistics (2019). Unemployment rate in the United States from 1990 to 2019. US Department of Labor. Retrieved on 9-​25-​2020 from https://​www.stati​sta.com/​sta​tist​ics/​193​ 290/​unemp​loym​ent-​rate-​in-​the-​usa-​since-​ 1990/​. Bureau of Labor Statistics (2020). Civilian unemployment rate. US Department of Labor. Retrieved on 9-​25-​2020 from https://​www. bls.gov/​cha​rts/​emp​loym​ent-​situat​ion/​civil​ian-​ unemp​loym​ent-​rate.htm. Burell, G. (1996). Group psychotherapy in Project New Life: treatment of coronary-​prone behaviors for patients who have had coronary artery bypass graft surgery. In Allan, R., & Scheidt, S. (eds), Heart and Mind: The Practice of Cardiac Psychology. Washington, DC: American Psychological Association, pp. 291–​310. Burke, A., Van Olphen, J., Eliason, M., Howell, R., & Gonzalez, A. (2014). Re-​examining religiosity as a protective factor: comparing alcohol use by self-​identified religious, spiritual, and secular college students. Journal of Religion and Health, 53(2), 305–​316. Burke, A., Lam, C. N., Stussman, B., & Yang, H. (2017). Prevalence and patterns of use of mantra, mindfulness and spiritual meditation among adults in the United States. BMC Complementary and Alternative Medicine, 17(1), 316. Burke, L. E., Dunbar-​Jacob, J. M., & Hill, M. N. (1997). Compliance with cardiovascular disease prevention strategies. Annals of Behavioral Medicine, 19(3), 239–​263. Burkett, S. R. (1993). Perceived parents’ religiosity, friends’ drinking, and hellfire: a panel study of adolescent drinking. Review of Religious Research, 35, 134–​153. Burr, J. A., Han, S. H., & Tavares, J. L. (2016). Volunteering and cardiovascular disease risk: does helping others get “under the skin?” Gerontologist, 56(5), 937–​947.

888 •  R eferences

Burris, J. L., Brechting, E. H., Salsman, J., & Carlson, C. R. (2009). Factors associated with the psychological well-​being and distress of university students. Journal of American College Health, 57(5), 536–​543. Burshtein, S., Dohrenwend, B. P., Levav, I., Werbeloff, N., Davidson, M., & Weiser, M. (2016). Religiosity as a protective factor against suicidal behaviour. Acta Psychiatrica Scandinavica, 133(6), 481–​488. Busby, D. M., Willoughby, B. J., & Carroll, J. S. (2013). Sowing wild oats: valuable experience or a field full of weeds? Personal Relationships, 20(4), 706–​718. Büssing, A., Frick, E., Jacobs, C., & Baumann, K. (2016). Health and life satisfaction of Roman Catholic pastoral workers. Pastoral Psychology, 65(1), 89–​102. Butler, P. M., McNamara, P., Ghofrani, J., & Durso, R. (2011). Disease-​associated differences in religious cognition in patients with Parkinson’s disease. Journal of Clinical and Experimental Neuropsychology, 33(8), 917–​928. Butler-​Barnes, S. T., Martin, P. P., Copeland-​Linder, N., Seaton, E. K., Matusko, N., Caldwell, C. H., et al. (2018). The protective role of religious involvement in African American and Caribbean Black adolescents’ experiences of racial discrimination. Youth & Society, 50(5), 659–​687. Button, T. M., Hewitt, J. K., Rhee, S. H., Corley, R. P., & Stallings, M. C. (2010). The moderating effect of religiosity on the genetic variance of problem alcohol use. Alcoholism: Clinical and Experimental Research, 34(9), 1619–​1624. Buttorff, C., Ruder, T., & Bauman, M. (2017). Multiple chronic conditions in the United States. RAND Corporation. Retrieved on 7-​25-​ 2020 from https://​www.rand.org/​pubs/​tools/​ TL221.html. Buttorff, C., Ruder, T., & Bauman, M. (2017). Multiple Chronic Conditions in the United States. Santa Monica, CA: Rand Corporation. Retrieved on 9-​21-​2020 from https://​www.rand.org/​pubs/​ tools/​TL221.html. Buzdar, M. A., Ali, A., Nadeem, M., & Nadeem, M. (2015). Relationship between religiosity and psychological symptoms in female university students. Journal of Religion and Health, 54(6), 2155–​2163. Buzdar, M. A., haq Tariq, R. U., Jalal, H., & Nadeem, M. (2019). Does religiosity reduce narcissistic personality disorder? Journal of Religion and Health, 58(5), 1463–​1470. Byrne, D. W., Rolando, L. A., Aliyu, M. H., McGown, P. W., Connor, L. R., Awalt, B. M., et al. (2016).

Modifiable healthy lifestyle behaviors. American Journal of Preventive Medicine 51(6), 1027–​1037. Byrnes, M. D., Antoni, M. H., & Goodkin, K. (1998). Stressful events, pessimism, natural killer cell cytotoxicty, and cytotoxic/​suppressor cells in HIV+​black women at risk for cervical cancer. Psychosomatic Medicine, 60, 714–​722. Cabral, G. A., Rogers, T. J., & Lichtman, A. H. (2015). Turning over a new leaf: cannabinoid and endocannabinoid modulation of immune function. Journal of Neuroimmune Pharmacology, 10(2), 193–​203. Cadeddu, C., Daugbjerg, S., Ricciardi, W., & Rosano, A. (2020). Beliefs towards vaccination and trust in the scientific community in Italy. Vaccine, 38(42), 6609–​6617. Cadet, T., Stewart, K., & Howard, T. (2017). Psychosocial correlates of cervical cancer screening among older Hispanic women. Social Work in Health Care, 56(2), 124–​139. Cadet, T., Burke, S. L., Bakk, L., Nedjat-​Haiem, F. R., & Schroepfer, T. (2021). Attending to the psychosocial needs of older Hispanic, Black and Non-​Hispanic White women and their breast cancer screening behaviors. Journal of the National Medical Association, 113(3), 342–​350. Cadman, D., Boyle, M., Szatmari, P., & Offord, D. R. (1987). Chronic illness, disability, and mental and social well-​being. Pediatrics, 79(5), 805–​813. Cagle, J. G., LaMantia, M. A., Williams, S. W., Pek, J., & Edwards, L. J. (2016). Predictors of preference for hospice care among diverse older adults. American Journal of Hospice and Palliative Medicine, 33(6), 574–​584. Cai, L., Wu, Y., Wilson, R. F., Segal, J. B., Kim, M. T., & Wang, Y. (2014). Effect of childhood obesity prevention programs on blood pressure. Circulation, 129(18), 1832–​1839. Cai, W., Mueller, C., Li, Y. J., Shen, W. D., & Stewart, R. (2019). Post stroke depression and risk of stroke recurrence and mortality. Ageing Research Reviews, 50, 102–​109. Calati, R., Ferrari, C., Brittner, M., Oasi, O., Olié, E., Carvalho, A. F., et al. (2019). Suicidal thoughts and behaviors and social isolation. Journal of Affective Disorders, 245, 653–​667. Calder, P. C. (2020). Nutrition, immunity and COVID-​19. BMJ Nutrition, Prevention & Health, 3(1), 74 http://​dx.doi.org/​10.1136/​bmj​nph-​ 2020-​000​085. Call, V. R. A., & Heaton, T. B. (1997). Religious influence on marital stability. Journal for the Scientific Study of Religion, 36, 382–​392. Callaghan, T., Moghtaderi, A., Lueck, J. A., Hotez, P. J., Strych, U., Dor, A., et al. (2020). Correlates

and disparities of COVID-​19 vaccine hesitancy. Social Science Research Network. https://​pap​ ers.ssrn.com/​sol3/​pap​ers.cfm?abst​ract​_​id=​ 3667​971. Callen, B. L., Mefford, L., Groër, M., & Thomas, S. P. (2011). Relationships among stress, infectious illness, and religiousness/​spirituality in community-​dwelling older adults. Research in Gerontological Nursing, 4(3), 195–​206. Campbell, A., Converse, P. E., & Rodgers, W. L. (1976). The Quality of Life in America. New York, NY: Russell Sage Foundation. Campbell, C. M., & Edwards, R. R. (2012). Ethnic differences in pain and pain management. Pain Management, 2(3), 219–​230. Campbell, D. (2018). Testing faith: An investigation of the relationship between prayer and test anxiety. Social Work & Christianity, 45(1), 122–​136. Campbell, M. K. (2016). Biological, environmental, and social influences on childhood obesity. Pediatric Research, 79(1–​2), 205. Canada, A. L., Murphy, P. E., Fitchett, G., & Stein, K. (2015). Re-​examining the contributions of faith, meaning, and peace to quality of life: A report from the American Cancer Society’s Studies of Cancer Survivors-​II (SCS-​II). Annals of Behavioral Medicine, 50(1), 79–​86. Canada, A. L., Murphy, P. E., Stein, K., Alcaraz, K. I., Leach, C. R., & Fitchett, G. (2020). Examining the impact of cancer on survivors’ religious faith: A report from the American Cancer Society study of cancer survivors‐I. Psycho‐Oncology, 29(6), 1036–​1043. Cann, A., Calhoun, L. G., Tedeschi, R. G., Taku, K., Vishnevsky, T., Triplett, K. N., et al. (2010). A short form of the Posttraumatic Growth Inventory. Anxiety, Stress, and Coping, 23, 127–​137. Cannon, A. J., Darrington, D. L., Reed, E. C., & Loberiza, F. R., Jr. (2011). Spirituality, patients’ worry, and follow-​up health-​care utilization among cancer survivors. Journal of Supportive Oncology, 9(4), 141–​148. Cao, Y., Nishihara, R., Wu, K., Wang, M., Ogino, S., Willett, W. C., et al. (2016). Population-​wide impact of long-​term use of aspirin and the risk for cancer. JAMA Oncology, 2(6), 762–​769. Capezza, N. M., Schumacher, E. C., & Brady, B. C. (2015). Trends in intimate partner violence services provided by substance abuse treatment facilities. Journal of Family Violence, 30(1), 85–​91. Capitulo, K. L. (2005). Evidence for healing interventions with perinatal bereavement.

References • 889

American Journal of Maternal Child Nursing, 30(6), 389–​396. Caplan, L. S., Sawyer, P., Holt, C., & Allman, R. M. (2013). Religiosity and function among community-​dwelling older adult survivors of cancer. Journal of Religion, Spirituality & Aging, 25(4), 311–​325. Caplette-​Gingras, A., & Savard, J. (2008). Depression in women with metastatic breast cancer. Palliative & Supportive Care, 6(4), 377–​387. Cappuccio, F. P., Cooper, D., D’Elia, L., Strazzullo, P., & Miller, M. A. (2011). Sleep duration predicts cardiovascular outcomes. European Heart Journal, 32(12), 1484–​1492. Captari, L. E., Hook, J. N., Hoyt, W., Davis, D. E., McElroy‐Heltzel, S. E., & Worthington, E. L., Jr. (2018). Integrating clients’ religion and spirituality within psychotherapy: a comprehensive meta‐analysis. Journal of Clinical Psychology, 74(11), 1938–​1951. Capuron, L., & Miller, A. H. (2011). Immune system to brain signaling. Pharmacology & Therapeutics, 130(2), 226–​238. Caputo, R. K. (2004). Parent religiosity, family processes, and adolescent outcomes. Families in Society, 85(4), 495–​510. Caqueo-​Urizar, A., Urzúa, A., Boyer, L., & Williams, D. R. (2016). Religion involvement and quality of life in patients with schizophrenia in Latin America. Social Psychiatry and Psychiatric Epidemiology, 51(4), 521–​528. Carbone, M., Arron, S. T., Beutler, B., Bononi, A., Cavenee, W., Cleaver, J. E., et al. (2020). Tumour predisposition and cancer syndromes as models to study gene–​environment interactions. Nature Reviews Cancer, 20(9), 533–​549. Cardozo, L. B., Bilukha, O. O., Gotway Crawford, C. A., Shaikh, I., Wolfe, M. I., Gerber, M. L., et al. (2004). Mental health, social functioning, and disability in postwar Afghanistan. Journal of the American Medical Association, 292(5), 575–​584. Caribe, A. C., Studart, P., Bezerra-​Filho, S., Brietzke, E., Noto, M. N., Vianna-​Sulzbach, M., et al. (2015a). Is religiosity a protective factor against suicidal behavior in bipolar I outpatients? Journal of Affective Disorders, 186, 156–​161. Caribe, A. C., Rocha, M. F. V., Junior, D. F. M., Studart, P., Quarantini, L. C., Guerreiro, N., et al. (2015b). Religiosity and impulsivity in mental health. Journal of Nervous and Mental Disease, 203(7), 551–​554. Carl, J. R., Soskin, D. P., Kerns, C., & Barlow, D. H. (2013). Positive emotion regulation in emotional disorders. Clinical Psychology Review, 33(3), 343–​360.

890 •  R eferences

Carlisle, R. D., & Tsang, J. A. (2013). The virtues: gratitude and forgiveness. In K. I. Pargament, J. J. Exline, & J. W. Jones (eds.), APA Handbook of Psychology, Religion, and Spirituality (Vol. 1): Context, Theory, and Research (pp. 423–​ 437). Washington, DC: American Psychological Association. Carlson, E. A., Egeland, B., & Sroufe, L. A. (2009). A prospective investigation of the development of borderline personality symptoms. Development and Psychopathology, 21(4), 1311–​1334. Carlson, M. C., Kuo, J. H., Chuang, Y. F., Varma, V. R., Harris, G., Albert, M. S., et al. (2015). Impact of the Baltimore Experience Corps Trial on cortical and hippocampal volumes. Alzheimer’s & Dementia, 11(11), 1340–​1348. Carlson, M. M., McElroy, S. E., Aten, J. D., Davis, E. B., Van Tongeren, D., Hook, J. N., et al. (2019). Understanding the relationship between religious orientation, religious commitment, personality, and prejudicial attitudes toward Syrian refugees. International Journal for the Psychology of Religion, 29(2), 94–​107. Carlson, S. A., Fulton, J. E., Pratt, M., Yang, Z., & Adams, E. K. (2015). Inadequate physical activity and health care expenditures in the United States. Progress in Cardiovascular Diseases, 57(4), 315–​323. Carlsson, A. C., Li, X., Holzmann, M. J., Wändell, P., Gasevic, D., Sundquist, J., et al. (2016). Neighborhood socioeconomic status and coronary heart disease in individuals between 40 and 50 years. Heart, 102(10), 775–​782. Carlton-​Ford, S., Ender, M. G., & Tabatabai, A. (2008). Iraqi adolescents: self-​regard, self-​ derogation, and perceived threat in war. Journal of Adolescence, 31(1), 53–​75. Carman, W. J., Su, S., Cook, S. F., Wurzelmann, J. I., & McAfee, A. (2011). Coronary heart disease outcomes among chronic opioid and cyclooxygenase‐2 users compared with a general population cohort. Pharmacoepidemiology and Drug Safety, 20(7), 754–​762. Carney, L. M., Park, C. L., & Gutierrez, I. A. (2020). Religious beliefs and well-​being and distress in congestive heart failure patients. Journal of Behavioral Medicine, 43, 437–​447. Carney, R. M., & Freedland, K. E. (2017). Depression and coronary heart disease. Nature Reviews Cardiology, 14(3), 145–​155. Carothers, S. S., Borkowski, J. G., Lefever, J. B., & Whitman, T. L. (2005). Religiosity and the socioemotional adjustment of adolescent mothers and their children. Journal of Family Psychology, 19(2), 263.

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: a meta-​analysis of randomized placebo-​controlled tribes. Depression and Anxiety, 35(6), 502–​514. Carr, D. C., Kail, B. L., & Rowe, J. W. (2018). The relation of volunteering and subsequent changes in physical disability in older adults. Journal of Gerontology: Series B, 73(3), 511–​521. Carrette, J., & King, R. (2004). Selling Spirituality: The Silent Takeover of Religion. London: Routledge. Carrico, A. W., Gifford, E. V., & Moos, R. H. (2007). Spirituality/​religiosity promotes acceptance-​ based responding and 12-​step involvement. Drug and Alcohol Dependence, 89(1), 66–​73. Carrico, A. W., Storholm, E. D., Flentje, A., Arnold, E. A., Pollack, L. M., Neilands, T. B., et al. (2017). Spirituality/​religiosity, substance use, and HIV testing among young black men who have sex with men. Drug and Alcohol Dependence, 174, 106–​112. Carroll, B. J., Cassidy, F., & Naftolowitz, D. (2007). Pathophysiology of hypercortisolism in depression. Acta Psychiatrica Scandinavica (Supp), 433, 90–​103. Carroll, M. D., Fryar, C. D., Nguyen, D. T., et al. (2017). Total and high-​density lipoprotein cholesterol in adults: United States, 2015–​2016. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved on 1-​11-​2020 from https://​www.cdc.gov/​nchs/​ produ​cts/​dat​abri​efs/​db290.htm. Carroll, S. T., Stewart-​Sicking, J. A., & Thompson, B. (2014). Sanctification of work: assessing the role of spirituality in employment attitudes. Mental Health, Religion & Culture, 17(6), 545–​556. Carson, V. B., & Koenig, H. G. (2004). Spiritual Caregiving: Healthcare as a Ministry. Conshohocken, PA: Templeton Foundation Press. Carter, B. D., Abnet, C. C., Feskanich, D., Freedman, N. D., Hartge, P., Lewis, C. E., et al. (2015). Smoking and mortality—​beyond established causes. New England Journal of Medicine, 372(7), 631–​640. Carter, E. W., Kleinert, H. L., LoBianco, T. F., Sheppard-​Jones, K., Butler, L. N., & Tyree, M. S. (2015). Congregational participation of a national sample of adults with intellectual and developmental disabilities. Intellectual and Developmental Disabilities, 53(6), 381–​393. Carter, J. R., & Palihawadana, M. (2000). The Dhammapada: The Sayings of the Buddha.

Oxford World’s Classics. Oxford, UK: Oxford University Press. Cartwright, K. (2021). Delivered from the temptation of smoking: an examination of religion and health behaviors of new US immigrants. Journal of Religion and Health, 60(3), 1739–​1759. Carvalho, A. F., Heilig, M., Perez, A., Probst, C., & Rehm, J. (2019). Alcohol use disorders. The Lancet, 394(10200), 781–​792. Carvalho, C. C., Chaves, E. D., Iunes, D. H., Simão, T. P., Grasselli, C. D., & Braga, C. G. (2014). Effectiveness of prayer in reducing anxiety in cancer patients. Revista da Escola de Enfermagem da USP, 48(4), 684–​690. Carvalho, L. D., Sagradim, D. E. V., Pianowski, G., & Gonçalves, A. P. (2020). Relationship between religiosity domains and traits from borderline and schizotypal personality disorders in a Brazilian community sample. Trends in Psychiatry and Psychotherapy, 42(3), 239–​246. Carver, C. S. (1997). You want to measure coping but your protocol’s too long: consider the brief COPE. International Journal of Behavioral Medicine, 4(1), 92–​100. Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: a theoretically based approach. Journal of Personality and Social Psychology, 56(2), 267–​283. Case, A., & Deaton, A. (2020). Deaths of Despair and the Future of Capitalism. Princeton, NJ: Princeton University Press. Casey, D. M., Williams, R. J., Mossière, A. M., Schopflocher, D. P., el-​Guebaly, N., Hodgins, D. C., et al. (2011). The role of family, religiosity, and behavior in adolescent gambling. Journal of Adolescence, 34(5), 841–​851. Caspi, A., McClay, J., Moffitt, T. E., Mill, J., Martin, J., Craig, I. W., et al. (2002). Role of genotype in the cycle of violence in maltreated children. Science, 297(5582), 851–​854. Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H., et al. (2003). Influence of life stress on depression: moderation by a polymorphism in the 5-​HTT gene. Science, 301(5631), 386–​389. Cassano, G. B., Rucci, P., Frank, E., Fagiolini, A., Dell’Osso, L., Shear, M. K., et al. (2004). The mood spectrum in unipolar and bipolar disorder: arguments for a unitary approach. American Journal of Psychiatry, 161(7), 1264–​1269. Cassidy, F., & Carroll, B. J. (2002). Vascular risk factors in late onset mania. Psychological Medicine, 32(2), 359–​362.

References • 891

Castillo-​Richmond, A., Schneider, R. H., Alexander, C. N., Cook, R., Myers, H., Nidich, S., et al. (2000). Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans. Stroke, 31(3), 568–​573. Castro-​Diehl, C., Roux, A. V., Seeman, T., Shea, S., Shrager, S., & Tadros, S. (2014). Associations of socioeconomic and psychosocial factors with urinary measures of cortisol and catecholamines in the Multi-​ Ethnic Study of Atherosclerosis (MESA). Psychoneuroendocrinology, 41, 132–​141. Catalano, R. F., Kosterman, R., Hawkins, J. D., Newcomb, M. D., & Abbott, R. D. (1996). Modeling the etiology of adolescent substance use: a test of the social development model. Journal of Drug Issues, 26(2), 429–​455. Catechism of the Catholic Church (1993). Libreria Editrice Vaticana, Citta del Vaticano. Retrieved from http://​www.vati​can.va/​arch​ive/​ENG0​015/​ _​IN​DEX.HTM. Cattelino, E., Glowacz, F., Born, M., Testa, S., Bina, M., & Calandri, E. (2014). Adolescent risk behaviors and protective factors against peer influence. Journal of Adolescence, 37, 1353–​1362. Cau, B. M., Sevoyan, A., & Agadjanian, V. (2013). Religious affiliation and under-​five mortality in Mozambique. Journal of Biosocial Science, 45(3), 415–​429. Cavigelli, S. A., & Chaudhry, H. S. (2012). Social status, glucocorticoids, immune function, and health. Hormones and Behavior, 62(3), 295–​313. CCC (1993a). Catechism of the Catholic Church. Libreria Editrice Vaticana, Citta del Vaticano. Retrieved on 6-​10-​2019 from http://​www.vati​ can.va/​arch​ive/​ENG0​015/​_​P7Z.HTM. CCC (1993b). Catechism of the Catholic Church, part 2, section 2, ­chapter 3, article 7: The sacrament of matrimony. Retrieved on 10-​17-​ 2019 from http://​www.vati​can.va/​arch​ive/​ENG0​ 015/​_​_​P50.HTM. CCC (1993c). Catechism of the Catholic Church, part 3, section 2, ­chapter 2, article 4, I: The family in God’s plan. Retrieved on 10-​17-​2019 from http://​www.scb​orro​meo.org/​ccc/​p3s2c​2a4.htm. CCC (2003). Catechism of the Catholic Church. Rome: Libreria Editrice Vaticana. Part 3, section 2, article 3, I. The Sabbath Day, line 2180 Retrieved on 11-​11-​2019 from http://​www.vati​ can.va/​arch​ive/​ccc_​css/​arch​ive/​catech​ism/​p3s2c​ 1a3.htm. CDC (2006). Pertussis outbreak in an Amish community—​Kent County, Delaware, September 2004–​February 2005. Morbidity and Mortality Weekly Report, 55(30), 817.

892 •  R eferences

CDC (2011). Vital signs: prevalence, treatment, and control of high levels of low-​density lipoprotein cholesterol—​United States, 1999–​2002 and 2005–​2008. Morbidity and Mortality Weekly Report, 60(4), 109–​114. CDC (2015). Definition of policy. Office of the Associate Director for Policy and Strategy, Centers for Disease Control. Retrieved on 10-​1-​2020 from https://​www.cdc.gov/​pol​icy/​analy​sis/​proc​ess/​ def​i nit​ion.html. CDC (2017a). WISQARS: leading causes of death reports, 1981–​2016. Retrieved on 6-​8-​2019 from https://​weba​ppa.cdc.gov/​sas​web/​ncipc/​ leadca​use.html. CDC (2017b). Living with an unmarried partner now common for young adults. Marriage and divorce. Retrieved on 10-​18-​2019 from https://​ www.cdc.gov/​nchs/​fast​ats/​marri​age-​divo​ rce.htm. CDC (2018a). Data brief 303. Prevalence of depression among adults aged 20 and over: United States, 2013–​2016. Retrieved on 5-​ 30-​2019 from https://​www.cdc.gov/​nchs/​produ​ cts/​dat​abri​efs/​db303.htm. CDC (2018b). Health, United States, 2018: data finder. Centers for Disease Control and Prevention, National Center for Health Statistics, Table 4. Retrieved on 7-​3-​2020 from https://​www.cdc. gov/​nchs/​hus/​conte​nts2​018.htm?sea​rch=​Life​_​ exp​ecta​ncy. CDC (2019). Current cigarette smoking among adults in the United States. Retrieved on 3-​16-​ 2020 from https://​www.cdc.gov/​toba​cco/​data​_​ sta​tist​ics/​fact​_​she​ets/​adu​lt_​da​ ta/​cig_​smok​ing/​ index.htm. CDC (2020a). Disability and health related conditions. Retrieved on 7-​18-​2020 from https://​www.cdc.gov/​ncb​ddd/​disa​bili​tyan​dhea​ lth/​relate​dcon​diti​ons.html. CDC (2020b). Flu vaccination coverage, United States, 2018–​19 influenza season. Retrieved on 8-​13-​2020 from https://​www.cdc.gov/​flu/​flu​ vaxv​iew/​cover​age-​1819es​tima​tes.htm. CDC (2020c). Adult and child immunization schedules 2020. Centers for Disease Control. Accessed on 8-​12-​2020 from https://​www.aafp. org/​pati​ent-​care/​pub​lic-​hea​lth/​immuni​zati​ons/​ schedu​les.html. Cederblad, M., Dahlin, L., Hagnell, O., & Hansson, K. (1995). Coping with life span crises in a group at risk of mental and behavioral disorders: from the Lundby study. Acta Psychiatrica Scandinavica, 91(5), 322–​330. Celano, C. M., Millstein, R. A., Bedoya, C. A., Healy, B. C., Roest, A. M., & Huffman, J. C. (2015).

Association between anxiety and mortality in patients with coronary artery disease: a meta-​analysis. American Heart Journal, 170(6), 1105–​1115. Celermajer, D. S., Chow, C. K., Marijon, E., Anstey, N. M., & Woo, K. S. (2012). Cardiovascular disease in the developing world: prevalences, patterns, and the potential of early disease detection. Journal of the American College of Cardiology, 60(14), 1207–​1216. CFNP (2020). Federal Centers for Faith-​Based and Neighborhood Partnerships. Retrieved on 10-​12-​ 2020 from https://​obam​awhi​teho​use.archi​ves. gov/​adm​inis​trat​ion/​eop/​ofbnp/​offi​ces/​fede​ral. Chaaya, M., Sibai, A., Fayad, R., & El-​Roueiheb, Z. (2007). Religiosity and depression in older people: evidence from underprivileged refugee and non-​refugee communities in Lebanon. Aging & Mental Health, 11(1), 37–​44. Chadwick, B. A., & Top, B. L. (1993). Religiosity and delinquency among LDS adolescents. Journal for the Scientific Study of Religion, 32, 51–​67. Champagne, F. A., & Curley, J. P. (2009). Epigenetic mechanisms mediating the long-​term effects of maternal care on development. Neuroscience & Biobehavioral Reviews, 33(4), 593–​600. Chamratrithirong, A., Miller, B. A., Byrnes, H. F., Rhucharoenpornpanich, O., Cupp, P. K., Rosati, M. J., et al. (2010). Spirituality within the family and the prevention of health risk behavior among adolescents in Bangkok, Thailand. Social Sciences and Medicine, 71(10), 1855–​1863. Chan, C. S., & Rhodes, J. E. (2013). Religious coping, posttraumatic stress, psychological distress, and posttraumatic growth among female survivors four years after Hurricane Katrina. Journal of Traumatic Stress, 26, 257–​265. Chan, D., Anderson, V., Pijnenburg, Y., Whitwell, J., Barnes, J., Scahill, R., et al. (2009). The clinical profile of right temporal lobe atrophy. Brain, 132(5), 1287–​1298. Chan, J. Y., Yiu, K. K., Kwok, T. C., Wong, S. Y., & Tsoi, K. K. (2019). Depression and antidepressants as potential risk factors in dementia: a systematic review and meta-​ analysis of 18 longitudinal studies. Journal of the American Medical Directors Association, 20(3), 279–​286. Chan, S. W., Lau, W. W., Hui, C. H., Lau, E. Y., & Cheung, S. F. (2020). Causal relationship between religiosity and value priorities: cross-​ sectional and longitudinal investigations. Psychology of Religion and Spirituality, 12(1), 77. Chandra, P. S., Gandhi, C., Satishchandra, P., Kamat, A., Desai, A., Ravi, V., et al. (2006). Quality of life

in HIV subtype C infection among asymptomatic subjects and its association with CD4 counts and viral loads: a study from South India. Quality of Life Research, 15(10), 1597–​1605. Chandra, S., Mohammadnezhad, M., & Ward, P. (2018). Trust and communication in a doctor-​ patient relationship: a literature review. Journal of Healthcare Communication, 3(3), 36. Chanen, A. M., & Kaess, M. (2012). Developmental pathways to borderline personality disorder. Current Psychiatry Reports, 14(1), 45–​53. Chang, B. H., Skinner, K. M., & Boehmer, U. (2001). Religion and mental health among women veterans with sexual assault experience. International Journal of Psychiatry in Medicine, 31(1), 77–​95. Chang, B. H., Skinner, K. M., Zhou, C., & Kazis, L. E. (2003). The relationship between sexual assault, religiosity and mental health among male veterans. International Journal of Psychiatry in Medicine, 33(3), 223–​239. Chang, B. L., van Servellen, G., & Lombardi, E. (2003). Factors associated with complementary therapy use in people living with HIV/​AIDS receiving antiretroviral therapy. Journal of Alternative & Complementary Medicine, 9(5), 695–​710. Chang, S. C., Glymour, M., Cornelis, M., Walter, S., Rimm, E. B., Tchetgen Tchetgen, E., et al. (2017). Social integration and reduced risk of coronary heart disease in women: the role of lifestyle behaviors. Circulation Research, 120(12), 1927–​1937. Charlemagne-​Badal, S. J., & Lee, J. W. (2016a). Intrinsic religiosity and hypertension among older North American Seventh-​Day Adventists. Journal of Religion and Health, 55(2), 695–​708. Charlemagne-​Badal, S. J., & Lee, J. W. (2016b). Religious social support and hypertension among older North American Seventh-​Day Adventists. Journal of Religion and Health, 55(2), 709–​728. Charlson, F. J., Ferrari, A. J., Santomauro, D. F., Diminic, S., Stockings, E., Scott, J. G., et al. (2018). Global epidemiology and burden of schizophrenia: findings from the global burden of disease study 2016. Schizophrenia Bulletin, 44(6), 1195–​1203. Charlton, J. P., Soh, P. C., Ang, P. H., & Chew, K. W. (2013). Religiosity, adolescent internet usage motives and addiction: an exploratory study. Information, Communication & Society, 16(10), 1619–​1638. Chastin, S. F., De Craemer, M., De Cocker, K., Powell, L., Van Cauwenberg, J., Dall, P.,

References • 893

et al. (2019). How does light-​intensity physical activity associate with adult cardiometabolic health and mortality? British Journal of Sports Medicine, 53(6), 370–​376. Chatters, L. M., & Taylor, R. J. (1989). Age differences in religious participation among Black adults. Journal of Gerontology, 44(5), S183–​S189. Chatters, L. M., Taylor, R. J., Bullard, K. M., & Jackson, J. S. (2008). Spirituality and subjective religiosity among African Americans, Caribbean Blacks, and Non‐Hispanic Whites. Journal for the Scientific Study of Religion, 47(4), 725–​737. Chatters, L. M., Nguyen, A. W., Taylor, R. J., & Hope, M. O. (2018). Church and family support networks and depressive symptoms among African Americans. Journal of Community Psychology, 46(4), 403–​417. Chaves, M. (2010). Rain dances in the dry season: overcoming the religious congruence fallacy. Journal for the Scientific Study of Religion, 49(1), 1–​14. Cheadle, A. C., & Schetter, C. D. (2018). Mastery, self-​esteem, and optimism mediate the link between religiousness and spirituality and postpartum depression. Journal of Behavioral Medicine, 41(5), 711–​721. Cheadle, A. C., Schetter, C. D., Lanzi, R. G., Vance, M. R., Sahadeo, L. S., Shalowitz, M. U., et al. (2015). Spiritual and religious resources in African American women: Protection from depressive symptoms after childbirth. Clinical Psychological Science, 3(2), 283–​291. Chen, C. Y., Dormitzer, C. M., Bejarano, J., & Anthony, J. C. (2004a). Religiosity and the earliest stages of adolescent drug involvement in seven countries of Latin America. American Journal of Epidemiology, 159(12), 1180–​1188. Chen, C. Y., Dormitzer, C. M., Gutierrez, U., Vittetoe, K., Gonzalez, G. B., & Anthony, J. C. (2004b). The adolescent behavioral repertoire as a context for drug exposure: behavioral autarcesis at play. Addiction, 99(7), 897–​906. Chen, G. C., Neelakantan, N., Martín-​Calvo, N., Koh, W. P., Yuan, J. M., Bonaccio, M., et al. (2019). Adherence to the Mediterranean diet and risk of stroke and stroke subtypes. European Journal of Epidemiology, 34, 337–​349. Chen, H., Wang, Z., Phillips, M. R., Sun, Y., & Cheng, H. G. (2014). Internal consistency and test-​retest reliability of the Chinese version of the 5-​item Duke University Religion Index. Shanghai Archives of Psychiatry, 26(5), 300–​309. Chen, H., Feng, Y., Li, S., Zhang, Y., & Yang, X. (2019). Bibliometric analysis of theme

894 •  R eferences

evolution and future research trends of the type A personality. Personality and Individual Differences, 150, 109507. Chen, R., Hu, Z., Wei, L., Ma, Y., Liu, Z., & Copeland, J. R. (2011). Incident dementia in a defined older Chinese population. PloS One, 6(9), e24817. Chen, R., Crichton, S., McKevitt, C., Rudd, A. G., Sheldenkar, A., & Wolfe, C. D. (2015). Association between socioeconomic deprivation and functional impairment after stroke: the South London Stroke Register. Stroke, 46(3), 800–​805. Chen, Y. Y. (2005). Written emotional expression and religion: effects on PTSD symptoms. International Journal of Psychiatry in Medicine, 35(3), 273–​286. Chen, Y., & VanderWeele, T. J. (2018). Associations of religious upbringing with subsequent health and well-​being from adolescence to young adulthood: an outcome-​ wide analysis. American Journal of Epidemiology, 187(11), 2355–​2364. Chen, Y., Kubzansky, L. D., & VanderWeele, T. J. (2019a). Parental warmth and flourishing in mid-​life. Social Science & Medicine, 220, 65–​72. Chen, Y., Kawachi, I., Berkman, L. F., Trudel-​ Fitzgerald, C., & Kubzansky, L. D. (2019b). Does optimal parenting style help offspring maintain healthy weight into mid-​life? Preventive Medicine, 123, 84–​90. Chen, Y., Kim, E. S., & VanderWeele, T. J. (2020a). Religious-​service attendance and subsequent health and well-​being throughout adulthood: evidence from three prospective cohorts. International Journal of Epidemiology, 49(6), 2030–​2040. Chen, Y., Koh, H. K., Kawachi, I., Botticelli, M., & Vanderweele, T. J. (2020b). Religious service attendance and deaths related to drugs, alcohol, and suicide among US health care professionals. JAMA Psychiatry, 77(7), 737–​744. Chhangur, R. R., Overbeek, G., Verhagen, M., Weeland, J., Matthys, W., & Engels, R. C. (2015). DRD4 and DRD2 genes, parenting, and adolescent delinquency: longitudinal evidence for a gene by environment interaction. Journal of Abnormal Psychology, 124(4), 791. Chhatre, S., Metzger, D. S., Frank, I., Boyer, J., Thompson, E., Nidich, S., et al. (2013). Effects of behavioral stress reduction Transcendental Meditation intervention in persons with HIV. AIDS Care, 25(10), 1291–​1297. Chiang, K. J., Tsai, J. C., Liu, D., Lin, C. H., Chiu, H. L., & Chou, K. R. (2017). Efficacy of

cognitive-​behavioral therapy in patients with bipolar disorder: a meta-​analysis of randomized controlled trials. PloS One, 12(5), e0176849. Chiba, Y., & VanderWeele, T. J. (2011). A simple method for principal strata effects when the outcome has been truncated due to death. American Journal of Epidemiology, 173(7), 745–​751. Chida, Y., & Hamer, M. (2008). Chronic psychosocial factors and acute physiological responses to laboratory-​induced stress in healthy populations: a quantitative review of 30 years of investigations. Psychological Bulletin, 134(6), 829–​885. Chida, Y., Hamer, M., Wardle, J., & Steptoe, A. (2008). Do stress-​related psychosocial factors contribute to cancer incidence and survival? Nature Clinical Practice Oncology, 5(8), 466–​475. Chida, Y., & Steptoe, A. (2008). Positive psychological well-​being and mortality: A quantitative review of prospective observational studies. Psychosomatic Medicine, 70, 741–​756. Chida, Y., Steptoe, A., & Powell, L. H. (2009). Religiosity/​spirituality and mortality. Psychotherapy and Psychosomatics, 78(2), 81–​90. Chidananda, S. (2002). Hinduism: monotheism and polytheism reconciled. Retrieved on 10-​12-​2020 from https://​www.dlshq.org/​discou​rse/​may2​ 002.htm. Chien, L. Y., George, M. A., Armstrong, R. W. (2002). Country of birth and language spoken at home in relation to illicit substance use. Canadian Journal of Public Health, 93(3), 188–​192. Chiswick, B. R., & Mirtcheva, D. M. (2013). Religion and child health: religious affiliation, importance, and attendance and health status among American youth. Journal of Family and Economic Issues, 34(1), 120–​140. Chiuve, S. E., McCullough, M. L., Sacks, F. M., & Rimm, E. B. (2006). Healthy lifestyle factors in the primary prevention of coronary heart disease among men. Circulation, 114, 160–​167. Chlan, K. M., Zebracki, K., & Vogel, L. C. (2011). Spirituality and life satisfaction in adults with pediatric-​onset spinal cord injury. Spinal Cord, 49(3), 371–​375. Chliaoutakis, J. E., Koukouli, S., Lajunen, T., & Tzamalouka, G. (2005). Lifestyle traits as predictors of driving behaviour in urban areas of Greece. Transportation Research Part F: Traffic Psychology and Behaviour, 8(6), 413–​428. Choi, M. (2020). Association between social participation and cognitive function among community‐dwelling older adults living

alone: analysis of a nationally representative survey. International Journal of Nursing Practice, 26(4), e12841. Choi, P. J., Curlin, F. A., & Cox, C. E. (2015). “The patient is dying, please call the chaplain”: the activities of chaplains in one medical center’s intensive care units. Journal of Pain and Symptom Management, 50(4), 501–​506. Chokkanathan, S. (2013). Religiosity and well-​being of older adults in Chennai, India. Aging & Mental Health, 17(7), 880–​887. Chooi, Y. C., Ding, C., & Magkos, F. (2019). The epidemiology of obesity. Metabolism, 92, 6–​10. Chou, A. F., Stewart, S. L., Wild, R. C., & Bloom, J. R. (2012). Social support and survival in young women with breast carcinoma. Psycho‐Oncology, 21(2), 125–​133. Chou, S. P., Goldstein, R. B., Smith, S. M., Huang, B., Ruan, W. J., Zhang, H., et al. (2016). The epidemiology of DSM-​5 nicotine use disorder. Journal of Clinical Psychiatry, 77(10), 1404–​1412. Choumanova, I., Wanat, S., Barrett, R., & Koopman, C. (2006). Religion and spirituality in coping with breast cancer: perspectives of Chilean women. Breast Journal, 12(4), 349–​352. Chowdhury, R., Ramond, A., O’Keeffe, L. M., Shahzad, S., Kunutsor, S. K., Muka, T., et al. (2018). Environmental toxic metal contaminants and risk of cardiovascular disease: systematic review and meta-​analysis. British Medical Journal, 362, k3310. Choy, L. T. (2014). The strengths and weaknesses of research methodology: comparison and complimentary between qualitative and quantitative approaches. IOSR Journal of Humanities and Social Science, 19(4), 99–​104. Christ, A., Lauterbach, M., & Latz, E. (2019). Western diet and the immune system: an inflammatory connection. Immunity, 51(5), 794–​811. Christensen, C. W. (1963). Religious conversion. Archives of General Psychiatry, 9, 207–​216. Christian, K. A., Iuliano, A. D., Uyeki, T. M., Mintz, E. D., Nichol, S. T., Rollin, P., et al. (2017). What we are watching: top global infectious disease threats, 2013–​2016. Health Security, 15(5), 453–​462. Christo, G., & Franey, C. (1995). Drug users’ spiritual beliefs, locus of control and the disease concept in relation to Narcotics Anonymous attendance and six-​month outcomes. Drug and Alcohol Dependence, 38, 51–​56. Chu, D. C., & Sung, H. E. (2009). Racial differences in desistance from substance abuse: the

References • 895

impact of religious involvement on recovery. International Journal of Offender Therapy and Comparative Criminology, 53, 696–​716. Chu, P. S., Saucier, D. A., & Hafner, E. (2010). Meta-​analysis of the relationships between social support and well-​being in children and adolescents. Journal of Social and Clinical Psychology, 29(6), 624–​645. Chung, G. S., Lawrence, R. E., Curlin, F. A., Arora, V., & Meltzer, D. O. (2012). Predictors of hospitalised patients’ preferences for physician-​ directed medical decision-​making. Journal of Medical Ethics, 38(2), 77–​82. Chung, J. W., Wong, B. Y., Chen, J. H., & Chung, M. W. (2016). Effects of praise dance on the quality of life of Chinese women. Journal of Alternative and Complementary Medicine, 22(12), 1013–​1019. Churakova, I., Burlaka, V., & Parker, T. W. (2017). Relationship between alcohol use, spirituality, and coping. International Journal of Mental Health and Addiction, 15(4), 842–​852. Cirhinlioğlu, F. G., Cirhinlioğlu, Z., & Tepe, Y. K. (2018). The mediating role of religiousness in the relationship between the attachment style and marital quality. Current Psychology, 37(1), 207–​215. Cisin, I. H., & Cahalan, D. (1968). Comparison of abstainers and heavy drinkers in a national survey. Psychiatric Research Reports, 24, 10–​21. Clark, A. E. (2019). Born to be mild? Cohort effects don’t (fully) explain why well-​being is U-​shaped in age. In Rojas, M. (ed.), The Economics of Happiness. Cham, Switzerland: Springer, pp. 387–​408. Clark, P. (2010). Preventing Future Crime with Cognitive Behavioral Therapy. Washington, DC: National Institute of Justice. Clemente, A. S., Diniz, B. S., Nicolato, R., Kapczinski, F. P., Soares, J. C., Firmo, J. O., et al. (2015). Bipolar disorder prevalence: a systematic review and meta-​analysis of the literature. Revista Brasileira de Psiquiatria, 37(2), 155–​161. Clements, A. D., & Cyphers, N. A. (2020). Prenatal substance use: religious women report lower use rates, but do they use less? Journal of Prevention & Intervention in the Community, 48(1), 47–​63. Clements, A. D., & Ermakova, A. V. (2012). Surrender to God and stress: a possible link between religiosity and health. Psychology of Religion and Spirituality, 4(2), 93–​107. Cline, K. M., & Ferraro, K. F. (2006). Does religion increase the prevalence and incidence of obesity in adulthood? Journal for the Scientific Study of Religion, 45(2), 269–​281.

896 •  R eferences

Cloninger, C. R. (1987). A systematic method for clinical description and classification of personality. Archives of General Psychiatry, 44, 573–​588. Clore, G. L., & Bryne, D. (1974). A reinforcement-​ affect model of attraction. In T. L. Huston (ed.), Foundations of Interpersonal Attraction. New York: Academic Press, pp. 143–​170. CMS (2015). Centers for Medicare and Medicaid Services. State Operations Manual, Appendix M -​ Guidance to Surveyors: Hospice (pp. 12, 18, 19, 23, 24, 35, 38, 39, 40, 41, 44, and elsewhere throughout the manual). See website: https://​ www.cms.gov/​Regu​lati​ons-​and-​Guida​nce/​Guida​ nce/​Manu​als/​downlo​ads/​som​107a​p_​m_​hosp​ice. pdf (last accessed 3-​22-​2019) CMS (2020a). Centers for Medicare and Medicaid Services. National health expenditure projections 2019–​28. Retrieved on 9-​21-​2020 from https://​www.cms.gov/​Resea​rch-​Sta​tist​ics-​ Data-​and-​Syst​ems/​Sta​tist​ics-​Tre​nds-​and-​Repo​ rts/​Natio​nalH​ealt​hExp​endD​ata/​Nati​onal​Heal​ thAc​coun​tsPr​ojec​ted. CMS (2020b). Centers for Medicare and Medicaid Services. NHE Projections 2018–​ 2027: Tables: National health expenditures; aggregate and per capita amounts, percent distribution and annual percent change by source of funds: calendar years 2011–​2027. Retrieved on 9-​21-​2020 from https://​www. cms.gov/​Resea​rch-​Sta​tist​ics-​Data-​and-​Syst​ ems/​Sta​tist​ics-​Tre​nds-​and-​Repo​r ts/​Natio​nalH​ ealt​hExp​endD​ata/​Nati​onal​Heal​thAc​coun​tsPr​ ojec​ted. Coats, H., Downey, L., Sharma, R. K., Curtis, J. R., & Engelberg, R. A. (2018). Quality of communication and trust in patients with serious illness. Journal of Pain and Symptom Management, 56(4), 530–​540. Cobb, C. L., Xie, D., & Sanders, G. L. (2016). Coping styles and depression among undocumented Hispanic immigrants. Journal of Immigrant and Minority Health, 18(4), 864–​870. Cobb, S. (1976). Social support as a moderator of life stress. Psychosomatic Medicine, 38, 300–​314. Cochran, J. K. (1991). The effects of religiosity on adolescent self-​reported frequency of drug and alcohol use. Journal of Drug Issues, 22, 91–​104. Cochran, J. K. (1993). The variable effects of religiosity and denomination on adolescent self-​ reported alcohol use by beverage type. Journal of Drug Issues, 23, 479–​491. Cochran, J. K., & Akers, R. L. (1989). Beyond hellfire: an exploration of the variable effects of religiosity on adolescent marijuana and alcohol

use. Journal of Research in Crime and Delinquency, 26, 198–​225. Cochran, J. K., & Beeghley, L. (1991). The influence of religion on attitudes toward nonmarital sexuality: a preliminary assessment of reference group theory. Journal for the Scientific Study of Religion, 30, 45–​62. Cochran, J. K., Beeghley, L., & Bock, E. W. (1988). Religiosity and alcohol behavior: an exploration of reference group theory. Sociological Forum, 3, 256–​276. Cochran, J. K., Beeghley, L., & Bock, E. W. (1992). The influence of religious stability and homogamy on the relationship between religiosity and alcohol use among Protestants. Journal for the Scientific Study of Religion, 31, 441–​456. Cockerham, W. C., Hamby, B. W., & Oates, G. R. (2017). The social determinants of chronic disease. American Journal of Preventive Medicine, 52(1S1), S5–​S12. Cohen, B. E., Edmondson, D., & Kronish, I. M. (2015). State of the art review: depression, stress, anxiety, and cardiovascular disease. American Journal of Hypertension, 28(11), 1295–​1302. Cohen, C. B., Wheeler, S. E., Scott, D. A., Edwards, B. S., Lusk, P., & Anglican Working Group in Bioethics. (2000). Prayer as therapy: a challenge to both religious belief and professional ethics. Hastings Center Report, 30(3), 40–​47. Cohen, C. I., Colemon, Y., Yaffee, R., & Casimir, G. J. (2008). Racial differences in suicidality in an older urban population. Gerontologist, 48(1), 71–​78. Cohen, J., Marcoux, I., Bilsen, J., Deboosere, P., van der Wal, G., & Deliens, L. (2006). European public acceptance of euthanasia. Social Sciences and Medicine, 63(3), 743–​756. Cohen, J., van Delden, J., Mortier, F., Lofmark, R., Norup, M., Cartwright, C., et al. (2008). Influence of physicians’ life stances on attitudes to end-​of-​life decisions and actual end-​of-​life decision-​making in six countries. Journal of Medical Ethics, 34(4), 247–​253. Cohen, L., Cole, S. W., Sood, A. K., Prinsloo, S., Kirschbaum, C., Arevalo, J. M., et al. (2012). Depressive symptoms and cortisol rhythmicity predict survival in patients with renal cell carcinoma: role of inflammatory signaling. PloS One, 7(8), e42324. Cohen, M. A., & Piquero, A. R. (2009). New evidence on the monetary value of saving a high-​ risk youth. Journal of Quantitative Criminology, 25, 25–​49.

Cohen, M. L. (2000). Changing patterns of infectious disease. Nature, 406(6797), 762–​767. Cohen, P., Crawford, T. N., Johnson, J. G., & Kasen, S. (2005). The children in the community study of developmental course of personality disorder. Journal of Personality Disorders, 19, 466–​486. Cohen, P. N. (2017). The divorce rate has been falling since the 1970s, but we don’t want it too low. Timeline. Retrieved on 10-​18-​2019 from https://​timel​ine.com/​divo​rce-​rates-​going-​down-​ d8547​7f83​055. Cohen, R., Bavishi, C., & Rozanski, A. (2016). Purpose in life and its relationship to all-​cause mortality and cardiovascular events: a meta-​ analysis. Psychosomatic Medicine, 78(2), 122–​133. Cohen, S. (1988). Perceived stress in a probability sample of the United States. In S. Spacapan & S. Oskamp (eds.), The Claremont Symposium on Applied Social Psychology: The Social Psychology of Health. Thousand Oaks, CA: Sage Publications, pp. 31–​67. Cohen, S., Tyrrell, D. A., & Smith, A. P. (1991). Psychological stress and susceptibility to the common cold. New England Journal of Medicine, 325(9), 606–​612. Cohen, S., Janicki-​Deverts, D., Doyle, W. J., Miller, G. E., Frank, E., Rabin, B. S., et al. (2012). Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. Proceedings of the National Academy of Sciences, 109(16), 5995–​5999. Cohen-​Mansfield, J., Shmotkin, D., & Hazan, H. (2016). Changes in religiosity in old age: an exploratory study. International Journal of Aging and Human Development, 83(3), 256–​273. Coid, J., Moran, P., Bebbington, P., Brugha, T., Jenkins, R., Farrell, M., et al. (2009). The co‐ morbidity of personality disorder and clinical syndromes in prisoners. Criminal Behaviour and Mental Health, 19(5), 321–​333. Coin, A., Perissinotto, E., Najjar, M., Girardi, A., Inelmen, E. M., Enzi, G., et al. (2010). Does religiosity protect against cognitive and behavioral decline in Alzheimer’s dementia? Current Alzheimer Research, 7(5), 445–​452. Colantonio, A., Kasl, S. V., & Ostfeld, A. M. (1992). Depressive symptoms and other psychosocial factors as predictors of stroke in the elderly. American Journal of Epidemiology, 136(7), 884–​894. Colditz, G. A. (2009). Cancer and the environment: the American Cancer Society prevention priorities. CA: A Cancer Journal for Clinicians, 59(6), 341.

References • 897

Coleman, P. G., Carare, R. O., Petrov, I., Forbes, E., Saigal, A., Spreadbury, J. H., et al. (2011). Spiritual belief, social support, physical functioning and depression among older people in Bulgaria and Romania. Aging & Mental Health, 15(3), 327–​333. Collins, R. L., Ellickson, P. L., & Klein, D. J. (2007). The role of substance use in young adult divorce. Addiction, 102(5), 786–​794. Collishaw, S., Gardner, F., Maughan, B., Scott, J., & Pickles, A. (2012). Do historical changes in parent–​child relationships explain increases in youth conduct problems? Journal of Abnormal Child Psychology, 40(1), 119–​132. Colloca, L., Ludman, T., Bouhassira, D., Baron, R., Dickenson, A. H., Yarnitsky, D., et al. (2017). Neuropathic pain. Nature Reviews Disease Primers, 3(1), 1–​19. Colman, R. A., Do Han Kim, S. M., Mitchell-​ Herzfeld, S., & Shady, T. A. (2009). Long-​Term Consequences of Delinquency: Child Maltreatment and Crime in Early Adulthood. New York State Office of Children and Family Services. Washington, DC: National Institute of Justice. Colman, R. A., Mitchell-​Herzfeld, S., & Shady, T. A. (2010). From delinquency to the perpetration of child maltreatment. Children and Youth Services Review, 32(10), 1410–​1417. Comings, D. E., Gonzales, N., Suacier, G., Jonhson, J. P., & MacMurray, J. P. (2001). The DRD4 gene and spirituality. Psychiatric Genetics, 10, 185–​189. Commentary (2007). Teenage suicide: losing their way. The Useless Tree: Ancient Chinese Thought in Modern American Life, March (see comments following article). Retrieved on 6-​10-​2019 from https://​usel​esst​ree.type​pad.com/​usele​ss_​t​ree/​ 2007/​03/​suic​ied_​losi​ng_​.html. Compton, M. T., & Shim, R. S. (2015). The social determinants of mental health. Focus, 13(4), 419–​425. Compton, M. T., Thompson, N. J., & Kaslow, N. J. (2005). Social environment factors associated with suicide attempt among low-​income African Americans: the protective role of family relationships and social support. Social Psychiatry & Psychiatric Epidemiology, 40(3), 175–​185. Compton, W. C., & Hoffman, E. (2019). Positive Psychology: The Science of Happiness and Flourishing. Thousand Oaks, CA: SAGE Publications. Compton, W. M., Han, B., Blanco, C., Johnson, K., & Jones, C. M. (2018). Prevalence and correlates of prescription stimulant use, misuse, use

898 •  R eferences

disorders, and motivations for misuse among adults in the United States. American Journal of Psychiatry, 175(8), 741–​755. Condrasky, M. D., Baruth, M., Wilcox, S., & Carter, C. (2013). Predictors of change in fruit and vegetable consumption in a faith-​based intervention with African American adults. Family & Community Health, 36(3), 236–​247. Connell, A., Koen, L., Niehaus, D., Cloete, K. J., Jordaan, E., & Botha, U. (2015). Religious delusions in a Xhosa schizophrenia population. Journal of Religion and Health, 54(5), 1555–​1562. Conner, K. R., Bridge, J. A., Davidson, D. J., Pilcher, C., & Brent, D. A. (2019). Metaanalysis of mood and substance use disorders in proximal risk for suicide deaths. Suicide and Life‐Threatening Behavior, 49(1), 278–​292. Conner, K. R., Duberstein, P. R., Conwell, Y., Seidlitz, L., & Caine, E. D. (2001). Psychological vulnerability to completed suicide: a review of empirical studies. Suicide and Life‐Threatening Behavior, 31(4), 367–​385. Connor, J. P., Haber, P. S., & Hall, W. D. (2016). Alcohol use disorders. The Lancet, 387(10022), 988–​998. Conover-​Williams, M., & Chang, J. (2016). Pray away the criminal? Crime, religiosity, gender and sexuality over the life course. Humboldt Journal of Social Relations, 1(38), 28–​45. Constable, C., & Caplan, A. (2020). Comparison of the implementation of human papillomavirus and hepatitis B vaccination programs in the United States: implications for future vaccines. Vaccine, 38(5), 954–​962. Contrada, R. J., Goyal, T. M., Cather, C., Rafalson, L., Idler, E. L., & Krause, T. J. (2004). Psychosocial factors in outcomes of heart surgery: the impact of religious involvement and depressive symptoms. Health Psychology, 23(3), 227–​238. Contrada, R. J., Boulifard, D. A., Hekler, E. B., Idler, E. L., Spruill, T. M., Labouvie, E. W., et al. (2008). Psychosocial factors in heart surgery: presurgical vulnerability and postsurgical recovery. Health Psychology, 27(3), 309–​319. Conway-​Phillips, R., & Janusek, L. (2014). Influence of sense of coherence, spirituality, social support and health perception on breast cancer screening motivation and behaviors in African American women. ABNF Journal, 25(3), 72–​91. Conwell, Y. (2014). Suicide later in life. American Journal of Preventive Medicine, 47(3), S244–​S250. Conyn-​van Spaendonck, M. A., Oostvogel, P. M., van Loon, A. M., Van Wijngaarden, J. K., & Kromhout, D. (1996). Circulation of poliovirus

during the poliomyelitis outbreak in the Netherlands, in 1992–​1993. American Journal of Epidemiology, 143, 929–​935. Cook, C. C. (2013a). Recommendations for psychiatrists on spirituality and religion. Position statement, Royal College of Psychiatrists, London. Retrieved on 6-​4-​2019 from https://​www.rcps​ych.ac.uk/​pdf/​PS03_​2​ 013.pdf. Cook, C. C., & Powell, A. (2013b). Spirituality is not bad for our mental health. The British Journal of Psychiatry, 202(5), 385–​386. Cook, C. C. (2014). Suicide and religion. British Journal of Psychiatry, 204(4), 254–​255. Cook, C. C. (2015). Religious psychopathology: the prevalence of religious content of delusions and hallucinations in mental disorder. International Journal of Social Psychiatry, 61(4), 404–​425. Cook, J. M., Pearson, J. L., Thompson, R., Black, B. S., & Rabins, P. V. (2002). Suicidality in older African Americans: findings from the EPOCH study. American Journal of Geriatric Psychiatry, 10(4), 437–​446. Cooley, T. (1898). General Principles of Constitutional Law in the United States, 3rd ed. Boston, MA: Little, Brown, pp. 224–​225. Cooper, C., Sommerlad, A., Lyketsos, C. G., & Livingston, G. (2015). Modifiable predictors of dementia in mild cognitive impairment: a systematic review and meta-​analysis. American Journal of Psychiatry, 172(4), 323–​334. Cooper, H. M. (1984). The Integrated Research Review: A Systematic Approach. Vol. 2. Beverly Hills, CA: Sage Publications, pp. 66–​71. Cooper, J., & Zimmerman, W. (2017). The effect of a faith community nurse network and public health collaboration on hypertension prevention and control. Public Health Nursing, 34(5), 444–​453. Cooper, R. S., Rotimi, C. N., & Ward, R. (1999). The puzzle of hypertension in African-​Americans. Scientific American, 280(2), 56–​63. Cordonnier, C., Sprigg, N., Sandset, E. C., Pavlovic, A., Sunnerhagen, K. S., & Caso, V. (2017). Women initiative for stroke in Europe (WISE) Group. Stroke in women—​from evidence to inequalities. Nature Reviews Neurology, 13(9), 521–​532. Corr, C. A. (1992). A task-​based approach to coping with dying. Omega-​Journal of Death and Dying, 24(2), 81–​94. Correa, A. A., Moreira-​Almeida, A., Meneze, P. R., Vallada, H., & Scazufca, M. (2011). Investigating the role played by social support

in the association between religiosity and mental health in low income older adults. Revista Brasileira de Psiquiatria, 33(2), 157–​164. Corrêa, J. C., Ávila, M. P., Lucchetti, A. L., & Lucchetti, G. (2019). Altruistic behaviour, but not volunteering, has been associated with cognitive performance in community‐dwelling older persons. Psychogeriatrics, 19(2), 117–​125. Corsentino, E. A., Collins, N., Sachs-​Ericsson, N., & Blazer, D. G. (2009). Religious attendance reduces cognitive decline among older women with high levels of depressive symptoms. Journals of Gerontology, 64A(12), 1283–​1289. Cortes, D. S., Skragge, M., Döllinger, L., Laukka, P., Fischer, H., Nilsson, M. E., et al. (2018). Mixed support for a causal link between single dose intranasal oxytocin and spiritual experiences. Social Cognitive and Affective Neuroscience, 13(9), 921–​932. Corvo, K., & Carpenter, E. H. (2000). Effects of parental substance abuse on current levels of domestic violence: a possible elaboration of intergenerational transmission processes. Journal of Family Violence, 15(2), 123–​135. Cosco, T. D., Stubbs, B., Prina, A. M., & Wu, Y. T. (2016). Religiosity and suicidal behaviour in the National Survey of American Life. Acta Psychiatrica Scandinavica, 134(2), 183–​184. Costa, B., Pini, S., Gabelloni, P., Abelli, M., Lari, L., Cardini, A., et al. (2009). Oxytocin receptor polymorphisms and adult attachment style in patients with depression. Psychoneuroendocrinology, 34(10), 1506–​1514. Costa, P. T., & McCrae, R. R. (1992). Normal personality assessment in clinical practice: the NEO Personality Inventory. Psychological Assessment 4, 5–​13. Costa, P. T., Jr., McCrae, R. R., & Dembroski, T. (2013). Agreeableness versus antagonism: explication of a potential risk factor for CHD. In Siegman, A. W., & Dembroski, T. M. (eds.), In Search of Coronary-​Prone Behavior. New York, NY: Psychology Press, pp. 55–​78. Costa, W., Nogueira, C., & Freire, T. (2010). The lack of teaching/​study of religiosity/​spirituality in psychology degree courses in Brazil. Journal of Religion and Health, 49(3), 322–​332. Costello, H., Gould, R. L., Abrol, E., & Howard, R. (2019). Systematic review and meta-​ analysis of the association between peripheral inflammatory cytokines and generalized anxiety disorder. BMJ Open, 9(7), e027925. Costigan, M., Scholz, J., & Woolf, C. J. (2009). Neuropathic pain: a maladaptive response of

References • 899

the nervous system to damage. Annual Review of Neuroscience, 32, 1–​32. Cotton, S., Puchalski, C. M., Sherman, S. N., Mrus, J. M., Peterman, A. H., Feinberg, J., et al. (2006). Spirituality and religion in patients with HIV/​ AIDS. Journal of General Internal Medicine, 21, S5–​S13. Cottrell, C. A., Neuberg, S. L., & Li, N. P. (2007). What do people desire in others? A sociofunctional perspective on the importance of different valued characteristics. Journal of Personality and Social Psychology, 92(2), 208–​231. Coughlin, S. S. (2019). Social determinants of breast cancer risk, stage, and survival. Breast Cancer Research and Treatment, 177, 537–​548. Counted, V., Possamai, A., & Meade, T. (2018). Relational spirituality and quality of life 2007 to 2017. Health and Quality of Life Outcomes, 16(1), 75. Courtney, K. E., & Ray, L. A. (2014). Methamphetamine: an update on epidemiology, pharmacology, clinical phenomenology, and treatment literature. Drug and Alcohol Dependence, 143, 11–​21. Coward, H. (1986). Intolerance in the world’s religions. Studies in Religion, 15, 419–​431. Cowlishaw, S., Niele, S., Teshuva, K., Browning, C., & Kendig, H. (2013). Older adults’ spirituality and life satisfaction. Ageing & Society, 33(7), 1243–​1262. Cozier, Y. C., Yu, J., Wise, L. A., VanderWeele, T. J., Balboni, T. A., Argentieri, M. A., et al. (2018). Religious and spiritual coping and risk of incident hypertension in the Black Women’s Health Study. Annals of Behavioral Medicine, 52(12), 989–​998. Cozolino, L. (2014). The Neuroscience of Human Relationships: Attachment and the Developing Social Brain. New York, NY: W. W. Norton. Crabtree, S. (2010). Religiosity highest in world’s poorest nations. Retrieved on 7-​15-​2019 from https://​news.gal​lup.com/​poll/​142​727/​reli​gios​ ity-​high​est-​world-​poor​est-​nati​ons.aspx. Cramer, R. J., & Kapusta, N. D. (2017). A social-​ ecological framework of theory, assessment, and prevention of suicide. Frontiers in Psychology, 8, 1756. Crammer, C., Kaw, C., Gansler, T., & Stein, K. D. (2011). Cancer survivors’ spiritual well-​being and use of complementary methods: a report from the American Cancer Society’s Studies Of Cancer Survivors. Journal of Religion and Health, 50(1), 92–​107. Crank, B. R., & Teasdale, B. (2019). “Create in me a clean heart”: The role of spirituality in desistance

900 •  R eferences

from substance use. Journal of Drug Issues, 49(2), 203–​227. Craven, J. (2020). More research needed on fetal exposure, psychopathology (Focus on Neuropsychiatry 2020). Clinical Psychiatry News, 48(10). Crawford, M. J., Thomas, O., Khan, N., & Kulinskaya, E. (2007). Psychosocial interventions following self-​harm: systematic review of their efficacy in preventing suicide. The British Journal of Psychiatry, 190(1), 11–​17. Crespi, B., Dinsdale, N., Read, S., & Hurd, P. (2019). Spirituality, dimensional autism, and schizotypal traits: the search for meaning. PloS One, 14(3), e0213456. Creswell, J. W., & Creswell, J. D. (2017). Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Thousand Oaks, CA: Sage Publications. Crichton, S. L., Bray, B. D., McKevitt, C., Rudd, A. G., & Wolfe, C. D. (2016). Patient outcomes up to 15 years after stroke: survival, disability, quality of life, cognition and mental health. Journal of Neurology, Neurosurgery & Psychiatry, 87(10), 1091–​1098. Croezen, S., Avendano, M., Burdorf, A., & van Lenthe, F. J. (2015). Social participation and depression in old age: a fixed-​effects analysis in 10 European countries. American Journal of Epidemiology, 182(2):168–​176. Cronan, T. A., Kaplan, R. M., Posner, L., Blumberg, E., & Kozin, F. (1989). Prevalence of the use of unconventional remedies for arthritis in a metropolitan community. Arthritis & Rheumatism, 32(12), 1604–​1607. Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297–​334. Croog, S. H., & Levine, S. (1972). Religious identity and response to serious illness: a report on heart patients. Social Science & Medicine, 6, 17–​32. Croswell, J. M., Ransohoff, D. F., & Kramer, B. S. (2010). Principles of cancer screening. Seminars in Oncology, 37(3), 202–​215. Crowell, J. A., Davis, C. R., Joung, K. E., Usher, N., McCormick, S. P., Dearing, E., et al. (2016). Metabolic pathways link childhood adversity to elevated blood pressure in midlife adults. Obesity Research & Clinical Practice, 10(5), 580–​588. Crowell, N., McCord, J., & Spatz Widom, C. (2001). Patterns and trends in juvenile crime and juvenile justice (­chapter 2). In McCord, J., Widom, C. S., & Crowell, N. (eds), Juvenile Crime, Juvenile Justice. Washington, DC: National Academy Press, pp. 25–​65.

Crump, C., Sundquist, K., Winkleby, M. A., & Sundquist, J. (2013). Comorbidities and mortality in bipolar disorder: a Swedish national cohort study. JAMA Psychiatry, 70(9), 931–​939. Crump, C., Sundquist, K., Sundquist, J., & Winkleby, M. A. (2014). Sociodemographic, psychiatric and somatic risk factors for suicide: a Swedish national cohort study. Psychological Medicine, 44(2), 279–​289. Cruz, J. P., Colet, P. C., Alquwez, N., Inocian, E. P., Al‐Otaibi, R. S., & Islam, S. M. (2017). Influence of religiosity and spiritual coping on health‐ related quality of life in Saudi haemodialysis patients. Hemodialysis International, 21(1), 125–​132. Cruz, M., Pincus, H. A., Welsh, D. E., Greenwald, D., Lasky, E., & Kilbourne, A. M. (2010). The relationship between religious involvement and clinical status of patients with bipolar disorder. Bipolar Disorders, 12(1), 68–​76. CSTH (2019). Religiously-​Integrated Cognitive Behavioral Therapy (RCBT) Manuals and Workbooks (including training video). Durham, NC: Duke University Center for Spirituality, Theology and Health. Retrieved on 6-​4-​2019 from http://​www. spirit​uali​tyan​dhea​lth.duke.edu/​index.php/​religi​ ous-​cbt-​study/​ther​apy-​manu​als. Cucciare, M. A., Han, X., Curran, G. M., & Booth, B. M. (2016). Associations between religiosity, perceived social support, and stimulant use in an untreated rural sample in the USA. Substance Use & Misuse, 51(7), 823–​834. Cuesta, J. M., & Singer, M. (2012). The stress response and critical illness: a review. Critical Care Medicine, 40(12), 3283–​3289. Cuevas, A. G., Williams, D. R., & Albert, M. A. (2017). Psychosocial factors and hypertension: a review of the literature. Cardiology Clinics, 35(2), 223–​230. Cuijpers, P., Vogelzangs, N., Twisk, J., Kleiboer, A., Li, J., & Penninx, B. W. (2014). Comprehensive meta-​analysis of excess mortality in depression in the general community versus patients with specific illnesses. American Journal of Psychiatry, 171(4), 453–​462. Culatto, A., & Sumerton, C. B. (2015). Spirituality and health education: a national survey of academic leaders UK. Journal of Religion and Health 54, 2269–​2275. Cummings, J. P., Ivan, M. C., Carson, C. S., Stanley, M. A., & Pargament, K. I. (2014). A systematic review of relations between psychotherapist religiousness/​spirituality and therapy-​related variables. Spirituality in Clinical Practice, 1(2), 116–​132.

Cummins, J. (2010). Why Some Wars Never End: The Stories of the Longest Conflicts in History. Beverly, MA: Fair Winds Press. Cunado, J., & de Gracia, F. P. (2012) Does education affect happiness? Evidence for Spain. Social Indicators Research, 108, 185–​196. Cuneo, M. W. (1999). Exorcism. In Roof, W. C. (ed.), Contemporary American Religion. New York, NY: Macmillan Reference, pp. 243–​245. Cunningham, A. M., & Knoester, C. (2007). Marital status, gender, and parents’ psychological well-​ being. Sociological Inquiry, 77(2), 264–​287. Cunningham, C., O’Sullivan, R., Caserotti, P., & Tully, M. A. (2020). Consequences of physical inactivity in older adults: a systematic review of reviews and meta-​analyses. Scandinavian Journal of Medicine & Science in Sports, 30(5), 816–​827. Cunningham, T. J., Ford, E. S., Rolle, I. V., Wheaton, A. G., & Croft, J. B. (2015). Associations of self-​reported cigarette smoking with chronic obstructive pulmonary disease and co-​morbid chronic conditions in the United States. COPD: Journal of Chronic Obstructive Pulmonary Disease, 12(3), 281–​291. Curiati, J. A., Bocchi, E., Freire, J. O., Arantes, A. C., Braga, M., Garcia, Y., et al. (2005). Meditation reduces sympathetic activation and improves the quality of life in elderly patients with optimally treated heart failure. Journal of Alternative & Complementary Medicine, 11(3), 465–​472. Curlin, F. A., Chin, M. H., Sellergren, S. A., Roach, C. J., & Lantos, J. D. (2006). The association of physicians’ religious characteristics with their attitudes and self-​reported behaviors regarding religion and spirituality in the clinical encounter. Medical Care, 44(5), 446–​453. Curlin, F. A., Lawrence, R. E., Chin, M. H., & Lantos, J. D. (2007). Religion, conscience, and controversial clinical practices. New England Journal of Medicine, 356(6), 593–​600. Curlin, F. A., Nwodim, C., Vance, J. L., Chin, M. H., & Lantos, J. D. (2008). To die, to sleep: US physicians’ religious and other objections to physician-​assisted suicide, terminal sedation, and withdrawal of life support. American Journal of Hospice & Palliative Medicine, 25(2), 112–​120. Currie, S. R., & Wang, J. (2004). Chronic back pain and major depression in the general Canadian population. Pain, 107(1–​2), 54–​60. Currier, J. M., Holland, J. M., & Drescher, K. D. (2015). Spirituality factors in the prediction of outcomes of PTSD treatment for U.S. military veterans. Journal of Traumatic Stress, 28(1), 57–​64.

References • 901

Currier, J. M., Drescher, K. D., Holland, J. M., Lisman, R., & Foy, D. W. (2016). Spirituality, forgiveness, and quality of life: testing a mediational model with military veterans with PTSD. International Journal for the Psychology of Religion, 26(2), 167–​179. Currier, J. M., Foster, J. D., Abernethy, A. D., Witvliet, C. V., Luna, L. M., Putman, K. M., et al. (2017). God imagery and affective outcomes in a spiritually integrative inpatient program. Psychiatry Research, 254, 317–​322. Currier, J. M., Pearce, M., Carroll, T. D., & Koenig, H. G. (2018a). Military veterans’ preferences for incorporating spirituality in psychotherapy or counseling. Professional Psychology: Research and Practice, 49(1), 39–​47. Currier, J. M., McDermott, R. C., McCormick, W. H., Churchwell, M. C., & Milkeris, L. (2018b). Exploring cross-​lagged associations between spiritual struggles and risk for suicidal behavior in a community sample of military veterans. Journal of Affective Disorders, 230, 93–​100. Curtin, S. C. (2020). State suicide rates among adolescents and young adults aged 10–​ 24: United States, 2000–​2018. National Vital Statistics Reports, 69(11), 1–​9. Curtin, S. C., & Heron, M. P. (2019). Death rates due to suicide and homicide among persons aged 10–​ 24: United States, 2000–​2017. National Center for Health Statistics, No. 352, October. Retrieved on 1-​17-​2020 from https://​sta​cks.cdc.gov/​view/​ cdc/​81944. Curtin, S. C., Warner, M., & Hedegaard, H. (2016). Increase in Suicide in the United States, 1999–​ 2014: NCHS Data Brief, No. 241. Hyattsville, MD: National Center for Health Statistics. Curtis, K. T., & Ellison, C. G. (2002). Religious heterogamy and marital conflict. Journal of Family Issues, 23(4), 551–​576. Da Silva, J. A., Geenen, R., & Jacobs, J. W. (2018). Chronic widespread pain and increased mortality: biopsychosocial interconnections. Annals of Rheumatic Diseases, 77(6), 790–​792. Dagenais, G. R., Leong, D. P., Rangarajan, S., Lanas, F., Lopez-​Jaramillo, P., Gupta, R., et al. (2020). Variations in common diseases, hospital admissions, and deaths in middle-​aged adults in 21 countries from five continents (PURE). The Lancet, 395(10226), 785–​794. Daghigh, A., DeShong, H. L., Daghigh, V., Niazi, M., & Titus, C. E. (2019). Exploring the relation between religiosity and narcissism in an Iranian sample. Personality and Individual Differences, 139, 96–​101.

902 •  R eferences

Daher, N., Koenig, H. G., Pearce, M. J., Nelson, B., Shaw, S. F., Berk, L. S., et al. (2016). Effects of religious vs. conventional cognitive-​behavioral therapy on purpose in life in clients with major depression and chronic medical illness: a randomized clinical trial. International Journal of Existential Psychology and Psychotherapy, 6(1), 16. Dahl, J., Ormstad, H., Aass, H. C., Malt, U. F., Bendz, L. T., Sandvik, L., et al. (2014). The plasma levels of various cytokines are increased during ongoing depression and are reduced to normal levels after recovery. Psychoneuroendocrinology, 45, 77–​86. Dahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., Mackey, S., DeBar, L., et al. (2018). Prevalence of chronic pain and high-​impact chronic pain among adults: United States, 2016. Morbidity and Mortality Weekly Report, 67(36), 1001–​1006. Daley, D. C., & Douaihy, A. (2015). Relapse Prevention Counseling: Clinical Strategies to Guide Addiction Recovery and Reduce Relapse. Eau Claire, WI: PESI Publishing & Media. Dalmida, S. G., Holstad, M. M., Dilorio, C., & Laderman, G (2009). Spiritual well-​being, depressive symptoms, and immune status among women living with HIV/​AIDS. Women & Health, 49(2–​3), 119–​143. Dalmida, S. G., McCoy, K., Koenig, HG., Miller, A., Holstad, M. M., Thomas, T., et al. (2017). Examination of the role of religious and psychosocial factors in HIV medication adherence rates. Journal of Religion and Health, 56(6), 2144–​2161. Damen, A., Labuschagne, D., Fosler, L., O’Mahony, S., Levine, S., & Fitchett, G. (2019). What do chaplains do: The views of palliative care physicians, nurses, and social workers. American Journal of Hospice and Palliative Medicine®, 36(5), 396–​401. Damian, E. (2019). Formal volunteering in Europe. Cross-​Cultural Research, 53(4), 385–​409. Danbolt, L. J., Moller, P., Lien, L., & Hestad, K. A. (2011). The personal significance of religiousness and spirituality in patients with schizophrenia. International Journal for the Psychology of Religion, 21(2), 145–​158. Daniels, N. A., Juarbe, T., Moreno-​John, G., & Perez-​Stable, E. J. (2007). Effectiveness of adult vaccination programs in faith-​based organizations. Ethnicity and Disease, 17(1 Suppl 1), S15–​S22. Dankner, R., Goldbourt, U., Boyko, V., Reicher-​ Reiss, H., & BIP Study Group. (2003). Predictors of cardiac and noncardiac mortality among

14,697 patients with coronary heart disease. American Journal of Cardiology, 91(2), 121–​127. Danner, D. D., Snowdon, D. A., & Friesen, W. V. (2001). Positive emotions in early life and longevity: findings from the nun study. Journal of Personality and Social Psychology, 80(5), 804. Dantzer, R., Cohen, S., Russo, S. J., & Dinan, T. G. (2018). Resilience and immunity. Brain, Behavior, and Immunity, 74, 28–​42. Dany, L., Baumstarck, K., Dudoit, E., Duffaud, F., Auquier, P., & Salas, S. (2015). Determinants of favourable opinions about euthanasia in a sample of French physicians. BMC Palliative Care, 14(1), 59. Daoud, N., Sergienko, R., & Shoham-​Vardi, I. (2020). Intimate partner violence prevalence, recurrence, types, and risk factors among Arab, and Jewish immigrant and nonimmigrant women of childbearing age in Israel. Journal of Interpersonal Violence, 35(15–​16), 2869–​2896. Darto, M., Setyadi, D., Riadi, S. S., & Hariyadi, S. (2015). The effect of transformational leadership, religiosity, job satisfaction, and organizational culture on organizational citizenship behavior and employee performance in the regional offices of national institute of public administration, Republic of Indonesia. European Journal of Business and Management, 7(23), 205–​219. Darviri, C., Fouka, G., Guardellis, C., Artemiadis, A. K., Tigani, X., & Alexopoulos E. C. (2012). Determinants of self-​rated health in a representative sample of a rural population. International Journal of Environmental Research and Public Health, 9, 943–​954. Darviri, C., Artemiadis, A., Tigani, X., Darvyri, P., & Gnardellis, C. (2016). Religiosity as a predictor of mortality: a retrospective cohort study in 1519 rural citizens in Greece. Psychology & Health, 31(9), 1080–​1090. Das, S., Punnoose, V. P., Doval, N., & Nair, V. Y. (2018). Spirituality, religiousness and coping in patients with schizophrenia: a cross-​sectional study in a tertiary care hospital. Psychiatry Research, 265, 238–​243. Dato, S., Rose, G., Crocco, P., Monti, D., Garagnani, P., Franceschi, C., et al. (2017). The genetics of human longevity: an intricacy of genes, environment, culture and microbiome. Mechanisms of Ageing and Development, 165, 147–​155. Dato, S., Soerensen, M., & Rose, G. (2019). Untangling the genetics of human longevity: a challenging quest. Genes, 10(8), 585. Daverio-​Zanetti, S., Schultz, K., del Campo, M. A., Malcarne, V., Riley, N., & Sadler, G. R. (2015).

Is religiosity related to attitudes toward clinical trials participation? Journal of Cancer Education, 30(2), 220–​224. David, P., & Stafford, L. (2015). A relational approach to religion and spirituality in marriage: the role of couples’ religious communication in marital satisfaction. Journal of Family Issues, 36(2), 232–​249. Davidson, L. A., Pettis, C. T., Joiner, A. J., Cook, D. M., & Klugman, C. M. (2010). Religion and conscientious objection: a survey of pharmacists’ willingness to dispense medications. Social Science & Medicine, 71(1), 161–​165. Davidson, M., Beeri, M. S., Silverman, J. M., Schmeidler, J., Noy, S., Ravona-​Springer, R., et al. (2004). P3-​109 Religiosity predicts dementia in Israeli men. Neurobiology of Aging, 25, S386. Davidson, R. J., Kabat-​Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S. F., et al. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564–​570. Davidsson, N., & Södergård, B. (2016). Access to healthcare among people with physical disabilities in rural Louisiana. Social Work in Public Health, 31(3), 188–​195. Davis, D. E., Worthington, E. L., Jr., Hook, J. N., & Hill, P. C. (2013). Research on religion/​ spirituality and forgiveness: a meta-​analytic review. Psychology of Religion and Spirituality, 5(4), 233–​241. Davis, J., & Daly, D. L. (2003). Girls and Boys Town Long-​Term Residential Program: Training Manual, 4th ed. Boys Town, NE: Boys Town Press. Davis, N. J., Vaughan, C. P., Johnson, T. M., II, Goode, P. S., Burgio, K. L., Redden, D. T., et al. (2013). Caffeine intake and its association with urinary incontinence in United States men. Journal of Urology, 189(6), 2170–​2174. Davis, R. F., & Kiang, L. (2016). Religious identity, religious participation, and psychological well-​ being in Asian American adolescents. Journal of Youth and Adolescence, 45(3), 532–​546. Davison, S., & Janca, A. (2012). Personality disorder and criminal behaviour: what is the nature of the relationship? Current Opinion in Psychiatry, 25(1), 39–​45. Day, A., & Golan, G. (2010). In God we trust: religiosity as a predictor of perceptions of media trust, factuality and privacy invasion. American Behavioural Scientist, 54(2), 120–​136. Day, A. L., & Livingstone, H. A. (2001). Chronic and acute stressors among military personnel: do coping styles buffer their negative impact on

References • 903

health? Journal of Occupational Health Psychology, 6(4), 348–​360. Day, J., Savani, S., Krempley, B. D., Nguyen, M., & Kitlinska, J. B. (2016). Influence of paternal preconception exposures on their offspring: through epigenetics to phenotype. American Journal of Stem Cells, 5(1), 11–​1 8. De Fazio, P., Gaetano, R., Caroleo, M., Cerminara, G., Giannini, F., Jaén Moreno, M., . . . Segura-​ García, C. (2016). Religiousness and spirituality in patients with bipolar disorder. International Journal of Psychiatry in Clinical Practice, 19, 233–​238. De Feudis, R., Lanciano, T., & Rinaldi, S. (2015). Coping strategies of southern Italian women predict distress following breast cancer surgery. Europe’s Journal of Psychology, 11(2), 280–​294. De Gouw, H. W., Westendorp, R. G., Kinst, A. E., Mackenbachh, J. P., & Vandenbroucke, J. P. (1995). Decreased mortality among contemplative Monks in the Netherlands. American Journal of Epidemiology, 141, 771–​775. De Jonge, L., Moreira, E. A., Martin, C. K., Ravussin, E., & Pennington CALERIE Team. (2010). Impact of 6‐month caloric restriction on autonomic nervous system activity in healthy, overweight, individuals. Obesity, 18(2), 414–​416. De La Rosa, M. R., & White, M. S. (2001). A review of the role of social support systems in the drug use behavior of Hispanics. Journal of Psychoactive Drugs, 33(3), 233–​240. De Leeuw, E., Clavier, C., & Breton, E. (2014). Health policy—​why research it and how: health political science. Health Research Policy and Systems, 12(1), 55. De Neve, J. E., Diener, E., Tay, L., & Xuereb, C. (2013). The objective benefits of subjective well-​being. In Helliwell, J., Layard, R., & Sachs, J. (eds.), World Happiness Report. New York, NY: UN Sustainable Development Solutions Network, pp. 54–​79. de Oliveira, E. O. F., Peteet, J. R., & Moreira-​ Almeida, A. (2020). Religiosity and spirituality in psychiatry residency programs: why, what, and how to teach? Revista Brasileira de Psiquiatria (Brazilian Journal of Psychiatry), EPUB ahead of press (https://​doi.org/​10.1590/​ 1516-​4446-​2020-​1106). De Ridder, D., Geenen, R., Kuijer, R., & van Middendorp, H. (2008). Psychological adjustment to chronic disease. Lancet, 372(9634), 246–​255.

904 •  R eferences

De Visser, R. O., Smith, A. M., Richters, J., & Rissel, C. E. (2007). Associations between religiosity and sexuality in a representative sample of Australian adults. Archives of Sexual Behavior, 36(1), 33–​46. De Vlieger, P., Crombez, G., & Eccleston, C. (2006). Worrying about chronic pain: an examination of worry and problem solving in adults who identify as chronic pain sufferers. Pain, 120(1–​2), 138–​144. Deal, J. A., Power, M. C., Palta, P., Alonso, A., Schneider, A. L., Perryman, K., et al. (2020). Relationship of cigarette smoking and time of quitting with incident dementia and cognitive decline. Journal of the American Geriatrics Society, 68(2), 337–​345. Deane, F. P., Wootton, D. J., Hsu, C. I., & Kelly, P. J. (2012). Predicting dropout in the first 3 months of 12-​step residential drug and alcohol treatment in an Australian sample. Journal of Studies on Alcohol and Drugs, 73(2), 216–​225. Deaton, A., & Stone, A. A. (2014). Evaluative and hedonic wellbeing among those with and without children at home. Proceedings of the National Academy of Sciences, 111(4), 1328–​1333. Debnam, K. J., Holt, C. L., Clark, E. M., Roth, D. L., Foushee, H. R., Crowther, M., et al. (2012). Spiritual health locus of control and health behaviors in African Americans. American Journal of Health Behavior, 36(3), 360–​372. Debnam, K. J., Milam, A. J., Furr-​Holden, C. D., & Bradshaw, C. (2016). The role of stress and spirituality in adolescent substance use. Substance Use & Misuse, 51(6), 733–​741. Debnam, K. J., Milam, A. J., Mullen, M. M., Lacey, K., & Bradshaw, C. P. (2018). The moderating role of spirituality in the association between stress and substance use among adolescents: differences by gender. Journal of Youth and Adolescence, 47(4), 818–​828. DeCamp, W., & Smith, J. M. (2019). Religion, nonreligion, and deviance: comparing faith’s and family’s relative strength in promoting social conformity. Journal of Religion and Health, 58(1), 206–​220. DeCesare, M. A. (2000). Public attitudes toward euthanasia and suicide for terminally ill persons: 1977 and 1996. Social Biology, 47(3–​4), 264–​276. Deckers, K., van Boxtel, M. P., Schiepers, O. J., de Vugt, M., Munoz Sanchez, J. L., Anstey, K. J., et al. (2015). Target risk factors for dementia prevention. International Journal of Geriatric Psychiatry, 30(3), 234–​246.

DeFranza, D., Lindow, M., Harrison, K., Mishra, A., & Mishra, H. (2020). Religion and reactance to COVID-​19 mitigation guidelines. American Psychologist, 76(5), 744–​754. Degenhardt, L., Chiu, W. T., Sampson, N., Kessler, R. C., & Anthony, J. C. (2007). Epidemiological patterns of extra-​medical drug use in the United States. Drug and Alcohol Dependence, 90(2–​3), 210–​223. Degenhardt, L., Bucello, C., Mathers, B., Briegleb, C., Ali, H., Hickman, M., et al. (2011). Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta‐analysis of cohort studies. Addiction, 106(1), 32–​51. Degenhardt, L., Baxter, A. J., Lee, Y. Y., Hall, W., Sara, G. E., Johns, N., et al. (2014a). The global epidemiology and burden of psychostimulant dependence: findings from the Global Burden of Disease Study 2010. Drug and Alcohol Dependence, 137, 36–​47. Degenhardt, L., Charlson, F., Mathers, B., Hall, W. D., Flaxman, A. D., Johns, N., et al. (2014b). The global epidemiology and burden of opioid dependence: results from the Global Burden of Disease 2010 Study. Addiction, 109(8), 1320–​1333. Dein, S. (2018). Against the stream: religion and mental health—​the case for the inclusion of religion and spirituality into psychiatric care. British Journal of Psychiatry Bulletin, 42(3), 127–​129. Dein, S., Cook, C. C., Powell, A., & Eagger, S. (2010). Religion, spirituality and mental health. The Psychiatrist, 34, 63–​64. Demak, M. M., & Becker, M. H. (1987). The doctor-​patient relationship and counseling for preventive care. Patient Education and Counseling, 9(1), 5–​24. Denhardt, D. T. (2018). Effect of stress on human biology: Epigenetics, adaptation, inheritance, and social significance. Journal of Cellular Physiology, 233(3), 1975–​1984. Denzin, N. K., & Lincoln, Y. (Eds.). (2000). Handbook of Qualitative Research, 2nd ed. Thousand Oaks, CA: SAGE Publications. Department of Justice (2019). Crime in the United States, 2017. Retrieved on 9-​25-​2019 from https://​ucr.fbi.gov/​crime-​in-​the-​u.s/​2017/​crime-​ in-​the-​u.s.-​2017/​topic-​pages/​pers​ons-​arres​ted. DePaulo, B. (2019). Divorce rates around the world: a love story. Psychology Today, Feb 3. Retrieved on 10-​19-​2019 from https://​www. psyc​holo​g yto​day.com/​us/​blog/​liv​ing-​sin​gle/​201​ 902/​divo​rce-​rates-​aro​und-​the-​world-​love-​story.

Dervic, K., Carballo, J. J., Baca-​Garcia, E., Galfalvy, H. C., Mann, J. J., Brent, D. A., et al. (2011). Moral or religious objections to suicide may protect against suicidal behavior in bipolar disorder. Journal of Clinical Psychiatry, 72(10), 1390–​1396. DeSalvo, K. B., Wang, Y. C., Harris, A., Auerbach, J., Koo, D., & O’Carroll, P. (2017). Public Health 3.0: a call to action for public health to meet the challenges of the 21st century. Preventing Chronic Disease, 14, E78. DeSantis, C. E., Siegel, R. L., Sauer, A. G., Miller, K. D., Fedewa, S. A., Alcaraz, K. I., et al. (2016). Cancer statistics for African Americans, 2016: progress and opportunities in reducing racial disparities. CA: A Cancer Journal for Clinicians, 66(4), 290–​308. Desmond, S. A., Ulmer, J. T., & Bader, C. D. (2013). Religion, self control, and substance use. Deviant Behavior, 34(5), 384–​406. Desmond, S. A., Kraus, R., & Dugan, B. J. (2018). “Let the heavens be glad, and the earth rejoice”: religion and life satisfaction among emerging adults in the United States. Mental Health, Religion & Culture, 21(3), 304–​318. Desormais, I., Amidou, S. A., Houehanou, Y. C., Houinato, S. D., Gbagouidi, G. N., Preux, P. M., et al. (2019). The prevalence, awareness, management and control of hypertension in men and women in Benin, West Africa. BMC Cardiovascular Disorders, 19(1), 303. Despoina, M., Marianna, T., Moses, G., & Magda, T. (2018). Differences in religiosity among cognitively intact, mildly cognitively impaired, and mildly demented elderly, and its possible relationship with depressive mood. Applied Nursing Research, 43, 69–​74. Dev, R., Kim, Y. J., Reddy, A., Hui, D., Tanco, K., Liu, D., et al. (2019). Association between tobacco use, pain expression, and coping strategies among patients with advanced cancer. Cancer, 125(1), 153–​160. DeVellis, R. F. (2017). Scale Development: Theory and Applications, 4th ed. Thousand Oaks, CA: SAGE Publications. Devinsky, O., & Lai, G. (2008). Spirituality and religion in epilepsy. Epilepsy & Behavior, 12(4), 636–​643. Dew, J., LeBaron, A., & Allsop, D. (2018). Can stress build relationships? Predictors of increased marital commitment resulting from the 2007–​ 2009 recession. Journal of Family and Economic Issues, 39(3), 405–​421. Dew, J. P., Uecker, J. E., & Willoughby, B. J. (2020). Joint religiosity and married couples’

References • 905

sexual satisfaction. Psychology of Religion and Spirituality, 12(2), 201–​212. Dew, R. E., Daniel, S. S., Goldston, D. B., McCall, W. V., Kuchibhatla, M., Schleifer, C., et al. (2010). A prospective study of religion/​spirituality and depressive symptoms among adolescent psychiatric patients. Journal of Affective Disorders, 120(1–​3), 149–​157. Dew, R. E., Fuemmeler, B., & Koenig, H. G. (2017). Mediation and moderation of religion-​substance abuse relationships by genotype. Medical Research Archives, 5(4), 1–​14. Dew, R. E., & Koenig, H. G. (2014). Religious involvement, the serotonin transporter promoter polymorphism, and drug use in young adults. International Journal of Social Sciences Studies, 2(1), 98–​104. DeWall, C. N., Pond, R. S., Jr., & Deckman, T. (2011). Acetaminophen dulls psychological pain. In G. MacDonald & L. A. Jensen-​Campbell (eds.), Social Pain: Neuropsychological and Health Implications of Loss and Exclusion. Washington, DC: American Psychological Association Press, pp. 123–​140. Dezutter, J., Wachholtz, A., & Corveleyn, J. (2011). Prayer and pain: the mediating role of positive re-​appraisal. Journal of Behavioral Medicine, 34(6), 542–​549. Dhabhar, F. S. (2014). Effects of stress on immune function: the good, the bad, and the beautiful. Immunologic Research, 58(2–​3), 193–​210. Dhabhar, F. S., Saul, A. N., Holmes, T. H., Daugherty, C., Neri, E., Tillie, J. M., et al. (2012). High-​anxious individuals show increased chronic stress burden, decreased protective immunity, and increased cancer progression in a mouse model of squamous cell carcinoma. PLoS One, 7(4), e33069. Dhammayut Order (2013). A Chanting Guide: Pali Passages with English Translations. Valley Center, CA: Metta Forest Monastery, p. 42. DHHS (2006). Your guide to lowering your blood pressure with DASH. U.S. Department of Health and Human Services, National Heart, Lung and Blood Institute. NIH Publication No. 06-​4082. Retrieved on 27-​7-​2022 from http://​www.nhlbi.nih.gov/​hea​ lth/​pub​lic/​heart/​hbp/​dash/​new_​d​ash.pdf. DHHS (2014). The Health Consequences of Smoking—​ 50 Years of Progress: A Report of the Surgeon General. Washington, DC: US Department of Health and Human Services. DHHS (2020a). US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved on 8-​12-​2020 from https://​hea​lth.gov/​about-​odphp.

906 •  R eferences

DHHS (2020b). US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People. Retrieved on 8-​12-​2020 from https://​www.health​ypeo​ple. gov/​2020/​lead​ing-​hea​lth-​ind​icat​ors/​2020-​LHI-​ Top​ics. Di Angelantonio, E., Bhupathiraju, S. N., Wormser, D., Gao, P., Kaptoge, S., de Gonzalez, A. B., et al. (2016). Body-​mass index and all-​ cause mortality: individual-​participant-​data meta-​analysis of 239 prospective studies in four continents. The Lancet, 388(10046), 776–​786. Di Marco, L. Y., Marzo, A., Munoz-​Ruiz, M., Ikram, M. A., Kivipelto, M., Ruefenacht, D., et al. (2014). Modifiable lifestyle factors in dementia: a systematic review of longitudinal observational cohort studies. Journal of Alzheimer’s Disease, 42(1), 119–​135. Dias, B. G., & Ressler, K. J. (2014). Parental olfactory experience influences behavior and neural structure in subsequent generations. Nature Neuroscience, 17(1), 89–​96. Dickinson, B. D., Head, C. A., Gitlow, S., & Osbahr, A. J., III (2010). Maldynia: pathophysiology and management of neuropathic and maladaptive pain—​a report of the AMA Council on Science and Public Health. Pain Medicine, 11(11), 1635–​1653. Dickson, D. A., Paulus, J. K., Mensah, V., Lem, J., Saavedra-​Rodriguez, L., Gentry, A., et al. (2018). Reduced levels of miRNAs 449 and 34 in sperm of mice and men exposed to early life stress. Translational Psychiatry, 8(1), 1–​10. Dickstein, B. D., Schorr, Y., Stein, N., Krantz, L. H., Solomon, Z., & Litz, B. T. (2012). Coping and mental health outcomes among Israelis living with the chronic threat of terrorism. Psychological Trauma, 4(4), 392–​399. Diener, E. (1984). Subjective well-​being. Psychological Bulletin, 95(3), 542–​575. Diener, E. (2000). Subjective well-​being: the science of happiness and a proposal for a national index. American Psychologist, 55(1), 34–​43. Diener, E., & Chan, M. Y. (2011). Happy people live longer: subjective well‐being contributes to health and longevity. Applied Psychology: Health and Well‐Being, 3(1), 1–​43. Diener, E., Lucas, R. E., Scollon, C. N. (2006). Beyond the hedonic treadmill: revising the adaptation theory of well-​being. American Psychologist, 61, 305–​314. Diener, E., Lucas, R. E., & Scollon, C. N. (2009). Beyond the hedonic treadmill: revising the adaptation theory of wellbeing. In Diener,

E. (ed.), The Science of Wellbeing. Dordrecht, Netherlands: Springer, pp. 103–​118. Diener, E., Ng, W., Harter, J., & Arora, R. (2010). Wealth and happiness across the world: material prosperity predicts life evaluation, whereas psychosocial prosperity predicts positive feeling. Journal of Personality and Social Psychology, 99(1), 52–​61. Diener, E., Tay, L., & Myers, D. G. (2011). The religion paradox: if religion makes people happy, why are so many dropping out? Journal of Personality and Social Psychology, 101(6), 1278. Diener, E., Pressman, S. D., Hunter, J., & Delgadillo‐ Chase, D. (2017). If, why, and when subjective well‐being influences health, and future needed research. Applied Psychology: Health and Well‐ Being, 9(2), 133–​167. Diener, E., Oishi, S., & Tay, L. (2018). Advances in subjective well-​being research. Nature Human Behaviour, 2(4), 253. Dietary Guidelines for Americans (2015). 2015–​ 2020 Guidelines for Americans. Retrieved on 1-​4-​ 2020 from https://​hea​lth.gov/​dietar​ygui​deli​nes/​ 2015/​gui​deli​nes/​. Dietrich, T., Webb, I., Stenhouse, L., Pattni, A., Ready, D., Wanyonyi, K. L., et al. (2017). Evidence summary: the relationship between oral and cardiovascular disease. British Dental Journal, 222(5), 381–​385. Digryte, L., & Baniene, I. (2017). Depression, anxiety and stress coping in parents of children with the oncological disease. Biological Psychiatry and Psychopharmacology, 19(1–​2), 9–​13. Dilmaghani, M. (2018a). Importance of religion or spirituality and mental health in Canada. Journal of Religion and Health, 57(1), 120–​135. Dilmaghani, M. (2018b). Religiosity and subjective wellbeing in Canada. Journal of Happiness Studies, 19(3), 629–​647. Dilmaghani, M. (2018c). Exploring the relationship between secularity and marital behavior. Marriage & Family Review, 54(5), 438–​458. Dilsaver, S. C. (2011). An estimate of the minimum economic burden of bipolar I and II disorders in the United States: 2009. Journal of Affective Disorders, 129(1–​3), 79–​83. Dima-​Cozma, C., & Cozma, S. (2012). Religion and medicine or the spiritual dimension of healing. Journal for the Study of Religions and Ideologies, 11(Spring), 31–​48. DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment. Archives of Internal Medicine, 160(14), 2101–​2107.

Ding, D., Kolbe-​Alexander, T., Nguyen, B., Katzmarzyk, P. T., Pratt, M., & Lawson, K. D. (2017). The economic burden of physical inactivity: a systematic review and critical appraisal. British Journal of Sports Medicine, 51(19), 1392–​1409. Ding, J., Eigenbrodt, M. L., Mosley, T. H., Jr., Hutchinson, R. G., Folsom, A. R., Harris, T. B., et al. (2004). Alcohol intake and cerebral abnormalities on magnetic resonance imaging in a community-​based population of middle-​aged adults. Stroke, 35(1), 16–​21. Divisi, D., Tommaso, S. D., Salvemini, S., Garramone, M., & Crisci, R. (2006). Diet and cancer. Acta Biomedica, 77, 118–​123. Djuric, Z., Mirasolo, J., Kimbrough, L., Brown, D. R., Heilbrun, L. K., Canar, L., et al. (2009). A pilot trial of spirituality counseling for weight loss maintenance in African American breast cancer survivors. Journal of the National Medical Association, 101(6), 552–​564. Dodor, B. (2012). The impact of religiosity on health behaviors and obesity among African Americans. Journal of Human Behavior in the Social Environment, 22(4), 451–​462. Doering, S., Muller, E., Kopcke, W., Pietzcker, A., Gaebel, W., Linden, M., et al. (1998). Predictors of relapse and rehospitalisation in schizophrenia and schizoaffective disorder. Schizophrenia Bulletin, 24, 87–​98. Doherty, A. M., & Gaughran, F. (2014). The interface of physical and mental health. Social Psychiatry and Psychiatric Epidemiology, 49(5), 673–​682. Doherty, W. J., & Allen, W. (1994). Family functioning and parental smoking as predictors of adolescent cigarette use: a six-​year prospective study. Journal of Family Psychology, 8(3), 347. Doll, R., Peto, R., Boreham, J., & Sutherland, I. (2004). Mortality in relation to smoking: 50 years’ observations on male British doctors. British Medical Journal, 328(7455), 1519. Domínguez, R., & López-​Noval, B. (2020). Religiosity and life satisfaction across countries: new insights from the self-​ determination theory. Journal of Happiness Studies, 22(3), 1165–​1188. Dong, X., & Zhang, M. (2015). Religiosity among US Chinese older adults in the greater Chicago area: findings from the PINE study. Journal of Religion, Spirituality & Aging, 27(4), 323–​342. Donkin, A., Goldblatt, P., Allen, J., Nathanson, V., & Marmot, M. (2017). Global action on the social determinants of health. British Medical Journal Global Health, 3(Suppl 1), e000603.

References • 907

D’Onofrio, B. M., Eaves, L. J., Murrelle, L., Maes, H. H., & Spilka, B. (1999). Understanding biological and social influences on religious affiliation, attitudes and behaviors. Journal of Personality, 67(6), 953–​984. Donohue, P. K., Boss, R. D., Aucott, S. W., Keene, E. A., & Teague, P. (2010). The impact of neonatologists’ religiosity and spirituality on health care delivery for high-​risk neonates. Journal of Palliative Medicine, 13(10), 1219–​1224. Donovan, D. M., Daley, D. C., Brigham, G. S., Hodgkins, C. C., Perl, H. I., Garrett, S. B., et al. (2013). Stimulant abuser groups to engage in 12-​Step: a multisite trial in the National Institute on Drug Abuse Clinical Trials Network. Journal of Substance Abuse Treatment, 44(1), 103–​114. Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, D. C. (2013). 12-​step interventions and mutual support programs for substance use disorders: an overview. Social Work in Public Health, 28(3–​4), 313–​332. Doody, M. M., Mandel, J. S., Linet, M. S., Ron, E., Lubin, J. H., Boice, J. D., Jr., et al. (2000). Mortality among Catholic nuns certified as radiologic technologists. American Journal of Industrial Medicine, 37(4), 339–​348. Doolittle, B. R., McGinnis, K., Ransome, Y., Fiellin, D., & Justice, A. (2021). Mortality, health, and substance abuse by religious attendance among HIV infected patients from the Veterans Aging Cohort Study. AIDS and Behavior, 25(3), 653–​660. Doom, J. R., Lumeng, J. C., Sturza, J., Kaciroti, N., Vazquez, D. M., & Miller, A. L. (2020). Longitudinal associations between overweight/​ obesity and stress biology in low-​income children. International Journal of Obesity, 44(3), 646–​655. Dorji, N., Dunne, M. P., Seib, C., & Deb, S. (2017). Quality of life among senior citizens in Bhutan: associations with adverse life experiences, chronic diseases, spirituality, and social connectedness. Asia Pacific Journal of Public Health, 29(1), 35–​46. Doron, J., Trouillet, R., Gana, K., Boiché, J., Neveu, D., & Ninot, G. (2014). Examination of the hierarchical structure of the brief COPE in a French sample: empirical and theoretical convergences. Journal of Personality Assessment, 96(5), 567–​575. Doss, B. D., Cicila, L. N., Georgia, E. J., Roddy, M. K., Nowlan, K. M., Benson, L. A., et al. (2016). A randomized controlled trial of the

908 •  R eferences

web-​based OurRelationship program: effects on relationship and individual functioning. Journal of Consulting and Clinical Psychology, 84(4), 285–​296. Doss, B. D., Feinberg, L. K., Rothman, K., Roddy, M. K., & Comer, J. S. (2017). Using technology to enhance and expand interventions for couples and families: Conceptual and methodological considerations. Journal of Family Psychology, 31(8), 983–​993. Dougherty, K. D., Johnson, B. R., & Polson, E. C. (2007). Recovering the lost: remeasuring US religious affiliation. Journal for the Scientific Study of Religion, 46(4), 483–​499. Doumas, M., Papademetriou, V., Faselis, C., & Kokkinos, P. (2013). Gender differences in hypertension: myths and reality. Current Hypertension Reports, 15(4), 321–​330. Doumit, R., Khazen, G., Katsounari, I., Kazandjian, C., Long, J., & Zeeni, N. (2017). Investigating vulnerability for developing eating disorders in a multi-​confessional population. Community Mental Health Journal, 53(1), 107–​116. Dour, H. J., Wiley, J. F., Roy‐Byrne, P., Stein, M. B., Sullivan, G., Sherbourne, C. D., et al. (2014). Perceived social support mediates anxiety and depressive symptom changes following primary care intervention. Depression and Anxiety, 31(5), 436–​442. Dowd, J. B., Palermo, T., Chyu, L., Adam, E., & McDade, T. W. (2014). Race/​ethnic and socioeconomic differences in stress and immune function in the National Longitudinal Study of Adolescent Health. Social Science & Medicine, 115, 49–​55. Dowlati, Y., Herrmann, N., Swardfager, W., Liu, H., Sham, L., Reim, E. K., et al. (2010). A meta-​ analysis of cytokines in major depression. Biological Psychiatry, 67(5), 446–​457. Drabble, L., Trocki, K. F., & Klinger, J. L. (2016). Religiosity is a protective factor for hazardous drinking and drug use among sexual minority and heterosexual women: findings from the National Alcohol Survey. Drug and Alcohol Dependence, 161, 127–​134. Drabble, L., Veldhuis, C. B., Riley, B. B., Rostosky, S., & Hughes, T. L. (2018). Relationship of religiosity and spirituality to hazardous drinking, drug use, and depression among sexual minority women. Journal of Homosexuality, 65(13), 1734–​1757. Draper, S., & Park, J. Z. (2010). Sunday celluloid: visual media and Protestant boundaries with secular culture. Sociological Spectrum, 30(4), 433–​458.

Drazen, J. M., Morrissey, S., & Campion, E. W. (2019). The dangerous flavors of e-​cigarettes. New England Journal of Medicine, 380, 679–​680. Dressler, W. W. (1996). Hypertension in the African American community: social, cultural, and psychological factors. Seminars in Nephrology, 16(2), 71–​82. Dressler, W. W. (2004). Culture and the risk of disease. British Medical Bulletin, 69(1), 21–​31. Drevenstedt, G. T. (1998). Race and ethnic differences in the effects of rleigious attendance on subjective health. Review of Religious Research, 39, 245–​263. Drewelies, J., Deeg, D. J., Huisman, M., & Gerstorf, D. (2018). Perceived constraints in late midlife: Cohort differences in the Longitudinal Aging Study Amsterdam (LASA). Psychology and Aging, 33(5), 754–​768. Droubay, B. A., Butters, R. P., & Shafer, K. (2021). The pornography debate: Religiosity and support for censorship. Journal of Religion and Health, 60(3), 1652–​1667. Drozdowska, B. A., Celis-​Morales, C. A., Lyall, D. M., & Quinn, T. J. (2019). Social engagement after stroke: is it relevant to cognitive function? AMRC Open Research, 1(3), 3. Druss, B. G., & Silke, A. (2006). Improving general medical care for persons with mental and addictive disorders: systematic review. General Hospital Psychiatry, 28(2), 145–​153. Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the Adverse Childhood Experiences Study. Pediatrics, 111(3), 564–​572. Duffin, E. (2020). Church membership among Americans 1992–​2019. Statistica. Retrieved on 10-​10-​2020 from https://​www.stati​sta.com/​ sta​tist​ics/​245​485/​chu​rch-​mem​bers​hip-​among-​ americ​ans/​. Dufournet, M., Dauphinot, V., Moutet, C., Verdurand, M., Delphin-​Combe, F., Krolak-​ Salmon, P., et al. (2019). Impact of cognitive, functional, behavioral disorders, and caregiver burden on the risk of nursing home placement. Journal of the American Medical Directors Association, 20(10), 1254–​1262. Dufur, M. J., Thorpe, J. D., Barton, H. S., Hoffmann, J. P., & Parcel, T. L. (2019). Can social capital protect adolescents from delinquent behavior, antisocial attitudes, and mental health problems? Archives of Psychology, 3(6), 1–​22. Duivenbode, R., Hall, S., & Padela, A. I. (2019). Assessing relationships between Muslim physicians’ religiosity and end-​of-​life health-​care

attitudes and treatment recommendations: an exploratory national survey. American Journal of Hospice and Palliative Medicine, 36(9), 780–​788. Dunn, E. C., Brown, R. C., Dai, Y., Rosand, J., Nugent, N. R., Amstadter, A. B., et al. (2015). Genetic determinants of depression: recent findings and future directions. Harvard Review of Psychiatry, 23(1), 1–​18. Dunn, E. W., Aknin, L. B., & Norton, M. I. (2014). Prosocial spending and happiness: using money to benefit others pays off. Current Directions in Psychological Science, 23(1), 41–​47. Dunn, K. S., & Horgas, A. L. (2004). Religious and nonreligious coping in older adults experiencing chronic pain. Pain Management Nursing, 5(1), 19–​28. Dunne, F. P. (1902). The duty of newspapers is to comfort the afflicted and to afflict the comfortable. Retrieved on 7-​25-​22 from https://​ quotei​nves​tiga​tor.com/​2019/​02/​01/​comf​ort/​. Dunne, L., Perich, T., & Meade, T. (2018). The relationship between social support and personal recovery in bipolar disorder. Psychiatric Rehabilitation Journal, 42(1), 100–​103. Duñó, R., Oliva, J. C., Tobeña, A., Palao, D., & Labad, J. (2020). Religiosity and psychotic ideation in stable schizophrenia: a role for empathic perspective-​taking. Behavioral Sciences, 10(2), 53. Dupre, M. E. (2016). Race, marital history, and risks for stroke in US older adults. Social Forces, 95(1), 439–​468. Dupre, M. E., Franzese, A. T., & Parrado, E. A. (2006). Religious attendance and mortality: implications for the black-​white mortality crossover. Demography, 43(1), 141–​164. Durkheim, E. (1897). Le Suicide. Paris: Felix Alcan. Durkheim, E., & Swain, J. W. (2008). The Elementary Forms of the Religious Life. Mineola, NY: Dover Publications. Duru, O. K., Sarkisian, C. A., Leng, M., & Mangione, C. M. (2010). Sisters in motion: a randomized controlled trial of a faith‐based physical activity intervention. Journal of the American Geriatrics Society, 58(10), 1863–​1869. Dwidiyanti, M., Sari, S. P., Wijayanti, D. Y., Ningsih, H. E., Wiguna, R. I., Pamungkas, A. Y., et al. (2020). Effects of spiritual mindfulness on spiritual self reliance and medication adherence in patients with schizophrenia. Jurnal Ilmu Keperawatan Jiwa, 3(3), 385–​390. Dwyer, J. W., Clarke, L. L., & Miller, M. K. (1990). The effect of religious concentration and affiliation on county cancer mortality rates.

References • 909

Journal of Health and Social Behavior, 31, 185–​202. Dwyer-​Lindgren, L., Bertozzi-​Villa, A., Stubbs, R. W., Morozoff, C., Shirude, S., Unützer, J., et al. (2018). Trends and patterns of geographic variation in mortality from substance use disorders and intentional injuries among US counties, 1980–​2014. Journal of the American Medical Association, 319(10), 1013–​1023. Dzivakwe, V. G., & Guarnaccia, C. (2014). Religiosity as a coping resource for depression and disease management among older diabetic patients. Annals of Behavioral Medicine, 47(1 Supp, A-​ 055), s17. Eapen, V., & Revesz, T. (2003). Psychosocial correlates of paediatric cancer in the United Arab Emirates. Supportive Care in Cancer, 11(3), 185–​189. Earp, B. D. (2015). Does religion deserve a place in secular medicine? Journal of Medical Ethics, 41, 865–​866. Ebert, T., Gebauer, J. E., Talman, J. R., & Rentfrow, P. J. (2020). Religious people only live longer in religious cultural contexts: a gravestone analysis. Journal of Personality and Social Psychology, 119(1), 1. Ecklund, E. H., & Park, J. Z. (2007). Religious diversity and community volunteerism among Asian Americans. Journal for the Scientific Study of Religion, 46(2), 233–​244. Edgren, G., Liang, L., Adami, H. O., & Chang, E. T. (2012). Enigmatic sex disparities in cancer incidence. European Journal of Epidemiology, 27(3), 187–​196. Edlund, M. J., Harris, K. M., Koenig, H. G., Han, X., Sullivan, G., Mattox, R., et al. (2010). Religiosity and decreased risk of substance use disorders. Social Psychiatry and Psychiatric Epidemiology, 45(8), 827–​836. Edman, J. S., Roberts, R. S., Dusek, J. A., Dolor, R., Wolever, R. Q., & Abrams, D. I. (2014). Characteristics of cancer patients presenting to an integrative medicine practice-​based research network. Integrative Cancer Therapies, 13(5), 405–​410. Edwards, K. J. (1976). Sex-​role behavior and religious experience. In Donaldson, W. J. (ed.), Research and Mental Health in Religious Behavior: An Introduction to Research in the Integration of Christianity and the Behavioral Sciences. Atlantal, GA: Psychological Studies Institute, pp. 224–​238. Edwards, J. N., & Klemmack, D. L. (1973). Correlates of life satisfaction: a re-​examination. Journal of Gerontology, 28, 497–​502.

910 •  R eferences

Edwards, L. M., Haglund, K., Fehring, R. J., & Pruszynski, J. (2011). Religiosity and sexual risk behaviors among Latina adolescents. Journal of Women’s Health, 20(6), 871–​877. Edwards, R. R., Dworkin, R. H., Sullivan, M. D., Turk, D. C., & Wasan, A. D. (2016). The role of psychosocial processes in the development and maintenance of chronic pain. Journal of Pain, 17(9), T70–​T92. EEOC (2014). What you should know: workplace religious accommodation. US Equal Employment Opportunity Commission. Washington, DC: EEOC. Retrieved on 10-​3-​2020 from https://​www.eeoc.gov/​laws/​guida​nce/​what-​ you-​sho​uld-​know-​workpl​ace-​religi​ous-​accomm​ odat​ion. Egan, K. M., Newcomb, P. A., Longnecker, M. P., TrenthamDietz, A., Baron J. A., Trichopoulos, D., et al. (1996). Jewish religion and risk of breast cancer. Lancet, 347(9016), 1645–​1646. Ehresmann, K. R., Crouch, N., Henry, P. M., Hunt, J. M., Habedank, T. L., Bowman, R., et al. (2004). An outbreak of measles among unvacinated young adults and measles seroprevalence study. Journal of Infectious Diseases, 189(Supp 1), S104–​S107. Ehsan, A. M., & De Silva, M. J. (2015). Social capital and common mental disorder. Journal of Epidemiology and Community Health, 69(10), 1021–​1028. Ehsan, A., Klaas, H. S., Bastianen, A., & Spini, D. (2019). Social capital and health. Social Sciences and Medicine: Population Health, 8, 100425. Eilat-​Adar, S., & Goldbourt, U. (2019). P4346 Religious education and midlife observance are associated with lower coronary heart disease (CHD) mortality 23 years later. European Heart Journal, 40(Supp 1), ehz745–​754. Eisenberger, N. I. (2012). The pain of social disconnection: examining the shared neural underpinnings of physical and social pain. Nature Reviews Neuroscience, 13(6), 421–​434. Eisenberger, N. I., & Cole, S. W. (2012). Social neuroscience and health: neurophysiological mechanisms linking social ties with physical health. Nature Neuroscience, 15(5), 669–​674. Eitle, D. (2011). Religion and gambling among young adults in the United States: moral communities and the deterrence hypothesis. Journal for the Scientific Study of Religion, 50(1), 61–​81. Ekelund, U., Tarp, J., Steene-​Johannessen, J., Hansen, B. H., Jefferis, B., Fagerland, M. W., et al. (2019). Dose-​response associations between accelerometry measured physical

activity and sedentary time and all cause mortality. British Medical Journal, 366, l4570. Ekholm, O., Kurita, G. P., Højsted, J., Juel, K., & Sjøgren, P. (2014). Chronic pain, opioid prescriptions, and mortality in Denmark: a population-​based cohort study. Pain, 155(12), 2486–​2490. Elbogen, E. B., & Johnson, S. C. (2009). The intricate link between violence and mental disorder results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry, 66(2), 152–​161. Eleftheriou, D., Benetou, V., Trichopoulou, A., La Vecchia, C., & Bamia, C. (2018). Mediterranean diet and its components in relation to all-​cause mortality: meta-​analysis. British Journal of Nutrition, 120(10), 1081–​1097. El-​Farhan, N., Rees, D. A., & Evans, C. (2017). Measuring cortisol in serum, urine and saliva–​ are our assays good enough? Annals of Clinical Biochemistry, 54(3), 308–​322. El-​Masry, R., Elhadidy, S. S., Shams, T., & Amr, M. (2018). Do religiosity and socio-​demographic factors affect adherence of cancer patients to analgesics? Egyptian Journal of Community Medicine, 36(4), 1–​10. Elfhag, K., & Morey, L. C. (2008). Personality traits and eating behavior in the obese: poor self-​ control in emotional and external eating but personality assets in restrained eating. Eating Behaviors, 9(3), 285–​293. Elham, H., Hazrati, M., Momennasab, M., & Sareh, K. (2015). The effect of need-​based spiritual/​ religious intervention on spiritual well-​being and anxiety of elderly people. Holistic Nursing Practice, 29(3), 136–​143. Elliott, C. (2012). On predatory publishers: a Q&A with Jeffrey Beall. The Chronicle of Higher Education. Retrieved on 4-​30-​2019 at https://​ www.chroni​cle.com/​blogs/​bra​inst​orm/​on-​predat​ ory-​pub​lish​ers-​a-​qa-​with-​jeff​rey-​beall/​47667. Ellis, L., Wahab, E. A., & Ratnasingan, M. (2013). Religiosity and fear of death. Mental Health, Religion & Culture, 16(2), 179–​199. Ellis, M. R., Thomlinson, P., Gemmill, C., & Harris, W. (2013). The spiritual needs and resources of hospitalized primary care patients. Journal of Religion and Health, 52(4), 1306–​1318. Ellison, C. G. (1991). Religious involvement and subjective well-​being. Journal of Health and Social Behavior, 32, 80–​99. Ellison, C. G. (1992). Are religious people nice people? Evidence from the National Survey of Black Americans. Social Forces, 71, 411–​430.

Ellison, C. G. (1993). Religious involvement and self-​perception among Black Americans. Social Forces, 71, 1027–​1055. Ellison, C. G. (1997). Religious involvement and subjective quality of family life among African Americans. In R. J. Taylor, J. S. Jackson, & L. M. Chatters (eds.), Family Life in Black America. Thousand Oaks, CA: SAGE, pp. 117–​131. Ellison, C. G. (1995). Race, religious involvement, and depressive symptomatology in a southeastern US community. Social Science and Medicine, 40, 1561–​1572. Ellison, C. G., & Anderson, K. L. (2001). Religious involvement and domestic violence among U.S. couples. Journal for the Scientific Study of Religion, 40(2), 269–​286. Ellison, C. G., & Fan, D. (2008). Daily spiritual experiences and psychological well-​being among U.S. adults. Social Indicators Research, 88, 247–​271. Ellison, C. G., & Flannelly, K. J. (2009). Religious involvement and risk of major depression in a prospective nationwide study of African-​ American adults. Journal of Nervous and Mental Disease, 197, 568–​573. Ellison, C. G., & Gay, D. A. (1990). Region, religious commitment, and life satisfaction among black Americans. Sociological Quarterly, 31, 123–​147. Ellison, C. G., & George, L. K. (1994). Religious involvement, social ties, and social support in a southeastern community. Journal for the Scientific Study of Religion, 33, 46–​61. Ellison, C. G., & McFarland, M. J. (2011). Religion and gambling among US adults. Journal for the Scientific Study of Religion, 50(1), 82–​102. Ellison, C. G., & Taylor, R. J. (1996). Turning to prayer: social and situational antecedents of religious coping among African Americans. Review of Religious Research, 38, 111–​131. Ellison, C. G., Gay, D. A., & Glass, T. A. (1989). Does religious commitment contribute to individual life satisfaction? Social Forces, 68, 100–​123. Ellison, C. G., Burr, J. A., & McCall, P. L. (1997). Religious homogeneity and metropolitan suicide rates. Social Forces, 76, 273–​299. Ellison, C. G., Bartkowski, J. P., & Anderson, K. L. (1999). Are there religious variations in domestic violence? Journal of Family Issues, 20, 87–​113. Ellison, C. G., Hummer, R. A., Cormier, S., & Rogers, R. G. (2000). Religious involvement and mortality risk among African American adults. Research on Aging, 22(6), 630–​667. Ellison, C. G., Boardman, J. D., Williams, D. R., & Jackson, J. S. (2001). Religious involvement,

References • 911

stress, and mental health. Social Forces, 80(1), 215–​249. Ellison, C. G., Trinitapoli, J. A., Anderson, K. L., & Johnson, B. R. (2007). Race/​ethnicity, religious involvement, and domestic violence. Violence Against Women, 13(11), 1094–​1112. Ellison, C. G., Barrett, J. B., & Mouton, B. E. (2008a). Gender, marital status, and alcohol behavior: The neglected role of religion. Journal for the Scientific Study of Religion 47, 660–​677. Ellison, C. G., Musick, M. A., & Henderson, A. K. (2008b). Balm in Gilead: racism, religious involvement, and psychological distress among African-​American adults. Journal for the Scientific Study of Religion, 47, 291–​309. Ellison, C. G., Burdette, A. M., & Hill, T. D. (2009a). Blessed assurance: Religion, anxiety, and tranquility among U.S. adults. Social Science Research, 38, 656–​667. Ellison, C. G., Finch, B. K., Ryan, D. N., Salinas, J. J. (2009b). Religious involvement and depressive symptoms among Mexican-​origin adults in California. Journal of Community Psychology, 37, 171–​193. Ellison, C. G., Krause, N. M., Shepherd, B. C., & Chaves, M. A. (2009c). Size, conflict, and opportunities for interaction: congregational effects on members’ anticipated support and negative interaction. Journal for the Scientific Study of Religion, 48(1), 1–​15. Ellison, C. G., Musick, M. A., & Holden, G. W. (2011). Does conservative Protestantism moderate the association between corporal punishment and child outcomes? Journal of Marriage and Family, 73, 946–​961. Ellison, C. G., Bradshaw, M., Flannelly, K. J., & Galek, K. C. (2014). Prayer, attachment to God, and symptoms of anxiety-​related disorders among US adults. Sociology of Religion, 75(2), 208–​233. Ellison, C. G., DeAngelis, R. T., & Güven, M. (2017). Does religious involvement mitigate the effects of major discrimination on the mental health of African Americans? Religions, 8(9), 195. El-​Masry, R., Elhadidy, S. S., Shams, T., & Amr, M. (2018). Do religiosity and socio-​demographic factors affect adherence of cancer patients to analgesics? An Egyptian study. Egyptian Journal of Community Medicine, 36(4), 1–​10. Elran, B., Yaari, S., Glazer, Y., Honovich, M., Grotto, I., & Anis, E. (2018). Parents’ perceptions of childhood immunization in Israel: information and concerns. Vaccine, 36(52), 8062–​8068. Emavardhana, T., & Tori, C. D. (1997). Changes in self-​concept, ego defense mechanisms,

912 •  R eferences

and religiosity following seven-​day Vipassana meditation retreats. Journal for the Scientific Study of Religion, 36, 194–​206. Eme, R. F. (2007). Sex differences in child-​onset, life-​course-​persistent conduct disorder: a review of biological influences. Clinical Psychology Review, 27(5), 607–​627. Enard, D., Cai, L., Gwennap, C., & Petrov, D. A. (2016). Viruses are a dominant driver of protein adaptation in mammals. eLife, 5, e12469. Eng, P. M., Rimm, E. B., Fitzmaurice, G., Kawachi, I. (2002). Social ties and change in social ties in relation to subsequent total and cause-​specific mortality and coronary heart disease incidence in men. American Journal of Epidemiology, 155(8), 700–​709. Engel, G. L. (1959). “Psychogenic” pain and the pain-​prone patient. American Journal of Medicine, 26(6), 899–​918. Engelke, M. (2010). Religion and the media turn: a review essay. American Ethnologist, 37(2), 371–​379. Engin, C., & Vezzoni, C. (2020). Who’s skeptical of vaccines? Prevalence and determinants of anti-​ vaccination attitudes in Italy. Population Review, 59(2), 156–​179. Engs, R. C. (1980). The drug-​use patterns of helping-​profession students in Brisbane, Australia. Drug and Alcohol Dependence, 6, 231–​246. Ennis, E. M., Jr., & Kazer, M. W. (2013). The role of spiritual nursing interventions on improved outcomes in older adults with dementia. Holistic Nursing Practice, 27(2), 106–​113. Enoch, M. A. (2012). The influence of gene–​ environment interactions on the development of alcoholism and drug dependence. Current Psychiatry Reports, 14(2), 150–​158. Enstrom, J. E. (1978). Cancer and total mortality among active Mormons. Cancer, 42, 1943–​1951. Enstrom, J. E. (1980). Cancer mortality among Mormons in California during 1968–​75. Journal of the National Cancer Institute, 65, 1073–​1082. Enstrom, J. E. (1989). Health practices and cancer mortality among active California Mormons. Journal of the National Cancer Institute, 31, 1807–​1814. Enstrom, J. E., & Breslow, L. (2008). Lifestyle and reduced mortality among active California Mormons, 1980–​2004. Preventive Medicine, 46(2), 133–​136. Entringer, T. M., Gebauer, J. E., Eck, J., Bleidorn, W., Rentfrow, P. J., Potter, J., et al. (2021). Big Five facets and religiosity. Journal of Personality and Social Psychology, 120(6), 1662–​1695.

Epel, E. S., Crosswell, A. D., Mayer, S. E., Prather, A. A., Slavich, G. M., Puterman, E., & Mendes, W. B. (2018). More than a feeling: a unified view of stress measurement for population science. Frontiers in Neuroendocrinology, 49, 146–​169. Epstein, F. H., Carol, R., & Simpson, R. (1956a). Estimation of caloric intake from dietary histories among population groups. American Journal of Clinical Nutrition, 4(1), 1–​10. Epstein, F. H., Simpson, R., & Boas, E. P. (1956b). Relations between diet and atherosclerosis among a working population of different ethnic origins. American Journal of Clinical Nutrition, 4(1), 10–​19. Eriksson, K. H., Hjalmarsson, R., Lindquist, M. J., & Sandberg, A. (2016). The importance of family background and neighborhood effects as determinants of crime. Journal of Population Economics, 29(1), 219–​262. Erlangsen, A., Appadurai, V., Wang, Y., Turecki, G., Mors, O., Werge, T., et al. (2020). Genetics of suicide attempts in individuals with and without mental disorders. Molecular Psychiatry, 25(10), 2410–​2421. Erlangsen, A., Banks, E., Joshy, G., Calear, A. L., Welsh, J., Batterham, P. J., et al. (2021). Measures of mental, physical, and social wellbeing and their association with death by suicide and self-​harm in a cohort of 266,324 persons aged 45 years and over. Social Psychiatry and Psychiatric Epidemiology, 56(2), 295–​303. Erisna, M., Runjati, R., Kartini, A., Azam, M., & Mulyantoro, D. K. (2020). The impact of Maryam exercise towards the stress level and cortisol serum level among primiparous pregnant women. International Journal of Nursing and Health Services (IJNHS), 3(5), 598–​607. Ernecoff, N. C., Curlin, F. A., Buddadhumaruk, P., & White, D. B. (2015). Health care professionals’ responses to religious or spiritual statements by surrogate decision makers during goals-​of-​care discussions. JAMA Internal Medicine, 175(10), 1662–​1669. Ernst, C., Lalovic, A., Lesage, A., Seguin, M., Tousignant, M., & Turecki, G. (2004). Suicide and no axis I psychopathology. BMC Psychiatry, 4(1), 7. Errihani, H., Mrabti, H., Boutayeb, S., El Ghissassi, I., El Mesbahi, O., Hammoudi, M., et al. (2008). Impact of cancer on Moslem patients in Morocco. Psycho‐oncology, 17(1), 98–​100. Ershler, W. B., & Keller, E. T. (2000). Age-​associated increased interleukin-​6 gene expression, late-​life diseases, and frailty. Annual Review of Medicine, 51(1), 245–​270.

Escobar, O. S., & Vaughan, E. L. (2014). Public religiosity, religious importance, and substance use among Latino emerging adults. Substance Use & Misuse, 49(10), 1317–​1325. Eskin, M. (2004). The effects of religious versus secular education on suicide ideation and suicidal attitudes in adolescents in Turkey. Social Psychiatry and Psychiatric Epidemiology, 39(7), 536–​542. Eskin, M., Poyrazli, S., Janghorbani, M., Bakhshi, S., Carta, M. G., Moro, M. F., et al. (2019). The role of religion in suicidal behavior, attitudes and psychological distress among university students. Transcultural Psychiatry, 56(5), 853–​877. Espinoza v. Montana Department of Revenue (2020). Supreme Court decision No. 18-​1195 (June 30). Retrieved on 10-​11-​2020 from https://​www. supre​meco​urt.gov/​opini​ons/​19pdf/​18-​1195_​g​ 314.pdf. Esse, K., Fossati‐Bellani, M., Traylor, A., & Martin‐Schild, S. (2011). Epidemic of illicit drug use, mechanisms of action/​addiction and stroke as a health hazard. Brain and Behavior, 1(1), 44–​54. Estruch, R., Ros, E., Salas-​Salvadó, J., Covas, M. I., Corella, D., Arós, F., et al. (2018). Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-​ virgin olive oil or nuts. New England Journal of Medicine, 378(25), e34. Esty, D., & Rushing, R. (2007). The promise of data-​driven policymaking. Issues in Science and Technology, 23(4), 67–​72. Evans, D. L., Charney, D. S., Lewis, L., Golden, R. N., Gorman, J. M., Krishnan, K. R., et al. (2005). Mood disorders in the medically ill. Biological Psychiatry, 58(3), 175–​189. Evans, W. R., Stanley, M. A., Barrera, T. L., Exline, J. J., Pargament, K. I., & Teng, E. J. (2018). Morally injurious events and psychological distress among veterans: Examining the mediating role of religious and spiritual struggles. Psychological Trauma, 10(3), 360–​367. Everhart, D. E., Watson, E. M., Bickel, K. L., & Stephenson, A. J. (2015). Right temporal lobe atrophy: a case that initially presented as excessive piety. Clinical Neuropsychologist, 29(7), 1053–​1067. Everitt, A. R., Clare, S., Pertel, T., John, S. P., Wash, R. S., Smith, S. E., et al. (2012). IFITM3 restricts the morbidity and mortality associated with influenza. Nature, 484(7395), 519–​523. Everson, S. A., Goldberg, D. E., Kaplan, G. A., Cohen, R. D., Pukkala, E., Tuomlehto, J., et al. (1996). Hopelessness and risk of mortality and

References • 913

incidence of myocardial infarction and cancer. Psychosomatic Medicine, 58, 113–​121. Everson v. Board of Education (1947). Establishment Clause jurisprudence since, whatever its twists and turns, maintains this view. Ruling 330 U.S. 1, 15. Executive Order (2017). Guidance regarding department of education grants and Executive Order 113798. US Department of Education. Retrieved on 10-​9-​2020 from https://​www2. ed.gov/​about/​offi​ces/​list/​ope/​religi​ous-​free​dom-​ rest​orat​ion-​act.html. Exline, J. J., Pargament, K. I., Grubbs, J. B., & Yali, A. M. (2014). The Religious and Spiritual Struggles Scale: development and initial validation. Psychology of Religion and Spirituality, 6(3), 208–​222. Express (2017). Loneliness on the RISE: one in eight people have no close friends to turn to. Retrieved on 8-​5-​2022 from https://​www.expr​ ess.co.uk/​news/​uk/​773​002/​One-​in-​eight-​peo​ ple-​faced-​with-​lon​elin​ess. Eysenck, H. (1964). Crime and Personality. London: Methuen, pp. 68–​69. Fairfax, B. P., & Knight, J. C. (2014). Genetics of gene expression in immunity to infection. Current Opinion in Immunology, 30, 63–​71. Falck, R. S., Davis, J. C., Best, J. R., Crockett, R. A., & Liu-​Ambrose, T. (2019). Impact of exercise training on physical and cognitive function among older adults. Neurobiology of Aging, 79, 119–​130. Fancourt, D., & Steptoe, A. (2018). Community group membership and multidimensional subjective well-​being in older age. Journal of Epidemiology & Community Health, 72(5), 376–​382. Faour, M. (2012). Islamists and education in the Arab world. Carnegie Middle East Center. Retrieved on 10-​3-​2020 from https://​carne​ gie-​mec.org/​2012/​04/​19/​islami​sts-​and-​educat​ ion-​in-​arab-​world-​pub-​47885. Faraco, G., & Iadecola, C. (2013). Hypertension: a harbinger of stroke and dementia. Hypertension, 62(5), 810–​817. Farias, M., & Newheiser, A. K. (2019). The effects of belief in God and science on acute stress. Psychology of Consciousness: Theory, Research, and Practice, 6(2), 214. Farley, T., Galves, A. L., Dickinson, L. M., & Perez, M. D. (2005). Stress, coping, and health: a comparison of Mexican immigrants, Mexican-​ Americans, and non-​Hispanic whites. Journal of Immigrant Health, 7(3), 213–​220. Faro, A. L., McKee, L. G., Garcia, R. L., & Jones, D. J. (2018). The relationships between religiosity

914 •  R eferences

and youth internalizing symptoms in African American parent–​adolescent dyads. Cultural Diversity and Ethnic Minority Psychology, 24(1), 139–​149. Farzanegan, B., Elkhatib, T. H., Elgazzar, A. E., Moghaddam, K. G., Torkaman, M., Zarkesh, M., et al. (2020). Impact of religiosity on delirium severity among critically ill Shi’a Muslims. Journal of Religion and Health, 60(2), 816–​840. Fässberg, M. M., Cheung, G., Canetto, S. S., Erlangsen, A., Lapierre, S., Lindner, R., et al. (2016). A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Aging & Mental Health, 20(2), 166–​194. Fauth, R. C., Roth, J. L., & Brooks-​Gunn, J. (2007). Does the neighborhood context alter the link between youth’s after-​school time activities and developmental outcomes? Developmental Psychology, 43(3), 760–​777. Fayaz, A., Croft, P., Langford, R. M., Donaldson, L. J., & Jones, G. T. (2016). Prevalence of chronic pain in the UK: a systematic review and meta-​ analysis of population studies. BMJ Open, 6(6), e010364. Feder, A., Ahmad, S., Lee, E. J., Morgan, J. E., Singh, R., Smith, B. W., et al. (2013). Coping and PTSD symptoms in Pakistani earthquake survivors. Journal of Affective Disorders, 147(1–​3), 156–​163. Feigelman, W., Gorman, B. S., & Varacalli, J. A. (1992). Americans who give up religion. Journal for the Scientific Study of Religion, 76(3), 138–​144. Feigelman, W., Cerel, J., McIntosh, J. L., Brent, D., & Gutin, N. (2019). Suicide bereavement and differences in religiosity. Crisis, 40(3), 176–​185. Feigin, V. L., Abajobir, A. A., Abate, K. H., Abd-​ Allah, F., Abdulle, A. M., Abera, S. F., et al. (2017a). Global, regional, and national burden of neurological disorders during 1990–​2015. Lancet Neurology, 16(11), 877–​897. Feigin, V. L., Norrving, B., & Mensah, G. A. (2017b). Global burden of stroke. Circulation Research, 120(3), 439–​448. Feinson, M. C., & Hornik-​Lurie, T. (2016). Body dissatisfaction and the relevance of religiosity: A focus on ultra-​orthodox Jews in a community study of adult women. Clinical Social Work Journal, 44(1), 87–​97. Feinstein, M., Liu, K., Ning, H., Fitchett, G., & Lloyd-​Jones, D. M. (2010). Burden of cardiovascular risk factors, subclinical atherosclerosis, and incident cardiovascular events across dimensions of religiosity. Circulation 121, 659–​666.

Feinstein, M., Liu, K., Ning, H., Fitchett, G., & Lloyd-​Jones, D. M. (2012). Incident obesity and cardiovascular risk factors between young adulthood and middle age by religious involvement. Preventive Medicine, 54(2), 117–​121. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (2019). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 56(6), 774–​786. Fenix, J. B., Cherlin, E. J., Prigerson, H. G., Johnson-​Hurzeler, R., Kasl, S. V., & Bradley, E. H. (2006). Religiousness and major depression among bereaved family caregivers: a 13-​month follow-​up study. Journal of Palliative Care, 22(4), 286–​292. Ferguson, J. K. (2010). Centering prayer: A method of Christian meditation for our time. In Plante, T. G. (ed.), Contemplative Practices in Action: Spirituality, Meditation, and Health. Santa Barbara, CA: Praeger/​ABC-​CLIO, pp. 60–​77. Ferguson, M. A., Nielsen, J. A., King, J. B., Dai, L., Giangrasso, D. M., Holman, R., et al. (2018). Reward, salience, and attentional networks are activated by religious experience in devout Mormons. Social Neuroscience, 13(1), 104–​116. Fergusson, D. M., Boden, J. M., & Horwood, L. J. (2008). The developmental antecedents of illicit drug use. Drug and Alcohol Dependence, 96(1–​2), 165–​177. Fernando, S. J. (1975). A cross-​cultural study of some familial and social factors in depressive illness. British Journal of Psychiatry, 127, 46–​53. Fernando, S. J. (1978). Aspects of depression in a Jewish minority group. Psychiatria Clinica, 11, 23–​33. Fernquist, R. M. (1995–​1996). Elderly suicide in western Europe 1975–​1989. Omega: Journal of Death and Dying, 32(1), 39–​48. Fernquist, R. M. (2003). Does the level of divorce or religiosity make a difference? Archives of Suicide Research, 7(3), 265–​277. Ferraro, K. F. (1998). Firm believers? Religion, body weight, and well-​being. Review of Religious Research, 39(3), 224–​244. Ferraro, K. F., & Koch, J. R. (1994). Religion and health among black and white adults: Examining social support and consolation. Journal for the Scientific Study of Religion, 33, 362–​375. Ferraro, K. F., & Kim, S. (2014). Health benefits of religion among Black and White older adults? Race, religiosity, and C-​reactive protein. Social Science & Medicine, 120, 92–​99.

Ferreira, A. J. (1965). Emotional factors in prenatal environment. Journal of Nervous and Mental Disease, 141(1), 108–​118. Ferreira-​Valente, A., Sharma, S., Torres, S., Smothers, Z., Pais-​R ibeiro, J., Abbott, J. H., et al. (2022). Does religiosity/​s pirituality play a role in function, pain-​related beliefs, and coping in patients with chronic pain? Journal of Religion and Health, 61, 2331–​2 385. Ferriss, A. L. (2002). Religion and the quality of life. Journal of Happiness Studies, 3(3), 199–​215. Ferro, M. A., Rhodes, A. E., Kimber, M., Duncan, L., Boyle, M. H., Georgiades, K., et al. (2017). Suicidal behaviour among adolescents and young adults with self-​reported chronic illness. Canadian Journal of Psychiatry, 62(12), 845–​853. Feuille, M., & Pargament, K. (2015). Pain, mindfulness, and spirituality: a randomized controlled trial comparing effects of mindfulness and relaxation on pain-​related outcomes in migraineurs. Journal of Health Psychology, 20(8), 1090–​1106. Fiala, W. E., Bjorck, J. P., & Gorsuch, R. (2002). The religious support scale: Construction, validation, and cross‐validation. American Journal of Community Psychology, 30(6), 761–​786. Fider, C. R., Lee, J. W., Gleason, P. C., & Jones, P. (2019). Influence of religion on later burden and health of new black and white caregivers. Journal of Applied Gerontology, 38(9), 1282–​1303. Field, A. E., Colditz, G. A., Willett, W. C., Longcope, C., & McKinlay, J. B. (1994). The relation of smoking, age, relative weight, and dietary intake to serum adrenal steroids, sex hormones, and sex hormone-​binding globulin in middle-​ aged men. Journal of Clinical Endocrinology and Metabolism, 79(5), 1310–​1316. Fiese, B. H., Rhodes, H. G., & Beardslee, W. R. (2013). Rapid changes in American family life: consequences for child health and pediatric practice. Pediatrics, 132(3), 552–​559. Fikriana, R., Devy, S. R., Ahsan, A., & Afik, A. (2019). Determinants of drug adherence on grade two and three patients with hypertension. Jurnal Ners, 14(2), 193–​198. Fillion, L., Kovacs, A. H., Gagnon, P., & Endler, N. S. (2002). Validation of the shortened COPE for use with breast cancer patients undergoing radiation therapy. Current Psychology, 21(1), 17–​34. Finch, B. K., & Vega, W. A. (2003). Acculturation stress, social support, and self-​rated health among Latinos in California. Journal of Immigrant Health, 5(3), 109–​117.

References • 915

Finch, C. E. (2010). Evolution of the human lifespan and diseases of aging: roles of infection, inflammation, and nutrition. Proceedings of the National Academy of Sciences, 107(Supp 1), 1718–​1724. Fincham, F. D. (2015). Forgiveness, family relationships and health. In Toussaint, L., Worthington, E., & Williams, D. R. (eds.), Forgiveness and Health. Dordrecht, Netherlands: Springer, pp. 255–​270. Fincham, F. D., Beach, S. R., & Davila, J. (2004). Forgiveness and conflict resolution in marriage. Journal of Family Psychology, 18(1), 72. Fincham, F. D., Ajayi, C., & Beach, S. R. (2011). Spirituality and marital satisfaction in African American couples. Psychology of Religion and Spirituality, 3(4), 259–​268. Fincham, F. D., May, R. W., & Carlos Chavez, F. L. (2020). Does being religious lead to greater self-​ forgiveness? Journal of Positive Psychology, 15(3), 400–​406. FindLaw (2018). Religion in the workplace. FindLaw. Retrieved on 10-​3-​2020 from https://​ emp​loym​ent.find​law.com/​emp​loym​ent-​dis​crim​ inat​ion/​relig​ion-​in-​the-​workpl​ace.html. Fink, G. (2010). Stress: definition and history. In Fink, G (ed.), Stress Science: Neuroendocrinology. San Diego, CA: Academic Press, pp. 3–​9. Finke, R., Mataic, D. R., & Fox, J. (2017). Assessing the impact of religious registration. Journal for the Scientific Study of Religion, 56(4), 720–​736. Finkelstein, E. A., Trogdon, J. G., Cohen, J. W., & Dietz, W. (2009). Annual medical spending attributable to obesity: payer-​and service-​ specific estimates. Health Affairs, 28(Supp 1), w822–​w831. Finocchario-​Kessler, S., Catley, D., Berkley-​Patton, J., Gerkovich, M., Williams, K., Banderas, J., et al. (2011). Baseline predictors of ninety percent or higher antiretroviral therapy adherence in a diverse urban sample. AIDS Patient Care and STDs, 25(2): 103–​111. Finzi, A., Colombo, D., Caputo, A., Andreassi, L., Chimenti, S., Vena, G., et al. (2007). Psychological distress and coping strategies in patients with psoriasis. Journal of the European Academy of Dermatology and Venereology, 21(9), 1161–​1169. Fiolet, T., Srour, B., Sellem, L., Kesse-​Guyot, E., Allès, B., Méjean, C., et al. (2018). Consumption of ultra-​processed foods and cancer risk: results from NutriNet-​Sante prospective cohort. British Medical Journal, 360, k322.

916 •  R eferences

Fiorillo, D., & Nappo, N. (2017). Formal volunteering and self-​perceived health. Causal evidence from the UK-​SILC. Review of Social Economy, 75(2), 112–​138. Fiório, C. E., Cesar, C. L., Alves, M. C., & Goldbaum, M. (2020). Prevalence of hypertension in adults in the city of São Paulo and associated factors. Revista Brasileira de Epidemiologia, 23, e200052. Fischel-​Wolovick, L. (2018). Traumatic Divorce and Separation: The Impact of Domestic Violence and Substance Abuse in Custody and Divorce. New York, NY: Oxford University Press. Fishbain, D. A., Bruns, D., Meyer, L. J., Lewis, J. E., Gao, J., & Disorbio, J. M. (2014). Exploration of affirmation of childhood molestation (sexual abuse) in chronic pain patients, acute pain patients, community patients with pain and community nonpatients without pain. Pain Practice, 14(6), 515–​525. Fishbain, D. A., Pulikal, A., Lewis, J. E., & Gao, J. (2017). Chronic pain types differ in their reported prevalence of post-​traumatic stress disorder (PTSD) and there is consistent evidence that chronic pain is associated with PTSD. Pain Medicine, 18(4), 711–​735. Fisher, H. E., Island, H. D., Rich, J., Marchalik, D., & Brown, L. L. (2015). Four broad temperament dimensions: description, convergent validation correlations, and comparison with the Big Five. Frontiers in Psychology, 6, 1098. Fitchett, G., & Powell, L. H. (2009). Daily spiritual experiences, systolic blood pressure, and hypertension among midlife women in SWAN. Annals of Behavioral Medicine, 37, 257–​276. Flannelly, K. J., Handzo, G. F., & Weaver, A. J. (2004). Factors affecting healthcare chaplaincy and the provision of pastoral care in the United States. Journal of Pastoral Care & Counseling, 58(1–​2), 127–​130. Flannelly, K. J., Galek, K., Kytle, J., & Silton, N. R. (2010). Religion in America—​1972–​ 2006: religious affiliation, attendance, and strength of faith. Psychological Reports, 106(3), 875–​890. Flegal, K. M., Kit, B. K., Orpana, H., & Graubard, B. I. (2013). Association of all-​cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-​analysis. Journal of the American Medical Association, 309(1), 71–​82. Fletcher, J., & Kumar, S. (2014). Religion and risky health behaviors among US adolescents and adults. Journal of Economic Behavior & Organization, 104, 123–​140.

Florenzano, R., Rodríguez, J., Sieverson, C., Cataldo, E., Pastorino, S., & Fernández, L. (2014). Suicidal risk, depression, and religiosity: a study of women in a general hospital in Santiago de Chile. Asia‐Pacific Psychiatry, 6(1), 23–​27. Floud, S., Balkwill, A., Canoy, D., Reeves, G. K., Green, J., Beral, V., et al. (2016). Social participation and coronary heart disease risk in a large prospective study of UK women. European Journal of Preventive Cardiology, 23(9), 995–​1002. Fluharty, M., Taylor, A. E., Grabski, M., & Munafò, M. R. (2016). The association of cigarette smoking with depression and anxiety: a systematic review. Nicotine & Tobacco Research, 19(1), 3–​13. Fogel, J. (2004). Internet breast health information use and coping among women with breast cancer. CyberPsychology & Behavior, 7(1), 59–​63. Foley, E, Baillie, A., Huxter, M., Price, M., & Sinclair, E. (2010). Mindfulness-​based cognitive therapy for individuals whose lives have been affected by cancer: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 78, 72–​79. Folkman, S. (1997). Positive psychological states and coping with severe stress. Social Science & Medicine, 45(8), 1207–​1221. Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle-​aged community sample. Journal of Health and Social Behavior, 21(3), 219–​239. Folkman S., & Lazarus, R. S. (1985). If it changes it must be a process: study of emotion and coping during three stages of a college examination. Journal of Personality and Social Psychology, 48, 150–​170. Folkman, S., & Lazarus, R. S. (1988a). Coping as a mediator of emotion. Journal of Personality and Social Psychology, 54(3), 466–​475. Folkman, S., & Lazarus, R. S. (1988b). The relationship between coping and emotion: implications for theory and research. Social Science & Medicine, 26(3), 309–​317. Folkman, S., Chesney, M. A., Pollack, L., & Phillips, C. (1992). Stress, coping, and high-​risk sexual behavior. Health Psychology, 11(4), 218. Folkman, S., Chesney, M. A., Cooke, M. Boccellari, A., & Collette, L. (1994). Caregiver burden in HIV-​positive and HIV-​negative parners of men with AIDS. Journal of Consulting and Clinical Psychology, 62, 746–​756. Folkman, S., Lazarus, R. S., Dunkel-​Schetter, C., DeLongis, A., & Gruen, R. J. (1986a). Dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes. Journal

of Personality and Social Psychology, 50(5), 992–​1003. Folkman, S., Lazarus, R. S., Gruen, R. J., & DeLongis, A. (1986b). Appraisal, coping, health status, and psychological symptoms. Journal of Personality and Social Psychology, 50(3), 571–​579. Folkman, S., & Moskowitz, J. T. (2000). Stress, positive emotion, and coping. Current Directions in Psychological Science, 9(4), 115–​118. Fontana, A., & Rosenheck, R. (2004). Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD. Journal of Nervous & Mental Disease, 192(9), 579–​584. Foo, Y. Z., Nakagawa, S., Rhodes, G., & Simmons, L. W. (2017). The effects of sex hormones on immune function: a meta-​analysis. Biological Reviews, 92(1), 551–​571. Foong, H. F., Hamid, T. A., Ibrahim, R., & Haron, S. A. (2018). Moderating effect of intrinsic religiosity on the relationship between depression and cognitive function among community-​dwelling older adults. Aging & Mental Health, 22(4), 483–​488. Ford, C. A., Miller, W. C., Cohen, M., Pence, B. W., Resnick, M. D., Bearinger, L. H., et al. (2005). Predicting adolescents’ longitudinal risk for sexually transmitted infection. Archives of Pediatrics and Adolescent Medicine, 159(7), 657–​664. Ford, D. W., Downey, L., Engelberg, R., Back, A. L., & Curtis, J. R. (2014). Association between physician trainee self-​assessments in discussing religion and spirituality and their patients’ reports. Journal of Palliative Medicine, 17(4), 453–​462. Ford, E. S., & Caspersen, C. J. (2012). Sedentary behaviour and cardiovascular disease: a review of prospective studies. International Journal of Epidemiology, 41(5), 1338–​1353. Ford, E. S., Loucks, E. B., & Berkman, L. F. (2006). Social integration and concentrations of C-​ reactive protein among US adults. Annals of Epidemiology, 16(2), 78–​84. Ford, E. S., Bergmann, M. M., Kroger, J., Schienkiewitz, A., Weikert, C., Boeing, H. (2009). Healthy living is the best revenge: findings from the European prospective investigation into cancer and nutrition-​Potsdam study. Archives of Internal Medicine, 169, 1355–​1362. Ford, J. A., & Hill, T. D. (2012). Religiosity and adolescent substance use: evidence from the National Survey on Drug Use and Health. Substance Use and Misuse, 47(7), 787–​798.

References • 917

Ford, J. A., Hinojosa, M. S., & Nicholson, H. L. (2018). Disability status and prescription drug misuse among US adults. Addictive Behaviors, 85, 64–​69. Ford, K., & Garzon, F. (2017). Research note: A randomized investigation of evangelical Christian accommodative mindfulness. Spirituality in Clinical Practice, 4(2), 92–​99. Ford, K., Jampaklay, A., & Chamratrithirong, A. (2017). Mental health in a conflict area: migration, economic stress and religiosity in the three southernmost provinces of Thailand. International Journal of Social Psychiatry, 63(2), 91–​98. Forehand, J. A., Peltzman, T., Westgate, C. L., Riblet, N. B., Watts, B. V., & Shiner, B. (2019). Causes of excess mortality in veterans treated for posttraumatic stress disorder. American Journal of Preventive Medicine, 57(2), 145–​152. Forouzanfar, M. H., Liu, P., Roth, G. A., Ng, M., Biryukov, S., Marczak, L., et al. (2017). Global burden of hypertension and systolic blood pressure of at least 110 to 115 mm Hg, 1990–​ 2015. Journal of the American Medical Association, 317(2), 165–​182. Forster, L. E., Pollow, R., & Stoller, E. P. (1993). Alcohol use and potential risk for alcohol-​related adverse drug reactions among community-​ based elderly. Journal of Community Health, 18, 225–​239. Foshee, V. A., & Hollinger, B. R. (1996). Maternal religiosity, adolescent social bonding, and adolescent alcohol use. Journal of Early Adolescence, 16, 451–​468. Fosse, R., Joseph, J., & Jones, M. (2016). Schizophrenia: a critical view on genetic effects. Psychosis, 8(1), 72–​84. Fox, B. (2017). It’s nature and nurture: integrating biology and genetics into the social learning theory of criminal behavior. Journal of Criminal Justice, 49, 22–​31. Fox, S. A., Pitkin, K., Paul, C., Carson, S., & Duan, N. (1998). Breast cancer screening adherence: does church attendance matter? Health Education and Behavior, 26, 742–​758. Fradelos, E. C., Alikari, V., Vus, V., Papathanasiou, I. V., Tsaras, K., Tzavella, F., et al. (2020). Assessment of the relation between religiosity, anxiety, depression and psychological resilience in nursing staff. Health Psychology Research, 8(1), 8234. Fragkaki, I., Cima, M., Verhagen, M., Maciejewski, D. F., Boks, M. P., van Lier, P. A., et al. (2019). Oxytocin receptor gene (OXTR) and deviant

918 •  R eferences

peer affiliation. Journal of Youth and Adolescence, 48(1), 86–​101. Franch, M. S. (2008). Spirituality, religion, and meaning. Journal of Nervous & Mental Disease, 196(8), 643–​646. Francis, L. J. (2000). The relationship between Bible reading and purpose in life among 13–​15-​ year-​olds. Mental Health, Religion & Culture, 3(1), 27–​36. Francis, L. J. (2013). Implicit religion, explicit religion and purpose in life: an empirical inquiry among 13-​to 15-​year-​old adolescents. Mental Health, Religion & Culture, 16(9), 909–​921. Francis, L. J., & Katz, Y. (2007). Measuring attitude toward Judaism: The internal consistency reliability of the Katz-​Francis Scale of Attitude toward Judaism. Mental Health, Religion & Culture, 10(4), 309–​324. Francis, L. J., Sahin, A., & Al-​Failakawi, F. (2008a). Psychometric properties of two Islamic measures among young adults in Kuwait: the Sahin-​ Francis Scale of Attitude toward Islam and the Sahin Index of Islamic Moral Values. Journal of Muslim Mental Health, 3(1), 9–​24. Francis, L. J., Santosh, R., Robbins, M., & Vij, S. (2008b). Assessing attitude toward Hinduism: The Santosh-​Francis Scale. Mental Health, Religion and Culture 11: 609–​621. Franco, M., Mazzucca, S., Padek, M., & Brownson, R. C. (2019). Going beyond the individual: how state-​level characteristics relate to HPV vaccine rates in the United States. BMC Public Health, 19(1), 246. Francoeur, R. B., Burke, N., & Wilson, A. M. (2016). The role of social workers in spiritual care to facilitate coping with chronic illness and self-​ determination in advance care planning. Social Work in Public Health, 31(5), 453–​466. Frankl, V. E. ([1946] 2006). Man’s Search for Meaning. Boston, MA: Beacon Press. Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., et al. (2017). Risk factors for suicidal thoughts and behaviors: a meta-​analysis of 50 years of research. Psychological Bulletin, 143(2), 187–​232. Franklin, S. S., Gustin, W., IV, Wong, N. D., Larson, M. G., Weber, M. A., Kannel, W. B., et al. (1997). Hemodynamic patterns of age-​related changes in blood pressure: the Framingham Heart Study. Circulation, 96(1), 308–​315. Franklin, T. B., Russig, H., Weiss, I. C., Gräff, J., Linder, N., Michalon, A., et al. (2010). Epigenetic transmission of the impact of early stress

across generations. Biological Psychiatry, 68(5), 408–​415. Franzen, A. B. (2016). Is this relevant? Physician perceptions, clinical relevance, and religious content in clinical interactions. Journal for the Scientific Study of Religion, 55(3), 438–​464. Frary, C. D., Johnson, R. K., & Wang, M. Q. (2005). Food sources and intakes of caffeine in the diets of persons in the United States. Journal of the American Dietetic Association 105:110–​113. Fraser, G. E., Cosgrove, C. M., Mashchak, A. D., Orlich, M. J., & Altekruse, S. F. (2020). Lower rates of cancer and all‐cause mortality in an Adventist cohort compared with a US Census population. Cancer, 126(5), 1102–​1111. Frayer, L., & Khan, F. L. (2019). Welcome to the world’s largest gathering of humans. National Public Radio. Retrieved on 1-​4-​2020 from https://​www.npr.org/​secti​ons/​goats​ands​oda/​ 2019/​01/​20/​686482​390/​welc​ome-​to-​the-​wor​ lds-​larg​est-​gather​ing-​of-​hum​ans. Freeman, D., Sheaves, B., Goodwin, G. M., Yu, L. M., Nickless, A., Harrison, P. J., et al. (2017). The effects of improving sleep on mental health (OASIS). Lancet Psychiatry, 4(10), 749–​758. Freeman, D., Waite, F., Rosebrock, L., Petit, A., Causier, C., East, A., et al. (2022). Coronavirus conspiracy beliefs, mistrust, and compliance with government guidelines in England. Psychological Medicine, 52(2), 251–​263. Freeman, R. B. (1986). Who escapes? The relation of churchgoing and other background factors to the socioeconomic performance of black male youths from inner-​city tracts. In Freeman, R. B., & Holzer, H. J. (eds.), The Black Youth Employment Crisis. Chicago, IL: University of Chicago Press, pp. 353–​376. Freire de Medeiros, C. M., Arantes, E. P., Tajra, R. D., Santiago, H. R., Carvalho, A. F., & Libório, A. B. (2017). Resilience, religiosity and treatment adherence in hemodialysis patients: a prospective study. Psychology, Health & Medicine, 22(5), 570–​577. French, D. C., Purwono, U., & Shen, M. (2020). Religiosity and positive religious coping as predictors of Indonesian Muslim adolescents’ externalizing behavior and loneliness. Psychology of Religion and Spirituality, 14(2), 189–​199. French, R. K. (1978) The thorax in history 1. From ancient times to Aristotle. Thorax, 33, 10–​18. Freud, S. (1927). Future of an illusion. In Strachey J (editor and translator), Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth Press, 1962.

Freund, A., Cohen, M., & Azaiza, F. (2019). Factors associated with routine screening for the early detection of breast cancer in cultural-​ethnic and faith-​based communities. Ethnicity & Health, 24(5), 527–​543. Frick, E., Büssing, A., Baumann, K., Weig, W., & Jacobs, C. (2016). Do self-​efficacy expectation and spirituality provide a buffer against stress-​ associated impairment of health? Journal of Religion and Health, 55(2), 448–​468. Friedenreich, C. M. (2010). Physical activity and breast cancer. In Senn, H. J., & Otto F. (eds.), Clinical Cancer Prevention. Berlin, Germany: Springer, pp. 125–​139. Friedlander, Y., Kark J. D., & Stein, Y. (1986). Religious orthodoxy and myocardial infarction in Jerusalem: a case-​control study. International Journal of Cardiology, 10, 33–​41. Friedlander, Y., Kark J. D., & Stein, Y. (1987). Religious observance and plasma lipids and lipoproteins among 17-​year-​old Jewish residents of Jerusalem. Preventive Medicine, 16, 70–​79. Friedman, E. H., & Hellerstein, H. K. (1968). Occupational stress, law school hierarchy, and coronary artery disease in Cleveland attorneys. Psychosomatic Medicine, 30(1), 72–​86. Friedman, L. M., Furberg, C. D., & DeMets, D. L. (1999). Fundamentals of Clinical Trials (3rd ed.). New York, NY: Springer. Friedman, M. R., Coulter, R. W., Silvestre, A. J., Stall, R., Teplin, L., Shoptaw, S., et al. (2017). Someone to count on: social support as an effect modifier of viral load suppression in a prospective cohort study. AIDS Care, 29(4), 469–​480. Friedrich, M. J. (2017). Depression is the leading cause of disability around the world. Journal of the American Medical Association, 317(15), 1517–​1517. Friedrich, R., Woods, B., & Williams, S. (2021). “Just because the mind is confused it doesn’t mean the spirit is confused”: exploring the role of Anglican clergy in ministry to persons with dementia. Dementia, 20(2), 698–​716. Fromm, E. (1964). The Heart of Man: Genius for Good and Evil. Brooklyn, NY: Lantern Books. Frost, J., & Edgell, P. (2018). Rescuing nones from the reference category: civic engagement among the nonreligious in America. Nonprofit and Voluntary Sector Quarterly, 47(2), 417–​438. Fuchs, F. D., Chambless, L. E., Whelton, P. K., Nieto, F. J., & Heiss, G. (2001). Alcohol consumption and the incidence of hypertension. Hypertension, 37(5), 1242–​1250.

References • 919

Fujikawa, T., Yamawaki, S., & Touhouda, Y. (1995). Silent cerebral infarctions in patients with late-​ onset mania. Stroke, 26(6), 946–​949. Fuller-​Thomson, E., & Kotchapaw, L. D. (2019). Remission from suicidal ideation among those in chronic pain. Journal of Pain, 20(9), 1048–​1056. Fuller-​Thomson, E., & West, K. J. (2019). Flourishing despite a cancer diagnosis: factors associated with complete mental health in a nationally-​representative sample of cancer patients aged 50 years and older. Aging & Mental Health, 23(9), 1263–​1274. Fuller-​Thomson, E., Agbeyaka, S., LaFond, D. M., & Bern-​Klug, M. (2016a). Flourishing after depression. Psychiatry Research, 242, 111–​120. Fuller‐Thomson, E., Lewis, D. A., & Agbeyaka, S. K. (2016b). Attention‐deficit/​hyperactivity disorder casts a long shadow: Findings from a population‐ based study of adult women with self‐reported ADHD. Child: Care, Health and Development, 42(6), 918–​927. Furman, D., Campisi, J., Verdin, E., Carrera-​ Bastos, P., Targ, S., Franceschi, C., et al. (2019). Chronic inflammation in the etiology of disease across the life span. Nature Medicine, 25(12), 1822–​1832. Gabriel, K. P., Sternfeld, B., Colvin, A., Stewart, A., Strotmeyer, E. S., Cauley, J. A., et al. (2017). Physical activity trajectories during midlife and subsequent risk of physical functioning decline in late mid-​life. Preventive Medicine, 105, 287–​294. Gafarov, V. V., Gromova, E. A., & Panov, D. O. (2019). Social support and stroke risk: an epidemiological study of a population aged 25–​64 years in Russia/​Siberia. Neurology, Neuropsychiatry, & Psychosomatics, 11(1), 12–​20. Gagne, A. M. (2020). Eating according to religious practices: kosher and halal. Gordon Food Service. Retrieved on 1-​6-​2020 from https://​www.gfs. com/​en-​us/​ideas/​eat​ing-​accord​ing-​religi​ous-​ practi​ces-​kos​her-​and-​halal. Gainey, A., Himathongkam, T., Tanaka, H., & Suksom, D. (2016). Effects of Buddhist walking meditation on glycemic control and vascular function in patients with type 2 diabetes. Complementary Therapies in Medicine, 26, 92–​97. Galanter, M., & Dermatis, H., Stanievich, J., & Santucci, C. (2013a). Physicians in long‐term recovery who are members of Alcoholics Anonymous. American Journal on Addictions, 22(4), 323–​328. Galanter, M., Dermatis, H., Post, S., & Sampson, C. (2013b). Spirituality-​based recovery from drug addiction in the twelve-​step fellowship

920 •  R eferences

of Narcotics Anonymous. Journal of Addiction Medicine, 7(3), 189–​195. Galek, K., Flannelly, K. J., Ellison, C. G., Silton, N. R., & Jankowski, K. R. (2015). Religion, meaning and purpose, and mental health. Psychology of Religion and Spirituality, 7(1), 1–​12. Gall, T. L., & Bilodeau, C. (2020). The role of positive and negative religious/​spiritual coping in women’s adjustment to breast cancer. Journal of Psychosocial Oncology, 38(1), 103–​117. Gall, T. L., Charbonneau, C., & Florack, P. (2011). The relationship between religious/​spiritual factors and perceived growth following a diagnosis of breast cancer. Psychology and Health, 26(3), 287–​305. Gallardo-​Peralta, L. P. (2017). The relationship between religiosity/​spirituality, social support, and quality of life among elderly Chilean people. International Social Work, 60(6), 1498–​1511. Gallemore, J. L., Jr., Wilson, W. P., & Rhoads, J. M. (1969). The religious life of patients with affective disorders. Diseases of the Nervous System, 30(7), 483–​487. Gallup International Poll (2017). Happiness, hope, and optimism. Gallup International’s 41st Annual Global End of Year Survey: October–​December 2017. Retrieved on 9-​24-​2020 from https://​ www.gal​lup-​intern​atio​nal.com/​surv​eys/​happin​ ess-​hope-​econo​mic-​optim​ism/​. Gallup Poll (2009). Importance of religion by country. The Gallup Poll. Retrieved on 5-​3-​2019 from https://​en.wikipe​dia.org/​wiki/​Import​ance​ _​of_​reli​gion​_​by_​coun​try. Gallup Poll (2015). Losing our religion? Two thirds of people still claim to be religious. Gallup International. Retrieved on 5-​6-​2019 from http://​gal​lup-​intern​atio​nal.bg/​en/​Publi​cati​ons/​ 2015/​223-​Los​ing-​Our-​Relig​ion-​Two-​Thi​rds-​of-​ Peo​ple-​Still-​Claim-​to-​Be-​Religi​ous. Gallup Poll (2017). 2017 Update on Americans and religion. Gallup Organization. Retrieved on 8-​28-​ 2018 from https://​news.gal​lup.com/​poll/​224​ 642/​2017-​upd​ate-​americ​ans-​relig​ion.aspx. Gallup Poll (2019a). 2019 Gallup global emotions. The Gallup Poll. Retrieved on 5-​3-​2019 from https://​news.gal​lup.com/​poll/​249​098/​americ​ ans-​str​ess-​worry-​anger-​inte​nsif​i ed-​2018.aspx. Gallup Poll (2019b). U.S. church membership down sharply in past two decades. The Gallup Poll. Retrieved on 9-​29-​2020 from https://​news. gal​lup.com/​poll/​248​837/​chu​rch-​mem​bers​hip-​ down-​shar​ply-​past-​two-​deca​des.aspx. Gallup Poll (2020). Religion. The Gallup Poll. Retrieved on 9-​25-​2020 from https://​news.gal​ lup.com/​poll/​1690/​relig​ion.aspx.

Galobardes, B., Smith, G. D., & Lynch, J. W. (2006). Systematic review of the influence of childhood socioeconomic circumstances on risk for cardiovascular disease in adulthood. Annals of Epidemiology, 16(2), 91–​104. Galor, I., Markovich, M. P., Wolf, D., Haber, M., Hartal, M., & Avramovich, E. (2020). Population seroprotection against hepatitis a virus in Israel 18 years after introduction of inactivated vaccine into the routine childhood vaccination schedule. Vaccine, 38(7), 1593–​1596. Galton, F. (1872). Statistical inquiries into the efficacy of prayer. Fortnightly Review, 12, 124–​135. Galvan, F. H., Collins, R. L., Kanouse, D. E., Pantoja, P., & Golinelli, D. (2007). Religiosity, denominational affiliation and sexual behaviors among people with HIV in the United States. Journal of Sex Research, 44(1), 49–​58. Gamaiunova, L., Brandt, P. Y., Bondolfi, G., & Kliegel, M. (2019). Exploration of psychological mechanisms of the reduced stress response in long-​term meditation practitioners. Psychoneuroendocrinology, 104, 143–​151. Gamsa, A. (1994). The role of psychological factors in chronic pain. I. A half century of study. Pain, 57(1), 5–​15. Ganasegeran, K., Abdulrahman, S. A., Al-​Dubai, S. A., Tham, S. W., & Perumal, M. (2020). Spirituality needs in chronic pain patients. Journal of Religion and Health, 59(3), 1201–​1216. Ganczak, M., Owsianka, B., & Korzeń, M. (2018). Factors that predict parental willingness to have their children vaccinated against HPV in a country with low HPV vaccination coverage. International Journal of Environmental Research and Public Health, 15(4), 645. GAO (2017). How much does crime cost? U.S. Government Accountability Office. Retrieved on 9-​ 21-​2020 from https://​blog.gao.gov/​2017/​11/​29/​ how-​much-​does-​crime-​cost/​. Gao, J., Sun, H., Liang, X., Gao, M., Zhao, H., Qi, Y., et al. (2015). Ideal cardiovascular health behaviors and factors prevent the development of hypertension in prehypertensive subjects. Clinical and Experimental Hypertension, 37(8), 650–​655. Gao, J., Leung, H. K., Wu, B. W., Skouras, S., & Sik, H. H. (2019). The neurophysiological correlates of religious chanting. Scientific Reports, 9(1), 1–​9. García, F. E., Barraza-​Peña, C. G., Wlodarczyk, A., Alvear-​Carrasco, M., & Reyes-​Reyes, A. (2018). Psychometric properties of the Brief-​COPE for the evaluation of coping strategies in the

Chilean population. Psicologia: Reflexão e Crítica, 31(1), 22. Garcia, G., Ellison, C. G., Sunil, T. S., & Hill, T. D. (2013). Religion and selected health behaviors among Latinos in Texas. Journal of Religion and Health, 52, 18–​31. Garcini, L. M., Stowe, R. P., Chirinos, D. A., Murdock, K. W., LeRoy, A. S., Chen, M. A., et al. (2019). Church attendance and CMV herpes virus latency among bereaved and non-​bereaved adults. Psychology of Religion and Spirituality, 11(3), 319. Gardner, J., & Sachdeva, H. (2019). Causes of pain worldwide. In Abd-​Elsayed, A. (ed)., Pain. Cham, Switzerland: Springer, pp. 1191–​1192. Garg, R., Chauhan, V., & Sabreen, B. (2018). Coping styles and life satisfaction in palliative care. Indian Journal of Palliative Care, 24(4), 491–​495. Garnick, M. B. (2009). Early-​stage prostate cancer: Treat or wait? Harvard Health Blog. Retrieved on 6-​26-​2020 from https://​www.hea​ lth.harv​ard.edu/​blog/​early-​stage-​prost​ate-​can​ cer-​treat-​or-​wait-​200​9031​010. Garssen, B., & Visser, A. (2016). Spiritual wellbeing predicting depression: Is it relevant? Journal of Behavioral Medicine, 39(2), 369–​369. Garssen, B., Visser, A., & de Jager Meezenbroek, E. (2012). Responses to: “Measures assessing spirituality as more than religiosity: A methodological review of nursing and health‐ related literature.” Journal of Advanced Nursing, 68(7), 1670–​1671. Garssen, B., Visser, A., & de Jager Meezenbroek, E. (2016). Examining whether spirituality predicts subjective well-​being. Psychology of Religion and Spirituality, 8(2), 141–​148. Garssen, B., Visser, A., & Pool, G. (2021). Does spirituality or religion positively affect mental health? Meta-​analysis of longitudinal studies. International Journal for the Psychology of Religion, 31(1), 4–​20. Gatell, V. I., Nguyen, T., Anderson, E. E., McCarthy, M. P., & Hardt, J. J. (2017). Characteristics of medical students planning to work in medically underserved settings. Journal of Health Care for the Poor and Underserved, 28(4), 1409–​1422. Gathright, E. C., Goldstein, C. M., Josephson, R. A., & Hughes, J. W. (2017). Depression increases the risk of mortality in patients with heart failure. Journal of Psychosomatic Research, 94, 82–​89. Gauthier, L. R., Rodin, G., Zimmermann, C., Warr, D., Librach, S. L., Moore, M., et al. (2012). The communal coping model and cancer pain. Journal of Pain, 13(12), 1258–​1268.

References • 921

Gawad, N. A., Desai, P., Ali, T., Lewis, K. K., Polo, R., Engstrom, A., et al. (2018). Religious activity, psychotic features, and suicidality in 688 acute psychiatric inpatients. Journal of Psychiatric Practice, 24(4), 253–​260. GBD 2015 Obesity Collaborators (2017). Health effects of overweight and obesity in 195 countries over 25 years. New England Journal of Medicine, 377(1), 13–​27. Gebauer, J. E., Sedikides, C., & Neberich, W. (2012). Religiosity, social self-​esteem, and psychological adjustment. Psychological Science, 23(2), 158–​160. Gebregziabher, M., Bernstein, L., Wang, Y., & Cozen, W. (2006). Risk patterns of multiple myeloma in Los Angeles County, 1972–​1999. Cancer Causes Control, 17(7), 931–​938. Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults. Cochrane Database of Systematic Reviews, 4, CD011279. (https://​www.coch​rane​libr​ary.com/​ cdsr/​doi/​10.1002/​14651​858.CD011​279.pub3/​ full). Gentile, D. A., Bailey, K., Bavelier, D., Brockmyer, J. F., Cash, H., Coyne, S. M., et al. (2017). Internet gaming disorder in children and adolescents. Pediatrics, 140(Supplement 2), S81–​S85. George, D., Luo, S., Webb, J., Pugh, J., Martinez, A., & Foulston, J. (2015). Couple similarity on stimulus characteristics and marital satisfaction. Personality and Individual Differences, 86, 126–​131. George, L. K. (1999). Religious/​spiritual history. In Multidimensional Measurement of Religiousness/​ Spirituality for Use in Health Research. Kalamazoo, MI: Fetzer Institute/​National Institute on Aging, pp. 65–​69. Gesselman, A. N., Bigatti, S. M., Garcia, J. R., Coe, K., Cella, D., & Champion, V. L. (2017). Spirituality, emotional distress, and post‐traumatic growth in breast cancer survivors and their partners. Psycho‐oncology, 26(10), 1691–​1699. Getz, G. E., Fleck, D. E., & Strakowski, S. M. (2001). Frequency and severity of religious delusions in Christian patients with psychosis. Psychiatry Research, 103(1), 87–​91. Geulayov, G., Drory, Y., Novikov, I., & Dankner, R. (2015). Sense of coherence and 22-​year all-​cause mortality in adult men. Journal of Psychosomatic Research, 78(4), 377–​383. Ghaffari, A., & Çiftçi, A. (2010). Religiosity and self-​esteem of Muslim immigrants to the United States. International Journal for the Psychology of Religion, 20(1), 14–​25.

922 •  R eferences

Ghafoor, H., Schulz, S. M., & Mohsin, H. (2018). Does religiosity ameliorate the negative impact of obsessive-​compulsive disorder on self-​esteem? Mental Health, Religion & Culture, 21(2), 171–​179. Ghahari, S., Fallah, R., Bolhari, J., Mousavi, M., & Akbari, M. E. (2017). Effect of cognitive-​ behavioral therapy and spiritual-​religious intervention on improving coping responses and quality of life among women surviving from breast cancer. Bali Medical Journal, 6(2), 409–​414. Ghandour, L. A., & El Sayed, D. S. (2013). Gambling behaviors among university youth: Does one’s religious affiliation and level of religiosity play a role? Psychology of Addictive Behaviors, 27(1), 279–​286. Gheorghe, A., Griffiths, U., Murphy, A., Legido-​ Quigley, H., Lamptey, P., & Perel, P. (2018). The economic burden of cardiovascular disease and hypertension in low-​and middle-​income countries. BMC Public Health, 18(1), 975. Ghorbani, N., Watson, P. J., Ghramaleki, A. F., Morris, R. J., & Hood, R. W., Jr. (2000). Muslim attitudes towards religion scale: factors, validity and complexity of relationships with mental health in Iran. Mental Health, Religion & Culture, 3(2), 125–​132. Giaquinto, S., Spiridigliozzi, C., & Caracciolo, B. (2007). Can faith protect from emotional distress after stroke? Stroke, 38(3), 993–​997. Giaquinto, S., Sarno, S., Dall’Armi, V., & Spiridigliozzi, C. (2010). Religious and spiritual beliefs in stroke rehabilitation. Clinical and Experimental Hypertension, 32(6), 329–​334. Gibson, S. J. (2007). IASP global year against pain in older persons: highlighting the current status and future perspectives in geriatric pain. Expert Review of Neurotherapeutics, 7(6), 627–​635. Gibson, S. J., & Farrell, M. (2004). A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. Clinical Journal of Pain, 20(4), 227–​239. Gidron, Y. (2004). The relationship between tourists’ agreeableness and openness to experience with coronary heart disease mortality. Journal of Psychosomatic Research, 57(3), 227–​229. Gigy, L., & Kelly, J. B. (1993). Reasons for divorce: perspectives of divorcing men and women. Journal of Divorce & Remarriage, 18(1–​ 2), 169–​188. Gilani, T. M., Ghodrati, F., Yazdanpanahi, Z., Amooee, S., & Akbarzadeh, M. (2019). The effect of teaching religious principles on the infants’ growth and development. Journal of Education and Health Promotion, 8, n.p.

Gili, M., Comas, A., García-​García, M., Monzón, S., Antoni, S. B., & Roca, M. (2010). Comorbidity between common mental disorders and chronic somatic diseases in primary care patients. General Hospital Psychiatry, 32(3), 240–​245. Gillum, R. F. (2005a). Religiosity and the validity of self-​reported smoking: The Third National Health and Nutrition Examination Survey. Review of Religious Research, 47(2), 190–​196. Gillum, R. F. (2005b). Frequency of attendance at religious services and cigarette smoking in American women and men: The Third National Health and Nutrition Examination Survey. Preventive Medicine, 41(2), 607–​613. Gillum, R. F. (2006a). Frequency of attendance at religious services, overweight, and obesity in American women and men: The Third National Health and Nutrition Examination Survey. Annals of Epidemiology, 16(9), 655–​660. Gillum, R. F. (2006b). Frequency of attendance at religious services and leisure-​time physical activity in American women and men: The Third National Health and Nutrition Examination Survey. Annals of Behavioral Medicine, 31(1), 30–​35. Gillum, R. F. (2011). Effect modification by acculturation and education of the association of religion and smoking in immigrants. Journal of Immigrant and Minority Health, 13(2), 193. Gillum, R. F., & Dupree, N. (2007). Religiousness, health, and health behavior in public-​use data of the National Center for Health Statistics. Journal of Religion and Health, 46(1), 155–​165. Gillum, R. F., & Holt, C. L. (2010). Religious involvement and seroprevalence of six infectious diseases in US adults. Southern Medical Journal, 103, 403–​408. Gillum, R. F., & Ingram, D. D. (2006). Frequency of attendance at religious services, hypertension, and blood pressure: The Third National Health and Nutrition Examination Survey. Psychosomatic Medicine, 68(3), 382–​385. Gillum, R. F., King, D. E., Obisesan, T. O., & Koenig, H. G. (2008a). Frequency of attendance at religious services and mortality in a U.S. national cohort. Annals of Epidemiology, 18(2), 124–​129. Gillum, R. F., & Masters, K. S. (2010). Religiousness and blood donation. Journal of Health Psychology, 15(2), 163–​172. Gillum, R. F., Obisesan, T. O., & Jarrett, N. C. (2009). Smokeless tobacco use and religiousness. International Journal of Environmental Research and Public Health, 6, 225–​231. Gillum, R. F., Dodd, K., & Dodd, I. M. (2016). Religion and screen hours in a US national sample. Howard Law Research Paper No. 16-​11.

Available at Social Science Research Network (SSRN): https://​ssrn.com/​abstr​act=​2825​157. Gillum, R. F., & Sullins, D. P. (2008b). Cigarette smoking during pregnancy: Independent associations with religious participation. Southern Medical Journal, 101(7), 686–​692. Gillum, R. F., & West, B. (2015). Religion and menthol cigarette use in a US national sample. Preventive Medicine, 81, 444. Gillum, R. F., & Williams, C. (2009). Associations between breast cancer risk factors and religiousness in American women in a national health survey. Journal of Religion and Health 48, 178–​188. Gilsanz, P., Quesenberry, C. P., Mayeda, E. R., Glymour, M. M., Farias, S. T., & Whitmer, R. A. (2019). Stressors in midlife and risk of dementia. Alzheimer Disease & Associated Disorders, 33(3), 200–​205. Giorgadze, K., Shengelia, R., & Durglishvili, N. (2017). Impact of Orthodox Christian faith and spirituality on society’s mental health (based on the population survey of Tbilisi, Georgia). Georgian Medical News, 271, 76–​85. Giri, V. N., & Beebe-​Dimmer, J. L. (2016). Familial prostate cancer. Seminars in Oncology, 43(5), 560–​565. Giubilini, A., & Savulescu, J. (2019). Vaccination, risks, and freedom: the seat belt analogy. Public Health Ethics, 12(3), 237–​249. Glanville, J. L., Sikkink, D., & Hernandez, E. I. (2008). Religious involvement and educational outcomes: The role of social capital and extracurricular participation. Sociological Quarterly, 49(1), 105–​137. Glaser, B. G., & Strauss, A. L. (2017). Discovery of Grounded Theory: Strategies for Qualitative Research. London: Routledge. Glass, J., & Levchak, P. (2014). Red states, blue states, and divorce: understanding the impact of Conservative Protestantism on regional variation in divorce rates. American Journal of Sociology, 119(4), 1002–​1046. Glasser, I. (2010). Nicotine anonymous may benefit nicotine-​dependent individuals. American Journal of Public Health, 100(2), 196. Gleeson, M., Bishop, N. C., Stensel, D. J., Lindley, M. R., Mastana, S. S., & Nimmo, M. A. (2011). The anti-​inflammatory effects of exercise. Nature Reviews Immunology, 11(9), 607–​615. Glei, D. A., & Preston, S. H. (2020). Estimating the impact of drug use on US mortality, 1999–​2016. PloS One, 15(1), e0226732. Glenn, N. D. (1982). Interreligious marriage in the United States. Journal of Marriage and the Family, 44, 555–​566.

References • 923

Glenn, N. D. (1984). Social and demographic correlates of divorce and separation in the United States. Journal of Marriage and the Family, 46, 563–​576. Glenn, N. D. (2009). Is the apparent U-​shape of well-​being over the life course a result of inappropriate use of control variables? Social Science & Medicine, 69(4), 481–​485. Glick, M., Michel, A. C., Dorn, J., Horwitz, M., Rosenthal, T., & Trevisan, M. (1998). Dietary cardiovascular risk factors and serum cholesterol in an old order Mennonite community. American Journal of Public Health, 88, 1202–​1205. Global Estimates of Health (2018). Global health estimates 2016: Deaths by cause, age, sex, by country and by region, 2000–​2016. Geneva: World Health Organization. Retrieved on 9-​16-​2020 from https://​www.who.int/​news-​ room/​fact-​she​ets/​det​ail/​the-​top-​10-​cau​ses-​of-​ death/​. Glock, C., & Stark, R. (1965). Christian Beliefs and Anti-​Semitism. San Francisco, CA: Harper & Row. Glomb, T. M., & Welsh, E. T. (2005). Can opposites attract? Personality heterogeneity in supervisor-​ subordinate dyads as a predictor of subordinate outcomes. Journal of Applied Psychology, 90(4), 749–​757. Glover-​Graf, N. M., Marini, I., Baker, J., & Buck, T. (2007). Religious and spiritual beliefs and practices of persons with chronic pain. Rehabilitation Counseling Bulletin, 51(1), 21–​33. Gluckman, P. D., Hanson, M. A., Cooper, C., & Thornburg, K. L. (2008). Effect of in utero and early-​life conditions on adult health and disease. New England Journal of Medicine, 359(1), 61–​73. Glueckauf, R. L., Davis, W. S., Allen, K., Chipi, P., Schettini, G., Tegen, L., et al. (2009). Integrative cognitive–​behavioral and spiritual counseling for rural dementia caregivers with depression. Rehabilitation Psychology, 54(4), 449. Gmel, G., Mohler-​Kuo, M., Dermota, P., Gaume, J., Bertholet, N., Daeppen, J. B., et al. (2013). Religion is good, belief is better: religion, religiosity, and substance use among young Swiss men. Substance Use & Misuse, 48(12), 1085–​1098. Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Borden, W. B., et al. (2013). Executive summary: heart disease and stroke statistics—​2013 update: a report from the American Heart Association. Circulation, 127(1), 143–​152. Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., et al. (2014). Heart disease and stroke statistics—​2014 update: a

924 •  R eferences

report from the American Heart Association. Circulation, 129(3), e28–​e292. Gobina, I., Villberg, J., Välimaa, R., Tynjälä, J., Whitehead, R., Cosma, A., et al. (2019). Prevalence of self‐reported chronic pain among adolescents: Evidence from 42 countries and regions. European Journal of Pain, 23(2), 316–​326. Godbolt, D., Vaghela, P., Burdette, A. M., & Hill, T. D. (2017). Religious attendance and body mass: an examination of variations by race and gender. Journal of Religion and Health, 57, 2140–​2152. Goeke‐Morey, M. C., Cairns, E., Merrilees, C. E., Schermerhorn, A. C., Shirlow, P., et al. (2013). Maternal religiosity, family resources and stressors, and parent–​child attachment security in Northern Ireland. Social Development, 22(1), 19–​37. Goes, F. S. (2016). Genetics of bipolar disorder: recent update and future directions. Psychiatric Clinics, 39(1), 139–​155. Goldberg, Z. J., & Richey, S. (2020). Anti-​ vaccination beliefs and unrelated conspiracy theories. World Affairs, 183(2), 105–​124. Goldblatt, H., Cohen, M., Azaiza, F., & Manassa, R. (2013). Being within or being between? The cultural context of Arab women’s experience of coping with breast cancer in Israel. Psycho‐ oncology, 22(4), 869–​875. Goldbourt, U., & Medalie, J. H. (1975). Characteristics of smokers, nonsmokers and ex-​smokers among 10,000 adult males in Israel. I. Distribution of selected sociodemographic and behavioral variables and the prevalence of disease. Israel Journal of Medical Sciences, 11, 1079–​1101. Goldbourt, U., Yaari, S., & Medalie, J. H. (1993). Factors predictive of long-​term coronary heart disease mortality among 10,059 male Israeli civil servants and municipal employees. Cardiology, 82, 100–​121. Goldfarb, L. M., Galanter, M., McDowell, D., Lifshutz, H., & Dermatis, H. (1996). Medical student and patient attitudes toward religion and spirituality in the recovery process. American Journal of Drug and Alcohol Abuse, 22, 549–​561. Goldman, D., Oroszi, G., & Ducci, F. (2005). The genetics of addictions: uncovering the genes. Nature Reviews: Genetics, 6, 521–​532. Goldman, N., Korenman, S., & Weinstein, R. (1995). Marital status and health among the elderly. Social Science and Medicine, 40, 1717–​1730. Goldstein, E. D. (2007). Sacred moments: Implications on well-​being and

stress. Journal of Clinical Psychology, 63(10), 1001–​1019. Goldstein, S. (1996). Changes in Jewish mortality and survival, 1963–​1987. Social Biology, 43, 72–​97. Goldzweig, G., Merims, S., Ganon, R., Peretz, T., & Baider, L. (2012). Coping and distress among spouse caregivers to older patients with cancer: An intricate path. Journal of Geriatric Oncology, 3(4), 376–​385. Gombrich, R. (1988), Theravada Buddhism: A Social History from Ancient Benāres to Modern Colombo. New York, NY: Routledge and Kegan Paul. Gomes, F. C., de Andrade, A. G., Izbicki, R., Moreira-​ Almeida, A., & de Oliveira, L. G. (2013). Religion as a protective factor against drug use among Brazilian university students. Revisa Brasileira de Psiquiatria, 35, 29–​37. Gomes, T., Tadrous, M., Mamdani, M. M., Paterson, J. M., & Juurlink, D. N. (2018). The burden of opioid-​related mortality in the United States. JAMA Network Open, 1(2), e180217–​e180217. Gomez-​Castillo, B. J., Hirsch, R., Groninger, H., Baker, K., Cheng, M. J., Phillips, J., et al. (2015). Increasing the number of outpatients receiving spiritual assessment: a pain and palliative care service quality improvement project. Journal of Pain and Symptom Management, 50(5), 724–​729. Gomez-​Pinilla, F., & Vaynman, S. (2005). A “deficient environment” in prenatal life may compromise systems important for cognitive function by affecting BDNF in the hippocampus. Experimental Neurology, 192(2), 235–​243. Gonçalves, J. P., Lucchetti, G., Menezes, P. R., & Vallada, H. (2015). Religious and spiritual interventions in mental health care. Psychological Medicine, 45(14), 2937–​2949. Gonzaga, G. C., Campos, B., & Bradbury, T. (2007). Similarity, convergence, and relationship satisfaction in dating and married couples. Journal of Personality and Social Psychology, 93, 34–​48. González, A. L. (2011). Measuring religiosity in a majority Muslim context. Journal for the Scientific Study of Religion, 50(2), 339–​350. Gonzales, D., Redtomahawk, D., Pizacani, B., Bjornson, W. G., Spradley, J., Allen, E., et al. (2007). Support for spirituality in smoking cessation. Nicotine & Tobacco Research, 9(2), 299–​303. Gonzales, R., Mooney, L., & Rawson, R. A. (2010). The methamphetamine problem in the United States. Annual Review of Public Health, 31, 385–​398. Gonçalves, J. P., Madruga, C. S., Lucchetti, G., Dias Latorre, M. D., Laranjeira, R., & Vallada, H.

(2020). The effect of religiosity on violence. PloS One, 15(8), e0238020. Good, M., Hamza, C., & Willoughby, T. (2017). A longitudinal investigation of the relation between non-​suicidal self-​injury and spirituality/​religiosity. Psychiatry Research, 250, 106–​112. Good, M., & Willoughby, T. (2011). Evaluating the direction of effects in the relationship between religious versus non-​religious activities, academic success, and substance use. Journal of Youth & Adolescence, 40, 680–​693. Goodman, G., & Manierre, A. (2008). Representations of God uncovered in a spirituality group of borderline inpatients. International Journal of Group Psychotherapy, 58(1), 1–​15. Goodwin, G. M., Haddad, P. M., Ferrier, I. N., Aronson, J. K., Barnes, T. R. H., Cipriani, A., et al. (2016). Evidence-​based guidelines for treating bipolar disorder: revised third edition Recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 30, 495. Gordon, S. M., Sterling, R., Siatkowski, C., Raively, K., Weinstein, S., Hill, P. C., et al. (2006). Inpatient desire to drink as a predictor of relapse to alcohol use following treatment. American Journal on Addictions, 15(3), 242–​245. Gorman, B. K., & Sivaganesan, A. (2007). The role of social support and integration for understanding socioeconomic disparities in self-​rated health and hypertension. Social Science & Medicine, 65(5), 958–​975. Gorrell, S., Trainor, C., & Le Grange, D. (2019). The impact of urbanization on risk for eating disorders. Current Opinion in Psychiatry, 32(3), 242–​247. Gorsuch, R. L., & McPherson, S. E. (1989). Intrinsic/​extrinsic measurement: I/​E-​revised and single-​item scales. Journal for the Scientific Study of Religion, 28(3), 348–​354. Gorsuch, R. L. (1984). The boon and bane of investigating religion. American Psychologist, 39, 228–​236. Gotham, H. J., Sher, K. J., & Wood, P. K. (2003). Alcohol involvement and developmental task completion during young adulthood. Journal of Studies on Alcohol, 64(1), 32–​42. Gottfredson, M. R., & Hirschi, T. (1990). A General Theory of Crime. Stanford, CA: Stanford University Press. Gottfried, M. A., & Polikoff, M S. (2012). A religious experience? Personal, parental, and peer religiosity and the academic success

References • 925

of sexual-​minority youth using nationally representative samples. Journal of LGBT Youth, 9(3), 183–​199. Gottman, J. M., & Silver, N. (2015). The Seven Principles for Making Marriage Work: A Practical Guide from the Country’s Foremost Relationship Expert. New York, NY: Harmony Books. Gottman, J. M., Driver, J., & Tabares, A. (2015). Repair during marital conflict in newlyweds: how couples move from attack–​ defend to collaboration. Journal of Family Psychotherapy, 26(2), 85–​108. Goudarzian, A. H., Jafari, A., Beik, S., & Nesami, M. B. (2018). Are religious coping and pain perception related together? Assessment in Iranian cancer patients. Journal of Religion and Health, 57(6), 2108–​2117. Graber, M., Baptiste, L., Mohr, S., Blanc-​Labarre, C., Dupont, G., Giroud, M., & Béjot, Y. (2019). A review of psychosocial factors and stroke. Revue Neurologique, 175(10), 686–​692. Gradus, J. L., Qin, P., Lincoln, A. K., Miller, M., Lawler, E., Sørensen, H. T., et al. (2010). Posttraumatic stress disorder and completed suicide. American Journal of Epidemiology, 171(6), 721–​727. Graff, R. E., Möller, S., Passarelli, M. N., Witte, J. S., Skytthe, A., Christensen, K., et al. (2017). Familial risk and heritability of colorectal cancer in the Nordic twin study of cancer. Clinical Gastroenterology and Hepatology, 15(8), 1256–​1264. Graham, E. K., Rutsohn, J. P., Turiano, N. A., Bendayan, R., Batterham, P. J., Gerstorf, D., et al. (2017). Personality predicts mortality risk: An integrative data analysis of 15 international longitudinal studies. Journal of Research in Personality, 70, 174–​186. Graham, N., Ward, J., Mackay, D., Pell, J. P., Cavanagh, J., Padmanabhan, S., et al. (2019). Impact of major depression on cardiovascular outcomes for individuals with hypertension: prospective survival analysis in UK Biobank. BMJ Open, 9(9), e024433. Granath, J., Ingvarsson, S., von Thiele, U., & Lundberg, U. (2006). Stress management: a randomized study of cognitive behavioural therapy and yoga. Cognitive Behavioral Therapy, 35(1), 3–​10. Grandahl, M., Chun Paek, S., Grisurapong, S., Sherer, P., Tyden, T., & Lundberg, P. (2018). Parents’ knowledge, beliefs, and acceptance of the HPV vaccination in relation to their socio-​ demographics and religious beliefs: a cross-​ sectional study in Thailand. PloS One, 13(2), e0193054.

926 •  R eferences

Granqvist, P., Fredrikson, M., Unge, P., Hagenfeldt, A., Valind, S., Larhammar, D., et al. (2005). Sensed presence and mystical experiences are predicted by suggestibility, not by the application of transcranial weak complex magnetic fields. Neuroscience Letters, 379(1), 1–​6. Granqvist, P., & Hagekull, B. (2001). Seeking security in the new age: on attachment and emotional compensation. Journal for the Scientific Study of Religion, 40(3), 527–​545. Grant, B. F., Chou, S. P., Saha, T. D., Pickering, R. P., Kerridge, B. T., Ruan, W. J., et al. (2017). Prevalence of 12-​month alcohol use, high-​risk drinking, and DSM-​IV alcohol use disorder in the United States, 2001–​2002 to 2012–​2013. JAMA Psychiatry, 74(9), 911–​923. Grant, J. A., Courtemanche, J., Duerden, E. G., Duncan, G. H., & Rainville, P. (2010). Cortical thickness and pain sensitivity in Zen meditators. Emotion, 10(1), 43–​53. Grant, J. E., Lust, K., Fridberg, D. J., King, A. C., & Chamberlain, S. R. (2019). E-​cigarette use (vaping) is associated with illicit drug use, mental health problems, and impulsivity in university students. Annals of Clinical Psychiatry, 31(1), 27. Gravelle, J. G., Marples, D. J., & Sherlock, M. F. (2020). Tax issues relating to charitable contributions and organizations. Congressional Research Service. Retrieved on 10-​3-​2020 from https://​fas.org/​sgp/​crs/​misc/​R45​922.pdf. Gray, C., & McCormack, S. (2019). Yoga for chronic non-​malignant pain management. Canadian Agency for Drugs and Technologies in Health. Retrieved on 8-​20-​2-​20 from https://​www.ncbi. nlm.nih.gov/​books/​NBK546​324/​. Greden, J. F. (2001). The burden of recurrent depression. Journal of Clinical Psychiatry, 62, 5–​9. Greeff, A. P., & Van Der Merwe, S. (2004). Variables associated with resilience in divorced families. Social Indicators Research, 68(1), 59–​75. Green, K. M., Doherty, E. E., Reisinger, H. S., Chilcoat, H. D., & Ensminger, M. (2010). Social integration in young adulthood and the subsequent onset of substance use and disorders among a community population of urban African Americans. Addiction, 105(3), 484–​493. Green, M., & Elliott, M. (2010). Religion, health, and psychological well-​being. Journal of Religion and Health, 49(2), 149–​163. Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R., et al. (1999). The economic burden of anxiety

disorders in the 1990s. Journal of Clinical Psychiatry, 60(7), 427–​435. Greenberg, P. E., Fournier, A. A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The economic burden of adults with major depressive disorder in the United States (2005 and 2010). Journal of Clinical Psychiatry, 76(2), 155–​162. Greene, K. V., & Yoon, B. J. (2004). Religiosity, economics and life satisfaction. Review of Social Economy, 62(2), 245–​261. Greenfield, B. L., Hallgren, K. A., Venner, K. L., Hagler, K. J., Simmons, J. D., Sheche, J. N., et al. (2015). Cultural adaptation, psychometric properties, and outcomes of the Native American Spirituality Scale. Psychological Services, 12(2), 123–​133. Greenfield, E. A., & Marks, N. F. (2007a). Religious social identity as an explanatory factor for associations between more frequent formal religious participation and psychological well-​ being. International Journal for the Psychology of Religion, 17(3), 245–​259. Greenfield, E. A., & Marks, N. F. (2007b). Continuous participation in voluntary groups as a protective factor for the psychological well-​being of adults who develop functional limitations: evidence from the National Survey of Families and Households. Journals of Gerontology, 62B(1), S60–​S68. Greenfield, P. M. (2013). The changing psychology of culture from 1800 through 2000. Psychological Science, 24(9), 1722–​1731. Greening, L., & Stoppelbein, L. (2002). Religiosity, attributional style, and social support as psychosocial buffers for African American and White adolescents’ perceived risk for suicide. Suicide & Life-​Threatening Behavior, 32(4), 404–​417. Greer, J. A., Applebaum, A. J., Jacobsen, J. C., Temel, J. S., & Jackson, V. A. (2020). Understanding and addressing the role of coping in palliative care for patients with advanced cancer. Journal of Clinical Oncology, 38(9), 915–​925. Greeson, J. M., Smoski, M. J., Suarez, E. C., Brantley, J. G., Ekblad, A. G., Lynch, T. R., et al. (2015). Decreased symptoms of depression after mindfulness-​based stress reduction: potential moderating effects of religiosity, spirituality, trait mindfulness, sex, and age. Journal of Alternative and Complementary Medicine, 21(3), 166–​174. Greil, A., McQuillan, J., Benjamins, M., Johnson, D. R., Johnson, K. M., & Heinz, C. R. (2010). Specifying the effects of religion on medical

helpseeking: the case of infertility. Social Science & Medicine, 71(4), 734–​742. Grella, C. E., & Lovinger, K. (2012). Gender differences in physical and mental health outcomes among an aging cohort of individuals with a history of heroin dependence. Addictive Behaviors, 37(3), 306–​312. Grewen, K. M., Girdler, S. S., Amico, J., & Light, K. C. (2005). Effects of partner support on resting oxytocin, cortisol, norepinephrine, and blood pressure before and after warm partner contact. Psychosomatic Medicine, 67(4), 531–​538. Griep, Y., Hanson, L. M., Vantilborgh, T., Janssens, L., Jones, S. K., & Hyde, M. (2017). Can volunteering in later life reduce the risk of dementia? PloS One, 12(3), e0173885. Griese, N. L. (2010). The Bible vs. Mao: A “best guess” of the top 25 bestselling books of all time. Retrieved on 5-​27-​2019 from https://​pub​lish​ ingp​ersp​ecti​ves.com/​2010/​09/​top-​25-​best​sell​ ing-​books-​of-​all-​time/​. Griffith, J. L., Myers, N., & Compton, M. T. (2016). How can community religious groups aid recovery for individuals with psychotic illnesses? Community Mental Health Journal, 52(7), 775–​780. Groer, M. W., & Davis, M. W. (2006). Cytokines, infections, stress, and dysphoric moods in breastfeeders and formula feeders. Journal of Obstetric, Gynecologic & Neonatal Nursing, 35(5), 599–​607. Gross, C., & Hen, R. (2004). The developmental origins of anxiety. Nature Reviews Neuroscience, 5(7), 545. Grossi, E., Blessi, G. T., & Sacco, P. L. (2019). Magic moments: determinants of stress relief and subjective wellbeing from visiting a cultural heritage site. Culture, Medicine, and Psychiatry, 43(1), 4–​24. Grosso, G., Marventano, S., Yang, J., Micek, A., Pajak, A., Scalfi, L., et al. (2017). A comprehensive meta-​analysis on evidence of Mediterranean diet and cardiovascular disease. Critical Reviews in Food Science and Nutrition, 57(15), 3218–​3232. Grossoehme, D. H., Opipari‐Arrigan, L., VanDyke, R., Thurmond, S., & Seid, M. (2012). Relationship of adherence determinants and parental spirituality in cystic fibrosis. Pediatric Pulmonology, 47(6), 558–​566. Grossoehme, D. H., Szczesniak, R. D., Britton, L. L., Siracusa, C. M., Quittner, A. L., Chini, B. A., et al. (2015). Adherence determinants in cystic fibrosis: cluster analysis of parental psychosocial, religious, and/​or spiritual factors. Annals of the American Thoracic Society, 12(6), 838–​846.

References • 927

Grossoehme, D. H., Friebert, S., Baker, J. N., Tweddle, M., Needle, J., Chrastek, J., et al. (2020). Association of religious and spiritual factors with patient-​reported outcomes of anxiety, depressive symptoms, fatigue, and pain interference among adolescents and young adults with cancer. JAMA Network Open, 3(6), e206696. Grover, S., & Helliwell, J. F. (2019). How’s life at home? New evidence on marriage and the set point for happiness. Journal of Happiness Studies, 20(2), 373–​390. Grover, S., Davuluri, T., & Chakrabarti, S. (2014). Religion, spirituality, and schizophrenia: a review. Indian Journal of Psychological Medicine, 36(2), 119. Grover, S., Hazari, N., Aneja, J., Chakrabarti, S., & Avasthi, A. (2016). Influence of religion and supernatural beliefs on clinical manifestation and treatment practices in patients with bipolar disorder. Nordic Journal of Psychiatry, 70(6), 442–​449. Grulke, N., Bailer, H., Blaser, G., Geyer, M., Brahler, E., & Albani, C. (2003). Measuring religious attitudes: reliability and validity of the German version of the Systems of Belief Inventory (SBI-​15R-​D) in a representative sample. Mental Health, Religion & Culture, 6(3), 203–​213. Grundy, S. M. (2016). Metabolic syndrome update. Trends in Cardiovascular Medicine, 26(4), 364–​373. Gryczynski, J., & Ward, B. W. (2011). Social norms and the relationship between cigarette use and religiosity among adolescents in the United States. Health Education & Behavior, 38(1), 39–​48. Gryczynski, J., & Ward, B. W. (2012). Religiosity, heavy alcohol use, and vicarious learning networks among adolescents in the United States. Health, Education & Behavior, 39(3), 341–​351. Grzywacz, J. G., & Keyes, C. L. (2004). Toward health promotion: physical and social behaviors in complete health. American Journal of Health Behavior, 28(2), 99–​111. Gu, D., Dupre, M. E., Liu, G., Gu, D., Dupre, M. E., & Liu, G. (2007). Characteristics of the institutionalized and community-​residing oldest-​old in China. Social Science & Medicine, 64(4), 871–​883. Guan, S. A., Bower, J. E., Almeida, D. M., Cole, S. W., Dahl, R. E., Irwin, M. R., et al. (2016). Parental support buffers the association of depressive symptoms with cortisol and C-​reactive protein

928 •  R eferences

during adolescence. Brain, Behavior, and Immunity, 57, 134–​143. Gubernskaya, Z. (2010). Changing attitudes toward marriage and children in six countries. Sociological Perspectives, 53(2), 179–​200. Guido, D., Leonardi, M., Mellor-​Marsá, B., Moneta, M. V., Sanchez-​Niubo, A., Tyrovolas, S., et al. (2020). Pain rates in general population for the period 1991–​2015 and 10-​years prediction. Journal of Headache and Pain, 21, 1–​11. Guinness World Records (2019). Best-​selling book of non-​fiction. Retrieved on 5-​27-​2019 from http://​www.guinn​essw​orld​reco​rds.com/​world-​ reco​rds/​best-​sell​ing-​book-​of-​non-​fict​ion/​. Guiraud, V., & Touzé, E. (2013). Psychological and psychiatric triggers and risk factors for stroke. In Neuropsychiatric Symptoms of Cerebrovascular Diseases. Springer, London, pp. 255–​297. Gulati, K., Guhathakurta, S., Joshi, J., Rai, N., & Ray, A. (2016). Cytokines and their role in health and disease: a brief overview. MOJ Immunology, 4(2), 1–​9. Gulli, G., Rutten-​Jacobs, L. C., Kalra, L., Rudd, A. G., Wolfe, C. D., & Markus, H. S. (2016). Differences in the distribution of stroke subtypes in a UK black stroke population: final results from the South London Ethnicity and Stroke Study. BMC Medicine, 14(1), 77. Gunderson, J. G., Herpertz, S. C., Skodol, A. E., Torgersen, S., & Zanarini, M. C. (2018). Borderline personality disorder. Nature Reviews Disease Primers, 4, 18029 (pp. 1–​20). Guo, C., Webb, N. J., Abzug, R., & Peck, L. R. (2013). Religious affiliation, religious attendance, and participation in social change organizations. Nonprofit and Voluntary Sector Quarterly, 42(1), 34–​58. Guo, S. (2021). Developmental patterns of religiosity in relation to criminal trajectories among serious offenders moving from adolescence to young adult. Crime & Delinquency, 67(10), 1614–​1644. Guo, S., & Metcalfe, C. (2019). Religion as a social control: A longitudinal study of religious involvement and substance use. Crime & Delinquency, 65(8), 1149–​1181. Gupta, D., & Morley, J. E. (2011). Hypothalamic‐ pituitary‐adrenal (HPA) axis and aging. Comprehensive Physiology, 4(4), 1495–​1510. Gupta, R., Prakash, H., Gupta, V. P., & Gupta, K. D. (1997). Prevalence and determinants of coronary heart disease in a rural population of India. Journal of Clinical Epidemiology, 50, 203–​209.

Gupta, R., Gupta, S., Sharma, S., Sinha, D. N., & Mehrotra, R. (2018). Risk of coronary heart disease among smokeless tobacco users: results of systematic review and meta-​analysis of global data. Nicotine and Tobacco Research, 21(1), 25–​31. Gupta, S., & Warner, J. (2008). Alcohol-​related dementia: a 21st-​century silent epidemic? British Journal of Psychiatry, 193, 351–​353. Gur, M., Miller, L., Warner, V., Wickramaratne, P., & Weissman, M. (2005). Maternal depression and the intergenerational transmission of religion. Journal of Nervous and Mental Disease, 193, 338–​345. Gurak, K. K., Weisman de Mamani, A., & Ironson, G. (2017). Does religiosity predict attrition from a culturally-​informed family treatment for schizophrenia that targets religious coping? Journal of Consulting and Clinical Psychology, 85(10), 937–​949. Gurrentz, B. (2018). Living with an unmarried partner now common for young adults. United States Census Bureau. Retrieved on 10-​18-​2019 from https://​www.cen​sus.gov/​libr​ary/​stor​ies/​ 2018/​11/​cohab​itai​ton-​is-​up-​marri​age-​is-​down-​ for-​young-​adu​lts.html. Gutierrez, J., Devia, C., Weiss, L., Chantarat, T., Ruddock, C., Linnell, J., et al. (2014). Health, community, and spirituality: evaluation of a multicultural faith-​based diabetes prevention program. Diabetes Educator, 40(2), 214–​222. Gutiérrez-​Zotes, A., Labad, J., Martín-​Santos, R., García-​Esteve, L., Gelabert, E., Jover, M., et al. (2016). Coping strategies for postpartum depression: a multi-​centric study of 1626 women. Archives of Women’s Mental Health, 19(3), 455–​461. Guttmann, J. (1984). Cognitive morality and cheating behavior in religious and secular school children. Journal of Educational Research, 77(4), 249–​254. Guure, C. B., Ibrahim, N. A., Adam, M. B., & Said, S. M. (2017). Impact of physical activity on cognitive decline, dementia, and its subtypes: Meta-​analysis of prospective studies. BioMed Research International, ID 9016924. Guyatt, G. H., Sackett, D. L., Sinclair, J. C., Hayward, R., Cook, D. J., Cook, R. J., et al. (1995). Users’ guides to the medical literature: IX. A method for grading health care recommendations. Journal of the American Medical Association, 274(22), 1800–​1804. Gyimah, S. O., Tenkorang, E. Y., Takyi, B. K., Adjei, J., & Fosu, G. (2010). Religion, HIV/​AIDS and sexual risk-​taking among men in Ghana. Journal of Biosocial Science, 42(4), 531–​547.

Gyimah, S. O., Kodzi, I., Emina, J., Adjei, J., & Ezeh, A. (2014). Adolescent sexual risk-​ taking in the informal settlements of Nairobi, Kenya: understanding the contributions of religion. Journal of Religion and Health, 53(1), 13–​26. Haack, M., Simpson, N., Sethna, N., Kaur, S., & Mullington, J. (2020). Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications. Neuropsychopharmacology, 45(1), 205–​216. Haass-​Koffler, C. L., Swift, R. M., & Leggio, L. (2018). Noradrenergic targets for the treatment of alcohol use disorder. Psychopharmacology, 235(6), 1625–​1634. Haber, J. R., & Jacob, T. (2007). Alcoholism risk moderation by a socio-​religious dimension. Journal of Studies on Alcohol and Drugs, 68(6), 912–​922. Haber, J. R., Grant, J. D., Jacob, T., Koenig, L. B., & Heath, A. (2012). Alcohol milestones, risk factors, and religion/​spirituality in young adult women. Journal of Studies on Alcohol and Drugs, 73(1), 34–​43. Haber, J. R., Grant, J. D., Sartor, C. E., Koenig, L. B., Heath, A., & Jacob, T. (2013). Religion/​ spirituality, risk, and the development of alcohol dependence in female twins. Psychology of Addictive Behaviors, 27(3), 562–​572. Haberstick, B. C., Young, S. E., Zeiger, J. S., Lessem, J. M., Hewitt, J. K., & Hopfer, C. J. (2014). Prevalence and correlates of alcohol and cannabis use disorders in the United States: results from the National Longitudinal Study of Adolescent Health. Drug and Alcohol Dependence, 136, 158–​161. Hackney, A. C., & Ağgön, E. (2019). Psychoneuroendocrinology and physical activity. In Braddick, O. (ed.), Oxford Research Encyclopedia of Psychology. New York, NY: Oxford University Press. Hackshaw, A., Morris, J. K., Boniface, S., Tang, J. L., & Milenković, D. (2018). Low cigarette consumption and risk of coronary heart disease and stroke: meta-​analysis of 141 cohort studies in 55 study reports. British Medical Journal, 360, j5855. Hadaway, C. K., & Roof, W. C. (1978). Religious commitment and the quality of life in American society. Review of Religious Research, 19, 295–​307. Hadaway, C. K., Marler, P. L., & Chaves, M. (1998). Overreporting church attendance in America: evidence that demands the same verdict. American Sociological Review, 63(1), 122–​130.

References • 929

Hafizi, S., Tabatabaei, D., & Koenig, H. G. (2014). Borderline personality disorder and religion: A perspective from a Muslim country. Iran Journal of Psychiatry, 9(3), 137–​141. Hafizi, S., Tabatabaei, D., Memari, A. H., Saghazadeh, A., & Koenig, H. G. (2016). Belief into action scale: psychometric properties of the Farsi version. Mental Health, Religion & Culture, 19(5), 440–​447. Haghighi, M., Rahmati-​Najarkolaei, F., & Ansarian, A. (2015). Correlation between spiritual wellbeing and religious orientation among staffs of one military medical university. Journal of Health Policy and Sustainable Health, 1(4), 137–​140. Haglund, K. A., & Fehring, R. J. (2010). The association of religiosity, sexual education, and parental factors with risky sexual behaviors among adolescents and young adults. Journal of Religion and Health, 49(4), 460–​472. Hai, A. H., Franklin, C., Park, S., Dinitto, D. M., & Aurelio, N. (2019). The efficacy of spiritual/​ religious interventions for substance use problems: a systematic review and meta-​analysis of randomized controlled trials. Drug and Alcohol Dependence, 202, 134–​148. Hajihasani, M., & Sim, T. (2019). Marital satisfaction among girls with early marriage in Iran: emotional intelligence and religious orientation. International Journal of Adolescence and Youth, 24(3), 297–​306. Hak, E., Schönbeck, Y., Van Essen, G. A., De Melker, H., & Sanders, E. A. (2005). Negative attitude of highly educated parents and health care workers towards future vaccinations in the Dutch childhood vaccination program. Vaccine, 23(24), 3103–​3107. Hales, C. M., Fryar, C. D., Carroll, M. D., Freedman, D. S., & Ogden, C. L. (2018). Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007–​2008 to 2015–​2016. Journal of the American Medical Association, 319(16), 1723–​1725. Hall, D. E. (2006). Religious attendance: more cost-​ effective than Lipitor? Journal of the American Board of Family Medicine, 19(2), 103–​109. Hall, D. E. (2020). We can do better: why pastoral care visitation to hospitals is essential, especially in times of crisis. Journal of Religion and Health, 59(5), 2283–​2287. Haller, S., Xekardaki, A., Delaloye, C., Canuto, A., Lövblad, K. O., Gold, G., et al. (2011). Combined analysis of grey matter voxel-​based morphometry and white matter tract-​based spatial statistics in late-​life bipolar disorder.

930 •  R eferences

Journal of Psychiatry & Neuroscience, 36(6), 391–​401. Hallfors, D. D., Cho, H., Iritani, B. J., Mapfumo, J., Mpofu, E., Luseno, W. K., et al. (2013). Preventing HIV by providing support for orphan girls to stay in school: does religion matter? Ethnicity & Health, 18(1), 53–​65. Hallstrom, T., & Persson, G. (1984). The relationship of social setting to major depression. Acta Psychiatrica Scandinavia, 70, 327–​336. Halpern, C. T., Waller, M. W., Spriggs, A., & Hallfors, D. D. (2006). Adolescent predictors of emerging adult sexual patterns. Journal of Adolescent Health, 39(6), 926.e1–​926.e10. Halstead, J. M., & Taylor, M. J. (2000). Learning and teaching about values. Cambridge Journal of Education, 30(2), 169–​202. Hamada, T., Yuan, C., Yurgelun, M. B., Perez, K., Khalaf, N., Morales-​Oyarvide, V., et al. (2019). Family history of cancer, Ashkenazi Jewish ancestry, and pancreatic cancer risk. British Journal of Cancer, 120(8), 848–​854. Hamdan, S., & Peterseil-​Yaul, T. (2020). Exploring the psychiatric and social risk factors contributing to suicidal behaviors in religious young adults. Psychiatry Research, 287, 112449. Hamil-​Luker, J., Land, K. C., & Blau, J. (2004). Diverse trajectories of cocaine use through early adulthood among rebellious and socially conforming youth. Social Science Research, 33(2), 300–​321. Hamilton, L. C. (2008). Statistics with STATA: Version 10. Pacific Grove, CA: Duxbury Press. Hampson, S. E. (2012). Personality processes: mechanisms by which personality traits “get outside the skin.” Annual Review of Psychology, 63, 315–​339. Hamren, K., Chungkham, H. S., & Hyde, M. (2015). Religion, spirituality, social support and quality of life: measurement and predictors CASP-​12 (v2) amongst older Ethiopians living in Addis Ababa. Aging & Mental Health, 19(7), 610–​621. Handing, E. P., Andel, R., Kadlecova, P., Gatz, M., & Pedersen, N. L. (2015). Midlife alcohol consumption and risk of dementia over 43 years of follow-​up. Journals of Gerontology, 70A(10), M1248–​1254. Hanel, P. H., Demmrich, S., & Wolfradt, U. (2019). Centrality of religiosity, schizotypy, and human values. Religions, 10(5), 297. Haney, A. M., & Rollock, D. (2020). The role of religion, doubt, and personality in emerging adult mental health. Psychology of Religion and Spirituality, 12(2), 247–​253.

Hank, K., & Schaan, B. (2008). Cross-​national variations in the correlation between frequency of prayer and health among older Europeans. Research on Aging, 30, 36–​54. Hanley, M. A., Jensen, M. P., Ehde, D. M., Hoffman, A. J., Patterson, D. R., & Robinson, L. R. (2004). Psychosocial predictors of long-​term adjustment to lower-​limb amputation and phantom limb pain. Disability and Rehabilitation, 26(14–​15), 882–​893. Hannighofer, J., Foran, H., Hahlweg, K., & Zimmermann, T. (2017). Impact of relationship status and quality (family type) on the mental health of mothers and their children. Frontiers in Psychiatry, 8, 266. Hänsel, A., Hong, S., Camara, R. J., & Von Kaenel, R. (2010). Inflammation as a psychophysiological biomarker in chronic psychosocial stress. Neuroscience & Biobehavioral Reviews, 35(1), 115–​121. Hanson, C. L., Crandall, A., Barnes, M. D., Magnusson, B., Novilla, M. L., & King, J. (2019). Family-​focused public health: supporting homes and families in policy and practice. Frontiers in Public Health, 7, 59. Hanson, T. L. (1999). Does parental conflict explain why divorce is negatively associated with child welfare? Social Forces, 77(4), 1283–​1316. Hantsoo, L., Kornfield, S., Anguera, M. C., & Epperson, C. N. (2019). Inflammation: a proposed intermediary between maternal stress and offspring neuropsychiatric risk. Biological Psychiatry, 85(2), 97–​106. Hardy, S. A., & Willoughby, B. J. (2017). Religiosity and chastity among single young adults and married adults. Psychology of Religion and Spirituality, 9(3), 285. Hare, R. D. (1993). Without Conscience: The Disturbing World of the Psychopaths Among Us. New York, NY: Guilford. Hargreaves, A. L., Nowak, G., Frew, P., Hinman, A. R., Orenstein, W. A., Mendel, J., et al. (2020). Adherence to timely vaccinations in the United States. Pediatrics, 145(3), e20190783. Harley, D. A. (2006). Indigenous healing practices among rural elderly African Americans. International Journal of Disability, Development and Education, 53(4), 433–​452. Harrell, J. P. (1980). Psychological factors and hypertension. Psychological Bulletin, 87(3), 482–​501. Harrell, Z. A., & Broman, C. L. (2009). Racial/​ethnic differences in correlates of prescription drug misuse among young adults. Drug and Alcohol Dependence, 104, 268–​271.

Harris, A., & Seckl, J. (2011). Glucocorticoids, prenatal stress and the programming of disease. Hormones and Behavior, 59(3), 279–​289. Harris, A. H., McKellar, J. D., Moos, R. H., Schaefer, J. A., & Cronkite, R. C. (2006). Predictors of engagement in continuing care following residential substance use disorder treatment. Drug & Alcohol Dependence, 84(1), 93–​101. Harris, A. H., & Thoresen, C. E. (2005). Volunteering is associated with delayed mortality in older people. Journal of Health Psychology, 10(6), 739–​752. Harris, J. I., Erbes, C. R., Engdahl, B. E., Thuras, P., Murray‐Swank, N., Grace, D., et al. (2011). The effectiveness of a trauma focused spiritually integrated intervention for veterans exposed to trauma. Journal of Clinical Psychology, 67(4), 425–​438. Harris, J. I., Usset, T., Voecks, C., Thuras, P., Currier, J., & Erbes, C. (2018a). Spiritually integrated care for PTSD: a randomized controlled trial of “Building Spiritual Strength”. Psychiatry Research, 267, 420–​428. Harris, J. I., Usset, T., Krause, L., Schill, D., Reuer, B., Donahue, R., & Park, C. L. (2018b). Spiritual/​religious distress is associated with pain catastrophizing and interference in veterans with chronic pain. Pain Medicine, 19(4), 757–​763. Harris, K. M., Edlund, M. J., & Larson, S. L. (2006). Religious involvement and the use of mental health care. Health Services Research, 41(2), 395–​410. Harris, S. A., & Harris, E. A. (2015). Herpes simplex virus type 1 and other pathogens are key causative factors in sporadic Alzheimer’s disease. Journal of Alzheimer’s Disease, 48(2), 319–​353. Harrison, T. C., & Stuifbergen, A. K. (2006). Life purpose: effect on functional decline and quality of life in polio survivors. Rehabilitation Nursing, 31, 149–​154. Harrow, M., Grossman, L. S., Herbener, E. S., & Davies, E. W. (2000). Ten-​year outcome: patients with schizoaffective disorders, schizophrenia, affective disorders and mood-​incongruent psychotic symptoms. British Journal of Psychiatry, 177(5), 421–​426. Hart, M. B. (2007). The Healthy Jew: The Symbiosis of Judaism and Modern Medicine. Cambridge, UK: Cambridge University Press. Hasenbring, M. I., Chehadi, O., Titze, C., & Kreddig, N. (2014). Fear and anxiety in the transition from acute to chronic pain. Pain Management, 4(5), 363–​374.

References • 931

Hasin, D., Endicott, J., & Collins, L. (1985). Alcohol and drug abuse in patients with affective syndromes. Comprehensive Psychiatry, 26, 283–​295. Hasin, D. S., Stinson, F. S., Ogburn, E., & Grant, B. F. (2007). Prevalence, correlates, disability, and comorbidity of DSM-​IV alcohol abuse and dependence in the United States. Archives of General Psychiatry, 64(7), 830–​842. Hasin, D. S., Saha, T. D., Kerridge, B. T., Goldstein, R. B., Chou, S. P., Zhang, H., et al. (2015). Prevalence of marijuana use disorders in the United States between 2001–​2002 and 2012–​ 2013. JAMA Psychiatry, 72(12), 1235–​1242. Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., et al. (2018). Epidemiology of adult DSM-​5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry, 75(4), 336–​346. Hasin, D. S., Shmulewitz, D., & Sarvet, A. L. (2019). Time trends in US cannabis use and cannabis use disorders overall and by sociodemographic subgroups. American Journal of Drug and Alcohol Abuse, 45(6), 623–​643. Haslam, S. A., McMahon, C., Cruwys, T., Haslam, C., Jetten, J., & Steffens, N. K. (2018). Social cure, what social cure? The propensity to underestimate the importance of social factors for health. Social Science & Medicine, 198, 14–​21. Hastert, T. A., Ruterbusch, J. J., Beresford, S. A., Sheppard, L., & White, E. (2016). Contribution of health behaviors to the association between area-​level socioeconomic status and cancer mortality. Social Science & Medicine, 148, 52–​58. Hatch, L. R. (1991). Informal support patterns of older African-​American and White women. Research on Aging, 13, 144–​170. Hatefi, M., Tarjoman, A., & Borji, M. (2019). Do religious coping and attachment to God affect perceived pain? Study of the elderly with chronic back pain in Iran. Journal of Religion and Health, 58(2), 465–​475. Hatefnia, E., Niknami, S., Bazargan, M., Mahmoodi, M., Lamyianm, M., & Alavi, N. (2010). Correlates of mammography utilization among working Muslim Iranian women. Health Care for Women International, 31(6), 499–​514. Hatoum, H. T., Thomas, S. K., Lin, S. J., Lane, R., & Bullock, R. (2009). Predicting time to nursing home placement based on activities of daily living scores: a modeling analysis using data on Alzheimer’s disease patients receiving rivastigmine or donepezil. Journal of Medical Economics, 12(2), 98–​103.

932 •  R eferences

Haug, S., Nunez, C. L., Becker, J., Gmel, G., & Schaub, M. P. (2014). Predictors of onset of cannabis and other drug use in male young adults. BMC Public Health, 12, 1202. Haushofer, J., & Reisinger, J. (2019). Atheist primes reduce religiosity and subjective wellbeing. Religion, Brain & Behavior, 9(2), 126–​142. Havighurst, R. J. (1956). Moral character and religious education. Religious Education, 51(3), 163–​169. Havlik, R. J., Garrison, R. J., Feinleib, M., Kannel, W. B., Castelli, W. P., & Mcnamara, P. M. (1979). Blood pressure aggregation in families. American Journal of Epidemiology, 110(3), 304–​312. Havranek, E. P., Mujahid, M. S., Barr, D. A., Blair, I. V., Cohen, M. S., Cruz-​Flores, S., et al. (2015). Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation, 132(9), 873–​898. Hawkes, C. H., Ramkumar, N., Baker, R., & Lyon, J. L. (2007). Multiple sclerosis in Latter Day Saints (Mormons). Acta Neurologica Scandinavica, 115(4), 260–​264. Hawkley, L. C., Cole, S. W., Capitanio, J. P., Norman, G. J., & Cacioppo, J. T. (2012). Effects of social isolation on glucocorticoid regulation in social mammals. Hormones and Behavior, 62(3), 314–​323. Hawthorne, D. M., Youngblut, J. M., & Brooten, D. (2016). Parent spirituality, grief, and mental health at 1 and 3 months after their infant’s/​ child’s death in an intensive care unit. Journal of Pediatric Nursing, 31, 73–​80. Hawthorne, S. (2001). Prayerwalking. Austin, TX: Waymakers. Retrieved on 1-​2-​2020 from https://​waymak​ers.org/​wp-​cont​ent/​uplo​ads/​ 2012/​08/​Pray​erwa​lkGu​ide.pdf. Hawthorne, S., & Kendrick, G. (1993). Prayer Walking: Praying on Site with Insight. Lake Mary, FL: Charisma Media. Hawton, K., Comabella, C. C., Haw, C., & Saunders, K. (2013). Risk factors for suicide in individuals with depression. Journal of Affective Disorders, 147(1–​3), 17–​28. Hayley, A. C., Stough, C., & Downey, L. A. (2017). DSM-​5 cannabis use disorder, substance use and DSM-​5 specific substance-​ use disorders: evaluating comorbidity in a population-​based sample. European Neuropsychopharmacology, 27(8), 732–​743. Hays, J. C., Meador, K. G., Branch, P. S., & George, L. K. (2001). The Spiritual History Scale in Four Dimensions (SHS-​4) validity and reliability. Gerontologist, 41(2), 239–​249.

Hays, K., & Lincoln, K. D. (2017). Mental health help-​seeking profiles among African Americans: exploring the influence of religion. Race and Social Problems, 9(2), 127–​138. Hays, R. D., Stacy A. W., Widaman, D. M., & Downey, R. (1986). Multistage path models of adolescent alcohol and drug use: a reanalysis. Journal of Drug Issues, 16, 357–​369. Hays, T. O. (2020). The economic costs of the U.S. criminal justice system. American Action Forum. Retrieved on 9-​21-​2020 from https://​ www.amer​ican​acti​onfo​rum.org/​resea​rch/​ the-​econo​mic-​costs-​of-​the-​u-​s-​crimi​nal-​just​ice-​ sys​tem/​. Hayut-​Man, Y. (2019). Re-​Genesis: The First Book of the Bible as Guidance for Our Time. Singapore: Partridge. Hayward, G. M. (2019). Religiosity and premarital sexual behaviors among adolescents. Journal for the Scientific Study of Religion, 58(2), 439–​458. Hayward, R. D., & Elliott, M. (2014). Cross-​national analysis of the influence of cultural norms and government restrictions on the relationship between religion and well-​being. Review of Religious Research, 56(1), 23–​43. Hayward, R. D., & Krause, N. (2013a). Trajectories of late-​life change in God-​mediated control. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 68(1), 49–​58. Hayward, R. D., & Krause, N. (2013b). Changes in church-​based social support relationships during older adulthood. Journals of Gerontology, 68B(1), 85–​96. Hayward, R. D., & Krause, N. (2015). Religion and strategies for coping with racial discrimination among African Americans and Caribbean Blacks. International Journal of Stress Management, 22(1), 70–​91. Hayward, R. D., & Krause, N. (2016a). Forms of attrition in a longitudinal study of religion and health in older adults and implications for sample bias. Journal of Religion and Health, 55(1), 50–​66. Hayward, R. D., Krause, N., Ironson, G., Hill, P. C., & Emmons, R. (2016b). Health and well-​being among the non-​religious: atheists, agnostics, and no preference compared with religious group members. Journal of Religion and Health, 55(3), 1024–​1037. Hayward, R. D., Owen, A. D., Koenig, H. G., Steffens, D. C., & Payne, M. E. (2011). Associations of religious behavior and experiences with extent of regional atrophy in the orbitofrontal cortex during older adulthood. Religion, Brain & Behavior, 1(2), 103–​118.

Hayward, R. D., Owen, A. D., Koenig, H. G., Steffens, D. C., & Payne, M. E. (2012a). Religion and the presence and severity of depression in older adults. American Journal of Geriatric Psychiatry, 20(2), 188–​192. Hayward, R. D., Owen, A. D., Koenig, H. G., Steffens, D. C., & Payne, M. E. (2012b). Longitudinal relationships of religion with posttreatment depression severity in older psychiatric patients: evidence of direct and indirect effects. Depression Research and Treatment, article ID 745970:1–​8. He, F. J., Li, J., & MacGregor, G. A. (2013). Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-​ analysis of randomised trials. British Medical Journal, 346, f1325. He, J., Assanangkornchai, S., Cai, L., & McNeil, E. (2016). Disparities in drinking patterns and risks among ethnic majority and minority groups in China: the roles of acculturation, religion, family and friends. Drug and Alcohol Dependence, 159, 198–​206. Headey, B., Hoehne, G., & Wagner, G. G. (2014). Does religion make you healthier and longer lived? Evidence for Germany. Social Indicators Research, 119(3), 1335–​1361. Healthy People 2020 (2019). Social determinants of health. Retrieved on 11-​9-​2019 from https://​ www.health​ypeo​ple.gov/​2020/​top​ics-​obj​ecti​ves/​ topic/​soc​ial-​deter​mina​nts-​of-​hea​lth. Heaton, R. B., & Pratt, E. L. (1990). The effects of religious homogamy on marital satisfaction and stability. Journal of Family Issues, 11, 191–​207. Hebert, R. S., Dang, Q., & Schulz, R. (2007). Religious beliefs and practices are associated with better mental health in family caregivers of patients with dementia: findings from the REACH study. American Journal of Geriatric Psychiatry, 15(4), 292–​300. Heckenberg, R. A., Eddy, P., Kent, S., & Wright, B. J. (2018). Do workplace-​based mindfulness meditation programs improve physiological indices of stress? A systematic review and meta-​ analysis. Journal of Psychosomatic Research, 114, 62–​71. Hedegaard, H., Curtin, S. C., Warner, M. (2018). Suicide mortality in the United States, 1999–​ 2017. National Center for Health Statistics, Data Brief No. 330 (November). Retrieved on 6-​8-​ 2019 from https://​www.cdc.gov/​nchs/​produ​cts/​ dat​abri​efs/​db330.htm. Hegerl, U., & Heinz, I. (2019). Reflections on causes of suicidal behaviour. Epidemiology and Psychiatric Sciences, 28(5), 469–​472.

References • 933

Heidari, S., Rezaei, M., Sajadi, M., Ajorpaz, N. M., & Koenig, H. G. (2017). Religious practices and self-​care in Iranian patients with type 2 diabetes. Journal of Religion and Health, 56(2), 683–​696. Heim, L., & Schaal, S. (2014). Rates and predictors of mental stress in Rwanda: investigating the impact of gender, persecution, readiness to reconcile and religiosity via a structural equation model. International Journal of Mental Health Systems, 8(1), 37. Hek, K., Direk, N., Newson, R. S., Hofman, A., Hoogendijk, W. J., Mulder, C. L., et al. (2013). Anxiety disorders and salivary cortisol levels in older adults. Psychoneuroendocrinology, 38(2), 300–​305. Helen, G. S., & Eaton, D. L. (2018). Public health consequences of e-​cigarette use. JAMA Internal Medicine, 178(7), 984–​986. Hellevik, O. (2017). The U-​shaped age–​happiness relationship? Quality & Quantity, 51(1), 177–​197. Helliwell, J. F., & Putnam, R. D. (2004). The social context of well-​being. Philosophical Transactions of the Royal Society of London -​Series B: Biological Sciences, 359, 1435–​1446. Helm, H. M., Hays, J. C., Flint, E. P., Koenig, H. G., & Blazer, D. G. (2000). Does private religious activity prolong survival? A six-​year follow-​ up study of 3,851 older adults. Journals of Gerontology, 55A(7), M400–​405. Helmer, C., Damon, D., Letenneur, L., Fabrigoule, C., Barberger-​Gateau, P., Lafont, S., et al. (1999). Marital status and risk of Alzheimer’s disease: a French population-​based cohort study. Neurology, 53(9), 1953–​1953. Helms, S. W., Gallagher, M., Calhoun, C. D., Choukas-​Bradley, S., Dawson, G. C., & Prinstein, M. J. (2015). Intrinsic religiosity buffers the longitudinal effects of peer victimization on adolescent depressive symptoms. Journal of Clinical Child & Adolescent Psychology, 44(3), 471–​479. Helvaci, A., Izgu, N., & Ozdemir, L. (2020). Relationship between symptom burden, medication adherence and spiritual well‐being in patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing, 29(13–​14), 2388–​2396. Hemmati, R., Bidel, Z., Nazarzadeh, M., Valadi, M., Berenji, S., Erami, E., Al Zaben, F., Koenig, H. G., et al. (2018). Religion, spirituality and risk of coronary heart disease: a matched case-​ controlled study and meta-​analysis. Journal of Religion and Health, 58, 1203–​1216.

934 •  R eferences

Hempel, A. G., Meloy, J. R., Stern, R., Ozone, S. J., & Gray, B. T. (2002). Fiery tongues and mystical motivations: glossolalia in a forensic population is associated with mania and sexual/​religious delusions. Journal of Forensic Science, 47(2), 305–​312. Hendershot, G. E. (2003). Mobility limitations and complementary and alternative medicine: are people with disabilities more likely to pray? American Journal of Public Health, 93(7), 1079–​1080. Henderson, A. K. (2016). The long arm of religion: childhood adversity, religion, and self‐ perception among Black Americans. Journal for the Scientific Study of Religion, 55(2), 324–​348. Henderson, A. K., Ellison, C. G., & Glenn, N. D. (2018). Religion and relationship quality among cohabiting and dating couples. Journal of Family Issues, 39(7), 1904–​1932. Henderson, L. (2017). Racial discrimination, religion, and the African American drinking paradox. Race and Social Problems, 9(1), 79–​90. Henderson, W. M., Uecker, J. E., & Stroope, S. (2016). The role of religion in parenting satisfaction and parenting stress among young parents. Sociological Quarterly, 57(4), 675–​710. Hendi, A. S. (2019). Proximate sources of change in trajectories of first marriage in the United States, 1960–​2010. Demography, 56(3), 835–​862. Hennebery, R. B., Dang, D. N., Sisson, C., & Naresh, A. (2020). Factors associated with initiation of HPV vaccination among young women and girls in urban and suburban New Orleans. Journal of Community Health, 45(4), 775–​784. Henrich, J., Bauer, M., Cassar, A., Chytilová, J., & Purzycki, B. G. (2019). War increases religiosity. Nature Human Behaviour, 3(2), 129–​135. Henslee, A. M., Coffey, S. F., Schumacher, J. A., Tracy, M. H., Norris, F., & Galea, S. (2015). Religious coping and psychological and behavioral adjustment after Hurricane Katrina. Journal of Psychology, 149(6), 630–​642. Hermann, C. P. (2001). Spiritual needs of dying patients: a qualitative study. Oncology Nursing Forum, 28(1), 67–​72. Herman-​Stahl, M. A., Krebs, C. P., Kroutil, L. A., & Heller, D. C. (2006). Risk and protective factors for nonmedical use of prescription stimulants and methamphetamine among adolescents. Journal of Adolescent Health, 39(3), 374–​380. Herman-​Stahl, M. A., Krebs, C. P., Kroutil, L. A., & Heller, D. C. (2007). Risk and protective factors for methamphetamine use and nonmedical

use of prescription stimulants among young adults aged 18 to 25. Addictive Behaviors, 32(5), 1003–​1015. Hermstad, A., Honeycutt, S., Flemming, S. S., Carvalho, M. L., Hodge, T., Escoffery, C., et al. (2018). Social environmental correlates of health behaviors in a faith-​based policy and environmental change intervention. Health Education & Behavior, 45(5), 672–​681. Hernán, M. A., Hernández-​Díaz, S., & Robins, J. M. (2004). A structural approach to selection bias. Epidemiology, 15(5), 615–​625. Herndon, C. N., & Jennings, R. G. (1951). A twin-​ family study of susceptibility to poliomyelitis. American Journal of Human Genetics, 3(1), 17. Herold, S. C., Hvidt, N. C., Möller, S., Christensen, K., & Ahrenfeldt, L. J. (2022). Is religiousness associated with better lifestyle and health among Danes? Journal of Religion and Health, 61, 1621–​1640. Heron, M. (2019). Deaths: leading cause for 2017. National Vital Statistics Report, 68(6), 1–​77. Herr, N. R., Hammen, C., & Brennan, P. A. (2007). Current and past depression as predictors of family functioning: a comparison of men and women in a community sample. Journal of Family Psychology, 21(4), 694–​702. Hess, C. (1977). An evaluation of the Teen Challenge Treatment Program. National Institute on Drug Abuse, Services Research Reports. No. 78-​ 440, 1977, 14, US: DHEW, National Institute on Drug Abuse. Heuch, I., Jacobsen, B. K., & Fraser, G. E. (2005). A cohort study found that earlier and longer Seventh-​day Adventist church membership was associated with reduced male mortality. Journal of Clinical Epidemiology, 58(1), 83–​91. Hicks, B. M., Carlson, M. D., Blonigen, D. M., Patrick, C. J., Iacono, W. G., & MGue, M. (2012). Psychopathic personality traits and environmental contexts. Personality Disorders: Theory, Research, and Treatment, 3(3), 209–​227. Hicks, B. M., Foster, K. T., Iacono, W. G., & McGue, M. (2013). Genetic and environmental influences on the familial transmission of externalizing disorders in adoptive and twin offspring. JAMA Psychiatry, 70(10), 1076–​1083. Hidaka, B. H. (2012). Depression as a disease of modernity: explanations for increasing prevalence. Journal of Affective Disorders, 140(3), 205–​214. Hilker, R., Helenius, D., Fagerlund, B., Skytthe, A., Christensen, K., Werge, T. M., et al. (2018). Heritability of schizophrenia and schizophrenia

spectrum based on the nationwide Danish twin register. Biological Psychiatry, 83(6), 492–​498. Hill, A. B. (1965). The environment and disease: ssociation or causation? Proceedings of the Royal Society of Medicine, 58, 1217–​1219. Hill, P. C., & Hood, R. W. (eds.). (1999). Measures of Religiosity. Birmingham, AL: Religious Education Press. Hill, P. C., Hood, R. W., Jr., Jong, J., & Harris, K. (eds.) (2nd edition, forthcoming). Measures of Religiousness and Spirituality. . Hill, P. C., & Pargament, K. I. (2003). Advances in the conceptualization and measurement of religion and spirituality: Implications for physical and mental health research. American Psychologist, 58(1), 64–​74. Hill, T. D. (2008). Religious involvement and healthy cognitive aging. Journals of Gerontology, 63A(5), M478–​479. Hill, T. D., Angel, J. L., Ellison, C. G., & Angel, R. J. (2005). Religious attendance and mortality: an 8-​year follow-​up of older Mexican Americans. Journals of Gerontology, 60(2), S102–​109. Hill, T. D., Burdette, A. M., Ellison, C. G., & Musick, M. A. (2006a). Religious attendance and the health behaviors of Texas adults. Preventive Medicine, 42(4), 309–​312. Hill, T. D., Burdette, A. M., Angel, J. L., & Angel, R. J. (2006b). Religious attendance and cognitive functioning among older Mexican Americans. Journals of Gerontology, 61B(1), P3–​P9. Hill, T. D., Ellison C. G., Burdette, A. M., & Musick, M. A. (2007). Religious involvement and healthy lifestyles: evidence from the Survey of Texas Adults. Annals of Behavioral Medicine, 34(2), 217–​222. Hill, T. D., Burdette, A. M., Regnersu, M., & Angel, R. J. (2008). Religious involvement and attitudes toward parenting among low-​income urban women. Journal of Family Issues, 29(7), 882–​900. Hill, T. D., & McCullough, M. E. (2008). Religious involvement and the intoxication trajectories of low-​income urban women. Journal of Drug Issues, 38(3), 847–​862. Hill, T. D., Rote, S. M., Ellison, C. G., & Burdette, A. M. (2014). Religious attendance and biological functioning: a multiple specification approach. Journal of Aging and Health, 26(5), 766–​785. Hill, T. D., Burdette, A. M., Taylor, J., & Angel, J. L. (2016a). Religious attendance and the mobility trajectories of older Mexican Americans: an application of the growth mixture model. Journal of Health and Social Behavior, 57(1), 118–​134.

References • 935

Hill, T. D., Ellison, C. G., Burdette, A. M., Taylor, J., & Friedman, K. L. (2016b). Dimensions of religious involvement and leukocyte telomere length. Social Science & Medicine, 163, 168–​175. Hill, T. D., Vaghela, P., Ellison, C. G., & Rote, S. (2017a). Processes linking religious involvement and telomere length. Biodemography and Social Biology, 63(2), 167–​188. Hill, T. D., Rote, S. M., & Ellison, C. G. (2017b). Religious participation and biological functioning in Mexico. Journal of Aging and Health, 29(6), 951–​972. Hill, T. D., Bradley, C. S., Dowd-​Arrow, B., & Burdette, A. M. (2019). Religious attendance and the social support trajectories of older Mexican Americans. Journal of Cross-​Cultural Gerontology, 34(4), 403–​416. Hill, T. D., Ellison, C., & Hale, L. (2020a). Religious attendance, depressive symptoms, and sleep disturbance in older Mexican Americans. Mental Health, Religion & Culture, 23(1), 24–​37. Hill, T. D., Saenz, J. L., & Rote, S. M. (2020b). Religious participation and mortality risk in Mexico. Journal of Gerontology, 75(5), 1053–​1061. Hill, T. D., Carr, D. C., Burdette, A. M., & Dowd-​ Arrow, B. (2020c). Life-​course religious attendance and cognitive functioning in later life. Research on Aging, 42(7–​8), 217–​225. Hillbom, M., Saloheimo, P., & Juvela, S. (2011). Alcohol consumption, blood pressure, and the risk of stroke. Current Hypertension Reports, 13(3), 208–​213. Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., et al. (2017). Mindfulness meditation for chronic pain: systematic review and meta-​analysis. Annals of Behavioral Medicine, 51(2), 199–​213. Hilton, S. C., Fellingham, G. W., & Lyon, J. L. (2002). Suicide rates and religious commitment in young adult males in Utah. American Journal of Epidemiology, 155(5), 413–​419. Himmerich, H., Patsalos, O., Lichtblau, N., Ibrahim, M. A., & Dalton, B. (2019). Cytokine research in depression: principles, challenges, and open questions. Frontiers in Psychiatry, 10, 30. Hintikka, J., Koskela, K., Kontula, O., & Viinamaki, H. (2000). Gender differences in associations between religious attendance and mental health in Finland. Journal of Nervous & Mental Disease, 188, 772–​776. Hintikka, J., Koskela, T., Kontula, O., Koskela, K., Koivumaa-​Honkanen, H. T., & Viinamaeki, H. (2001). Religious attendance and life satisfaction

936 •  R eferences

in the Finnish general population. Journal of Psychology & Theology, 29(2), 158–​164. Hirschi, T. (2017). Causes of Delinquency. London, UK: Routledge. Hjelmborg, V., Iachine, I., Skytthe, A., Vaupel, J. W., McGue, M., & Koskenvuo, M. (2006). Genetic influence on human lifespan and longevity. Human Genetics, 119(3), 312–​321. Ho, P. M., Bryson, C. L., & Rumsfeld, J. S. (2009). Medication adherence: its importance in cardiovascular outcomes. Circulation, 119(23), 3028–​3035. Ho, R. T., Sing, C. Y., Fong, T. C., Au-​Yeung, F. S., Law, K. Y., Lee, L. F., et al. (2016). Underlying spirituality and mental health: the role of burnout. Journal of Occupational Health, 58(1), 66–​71. Hockenberry, J. M., Joski, P., Yarbrough, C., & Druss, B. G. (2019). Trends in treatment and spending for patients receiving outpatient treatment of depression in the United States, 1998–​2015. JAMA Psychiatry, 76(8), 810–​817. Hodge, D. R., Marsiglia, F. F., & Nieri, T. (2011). Religion and substance use among youths of Mexican heritage: a social capital perspective. Social Work Research, 35(3), 137–​146. Hodge, D. R., Salas-​Wright, C. P., & Wolosin, R. J. (2016). Addressing spiritual needs and overall satisfaction with service provision among older hospitalized inpatients. Journal of Applied Gerontology, 35(4), 374–​400. Hodge, D. R., & Wolosin, R. J. (2015a). Addressing the spiritual needs of American Indians: predictors of satisfaction. Social Work in Health Care, 54(2), 118–​133. Hodge, D. R., & Wolosin, R. J. (2015b). Failure to address African Americans’ spiritual needs during hospitalization: identifying predictors of dissatisfaction across the arc of service provision. Journal of Gerontological Social Work, 58(2), 190–​205. Hodgins, S., & Klein, S. (2019). Severe mental illness: crime, antisocial and aggressive behavior (Ch. 16). In Polaschek, D. L., Day, A., & Hollin, C. R. (eds.), The Wiley International Handbook of Correctional Psychology. Hoboken, NJ: John Wiley & Sons, pp. 251–​264. Hoertel, N., Le Strat, Y., Angst, J., & Dubertret, C. (2013). Subthreshold bipolar disorder in a US national representative sample: prevalence, correlates and perspectives for psychiatric nosography. Journal of Affective Disorders, 146(3), 338–​347. Hoffman, S., & Marsiglia, F. F. (2014). The impact of religiosity on suicidal ideation among youth

in central Mexico. Journal of Religion and Health, 53(1), 255–​266. Hofmann, L., & Walach, H. (2011). Spirituality and religiosity in psychotherapy: a representative survey among German psychotherapists. Psychotherapy Research, 21(2), 179–​192. Hofmann‐Towfigh, N. (2007). Do students’ values change in different types of schools? Journal of Moral Education, 36(4), 453–​473. Hogan, D. B., Jetté, N., Fiest, K. M., Roberts, J. I., Pearson, D., Smith, E. E., et al. (2016). The prevalence and incidence of frontotemporal dementia: a systematic review. Canadian Journal of Neurological Sciences, 43(S1), S96–​S109. Hoge, D. R. (1972). A validated intrinsic religious motivation scale. Journal for the Scientific Study of Religion, 11, 369–​376. Hoggatt, K. J., Lehavot, K., Krenek, M., Schweizer, C. A., & Simpson, T. (2017). Prevalence of substance misuse among US veterans in the general population. American Journal on Addictions, 26(4), 357–​365. Hohensinner, P. J., Niessner, A., Huber, K., Weyand, C. M., & Wojta, J. (2011). Inflammation and cardiac outcome. Current Opinion in Infectious Diseases, 24(3), 259–​264. Holbrook, C., Hahn-​Holbrook, J., & Holt-​Lunstad, J. (2015). Self-​reported spirituality correlates with endogenous oxytocin. Psychology of Religion and Spirituality, 7(1), 46–​50. Holden, C. L., & Rollins, P. (2019). Discrepant alcohol use, conflict, and couples’ satisfaction in a community sample. American Journal of Family Therapy, 47(5), 311–​327. Holder, M. D., Coleman, B., Krupa, T., & Krupa, E. (2016). Well-​being’s relation to religiosity and spirituality in children and adolescents in Zambia. Journal of Happiness Studies 17(3): 1235–​1253. Holland, K. J., Lee, J. W., Marshak, H. H., & Martin, L. R. (2016). Spiritual intimacy, marital intimacy, and physical/​psychological well-​being: spiritual meaning as a mediator. Psychology of Religion and Spirituality, 8(3), 218–​227. Holt, C. L., Litaker, M. S., Scarinci, I. C., Debnam, K. J., McDavid, C., McNeal, S. F., et al. (2013). Spiritually based intervention to increase colorectal cancer screening among African Americans: screening and theory-​based outcomes from a randomized trial. Health, Education & Behavior, 40(4), 458–​468. Holt, C. L., Clark, E. M., Debnam, K. J., & Roth, D. L. (2014). Religion and health in African

Americans: the role of religious coping. American Journal of Health Behavior, 38(2), 190–​199. Holt, C. L., Clark, E. M., Wang, M. Q., Williams, B. R., & Schulz, E. (2015a). The religion–​health connection among African Americans: what is the role of social capital? Journal of Community & Applied Social Psychology, 25(1), 1–​18. Holt, C. L., Roth, D. L., Huang, J., & Clark, E. M. (2015b). Gender differences in the roles of religion and locus of control on alcohol use and smoking among African Americans. Journal of Studies on Alcohol and Drugs, 76(3), 482–​492. Holt, C. L., Roth, D. L., Huang, J., Park, C. L., & Clark, E. M. (2017). Longitudinal effects of religious involvement on religious coping and health behaviors in a national sample of African Americans. Social Science & Medicine, 187, 11–​19. Holt, C. L., Roth, D. L., Huang, J., & Clark, E. M. (2018). Role of religious social support in longitudinal relationships between religiosity and health-​related outcomes in African Americans. Journal of Behavioral Medicine, 41(1), 62–​73. Holthouser, B., & Bui, N. H. (2016). Meditative interventions and antisocial personality disorder. Counselling Psychology Quarterly, 29(3), 235–​252. Holt-​Lunstad, J., & Smith, T. B. (2016). Loneliness and social isolation as risk factors for CVD: implications for evidence-​based patient care and scientific inquiry. Heart, 102(13), 987–​989. Holt-​Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk. PLoS Medicine, 7(7), e1000316. Holt-​Lunstad, J., Smith, T. B., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and social isolation as risk factors for mortality: a meta-​ analytic review. Perspectives on Psychological Science, 10(2), 227–​237. Honce, R. R., & Schultz-​Cherry, S. (2019). Impact of obesity on influenza A virus pathogenesis, immune response, and evolution. Frontiers in Immunology, 10, 1071. Hong, I., Pryor, L., Wong, R., Ottenbacher, K. J., & Reistetter, T. A. (2020). Comparisons of the association of family and social factors with functional limitations across the United States, Mexico, and South Korea. Journal of Aging and Health, 32(9), 1042–​1051. Hood, R. W., Jr. (1970). Religious orientation and the report of religious experience. Journal for the Scientific Study of Religion, 9, 285–​291. Hood, R. W., Jr. (1974). The construction and preliminary validation of a measure of reported

References • 937

mystical experience. Journal for the Scientific Study of Religion, 14, 29–​41. Hook, J. N., Worthington, E. L., Jr., Davis, D. E., Jennings, D. J., Gartner, A. L., & Hook, J. P. (2010). Empirically supported religious and spiritual therapies. Journal of Clinical Psychology, 66(1), 46–​72. Hoover, J. E. (1948). The youth problem today. Chicago Schools Journal, 30, 33–​35. Hoover, S. M. (1998). Religion in the News: Faith and Journalism in American Public Discourse. Thousand Oaks, CA: SAGE Publications. Hoover’s (2009). The Rich Register. Austin, TX: Hoover’s Business Press. Hope, M. O., Assari, S., Cole-​Lewis, Y. C., & Caldwell, C. H. (2017). Religious social support, discrimination, and psychiatric disorders among Black adolescents. Race and Social Problems, 9(2), 102–​114. Hopkinson, M. D., Reavell, J., Lane, D. A., & Mallikarjun, P. (2019). Cognitive behavioral therapy for depression, anxiety, and stress in caregivers of dementia patients: a systematic review and meta-​analysis. Gerontologist, 59(4), e343–​e362. Hor, K., & Taylor, M. (2010). Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of Psychopharmacology, 24(4 Supp), 81–​90. Horne, B. D., May, H. T., Anderson, J. L., Kfoury, A. G., Bailey, B. M., McClure, B. S., et al. (2008). Usefulness of routine periodic fasting to lower risk of coronary artery disease in patients undergoing coronary angiography. American Journal of Cardiology, 102(7), 814–​819. Horowitz, J., & Povoledo, E. (2020). As they console coronavirus’s victims, Italy’s priests are dying, too. New York Times, April 11. Retrieved on 10-​8-​2020 from https://​www.nyti​mes.com/​ 2020/​04/​11/​world/​eur​ope/​italy-​prie​sts-​coro​ navi​rus.html. Horton, G., Luna, N., & Malloy, T. (2016a). Exploring relationships between adult attachment, spirituality and personality disorder traits among individuals in inpatient treatment for substance use disorders. International Journal of Social Work, 3(1), 16–​41. Horton, E. G., Luna, N., & Malloy, T. (2016b). Exploring the relationships between spirituality and personality disorder traits among a sample of in-​patients in treatment for substance use disorder. International Journal of Mental Health and Addiction, 14(4), 459–​471. Horwitz, I. M., Domingue, B. W., & Harris, K. M. (2020). Not a family matter: the effects

938 •  R eferences

of religiosity on academic outcomes based on evidence from siblings. Social Science Research, 88, 102426. Hosack, L. (2019). Borderline personality disorder and religiosity. Social Work & Christianity, 46(2), 40–​56. Hosseini, L., Kashani, F. L., Akbari, S., Akbari, M. E., & Mehr, S. S. (2016). The Islamic perspective of spiritual intervention effectiveness on bio-​psychological health displayed by gene expression in breast cancer patients. Iranian Journal of Cancer Prevention, 9(2), e6360. Hosseini, M., Salehi, A., Khoshknab, M. F., Rokofian, A., & Davidson, P. M. (2013). The effect of a preoperative spiritual/​religious intervention on anxiety in Shia Muslim patients undergoing coronary artery bypass graft surgery: a randomized controlled trial. Journal of Holistic Nursing, 31(3), 164–​172. Hougaard, A., Lindberg, U., Arngrim, N., Larsson, H. B., Olesen, J., Amin, F. M., et al. (2015). Evidence of a Christmas spirit network in the brain: functional MRI study. British Medical Journal, 351, h6266. Hourani, L. L., Williams, J., Forman-​Hoffman, V., Lane, M. E., Weimer, B., & Bray, R. M. (2012). Influence of spirituality on depression, posttraumatic stress disorder, and suicidality in active duty military personnel. Depression Research and Treatment, Article ID 425463, 1–​9. House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health. Science, 241, 540–​545. House, J. S., Robbins, C., & Metzner, H. L. (1982). The association of social relationships and activities with mortality: prospective evidence from the Tecumseh Community Health Study. American Journal of Epidemiology, 116, 123–​140. Hovey, J. D., Hurtado, G., Morales, L. R., & Seligman, L. D. (2014). Religion-​based emotional social support mediates the relationship between intrinsic religiosity and mental health. Archives of Suicide Research, 18(4), 376–​391. Hoving, C., Reubsaet, A., & de Vries, H. (2007). Predictors of smoking stage transitions for adolescent boys and girls. Preventive Medicine, 44(6), 485–​489. Howard, D. M., Adams, M. J., Clarke, T. K., Hafferty, J. D., Gibson, J., Shirali, M., et al. (2019). Genome-​wide meta-​analysis of depression identifies 102 independent variants and highlights the importance of the prefrontal brain regions. Nature Neuroscience, 22(3), 343-​352. Howard, V. J., Madsen, T. E., Kleindorfer, D. O., Judd, S. E., Rhodes, J. D., Soliman, E. Z.,

et al. (2019). Sex and race differences in the association of incident ischemic stroke with risk factors. JAMA Neurology, 76(2), 179–​186. Howes, O. D., & McCutcheon, R. (2017). Inflammation and the neural diathesis-​stress hypothesis of schizophrenia. Translational Psychiatry, 7(2), e1024. Hoyt, L. T., Craske, M. G., Mineka, S., & Adam, E. K. (2015). Positive and negative affect and arousal: cross-​sectional and longitudinal associations with adolescent cortisol diurnal rhythms. Psychosomatic Medicine, 77(4), 392. Hoyt, L. T., Zeiders, K. H., Ehrlich, K. B., & Adam, E. K. (2016). Positive upshots of cortisol in everyday life. Emotion, 16(4), 431. Hsee, C. K., & Zhang, J. (2010). General evaluability theory. Perspectives on Psychological Science, 5(4), 343–​355. Hsieh, N. (2017). A global perspective on religious participation and suicide. Journal of Health and Social Behavior, 58(3), 322–​339. Hsu, H. C. (2007). Does social participation by the elderly reduce mortality and cognitive impairment? Aging & Mental Health, 11(6), 699–​707. Hu, F. B. (2003). The Mediterranean Diet and mortality: olive oil and beyond. New England Journal of Medicine, 348, 2595–​2596. Hu, S. S., Homa, D. M., Wang, T., Gomez, Y., Walton, K., Lu, H., et al. (2019). Peer-​reviewed: state-​ specific patterns of cigarette smoking, smokeless tobacco use, and e-​cigarette use among adults—​ United States, 2016. Preventing Chronic Disease, 16, E–​17, 1–​15. Hua, H. (2003). The Shurangama Sutra with Commentary, vol. 2, 2nd ed. Ukiah, CA: Buddhist Text Translation Society, p. 46 (also see the Abhisanda Sutta, AN VIII.39, and the Vipaka Sutta, AN VIII.40). Huang, H. T., Kuo, Y. M., Wang, S. R., Wang, C. F., & Tsai, C. H. (2016). Structural factors affecting health examination behavioral intention. International Journal of Environmental Research and Public Health, 13(4), 395. Huang, J. X., Xu, Y. M., & Zhong, B. L. (2020). Relationship between Buddhist belief and suicide risk in Chinese persons undergoing methadone maintenance therapy for heroin dependence. Frontiers in Psychiatry, 11, 414. Huang, Y., Kotov, R., De Girolamo, G., Preti, A., Angermeyer, M., Benjet, C., et al. (2009). DSM–​IV personality disorders in the WHO World Mental Health Surveys. British Journal of Psychiatry, 195(1), 46–​53. Huang, Y. J., Huang, T. W., Lin, F. H., Chung, C. H., Tsao, C. H., & Chien, W. C. (2017). Radiation

therapy for invasive breast cancer increases the risk of second primary lung cancer. Journal of Thoracic Oncology, 12(5), 782–​790. Huber, S. (2003). Zentralitat und Inhalt: Ein Neues Multidimensionales Messmodell der Religiositat. Opladen: Les and Budrich. Huber, S., & Huber, O. W. (2012). The centrality of religiosity scale (CRS). Religions, 3(3), 710–​724. Huda, M., Jasmi, K. A., Mustari, M. I. B., & Basiron, A. B. (2017). Understanding of Wara’(Godliness) as a feature of character and religious education. Social Sciences, 12(6), 1106–​1111. Hudson, D. L., Purnell, J. Q., Duncan, A. E., & Baker, E. (2015). Subjective religiosity, church attendance, and depression in the National Survey of American Life. Journal of Religion and Health, 54(2), 584–​597. Huffman, J. C., Celano, C. M., Beach, S. R., Motiwala, S. R., & Januzzi, J. L. (2013). Depression and cardiac disease: epidemiology, mechanisms, and diagnosis. Cardiovascular Psychiatry and Neurology, Article ID 695925: 1–​14. Hughes, J. R., Solomon, L. J., Naud, S., Fingar, J. R., Helzer, J. E., & Callas, P. W. (2014). Natural history of attempts to stop smoking. Nicotine & Tobacco Research, 16(9), 1190–​1198. Hughes, J. W., Watkins, L., Blumenthal, J. A., Kuhn, C., & Sherwood, A. (2004). Depression and anxiety symptoms are related to increased 24-​hour urinary norepinephrine excretion among healthy middle-​aged women. Journal of Psychosomatic Research, 57(4), 353–​358. Hughes, M., & Thomas, M. E. (1998). The continuing significance of race revisited: A study of race, class, and quality of life in America, 1972 to 1996. American Sociological Review, 785–​795. Hughes, S., Jaremka, L. M., Alfano, C. M., Glaser, R., Povoski, S. P., Lipari, A. M., et al. (2014). Social support predicts inflammation, pain, and depressive symptoms: longitudinal relationships among breast cancer survivors. Psychoneuroendocrinology, 42, 38–​44. Huguelet, P., Mohr, S., Betrisey, C., Borras, L., Gillieron, C., Marie, A. M., et al. (2011). A randomized trial of spiritual assessment of outpatients with schizophrenia: patients’ and clinicians’ experience. Psychiatric Services, 62, 79–​86. Hui, C. H., Lau, E. Y., Lam, J., Cheung, S. F., & Lau, W. W. (2015). Psychological predictors of Chinese Christians’ church attendance and religious steadfastness: a three-​wave prospective study. Psychology of Religion and Spirituality, 7(3), 250–​264.

References • 939

Hui, C. H., Cheung, S. H., Lam, J., Lau, E. Y., Yuliawati, L., & Cheung, S. F. (2017). In search of the psychological antecedents and consequences of Christian conversion: a three-​year prospective study. Psychology of Religion and Spirituality, 9(2), 220–​230. Hui, C. H., Cheung, S. H., Lam, J., Lau, E. Y., Cheung, S. F., & Yuliawati, L. (2018). Psychological changes during faith exit: a three-​ year prospective study. Psychology of Religion and Spirituality, 10(2), 103–​118. Huijts, T., & Kraaykamp, G. (2011). Religious involvement, religious context, and self-​assessed health in Europe. Journal of Health & Social Behavior, 52, 91–​106. Huizinga, D. (1994). Urban Delinquency and Substance Abuse, Initial Findings: Research Summary. US Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Hulett, J. M., & Armer, J. M. (2016). A systematic review of spiritually based interventions and psychoneuroimmunological outcomes in breast cancer survivorship. Integrative Cancer Therapies, 15(4), 405–​423. Hulett, J. M., Armer, J. M., Leary, E., Stewart, B. R., McDaniel, R., Smith, K., et al. (2018). Religiousness, spirituality, and salivary cortisol in breast cancer survivorship: a pilot study. Cancer Nursing, 41(2), 166–​175. Hull, S. J., Hennessy, M., Bleakley, A., Fishbein, M., & Jordan, A. (2011). Identifying the causal pathways from religiosity to delayed adolescent sexual behavior. Journal of Sex Research, 48(6), 543–​553. Hulley, S. B., Cummings, S. R., Browner, W. S., Grady, D. G., & Hearst, N. (2001). Designing Clinical Research: An Epidemiologic Approach, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins. Hulse, G. K., Lautenschlager, N. T., Tait, R. J., & Almeida, O. P. (2005). Dementia associated with alcohol and other drug use. International Psychogeriatrics, 17(s1), S109–​S127. Hülür, G., Heckhausen, J., Hoppmann, C. A., Infurna, F. J., Wagner, G. G., Ram, N., et al. (2017). Levels of and changes in life satisfaction predict mortality hazards. Psychology and Aging, 32(6), 507. Hummer, R., Rogers, R., Nam, C., & Ellison, C. G. (1999). Religious involvement and U.S. adult mortality. Demography, 36, 273–​285. Hummer, R. A., Benjamins, M. R., Ellison, C. G., & Rogers, R. G. (2010). Religious involvement and mortality risk among pre-​retirement aged U.S. adults. In Ellison, C. G., & Hummer, R. A.

940 •  R eferences

(eds.), Religion, Families, and Health: Population-​ Based Research in the United States. Piscataway, NJ: Rutgers University Press, pp. 273–​291. Humphrey, L. L., Fu, R., Buckley, D. I., Freeman, M., & Helfand, M. (2008). Periodontal disease and coronary heart disease incidence. Journal of General Internal Medicine, 23(12), 2079–​2086. Humphries, S. E., & Morgan, L. (2004). Genetic risk factors for stroke and carotid atherosclerosis. Lancet Neurology, 3(4), 227–​236. Hunt, B. R., Silva, A., Lock, D., & Hurlbert, M. (2019). Predictors of breast cancer mortality among White and Black women in large United States cities. Cancer Causes & Control, 30(2), 149–​164. Hunt, K. (2019). One person dies every 40 seconds from suicide, WHO says. Cable Network News (CNN), September 9. Retrieved on 9-​9-​2019 from https://​www.cnn.com/​2019/​09/​09/​hea​lth/​ who-​glo​bal-​suic​ide-​rates-​intl/​index.html. Hunt, R. A., & King, M. B. (1971). The intrinsic-​ extrinsic concept: a review and evaluation. Journal for the Scientific Study of Religion, 10, 339–​356. Hunter, C. A., & Jones, S. A. (2015). IL-​6 as a keystone cytokine in health and disease. Nature Immunology, 16(5), 448–​457. Hussain, A., Weisaeth, L., & Heir, T. (2011). Changes in religious beliefs and the relation of religiosity to posttraumatic stress and life satisfaction after a natural disaster. Social Psychiatry and Psychiatric Epidemiology, 46(10), 1027–​1032. Hussain, M., Walker, C., & Moon, G. (2019). Smoking and religion: untangling associations using English survey data. Journal of Religion and Health, 58(6), 2263–​2276. Hustoft, H., Hestad, K. A., Lien, L., Møller, P., & Danbolt, L. J. (2013). “If I didn’t have my faith I would have killed myself!”: Spiritual coping in patients suffering from schizophrenia. International Journal for the Psychology of Religion, 23(2), 126–​144. Hvidt, N. C., Hvidtjørn, D., Christensen, K., Nielsen, J. B., & Søndergaard, J. (2017). Faith moves mountains—​mountains move faith: Two opposite epidemiological forces in research on religion and health. Journal of Religion and Health, 56(1), 294–​304. Hwang, J., Park, S., & Kim, S. (2018). Effects of participation in social activities on cognitive function among middle-​aged and older adults in Korea. International Journal of Environmental Research and Public Health, 15(10), 2315. Hwang, W., Yoon, J., Silverstein, M., & Brown, M. T. (2019). Husband–​wife religious discordance,

marital satisfaction, and risk of marital dissolution in two generations. Journal of Family Issues, 40(9), 1201–​1223. Hwang, W., Cakirsoy‐Aslan, A. D., Brown, M. T., & Silverstein, M. (2021). Husband–​wife religious denomination homogamy and marital satisfaction over time. Family Relations, 70(5), 1498–​1513. Hybels, C. F., George, L. K., Blazer, D. G., Pieper, C. F., Cohen, H. J., & Koenig, H. G. (2014). Inflammation and coagulation as mediators in the relationships between religious attendance and functional limitations in older adults. Journal of Aging and Health, 26(4), 679–​697. Hyman, M. A., Ornish, D., & Roizen, M. (2009). Lifestyle medicine: treating the causes of disease. Alternative Therapies in Health & Medicine, 15(6), 12–​14. Hyyppa, M. T., & Maki, J. (2001). Individual-​level relationships between social capital and self-​ rated health in a bilingual community. Preventive Medicine, 32(2), 148–​155. Hyyppa, M. T., & Maki, J. (2003). Social participation and health in a community rich in stock of social capital. Health Education Research, 18(6), 770–​779. IARC (2007). Evaluation of carcinogenic risks to humans. International Agency for Research on Cancer, Smokeless Tobacco and Some Tobacco-​ Specific N-​Nitrosamines, vol. 89 of IARC Monographs. Lyon, France: World Health Organization International Agency for Research on Cancer. Iceland, J., & Ludwig-​Dehm, S. (2019). Black-​white differences in happiness, 1972–​2014. Social Science Research, 77, 16–​29. Idler, E. L. (1987). Religious involvement and the health of the elderly: some hypotheses and an initial test. Social Forces, 66, 226–​238. Idler, E. L. (1995). Religion, health, and nonphysical senses of self. Social Forces, 74, 683–​704. Idler, E. L. (ed.). (2014). Religion as a Social Determinant of Public Health. New York, NY: Oxford University Press. Idler, E. (2020). Equal protection? Differential effects of religious attendance on black-​white older adult mortality. Innovation in Aging, 4(Supp 1), 395. Idler, E. L., & Kasl, S. (1991). Health perceptions and survival: do global evaluations of health status really predict mortality? Journal of Gerontology, 46, S55–​S63. Idler, E. L., & Kasl, S. V. (1992). Religion, disability, depression, and the timing of death. American Journal of Sociology, 97(4), 1052–​1079.

Idler, E. L., & Kasl, S. V. (1997a). Religion among disabled and nondisabled elderly persons: cross-​ sectional patterns in health practices, social activities, and well-​being. Journal of Gerontology, 52B, 300–​305. Idler, E. L., & Kasl, S. V. (1997b). Religion among disabled and nondisabled elderly persons, II: Attendance at religious services as a predictor of the course of disability. Journal of Gerontology, 52B, 306–​316. Idler, E. L., Kasl, S. V., & Hays, J. C. (2001). Patterns of religious practice and beliefs in the last year of life. Journals of Gerontology, 56B(6), S326–​S334. Idler, E. L., Musick, M. A., Ellison, C. G., George, L. K., Krause, N., Ory, M. G., et al. (2003). Measuring multiple dimensions of religion and spirituality for health research conceptual background and findings from the 1998 General Social Survey. Research on Aging, 25(4), 327–​365. Idler, E. L., Boulifard, D. A., Labouvie, E., Chen, Y. Y., Krause, T. J., & Contrada, R. J. (2009). Looking inside the black box of “attendance at services.” International Journal for the Psychology of Religion, 19(1), 1–​20. Idler, E. L., Blevins, J., Kiser, M., & Hogue, C. (2017). Religion, a social determinant of mortality? A 10-​year follow-​up of the Health and Retirement Study. PloS One, 12(12), e0189134. Idler, E. L., Levin, J., VanderWeele, T. J., & Khan, A. (2019). Partnerships between public health agencies and faith communities. American Journal of Public Health, 109(3), 346–​347. Idris, A. M., Prokopczyk, B., & Hoffmann, D. (1994). Toombak: A major risk factor for cancer of the oral cavity in Sudan. Preventive Medicine, 23(6), 832–​839. Ifeagwazi, C. M., Egberi, H. E., & Chukwuorji, J. C. (2018). Emotional reactivity and blood pressure elevations. Psychology, Health & Medicine, 23(5), 585–​592. Ikedo, F., Gangahar, D. M., Quader, M. A., & Smith, L. M. (2007). The effects of prayer, relaxation technique during general anesthesia on recovery outcomes following cardiac surgery. Complementary Therapies in Clinical Practice, 13(2), 85–​94. Ikram, U. Z., Snijder, M. B., de Wit, M. A., Schene, A. H., Stronks, K., & Kunst, A. E. (2016). Perceived ethnic discrimination and depressive symptoms. Social Psychiatry and Psychiatric Epidemiology, 51(5), 679–​688. Imamura, Y., Mizoguchi, Y., Nabeta, H., Matsushima, J., Watanabe, I., Kojima, N., et al. (2015). Belief in life after death, salivary

References • 941

3‐methoxy‐4‐hydroxyphenylglycol, and well‐ being among older people without cognitive impairment dwelling in rural Japan. International Journal of Geriatric Psychiatry, 30(3), 256–​264. Imamura, Y., Mizoguchi, Y., Nabeta, H., Haraguchi, Y., Matsushima, J., Kojima, N., et al. (2017). An association between belief in life after death and serum oxytocin in older people in rural Japan. International Journal of Geriatric Psychiatry, 32(1), 102–​109. IMF (2020). Unemployment rate, advanced economies. International Money Fund. Retrieved on 9-​25-​2020 from https://​www.imf. org/​exter​nal/​dat​amap​per/​LUR@WEO/​OEMDC/​ ADVEC/​WEOWO​RLD. Infante, J. R., Peranb, F., Rayoa, J. I., Serranoa, J., Garciaa, L., Durana, C., et al. (2010). Daytime hormonal rhythms in practitioners of the transcendental meditation-​Sidhi program. Biomedical Research, 21(2), 161–​166. Inglehart, R. (2002). Gender, aging, and subjective well-​being. International Journal of Comparative Sociology, 43(3–​5), 391–​408. Inouye, S. K., & Fiellin, D. A. (2005). An evidence-​ based guide to writing grant proposals for clinical research. Annals of Internal Medicine, 142, 274–​282. Inozu, M., Kahya, Y., & Yorulmaz, O. (2020). The role of obsessive beliefs, thought-​control strategies and guilt in scrupulosity and obsessive–​compulsive symptoms among Muslim undergraduates. Journal of Religion and Health, 59(3), 1144–​1160. Inserra, A., Mastronardi, C. A., Rogers, G., Licinio, J., & Wong, M. L. (2019). Neuroimmunomodulation in major depressive disorder. Molecular Neurobiology, 56(6), 4288–​4305. Institute of Medicine (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press. Inzelberg, R., Afgin, A., Massarwa, M., Schechtman, E., Israeli-​Korn, S., Strugastsky, R., et al. (2013). Prayer at midlife is associated with reduced risk of cognitive decline in Arabic women. Current Alzheimer Research, 10(3), 340–​346. Irmak, M. K. (2014). Schizophrenia or possession? Journal of Religion and Health, 53, 773–​777. Ironson, G. (2008). Do positive psychosocial factors predict disease progression in HIV-​1? Psychosomatic Medicine, 70(5), 546–​554. Ironson, G., & Kremer, H. (2009). Spiritual transformation, psychological well-​being, health,

942 •  R eferences

and survival in people with HIV. International Journal of Psychiatry in Medicine, 39, 263–​281. Ironson, G., Stuezle, R., Fletcher, M. A., & Ironson, D. (2006a). View of God is associated with disease progression in HIV. Annals of Behavioral Medicine, 31(Supp), S074 (see website: http://​ www.sprin​gerl​ink.com/​cont​ent/​62402​7nm8​ 3812​634/​fullt​ext.pdf). Ironson, G., Stuetzle, R., Fletcher, M. A. (2006b). An increase in religiousness/​spirituality occurs after HIV diagnosis and predicts slower disease progression over 4 years in people with HIV. Journal of General Internal Medicine, 21(Supp 5), S62–​68. Ironson, G., Stuetzle, R., Ironson, D., Balbin, E., Kremer, H., George, A., et al. (2011). View of God as benevolent and forgiving or punishing and judgmental predicts HIV disease progression. Journal of Behavioral Medicine, 34(6), 414–​425. Ironson, G., Kremer, H., & Lucette, A. (2016). Relationship between spiritual coping and survival in patients with HIV. Journal of General Internal Medicine, 31(9), 1068–​1076. Ironson, G., Lucette, A., Hylton, E., Pargament, K. I., & Krause, N. (2018). The relationship between religious and psychospiritual measures and an inflammation marker (CRP) in older adults experiencing life event stress. Journal of Religion and Health, 57(4), 1554–​1566. Ironson, G., Henry, S. M., & Gonzalez, B. D. (2020). Impact of stressful death or divorce in people with HIV: a prospective examination and the buffering effects of religious coping and social support. Journal of Health Psychology, 25(5), 606–​616. Irwin, M. R., Thompson, J., Miller, C., Gillin, J. C., & Ziegler, M. (1999). Effects of sleep and sleep deprivation on catecholamine and interleukin-​2 levels in humans: clinical implications. Journal of Clinical Endocrinology and Metabolism, 84(6), 1979–​1985. Isaacs, K., Mota, N. P., Tsai, J., Harpaz-​Rotem, I., Cook, J. M., Kirwin, P. D., et al. (2017). Psychological resilience in US military veterans. Journal of Psychiatric Research, 84, 301–​309. Isehunwa, O. O., Warner, E. T., Spiegelman, D., Zhang, Y., Palmer, J. R., Kanaya, A. M., et al. (2022). Depression, religiosity, and telomere length in the Study on Stress, Spirituality, and Health (SSSH). International Journal of Mental Health and Addiction, 20(3), 1465–​1484. IsHak, W. W., Wen, R. Y., Naghdechi, L., Vanle, B., Dang, J., Knosp, M., et al. (2018). Pain and

depression. Harvard Review of Psychiatry, 26(6), 352–​363. Islami, F., Goding Sauer, A., Miller, K. D., Siegel, R. L., Fedewa, S. A., Jacobs, E. J., et al. (2018). Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA: A Cancer Journal for Clinicians, 68(1), 31–​54. Ismail, Z., & Desmukh, S. (2012). Religiosity and psychological well-​being. International Journal of Business and Social Science, 3(11), 20–​28. Isralowitz, R., Reznik, A., Sarid, O., Dagan, A., Grinstein-​Cohen, O., & Wishkerman, V. Y. (2018). Religiosity as a substance use protective factor among female college students. Journal of Religion and Health, 57, 1451–​1457. Ives, B., & Lewis, J. S. (2020). From rallies to riots: Why some protests become violent. Journal of Conflict Resolution, 64(5), 958–​986. Jackson, K. M., Sher, K. J., & Schulenberg, J. E. (2008). Conjoint developmental trajectories of young adult substance use. Alcoholism, 32(5), 723–​737. Jackson, T., Thomas, S., Stabile, V., Shotwell, M., Han, X., & McQueen, K. (2016). A systematic review and meta-​analysis of the global burden of chronic pain without clear etiology in low-​and middle-​income countries. Anesthesia & Analgesia, 123(3), 739–​748. Jacob, B., White, A., & Shogbon, A. (2017). First-​ year student pharmacists’ spirituality and perceptions regarding the role of spirituality in pharmacy education. American Journal of Pharmaceutical Education, 81(6), 108. Jacobs, D. G. (2007). The Foundation 1000, 2006–​ 2007: In-​Depth Profiles of the 1000 Largest U.S. Foundations. New York, NY: The Foundation Center. Jacobs, M., Miller, L., Wickramaratne, P., Gameroff, M., & Weissman, M. M. (2012). Family religion and psychopathology in children of depressed mothers: ten-​year follow-​up. Journal of Affective Disorders, 136(3), 320–​327. Jacobson, N. C., & Newman, M. G. (2017). Anxiety and depression as bidirectional risk factors for one another: a meta-​analysis of longitudinal studies. Psychological Bulletin, 143, 1155–​1200. Jacoby, S. F., Tach, L., Guerra, T., Wiebe, D. J., & Richmond, T. S. (2017). The health status and well‐being of low‐resource, housing‐unstable, single‐parent families living in violent neighborhoods in Philadelphia, Pennsylvania. Health & Social Care in the Community, 25(2), 578–​589.

Jafari, N., Zamani, A., Farajzadegan, Z., Bahrami, F., Emami, H., & Doghmani, A. (2013). The effect of spiritual therapy for improving the quality of life of women with breast cancer: a randomized controlled trial. Psychology, Health & Medicine, 18(1), 56–​69. Jaffe, D. H., Eisenbach, Z., Neumark, Y. D., & Manor, O. (2005). Does living in a religiously affiliated neighborhood lower mortality? Annals of Epidemiology, 15(10), 804–​810. Jafri, S. H., Ali, F., Mollaeian, A., Mojiz Hasan, S., Hussain, R., Akkanti, B., et al. (2019). Major stressful life events and risk of developing lung cancer: a case-​controlled study. Clinical Medicine Insights: Oncology, 13, 1–​7. Jain, S., Shapiro, S. L., Swanick, S., Roesch, S. C., Mills, P. J., Bell, I., et al. (2007). A randomized controlled trial of mindfulness meditation versus relaxation training. Annals of Behavioral Medicine, 33(1), 11–​21. Jalal, H., Buchanich, J. M., Roberts, M. S., Balmert, L. C., Zhang, K., & Burke, D. S. (2018). Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science, 361(6408), eaau1184. Jamal, M., & Badawi, J. (1993). Job stress among Muslim immigrants in North America: moderating effects of religiosity. Stress Medicine, 9(3), 145–​151. James, B. D., & Bennett, D. A. (2019). Causes and patterns of dementia: an update in the era of redefining Alzheimer’s disease. Annual Review of Public Health, 40, 65–​84. James, B. D., Bennett, D. A., Boyle, P. A., Leurgans, S., & Schneider, J. A. (2012). Dementia from Alzheimer disease and mixed pathologies in the oldest old. Journal of the American Medical Association, 307(17), 1798–​1800. James, P., Kim, E. S., Kubzansky, L. D., Zevon, E. S., Trudel-​Fitzgerald, C., & Grodstein, F. (2019). Optimism and healthy aging in women. American Journal of Preventive Medicine, 56(1), 116–​124. James, S. L., Abate, D., Abate, K. H., Abay, S. M., Abbafati, C., Abbasi, N., et al. (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–​ 2017. Lancet, 392(10159), 1789–​1858. James, W. (1890). The Principles of Psychology. New York, NY: Holt. James, W. (1902). The Varieties of Religious Experience: A Study in Human Nature. Cambridge, MA: Harvard University Press.

References • 943

James, W. (1950). The Principles of Psychology. New York, NY: Dover Press. Jane-​Llopis, E. V., Jané-​Llopis, E., Matytsina, I., Jané-​Llopis, E., & Matytsina, I. (2006). Mental health and alcohol, drugs and tobacco: a review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs. Drug and Alcohol Review, 25(6), 515–​536. Janevic, M. R., McLaughlin, S. J., Heapy, A. A., Thacker, C., & Piette, J. D. (2017). Racial and socioeconomic disparities in disabling chronic pain. Journal of Pain, 18(12), 1459–​1467. Jang, J. E., Kim, S. W., Kim, S. Y., Kim, J. M., Park, M. H., Yoon, J. H., et al. (2013). Religiosity, depression, and quality of life in Korean patients with breast cancer: a 1‐year prospective longitudinal study. Psycho‐Oncology, 22(4), 922–​929. Jang, M., Ko, J. A., & Kim, E. J. (2018). Religion and mental health among Nepal earthquake survivors in temporary tent villages. Mental Health, Religion & Culture, 21(4), 329–​335. Jang, S. J. (2018). Religiosity, crime, and drug use among juvenile offenders. International Journal of Offender Therapy and Comparative Criminology, 62(14), 4445–​4464. Jang, S. J. (2019). Religiosity, crime, and drug use among juvenile offenders: a latent growth modeling approach. Journal of Quantitative Criminology, 35(1), 27–​60. Jang, S. J., & Johnson, B. R. (2003). Strain, negative emotions, and deviant coping among African Americans: a test of general strain theory. Journal of Quantitative Criminology, 19(1), 79–​105. Jang, S. J., & Johnson, B. R. (2005). Gender, religiosity, and reactions to strain among African Americans. Sociological Quarterly, 46(2), 323–​357. Jang, Y., Haley, W. E., Mortimer, J. A., & Small, B. J. (2003). Moderating effects of psychosocial attributes on the association between risk factors and disability in later life. Aging & Mental Health, 7(3), 163–​170. Janoff-​Bulman, R., & Marshall, G. (1982). Mortality, well-​being, and control: a study of a population of institutionalized aged. Personality and Social Psychology Bulletin, 8, 691–​698. Jans-​Beken, L., Jacobs, N., Janssens, M., Peeters, S., Reijnders, J., Lechner, L., et al. (2020). Gratitude and health: an updated review. Journal of Positive Psychology, 15(6), 743–​782. Janusek, L. W., Tell, D., & Mathews, H. L. (2019). Epigenetic perpetuation of the impact of early

944 •  R eferences

life stress on behavior. Current Opinion in Behavioral Sciences, 28, 1–​7. Janz, N. K., Friese, C. R., Li, Y., Graff, J. J., Hamilton, A. S., & Hawley, S. T. (2014). Emotional well-​being years post-​treatment for breast cancer: prospective, multi-​ethnic, and population-​based analysis. Journal of Cancer Survivorship, 8(1), 131–​142. Jarvis, G. E., Kirmayer, L. J., Weinfeld, M., & Lasry, J. C. (2005). Religious practice and psychological distress: the importance of gender, ethnicity and immigrant status. Transcultural Psychiatry, 42(4), 657–​675. Jarvis, G. K. (1977). Mormon mortality rates in Canada. Social Biology, 24, 294–​302. Jasilioniene, A. (2007). Premarital conception and divorce risk in Russia in light of the GGS data. Rostock, Germany: Max Planck Institute for Demographic Research (MPIDR Working Paper WP-​2007-​025). Jasperse, M., Ward, C., & Jose, P. E. (2012). Identity, perceived religious discrimination, and psychological well‐being in Muslim immigrant women. Applied Psychology, 61(2), 250–​271. Jayaram, V. (2019). Human body symbolism in Hinduism. Hinduwebsite.com. Retrieved on 9-​ 1-​2020 from https://​www.hindu​webs​ite.com/​ symbol​ism/​theb​ody.asp. Jayawardena, R., Sooriyaarachchi, P., Chourdakis, M., Jeewandara, C., & Ranasinghe, P. (2020). Enhancing immunity in viral infections, with special emphasis on COVID-​19: a review. Diabetes & Metabolic Syndrome, 14(4), 367–​382. Jayedi, A., Ghomashi, F., Zargar, M. S., & Shab-​ Bidar, S. (2019). Dietary sodium, sodium-​to-​ potassium ratio, and risk of stroke: a systematic review and nonlinear dose-​response meta-​ analysis. Clinical Nutrition, 38(3), 1092–​1100. JCAHO (2009). Joint Commission for the Accreditation of Hospital Organizations. Retrieved on 3-​22-​2019 from https://​www.join​ tcom​miss​ion.org/​ass​ets/​1/​6/​2009_​CLAS​Rela​ tedS​tand​ards​HAP.pdf. JCAHO (2017). Joint Commission for the Accreditation of Hospital Organizations. Spiritual Assessment. Does the Joint Commission specify what needs to be included in a spiritual assessment? Retrieved on 3-​18-​ 2019 from https://​www.join​tcom​miss​ion.org/​ standa​rds_​info​rmat​ion/​jcfaq​deta​ils.aspx?Sta​ ndar​dsFa​qId=​1492&Progra​mId=​46. Je, Y., Jeon, J. Y., Giovannucci, E. L., & Meyerhardt, J. A. (2013). Association between physical activity and mortality in colorectal

cancer: a meta-​analysis of prospective studies. International Journal of Cancer, 133(8), 1905–​1913. Jebb, A. T., Tay, L., Diener, E., & Oishi, S. (2018). Happiness, income satiation and turning points around the world. Nature Human Behaviour, 2(1), 33. Jelly, P., & Choudhary, S. (2019). Breastfeeding and breast cancer: a risk reduction strategy. International Journal of Medical Pediatrics & Oncology, 5(2), 47–​50. Jensen, M. P., Moore, M. R., Bockow, T. B., Ehde, D. M., & Engel, J. M. (2011). Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. Archives of Physical Medicine and Rehabilitation, 92(1), 146–​160. Jessor, R., Costa, F. M., Krueger, P. M., & Turbin, M. S. (2006). A developmental study of heavy episodic drinking among college students. Journal of Studies on Alcohol & Drugs, 67(1), 86–​94. Jesus, T. S., Landry, M. D., & Hoenig, H. (2019). Global need for physical rehabilitation. International Journal of Environmental Research and Public Health, 16(6), 980. Jetten, J., Haslam, C., & Alexander, S. H. (2012). The Social Cure: Identity, Health and Well-​Being. New York, NY: Psychology Press. Jeuland, J., Fitchett, G., Schulman-​Green, D., & Kapo, J. (2017). Chaplains working in palliative care: who they are and what they do. Journal of Palliative Medicine, 20(5), 502–​508. Jewish Bible (1997). Jewish Publication Society Bible, by Benyamin Pilant. Accessed on 7-​22-​2020 from http://​www.bres​lov.com/​bible/​. Jewish Virtual Library (2008). Asceticism. Retrieved on 8-​15-​2020 from https://​www.jewis​ hvir​tual​libr​ary.org/​asc​etic​ism. Jeynes, W. H. (2006). Adolescent religious commitment and their consumption of marijuana, cocaine, and alcohol. Journal of Health & Social Policy, 21(4), 1–​20. Jia, Y., Li, F., Liu, Y. F., Zhao, J. P., Leng, M. M., & Chen, L. (2017). Depression and cancer risk: a systematic review and meta-​analysis. Public Health, 149, 138–​148. Jiang, Y., Bachner-​Melman, R., Chew, S. H., & Ebstein, R. P. (2015). Dopamine D4 receptor gene and religious affiliation correlate with dictator game altruism in males and not females. Frontiers in Neuroscience, 9, 338. Jin, P. (1992). Efficacy of Tai Chi, brisk walking, meditation, and reading in reducing mental and emotional stress. Journal of Psychosomatic Research, 36(4), 361–​70.

Jipping, T., & Perry, S. P. (2021). The Religious Freedom Restoration Act: history, status, and threats. Retrieved on 7-​31-​2022 from https://​ www.herit​age.org/​sites/​defa​ult/​files/​2021-​05/​ LM284.pdf. Jirásek, I., & Hurych, E. (2018). The perception of spiritual health differences between citizens and physicians in the Czech Republic. Health Promotion International, 33, 858–​866. John, P. J., Sharma, N., Sharma, C. M., & Kankane, A. (2007). Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial. Headache, 47(5), 654–​661. John-​Henderson, N. A., Kamarck, T. W., Muldoon, M. F., & Manuck, S. B. (2016). Early life family conflict, social interactions and carotid artery intima-​media thickness in adulthood. Psychosomatic Medicine, 78(3), 319. Johnson, B. H., Bonafede, M. M., & Watson, C. (2016). Short-​and longer-​term health-​care resource utilization and costs associated with acute ischemic stroke. ClinicoEconomics and Outcomes Research, 8, 53. Johnson, B. R. (2004). Religious programs and recidivism among former inmates in prison fellowship programs: a long-​term follow-​up study. Justice Quarterly, 21(2), 329–​354. Johnson, B. R., & Larson, D. B. (2008). The InnerChange Freedom Initiative: A preliminary evaluation of a faith-​based prison program. Waco, TX: Baylor University Institute for Studies of Religion. Retrieved on 10-​3-​2019 from https://​ www.issue​lab.org/​resou​rce/​the-​inner-​cha​nge-​ free​dom-​ini​tiat​ive-​a-​prel​imin​ary-​eva​luat​ion-​of-​ a-​faith-​based-​pri​son-​prog​ram.html. Johnson, B. R., Larson, D. B., & Pitts, T. C. (1997). Religious programs, institutional adjustment, and recidivism among former inmates in prison fellowship programs. Justice Quarterly, 14(1), 145–​166. Johnson, B. R., Larson, D. B., Spencer, D. L., & Jang, S. J. (2000). Escaping from the crime of inner cities: church attendance and religious salience among disadvantaged youth. Justice Quarterly, 17(2), 377–​391. Johnson, B. R., Jang, S. J., Larson, D. B., & De Li, S. (2001). Does adolescent religious commitment matter? A reexamination of the effects of religiosity on delinquency. Journal of Research in Crime and Delinquency, 38(1), 22–​44. Johnson, B. T., & Acabchuk, R. L. (2018). What are the keys to a longer, happier life? Answers from five decades of health psychology research. Social Science & Medicine, 196, 218–​226.

References • 945

Johnson, H. M. (2019). Anxiety and hypertension: Is there a link? A literature review of the comorbidity relationship between anxiety and hypertension. Current Hypertension Reports, 21(9), 66. Johnson, J. R., Engelberg, R. A., Nielsen, E. L., Kross, E. K., Smith, N. L., Hanada, J. C., et al. (2014). The association of spiritual care providers’ activities with family members’ satisfaction with care after a death in the ICU. Critical Care Medicine, 42(9), 1991–​2000. Johnson, J., Chaudieu, I., Ritchie, K., Scali, J., Ancelin, M. L., & Ryan, J. (2020a). The extent to which childhood adversity and recent stress influence all-​cause mortality risk in older adults. Psychoneuroendocrinology, 111, 104492. Johnson, N. F., Velásquez, N., Restrepo, N. J., Leahy, R., Gabriel, N., El Oud, S., et al. (2020b). The online competition between pro-​and anti-​vaccination views. Nature, 582(7811), 230–​233. Johnson, P. (2002). Predictors of family functioning within alcoholic families. Contemporary Family Therapy, 24(2), 371–​384. Johnson, S. L., Winett, C. A., Meyer, B., Greenhouse, W. J., & Miller, I. (1999). Social support and the course of bipolar disorder. Journal of Abnormal Psychology, 108(4), 558–​566. Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2007). Monitoring the future: National survey results on drug use, 1975–​2006. Volume I: Secondary school students. National Institute on Drug Abuse (NIDA), NIH Publication No. 07-​6205. Johnstone, B., Bodling, A., Cohen, D., Christ, S. E., & Wegrzyn, A. (2012). Right parietal lobe-​ related “selflessness” as the neuropsychological basis of spiritual transcendence. International Journal for the Psychology of Religion, 22(4), 267–​284. Jokela, M., Pulkki-​R åback, L., Elovainio, M., & Kivimäki, M. (2014). Personality traits as risk factors for stroke and coronary heart disease mortality: pooled analysis of three cohort studies. Journal of Behavioral Medicine, 37(5), 881–​889. Jokela, M., Airaksinen, J., Virtanen, M., Batty, G. D., Kivimäki, M., & Hakulinen, C. (2020). Personality, disability‐free life years, and life expectancy: individual participant meta-​analysis of 131,195 individuals from 10 cohort studies. Journal of Personality, 88(3), 596–​605. Jones, A. A., Webb, F. J., Lasopa, S. O., Striley, C. W., & Cottler, L. B. (2018). The association between religiosity and substance use patterns among

946 •  R eferences

women involved in the criminal justice system. Journal of Drug Issues, 48(3), 327–​336. Jones, B. M. (2001). Changes in cytokine production in healthy subjects practicing Guolin Qigong: a pilot study. BMC Complementary & Alternative Medicine, 1, 8. Jones, J. M. (2019). U.S. church membership down sharply in past two decades. Retrieved on 1-​10-​ 2020 from https://​news.gal​lup.com/​poll/​248​ 837/​chu​rch-​mem​bers​hip-​down-​shar​ply-​past-​ two-​deca​des.aspx. Jones, R. K., & Brayfield, A. (1997). Life’s greatest joy? European attitudes toward the centrality of children. Social Forces, 75(4), 1239–​1269. Jones, R. K., Darroch, J. E., & Singh, S. (2005). Religious differentials in the sexual and reproductive behaviors of young women in the United States. Journal of Adolescent Health, 36(4), 279–​288. Jones, T. M., Hill, K. G., Epstein, M., Lee, J. O., Hawkins, J. D., & Catalano, R. F. (2016). Understanding the interplay of individual and social–​developmental factors in the progression of substance use and mental health from childhood to adulthood. Development and Psychopathology, 28(3), 721–​741. Jongkind, M., van den Brink, B., Schaap‐Jonker, H., van der Velde, N., & Braam, A. W. (2019). Dimensions of religion associated with suicide attempt and suicide ideation in depressed, religiously affiliated patients. Suicide and Life‐ Threatening Behavior, 49(2), 505–​519. Jordan, K. D., Masters, K. S., Hooker, S. A., Ruiz, J. M., & Smith, T. W. (2014). An interpersonal approach to religiousness and spirituality: Implications for health and well‐ being. Journal of Personality, 82(5), 418–​431. Jordan, K. P., Thomas, E., Peat, G., Wilkie, R., & Croft, P. (2008). Social risks for disabling pain in older people: a prospective study of individual and area characteristics. PAIN®, 137(3), 652–​661. Jose, A., O’Leary, D. K., & Moyer, A. (2010). Does premarital cohabitation predict subsequent marital stability and marital quality? A meta-​ analysis. Journal of Marriage and Family, 72(1), 105–​116. Joseph, S. (2011). Religiosity and posttraumatic growth: a note concerning the problems of confounding in their measurement and the inclusion of religiosity within the definition of posttraumatic growth. Mental Health, Religion & Culture, 14(8), 843–​845. Jospe, M. R., Roy, M., Brown, R. C., Haszard, J. J., Meredith-​Jones, K., Fangupo, L. J., et al.

(2020). Intermittent fasting, Paleolithic, or Mediterranean diets in the real world. American Journal of Clinical Nutrition, 111(3), 503–​514. Joutsenniemi, K., Martelin, T., Kestila, L., Martikainen, P., Pirkola, S., Koskinen, S., et al. (2007). Living arrangements, heavy drinking and alcohol dependence. Alcohol & Alcoholism, 42(5), 480–​491. Ju, C., Zhang, B., You, X., Alterman, V., & Li, Y. (2018). Religiousness, social support and subjective well‐being: an exploratory study among adolescents in an Asian atheist country. International Journal of Psychology, 53(2), 97–​106. Jung, J. H. (2018). Childhood adversity, religion, and change in adult mental health. Research on Aging, 40(2), 155–​179. Jung, J., Lee, C. H., Shin, K., Roh, D., Lee, S. K., Moon, Y. S., et al. (2019). Specific association between religiosity and cognitive functions in Alzheimer’s Disease. American Journal of Alzheimer’s Disease & Other Dementias, 34(4), 254–​260. Jung, J. H., & Olson, D. V. (2017). Where does religion matter most? Personal religiosity and the acceptability of wife‐beating in cross‐ national perspective. Sociological Inquiry, 87(4), 608–​633. Jung, JaeHoon, Roh, D., Moon, Y. S., & Kim, D. H. (2017). The moderating effect of religion on the relationship between depression and suicidal ideation in the elderly. Journal of Nervous and Mental Disease, 205(8), 605–​610. Jung, Jong Hyun (2018). Childhood adversity, religion, and change in adult mental health. Research on Aging, 40(2), 155–​179. Justice Policy Institute (2014). Sticker shock: calculating the full price tag for youth incarceration. Retrieved on 9-​24-​2019 from http://​www.justic​epol​icy.org/​uplo​ads/​justic​epol​ icy/​docume​nts/​sti​cker​_​sho​ck_​f​i nal​_​v2.pdf. Kabat-​Zinn, J. (2003). Mindfulness-​based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2), 144–​156. Kabiru, C. W., Elung’ata, P., Mojola, S. A., & Beguy, D. (2014). Adverse life events and delinquent behavior among Kenyan adolescents: a cross-​ sectional study on the protective role of parental monitoring, religiosity, and self-​esteem. Child and Adolescent Psychiatry and Mental Health, 8(1), 24. Kabiru, C. W., & Orpinas, P. (2009). Factors associated with sexual activity among high-​ school students in Nairobi, Kenya. Journal of Adolescence, 32(4), 1023–​1039.

Kagesten, A., & Blum, R. W. (2015). Characteristics of youth who report early sexual experiences in Sweden. Archives of Sexual Behavior, 44, 679–​694. Kagimu, M., Guwatudde, D., Rwabukwali, C., Kaye, S., Walakira, Y., & Ainomugisha, D. (2012). Religiosity for HIV prevention in Uganda: a case study among Christian youth in Wakiso district. African Health Sciences, 12(1), 17–​25. Kagimu, M., Guwatudde, D., Rwabukwali, C., Kaye, S., Walakira, Y., & Ainomugisha, D. (2013). Religiosity for promotion of behaviors likely to reduce new HIV infections in Uganda: a study among Muslim youth in Wakiso district. Journal of Religion and Health, 52(4), 1211–​1227. Kahan, D. (2002). Religiosity as a determinant of physical activity: the case of Judaism. Quest, 54(2), 97–​115. Kahan, D. (2003). Islam and physical activity: implications for American sport and physical educators. Journal of Physical Education, Recreation, & Dance, 74(3), 48–​54. Kahan, D. (2015). Adult physical inactivity prevalence in the Muslim world: analysis of 38 countries. Preventive Medicine Reports, 2, 71–​75. Kahan, D., & Nicaise, V. (2012). Virtual Umra: an interdisciplinary faith-​based pedometer intervention for increasing steps at school. Journal of Physical Activity and Health, 9(3), 402–​413. Kahn, J. R., & London, K. A. (1991). Premarital sex and the risk of divorce. Journal of Marriage and the Family, 53(4), 845–​855. Kahneman, D., & Deaton, A. (2010). High income improves evaluation of life but not emotional well-​being. Proceedings of the National Academy of Sciences, 107(38), 16489–​16493. Kahneman, D., Diener, E., & Schwarz, N. (eds.) (1999). Well-​being: The Foundations of Hedonic Psychology. New York, NY: Russell Sage Foundation, pp. 3–​25, 61–​84. Kaliampos, A., & Roussi, P. (2017). Religious beliefs, coping, and psychological well-​being among Greek cancer patients. Journal of Health Psychology, 22(6), 754–​764. Kalichman, L., Alperovitch-​Najenson, D., & Treger, I. (2016). The impact of patient’s weight on post-​stroke rehabilitation. Disability and Rehabilitation, 38(17), 1684–​1690. Kalil, A., Born, C. E., Kunz, J., & Caudill, P. J. (2001). Life stressors, social support, and depressive symptoms among first-​time welfare recipients. American Journal of Community Psychology, 29(2), 355–​369. Kaliman, P., Alvarez-​Lopez, M. J., Cosin-​Tomas, M., Rosenkranz, M. A., Lutz, A., & Davidson, R. J.

References • 947

(2014). Rapid changes in histone deacetylases and inflammatory gene expression in expert meditators. Psychoneuroendocrinology, 40, 96–​107. Kalk, N. J., Nutt, D. J., & Lingford-​Hughes, A. R. (2011). The role of central noradrenergic dysregulation in anxiety disorders: evidence from clinical studies. Journal of Psychopharmacology, 25(1), 3–​16. Kalkhoran, S., Thorndike, A. N., Rigotti, N. A., Fung, V., & Baggett, T. P. (2019). Cigarette smoking and quitting-​related factors among US adult health center patients with serious mental Illness. Journal of General Internal Medicine, 34(6), 986–​991. Kalokerinos, E. K., von Hippel, W., Henry, J. D., & Trivers, R. (2014). The aging positivity effect and immune function. Psychology and Aging, 29(3), 636. Kalokhe, A. S., Potdar, R. R., Stephenson, R., Dunkle, K. L., Paranjape, A., del Rio, C., et al. (2015). How well does the World Health Organization definition of domestic violence work for India? PloS One, 10(3), e0120909. Kalter-​Leibovici, O., Chetrit, A., Avni, S., Averbuch, E., Novikov, I., & Daoud, N. (2016). Social characteristics associated with disparities in smoking rates in Israel. Israel Journal of Health Policy Research, 5(1), 36. Kandel, D. B. (1990). Early onset of adolescent sexual behavior and drug involvement. Journal of Marriage and the Family, 42, 783–​798. Kandel, D. B., & Chen, K. (2000). Types of marijuana users by longitudinal course. Journal of Studies on Alcohol, 61(3), 367–​378. Kang, M., La Young Park, S., Lim, J., & Kim, Y. (2020). Religion and health behaviors in primary care patients. Korean Journal of Family Medicine, 41(2), 105–​110. Kanwal, M., Ding, X. J., & Cao, Y. (2017). Familial risk for lung cancer. Oncology Letters, 13(2), 535–​542. Kaplan, R. M., & Kronick, R. G. (2006). Marital status and longevity in the United States population. Journal of Epidemiology & Community Health, 60(9), 760–​765. Karanci, A. N. (2014). Concerns about schizophrenia or possession? Journal of Religion and Health, 53, 1691–​1692. Karches, K. E., Chung, G. S., Arora, V., Meltzer, D. O., & Curlin, F. A. (2012). Religiosity, spirituality, and end-​of-​life planning. Journal of Pain and Symptom Management, 44(6), 843–​851. Karg, K., Burmeister, M., Shedden, K., & Sen, S. (2011). The serotonin transporter promoter

948 •  R eferences

variant (5-​HTTLPR), stress, and depression meta-​analysis revisited: evidence of genetic moderation. Archives of General Psychiatry, 68(5), 444–​454. Kark, J. D., Carmel, S., Sinnreich, R., Goldberger, N., & Friedlander, Y. (1996a). Psychosocial factors among members of religious and secular kibbutzim. Israel Journal of Medical Science, 32, 185–​194. Kark, J. D., Shemi, G., Friedlander, Y., Martin, O., & Manor, O., & Blondheim, S. H. (1996b). Does religious observance promote health? Mortality in secular vs. religious kibbutzim in Israel. American Journal of Public Health, 86, 341–​346. Karlsson, H., Hirvonen, J., Salminen, J. K., & Hietala, J. (2011). No association between serotonin 5-​HT 1A receptors and spirituality among patients with major depressive disorders or healthy volunteers. Molecular Psychiatry, 16(3), 282–​285. Karvinen, K. H., & Carr, L. J. (2014). Does the perception that God controls health outcomes matter for health behaviors? Journal of Health Psychology, 19(4), 521–​530. Kashdan, T. B., & Nezlek, J. B. (2012). Whether, when, and how is spirituality related to well-​being? Moving beyond single occasion questionnaires to understanding daily process. Personality and Social Psychology Bulletin, 38(11), 1523–​1535. Kaskutas, L. A., Subbaraman, M. S., Witbrodt, J., & Zemore, S. E. (2009). Effectiveness of making Alcoholics Anonymous easier: a group format 12-​step facilitation approach. Journal of Substance Abuse Treatment, 37(3), 228–​239. Kass, J. D., Friedman, R., Leserman, J., Zuttermeister, P. C., & Benson, H. (1991). Health outcomes and a new index of spiritual experience. Journal for the Scientific Study of Religion, 30(2), 203–​211. Kassebaum, N. J., Arora, M., Barber, R. M., Bhutta, Z. A., Brown, J., Carter, A., et al. (2016). Global, regional, and national disability-​adjusted life-​ years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–​2015. Lancet, 388(10053), 1603–​1658. Kasule, O. H. (2008). Physical activity and exercise: an Islamic perspective. Islamic Medical Education Resources. Retrieved on 8-​5-​2022 from http://​oma​rkas​ule-​05.tri​pod.com/​id295.html. Katan, M., & Luft, A. (2018). Global burden of stroke. Seminars in Neurology, 38(2), 208–​211. Katerndahl, D., Burge, S., Ferrer, R., Becho, J., & Wood, R. (2015). Effects of religious and spiritual variables on outcomes in violent

relationships. International Journal of Psychiatry in Medicine, 49(4), 249–​263. Kaufman, M. (2018). 5 surprising facts about Judaism, health and fitness. Aish.com. Retrieved on 12-​26-​2019 from https://​www.aish.com/​ci/​s/​ 5-​Sur​pris​ing-​Facts-​about-​Juda​ism-​Hea​lth-​and-​ Fitn​ess.html. Kaufman, N. J., Castrucci, B. C., Mowery, P. D., Gerlach, K. K., Emont, S., Orleans, C. T., et al. (2002). Predictors of change on the smoking uptake continuum among adolescents. Archives of Pediatrics & Adolescent Medicine, 156(6), 581–​587. Kaufman, Y., Anaki, D., Binns, M., & Freedman, M. (2007). Cognitive decline in Alzheimer disease: impact of spirituality, religiosity, and QOL. Neurology, 68(18), 1509–​1514. Kaup, A. R., Harmell, A. L., & Yaffe, K. (2019). Conscientiousness is associated with lower risk of dementia among Black and White older adults. Neuroepidemiology, 52(1–​2), 86–​92. Kawachi, I. (1999). Social capital and community effects on population and individual health. Annals of the New York Academy of Sciences, 896(1), 120–​130. Kazmer, M. M., Glueckauf, R. L., Schettini, G., Ma, J., & Silva, M. (2018). Qualitative analysis of faith community nurse–​led cognitive-​behavioral and spiritual counseling for dementia caregivers. Qualitative Health Research, 28(4), 633–​647. Kearney, P. M., Whelton, M., Reynolds, K., Whelton, P. K., He, J., Kearney, P. M., et al. (2004). Worldwide prevalence of hypertension. Journal of Hypertension, 22(1), 11–​19. Keating, T., & Osborne, J. (2008). The Heart of the World: An Introduction to Contemplative Christianity. New York, NY: Crossroad. Kehyayan, V., Hirdes, J. P., Tyas, S. L., & Stolee, P. (2016). Predictors of long-​term care facility residents’ self-​reported quality of life with individual and facility characteristics in Canada. Journal of Aging and Health, 28(3), 503–​529. Keivan, N., Daryabeigi, R., & Alimohammadi, N. (2019). Effects of religious and spiritual care on burn patients’ pain intensity and satisfaction with pain control during dressing changes. Burns, 45(7), 1605–​1613. Kelley-​Moore, J. A., & Ferraro, K. F. (2001). Functional limitations and religious service attendance in later life: barrier and/​or benefit mechanism? Journals of Gerontology Series B-​Psychological Sciences & Social Sciences, 56(6), S365–​373. Kelly, J. F., Abry, A., Ferri, M., & Humphreys, K. (2020). Alcoholics Anonymous and 12-​ step facilitation treatments for alcohol use

disorder: a distillation of a 2020 Cochrane Review for clinicians and policy makers. Alcohol and Alcoholism, 55(6), 641–​651. Kelly, J. F., Dow, S. J., Yeterian, J. D., & Kahler, C. W. (2010). Can 12-​step group participation strengthen and extend the benefits of adolescent addiction treatment? A prospective analysis. Drug and Alcohol Dependence, 110(1–​2), 117–​125. Kelly, J. F., Pagano, M. E., Stout, R. L., & Johnson, S. M. (2011a). Influence of religiosity on 12-​step participation and treatment response among substance-​dependent adolescents. Journal of Studies on Alcohol & Drugs, 72(6), 1000–​1011. Kelly, J. F., Stout, R. L., Magill, M., Tonigan, J. S., & Pagano, M. E. (2011b). Spirituality in recovery: a lagged mediational analysis of Alcoholics Anonymous’ principal theoretical mechanism of behavior change. Alcoholism: Clinical and Experimental Research, 35(3), 454–​463. Kelly, J. F., Hoeppner, B., Stout, R. L., & Pagano, M. (2012). Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: a multiple mediator analysis. Addiction, 107(2), 289–​299. Kelly, J. F., Bergman, B., Hoeppner, B. B., Vilsaint, C., & White, W. L. (2017). Prevalence and pathways of recovery from drug and alcohol problems in the United States population. Drug and Alcohol Dependence, 181, 162–​169. Kelly, J. F., Humphreys, K., & Ferri, M. (2020). Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database of Systematic Reviews, 3, CD012880. Kelly‐Hayes, M. (2010). Influence of age and health behaviors on stroke risk: lessons from longitudinal studies. Journal of the American Geriatrics Society, 58, S325–​S328. Kelly-​Hayes, M., Beiser, A., Kase, C. S., Scaramucci, A., D’Agostino, R. B., & Wolf, P. A. (2003). The influence of gender and age on disability following ischemic stroke. Journal of Stroke and Cerebrovascular Diseases, 12(3), 119–​126. Kelsch, C. B., Ironson, G., Szeto, A., Kremer H., Schneiderman, N., & Mendez, A. J. (2013). The relationship of spirituality, benefit finding, and other psychosocial variables to the hormone oxytocin in HIV/​AIDS. Research in the Social Scientific Study of Religion, 24, 137–​162. Kemp, B. R., Ferraro, K. F., Morton, P. M., & Mustillo, S. A. (2018). Early origins of adult cancer risk among men and women: influence of childhood misfortune? Journal of Aging and Health, 30(1), 140–​163.

References • 949

Kendler, K. S., & Gardner, C. O. (2016). Depressive vulnerability, stressful life events and episode onset of major depression: a longitudinal model. Psychological Medicine, 46(9), 1865–​1874. Kendler, K. S., Gardner, C. O., & Prescott, C. A. (1997). Religion, psychopathology, and substance use and abuse: a multi-​measure, genetic-​epidemiologic study. American Journal of Psychiatry, 154, 322–​329. Kendler, K. S., Hettema, J. M., Butera, F., Gardner, C. O., & Prescott, C. A. (2003). Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Archives of General Psychiatry, 60(8), 789–​796. Kendler, K. S., Kuhn, J. W., & Prescott, C. A. (2004). Childhood sexual abuse, stressful life events and risk for major depression in women. Psychological Medicine, 34(8), 1475–​1482. Kenkel, D. S. (1991). Health behavior, health knowledge, and schooling. Journal of Political Economy, 99(2), 287–​305. Kennedy, G. J., Kelman, H. R., Thomas, C., & Chen, J. (1996). The relation of religious preference and practice to depressive symptoms among 1,855 older adults. Journal of Gerontology, 51B, P301–​P308. Kenney, A. D., Dowdle, J. A., Bozzacco, L., McMichael, T. M., St. Gelais, C., Panfil, A. R., et al. (2017). Human genetic determinants of viral diseases. Annual Review of Genetics, 51, 241–​263. Kent, B. V., Bradshaw, M., & Uecker, J. E. (2018). Forgiveness, attachment to God, and mental health outcomes in older US adults: a longitudinal study. Research on Aging, 40(5), 456–​479. Kent, L. M., Morton, D. P., Ward, E. J., Rankin, P. M., Ferret, R. B., Gobble, J., et al. (2016). The influence of religious affiliation on participant responsiveness to the Complete Health Improvement Program (CHIP) lifestyle intervention. Journal of Religion and Health, 55(5), 1561–​1573. Keown, D. (1996). Buddhism and suicide: the case of Channa. Journal of Buddhist Ethics, 3, 8–​31. Kéri, S., & Kelemen, O. (2018). Christianity and schizophrenia redux: an empirical study. Journal of Religion and Health, 59(1), 452–​469. Kerksieck, P., Büssing, A., Frick, E., Jacobs, C., & Baumann, K. (2017). Reduced sense of coherence due to neuroticism: are transcendent beliefs protective among Catholic pastoral workers? Journal of Religion and Health, 56(6), 1956–​1970.

950 •  R eferences

Kerr, J., Anderson, C., & Lippman, S. M. (2017). Physical activity, sedentary behaviour, diet, and cancer: an update and emerging new evidence. Lancet Oncology, 18(8), e457–​e471. Kerr, J. I., & Burri, A. (2017). Genetic and epigenetic epidemiology of chronic widespread pain. Journal of Pain Research, 10, 2021–​2029. Kerr, P. A. (2003). The framing of fundamentalist Christians: network television news, 1980–​2000. Journal of Media and Religion, 2(4), 203–​235. Kerridge, B. T., Chou, S. P., Pickering, R. P., Ruan, W. J., Huang, B., Jung, J., et al. (2019). Changes in the prevalence and correlates of cocaine use and cocaine use disorder in the United States, 2001–​2002 and 2012–​2013. Addictive Behaviors, 90, 250–​257. Kesebir, P., & Kesebir, S. (2012). The cultural salience of moral character and virtue declined in twentieth century America. Journal of Positive Psychology, 7(6), 471–​480. Kesselring, A., Dodd, M. J., Lindsey, A. M., & Strauss, A. L. (1986). Attitudes of patients living in Switzerland about cancer and its treatment. Cancer Nursing, 9(2), 77–​91. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005a). Lifetime prevalence and age-​of-​onset distributions of DSM-​IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–​602. Kessler, R. C., Birnbaum, H., Demler, O., Falloon, I. R., Gagnon, E., Guyer, M., et al. (2005b). The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-​R). Biological Psychiatry, 58(8), 668–​676. Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005c). Prevalence, severity, and comorbidity of 12-​month DSM-​IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–​627. Kessler, R. C., Galea, S., Jones, R. T., Parker, H. A., Hurricane Katrina Community Advisory Group (2006). Mental illness and suicidality after Hurricane Katrina. Bulletin of the World Health Organization, 84(12), 930–​939. Kessler, R. C., Angermeyer, M., Anthony, J. C., De Graaf, R. O., Demyttenaere, K., Gasquet, I., et al. (2007). Lifetime prevalence and age-​of-​ onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry, 6(3), 168–​176. Kessler, R. C., Aguilar-​Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., & Üstün, T. B. (2009). The

WHO world mental health (WMH) surveys. Die Psychiatrie, 6(01), 5–​9. Kessler, R. C., Barker, P. R., Colpe, L. J., Epstein, J. F., Gfroerer, J. C., Hiripi, E., et al. (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry, 60(2), 184–​189. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve‐month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169–​184. Keyes, C. L., Myers, J. M., & Kendler, K. S. (2010). The structure of the genetic and environmental influences on mental well-​being. American Journal of Public Health, 100(12), 2379–​2384. Keysar, A., & Navarro-​Rivera, J. (2017). Chapter 36. A world of atheism: global demographics. In S. Bullivant & M. Ruse (eds.), The Oxford Handbook of Atheism. Oxford, UK: Oxford University Press (pp. 553–​586). Khaledian, M., Pishvaei, M., Baghteyfouni, Z. K., & Smaeili, M. (2017). Effect of Islamic-​based spiritual therapy on self-​esteem and mental health of addicts. Journal of Research and Health 7(2), 719–​728. Khalifeh, H., Moran, P., Borschmann, R., Dean, K., Hart, C., Hogg, J., et al. (2015). Domestic and sexual violence against patients with severe mental illness. Psychological Medicine, 45(4), 875–​886. Khalili, N., Farajzadegan, Z., Mokarian, F., & Bahrami, F. (2013). Coping strategies, quality of life and pain in women with breast cancer. Iranian Journal of Nursing and Midwifery Research, 18(2), 105–​111. Khambati, N., Mahedy, L., Heron, J., & Emond, A. (2018). Educational and emotional health outcomes in adolescence following maltreatment in early childhood. Child Abuse & Neglect, 81, 343–​353. Khamis, R. Y., Ammari, T., & Mikhail, G. W. (2016). Gender differences in coronary heart disease. Heart, 102(14), 1142–​1149. Khan, I. D., & Sahni, A. K. (2013). Possession at high altitude (4575 m/​15000 ft). Kathmandu University Medical Journal, 11(3), 253–​55. Khan, T. H. (2019). Another dimension of pain. Anaesthesia, Pain & Intensive Care, 19(1), 1–​2. Khan, Z. H., & Watson, P. J. (2006). Construction of the Pakistani Religious Coping Practices Scale: correlations with religious coping, religious orientation, and reactions to stress among Muslim university students. International

Journal for the Psychology of Religion, 16(2), 101–​112. Khera, A. V., Emdin, C. A., Drake, I., Natarajan, P., Bick, A. G., Cook, N. R., et al. (2016). Genetic risk, adherence to a healthy lifestyle, and coronary disease. New England Journal of Medicine, 375(24), 2349–​2358. Khodadadi, J., Rezaiee Ahvanuiee, M., & Abdollahi, A. (2018). The prediction of marital intimacy according to religious attitude and family problem solving in women. Health, Spirituality and Medical Ethics, 5(2), 38–​44. Khosravi, N., Stoner, L., Farajivafa, V., & Hanson, E. D. (2019). Exercise training, circulating cytokine levels and immune function in cancer survivors: a meta-​analysis. Brain, Behavior, and Immunity, 81, 92–​104. Kidwai, R., Mancha, B. E., Brown, Q. L., & Eaton, W. W. (2014). The effect of spirituality and religious attendance on the relationship between psychological distress and negative life events. Social Psychiatry and Psychiatric Epidemiology, 49(3), 487–​497. Kilicaslan, E. E., Acar, G., Eksioglu, S., Kesebir, S., & Tezcan, E. (2016). The effect of delusion and hallucination types on treatment response in schizophrenia and schizoaffective disorder. Journal of Psychiatry & Neurological Sciences, 29(1), 29–​35. Kilpatrick, D. G. (2000). Definitions of public policy and the law. National Violence Against Women Prevention Research Center. Charleston, SC: Medical University of South Carolina. Retrieved on 10-​1-​ 2020 from https://​main​web-​v.musc.edu/​vawpre​ vent​ion/​pol​icy/​def​i nit​ion.shtml. Kim, D. (2020). The effect of becoming disabled on the subjective well-​being of religious and nonreligious people. Journal of Religion and Health, 59, 816–​827. Kim, D., & Kawachi, I. (2006). A multilevel analysis of key forms of community-​and individual-​level social capital as predictors of self-​rated health in the United States. Journal of Urban Health, 83(5), 813–​826. Kim, D., Curlin, F., Wolenberg, K., & Sulmasy, D. (2014). Religion in organized medicine: The AMA’s Committee and Department of Medicine and Religion, 1961–​1974. Perspectives in Biology and Medicine, 57(3), 393–​414. Kim, D. D., & Basu, A. (2016). Estimating the medical care costs of obesity in the United States. Value in Health, 19(5), 602–​613. Kim, D. H., Harty, J., Takahashi, L., & Voisin, D. R. (2018). The protective effects of religious beliefs on behavioral health factors among low

References • 951

income among African American adolescents in Chicago. Journal of Child and Family Studies, 27(2), 355–​364. Kim, D. H., Hoon, J. J., & Moon, Y. S. (2019). P1‐611: Specific association between religiosity and cognitive functions in Alzheimer’s disease. Alzheimer’s & Dementia, 15, P510–​P511. Kim, E. S., Kawachi, I., Chen, Y., & Kubzansky, L. D. (2017). Association between purpose in life and objective measures of physical function in older adults. JAMA Psychiatry, 74(10), 1039–​1045. Kim, E. S., James, P., Zevon, E. S., Trudel-​Fitzgerald, C., Kubzansky, L. D., & Grodstein, F. (2019). Optimism and healthy aging in women and men. American Journal of Epidemiology, 188(6), 1084–​1091. Kim, E. S., & VanderWeele, T. J. (2019). Mediators of the association between religious service attendance and mortality. American Journal of Epidemiology, 188(1), 96–​101. Kim, H. J., Jen, S., & Fredriksen-​Goldsen, K. I. (2017). Race/​ethnicity and health-​related quality of life among LGBT older adults. The Gerontologist, 57(Supp 1), S30–​S39. Kim, H. J., Kim, Y., Kim, S., Chin, H. J., Lee, H., Lee, J. P., et al. (2018). Age, sex, and the association of chronic kidney disease with all-​cause mortality in Buddhist priests: an analysis of the standardized mortality ratio from the Korean Buddhist priests cohort. Medicine, 97(45), e13099. Kim, J., Kang, J. H., Lee, M. A., & Lee, Y. (2007). Volunteering among older people in Korea. Journals of Gerontology, 62B(1), S69–​S73. Kim, J., Smith, T. W., & Kang, J. H. (2015). Religious affiliation, religious service attendance, and mortality. Journal of Religion and Health, 54(6), 2052–​2072. Kim, J. H., Son, Y. D., Kim, J. H., Choi, E. J., Lee, S. Y., Joo, Y. H., et al. (2015). Self-​transcendence trait and its relationship with in vivo serotonin transporter availability in brainstem raphe nuclei: an ultra-​high-​resolution PET-​MRI study. Brain Research, 1629, 63–​71. Kim, K. H. (2007). Religion, weight perception, and weight control behavior. Eating Behaviors, 8(1), 121–​131. Kim, K. H., Sobal, J., & Wethington, E. (2003). Religion and body weight. International Journal of Obesity & Related Metabolic Disorders, 27(4), 469–​477. Kim, K. I., Li, D., Jiang, Z., Cui, X. J., Lin, L., Kang, J. J., et al. (1993). Schizophrenic delusions among Koreans, Korean-​Chinese and Chinese: a

952 •  R eferences

transcultural study. International Journal of Social Psychiatry, 39(3), 190–​199. Kim, M., & Lee, Y. H. (2018). Gender-​specific factors related to suicidal ideation among community-​ dwelling stroke survivors. PLoS One, 13(8), e0201717. Kim, M. S. (2016). Social exchange theory. In Jensen, K. B., Craig, R. T., Pooley, J. D., & Rothenbuhler, E. W. (eds.), The International Encyclopedia of Communication Theory and Philosophy, Hoboken, NJ: John Wiley & Sons, Inc., pp. 1890–​1898. Kim, N. Y., Hugh, K. J., & Chae, J. H. (2015). Effects of religiosity and spirituality on the treatment response in patients with depressive disorders. Comprehensive Psychiatry, 60, 26–​34. Kim, S. W., Kim, S. Y., Kim, J. M., Park, M. H., Yoon, J. H., Shin, M. G., et al. (2011). Relationship between a hopeful attitude and cellular immunity in patients with breast cancer. General Hospital Psychiatry, 33(4), 371–​376. Kim, Y. I., & Dew, J. (2019). Religion and volunteering in marital relationships. Review of Religious Research, 61(4), 323–​340. Kim, Y. J., Moon, S. S., Kim, Y. K., & Boyas, J. (2020). Protective factors of suicide: religiosity and parental monitoring. Children and Youth Services Review, 114, 105073. Kim-​Cohen, J., Caspi, A., Taylor, A., Williams, B., Newcombe, R., Craig, I. W., et al. (2006). MAOA, maltreatment, and gene–​environment interaction predicting children’s mental health: new evidence and a meta-​analysis. Molecular Psychiatry, 11(10), 903–​913. Kim-​Spoon, J., Longo, G. S., & McCullough, M. E. (2012). Parent-​adolescent relationship quality as a moderator for the influences of parents’ religiousness on adolescents’ religiousness and adjustment. Journal of Youth and Adolescence, 41(12), 1576–​1587. Kim-​Yeary, K. H., Ounpraseuth, S., Moore, P., Bursac, Z., & Greene, P. (2012). Religion, social capital, and health. Review of Religious Research, 54, 331–​347. Kimhi, S., Eshel, Y., & Bonanno, G. A. (2020). Resilience protective and risk factors as prospective predictors of depression and anxiety symptoms following intensive terror attacks in Israel. Personality and Individual Differences, 159, 109864. King, D. E., Mainous, A. G., & Pearson, W. S. (2002). C-​reactive protein, diabetes, and attendance at religious services. Diabetes Care, 25(7), 1172–​1176.

King, D. E., & Pearson, W. S. (2003). Religious attendance and continuity of care. International Journal of Psychiatry in Medicine, 33(4), 377–​389. King, D. E., Mainous, A. G., Steyer, T. E., & Pearson, W. (2001). The relationship between attendance at religious services and cardiovascular inflammatory markers. International Journal of Psychiatry in Medicine, 31(4), 415–​425. King, K. A., Topalian, A., & Vidourek, R. A. (2020). Religiosity and adolescent major depressive episodes among 12–​17-​year-​olds. Journal of Religion and Health, 59, 2611–​2622. King, Michael B. (2014). The challenge of research into religion and spirituality. Journal for the Study of Spirituality, 4, 106–​120. King, Michael B., & Leavey, G. (2010). Spirituality and religion in psychiatric practice: why all the fuss? The Psychiatrist, 34(5), 190–​193. King, Michael B., Walker, C., Levy, G., Bottomley, C., Royston, P., Weich, S., et al. (2008). Development and validation of an international risk prediction algorithm for episodes of major depression in general practice attendees. Archives of General Psychiatry, 65(12), 1368–​1376. King, Michael B., Marston, L., McManus, S., Brugha, T., Meltzer, H., & Bebbington, P. (2013a). Religion, spirituality and mental health: results from a national study of English households. British Journal of Psychiatry, 202(1), 68–​73. King, Michael B., Llewellyn, H., Leurent, B., Owen, F., Leavey, G., Tookman, A., et al. (2013b). Spiritual beliefs near the end of life. Psycho‐ Oncology, 22(11), 2505–​2512. King, Morton B., & Hunt, R. A. (1972). Measuring the religious variable: replication. Journal for the Scientific Study of Religion, 11, 240–​251. King, Morton B., & Hunt, R. A. (1975). Measuring the religious variable: national replication. Journal for the Scientific Study of Religion, 14, 13–​22. King, S. D., Fitchett, G., Murphy, P. E., Pargament, K. I., Martin, P. J., Johnson, R. H., et al. (2017). Spiritual or religious struggle in hematopoietic cell transplant survivors. Psycho‐Oncology, 26(2), 270–​277. King, V., Ledwell, M., & Pearce-​Morris, J. (2013). Religion and ties between adult children and their parents. Journals of Gerontology, 68B(5), 825–​836. King, V., Lindstrom, R., & Washington, C. (2019). Patterns of shared religious attendance and positive stepfamily functioning. Journal of Research on Adolescence, 29(2), 357–​368. King, V., Wickrama, K. A., & Beach, S. R. (2022). Religiosity and joint activities of husbands

and wives in enduring marriages. Psychology of Religion and Spirituality, 14(1), 97–​107. Kinney, A. Y., Bloor, L. E., Dudley, W. N., Millikan, R. C., Marshall, E., Martin, C., et al. (2003). Roles of religious involvement and social support in the risk of colon cancer among Blacks and Whites. American Journal of Epidemiology, 158(11), 1097–​1107. Kiran, U., Ladha, S., Makhija, N., Kapoor, P. M., Choudhury, M., Das, S., et al. (2017). The role of Rajyoga meditation for modulation of anxiety and serum cortisol in patients undergoing coronary artery bypass surgery: a prospective randomized control study. Annals of Cardiac Anaesthesia, 20(2), 158. Kirk, K. M., Blomberg, S. P., Duffy, D. L., Heath, A. C., Owens, I. P., & Martin, N. G. (2001). Natural selection and quantitative genetics of life-​history traits in Western women: a twin study. Evolution, 55(2), 423–​435. Kisenyi, R. N., Muliira, J. K., & Ayebare, E. (2013). Religiosity and adherence to antiretroviral therapy among patients attending a public hospital-​based HIV/​AIDS clinic in Uganda. Journal of Religion and Health, 52(1), 307–​317. Kitano, A., Yamauchi, H., Hosaka, T., Yagata, H., Hosokawa, K., Ohde, S., et al. (2015). Psychological impact of breast cancer screening in Japan. International Journal of Clinical Oncology, 20(6), 1110–​1116. Kitayama, S., Karasawa, M., Curhan, K. B., Ryff, C. D., & Markus, H. R. (2010). Independence and interdependence predict health and wellbeing: divergent patterns in the United States and Japan. Frontiers in Psychology, 1, 163. Kivimäki, M., & Steptoe, A. (2018). Effects of stress on the development and progression of cardiovascular disease. Nature Reviews Cardiology, 15(4), 215. Kivipelto, M., Rovio, S., Ngandu, T., Kåreholt, I., Eskelinen, M., Winblad, B., et al. (2008). Apolipoprotein E ɛ4 magnifies lifestyle risks for dementia. Journal of Cellular and Molecular Medicine, 12(6b), 2762–​2771. Kjaer, T. W., Bertelsen, C., Piccini, P., Brooks, D., Alving, J., & Lou, H. C. (2002). Increased dopamine tone during meditation-​induced change of consciousness. Cognitive Brain Research, 13(2), 255–​259. Klabunde, R. (2011). Cardiovascular Physiology Concepts. Philadelphia, PA: Lippincott Williams & Wilkins. Klatsky, A. L. (2004). Alcohol-​associated hypertension: when one drink makes a difference. Hypertension, 44(6), 805–​806.

References • 953

Kleiman, E. M., & Liu, R. T. (2013). Social support as a protective factor in suicide: findings from two nationally representative sample. Journal of Affective Disorders, 150(2), 540–​545. Kleiman, E. M., & Liu, R. T. (2014). Prospective prediction of suicide in a nationally representative sample: religious service attendance as a protective factor. British Journal of Psychiatry, 204, 262–​266. Kleiman, E. M., Riskind, J. H., & Schaefer, K. E. (2014). Social support and positive events as suicide resiliency factors: examination of synergistic buffering effects. Archives of Suicide Research, 18(2), 144–​155. Klengel, T., & Binder, E. B. (2015). Epigenetics of stress-​related psychiatric disorders and gene× environment interactions. Neuron, 86(6), 1343–​1357. Kliewer, W., & Murrelle, L. (2007). Risk and protective factors for adolescent substance use: findings from a study in selected Central American countries. Journal of Adolescent Health, 40(5), 448–​455. Kliewer, W., Washington-​Nortey, M., Yendork, J. S., Sosnowski, D. W., Wright, A. W., et al. (2020). Maternal and family correlates of intrinsic religiosity profiles among low-​income urban African American adolescents. Journal of Youth and Adolescence, 49(1), 323–​334. Klok, M. D., Jakobsdottir, S., & Drent, M. L. (2007). The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review. Obesity Reviews, 8(1), 21–​34. Knight, A., Bryan, J., & Murphy, K. (2016). Is the Mediterranean diet a feasible approach to preserving cognitive function and reducing risk of dementia for older adults in Western countries? New insights and future directions. Ageing Research Reviews, 25, 85–​101. Knight, H. L. (2004). The effects of spiritual disciplines on smoking cessation: A Christ-​ centered approach to smoking cessation for an inner-​city African-​American church. Dissertation. Madison, NJ: Drew University. Retrieved on 12-​ 21-​2019 from https://​sea​rch.proqu​est.com/​docv​ iew/​305174​886?pq-​origs​ite=​gscho​lar. Knighton, A. J., Savitz, L. A., Benuzillo, J., & VanDerslice, J. A. (2018). It takes a village: exploring the impact of social determinants on delivery system outcomes for heart failure patients. Healthcare, 6(2), 112–​116. Knoops, K. T., de Groot, L. C., Kromhout, D., Perrin, A. E., Moreiras-​Varela, O., et al., (2004). Mediterranean diet, lifestyle factors, and 10-​year mortality in elderly European men

954 •  R eferences

and women: the HALE project. Journal of the American Medical Association, 292, 1433–​1439. Knowles, L. M., Ruiz, J. M., & O’Connor, M. F. (2019). A systematic review of the association between bereavement and biomarkers of immune function. Psychosomatic Medicine, 81(5), 415–​433. Kobau, R., Seligman, M. E., Peterson, C., Diener, E., Zack, M. M., Chapman, D., et al. (2011). Mental health promotion in public health: perspectives and strategies from positive psychology. American Journal of Public Health, 101(8), e1–​e9. Kobayashi, D., Shimbo, T., Takahashi, O., Davis, R. B., & Wee, C. C. (2015). The relationship between religiosity and cardiovascular risk factors in Japan: a large-​scale cohort study. Journal of the American Society of Hypertension, 9(7), 553–​562. Kobayashi, H., Song, C., Ikei, H., Park, B. J., Kagawa, T., & Miyazaki, Y. (2019). Combined effect of walking and forest environment on salivary cortisol concentration. Frontiers in Public Health, 7, 376. Kochanek, K. D., Anderson, R. N., & Arias, E. (2020). Changes in life expectancy at birth, 2010-​2018. NCHS Health E-​Stat. Retrieved on 7-​3-​2020 from https://​www.cdc.gov/​nchs/​ data/​hes​tat/​life-​exp​ecta​ncy/​life-​exp​ecta​ncy-​ 2018.htm. Kodama, S., Saito, K., Tanaka, S., Maki, M., Yachi, Y., Asumi, M., et al. (2009). Cardiorespiratory fitness as a quantitative predictor of all-​cause mortality and cardiovascular events in healthy men and women: a meta-​analysis. Journal of the American Medical Association, 301(19), 2024–​2035. Kodzi, I. A., Gyimah, S. O., Emina, J., & Ezeh, A. C. (2011). Religious involvement, social engagement, and subjective health status of older residents of informal neighborhoods of Nairobi. Journal of Urban Health, 88(2), 370–​380. Koenig, H. G. (2001). Spirituality in Patient Care, 1st ed. Conshohocken, PA: Templeton Foundation Press. Koenig, H. G. (2002). An 83-​year-​old woman with chronic illness and strong religious beliefs. Journal of the American Medical Association, 288(4), 487–​493. Koenig, H. G. (2005). Faith and Mental Health: Religious Resources for Healing. Conshohocken, PA: Templeton Foundation Press. Koenig, H. G. (2007). Religion and remission of depression in medical inpatients with heart failure/​pulmonary disease. Journal of Nervous and Mental Disease, 195(5), 389–​395.

Koenig, H. G. (2007b). In the Wake of Disaster: Religious Responses to Terrorism & Catastrophe. Conshohocken, PA: Templeton Foundation Press. Koenig, H. G. (2008). Concerns about measuring “spirituality” in research. Journal of Nervous & Mental Disease, 196(5), 349–​355. Koenig, H. G. (2011a). Spirituality and Health Research: Methods, Measurement, Statistics, & Resources. Conshohocken, PA: Templeton Foundation Press. Koenig, H. G. (2011b). Schizophrenia and other psychotic disorders (Ch. 2). In Peteet, J., Lu, F. G., & Narrow, W. E. (eds.), Religious and Spiritual Issues in Psychiatric Diagnosis: A Research Agenda for DSM-​V. Arlington, VA: American Psychiatric Association Press, pp. 31–​52. Koenig, H. G. (2013). Spirituality in Patient Care, 3rd ed. Conshohocken, PA: Templeton Foundation Press. Koenig, H. G. (2016). Association of religious involvement and suicide. JAMA Psychiatry, 73(8), 775–​776. Koenig, H. G. (2017a). Hinduism and Mental Health: Beliefs, Research and Applications. Amazon: CreateSpace Platform. Koenig, H. G. (2017b). Buddhism and Mental Health: Beliefs, Research and Applications. Amazon: CreateSpace Platform. Koenig, H. G. (2017c). Catholic Christianity and Mental Health: Beliefs, Research, and Applications. Amazon: CreateSpace Platform. Koenig, H. G. (2018a). Religion and Mental Health: Research and Clinical Applications. San Diego, CA: Academic Press. Koenig, H. G., Smiley, M., & Gonzales, A. P. (1988a). Religion, Health, and Aging. Westport, CT: Greenwood Press. Koenig, H. G., Moberg, D. O., & Kvale, J. N. (1988b). Religious activities and attitudes of older adults in a geriatric assessment clinic. Journal of the American Geriatrics Society, 36, 362–​374. Koenig, H. G., Siegler, I. C., Meador, K. G., & George, L. K. (1990). Religious coping and personality in later life. International Journal of Geriatric Psychiatry, 5(2), 123–​131. Koenig, H. G., Cohen, H. J., Blazer, D. G., Pieper, C., Meador, K. G., Shelp, F., et al. (1992). Religious coping and depression in elderly hospitalized medically ill men. American Journal of Psychiatry, 149, 1693–​1700. Koenig, H. G., George, L. K., Blazer, D. G., Pritchett, J., & Meador, K. G. (1993a). The relationship between religion and anxiety in a sample of

community-​dwelling older adults. Journal of Geriatric Psychiatry, 26(1), 65–​93. Koenig, H. G., Ford, S., George, L. K., Blazer, D. G., & Meador, K. G. (1993b). Religion and anxiety disorder: an examination and comparison of associations in young, middle-​aged, and elderly adults. Journal of Anxiety Disorders, 7, 321–​342. Koenig, H. G., George, L. K., Meador, K. G., Blazer, D. G., & Ford, S. M. (1994a). The relationship between religion and alcoholism in a sample of community-​dwelling adults. Hospital and Community Psychiatry, 45, 225–​231. Koenig, H. G., George, L. K., Meador, K. G., Blazer, D. G., & Dyke, P. (1994b). Religious affiliation and psychiatric disorder in Protestant baby boomers. Hospital and Community Psychiatry, 45, 586–​596. Koenig, H. G., Cohen, H. J., Blazer, D. G., Kudler, H. S., Krishnan, K. R. R., & Sibert, T. E. (1995a). Cognitive symptoms of depression and religious coping in elderly medical patients. Psychosomatics, 36, 369–​375. Koenig, H. G., & Futterman, A. (1995b). Religion and health outcomes: A review and synthesis of the literature. Background paper, published in proceedings of Conference on Methodological Approaches to the Study of Religion, Aging, and Health, sponsored by the National Institute on Aging and the Fetzer Institute (March 16–​17). Koenig, H. G., Hays, J. C., George, L. K., & Blazer, D. G., Larson, D. B., & Landerman, L. R. (1997a). Modeling the cross-​sectional relationships between religion, physical health, social support, and depressive symptoms. American Journal of Geriatric Psychiatry, 5, 131–​143. Koenig, H. G., Cohen, H. J., George, L. K., Hays, J. C., Larson, D. B., & Blazer, D. G. (1997b). Attendance at religious services, interleukin-​ 6, and other biological indicators of immune function in older adults. International Journal of Psychiatry in Medicine, 27, 233–​250. Koenig, H. G., Meador, K., & Parkerson, G. (1997c). Religion index for psychiatric research: a 5-​item measure for use in health outcome studies. American Journal of Psychiatry, 154, 885–​886. Koenig, H. G., George, L. K., & Peterson, B. L. (1998a). Religiosity and remission of depression in medically ill older patients. American Journal of Psychiatry, 155(4), 536–​542. Koenig, H. G., Larson, D. B., Hays, J. C., McCullough, M. E., George, L. K., Branch, P. S., et al. (1998b). Religion and the survival of 1010 hospitalized veterans. Journal of Religion and Health, 37(1), 15–​30.

References • 955

Koenig, H. G., & Larson, D. B. (1998c). Use of hospital services, church attendance, and religious affiliation. Southern Medical Journal, 91, 925–​932. Koenig, H. G., Pargament, K. I., & Nielsen, J. (1998d). Religious coping and health status in medically ill hospitalized older adults. Journal of Nervous and Mental Disease, 186(9), 513–​521. Koenig, H. G., George, L. K., Hays, J. C., Larson, D. B., Cohen, H. J., & Blazer, D. G. (1998e). The relationship between religious activities and blood pressure in older adults. International Journal of Psychiatry in Medicine, 28(2), 189–​213. Koenig, H. G., George, L. K., Cohen, H. J., Hays, J. C., Larson, D. B., & Blazer, D. G. (1998f). The relationship between religious activities and cigarette smoking in older adults. Journals of Gerontology, 53(6), M426–​M434. Koenig, H. G., Hays, J. C., Larson, D. B., George, L. K., Cohen, H. J., McCullough, M. E., et al. (1999). Does religious attendance prolong survival? A six-​year follow-​up study of 3,968 older adults. Journals of Gerontology, 54(7), M370–​M376. Koenig, H. G., Larson, D. B., & McCullough, M. E. (2001). Handbook of Religion and Health, 1st ed. New York, NY: Oxford University Press. Koenig, H. G., George, L. K., Titus, P., & Meador, K. G. (2004). Religion, spirituality, and acute care hospitalization and long-​term care use by older patients. Archives of Internal Medicine, 164(14), 1579–​1585. Koenig, H. G., & Bussing, A. (2010a). The Duke Religion Index: a brief measure for use in epidemiological studies. Religions 1(1):78–​85. Koenig, H. G., Hooten, E. G., Lindsay-​Calkins, E., & Meador, K. G. (2010b). Spirituality in medical school curricula: findings from a national survey. International Journal of Psychiatry in Medicine, 40(4), 391–​398. Koenig, H. G., King, D. E., & Carson, V. B. (2012). Handbook of Religion and Health, 2nd edition. New York, NY: Oxford University Press. Koenig, H. G., & Al Shohaib, S. (2014). Health and Well-​being in Islamic Societies. Cham, Switzerland: Springer. Koenig, H. G., Al-​Zaben, F., Khalifa, D. A., & Al Shohaib, S. (2015a). Measures of religiosity (Ch. 19). In Boyle, G. J., Saklofske, D. H., & Mathews, G. (eds.), Measures of Personality and Social Psychological Constructs. San Diego, CA: Academic Press, pp. 533–​564. Koenig, H. G., Nelson, B., Shaw, S. F., Al Zaben, F., Wang, Z., & Saxena, S. (2015b). Belief into Action scale: A brief but comprehensive measure

956 •  R eferences

of religious commitment. Open Journal of Psychiatry, 5(1), 66–​77. Koenig, H. G., Wang, Z., Al Zaben, F., & Adi, A. (2015c). Belief into Action Scale: a comprehensive and sensitive measure of religious involvement. Religions, 6(3), 1006–​1016. Koenig, H. G., Pearce, M. J., Nelson, B., Shaw, S. F., Robins, C. J., Daher, N. S., et al. (2015d). Religious vs. conventional cognitive behavioral therapy for major depression in persons with chronic medical illness: a pilot randomized trial. Journal of Nervous and Mental Disease, 203(4), 243–​251. Koenig, H. G., Pearce, M. J., Nelson, B., & Daher, N. (2015e). Effects of religious versus standard cognitive‐behavioral therapy on optimism in persons with major depression and chronic medical illness. Depression and Anxiety, 32(11), 835–​842. Koenig, H. G., Nelson, B., Shaw, S. F., Saxena, S., & Cohen, H. J. (2016a). Religious involvement and adaptation in female family caregivers. Journal of the American Geriatrics Society, 64(3), 578–​583. Koenig, H. G., Nelson, B., Shaw, S. F., Saxena, S., & Cohen, H. J. (2016b). Religious involvement and telomere length in women family caregivers. Journal of Nervous and Mental Disease, 204(1), 36–​42. Koenig, H. G., Perno, K., & Hamilton, T. (2017a). Integrating spirituality into outpatient practice in the Adventist Health System. Southern Medical Journal, 110(1), 1–​7. Koenig, H. G., Perno, K., & Hamilton, T. (2017b). Effects of a 12-​month educational intervention on outpatient clinicians’ attitudes and behaviors concerning spiritual practices with patients. Advances in Medical Education and Practice, 8, 129–​139. Koenig, H. G., Perno, K., Erkanli, A., & Hamilton, T. (2017c). Effects of a 12-​month educational intervention on clinicians’ attitudes/​practices regarding the screening spiritual history. Southern Medical Journal, 110(6), 412–​418. Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., et al. (2018a). The moral injury symptom scale-​military version. Journal of Religion and Health, 57(1), 249–​265. Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., et al. (2018b). Screening for moral injury: The Moral Injury Symptom Scale–​ Military Version Short Form. Military Medicine, 183(11–​12), e659–​e665. Koenig, H. G., Youssef, N. A., Ames, D., Oliver, J. P., Teng, E. J., Haynes, K., et al. (2018c). Moral injury and religiosity in US veterans with

posttraumatic stress disorder symptoms. Journal of Nervous and Mental Disease, 206(5), 325–​331. Koenig, H. G., Youssef, N. A., & Ames, D. (2019a). Assessment of moral injury in Veterans and Active Duty Military with PTSD: A Review. Frontiers in Psychiatry, 10(443), 1–​15. Koenig, H. G., Ames, D., & Pearce, M. (2019b). Religion and Recovery from PTSD. London, UK: Jessica Kingsley. Koenig, H. G., Youssef, N. A., Ames, D., Teng, E. J., & Hill, T. D. (2020). Examining the overlap between moral injury and PTSD in US Veterans and active duty military. Journal of Nervous and Mental Disease, 208(1), 7–​12. Koenig, H. G., Hill, T. D., Pirutinsky, S., & Rosmarin, D. H. (2021). Commentary on “Does spirituality or religion positively affect mental health?” International Journal for the Psychology of Religion, 31(1), 27–​44. Koenig, L. B., McGue, M., & Iacono, W. G. (2008). Stability and change in religiousness during emerging adulthood. Developmental Psychology, 44(2), 532–​543. Koenig, L. B., & Vaillant, G. E. (2009). A prospective study of church attendance and health over the lifespan. Health Psychology, 28(1), 117–​124. Kogan, A., Saslow, L. R., Impett, E. A., Oveis, C., Keltner, D., & Saturn, S. R. (2011). Thin-​slicing study of the oxytocin receptor (OXTR) gene and the evaluation and expression of the prosocial disposition. Proceedings of the National Academy of Sciences, 108(48), 19189–​19192. Kogan, I., & Weißmann, M. (2020). Religion and sexuality: between-​and within-​individual differences in attitudes to pre-​marital cohabitation among adolescents in four European countries. Journal of Ethnic and Migration Studies, 46(17), 3630–​3654. Köhler, C. A., Evangelou, E., Stubbs, B., Solmi, M., Veronese, N., Belbasis, L., et al. (2018). Mapping risk factors for depression across the lifespan: an umbrella review of evidence from meta-​analyses and Mendelian randomization studies. Journal of Psychiatric Research, 103, 189–​207. Köhler, S., Buntinx, F., Palmer, K., & Van Den Akker, M. (2015). Depression, vascular factors, and risk of dementia in primary care. Journal of the American Geriatrics Society, 63(4), 692–​698. Kohut, T., & Štulhofer, A. (2018). The role of religiosity in adolescents’ compulsive pornography use: a longitudinal assessment. Journal of Sex & Marital Therapy, 44(8), 759–​775. Koh, H. K., Geller, A. C., and VanderWeele, T. J. (2021). Deaths from COVID-​19. Journal of the American Medical Association, 325, 133–​134.

Koivisto, K., Reinikainen, K. J., Hanninen, T., Vanhanen, M., Helkala, E. L., Mykkanen, L., et al. (1995). Prevalence of age-​associated memory impairment in a randomly selected population from eastern Finland. Neurology, 45(4), 741–​747. Kok, L. (1988). Race, religion and female suicide attempters in Singapore. Social Psychiatry & Psychiatric Epidemiology, 23(4), 236–​239. Kolata, G. (2006), Live long? Die young? Answer isn’t just in genes. New York Times, August 31. Retrieved on 7-​3-​2020 from https://​www.nyti​ mes.com/​2006/​08/​31/​hea​lth/​31age.html?ex=​ 117​7732​800&en=​3735f​4581​0a0a​9e1&ei=​5070. Kolla, B. P., Oesterle, T., Gold, M., Southwick, F., & Rummans, T. (2020). Infectious diseases occurring in the context of substance use disorders: a concise review. Journal of the Neurological Sciences, 411, 116719. Kolotkin, R. L., & Andersen, J. R. (2017). A systematic review of reviews: exploring the relationship between obesity, weight loss and health‐related quality of life. Clinical Obesity, 7(5), 273–​289. Komori, T. (2017). The significance of proinflammatory cytokines and Th1/​Th2 balance in depression and action of antidepressants. Neuropsychiatry, 7(1), 57–​60. Koob, G. F., & Volkow, N. D. (2010). Neurocircuitry of addiction. Neuropsychopharmacology, 35(1), 217–​238. Koolhaas, C. M., Dhana, K., Schoufour, J. D., Ikram, M. A., Kavousi, M., & Franco, O. H. (2017). Impact of physical activity on the association of overweight and obesity with cardiovascular disease: the Rotterdam Study. European Journal of Preventive Cardiology, 24(9), 934–​941. Koopmans, J. R., Slutske, W. S., Van Baal, G. C., & Boomsma, D. I. (1999). The influence of religion on alcohol use initiation: evidence for genotype X environment interaction. Behavior Genetics, 29(6), 445–​453. Kopacz, M. S. (2014). The spiritual health of veterans with a history of suicide ideation. Health Psychology and Behavioral Medicine, 2(1), 349–​358. Kopacz, M. S., Currier, J. M., Drescher, K. D., & Pigeon, W. R. (2016). Suicidal behavior and spiritual functioning in a sample of veterans diagnosed with PTSD. Journal of Injury and Violence Research, 8(1), 6–​14. Kopacz, M. S., Crean, H. F., Park, C., & Hoff, R. A. (2017). Religious coping and suicide risk in a sample of recently returned veterans. Archives of Suicide Research, 22(4), 615–​627.

References • 957

Koponen, S., Taiminen, T., Portin, R., Himanen, L., Isoniemi, H., Heinonen, H., et al. (2002). Axis I and II psychiatric disorders after traumatic brain injury: a 30-​year follow-​up study. American Journal of Psychiatry, 159(8), 1315–​1321. Kor, A., Pirutinsky, S., Mikulincer, M., Shoshani, A., & Miller, L. (2019). A longitudinal study of spirituality, character strengths, subjective well-​being, and prosociality in middle school adolescents. Frontiers in Psychology, 10, 377. Korenromp, M. J., Page-​Christiaens, G., Bout, J., Multer, E. J., & Visser, G. H. (2009). Adjustment to termination of pregnancy for fetal anomaly. American Journal of Obstetrics & Gynecology, 201(2), 160 e1–​160 e7. Korn, L., & Zukerman, G. (2011). Affective and behavioral changes following exposure to traumatic events: the moderating effect of religiosity on avoidance behavior among students studying under a high level of terror event exposure. Journal of Religion and Health, 50(4), 911–​921. Kortt, M. A., & Dollery, B. (2014). Religion and BMI in Australia. Journal of Religion and Health, 53(1), 217–​228. Kos, L., Šagud, M., Mihaljevic-​Peleš, A., Kutleša, M., Kovac, T., & Trkulja, V. (2019). Religiosity and severity of symptoms in Croatian patients with major depressive disorder or schizophrenia. Journal of Nervous and Mental Disease, 207(6), 515–​522. Koss, S. E., Weissman, R., Chow, V., Smith, P. T., Slack, B., Voytenko, V., et al. (2018). Training community clergy in serious illness: balancing faith and medicine. Journal of Religion and Health, 57(4), 1413–​1427. Kostadinovic, M., Nikolic, D., Petronic, I., Cirovic, D., Grajic, M., & Santric Milicevic, M. (2019). Sociodemographic predictors of physical functioning in the elderly: a national health survey. International Journal of Environmental Research and Public Health, 16(1), 37. Koszycki, D., Bilodeau, C., Raab‐Mayo, K., & Bradwejn, J. (2014). A multifaith spiritually based intervention versus supportive therapy for generalized anxiety disorder: a pilot randomized controlled trial. Journal of Clinical Psychology, 70(6), 489–​509. Kotlęga, D., Gołąb-​Janowska, M., Masztalewicz, M., Ciećwież, S., & Nowacki, P. (2016). The emotional stress and risk of ischemic stroke. Neurologia i Neurochirurgia Polska, 50(4), 265–​270. Koton, S., Schneider, A. L., Rosamond, W. D., Shahar, E., Sang, Y., Gottesman, R. F., et al.

958 •  R eferences

(2014). Stroke incidence and mortality trends in US communities, 1987 to 2011. Journal of the American Medical Association, 312(3), 259–​268. Koutra, K., Vgontzas, A. N., Lionis, C., & Triliva, S. (2014). Family functioning in first-​episode psychosis: a systematic review of the literature. Social Psychiatry and Psychiatric Epidemiology, 49(7), 1023–​1036. Kovacs, E., Piko, B. F., & Fitzpatrick, K. M. (2011). Religiosity as a protective factor against substance use among Hungarian high school students. Substance Use & Misuse, 46(10), 1346–​1357. Kovess‐Masfety, V., Saha, S., Lim, C. C., Aguilar‐ Gaxiola, S., Al‐Hamzawi, A., Alonso, J., et al. (2018). Psychotic experiences and religiosity: data from the WHO World Mental Health Surveys. Acta Psychiatrica Scandinavica, 137(4), 306–​315. Koyn, B. (2015). Religious participation: the missing link in the ready and resilient campaign. Military Review, 95(5), 2–​12. Koyuncu, A., Alkın, T., & Tükel, R. (2018). Development of social anxiety disorder secondary to attention deficit/​hyperactivity disorder (the developmental hypothesis). Early Intervention in Psychiatry, 12(2), 269–​272. Kposowa, A. J., & Aly Ezzat, D. (2019). Religiosity, conservatism, and acceptability of anti-​ female spousal violence in Egypt. Journal of Interpersonal Violence, 34(12), 2525–​2550. Kraal, A. Z., Sharifian, N., Zaheed, A. B., Sol, K., & Zahodne, L. B. (2019). Dimensions of religious involvement represent positive pathways in cognitive aging. Research on Aging, 41(9), 868–​890. Krakow, M. M., Jensen, J. D., Carcioppolo, N., Weaver, J., Liu, M., & Guntzviller, L. M. (2015). Psychosocial predictors of human papillomavirus vaccination intentions for young women 18 to 26: religiosity, morality, promiscuity, and cancer worry. Women’s Health Issues, 25(2), 105–​111. Kralev, S., Schneider, K., Lang, S., Süselbeck, T., & Borggrefe, M. (2011). Incidence and severity of coronary artery disease in patients with atrial fibrillation undergoing first-​time coronary angiography. PloS One, 6(9), e24964. Kralovec, K., Kunrath, S., Fartacek, C., Pichler, E. M., & Plöderl, M. (2018). The gender‐specific associations between religion/​spirituality and suicide risk in a sample of Austrian psychiatric inpatients. Suicide and Life‐Threatening Behavior, 48(3), 281–​293. Krause, N. (1991). Stress, religiosity, and abstinence from alcohol. Psychology and Aging, 6, 134–​144.

Krause, N. (1992). Stress, religiosity, and psychological well-​being among older blacks. Journal of Aging and Health, 4, 412–​439. Krause, N. (1993). Measuring religiosity in later life. Research on Aging, 15, 170–​197. Krause, N. (1995). Religiosity and self-​esteem among older adults. Journal of Gerontology, 50, P236–​P246. Krause, N. (1997). Religion, aging, and health: current status and future prospects. Journals of Gerontology, 52B, S291–​S293. Krause, N. (1998a). Stressors in highly valued roles, religious coping, and mortality. Psychology and Aging, 13, 242–​255. Krause, N. (1998b). Neighborhood deterioration, religious coping, and changes in health during late life. Gerontologist, 38, 653–​664. Krause, N. (1999). Religious support. In Multidimensional Measurement of Religiousness/​ Spirituality for Use in Health Research: A Report of the Fetzer Institute /​National Institute on Aging Workshop Group. Kalamazoo, MI: Fetzer Foundation, pp. 57–​63. Krause, N. (2002a). A comprehensive strategy for developing closed-​ended survey items for use in studies of older adults. Journal of Gerontology, 57B(5), S263–​S274. Krause, N. (2002b). Church-​based social support and health in old age: exploring variations by race. Journals of Gerontology, 57B(6), S332–​S347. Krause, N. (2003). Religious meaning and subjective well-​being in late life. Journals of Gerontology, 58(3), S160–​170. Krause, N. (2004a). Common facets of religion, unique facets of religion, and life satisfaction among older African Americans. Journals of Gerontology, 59B(2), S109–​117. Krause, N. (2004b). Assessing the relationships among prayer expectancies, race, and self-​esteem in late life. Journal for the Scientific Study of Religion, 43, 395–​408. Krause, N. (2005). God-​mediated control and psychological well-​being in late life. Research on Aging, 27, 136–​164. Krause, N. (2006a). Church-​based social support and mortality. Journals of Gerontology, 61B(3), S140–​146. Krause, N. (2006b). Exploring the stress-​buffering effects of church-​based and secular social support on self-​rated health in late life. Journals of Gerontology, 61B(1), S35–​43. Krause, N. (2006c). Gratitude toward God, stress, and health in late life. Research on Aging, 28, 163–​183.

Krause, N. (2006d). Religious doubt and psychological well-​being: a longitudinal investigation. Review of Religious Research, 47, 287–​302. Krause, N. (2006e). Church-​based social support and change in health over time. Review of Religious Research, 48, 125–​140. Krause, N. (2009a). Lifetime trauma, prayer, and psychological distress in later life. International Journal for the Psychology of Religion, 19, 55–​72. Krause, N. (2009b). Church-​based volunteering, providing informal support at church, and self-​ rated health in late life. Journal of Aging and Health, 21, 63–​84. Krause, N. (2009c). Close companion friends in church and health in later life. Review of Religious Research, 51, 181–​200. Krause, N. (2009d). Religious involvement, gratitude, and change in depressive symptoms over time. International Journal for the Psychology of Religion, 19, 155–​172. Krause, N. (2009e). Meaning in life and mortality. Journal of Gerontology, 64B, S517–​S527. Krause N. (2010a). Church-​based emotional support and self-​forgiveness in late life. Review of Religious Research, 52(1), 72–​89. Krause, N. (2010b). Religious involvement, humility, and self-​rated health. Social Indicators Research, 98(1), 23–​39. Krause, N. (2010c). Close companions at church, health, and health care use in late life. Journal of Aging and Health, 22(4), 434–​453. Krause, N. (2010d). God-​mediated control and change in self-​rated health. International Journal for the Psychology of Religion, 20(4), 267–​287. Krause, N. (2012a). Religious doubt, financial strain, and depressive symptoms among older Mexican Americans. Mental Health, Religion and Culture, 15(4), 335–​348. Krause, N. (2012b). Valuing the life experience of old adults and change in depressive symptoms. Journal of Aging and Health, 24(2), 227–​249. Krause, N. (2015). Assessing the religious roots of volunteer work in middle and late life. Research on Aging, 37(5), 439–​463. Krause, N. (2018a). Assessing the relationships among religion, humility, forgiveness, and self-​ rated health. Research in Human Development, 15(1), 33–​49. Krause, N. (2019). Religion and health among Hispanics: exploring variations by age. Journal of Religion and Health, 58(5), 1817–​1832. Krause, N., & Tran, T. V. (1989). Stress and religious involvement among older Blacks. Journal of Gerontology, 44, S4–​S13.

References • 959

Krause, N., Liang, J., Shaw, B. A., Sugisawa, H., Kim, H. K., Sugihara, Y., et al. (2002a). Religion, death of a loved one, and hypertension among older adults in Japan. Journals of Gerontology, 57(2), S96–​S107. Krause, N., Ellison, C. G., & Marcum, J. P. (2002b). The effects of church-​based emotional support on health: do they vary by gender. Sociology of Religion, 63, 21–​47. Krause, N., & Ellison, C. G. (2003). Forgiveness by God, forgiveness of others, and psychological well-​being in late life. Journal for the Scientific Study of Religion, 42(1), 77–​93. Krause, N., & Ellison, C. G. (2007). Parental religious socialization practices and self-​esteem in late life. Review of Religious Research, 49, 109–​127. Krause, N., & Bastida, E. (2009). Core religious beliefs and providing support to others in late life. Mental Health, Religion & Culture, 12(1), 75–​96. Krause, N., & Ellison, C. E. (2009). The doubting process: a longitudinal study of the precipitants and consequences of religious doubt in older adults. Journal for the Scientific Study of Religion, 48, 293–​312. Krause, N., & Bastida, E. (2011). Religion, suffering, and self-​rated health among older Mexican Americans. Journals of Gerontology Series B-​ Psychological Sciences & Social Sciences, 66(2), 207–​216. Krause, N., & Hayward, R. D. (2012a). Awareness of the historical role of the church and change in self‐esteem among older African Americans. Applied Psychology: Health and Well‐Being, 4(2), 240–​260. Krause N., & Hayward, R. D. (2012b). Volunteer work in the church among older Mexican Americans. Cultural Diversity and Ethnic Minority Psychology, 18(3), 277–​284. Krause, N., & Hayward, R. D. (2012c). Religion, meaning in life, and change in physical functioning during late adulthood. Journal of Adult Development, 19(3), 158–​169. Krause, N., & Bastida, E. (2012). Contact with the dead, religion, and death anxiety among older Mexican Americans. Death Studies, 36(10), 932–​948. Krause, N., & Hayward, R. D. (2014a). Church-​based social support, functional disability, and change in personal control over time. Journal of Religion and Health, 53(1), 267–​278. Krause N., & Hayward, R. D. (2014b). Religious music and health in late life: a longitudinal investigation. International Journal of Psychology and Religion, 24(1), 47–​63.

960 •  R eferences

Krause, N., & Hayward, R. D. (2014c). Religion, finding interests in life, and change in self-​ esteem during late life. Research on Aging, 36(3), 364–​381. Krause N., Emmons, R. A., & Ironson, G. (2015). Benevolent images of God, gratitude, and physical health status. Journal of Religion & Health, 54(4), 1503–​1519. Krause, N., & Hayward, R. D. (2015). Race, religion, and virtues. International Journal for the Psychology of Religion, 25(2), 152–​169. Krause, N., Ironson, G., & Pargament, K. I. (2016a). Lifetime trauma, praying for others, and C-​ reactive protein. Biodemography and Social Biology, 62(3), 249–​261. Krause, N., & Hayward, R. D. (2016). Anxious attachment to God, spiritual support, and obesity: findings from a recent nationwide survey. Journal for the Scientific Study of Religion, 55(3), 485–​497. Krause, N., Pargament, K. I., Ironson, G., & Hill, P. (2017a). Religious involvement, financial strain, and poly-​drug use: exploring the moderating role of meaning in life. Substance Use & Misuse, 52(3), 286–​293. Krause N., Ironson, G., & Hill, P. C. (2017b). Volunteer work, religious commitment, and resting pulse rate. Journal of Religion and Health, 56, 591–​603. Krause, N., & Ironson, G. (2017a). Is involvement in religion associated with better sleep quality? Pastoral Psychology, 66, 595–​608. Krause, N., & Ironson, G. (2017b). God-​mediated control beliefs and the Epstein-​Barr virus: Is more God-​mediated control always better? Journal of Religion, Spirituality & Aging, 29(4), 299–​316. Krause, N., & Pargament, K. I. (2017). Losing my religion: Exploring the relationship between a decline in faith and a positive affect. Applied Research in Quality of Life, 12(4), 885–​901. Krause, N., Ironson, G., Pargament, K., & Hill, P. (2017). Neighborhood conditions, religious coping, and uncontrolled hypertension. Social Science Research, 62, 161–​174. Krause, N., Pargament, K. I., Hill, P. C., & Ironson, G. (2018a). Spiritual struggles and problem drinking: are younger adults at greater risk than older adults. Substance Use & Misuse, 53(5), 808–​815. Krause, N., Ironson, G., & Hill, P. (2018b). Religious involvement and happiness: Assessing the mediating role of compassion and helping others. Journal of Social Psychology, 158(2), 256–​270.

Kraut, A., Melamed, S., Gofer, D., & Froom, P. (2003). Effect of school age sports on leisure time physical activity in adults: the CORDIS study. Medicine & Science in Sports & Exercise, 35(12), 2038–​2042. Kraut, A., Melamed, S., Gofer, D., & Froom, P. (2004). Association of self-​reported religiosity and mortality in industrial employees: the CORDIS study. Social Science & Medicine, 58(3), 595–​602. Kremer, H., & Ironson, G. (2014). Longitudinal spiritual coping with trauma in people with HIV: implications for healthcare. AIDS Patient Care and STDs, 28(3), 144–​154. Kremer, H., Ironson, G., Kaplan, L., Stuetzele, R., Baker, N., & Fletcher, M. A. (2015). Spiritual coping predicts CD4-​cell preservation and undetectable viral load over four years. AIDS Care, 27(1), 71–​79. Krentzman, A. R., Farkas, K. J., & Townsend, A. L. (2010). Spirituality, religiousness, and alcoholism treatment outcomes: a comparison between black and white participants. Alcoholism Treatment Quarterly, 28(2), 128–​150. Kress, V. E., Newgent, R. A., Whitlock, J., & Mease, L. (2015). Spirituality/​religiosity, life satisfaction, and life meaning as protective factors for non-​suicidal self‐injury in college students. Journal of College Counseling, 18(2), 160–​174. Kretchy, I., Owusu-​Daaku, F., & Danquah, S. (2013). Spiritual and religious beliefs: do they matter in the medication adherence behaviour of hypertensive patients? BioPsychoSocial Medicine, 7(1), 15. Kretzler, B., König, H. H., & Hajek, A. (2020). Religious attendance and cancer screening behavior. Frontiers in Oncology, 10, 2133. Kristeller, J. L., Rhodes, M., Cripe, L. D., & Sheets, V. (2005). Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. International Journal of Psychiatry in Medicine, 35(4), 329–​347. Kroenke, C. H., Kubzansky, L. D., Schernhammer, E. S., Holmes, M. D., & Kawachi, I. (2006). Social networks, social support, and survival after breast cancer diagnosis. Journal of Clinical Oncology, 24(7), 1105–​1111. Krok‐Schoen, J. L., Bernardo, B. M., Weier, R. C., Peng, J., Katz, M. L., Reiter, P. L., et al. (2018). Belief about mandatory school vaccinations and vaccination refusal among Ohio Appalachian parents. Journal of Rural Health, 34(3), 283–​292.

Krukowski, R. A., Lueders, N. K., Prewitt, T. E., Williams, D. K., & Smith West, D. (2010). Obesity treatment tailored for a Catholic faith community. Journal of Health Psychology, 15(3), 382–​390. Krul, I. M., Opstal–​van Winden, A. W., Aleman, B. M., Janus, C. P., van Eggermond, A. M., De Bruin, M. L., et al. (2017). Breast cancer risk after radiation therapy for Hodgkin lymphoma. International Journal of Radiation Oncology*Biology* Physics, 99(4), 843–​853. Krull, C., & Trovato, F. (1994). The quiet revolution and the sex differential in Quebec’s suicide rates: 1931–​1986. Social Forces, 72(4), 1121–​1147. Krumrei, E. J., Mahoney, A., & Pargament, K. I. (2011). Spiritual stress and coping model of divorce. Journal of Family Psychology, 25(6), 973–​985. Kubzansky, L. D., Park, N., Peterson, C., Vokonas, P., & Sparrow, D. (2011). Healthy psychological functioning and incident coronary heart disease: the importance of self-​regulation. Archives of General Psychiatry, 68(4), 400–​408. Kudel, I., Cotton, S., Szaflarski, M., Holmes, W. C., & Tsevat, J. (2011). Spirituality and religiosity in patients with HIV: a test and expansion of a model. Annals of Behavioral Medicine, 41(1), 92–​103. Kuemmerer, J. M., & Comstock, G. W. (1967). Sociologic concomitants of tuberculin sensitivity. American Review of Respiratory Diseases, 96, 885–​892. Kuijpers, H. J., Van der Heijden, F. M., Tuinier, S., & Verhoeven, W. M. (2007). Meditation-​induced psychosis. Psychopathology, 40(6), 461–​464. Kuin, N. C., Scherder, E. J., Gijsbers, H., & Masthoff, E. D. (2019). Traumatic brain injury in prisoners: relation to risky decision-​making, aggression and criminal behavior. Journal of Behavioral and Brain Science, 9(7), 289. Kulmala, J., von Bonsdorff, M. B., Stenholm, S., Törmäkangas, T., von Bonsdorff, M. E., Nygård, C. H., et al. (2013). Perceived stress symptoms in midlife predict disability in old age. Journal of Gerontology, 68(8), M984–​991. Kulmala, J., Solomon, A., Kåreholt, I., Ngandu, T., Rantanen, T., Laatikainen, T., et al. (2014). Association between mid‐to late life physical fitness and dementia. Journal of Internal Medicine, 276(3), 296–​307. Kuklina, E. V., Tong, X., George, M. G., & Bansil, P. (2012). Epidemiology and prevention of stroke: a worldwide perspective. Expert review of Neurotherapeutics, 12(2), 199–​208.

References • 961

Kumanyika, S. K., & Charleston, J. B. (1992). Lose weight and win: a church-​based weight loss program for blood pressure control among Black women. Patient Education and Counseling, 19, 19–​32. Kumar, C. S., & Parashar, N. (2015). Death anxiety, coping and spirituality among cancer patients. Indian Journal of Positive Psychology, 6(3), 291–​294. Kumar, D., Goel, N. K., Pandey, A. K., & Sarpal, S. S. (2016). Complementary and alternative medicine use among the cancer patients in Northern India. South Asian Journal of Cancer, 5(01), 008–​011. Kunto, Y. S., & Mandemakers, J. J. (2019). The effects of prenatal exposure to Ramadan on stature during childhood and adolescence. Economics & Human Biology, 33, 29–​39. Kunzmann, A. T., Coleman, H. G., Huang, W. Y., & Berndt, S. I. (2018). The association of lifetime alcohol use with mortality and cancer risk in older adults. PLoS Medicine, 15(6), e1002585. Kupper, N., & Denollet, J. (2018). Type D personality as a risk factor in coronary heart disease. Current Cardiology Reports, 20(11), 104. Kurita, A., Takase, B., Shinagawa, N., Kodani, E., Okada, K., Iwahara, S., et al. (2011). Spiritual activation in very elderly individuals assessed as heart rate variability and plasma IL/​10/​ IL-​6 ratios. International Heart Journal, 52(5), 299–​303. Kushner, H. S. (1981). When Bad Things Happen to Good People. New York: Schocken Books. Kvaavik, E., Batty, G. D., Ursin, G., Huxley, R., Gale, C. R. (2010). Influence of individual and combined health behaviors on total and cause-​ specific mortality in men and women. Archives of Internal Medicine, 170, 711–​718. Kvande, M. N., Klockner, C. A., & Mielsen, M. E. (2015a). Church attendance and religious experience: Differential associations to well-​ being for Norwegian women and men? Sage Open 5(4): 1–​13. Kvande, M. N., Reidunsdatter, R. J., Løhre, A., Nielsen, M. E., & Espnes, G. A. (2015b). Religiousness and social support: a study in secular Norway. Review of Religious Research, 57(1), 87–​109. Kvarfordt, C. L., Sheridan, M. J., & Taylor, O. (2017). Religion and spirituality in social work curriculum: A survey of Canadian educators. British Journal of Social Work, 47, 1–​1 9.

962 •  R eferences

Kyu, H. H., Bachman, V. F., Alexander, L. T., Mumford, J. E., Afshin, A., Estep, K., et al. (2016). Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events. British Medical Journal, 354, i3857. Lace, J. W., Evans, L. N., Merz, Z. C., & Handal, P. J. (2020). Five-​Factor Model personality traits and self-​classified religiousness and spirituality. Journal of Religion and Health, 59, 1344–​1369. La Cour, P., Avlund, K., & Schultz-​L arsen, K. (2006). Religion and survival in a secular region: a 20 year follow-​up of 734 Danish adults born in 1914. Social Science & Medicine, 62(1), 157–​164. Labaki, W. W., Gu, T., Murray, S., Curtis, J. L., Soler, X., Bhatt, S. P., et al. (2019). Causes and predictors of death in smokers with and without COPD: an analysis of the COPDGene Cohort. In B93: COPD: Mortality and Risk Prediction. New York, NY: American Thoracic Society, 199, p. A3995. Labrecque, L. T., & Whisman, M. A. (2017). Attitudes toward and prevalence of extramarital sex and descriptionsof extramarital partners in the 21st century. Journal of Family Psychology, 31, 952–​957. Labrecque, L. T., & Whisman, M. A. (2020). Extramarital sex and marital dissolution: does identity of the extramarital partner matter? Family Process, 59(3), 1308–​1318. Labuschagne, I., Phan, K. L., Wood, A., Angstadt, M., Chua, P., Heinrichs, M., et al. (2010). Oxytocin attenuates amygdala reactivity to fear in generalized social anxiety disorder. Neuropsychopharmacology, 35(12), 2403–​2413. Lacombe, J., Armstrong, M. E., Wright, F. L., & Foster, C. (2019). The impact of physical activity and an additional behavioural risk factor on cardiovascular disease, cancer and all-​cause mortality: a systematic review. BMC Public Health, 19(1), 900. Laffey, M. E., Bjorck, J. P., & Currier, J. M. (2020). Coping and quality of life in veterans with chronic posttraumatic stress disorder. Traumatology, 26(2), 215–​226. Lai, H., Moore, R., Celentano, D. D., Gerstenblith, G., Treisman, G., Keruly, J. C., et al. (2016). HIV infection itself may not be associated with subclinical coronary artery disease among African Americans without cardiovascular symptoms. Journal of the American Heart Association, 5(3), e002529.

Lai, J. H., Zhu, Y. S., Huo, Z. H., Sun, R. F., Yu, B., Wang, Y. P., et al. (2010). Association study of polymorphisms in the promoter region of DRD4 with schizophrenia, depression, and heroin addiction. Brain Research, 1359, 227–​232. Laird, R. D., Marks, L. D., & Marrero, M. D. (2011). Religiosity, self-​control, and antisocial behavior. Journal of Applied Developmental Psychology, 32(2), 78–​85. Lake, B., Fuller, H. R., Rastall, S., & Usman, T. (2019). Breast reconstruction affects coping mechanisms in breast cancer survivors. Indian Journal of Surgery, 81(1), 43–​50. Lala, S. V., & Sajatovic, M. (2012). Medical and psychiatric comorbidities among elderly individuals with bipolar disorder. Journal of Geriatric Psychiatry and Neurology, 25(1), 20–​25. Lamb, K. M., Nogg, K. A., Rooney, B. M., & Blashill, A. J. (2018). Organizational religious activity, hypertension, and sexual orientation: results from a nationally representative sample. Annals of Behavioral Medicine, 52(11), 930–​940. Lamb, K. M., Vaughn, A. A., Calzo, J. P., & Blashill, A. J. (2020). The role of sexual orientation in the associations between religiousness and hypertension. Journal of Religion and Health, 59(6), 3141–​3156. Lambert, G., Johansson, M., Ågren, H., & Friberg, P. (2000). Reduced brain norepinephrine and dopamine release in treatment-​refractory depressive illness: evidence in support of the catecholamine hypothesis of mood disorders. Archives of General Psychiatry, 57(8), 787–​793. Lambert, N. M., Fincham, F. D., Braithwaite, S. R., Graham, S. M., & Beach, S. R. (2009). Can prayer increase gratitude? Psychology of Religion and Spirituality, 1, 139–​149. Lambert, N. M., Fincham, F. D., Marks, L. D., & Stillman, T. F. (2010). Invocations and intoxication: does prayer decrease alcohol consumption? Psychology of Addictive Behaviors, 24(2), 209–​219. Lamers, S. M., Bolier, L., Westerhof, G. J., Smit, F., & Bohlmeijer, E. T. (2012). The impact of emotional well-​being on long-​term recovery and survival in physical illness: a meta-​analysis. Journal of Behavioral Medicine, 35(5), 538–​547. Lamkin, D. M., Lutgendorf, S. K., McGinn, S., Dao, M., Maiseri, H., DeGeest, K., et al. (2008). Positive psychosocial factors and NKT cells in ovarian cancer patients. Brain, Behavior, and Immunity, 22(1), 65–​73. Lammers, C., Ireland, M., Resnick, M., & Blum, R. (2000). Influences on adolescents’ decision to postpone onset of sexual intercourse: a

survival analysis of virginity among youths aged 13 to 18 years. Journal of Adolescent Health, 26(1), 42–​48. Landenberger, N. A., & Lipsey, M. W. (2005). The positive effects of cognitive–​behavioral programs for offenders: a meta-​analysis of factors associated with effective treatment. Journal of Experimental Criminology, 1(4), 451–​476. Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159–​174. Landor, A., Simons, L. G., Simons, R. L., Brody, G. H., & Gibbons, F. X. (2011). The role of religiosity in the relationship between parents, peers, and adolescent risky sexual behavior. Journal of Youth and Adolescence, 40(3), 296–​309. Lanfredi, M., Candini, V., Buizza, C., Ferrari, C., Boero, M. E., Giobbio, G. M., et al. (2014). The effect of service satisfaction and spiritual well-​being on the quality of life of patients with schizophrenia. Psychiatry Research, 216, 185–​191. Langa, K. M., Larson, E. B., Crimmins, E. M., Faul, J. D., Levine, D. A., Kabeto, M. U., et al. (2017). A comparison of the prevalence of dementia in the United States in 2000 and 2012. JAMA Internal Medicine, 177(1), 51–​58. Langille, D. B., Asbridge, M., Cragg, A., & Rasic, D. (2015). Associations of school connectedness with adolescent suicidality. Canadian Journal of Psychiatry, 60(6), 258–​267. Lapane, K. L., Lasater, T. M., Allan, C., & Carleton, R. A. (1997). Religion and cardiovascular disease risk. Journal of Religion and Health, 36(2), 155–​163. Lappin, J. M., Darke, S., & Farrell, M. (2017). Stroke and methamphetamine use in young adults: a review. Journal of Neurology, Neurosurgery & Psychiatry, 88(12), 1079–​1091. Lara, E., Martín-​María, N., De la Torre-​Luque, A., Koyanagi, A., Vancampfort, D., Izquierdo, A., et al. (2019a). Does loneliness contribute to mild cognitive impairment and dementia? Ageing Research Reviews, 52, 7–​16. Lara, E., Caballero, F. F., Rico‐Uribe, L. A., Olaya, B., Haro, J. M., Ayuso‐Mateos, J. L., et al. (2019b). Are loneliness and social isolation associated with cognitive decline? International Journal of Geriatric Psychiatry, 34(11), 1613–​1622. Lariscy, J. T., Hummer, R. A., & Rogers, R. G. (2018). Cigarette smoking and all-​cause and cause-​specific adult mortality in the United States. Demography, 55(5), 1855–​1885.

References • 963

Larson, D. B., Hohmann, A. A., Kessler, L. G., Meador, K. G., Boyd, J. H., & McSherry, E. (1988). The couch and the cloth: the need for linkage. Hospital and Community Psychiatry, 39, 1064–​1069. Larson, D. B., & Matthews, D. E. (1996). Faith and medicine curricular awards. Journal of Alternative and Complementary Medicine, 2(4), 546. Larson, D. B., & Wilson, W. P. (1980). Religious life of alcoholics. Southern Medical Journal, 73, 723–​727. Larson, H. J., De Figueiredo, A., Xiahong, Z., Schulz, W. S., Verger, P., Johnston, I. G., et al. (2016). The state of vaccine confidence 2016: global insights through a 67-​country survey. EBioMedicine, 12, 295–​301. Larson, J. H., & Holman, T. B. (1994). Premarital predictors of marital quality and stability. Family Relations, 43(2), 228–​237. Larson, L. E., & Goltz, J. W. (1989). Religious participation and marital commitment. Review of Religious Research, 30, 387–​400. Larson, R. W., Hansen, D. M., Moneta, G. (2006). Differing profiles of developmental experiences across types of organized youth activities. Developmental Psychology, 42(5), 849–​863. Larzelere, R. E., Daly, D. L., Davis, J. L., Chmelka, M. B., & Handwerk, M. L. (2004). Outcome evaluation of Girls and Boys Town’s family home program. Education and Treatment of Children, 27(2), 130–​149. Lash, T. L., VanderWeele, T. J., Haneuse, S., & Rothman, K. J. (2021). Modern Epidemiology, 4th ed. Philadelphia, PA: Wolters Kluwer. Lassiter, J. M., Saleh, L., Grov, C., Starks, T., Ventuneac, A., & Parsons, J. T. (2019). Spirituality and multiple dimensions of religion are associated with mental health in gay and bisexual men. Psychology of Religion and Spirituality, 11(4), 408. Lasson, K. (1992). Religious liberty in the military: the First Amendment under “friendly fire.” Journal of Law and Religion, 9(2), 471–​499. Latham, K., & Clarke, P. J. (2018). Neighborhood disorder, perceived social cohesion, and social participation among older Americans. Journal of Aging and Health, 30(1), 3–​26. Latham-​Mintus, K., & Aman, K. M. (2019). Childhood disadvantage, psychosocial resiliency, and later life functioning: linking early-​life circumstances to recovery from mobility limitation. Journal of Aging and Health, 31(3), 463–​483. Latifynia, A., Vojgani, M., Jafarieh, H., & Abofazeli, T. (2007). Neutrophil respiratory burst (innate

964 •  R eferences

immunity) during Ramadan. Journal of Biological Sciences, 7(6), 997–​1000. Lauby-​Secretan, B., Scoccianti, C., Loomis, D., Grosse, Y., Bianchini, F., & Straif, K. (2016). Body fatness and cancer. New England Journal of Medicine, 375(8), 794–​798. Laufer, A., & Solomon, Z. (2011). The role of religious orientations in youth’s posttraumatic symptoms after exposure to terror. Journal of Religion and Health, 50(3), 687–​699. Laufer, A., Solomon, Z., & Levine, S. Z. (2010). Elaboration on posttraumatic growth in youth exposed to terror: The role of religiosity and political ideology. Social Psychiatry and Psychiatric Epidemiology, 45(6), 647–​653. Laurenceau, J. P., Stanley, S. M., Olmos-​Gallo, A., Baucom, B., & Markman, H. J. (2004). Community-​based prevention of marital dysfunction: multilevel modeling of a randomized effectiveness study. Journal of Consulting & Clinical Psychology, 72(6), 933–​943. Lavie, C. J., Arena, R., & Franklin, B. A. (2016). Cardiac rehabilitation and healthy life-​style interventions: rectifying program deficiencies to improve patient outcomes. Journal of the American College of Cardiology, 16(1), 13–​15. Lavie, C. J., Carbone, S., Kachur, S., O’Keefe, E. L., & Elagizi, A. (2019). Effects of physical activity, exercise, and fitness on obesity-​related morbidity and mortality. Current Sports Medicine Reports, 18(8), 292–​298. Lavner, J. A., & Clark, M. A. (2017). Workload and marital satisfaction over time: testing lagged spillover and crossover effects during the newlywed years. Journal of Vocational Behavior, 101, 67–​76. Lavrič, M., & Flere, S. (2010). Trait anxiety and measures of religiosity in four cultural settings. Mental Health, Religion & Culture, 13(7–​8), 667–​682. Lawes, C. M., Bennett, D. A., Feigin, V. L., & Rodgers, A. (2004). Blood pressure and stroke. Stroke, 35(3), 776–​785. Lawrence, E. M., Rogers, R. G., & Wadsworth, T. (2015). Happiness and longevity in the United States. Social Science & Medicine, 145, 115–​119. Lawrence, E. M., Rogers, R. G., Zajacova, A., & Wadsworth, T. (2019). Marital happiness, marital status, health, and longevity. Journal of Happiness Studies, 20(5), 1539–​1561. Lawrence, G. M., Friedlander, Y., Calderon-​Margalit, R., Enquobahrie, D. A., Huang, J. Y., Tracy, R. P., et al. (2017). Associations of social environment, socioeconomic position and social mobility with immune response in young adults. BMJ Open, 7(12), e016949.

Lawrence, R. E., Rasinski, K. A., Yoon, J. D., Koenig, H. G., Meador, K. G., & Curlin, F. A. (2012). Physicians’ beliefs about faith-​based treatments for alcoholism. Psychiatric Services, 63(6), 597–​604. Lawrence, R. E., Rasinski, K. A., Yoon, J. D., & Curlin, F. A. (2014). Primary care physicians’ and psychiatrists’ willingness to refer to religious mental health providers. International Journal of Social Psychiatry, 60(7), 627–​636. Lawrence, R. E., Brent, D., Mann, J. J., Burke, A. K., Grunebaum, M. F., Galfalvy, H. C., et al. (2016). Religion as a risk factor for suicide attempt and suicide ideation among depressed patients. Journal of Nervous and Mental Disease, 204(11), 845–​850. Laws, K. R., Darlington, N., Kondel, T. K., McKenna, P. J., & Jauhar, S. (2018). Cognitive Behavioural Therapy for schizophrenia-​outcomes for functioning, distress and quality of life: a meta-​ analysis. BMC Psychology, 6(1), 32. Layous, K., Chancellor, J., & Lyubomirsky, S. (2014). Positive activities as protective factors against mental health conditions. Journal of Abnormal Psychology, 123(1), 3–​12. Lazarus, S. R. (1966). Psychological Stress and the Coping. New York, NY: McGraw-​Hill. Lazarus, S. R., & Folkman, S. (1984). Stress, Appraisal and Coping. New York, NY: Springer. Lazenby, M. (2018). Understanding and addressing the religious and spiritual needs of advanced cancer patients. Seminars in Oncology Nursing, 34(3), 274–​283. Lazzarino, A. I., Hamer, M., Stamatakis, E., & Steptoe, A. (2013). Low socioeconomic status and psychological distress as synergistic predictors of mortality from stroke and coronary heart disease. Psychosomatic Medicine, 75(3), 311. Le, D., Holt, C. L., Hosack, D. P., Huang, J., & Clark, E. M. (2016). Religious participation is associated with increases in religious social support in a national longitudinal study of African Americans. Journal of Religion and Health, 55(4), 1449–​1460. Le, T. N., Tov, W., & Taylor, J. (2007). Religousness and depressive symptoms in five ethnic adolescent groups. International Journal for the Psychology of Religion, 17(3), 209–​232. Lea, C. R., Oliver, J. P., Smothers, Z., Boucher, N. A., Youssef, N. A., Ames, D., et al. (2019). The moderating effect of religious involvement on the relationship between PTSD symptoms and physical pain in US Veterans and active duty military. Military Behavioral Health, 7(3), 327–​335.

Lechner, C. M., & Leopold, T. (2015). Religious attendance buffers the impact of unemployment on life satisfaction. Journal for the Scientific Study of Religion, 54(1), 166–​174. Lechner, S. C., Carver, C. S., Antoni, M. H., Weaver, K. E., & Phillips, K. M. (2006). Curvilinear associations between benefit finding and psychosocial adjustment to breast cancer. Journal of Consulting & Clinical Psychology, 74(5), 828–​840. Lee v. Weisman (1992). Constitutional tradition that religion is out of bounds, even if not correct as a matter of history. 112 S. Ct. 2649, 2678, 2683-​ 84 (Justice Scalia, joined by the Chief Justice Rehnquist and Justices White and Thomas, dissenting). Retrieved on 10-​8-​2020 from https://​const​itut​ion.find​law.com/​ame​ndme​nt1/​ annot​atio​n01.html#f11. Lee, C. D., Sui, X., & Blair, S. N. (2009). Combined effects of cardiorespiratory fitness, not smoking, and normal waist girth on morbidity and mortality in men. Archives of Internal Medicine, 169, 2096–​2101. Lee, D. B., & Neblett, E. W. (2019). Religious development in African American adolescents. Child Development, 90(1), 245–​259. Lee, D. B., Peckins, M. K., Miller, A. L., Hope, M. O., Neblett, E. W., Assari, S., et al. (2021). Pathways from racial discrimination to cortisol/​ DHEA imbalance: Protective role of religious involvement. Ethnicity & Health, 26(3), 413–​430. Lee, D. C., & Ellingson, L. (2018). Physical inactivity and ill health (Ch. 4). In Draper, N., & Stratton, G. (eds.), Physical Activity: A Multi-​disciplinary Introduction. New York, NY: Routledge, pp. 46–​65. Lee, E. B., An, W., Levin, M. E., & Twohig, M. P. (2015). An initial meta-​analysis of Acceptance and Commitment Therapy for treating substance use disorders. Drug and Alcohol Dependence, 155, 1–​7. Lee, E. E., Depp, C., Palmer, B. W., Glorioso, D., Daly, R., Liu, J., et al. (2019). High prevalence and adverse health effects of loneliness in community-​dwelling adults across the lifespan. International Psychogeriatrics, 31(10), 1447–​1462. Lee, G. P., Ghandour, L. A., Takache, A. H., & Martins, S. S. (2014). Investigating the association between strategic and pathological gambling behaviors and substance use in youth: Could religious faith play a differential role? American Journal on Addictions, 23(3), 280–​287. Lee, G. R., & Ishii-​Kuntz, M. (1987). Social interaction, loneliness, and emotional well-​being

References • 965

among the elderly. Research on Aging, 9, 359–​482. Lee, J. Y., Kim, W., Brook, J. S., Finch, S. J., & Brook, D. W. (2020). Adolescent risk and protective factors predicting triple trajectories of substance use from adolescence into adulthood. Journal of Child and Family Studies, 29(2), 403–​412. Lee, L. A., Franzel, L., Atwell, J., Datta, S. D., Friberg, I. K., Goldie, S. J., et al. (2013). The estimated mortality impact of vaccinations forecast to be administered during 2011–​2020 in 73 countries supported by the GAVI Alliance. Vaccine, 31, B61–​B72. Lee, L. O., James, P., Zevon, E. S., Kim, E. S., Trudel-​ Fitzgerald, C., Spiro, A., et al. (2019). Optimism is associated with exceptional longevity in 2 epidemiologic cohorts of men and women. Proceedings of the National Academy of Sciences, 116(37), 18357–​18362. Lee, M. R. (2006). The religious institutional base and violent crime in rural areas. Journal for the Scientific Study of Religion, 45(3), 309–​324. Lee, M. R., & Bartkowski, J. P. (2004). Love thy neighbor? Moral communities, civic engagement, and juvenile homicide in rural areas. Social Forces, 82(3), 1001–​1035. Lee, M. T., Pagano, M. E., Johnson, B. R., Post, S. G., Leibowitz, G. S., & Dudash, M. (2017). From defiance to reliance: Spiritual virtue as a pathway towards desistence, humility, and recovery among juvenile offenders. Spirituality in Clinical Practice, 4(3), 161. Lee, T., & Sachdev, P. (2014). The contributions of twin studies to the understanding of brain ageing and neurocognitive disorders. Current Opinion in Psychiatry, 27(2), 122–​127. Lee, Y. R., & Enright, R. D. (2019). A meta-​analysis of the association between forgiveness of others and physical health. Psychology & Health, 34(5), 626–​643. Lee-​Poy, M., Stewart, M., Ryan, B. L., & Brown, J. B. (2016). Asking patients about their religious and spiritual beliefs. Canadian Family Physician, 62(9), e555–​e561. Legal Information Institute (1992). First Amendment. Ithaca, NY: Cornell Law School. Retrieved on 10-​8-​2020 from https://​www.law. corn​ell.edu/​wex/​firs​t_​am​endm​ent. Lehrer, E. L., & Chiswick, C. U. (1993). Religion as a determinant of marital stability. Demography, 30, 385–​404. Lehrer, J. A., Buka, S., Gortmaker, S., & Shrier, L. A. (2006). Depressive symptomatology as a predictor of exposure to intimate partner violence among US female adolescents and

966 •  R eferences

young adults. Archives of Pediatrics & Adolescent Medicine, 160(3), 270–​276. Lehto, U. S., Ojanen, M., Dyba, T., Aromaa, A., & Kellokumpu-​Lehtinen, P. (2007). Baseline psychosocial predictors of survival in localized melanoma. Journal of Psychosomatic Research, 63(1), 9–​15. Lekhak, N., Bhatta, T. R., & Zauszniewski, J. A. (2020). Episodic memory in later life: benefits of prayer and meditation. Journal of Holistic Nursing, 38(1), 30–​40. Lelkes, O. (2006). Tasting freedom: happiness, religion and economic transition. Journal of Economic Behavior & Organization, 59(2), 173–​194. Lemere, F. (1953). What happens to alcoholics. American Journal of Psychiatry, 109, 674–​676. Lemon, F. R., & Walden, R. T. (1966). Death from respiratory system disease among Seventh-​Day Adventist men. Journal of the American Medical Association, 198, 137–​146. Lemstra, M., Nwankwo, C., Bird, Y., & Moraros, J. (2018). Primary nonadherence to chronic disease medications. Patient Preference and Adherence, 12, 721–​731. Lenderking, W. R. (2005) Comments on the ISPOR Task Force Report on translation and adaptation of outcome measures. Value in Health, 8(2), 92–​93. Lensch, T., Clements-​Nolle, K., Oman, R. F., & Lu, M. (2021). A longitudinal study of the protective influence of youth assets on juvenile arrest. Journal of Public Health, 43(2), 295–​301. Lenze, E. J., Rogers, J. C., Martire, L. M., Mulsant, B. H., Rollman, B. L., Dew, M. A., et al. (2001). The association of late-​life depression and anxiety with physical disability. American Journal of Geriatric Psychiatry, 9(2), 113–​135. Lenzenweger, M. F. (2008). Epidemiology of personality disorders. Psychiatric Clinics of North America, 31(3), 395–​403. Leone, A. F. (2011). Improving compliance: does it matter to your patients if you are spiritual? Journal of the South Carolina Medical Association (1975), 107(2), 42–​47. Leopold, T. (2018). Gender differences in the consequences of divorce. Demography, 55(3), 769–​797. Lerch, M., Oris, M., Wanner, P., Forney, Y., & Dutreuilh, C. (2010). Religious affiliation and mortality in Switzerland, 1991–​2004. Population, 65(2), 217–​250. Lerman, S., Jung, M., Arredondo, E. M., Barnhart, J. M., Cai, J., Castañeda, S. F., et al. (2018). Religiosity prevalence and its association with depression and

anxiety symptoms among Hispanic/​Latino adults. PloS One, 13(2), e0185661. Lester, D. (1992). Religiosity, suicide, and homicide. Psychological Reports, 71, 1282. Letourneau, N. L., Tramonte, L., & Willms, J. D. (2013). Maternal depression, family functioning and children’s longitudinal development. Journal of Pediatric Nursing, 28(3), 223–​234. Leurent, B., Nazareth, I., Bellón-​Saameño, J., Geerlings, M. I., Maaroos, H., Saldivia, S., et al. (2013). Spiritual and religious beliefs as risk factors for the onset of major depression. Psychological Medicine, 43(10), 2109–​2120. Levav, I., & Aisenberg, E. (1989). The epidemiology of suicide in Israel. Suicide and Life‐Threatening Behavior, 19(2), 184–​200. Levav, I., Kohn, R., Golding, J. M., & Weissman, M. M. (1997). Vulnerability of Jews to affective disorders. American Journal of Psychiatry, 154, 941–​947. Levin, J. S. (1994). Religion and health: is there an association, is it valid, and is it causal? Social Science & Medicine, 38, 1475–​1482. Levin, J. S. (1996). How religion influences morbidity and health: Reflections on natural history, salutogenesis and host resistance. Social Sciences and Medicine, 43, 849–​864. Levin, J. S. (2011). Health impact of Jewish religious observance in the USA: findings from the 2000–​01 National Jewish Population Survey. Journal of Religion and Health, 50(4), 852–​868. Levin, J. S. (2012a). Religion and positive well-​being among Israeli and diaspora Jews: findings from the World Values Survey. Mental Health, Religion & Culture, 15(7), 709–​720. Levin, J. S. (2012b). Religion and physical health among older Israeli Jews: findings from the SHARE-​Israel Study. Israel Medical Association Journal, 14(10):595–​601. Levin, J. S. (2013). Religious behavior, health, and well-​being among Israeli Jews: findings from the European Social Survey. Psychology of Religion and Spirituality, 5(4), 272–​283. Levin, J. S. (2014). Religion and happiness among Israeli Jews: findings from the ISSP religion III survey. Journal of Happiness Studies, 15(3), 593–​611. Levin, J. S. (2016a). Prevalence and religious predictors of healing prayer use in the USA: findings from the Baylor Religion Survey. Journal of Religion and Health, 55(4), 1136–​1158. Levin, J. S. (2016b). Partnerships between the faith-​based and medical sectors: Implications for preventive medicine and public health. Preventive Medicine Reports, 4, 344–​350.

Levin, J. S. (2018). Religion and the Social Sciences: Basic and Applied Research Perspectives. Conshohocken, PA: Templeton Press. Levin, J. S. (2020). Religion and Medicine: A History of the Encounter Between Humanity’s Two Greatest Institutions. New York, NY: Oxford University Press. Levin, J. S., & Kaplan, B. H. (2010). The Sorokin multidimensional inventory of love experience (SMILE): development, validation, and religious determinants. Review of Religious Research, 51(4), 380–​401. Levin, J. S., & Markides, K. S. (1986). Religious attendance and subjective health. Journal for the Scientific Study of Religion, 25, 31–​40. Levin, J. S., & Markides, K. S. (1988). Religious attendance and psychological well-​being in middle-​aged and older Mexican Americans. Sociological Analysis, 49, 66–​72. Levin, J. S., & Schiller, P. L. (1987). Is there a religious factor in health? Journal of Religion and Health, 26, 9–​36. Levin, J. S., Chatters, L. M., & Taylor, R. J. (1995a). Religious effects on health status and life satisfaction among black Americans. Journal of Gerontology: Social Sciences, 50B, S154–​S163. Levin, J. S., Taylor, R. J., & Chatters, L. M. (1995b). A multidimensional measure of religious involvement for African Americans. Sociological Quarterly, 36, 157–​173. Levin, J. S., Markides, K. S., & Ray, L. A. (1996a). Religious attendance and psychological well-​ being in Mexican Americans: a panel analysis of three-​generations data. Gerontologist, 36, 454–​463. Levin, J. S., Chatters, L. M., Ellison, C. G., & Taylor, R. J. (1996b). Religious involvement, health outcomes, and public health practice. Current Issues in Public Health, 2, 220–​225. Levine, D. S., Taylor, R. J., Nguyen, A. W., Chatters, L. M., & Himle, J. A. (2015). Family and friendship informal support networks and social anxiety disorder among African Americans and Black Caribbeans. Social Psychiatry and Psychiatric Epidemiology, 50(7), 1121–​1133. Levine, G. N., Cohen, B. E., Commodore-​Mensah, Y., Fleury, J., Huffman, J. C., Khalid, U., et al. (2021). Psychological health, well-​being, and the mind-​heart-​body connection: A scientific statement from the American Heart Association. Circulation, 143(10), e763–​e783. Levinson, N. P. (1987). Pain and suffering: views of Jewish theology. In Brihaye, J., Loew, F., & Pia, H. W. (eds.), Pain: A Medical and Anthropological

References • 967

Challenge. Vienna, Austria: Springer, pp. 129–​131. Lew, B., Huen, J., Yuan, L., Stack, S., Maniam, T., Yip, P., et al. (2018). Religious orientation and its relationship to suicidality: a study in one of the least religious countries. Religions, 9(1), 15. Lewis, C. A., Shevlin, M., Francis, L. J., & Quigley, C. F. (2011). The association between church attendance and psychological health in Northern Ireland. Journal of Religion and Health, 50(4), 986–​995. Lewis, V. A., MacGregor, C. A., & Putnam, R. D. (2013). Religion, networks, and neighborliness: the impact of religious social networks on civic engagement. Social Science Research, 42(2), 331–​346. Lewis-​Fernandez, R., Horvitz-​Lennon, M., Blanco, C., Guarnaccia, P. J., Cao, Z., & Alegria, M. (2009). Significance of endorsement of psychotic symptoms by U.S. Latinos. Journal of Nervous and Mental Disease, 197, 337–​347. Leyva, B., Nguyen, A. B., Allen, J. D., Taplin, S. H., & Moser, R. P. (2015). Is religiosity associated with cancer screening? Results from a national survey. Journal of Religion and Health, 54(3), 998–​1013. Li, J., & Lambert, V. A. (2007). Coping strategies and predictors of general well‐being in women with breast cancer in the People’s Republic of China. Nursing & Health Sciences, 9(3), 199–​204. Li, L., Setoguchi, S., Cabral, H., & Jick, S. (2013). Opioid use for noncancer pain and risk of myocardial infarction amongst adults. Journal of Internal Medicine, 273(5), 511–​526. Li, P., Huang, J., Wu, H., Fu, C., Li, Y., & Qiu, J. (2016). Impact of lifestyle and psychological stress on the development of early onset breast cancer. Medicine, 95(50), e5529. Li, Q.-​Z., Li, P., Garcia, G. E., Johnson, R. J., & Feng, L. (2005). Genomic profiling of neutrophil transcripts in Asian Qigong practitioners: a pilot study in gene regulation by mine-​body interaction. Journal of Alternative and Complementary Medicine, 11(1), 29–​39. Li, S., Okereke, O. I., Chang, S. C., Kawachi, I., & VanderWeele, T. J. (2016a). Religious service attendance and lower depression among women: a prospective cohort study. Annals of Behavioral Medicine, 50(6), 876–​884. Li, S., Stampfer, M. J., Williams, D. R., & VanderWeele, T. J. (2016b). Association of religious service attendance with mortality among women. JAMA Internal Medicine, 176(6), 777–​785.

968 •  R eferences

Li, S., Kubzansky, L. D., & VanderWeele, T. J. (2018a). Religious service attendance, divorce, and remarriage among US nurses in mid and late life. PloS One, 13(12), e0207778. Li, S., Hagan, K., Grodstein, F., & VanderWeele, T. J. (2018b). Social integration and healthy aging among US women. Preventive Medicine Reports, 9, 144–​148. Li, X., Kawachi, I., Buxton, O. M., Haneuse, S., & Onnela, J. P. (2019). Social network analysis of group position, popularity, and sleep behaviors among US adolescents. Social Science & Medicine, 232, 417–​426. Li, Z. H., Zhang, X. R., Lv, Y. B., Shen, D., Li, F. R., Zhong, W. F., et al. (2020a). Leisure activities and all-​cause mortality among the Chinese oldest-​old population. Journal of the American Medical Directors Association, 21(6), 713–​719. Li, Z. H., Chen, Q., Kraus, V. B., Shen, D., Zhang, X. R., Zhang, P. D., et al. (2020b). Leisure activities and disability in activities of daily living among the oldest-​old Chinese population. Aging, 12(11), 10687. Liefbroer, A. C., & Rijken, A. J. (2019). The association between Christianity and marriage attitudes in Europe. European Sociological Review, 35(3), 363–​379. Lightbody, C. E., Clegg, A., Patel, K., Lucas, J. C., Storey, H., Hackett, M. L., et al. (2017). Systematic review and meta-​analysis of psychosocial risk factors for stroke. Seminars in Neurology, 37(3), 294–​306. Lillard, L. A., & Panis, C. W. (1996). Marital status and mortality. Demography, 33(3), 313–​327. Lim, C., & Putnam, R. D. (2010). Religion, social networks, and life satisfaction. American Sociological Review, 75(6), 914–​933. Lim, C., MacGregor, C. A., & Putnam, R. D. (2010). Secular and liminal: discovering heterogeneity among religious nones. Journal for the Scientific Study of Religion, 49(4), 596–​618. Lin, C. Y., Saffari, M., Koenig, H. G., & Pakpour, A. H. (2018). Effects of religiosity and religious coping on medication adherence and quality of life among people with epilepsy. Epilepsy & Behavior, 78, 45–​51. Lin, K. M., & Kleinman, A. M. (1988). Psychopathology and clinical course of schizophrenia: a cross-​cultural perspective. Schizophrenia Bulletin, 14(4), 555–​567. Lin, P., Li, L., Wang, Y., Zhao, Z., Liu, G., Chen, W., et al. (2018). Type D personality, but not Type A behavior pattern, is associated with coronary plaque vulnerability. Psychology, Health & Medicine, 23(2), 216–​223.

Linardakis, M., Papadaki, A., Smpokos, E., Sarri, K., Vozikaki, M., & Philalithis, A. (2015). Are religiosity and prayer use related with multiple behavioural risk factors for chronic diseases in European adults aged 50+​years? Public Health, 129(5), 436–​443. Linden, S. C., Harris, M., Whitaker, C., & Healy, D. (2010). Religion and psychosis: the effects of the Welsh religious revival in 1904–​1905. Psychological Medicine, 40(8), 1317–​1323. Lindson, N., Thompson, T. P., Ferrey, A., Lambert, J. D., & Aveyard, P. (2019). Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews, 7, CD006936. Ling, S., Umbach, R., & Raine, A. (2019). Biological explanations of criminal behavior. Psychology, Crime & Law, 25(6), 626–​640. Linnemann, C., & Lang, U. E. (2020). Pathways connecting late-​life depression and dementia. Frontiers in Pharmacology, 11, 279. Lipka, M., & Gecewica, C. (2017). More Americans now say they’re spiritual but not religious. Pew Research Center. Retrieved on 4-​16-​2019 from https://​www.pewr​esea​rch.org/​fact-​tank/​2017/​ 09/​06/​more-​americ​ans-​now-​say-​the​yre-​spirit​ ual-​but-​not-​religi​ous/​. Lippo, C. (2018). This is why we say “until death do us part” in wedding vows. Redbook. Retrieved on 10-​17-​2019 from https://​www.msn.com/​ en-​in/​lifest​yle/​relati​onsh​ips/​this-​is-​why-​we-​ say-​until-​death-​do-​us-​part-​in-​wedd​ing-​vows/​ ar-​BBOd​R1p. Lissoni, P., Messina, G., Balestra, A., Colciago, M., Brivio, F., Fumagalli, L., et al. (2008a). Efficacy of cancer chemotherapy in relation to synchronization of cortisol rhythm, immune status and psychospiritual profile in metastatic non-​small cell lung cancer. In Vivo: International Institute of Anticancer Research, 22(2), 257–​62. Lissoni, P., Messina, G., Parolini, D., Balestra, A., Brivio, F., & Fumagalli, L (2008b). A spiritual approach in the treatment of cancer: Relation between faith score and response to chemotherapy in advanced non-​small cell lung cancer patients. In Vivo: International Institute of Anticancer Research, 22(5), 577–​582. Litman, L., Robinson, J., Weinberger-​Litman, S. L., & Finkelstein, R. (2019). Both intrinsic and extrinsic religious orientation are positively associated with attitudes toward cleanliness. Journal of Religion and Health, 58(1), 41–​52. Litton, A. G., Desmond, R. A., Gilliland, J., Huh, W. K., & Franklin, F. A. (2011). Factors associated with intention to vaccinate a daughter against

HPV. Journal of Pediatric and Adolescent Gynecology, 24(3), 166–​171. Litwin, H. (2001). Social network type and morale in old age. Gerontologist, 41(4), 516–​524. Litwin, H. (2007). What really matters in the social network-​mortality association? A multivariate examination among older Jewish-​Israelis. European Journal of Ageing, 4(2), 71–​82. Litwin, H., Schwartz, E., & Avital, D. (2017). Religiosity and well-​being among older Jewish Israelis: findings from SHARE. Journal of Religion, Spirituality & Aging, 29(2–​3), 208–​223. Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., et al. (2009). Moral injury and moral repair in war veterans. Clinical Psychology Review, 29(8), 695–​706. Liu, E. Y., & Koenig, H. G. (2013). Measuring intrinsic religiosity: scales for use in mental health studies in China—​a research report. Mental Health, Religion & Culture, 16(2), 215–​224. Liu, J., Svob, C., Wickramaratne, P., Hao, X., Talati, A., Kayser, J., et al. (2017). Neuroanatomical correlates of familial risk-​for-​depression and religiosity/​spirituality. Spirituality in Clinical Practice, 4(1), 32–​42. Liu, K., Xu, Y., Wang, S., Shi, R., Gong, S., Li, X., et al. (2019). Buddhist activities related to sedentary behavior and hypertension in Tibetan monks. Journal of Human Hypertension, 33(10), 756–​762. Liu, M. Y., Li, N., Li, W. A., & Khan, H. (2017). Association between psychosocial stress and hypertension: a systematic review and meta-​ analysis. Neurological Research, 39(6), 573–​580. Liu, X. K., Xiao, S. Y., Zhou, L., Hu, M., Zhou, W., & Liu, H. M. (2018). Sleep quality and covariates as predictors of pain intensity among the general population in rural China. Journal of Pain Research, 11, 857–​866. Liu, X., Zhang, D., Liu, Y., Sun, X., Hou, Y., Wang, B., et al. (2018). A J-​shaped relation of BMI and stroke. Nutrition, Metabolism and Cardiovascular Diseases, 28(11), 1092–​1099. Liu, Y., Croft, J. B., Wheaton, A. G., Kanny, D., Cunningham, T. J., Lu, H., et al. (2016). Clustering of five health-​related behaviors for chronic disease prevention among adults, United States, 2013. Prevention of Chronic Disease, 13, 160054. Liu, Z., Zhou, X., Zhang, W., & Zhou, L. (2020). Resilience and its correlates among first ischemic stroke survivors at acute stage of hospitalization from a tertiary hospital in China. Aging & Mental Health, 24(5), 828–​836.

References • 969

Livermore, N., Sharpe, L., & McKenzie, D. (2010). Panic attacks and panic disorder in chronic obstructive pulmonary disease. Respiratory Medicine, 104(9), 1246–​1253. Livingston, G. (2018). About one-​third of U.S. children are living with an unmarried parent. Pew Research Center, April 27. Retrieved on 12-​27-​2019 from https://​www.pewr​esea​rch. org/​fact-​tank/​2018/​04/​27/​about-​one-​third-​ of-​u-​s-​child​ren-​are-​liv​ing-​with-​an-​unmarr​ied-​ par​ent/​. Livingston, G., Sommerlad, A., Orgeta, V., Costafreda, S. G., Huntley, J., Ames, D., et al. (2017). Dementia prevention, intervention, and care. The Lancet, 390(10113), 2673–​2734. Livingston, I. L., Levine, D. M., & Moore, R. D. (1991). Social integration and Black intraracial variation in blood pressure. Ethnicity & Disease, 1, 135–​149. Lloyd, S., & Raikhel, E. (2018). Environmental epigenetics and suicide risk at a molecular scale. In Gibbon, S., Prainsack, B., Hilgartner, S., & Lamoreaux, J. (eds.), Handbook of Genomics, Health and Society. London: Routledge, pp. 254–​262. Lo, C. C., Tenorio, K. A., & Cheng, T. C. (2012). Racial differences in co-​occurring substance use and serious psychological distress: the roles of marriage and religiosity. Substance Use & Misuse, 47(6), 734–​744. Loch, A. A., Freitas, E. L., Hortêncio, L., Chianca, C., Alves, T. M., Serpa, M. H., et al. (2019). Hearing spirits? Religiosity in individuals at risk for psychosis. Schizophrenia Research, 204, 353–​359. Locher, J. L., Ritchie, C. S., Roth, D. L., Baker, P. S., Bodner, E. V., Allman, R. M., et al. (2005). Social isolation, support, and capital and nutritional risk in an older sample: ethnic and gender differences. Social Science & Medicine, 60(4), 747–​761. Loef, M., & Walach, H. (2012). The combined effects of healthy lifestyle behaviors on all-​ cause mortality: a systematic review and meta-​ analysis. Preventive Medicine, 55(3), 163–​170. Lofters, A. K., Slater, M., & Vahabi, M. (2018). Cancer screening among patients who self-​ identify as Muslim: combining self-​reported data with medical records in a family practice setting. Journal of Immigrant and Minority Health, 20(1), 44–​50. Loftfield, E., Freedman, N. D., Dodd, K. W., Vogtmann, E., Xiao, Q., Sinha, R., et al. (2016). Coffee drinking is widespread in the United States, but usual intake varies by key

970 •  R eferences

demographic and lifestyle factors. Journal of Nutrition, 146(9), 1762–​1768. Logan-​Greene, P., Tennyson, R. L., Nurius, P. S., & Borja, S. (2017). Adverse childhood experiences, coping resources, and mental health problems among court-​involved youth. Child & Youth Care Forum, 46(6), 923–​946. Lohoff, F. W. (2010). Overview of the genetics of major depressive disorder. Current Psychiatry Reports, 12(6), 539–​546. Løkken, B. I., Merom, D., Sund, E. R., Krokstad, S., & Rangul, V. (2020). Cultural participation and all-​cause mortality, with possible gender differences: an 8-​year follow-​up in the HUNT Study, Norway. Journal of Epidemiology & Community Health, 74(8), 624–​630. Long, K. N., Chen, Y., Potts, M., Hanson, J., & VanderWeele, T. J. (2020a). Spiritually motivated self-​forgiveness and divine forgiveness, and subsequent health and well-​being among middle-​aged female nurses. Frontiers in Psychology, 11, 1337. Long, K. N., Kim, E. S., Chen, Y., Wilson, M. F., Worthington, E. L., Jr., & VanderWeele, T. J. (2020b). The role of hope in subsequent health and well-​being for older adults: an outcome-​wide longitudinal approach. Global Epidemiology, 2, 100018. Long, K. N., Worthington, E. L., VanderWeele, T. J., & Chen, Y. (2020c). Forgiveness of others and subsequent health and well-​being in mid-​ life: a longitudinal study on female nurses. BMC Psychology, 8, 104. Longden, E., & Read, J. (2016). Social adversity in the etiology of psychosis: a review of the evidence. American Journal of Psychotherapy, 70(1), 5–​33. Longest, B. B. (2015). Health and health policy (Ch. 1). In B. B. Longest (ed.), Health Policymaking in the United States, 6th edition. Chicago, IL: Health Administration Press, Foundation of the American College of Healthcare Executives. Retrieved on 10-​3-​2020 from http://​acco​unt. ache.org/​eweb/​upl​oad/​Long​est-​228​7_​Ch​ap1-​ e8ed4​666.pdf. Lopez, S. J., Pedrotti, J. T., & Snyder, C. R. (2018). Positive Psychology: The Scientific and Practical Explorations of Human Strengths. Thousand Oaks, CA: SAGE Publications. López-​Cevallos, D. F., Flórez, K. R., & Derose, K. P. (2021). Examining the association between religiosity and medical mistrust among churchgoing Latinos in Long Beach, CA. Translational Behavioral Medicine, 11(1), 114–​121.

Lopizzo, N., Bocchio Chiavetto, L., Cattane, N., Plazzotta, G., Tarazi, F. I., Pariante, C. M., et al. (2015). Gene–​environment interaction in major depression. Frontiers in Psychiatry, 6, 68. Lorch, B. R., & Hughes, R. H. (1985). Religion and youth substance use. Journal of Religion and Health, 24, 197–​208. Lorenz, L., Doherty, A., & Casey, P. (2019). The role of religion in buffering the impact of stressful life events on depressive symptoms in patients with depressive episodes or adjustment disorder. International Journal of Environmental Research and Public Health, 16(7), 1238. Losada, A., Márquez-​González, M., Romero-​ Moreno, R., Mausbach, B. T., López, J., Fernández-​Fernández, V., et al. (2015). Cognitive–​behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for dementia family caregivers with significant depressive symptoms. Journal of Consulting and Clinical Psychology, 83(4), 760. Löser, H., & Majewski, F. (1977). Type and frequency of cardiac defects in embryofetal alcohol syndrome. Report of 16 cases. Heart, 39(12), 1374–​1379. Loucks, E. B., Taylor, S. E., Polak, J. F., Wilhelm, A., Kalra, P., & Matthews, K. A. (2014). Childhood family psychosocial environment and carotid intima media thickness: the CARDIA study. Social Science & Medicine, 104, 15–​22. Loureiro, A. C., de Rezende Coelho, M. C., Coutinho, F. B., Borges, L. H., & Lucchetti, G. (2018). The influence of spirituality and religiousness on suicide risk and mental health of patients undergoing hemodialysis. Comprehensive Psychiatry, 80, 39–​45. Lowell, E. P., Tonnsen, B. L., Bailey, D. B., & Roberts, J. E. (2017). The effects of optimism, religion, and hope on mood and anxiety disorders in women with the FMR1 premutation. Journal of Intellectual Disability Research, 61(10), 916–​927. Lowery, C. L., III, Woulfe, D., & Kilic, F. (2019). Responses of plasma catecholamine, serotonin, and the platelet serotonin transporter to cigarette smoking. Frontiers in Neuroscience, 13, 32. Luberto, C. M., Shinday, N., Song, R., Philpotts, L. L., Park, E. R., Fricchione, G. L., et al. (2018). A systematic review and meta-​analysis of the effects of meditation on empathy, compassion, and prosocial behaviors. Mindfulness, 9(3), 708–​724. Lubin, G., Glasser, S., Boyko, V., & Barell, V. (2001). Epidemiology of suicide in Israel. Social

Psychiatry and Psychiatric Epidemiology, 36(3), 123–​127. Luca, S. A., Jamthikar, A., Gupta, D., Khanna, N. N., Viskovic, K., Suri, H. S., et al. (2019). Global perspective on carotid intima-​media thickness and plaque: should the current measurement guidelines be revisited? International Angiology, 38(6), 451–​465. Lucas, R. E. (2007). Adaptation and the set-​point model of subjective well-​being: Does happiness change after major life events? Current Directions in Psychological Science, 16(2), 75–​79. Lucas, R. E., Clark, A. E., Georgellis, Y., & Diener, E. (2003). Reexamining adaptation and the set point model of happiness. Journal of Personality and Social Psychology, 84(3), 527–​539. Lucas, R. E., Clark, A. E., Georgellis, Y., & Diener, E. (2004). Unemployment alters the set point for life satisfaction. Psychological Science, 15(1), 8–​13. Lucchetti, G., Lucchetti, A. L., & Koenig, H. G. (2011). Impact of spirituality/​religiosity on mortality: comparison with other health interventions. Explore, 7(4), 234–​238. Lucchetti, G., Peres, M. F., Lucchetti, A. L., & Koenig, H. G. (2012). Religiosity and tobacco and alcohol use in a Brazilian shantytown. Substance Use & Misuse, 47(7), 837–​846. Lucchetti, G., de Oliveira, L. R., Koenig, H. G., Leite, J. R., & Lucchetti, A. L. (2013). Medical students, spirituality and religiosity-​results from the multicenter study SBRAME. BMC Medical Education, 13(1), 162. Lucchetti, G., de Oliveira, L. R., Leite, J. R., & Lucchetti, A. L. (2014). Medical students and controversial ethical issues: results from the multicenter study SBRAME. BMC Medical Ethics, 15(1), 85. Lucette, A., Ironson, G., Pargament, K. I., & Krause, N. (2016). Spirituality and religiousness are associated with fewer depressive symptoms in individuals with medical conditions. Psychosomatics, 57(5), 505–​513. Ludema, C., Doherty, I. A., White, B. L., Simpson, C. A., Villar-​Loubet, O., McLellan-​Lemal, E., et al. (2015). Religiosity, spirituality, and HIV risk behaviors among African American women from four rural counties in the southeastern U.S. Journal of Health Care for the Poor and Underserved, 26(1), 168–​181. Lukachko, A., Myer, I., & Hankerson, S. (2015). Religiosity and mental health service utilization among African Americans. Journal of Nervous and Mental Disease, 203(8), 578.

References • 971

Lun, V. M. C., & Bond, M. H. (2013). Examining the relation of religion and spirituality to subjective well-​being across national cultures. Psychology of Religion and Spirituality, 5(4), 304–​316. Luna, R., Lindsey, M., & Van Tongeren, D. R. (2017). Virtue, positive psychology, and religion: Consideration of an overarching virtue and an underpinning mechanism. Psychology of Religion and Spirituality, 9(3), 299–​302. Lung, F. W., Yang, M. C., & Shu, B. C. (2011). The interleukin 10 promoter haplotype ACA and the long-​form variant of the DRD4 uVNTR polymorphism are associated with vulnerability to schizophrenia. Psychiatry Research, 188(2), 294–​296. Luoh, M. C., & Herzog, A. R. (2002). Individual consequences of volunteer and paid work in old age: health and mortality. Journal of Health and Social Behavior, 43, 490–​509. Luoni, A., Richetto, J., Racagni, G., & Molteni, R. (2015). The long-​term impact of early adversities on psychiatric disorders: focus on neuronal plasticity. Current Pharmaceutical Design, 21(11), 1388–​1395. Luszczynska, A., Gerstorf, D., Boehmer, S., Knoll, N., & Schwarzer, R. (2007). Patients’ coping profiles and partners’ support provision. Psychology and Health, 22(7), 749–​764. Lutgendorf, S. K., Russell, D., Ullrich, P., Harris, T. B., & Wallace, R. (2004). Religious participation, interleukin-​6, and mortality in older adults. Health Psychology, 23(5), 465–​475. Lutgendorf, S. K., Sood, A. K., Anderson, B., McGinn, S., Maiseri, H., Dao, M., et al. (2005). Social support, psychological distress, and natural killer cell activity in ovarian cancer. Journal of Clinical Oncology, 23(28), 7105–​7113. Lutgendorf, S. K., Lamkin, D. M., DeGeest, K., Anderson, B., Dao, M., McGinn, S., et al. (2008). Depressed and anxious mood and T-​cell cytokine expressing populations in ovarian cancer patients. Brain, Behavior, and Immunity, 22(6), 890–​900. Lutgendorf, S. K., DeGeest, K., Sung, C. Y., Arevalo, J. M., Penedo, F., & Lucci, J. (2009). Depression, social support, and beta-​adrenergic transcription control in human ovarian cancer. Brain, Behavior, & Immunity, 23(2), 176–​183. Lutgendorf, S. K., DeGeest, K., Dahmoush, L., Farley, D., Penedo, F., Bender, D., et al. (2011). Social isolation is associated with elevated tumor norepinephrine in ovarian carcinoma patients. Brain, Behavior, and Immunity, 25(2), 250–​255. Lutjen, L. J., Silton, N. R., & Flannelly, K. J. (2012). Religion, forgiveness, hostility and health: a

972 •  R eferences

structural equation analysis. Journal of Religion and Health, 51(2), 468–​478. Lycett, D. (2015). The association of religious affiliation and body mass index (BMI): an analysis from the Health Survey for England. Journal of Religion and Health, 54(6), 2249–​2267. Lykken, D., & Tellegen, A. (1996). Happiness is a stochastic phenomenon. Psychological Science, 7, 186–​189. Lynch, J., McKenzie, D., Snyder, H., Weisburd, D., & Wellford, C. (2012). Understanding the “Whys” Behind Juvenile Crime Trends. Philadelphia, PA: University of Pennsylvania, Wharton School, Center for Studies in Criminology and Criminal Law, & United States of America. Retrieved on 9-​ 19-​2020 from https://​www.ncjrs.gov/​App/​Publi​ cati​ons/​abstr​act.aspx?ID=​271​092. Lynn, C. D., Paris, J., Frye, C. A., & Schell, L. M. (2010). Salivary alpha‐amylase and cortisol among Pentecostals on a worship and non-​ worship day. American Journal of Human Biology, 22(6), 819–​822. Lyon, J. L., Gardner, K., & Gress, R. E. (1994). Cancer incidence among Mormons and non-​ Mormons in Utah 1971–​1985. Cancer Causes & Control, 5(2), 149–​156. Lyon, M. E., D’Angelo, L. J., Cheng, Y. I., Dallas, R. H., Garvie, P. A., Wang, J., et al. (2020). The influence of religious beliefs and practices on health care decision-​making among HIV positive adolescents. AIDS Care, 32(7), 896–​900. Lyons, H. A., & Smith, S. J. (2014). Religiosity and the transition to nonmarital parity. Sex Research & Social Policy, 11(2), 163–​175. Lytle, L. A., Varnell, S., Murray, D. M., Story, M., Perry, C., Birnbaum, A. S., et al. (2003). Predicting adolescents’ intake of fruits and vegetables. Journal of Nutrition Education and Behavior, 35(4), 170–​178. Lyu, J., Lim, Y. O., & Kim, Y. B. (2020). Gender-​ specific predictors of suicidal ideation among Korean older adults: A 2-​year prospective study. SAGE Open, 10(3), 2158244020957027. Lyubomirsky, S., King, L. A., & Diener, E. (2005). The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin, 131, 803–​855. Ma, L. K., Tunney, R. J., & Ferguson, E. (2017). Does gratitude enhance prosociality? Psychological Bulletin, 143(6), 601. Maas, A. H., & Appelman, Y. E. (2010). Gender differences in coronary heart disease. Netherlands Heart Journal, 18(12), 598–​603. MacArthur, A. C., Le, N. D., Abanto, Z. U., Gallagher, R. P. (2007). Occupational female breast

and reproductive cancer mortality in British Columbia, Canada, 1950–​94. Occupational Medicine, 57(4), 246–​253. MacDonald, G., & Leary, M. R. (2005). Why does social exclusion hurt? The relationship between social and physical pain. Psychological Bulletin, 131(2), 202–​223. Macfarlane, G. J., Beasley, M., Smith, B. H., Jones, G. T., & Macfarlane, T. V. (2015). Can large surveys conducted on highly selected populations provide valid information on the epidemiology of common health conditions? British Journal of Pain, 9(4), 203–​2 12. Macfarlane, G. J., Barnish, M. S., & Jones, G. T. (2017). Persons with chronic widespread pain experience excess mortality. Annals of the Rheumatic Diseases, 76(11), 1815–​1822. Machado, L., Tavares, H., Petribú, K., Pinto, T., & Cantilino, A. (2016). Happiness and defense styles in psychiatrists. Journal of Nervous and Mental Disease, 204(3), 181–​187. Machida, S., Sunagawa, M., & Takahashi, T. (2018). Oxytocin release during the meditation of altruism and appreciation (Arigato-​Zen). International Journal of Neurology Research, 4(1), 364–​370. Maciejewski, P. K., Phelps, A. C., Kacel, E. L., Balboni, T. A., Balboni, M., Wright, A. A., et al. (2012). Religious coping and behavioral disengagement: opposing influences on advance care planning and receipt of intensive care near death. Psycho‐Oncology, 21(7), 714–​723. MacIntyre, A. (1984). After Virtue, 2nd ed. South Bend, IN: University of Notre Dame Press. Mackenbach, J. D., Beenackers, M. A., Noordzij, J. M., Oude Groeniger, J., Lakerveld, J., et al. (2019). The moderating role of self-​control and financial strain in the relation between exposure to the food environment and obesity. International Journal of Environmental Research and Public Health, 16(4), 674. Macleod, A. K., & Moore, R. (2000). Positive thinking revisited: positive cognitions, well‐ being and mental health. Clinical Psychology & Psychotherapy, 7(1), 1–​10. MacLeod, R., Wilson, D. M., Crandall, J., & Austin, P. (2019). Death anxiety among New Zealanders: The predictive roles of religion, spirituality, and family connection. OMEGA-​ Journal of Death and Dying, 80(1), 3–​19. Maddock, M. E., Steele, K., Esplin, C. R., Hatch, S. G., & Braithwaite, S. R. (2019). What is the relationship among religiosity, self-​perceived problematic pornography use, and depression

over time? Sexual Addiction & Compulsivity, 26(3–​ 4), 211–​238. Maheri, A., Sadeghi, R., Shojaeizadeh, D., Tol, A., Yaseri, M., & Ebrahimi, M. (2016). Associations between a health-​promoting lifestyle and quality of life among adults with beta-​thalassemia major. Epidemiology and Health, 38, e2016050. Mai, T. T., Choi, J. H., Lee, M. K., Chang, Y. J., Jung, S. Y., Cho, H., et al. (2019). Prognostic value of post-​diagnosis health-​related quality of life for overall survival in breast cancer. Cancer Research and Treatment, 51(4), 1600–​1611. Maideen, S. F., Sidik, S. M., Rampal, L., & Mukhtar, F. (2015). Prevalence, associated factors and predictors of anxiety: a community survey in Selangor, Malaysia. BMC Psychiatry, 15(1), 262. Maiorino, M. I., Bellastella, G., Giugliano, D., & Esposito, K. (2017). Can diet prevent diabetes? Journal of Diabetes and Its Complications, 31(1), 288–​290. Majeed, M. H., Ali, A. A., & Sudak, D. M. (2018). Mindfulness-​based interventions for chronic pain: Evidence and applications. Asian Journal of Psychiatry, 32, 79–​83. Major, J., & Ádám, S. (2020). Self–​reported specific learning disorders and risk factors among Hungarian adolescents with functional abdominal pain disorders. BMC Pediatrics, 20(1), 1–​8. Mak, H. W. (2019). Dimensions of religiosity: the effects of attendance at religious services and religious faith on discontinuity in substance use. Journal of Studies on Alcohol and Drugs, 80(3), 358–​365. Makarem, N., Bandera, E. V., Nicholson, J. M., & Parekh, N. (2018). Consumption of sugars, sugary foods, and sugary beverages in relation to cancer risk. Annual Review of Nutrition, 38, 17–​39. Makarić, Z. L., Kolarić, B., Tomljenović, M., & Posavec, M. (2018). Attitudes and beliefs related to childhood vaccinations among parents of 6 years old children in Zagreb, Croatia. Vaccine, 36(49), 7530–​7535. Makinen V. (2014). Moral philosophical arguments against suicide in the Middle Ages. In Honkasalo, M. L., & Tuominen, M. (eds.), Culture, Suicide, and the Human Condition. New York, NY: Berghahn Books, pp. 129–​145. Makridis, C. A., Johnson, B., & Koenig, H. G. (2021). Does religious affiliation protect people’s well-​being? Evidence from the Great Recession after correcting for selection effects. Journal for the Scientific Study of Religion, 60(2), 252–​273. (https://​doi.org/​10.1111/​jssr.12700).

References • 973

Maksuti, E., Westerhof, N., Westerhof, B. E., Broome, M., & Stergiopulos, N. (2016). Contribution of the arterial system and the heart to blood pressure during normal aging: a simulation study. PloS One, 11(6), e0157493. Malik, R., & Dichgans, M. (2018). Challenges and opportunities in stroke genetics. Cardiovascular Research, 114(9), 1226–​1240. Malina, A., Głogiewicz, M., & Piotrowski, J. (2019). Supportive social interactions in infertility treatment decrease cortisol levels: experimental study report. Frontiers in Psychology, 10, 2779. Malinakova, K., Kopcakova, J., Geckova, A. M., van Dijk, J. P., Furstova, J., Kalman, M., et al. (2019a). “I am spiritual, but not religious”: does one without the other protect against adolescent health-​risk behaviour? International Journal of Public Health, 64(1), 115–​124. Malinakova, K., Trnka, R., Bartuskova, L., Glogar, P., Kascakova, N., Kalman, M., et al. (2019b). Are adolescent religious attendance/​spirituality associated with family characteristics? International Journal of Environmental Research and Public Health, 16(16), 2947. Malinakova, K., Geckova, A. M., van Dijk, J. P., Kalman, M., Tavel, P., & Reijneveld, S. A. (2018). Adolescent religious attendance and spirituality: are they associated with leisure-​time choices? PloS One, 13(6), e0198314. Malon, J., Shah, P., Koh, W. Y., Cattabriga, G., Li, E., & Cao, L. (2018). Characterizing the demographics of chronic pain patients in the state of Maine using the Maine all payer claims database. BMC Public Health, 18(1), 1–​12. Malouff, J. M., Thorsteinsson, E. B., Schutte, N. S., Bhullar, N., & Rooke, S. E. (2010). The five-​ factor model of personality and relationship satisfaction of intimate partners: a meta-​ analysis. Journal of Research in Personality, 44(1), 124–​127. Mamier, I., Taylor, E. J., & Winslow, B. W. (2019). Nurse spiritual care: prevalence and correlates. Western Journal of Nursing Research, 41(4), 537–​554. Mancini, J. A., & Orthner, D. J. (1980). Situational influences on leisure satisfaction and morality and old age. Journal of the American Geriatrics Society, 28, 466–​471. Mandhouj, O., Perroud, N., Hasler, R., Younes, N., & Huguelet, P. (2016). Characteristics of spirituality and religion among suicide attempters. Journal of Nervous and Mental Disease, 204(11), 861–​867. Manfredini, R., De Giorgi, A., Tiseo, R., Boari, B., Cappadona, R., Salmi, R., et al. (2017).

974 •  R eferences

Marital status, cardiovascular diseases, and cardiovascular risk factors: a review of the evidence. Journal of Women’s Health, 26(6), 624–​632. Mann, E. G., Harrison, M. B., LeFort, S., & Van Den Kerkhof, E. G. (2018). A Canadian survey of self-​ management strategies and satisfaction with ability to control pain. Pain Management Nursing, 19(4), 377–​390. Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., et al. (2005). Suicide prevention strategies: a systematic review. Journal of the American Medical Association, 294(16), 2064–​2074. Mann, J. R., McKeown, R. E., Bacon, J., Vesselinov, R., & Bush, F. A. (2008). Do antenatal religious and spiritual factors impact the risk of postpartum depressive symptoms? Journal of Women’s Health, 17(5), 745–​755. Manne, S., Duhamel, K., Ostroff, J., Parsons, S., Martini, D. R., Williams, S. E., et al. (2003). Coping and the course of mother’s depressive symptoms during and after pediatric bone marrow transplantation. Journal of the American Academy of Child & Adolescent Psychiatry, 42(9), 1055–​1068. Manning, L. K., Carr, D. C., & Kail, B. L. (2016). Do higher levels of resilience buffer the deleterious impact of chronic illness on disability in later life? Gerontologist, 56(3), 514–​524. Manning, V., Best, D., Faulkner, N., Titherington, E., Morinan, A., Keaney, F., et al. (2012). Does active referral by a doctor or 12-​step peer improve 12-​step meeting attendance? Drug and Alcohol Dependence, 126(1–​2), 131–​137. Manning, W. D., & Cohen, J. A. (2012). Premarital cohabitation and marital dissolution: An examination of recent marriages. Journal of Marriage and Family, 74(2), 377–​387. Mantri, S., Lawson, J. M., Wang, Z., & Koenig, H. G. (2020). Identifying moral injury in healthcare professionals: The Moral Injury Symptom Scale-​HP. Journal of Religion and Health, 59, 2323–​2340. Mao, C., Li, Z. H., Lv, Y. B., Gao, X., Kraus, V. B., Zhou, J. H. et al. (2020). Specific leisure activities and cognitive functions among the oldest-​old. Journals of Gerontology, 75(4), 739–​746. Marangoni, C., Hernandez, M., & Faedda, G. L. (2016). The role of environmental exposures as risk factors for bipolar disorder. Journal of Affective Disorders, 193, 165–​174. Marciniak, R., Sheardova, K., Čermáková, P., Hudeček, D., Šumec, R., & Hort, J. (2014). Effect

of meditation on cognitive functions in context of aging and neurodegenerative diseases. Frontiers in Behavioral Neuroscience, 8, 17. Marciniak, R., Šumec, R., Vyhnálek, M., Bendíčková, K., Lázničková, P., Forte, G., et al. (2020). The effect of mindfulness-​based stress reduction (MBSR) on depression, cognition, and immunity in mild cognitive impairment. Clinical Interventions in Aging, 15, 1365. Marcum, Z. A., Sevick, M. A., & Handler, S. M. (2013). Medication nonadherence. Journal of the American Medical Association, 309(20), 2105–​2106. Margelisch, K., Schneewind, K. A., Violette, J., & Perrig-​Chiello, P. (2017). Marital stability, satisfaction and well-​being in old age. Aging & Mental Health, 21(4), 389–​398. Margolin, A., Beitel, M., Schuman-​Olivier, Z., & Avants, S. K. (2006). A controlled study of a spirituality-​focused intervention for increasing motivation for HIV prevention among drug users. AIDS Education and Prevention, 18(4), 311–​322. Marier, C. J., & Fridell, L. A. (2020). Demonstrations, demoralization, and de‐ policing. Criminology & Public Policy, 19(3), 693–​719. Markides, K. S., Levin, J. S., & Ray, L. A. (1987). Religion, aging, and life satisfaction. Gerontologist, 27, 660–​665. Markota, M., Rummans, T. A., Bostwick, J. M., & Lapid, M. I. (2016). Benzodiazepine use in older adults: dangers, management, and alternative therapies. Mayo Clinic Proceedings, 91(11), 1632–​1639. Marks, N. F., & Lambert, J. D. (1998). Marital status continuity and change among young and midlife adults. Journal of Family Issues, 19(6), 652–​686. Marques, A. H., Bjørke-​Monsen, A. L., Teixeira, A. L., & Silverman, M. N. (2015). Maternal stress, nutrition and physical activity: impact on immune function, CNS development and psychopathology. Brain Research, 1617, 28–​46. Marshall, J. (2019). Are religious people happier, healthier? Our new global study explores this question. Pew Research Center’s Forum on Religion & Public Life. Retrieved on 2-​11-​2019 from http://​www.pewr​esea​rch.org/​fact-​tank/​2019/​ 01/​31/​are-​religi​ous-​peo​ple-​happ​ier-​health​ier-​ our-​new-​glo​bal-​study-​explo​res-​this-​quest​ion/​. Martens, M. J., Rutters, F., Lemmens, S. G., Born, J. M., & Westerterp-​Plantenga, M. S. (2010). Effects of single macronutrients on serum cortisol concentrations in normal weight men. Physiology & Behavior, 101(5), 563–​567.

Martin, J. E., Calfas, K. J., Patten, C. A., Polarek, M., Hofstetter, C. R., Noto, J., et al. (1997). Prospective evaluation of three smoking interventions in 205 recovering alcoholics. Journal of Consulting and Clinical Psychology, 65(1), 190–​194. Martin, J. L., Barnes, I., Green, J., Reeves, G. K., Beral, V., & Floud, S. (2019). Social influences on smoking cessation in mid-​life. PloS One, 14(12), 1–​10. Martin, K. R., & Levy, B. R. (2006). Opposing trends of religious attendance and religiosity in predicting elders’ functional recovery after an acute myocardial infarction. Journal of Religion and Health, 45(3), 440–​451. Martin, R. A., Ellingsen, V. J., Tzilos, G. K., & Rohsenow, D. J. (2015). General and religious coping predict drinking outcomes for alcohol dependent adults in treatment. American Journal on Addictions, 24(3), 240–​245. Martin, S., Calabrese, S. K., Wolters, P. L., Walker, K. A., Warren, K., & Hazra, R. (2012). Family functioning and coping styles in families of children with cancer and HIV disease. Clinical Pediatrics, 51(1), 58–​64. Martinez, E. Z., Giglio, F. M., Terada, N. A., da Silva, A. S., & Zucoloto, M. L. (2017). Smoking prevalence among users of primary healthcare units in Brazil. Journal of Religion and Health, 56(6), 2180–​2193. Martinez, S. M., Arredondo, E. M., & Roesch, S. (2013). Physical activity promotion among churchgoing Latinas in San Diego, California. Journal of Health Psychology, 18(10), 1319–​1329. Martín-​María, N., Miret, M., Caballero, F. F., Rico-​ Uribe, L. A., Steptoe, A., Chatterji, S., et al. (2017). The impact of subjective well-​being on mortality. Psychosomatic Medicine, 79(5), 565–​575. Martins, S. S., Sarvet, A., Santaella-​Tenorio, J., Saha, T., Grant, B. F., & Hasin, D. S. (2017). Changes in US lifetime heroin use and heroin use disorder. JAMA Psychiatry, 74(5), 445–​455. Martz, E., & Livneh, H. (2016). Psychosocial adaptation to disability within the context of positive psychology. Journal of Occupational Rehabilitation, 26(1), 4–​12. Maselko, J., & Kubzansky, L. D. (2006a). Gender differences in religious practices, spiritual experiences and health. Social Sciences & Medicine, 62(11), 2848–​2860. Maselko, J., Kubzansky, L. D., Kawachi, I., Staudenmayer, J., & Berkman, L. (2006b). Religious service attendance and decline in

References • 975

pulmonary function in a high-​functioning elderly cohort. Annals of Behavioral Medicine, 32(3), 245–​253. Maselko, J., Kubzansky, L., Kawachi, I., Seeman, T., & Berkman, L. (2007). Religious service attendance and allostatic load among high-​ functioning elderly. Psychosomatic Medicine, 69(5), 464–​472. Maselko, J., Hayward, R. D., Hanlon, A., Buka, S., & Meador, K. G. (2012). Religious services attendance and major depression: a case of reverse causality? American Journal of Epidemiology, 175(6), 576–​583. Masi, C. M., Rickett, E. M., Hawkley, L. C., & Cacioppo, J. T. (2004). Gender and ethnic differences in urinary stress hormones. Journal of Applied Physiology, 97(3), 941–​947. Maslow, A. (1971). The Farther Reaches of Human Nature. New York, NY: Viking Press. Maslow, G., Haydon, A. A., McRee, A. L., & Halpern, C. T. (2012). Protective connections and educational attainment among young adults with childhood‐onset chronic illness. Journal of School Health, 82(8), 364–​370. Mason, R. E., Sappenfield, O. R., Turyk, M. E., Caskey, R. N., & Chor, J. (2020). Prevalence of and factors associated with receiving a pelvic examination or pap testing under the age of 21 years. Journal of Adolescent Health, 67(4), 562–​568. Massarwi, A. A., Khoury-​Kassabri, M., & Eseed, R. (2019). The correlation between delinquent peers and perpetration of serious physical violence. Child Indicators Research, 12(6), 2051–​2065. Masters, K. S., Hill, R. D., Kircher, J. C., Lensegrav Benson, T. L., & Fallon, J. A. (2004). Religious orientation, aging, and blood pressure reactivity to interpersonal and cognitive stressors. Annals of Behavioral Medicine, 28(3), 171–​178. Masters, K. S., & Knestel, A. (2011). Religious motivation and cardiovascular reactivity among middle aged adults: is being pro-​religious really that good for you? Journal of Behavioral Medicine, 34, 449–​461. Masters, K. S., Lensegrav-​Benson, T. L., Kircher, J. C., & Hill, R. D. (2005). Effects of religious orientation and gender on cardiovascular reactivity among older adults. Research on Aging, 27(2), 221–​240. Masters, K. S., Emerson, R. W., IV, & Hooker, S. A. (2022). Effects of devotional prayer and secular meditation on cardiovascular response to a faith challenge among Christians. Psychology of Religion and Spirituality, 14(2), 251–​259.

976 •  R eferences

Matheson, F. I., Smith, K. L., Fazli, G. S., Moineddin, R., Dunn, J. R., & Glazier, R. H. (2014). Physical health and gender as risk factors for usage of services for mental illness. Journal of Epidemiology and Community Health, 68(10), 971–​978. Mathur, M. B., Mathur, V. S., & Reichling, D. B. (2010). Participation in the decision to become vaccinated against human papillomavirus by California high school girls and the predictors of vaccine status. Journal of Pediatric Health Care, 24(1), 14–​24. Maton, K. I., & Wells, E. A. (1995). Religion as a community resource for well‐being: prevention, healing, and empowerment pathways. Journal of Social Issues, 51(2), 177–​193. Matthews, G. A., & Tye, K. M. (2019). Neural mechanisms of social homeostasis. Annals of the New York Academy of Sciences, 1457(1), 5–​25. Mavor, K. I., Louis, W. R., & Laythe, B. (2011). Religion, prejudice, and authoritarianism: is RWA a boon or bane to the psychology of religion? Journal for the Scientific Study of Religion, 50(1), 22–​43. Mazure, C. M. (1998). Life stressors as risk factors in depression. Clinical Psychology: Science and Practice, 5(3), 291–​313. McAll, R. K. (1982). Healing the Family Tree. London, UK: Sheldon Press. McAloney, K. (2013). Inter-​faith relationships in Great Britain: prevalence and implications for psychological well-​being. Mental Health, Religion & Culture, 16(7), 686–​694. McArthur, J. C. (2004). HIV dementia: an evolving disease. Journal of Neuroimmunology, 157(1–​ 2), 3–​10. McCain, N. L., Gray, D. P., Elswick, R. K., Robins, J. W., Tuck, I., Walter, J. M., et al. (2008). A randomized clinical trial of alternative stress management interventions in persons with HIV infection. Journal of Consulting & Clinical Psychology, 76(3), 431–​441. McCarthy, J. (2019). Six in seven Americans satisfied with their personal lives. Retrieved on 11-​16-​2019 from https://​news.gal​lup.com/​poll/​ 246​326/​six-​seven-​americ​ans-​satisf​i ed-​perso​nal-​ lives.aspx. McClintock, C. H., Anderson, M., Svob, C., Wickramaratne, P., Neugebauer, R., Miller, L., et al. (2019). Multidimensional understanding of religiosity/​spirituality: relationship to major depression and familial risk. Psychological Medicine, 49(14), 2379–​2388. McClintock, C. H., Lau, E., & Miller, L. (2016). Phenotypic dimensions of

spirituality: implications for mental health in China, India, and the United States. Frontiers in Psychology, 7, 1600 (1–​16). McComb, S., Thiriot, A., Akache, B., Krishnan, L., & Stark, F. (2019). Introduction to the immune system. In Fulton, K. M., & Twine, S. M. (eds.), Immunoproteomics. New York, NY: Humana Press, pp. 1–​24. McCord, J. (1991). Family relationships, juvenile delinquency, and adult criminality. Criminology, 29(3), 397–​417. McCullough, M. E. (1999). Research on religion-​ accommodative counseling: review and meta-​ analysis. Journal of Counseling Psychology, 46, 92–​98. McCullough, M. E., Hoyt, W. T., Larson, D. B., Koenig, H. G., & Thoresen, C. (2000). Religious involvement and mortality: a meta-​analytic review. Health Psychology, 19(3), 211–​222. McCullough, M. E., Tsang, J. A., & Brion, S. (2003). Personality traits in adolescence as predictors of religiousness in early adulthood: findings from the Terman Longitudinal Study. Personality & Social Psychology Bulletin, 29(8), 980–​991. McCullough, M. E., Enders, C. K., Brion, S. L., Jain, A. R. (2005). The varieties of religious development in adulthood: a longitudinal investigation of religion and rational choice. Journal of Personality & Social Psychology, 89(1), 78–​89. McCullough, M. E., Friedman, H. S., Enders, C. K., & Martin, L. R. (2009). Does devoutness delay death? Psychological investment in religion and its association with longevity in the Terman sample. Journal of Personality and Social Psychology, 97, 866–​882. McCullough, M. E., & Laurenceau, J. P. (2005). Religiousness and the trajectory of self-​rated health across adulthood. Personality & Social Psychology Bulletin, 31(4), 560–​573. McCullough, M. E., & Willoughby, B. L. (2009). Religion, self-​regulation, and self-​ control: associations, explanations, and implications. Psychological Bulletin, 135(1), 69–​93. McDonald, J. E., Olson, J. R., Lanning, A. H., Goddard, H. W., & Marshall, J. P. (2018). Effects of religiosity, forgiveness, and spousal empathy on marital adjustment. Marriage & Family Review, 54(4), 393–​416. McDougle, L., Handy, F., Konrath, S., & Walk, M. (2014). Health outcomes and volunteering: The moderating role of religiosity. Social Indicators Research, 117(2), 337–​351. McDougle, L., Konrath, S., Walk, M., & Handy, F. (2016). Religious and secular coping strategies

and mortality risk among older adults. Social Indicators Research, 125(2), 677–​694. McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338(3), 171–​179. McFarland, M. J. (2010). Religion and mental health among older adults: Do the effects of religious involvement vary by gender? Journals of Gerontology, 65B(5), 621–​630. McFarland, M. J., Uecker, J. E., & Regnerus, M. D. (2011). The role of religion in shaping sexual frequency and satisfaction: evidence from married and unmarried older adults. Journal of Sex Research, 48(2–​3), 297–​308. McFarland, M. J., Pudrovska, T., Schieman, S., Ellison, C. G., & Bierman, A. (2013). Does a cancer diagnosis influence religiosity? Social Science Research, 42(2), 311–​320. McGinty, E. E., Kennedy-​Hendricks, A., Choksy, S., & Barry, C. L. (2016). Trends in news media coverage of mental illness in the United States: 1995–​2014. Health Affairs, 35(6), 1121–​1129. McGovern, T. F., McMahon, T., Nelson, J., Bundoc-​ Baronia, R., Giles, C., & Schmidt, V. (2017). A descriptive study of a spirituality curriculum for general psychiatry residents. Academic Psychiatry, 41(4), 471–​476. McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for substance use disorders. Psychiatric Clinics, 33(3), 511–​525. McIntosh, B., & Danigelis, N. L. (1995). Race, gender, and the relevance of productive activity for elders’ affect. Journal of Gerontology, 50B, S229–​S239. McIntosh, D. N., Poulin, M. J., Silver, R. C., & Holman, E. A. (2011). The distinct roles of spirituality and religiosity in physical and mental health after collective trauma: a national longitudinal study of responses to the 9/​11 attacks. Journal of Behavioral Medicine, 34(6), 497–​507. McIntosh, R. C., Ironson, G., & Krause, N. (2020). Do religious and spiritual identity confer risk for hypertension via psychosocial and lifestyle factors? Journal of Health Psychology, 25(8), 1082–​1097. McIntosh, W. A., Fitch, S. D., Wilson, J. B., & Nyberg, K. L. (1981). The effects of mainstream religious social controls on adolescent drug use in rural areas. Review of Religious Research, 23, 54–​75. McKee-​Ryan, F., Song, Z., Wanberg, C. R., & Kinicki, A. J. (2005). Psychological and physical

References • 977

well-​being during unemployment: a meta-​ analytic study. Journal of Applied Psychology, 90(1), 53–​76. McLaughlin, S. S., McLaughlin, A. D., & Van, J. S. (2010). Faith and religious beliefs in an outpatient military population. Southern Medical Journal, 103(6), 527–​531. McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284(13), 1689–​1695. McLuckie, B. F., Zahn, M., & Wilson, A. (1975). Religious correlates of teenage drug use. Journal of Drug Issues, 5(2), 129–​139. McQuaid, R. J., McInnis, O. A., Paric, A., Al-​ Yawer, F., Matheson, K., & Anisman, H. (2016). Relations between plasma oxytocin and cortisol: the stress buffering role of social support. Neurobiology of Stress, 3, 52–​60. Meade, M. A., Mahmoudi, E., & Lee, S. Y. (2015). The intersection of disability and healthcare disparities: a conceptual framework. Disability and Rehabilitation, 37(7), 632–​641. Meadows, R., & Bower, J. K. (2020). Associations of anthropometric measures of obesity with physical limitations in older adults. Disability and Rehabilitation, 42(8), 1101–​1106. Meaney, M. J., & Szyf, M. (2005). Environmental programming of stress responses through DNA methylation: life at the interface between a dynamic environment and a fixed genome. Dialogues in Clinical Neuroscience, 7(2), 103. Meanley, S., Pingel, E. S., & Bauermeister, J. A. (2016). Psychological well-​being among religious and spiritual identified young gay and bisexual men. Sexuality Research and Social Policy, 13(1), 35–​45. Medlock, M. M., Rosmarin, D. H., Connery, H. S., Griffin, M. L., Weiss, R. D., Karakula, S. L., et al. (2017). Religious coping in patients with severe substance use disorders receiving acute inpatient detoxification. American Journal on Addictions, 26(7), 744–​750. Meertens, V., Scheepers, P., & Tax, B. (2003). Depressive symptoms in the Netherlands 1975–​ 1996: a theoretical framework and an empirical analysis of socio-​demographic characteristics, gender differences and changes over time. Sociology of Health & Illness, 25(2), 208–​231. Mehr, S. S., Pornour, M., Movafagh, A., Akbari, M. E., Vaziri, S., Pourtoloei, H., et al. (2020a). The effect of spiritual intervention on the concentration of interleukin-​1β, interleukin-​6,

978 •  R eferences

interleukin-​8 and tumor necrosis factor alpha cytokines in patients with breast cancer. Clinical Cancer Investigation Journal, 9(6), 249. Mehr, S. S., Akbari, M. E., Movafagh, A., Pornour, M., Vaziri, S., Pourtoloei, H., et al. (2020b). Spiritual effect of intervention on oxytocin and its receptor (OXTR) in women patients with breast cancer. Pakistan Journal of Medical & Health Sciences, 14(2), 719–​726. Meier, S. M., & Deckert, J. (2019). Genetics of anxiety disorders. Current Psychiatry Reports, 21(3), 16. Meijer, A., Conradi, H. J., Bos, E. H., Anselmino, M., Carney, R. M., Denollet, J., et al. (2013). Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events. British Journal of Psychiatry, 203(2), 90–​102. Meints, S. M., & Edwards, R. R. (2018). Evaluating psychosocial contributions to chronic pain outcomes. Progress in Neuro-​Psychopharmacology and Biological Psychiatry, 87, 168–​182. Meints, S. M., Mosher, C., Rand, K. L., Ashburn-​ Nardo, L., & Hirsh, A. T. (2018). An experimental investigation of the relationships among race, prayer, and pain. Scandinavian Journal of Pain, 18(3), 545–​553. Melhem, N. M., Porta, G., Oquendo, M. A., Zelazny, J., Keilp, J. G., Iyengar, S., et al. (2019). Severity and variability of depression symptoms predicting suicide attempt in high-​risk individuals. JAMA Psychiatry, 76(6), 603–​613. Mello, N. K. (2010). Hormones, nicotine, and cocaine. Hormones and Behavior, 58(1), 57–​71. Melnyk, B. M., Small, L., Morrison-​Beedy, D., Strasser, A., Spath, L., Kreipe, R., et al. (2006). Mental health correlates of healthy lifestyle attitudes, beliefs, choices, and behaviors in overweight adolescents. Journal of Pediatric Health Care, 20(6), 401–​406. Melnyk, B. M., Jacobson, D., Kelly, S., Belyea, M., Shaibi, G., Small, L., et al. (2013). Promoting healthy lifestyles in high school adolescents: a randomized controlled trial. American Journal of Preventive Medicine, 45(4), 407–​415. Meltzer, H. I., Dogra, N., Vostanis, P., & Ford, T. (2011). Religiosity and the mental health of adolescents in Great Britain. Mental Health, Religion & Culture, 14(7), 703–​713. Melvin, C. L., Jefferson, M. S., Rice, L. J., Cartmell, K. B., & Halbert, C. H. (2016). Predictors of participation in mammography screening among non-​Hispanic black, non-​Hispanic white, and Hispanic women. Frontiers in Public Health, 4, 188.

Melzack, R. (1999). From the gate to the neuromatrix. Pain, 82, S121–​S126. Melzack, R., & Wall, P. D. (1965). Pain mechanisms: a new theory. Science, 150(3699), 971–​979. Mendell, L. M. (2014). Constructing and deconstructing the gate theory of pain. Pain®, 155(2), 210–​216. Mendolia, S., Paloyo, A., & Walker, I. (2019). Intrinsic religiosity, personality traits, and adolescent risky behaviors. BE Journal of Economic Analysis & Policy, 19(3). Menegatti-​Chequini, M. C., Gonçalves, J. P., Leão, F. C., Peres, M. F., & Vallada, H. (2016). A preliminary survey on the religious profile of Brazilian psychiatrists and their approach to patients’ religiosity in clinical practice. BJPsych Open, 2(6), 346–​352. Meng, J., McLaughlin, M., Pariera, K., & Murphy, S. (2016). A comparison between Caucasians and African Americans in willingness to participate in cancer clinical trials: the roles of knowledge, distrust, information sources, and religiosity. Journal of Health Communication, 21(6), 669–​677. Meng, L., Chen, D., Yang, Y., Zheng, Y., & Hui, R. (2012). Depression increases the risk of hypertension incidence: a meta-​analysis of prospective cohort studies. Journal of Hypertension, 30(5), 842–​851. Meng, Q., Zhang, X., Shi, R., Liao, H., & Chen, X. (2019). Correlation between religion and hypertension. Internal and Emergency Medicine, 14(2), 209–​237. Merchant, A. T., Pitiphat, W., Ahmed, B., Kawachi, I., Joshipura, K. (2003). A prospective study of social support, anger expression and risk of periodontitis in men. Journal of the American Dental Association, 134(12), 1591–​1596. Meredith, K. L., Jeffe, D. B., Mundy, L. M., & Fraser, V. J. (2001). Sources influencing patients in their HIV medication decisions. Health Education & Behavior, 28(1), 40–​50. Meredith, S. E., Juliano, L. M., Hughes, J. R., & Griffiths, R. R. (2013). Caffeine use disorder: a comprehensive review and research agenda. Journal of Caffeine Research, 3(3), 114–​130. Merrill, J. O., Rhodes, L. A., Deyo, R. A., Marlatt, G. A., & Bradley, K. A. (2002). Mutual mistrust in the medical care of drug users. Journal of General Internal Medicine, 17(5), 327–​333. Merritt, M. M., & McCallum, T. J. (2013). Too much of a good thing? Positive religious coping predicts worse diurnal salivary cortisol patterns for overwhelmed African American female

dementia family caregivers. American Journal of Geriatric Psychiatry, 21(1), 46–​56. Merskey, H., & Bogduk, N. (eds.) (1994). Pain Terms: A Current List with Definitions and Notes on Usage: Classification of Chronic Pain. Seattle, WA: IASP Press, pp. 209–​214. Messina, G., Lissoni, P., Bartolacelli, E., Tancini, G., Villa, S., Gardani, G. S., et al. (2003). A psychoncological study of lymphocyte subpopulations in relation to pleasure-​related neurobiochemistry and sexual and spiritual profile to Rorschach’s test in early or advanced cancer patients. Journal of Biological Regulators & Homeostatic Agents, 17(4), 322–​326. Meyers, J. L., Brown, Q., Grant, B. F., & Hasin, D. (2017). Religiosity, race/​ethnicity, and alcohol use behaviors in the United States. Psychological Medicine, 47(1), 103–​114. Meyers, J. L., Salvatore, J. E., Aliev, F., Johnson, E. C., McCutcheon, V. V., Su, J., et al. (2019). Psychosocial moderation of polygenic risk for cannabis involvement: the role of trauma exposure and frequency of religious service attendance. Translational Psychiatry, 9(1), 1–​12. Mhaka-​Mutepfa, M., Mpofu, E., & Cumming, R. (2015). Impact of protective factors on resilience of grandparent carers fostering orphans and non-​orphans in Zimbabwe. Journal of Aging and Health, 27(3), 454–​479. Michaelson, V., Robinson, P., & Pickett, W. (2014). Participation in church or religious groups and its association with health: a national study of young Canadians. Journal of Religion and Health, 53(5), 1353–​1373. Michalak, L., Trocki, K., & Bond, J. (2007). Religion and alcohol in the U.S. National Alcohol Survey: how important is religion for abstention and drinking? Drug and Alcohol Dependence, 87(2–​3): 268–​280. Michopoulos, V., Powers, A., Gillespie, C. F., Ressler, K. J., & Jovanovic, T. (2017). Inflammation in fear-​and anxiety-​based disorders: PTSD, GAD, and beyond. Neuropsychopharmacology, 42(1), 254–​270. Migdal, L., & MacDonald, D. A. (2013). Clarifying the relation between spirituality and well-​being. Journal of Nervous and Mental Disease, 201(4), 274–​280. Migration Policy Institute (2017). Top 25 destinations of international migrants. Retrieved on 5-​3-​2019 from https://​www.migr​ atio​npol​icy.org/​progr​ams/​data-​hub/​cha​rts/​top-​ 25-​desti​nati​ons-​intern​atio​nal-​migra​nts. Mihaljević, S., Vuksan-​Ćusa, B., Marčinko, D., Koić, E., Kušević, Z., & Jakovljević, M. (2011).

References • 979

Spiritual well-​being, cortisol, and suicidality in Croatian war veterans suffering from PTSD. Journal of Religion and Health, 50(2), 464–​473. Mihaljevic, S., Aukst-​Margetic, B., Karnicnik, S., Vuksan-​Cusa, B., & Milosevic, M. (2016). Do spirituality and religiousness differ with regard to personality and recovery from depression? Comprehensive Psychiatry, 70, 17–​24. Mihara, S., & Higuchi, S. (2017). Cross‐sectional and longitudinal epidemiological studies of Internet gaming disorder: a systematic review of the literature. Psychiatry and Clinical Neurosciences, 71(7), 425–​444. Miklossy, J. (2015). Historic evidence to support a causal relationship between spirochetal infections and Alzheimer’s disease. Frontiers in Aging Neuroscience, 7, 46. Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., Snyder, K. S., & Mintz, J. (1988). Family factors and the course of bipolar affective disorder. Archives of General Psychiatry, 45(3), 225–​231. Mikosz, C. A., Danielson, M., Anderson, K. N., Pollack, L. A., Currie, D. W., Njai, R., et al. (2020). Characteristics of patients experiencing rehospitalization or death after hospital discharge in a nationwide outbreak of e-​c igarette, or vaping, product use–​a ssociated lung injury: United States, 2019. Morbidity and Mortality Weekly Report, 68(5152), 1183. Milaneschi, Y., & Penninx, B. (2014). Depression in older persons with mobility limitations. Current Pharmaceutical Design, 20(19), 3114–​3118. Miller, G. E., Chen, E., & Zhou, E. S. (2007). If it goes up, must it come down? Chronic stress and the hypothalamic-​pituitary-​adrenocortical axis in humans. Psychological Bulletin, 133(1), 25–​45. Miller, H. V. (2010). If your friends jumped off of a bridge, would you do it too? Delinquent peers and susceptibility to peer influence. Justice Quarterly, 27(4), 473–​491. Miller, L. (2020). Spirituality and Mental Health Webinar Series: A Partnership between the U.S. Department of HHS and Columbia University Teachers College. New York, NY: Spirituality Mind-​Body Institute, Columbia University. Miller, L., & Gur, M. (2002). Religiousness and sexual responsibility in adolescent girls. Journal of Adolescent Health, 31(5), 401–​406. Miller, L., Warner, V., Wickramaratne, P., & Weissman, M. (1997). Religiosity and depression: Ten-​year follow-​up of depressed mothers and offspring. Journal of the American

980 •  R eferences

Academy of Child & Adolescent Psychiatry, 36(10), 1416–​1425. Miller, L., Davies, M., & Greenwald, S. (2000). Religiosity and substance use and abuse among adolescents in the National Comorbidity Survey. Journal of the American Academy of Child & Adolescent Psychiatry, 39(9), 1190–​1197. Miller, L., Weissman, M., Gur, M., & Adams, P. (2001). Religiousness and substance use in children of opiate addicts. Journal of Substance Abuse, 13(3), 323–​336. Miller, L., Wickramaratne, P., Gameroff, M. J., Sage, M., Tenke, C. E., & Weissman, M. (2012). Religiosity and major depression in adults at high risk: a ten-​year prospective study. American Journal of Psychiatry, 169(1), 89–​94. Miller, L., Bansal, R., Wickramaratne, P., Hao, X., Tenke, C. E., Weissman, M., et al. (2014). Neuroanatomical correlates of religiosity and spirituality: a study in adults at high and low familial risk for depression. JAMA Psychiatry, 71(2), 128–​135. Miller, P. Y., & Simon, W. (1974). Adolescent sexual behavior: context and change. Social Problems, 22, 58–​76. Miller, T. A., & DiMatteo, M. R. (2013). Importance of family/​social support and impact on adherence to diabetic therapy. Diabetes, Metabolic Syndrome and Obesity, 6, 421. Miller, T., & Vuolo, M. (2018). Examining the antiascetic hypothesis through social control theory: Delinquency, religion, and reciprocation across the early life course. Crime & Delinquency, 64(11), 1458–​1488. Miller, W. R., Forcehimes, A., O’Leary, M. J., & Lanoue, M. D. (2008). Spiritual direction in addiction treatment: two clinical trials. Journal of Substance Abuse Treatment, 35(4), 434–​442. Mills, K. T., Bundy, J. D., Kelly, T. N., Reed, J. E., Kearney, P. M., Reynolds, K., et al. (2016). Global disparities of hypertension prevalence and control: a systematic analysis of population-​ based studies from 90 countries. Circulation, 134(6), 441–​450. Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16, 223–​237. Mills, S. E., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: a review of its epidemiology and associated factors in population-​based studies. British Journal of Anaesthesia, 123(2), e273–​e283. Min, J., Silverstein, M., & Gruenewald, T. L. (2018). Intergenerational similarity of religiosity over the family life course. Research on Aging, 40(6), 580–​596.

Mishra, A., Das, B., & Goyal, N. (2018). Religiosity and religious delusions in schizophrenia–​An observational study in a Hindu population. Asian Journal of Psychiatry, 32, 35–​39. Misiak, B., Stramecki, F., Gawęda, Ł., Prochwicz, K., Sąsiadek, M. M., Moustafa, A. A., et al. (2018). Interactions between variation in candidate genes and environmental factors in the etiology of schizophrenia and bipolar disorder. Molecular Neurobiology, 55(6), 5075–​5100. Mitchell, A. M., & Christian, L. M. (2019). Repetitive negative thinking, meaning in life, and serum cytokine levels in pregnant women: varying associations by socioeconomic status. Journal of Behavioral Medicine, 42(5), 960–​972. Mitchell, C. M., Epstein-​Peterson, Z. D., Bandini, J., Amobi, A., Cahill, J., Enzinger, A., et al. (2016). Developing a medical school curriculum for psychological, moral, and spiritual wellness. Journal of Pain and Symptom Management, 52(5), 727–​736. Mitchell, J., Mathews, H. F., & Yesavage, J. A. (1993). A multidimensional examination of depression among the elderly. Research on Aging, 15, 198–​219. Mitrou, P. N., Kipnis, V., Thiebaut, A. C., Reedy, J., Subar, A. F., Wirfalt, E., & Flood, A. (2007). Mediterranean dietary pattern and prediction of all-​cause mortality in a U.S. population. Archives of Internal Medicine, 167, 2461–​2468. Mizock, L., Millner, U. C., & Russinova, Z. (2012). Spiritual and religious issues in psychotherapy with schizophrenia: cultural implications and implementation. Religions, 3(1), 82–​98. Mizuno, Y., Hofer, A., Frajo‐Apor, B., Wartelsteiner, F., Kemmler, G., Pardeller, S., et al. (2018). Religiosity and psychological resilience in patients with schizophrenia and bipolar disorder. Acta Psychiatrica Scandinavica, 137(4), 316–​327. Moaddel, M., & Karabenick, S. A. (2008). Religious fundamentalism among young Muslims in Egypt and Saudi Arabia. Social Forces, 86(4), 1675–​1710. Moadel, A. B., Shah, C., Wylie-​Rosett, J., Harris, M. S., Patel, S. R., Hall, C. B., et al. (2007). Randomized controlled trial of yoga among a multiethnic sample of breast cancer patients. Journal of Clinical Oncology, 25(28), 4387–​4395. Moberg, D. O. (1951). Religion and Personal Adjustment in Old Age: A Study of Some Aspects of the Christian Religion in Relation to Personal Adjustment of the Aged in Institutions. Minneapolis, MN: University of Minnesota.

Moberg, D. O. (1953a). The Christian religion and personal adjustment in old age. American Sociological Review, 18(1), 87–​90. Moberg, D. O. (1953b). Church membership and personal adjustment in old age. Journal of Gerontology, 8(2), 207–​211. Mockabee, S. T., Monson, J. Q., & Grant, J. (2001). Measuring religious commitment among Catholics and Protestants: a new approach. Journal for the Scientific Study of Religion, 40(4), 675–​690. Modrego, P. J. (2009). Depression in the prodromal phase of Alzheimer disease and the reverse causal hypothesis. Archives of General Psychiatry, 66(1), 107–​109. Moeini, M., Sharifi, S., & Kajbaf, M. B. (2016). Effect of Islam-​based religious program on spiritual wellbeing in elderly with hypertension. Iranian Journal of Nursing and Midwifery Research, 21(6), 566–​571. Moffat, J., & Yoo, H. I. (2020). Religion, religiosity and educational attainment. Applied Economics, 52(4), 430–​442. Mogilner, C., & Norton, M. I. (2016). Time, money, and happiness. Current Opinion in Psychology, 10, 12–​16. Mohamed, B., Cox, K., Diamant, J., & Gecewicz, C. (2021). Faith among Black Americans. Pew Research Center. Retrieved on 7-​27-​22 from https://​www.pewr​esea​rch.org/​relig​ion/​2021/​02/​ 16/​faith-​among-​black-​americ​ans/​. Mohammad, K. Q., Bahman, M., Farhad, M., Ali, S., & Mehdi, N. (2019). Investigating the effects of religiosity on sport for all in East Azerbaijan, Iran. International Academic Journal of Politics and Law, 6(1), 26–​38. Mohammadpoorasl, A., Ghahramanloo, A. A., Allahverdipour, H., & Augner, C. (2014). Substance abuse in relation to religiosity and familial support in Iranian college students. Asian Journal of Psychiatry, 9, 41–​44. Mohanty, M. S. (2010). Effects of positive attitude and optimism on employment: evidence from the US data. The Journal of Socio-​Economics, 39(2), 258–​270. Mohr, S., Borras, L., Rieben, I., Betrisey, C., Gillieron, C., Brandt, P. Y., et al. (2010). Evolution of spirituality and religiousness in chronic schizophrenia or schizo-​affective disorders: a 3-​year follow-​up study. Social Psychiatry and Psychiatric Epidemiology, 45(11), 1095–​1103. Mohr, S., Borras, L., Nolan, J., Gillieron, C., Brandt, P. Y., Eytan, A., et al. (2012). Spirituality and religion in outpatients with schizophrenia: a

References • 981

multi-​site comparative study of Switzerland, Canada, and the United States. International Journal of Psychiatry in Medicine, 44(1), 29–​52. Mohr, S., & Huguelet, P. (2014). The wishes of outpatients with severe mental disorders to discuss spiritual and religious issues in their psychiatric care. International Journal of Psychiatry in Clinical Practice, 18(4), 304–​307. Mokhtar, N., Elati, J., Chabir, R., Bour, A., Elkari, K., Schlossman, N. P., et al. (2001). Diet culture and obesity in northern Africa. Journal of Nutrition, 131(3), S887–​S892. Mokhtari, M., Arfken, C., & Boutros, N. (2013). The DEX/​CRH test for major depression: a potentially useful diagnostic test. Psychiatry Research, 208(2), 131–​139. Mollidor, C., Hancock, N., & Pepper, M. (2015). Volunteering, religiosity and well-​ being: interrelationships among Australian churchgoers. Mental Health, Religion & Culture, 18(1), 20–​32. Momtaz, Y. A., Ibrahim, R., Hamid, T. A., & Yahaya, N. (2010). Mediating effects of social and personal religiosity on the psychological well-​being of widowed elderly people. OMEGA-​ Journal of Death and Dying, 61(2), 145–​162. Momtaz, Y. A., Hamid, T. A., Ibrahim, R., Yahaya, N., & Tyng Chai, S. (2011). Moderating effect of religiosity on the relationship between social isolation and psychological well-​being. Mental Health, Religion & Culture, 14(2), 141–​156. Momtaz, Y. A., Hamid, T. A., Ibrahim, R., Yahaya, N., & Abdullah, S. S. (2012). Moderating effect of Islamic religiosity on the relationship between chronic medical conditions and psychological well‐being among elderly Malays. Psychogeriatrics, 12(1), 43–​53. Monahan, J., Steadman, H. J., Silver, E., Appelbaum, P. S., Robbins, P. C., Mulvey, E. P., et al. (2001). Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York, NY: Oxford University Press. Moncrief, T., Beck, A. F., Simmons, J. M., Huang, B., & Kahn, R. S. (2014). Single parent households and increased child asthma morbidity. Journal of Asthma, 51(3), 260–​266. Mondal, S. (2013). Science of exercise: ancient Indian origin. Journal of the Association of Physicians of India, 61(8), 560–​562. Monico, L. B., Gryczynski, J., Mitchell, S. G., Schwartz, R. P., O’Grady, K. E., & Jaffe, J. H. (2015). Buprenorphine treatment and 12-​step meeting attendance: conflicts, compatibilities, and patient outcomes. Journal of Substance Abuse Treatment, 57, 89–​95.

982 •  R eferences

Monserud, M. A. (2019). Trajectories of limitations with activities of daily living among older adults of Mexican descent. Marriage & Family Review, 55(2), 99–​125. Montag, C., Brockmann, E. M., Lehmann, A., Müller, D. J., Rujescu, D., & Gallinat, J. (2012). Association between oxytocin receptor gene polymorphisms and self-​rated ‘empathic concern’ in schizophrenia. PloS One, 7(12), e51882. Montague, D. P., Magai, C., Consedine, N. S., & Gillespie, M. (2003). Attachment in African American and European American older adults: the roles of early life socialization and religiosity. Attachment & Human Development, 5(2), 188–​214. Montel, S., Albertini, L., & Spitz, E. (2012). Coping strategies as related to medical and demographic data in amyotrophic lateral sclerosis. Acta Neurologica Scandinavica, 125(2), 136–​141. Moons, P., Luyckx, K., Dezutter, J., Kovacs, A. H., Thomet, C., Budts, W., et al. (2019). Religion and spirituality as predictors of patient-​reported outcomes in adults with congenital heart disease around the globe. International Journal of Cardiology, 274, 93–​99. Moore, E. W., Berkley-​Patton, J. Y., Berman, M., Burleson, C., & Judah, A. (2016). Physical health screenings among African-​American church and community members. Journal of Religion and Health, 55(5), 1786–​1799. Moore, J. T., & Leach, M. M. (2016). Dogmatism and mental health: a comparison of the religious and secular. Psychology of Religion and Spirituality, 8(1), 54–​64. Moorman, P. G., Barrett, N. J., Wang, F., Alberg, J. A., Bandera, E. V., Barnholtz-​Sloan, J. B., et al. (2019). Effect of cultural, folk, and religious beliefs and practices on delays in diagnosis of ovarian cancer in African American women. Journal of Women’s Health, 28(4), 444–​451. Moradi, Z., Madani, Y., & Sadeghi, M. (2020). The effectiveness of using integrated cognitive-​ spiritual counseling interventional approach on adherence to the treatment regimen and its components in hemodialysis patients. Iranian Journal of Psychiatric Nursing, 7(6), 53–​62. Morales-​Jinez, A., Gallegos Cabriales, E. C., D’Alonzo, K. T., Ugarte-​Esquivel, A., López-​ Rincón, F. J., & Salazar-​González, B. C. (2018). Social factors contributing to the development of allostatic load in older adults. Aquichan, 18(3), 298–​310. Moran, J. D., III, & Jennings, M. S. (1983). Moral judgments in parochial and public school

second-​graders. Psychological Reports, 52(2), 579–​585. Moran, M. B., Chatterjee, J. S., Frank, L. B., Murphy, S. T., Zhao, N., Chen, N., et al. (2017). Individual, cultural and structural predictors of vaccine safety confidence and influenza vaccination among Hispanic female subgroups. Journal of Immigrant and Minority Health, 19(4), 790–​800. Moreira‐Almeida, A., Sharma, A., van Rensburg, B. J., Verhagen, P. J., & Cook, C. C. (2016). WPA position statement on spirituality and religion in psychiatry. World Psychiatry, 15(1), 87–​88. Moreno, O., & Cardemil, E. (2018). The role of religious attendance on mental health among Mexican populations: a contribution toward the discussion of the immigrant health paradox. American Journal of Orthopsychiatry, 88(1), 10–​15. Moreno-​Smith, M., Lutgendorf, S. K., & Sood, A. K. (2010). Impact of stress on cancer metastasis. Future Oncology, 6(12), 1863–​1881. Morgenstern, L. B., Sánchez, B. N., Skolarus, L. E., Garcia, N., Risser, J. M., Wing, J. J., et al. (2011). Fatalism, optimism, spirituality, depressive symptoms, and stroke outcome. Stroke, 42, 3518–​3523. Moritz, K. M., Reid, N., & Akison, L. K. (2019). Can fetal alcohol exposure increase the risk of hypertension? A new study in children and adolescents diagnosed with fetal alcohol spectrum disorder suggests it can. Alcoholism, 43(10), 2057–​2059. Moro, L., Simon, K., Bárd, I., & Racz, J. (2011). Voice of the psychonauts: coping, life purpose, and spirituality in psychedelic drug users. Journal of Psychoactive Drugs, 43(3), 188–​198. Morrow-​Howell, N., Hinterlong, J., Rozario, P. A., & Tang, F. (2003). Effects of volunteering on the well-​being of older adults. Journal of Gerontology, 58(3), S137–​S145. Morton, D. H., Morton, C. S., Strauss, K. A., Robinson, D. L., Puffenberger, E. G., Hendrickson, C., et al. (2003). Pediatric medicine and the genetic disorders of the Amish and Mennonite people of Pennsylvania. American Journal of Medical Genetics, 121(1), 5–​17. Morton, K. R., Lee, J. W., Haviland, M. G., & Fraser, G. E. (2012). Religious engagement in a risky family model predicting health in older Black and White Seventh-​Day Adventists. Psychology of Religion and Spirituality, 4(4), 298–​311. Morton, K. R., Lee, J. W., & Martin, L. R. (2017). Pathways from religion to health: Mediation by psychosocial and lifestyle mechanisms.

Psychology of Religion and Spirituality, 9(1), 106–​117. Morton, P. M., Schafer, M. H., & Ferraro, K. F. (2012). Does childhood misfortune increase cancer risk in adulthood? Journal of Aging and Health, 24(6), 948–​984. Moscati, A., & Mezuk, B. (2014). Losing faith and finding religion: religiosity over the life course and substance use and abuse. Drug and Alcohol Dependence, 136, 127–​134. Moskowitz, J. T., Carrico, A. W., Duncan, L. G., Cohn, M. A., Cheung, E. O., Batchelder, A., et al. (2017). Randomized controlled trial of a positive affect intervention for people newly diagnosed with HIV. Journal of Consulting and Clinical Psychology, 85(5), 409–​423. Moskowitz, J. T., Cheung, E. O., Snowberg, K. E., Verstaen, A., Merrilees, J., Salsman, J. M., et al. (2019). Randomized controlled trial of a facilitated online positive emotion regulation intervention for dementia caregivers. Health Psychology, 38(5), 391–​402. Mosqueiro, B. P., da Rocha, N. S., & de Almeida Fleck, M. P. (2015). Intrinsic religiosity, resilience, quality of life, and suicide risk in depressed inpatients. Journal of Affective Disorders, 179, 128–​133. Mosqueiro, B. P., Fleck, M. P., & Rocha, N. S. (2019). Increased levels of brain-​derived neurotrophic factor are associated with high intrinsic religiosity among depressed inpatients. Frontiers in Psychiatry, 10, 671. Mosqueiro, B. P., Caldieraro, M. A., Messinger, M., da Costa, F. B., Peteet, J. R., & Fleck, M. P. (2021). Religiosity, spirituality, suicide risk and remission of depressive symptoms. Journal of Affective Disorders, 279, 434–​442. Mota, N. P., Medved, M., Whitney, D., Hiebert-​ Murphy, D., & Sareen, J. (2013). Protective factors for mental disorders and psychological distress in female, compared with male, service members in a representative sample. Canadian Journal of Psychiatry, 58(10), 570–​578. Mota, N. P., Tsai, J., Kirwin, P. D., Sareen, J., Southwick, S. M., & Pietrzak, R. H. (2016). Purpose in life is associated with a reduced risk of incident physical disability in aging US military veterans. American Journal of Geriatric Psychiatry, 24(9), 706–​714. Mota, N. P., Cook, J. M., Smith, N. B., Tsai, J., Harpaz-​Rotem, I., Krystal, J. H., et al. (2019). Posttraumatic stress symptom courses in US military veterans: a seven-​year, nationally representative, prospective cohort study. Journal of Psychiatric Research, 119, 23–​31.

References • 983

Motta, M., Callaghan, T., & Sylvester, S. (2018). Knowing less but presuming more: Dunning-​ Kruger effects and the endorsement of anti-​vaccine policy attitudes. Social Science & Medicine, 211, 274–​281. Mottillo, S., Filion, K. B., Genest, J., Joseph, L., Pilote, L., Poirier, P., et al. (2010). The metabolic syndrome and cardiovascular risk. Journal of the American College of Cardiology, 56(14), 1113–​1132. Motulsky, H. (1995). Intuitive Biostatistics. New York, NY: Oxford University Press. Moulton, B. E., & Sherkat, D. E. (2012). Specifying the effects of religious participation and educational attainment on mortality risk for US adults. Sociological Spectrum, 32(1), 1–​19. Moutinho, I. L., Lucchetti, A. L., da Silva Ezequiel, O., & Lucchetti, G. (2019). Prevalence, incidence, and factors associated with substance use among medical students: a 2-​year longitudinal study. Journal of Addiction Medicine, 13(4), 295–​299. Movafagh, A., Heidari, M. H., Abdoljabbari, M., Mansouri, N., Taghavi, A., Karamatinia, A., et al. (2017). Spiritual therapy in coping with cancer as a complementary medical preventive practice. Journal of Cancer Prevention, 22(2), 82–​88. Movahedizadeh, M., Sheikhi, M. R., Shahsavari, S., & Chen, H. (2019). The association between religious belief and drug adherence mediated by religious coping in patients with mental disorders. Social Health and Behavior, 2(3), 77. Moxey, A., McEvoy, M., Bowe, S., & Attia, J. (2011). Spirituality, religion, social support and health among older Australian adults. Australasian Journal on Ageing, 30(2), 82–​88. Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., et al. (2015). Executive summary: heart disease and stroke statistics—​2015 update. Circulation, 131(4), 434–​441. Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., et al. (2016). Heart disease and stroke statistics—​2016 update: a report from the American Heart Association. Circulation, 133(4), e37–​e360. Mrus, J., Leonard, A., Yi, M., Sherman, S., Fultz, S., Justice, A., et al. (2006). Health-​relatd quality of life in veterans and nonveterans with HIV/​AIDS. Journal of General Internal Medicine, 21, S39–​S47. Mueser, K. T., Goodman, L. B., Trumbetta, S. L., Rosenberg, S. D., Osher, F. C., Vidaver, R., et al. (1998). Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 66(3), 493–​499.

984 •  R eferences

Mueser, K. T., Deavers, F., Penn, D. L., & Cassisi, J. E. (2013). Psychosocial treatments for schizophrenia. Annual Review of Clinical Psychology, 9, 465–​497. Muhsen, K., Sinnreich, R., Merom, D., Nassar, H., Cohen, D., & Kark, J. D. (2019). Helicobacter pylori infection, serum pepsinogens as markers of atrophic gastritis, and leukocyte telomere length. Human Genomics, 13(1), 1–​11. Muka, T., Koromani, F., Portilla, E., O’Connor, A., Bramer, W. M., Troup, J., et al. (2016). The role of epigenetic modifications in cardiovascular disease. International Journal of Cardiology, 212, 174–​183. Mukamal, K. J., Kuller, L. H., Fitzpatrick, A. L., Lonstreth, W. T., Mittleman, M. A., & Siscovick, D. S. (2003). Prospective study of alcohol consumption and risk of dementia in older adults. Journal of the American Medical Association, 289, 1405–​1413. Mukerjee, S., & Venugopal, A. (2018). Religiosity and health through the decades: is there a gender difference. American Journal of Health Promotion, 32(4), 1028–​1041. Mullins, L. C., Brackett, K. P., Bogie, D. W., & Pruett, D. (2004). The impact of religious homogeneity on the rate of divorce in the United States. Sociological Inquiry, 74(3), 338–​354. Mullins, N., Bigdeli, T. B., Borglum, A. D., Coleman, J. R., Demontis, D., Mehta, D., et al. (2019). GWAS of suicide attempt in psychiatric disorders in association with major depression polygenic risk scores. American Journal of Psychiatry, 176(8), 651–​660. Mumford, E. A., & Liu, W. (2016). Social integration and maternal smoking: a longitudinal analysis of a national birth cohort. Maternal and Child Health Journal, 20(8), 1586–​1597. Munn‐Chernoff, M. A., & Baker, J. H. (2016). A primer on the genetics of comorbid eating disorders and substance use disorders. European Eating Disorders Review, 24(2), 91–​100. Murphy, G. E., & Robins, E. (1967). Social factors in suicide. Journal of the American Medical Association, 199(5), 303–​308. Murphy, H. B. M., & Taumoepeau, B. M. (1980). Traditionalism and mental health in the South Pacific: a re-​examination of an old hypothesis. Psychological Medicine, 10(3), 471–​482. Murphy, S. L., Xu J., Kochanek, K. D. (2013). Deaths: final data for 2010. National Vital Statistics Reports, 61(4), 1–​117. Murphy, S. L., Xu, J., Kochanek, K. D., & Arias, E. (2018). Mortality in the United States, 2017.

NCHS Brief, No. 328. Retrieved on 8-​13-​2020 from https://​sta​cks.cdc.gov/​view/​cdc/​60896. Murthy, V. H. (2016). Ending the opioid epidemic: a call to action. New England Journal of Medicine, 375(25), 2413–​2415. Murthy, V. H. (2017). E-​cigarette use among youth and young adults: a major public health concern. JAMA Pediatrics, 171(3), 209–​210. Musa, A. S. (2017). Spiritual care intervention and spiritual well-​being: Jordanian Muslim nurses’ perspectives. Journal of Holistic Nursing, 35(1), 53–​61. Memory and Music Project (2020). Alive Inside: Film of Music and Memory Project—​Henry’s Story. Retrieved on 5-​16-​2020 from https://​www.yout​ ube.com/​watch?v=​5FWn​4JB2​YLU. Musich, S., Wang, S. S., Kraemer, S., Hawkins, K., & Wicker, E. (2018). Purpose in life and positive health outcomes among older adults. Population Health Management, 21(2), 139–​147. Musick, M. A. (1996). Religion and subjective health among black and white elders. Journal of Health and Social Behavior, 37, 221–​237. Musick, M. A., Koenig, H. G., Hays, J. C., & Cohen, H. J. (1998). Religious activity and depression among community-​dwelling elderly persons with cancer: the moderating effect of race. Journals of Gerontology, 53B(4), S218–​S227. Musick, M. A., House, J. S., & Williams, D. R. (2004). Attendance at religious services and mortality in a national sample. Journal of Health & Social Behavior, 45(2), 198–​213. Musick, M. A., & Wilson, J. (2003). Volunteering and depression: the role of psychological and social resources in different age groups. Social Science & Medicine, 56(2), 259–​269. Mutti-​Packer, S., Hodgins, D. C., Williams, R. J., & Thege, B. K. (2017). The protective role of religiosity against problem gambling: findings from a five-​year prospective study. BMC Psychiatry, 17(1), 356. Mutumba, M., Musiime, V., Lepkwoski, J. M., Harper, G. W., Snow, R. C., Resnicow, K., et al. (2016). Examining the relationship between psychological distress and adherence to anti-​retroviral therapy among Ugandan adolescents living with HIV. AIDS Care, 28(7), 807–​815. Muula, A. S., Thomas, J. C., Pettifor, A. E., Strauss, R. P., Suchindran, C. M., & Meshnick, S. R. (2012). Religion is not associated with HIV infection among women in Malawi. International Journal on Disability and Human Development, 11(2), 121–​131.

Myers, D. G. (1993). The Pursuit of Happiness: Who Is Happy and Why? New York, NY: The Aquarian Press. Myers, D. G., & Denier, E. (1996). The pursuit of happiness: new research uncovers some non-​intuitive insights into how many people are happy—​and why. Scientific American, 274, 54–​56. Myers, R. H., Kiely, D. K., Cupples, L. A., & Kannel, W. B. (1990). Parental history is an independent risk factor for coronary artery disease: the Framingham Study. American Heart Journal, 120(4), 963–​969. Myint, A. M., Leonard, B. E., Steinbusch, H. W., & Kim, Y. K. (2005). Th1, Th2, and Th3 cytokine alterations in major depression. Journal of Affective Disorders, 88(2), 167–​173. Nabipour, A. R., Khanjani, N., Nakhaee, N., Moradlou, H. Z., & Sullman, M. J. (2015). The relationship between religion and the on-​road behaviour of adolescents in Iran. Transportation Research Part F: Traffic Psychology and Behaviour, 29, 113–​120. NACDD (2018). Chronic Disease Prevention: For Dollars and Sense. National Association of Chronic Disease Directors. Retrieved on 12-​3-​ 2019 from www.chr​onic​dise​ase.org › resmgr › NACDD.2018_​White_​Paper_​fina.docx. Nadal, A. R., Hardy, S. A., & Barry, C. M. (2018). Understanding the roles of religiosity and spirituality in emerging adults in the United States. Psychology of Religion and Spirituality, 10(1), 30–​43. Naeem, F., Khoury, B., Munshi, T., Ayub, M., Lecomte, T., Kingdon, D., et al. (2016). Brief cognitive behavioral therapy for psychosis (CBTp) for schizophrenia: literature review and meta-​analysis. International Journal of Cognitive Therapy, 9(1), 73–​86. Nagase, M. (2012). Does a multi-​dimensional concept of health include spirituality? Analysis of Japan Health Science Council’s discussions on WHO’s “Definition of Health” (1998). International Journal of Applied Sociology, 2(6), 71–​77. Naguib, S. M., Geiser, P. B., & Comstock, G. W. (1968). Responses to a program of screening for cervical cancer. Public Health Reports, 83, 990–​998. Nair, D., Cavanaugh, K. L., Wallston, K. A., Mason, O., Blot, W. J., Ikizler, T. A., et al. (2020). Religion, spirituality, and risk of end-​ stage kidney disease among adults of low socioeconomic status in the southeastern United

References • 985

States. Journal of Health Care for the Poor and Underserved, 31(4), 1727–​1746. Naja, W. J., Aoun, M. P., El Khoury, E. L., Abdallah, F. J., & Haddad, R. S. (2016). Prevalence of depression in Syrian refugees and the influence of religiosity. Comprehensive Psychiatry, 68, 78–​85. Najafizadeh, K., Ghorbani, F., Hamidinia, S., Elmamhadi, M. A., Moinfar, M. A., Ghobadi, O., et al. (2010). Holy month of Ramadan and increase in organ donation willingness. Saudi Journal of Kidney Diseases and Transplantation, 21(3), 443–​446. Najt, P., Fusar-​Poli, P., & Brambilla, P. (2011). Co-​occurring mental and substance abuse disorders: a review on the potential predictors and clinical outcomes. Psychiatry Research, 186(2–​3), 159–​164. Nakaya, M., & Ohmori, K. (2010). Psychosis induced by spiritual practice and resolution of pre-​morbid inner conflicts. German Journal of Psychiatry, 13(3), 161–​3. Nam, S. (2013a). Effects of social support and spirituality on weight loss for rural African-​ American women. ABNF Journal, 24, 71–​76. Nam, S. (2013b). The effects of religious attendance and obesity on health by race/​ethnicity. Osong Public Health and Research Perspectives, 4(2), 81–​88. Narayanan, S., Milbury, K., Wagner, R., & Cohen, L. (2020). Religious coping in cancer. Journal of Pain and Symptom Management, 60(4), 737–​745. Nasiri, M., Fayazi, S., Ghaderi, M., Naseri, M., & Adarvishi, S. (2014). The effect of reciting the word “Allah” on pain severity after coronary artery bypass graft surgery: a randomized clinical trial study in Iran. Anesthesiology and Pain Medicine, 4(5), e23149. Natan, M. B., Aharon, O., Palickshvili, S., & Gurman, V. (2011). Attitude of Israeli mothers with vaccination of their daughters against human papilloma virus. Journal of Pediatric Nursing, 26(1), 70–​77. National Cancer Institute (2020a). Cancer survival statistics. National Cancer Institute: Division of Cancer Control and Population Sciences. Retrieved on 6-​24-​2020 from https://​seer.can​ cer.gov/​csr/​1975_​2​017/​res​ults​_​mer​ged/​top​ic_​s​ urvi​val.pdf. National Cancer Institute (2020b). Financial burden of cancer care. National Cancer Institute: Division of Cancer Control and Population Sciences. Retrieved on 6-​24-​2020 from https://​pro​gres​srep​ort.can​cer.gov/​after/​ econ​omic​_​bur​den.

986 •  R eferences

National Institute on Aging (2019). What are frontotemporal disorders? Retrieved on 5-​8-​ 2020 from https://​www.nia.nih.gov/​hea​lth/​ what-​are-​fro​ntot​empo​ral-​disord​ers. National Prevention Council (2011). Economic benefits of preventing disease, Appendix 1. In National Prevention Strategy. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General, p. 51. Naylor, B., Boag, S., & Gustin, S. M. (2017). New evidence for a pain personality? A critical review of the last 120 years of pain and personality. Scandinavian Journal of Pain, 17, 58–​67. NCCDPHP (2020). Health and economic costs of chronic disease. National Center for Chronic Disease Prevention and Health Promotion. Retrieved on 9-​21-​2020 from https://​www.cdc. gov/​chr​onic​dise​ase/​about/​costs/​index.htm. NCES (2019a). The condition of education 2019: immediate college enrollment rate. US Department of Education, National Center for Education Statistics (NCES 2019-​144). Retrieved on 9-​25-​2020 from https://​nces.ed.gov/​fastfa​ cts/​disp​lay.asp?id=​51. NCES (2019b). The condition of education 2019: graduation rates. US Department of Education, National Center for Education Statistics (NCES 2019-​144). Retrieved on 9-​25-​ 2020 from https://​nces.ed.gov/​fastfa​cts/​disp​lay. asp?id=​40. NCES (2020a). The condition of education 2020: public high school graduation rates. US Department of Education, National Center for Education Statistics (NCES 2020-​144). Retrieved on 9-​25-​2020 from https://​nces.ed.gov/​fastfa​ cts/​disp​lay.asp?id=​805. NCES (2020b). Conditions of education (at a glance). National Center of Education Statistics. Retrieved on 10-​9-​2020 from https://​nces. ed.gov/​pubsea​rch/​pubsi​nfo.asp?pubid=​ 2020​144. NCHS (2012). Health, United States, 2011. Hyattsville, MD: National Center for Health Statistics. Ndanuko, R. N., Tapsell, L. C., Charlton, K. E., Neale, E. P., & Batterham, M. J. (2016). Dietary patterns and blood pressure in adults: a systematic review and meta-​analysis of randomized controlled trials. Advances in Nutrition, 7(1), 76–​89. Nedderman, A. B., Underwood, L. A., & Hardy, V. L. (2010). Spirituality group with female prisoners. Journal of Correctional Health Care, 16(2), 117–​132.

Nedelec, J. L., Richardson, G., & Silver, I. A. (2017). Religiousness, spirituality, and substance use: A genetically sensitive examination and critique. Journal of Drug Issues, 47(3), 340–​355. Neeleman, J. (1998). Regional suicide rates in the Netherlands: does religion still play a role? International Journal of Epidemiology, 27, 466–​472. Neeleman, J., Halpern, D., Leon, D., & Lewis, G. (1997). Tolerance of suicide, religion and suicide rates: an ecological and individual study in 19 Western countries. Psychological Medicine, 27, 1165–​1171. Neeleman, J., & Lewis, G. (1999). Suicide, religion, and socioeconomic conditions: an ecological study in 26 countries, 1990. Journal of Epidemiology and Community Health, 53, 204–​210. Neeleman, J., Wessely, S., & Lewis, G. (1998). Suicide acceptability in African-​and white Americans: the role of religion. Journal of Nervous and Mental Disease, 186, 12–​16. Neighbors, C., Brown, G. A., Dibello, A. M., Rodriguez, L. M., & Foster, D. W. (2013). Reliance on God, prayer, and religion reduces influence of perceived norms on drinking. Journal of Studies on Alcohol and Drugs, 74(3), 361–​368. Nelson, B., Shaw, S. F., Berk, L. S., Prowse, M., & King, D. (2009). The effect of perceived stress and religiosity as modulators of the hs-​C-​reactive protein, a known risk factor for cardiovascular disease. Presented at the Global Conference on Health and Lifestyle, University of Geneva, Geneva, Switzerland, July 6–​10. Nelson, B. W., Wright, D. B., Allen, N. B., & Laurent, H. K. (2020). Maternal stress and social support prospectively predict infant inflammation. Brain, Behavior, and Immunity, 86, 14–​21. Nelson, H. D., Pappas, M., Zakher, B., Mitchell, J. P., Okinaka-​Hu, L., & Fu, R. (2014). Risk assessment, genetic counseling, and genetic testing for BRCA-​related cancer in women. Annals of Internal Medicine, 160(4), 255–​266. Nelson, J. J., & Uecker, J. E. (2018). Are religious parents more satisfied parents? Individual-​and couple-​level religious correlates of parenting satisfaction. Journal of Family Issues, 39(7), 1770–​1796. Nelson, L. D., & Dynes, R. R. (1976). The impact of devotionalism and attendance on ordinary and emergency helping behavior. Journal for the Scientific Study of Religion, 15, 47–​59. Nelson, L. E., Wilton, L., Zhang, N., Regan, R., Thach, C. T., Dyer, T. V., et al. (2017). Childhood

exposure to religions with high prevalence of members who discourage homosexuality is associated with adult HIV risk behaviors and HIV infection in Black men who have sex with men. American Journal of Men’s Health, 11(5), 1309–​1321. Neria, Y., Besser, A., Kiper, D., & Westphal, M. (2010). A longitudinal study of posttraumatic stress disorder, depression, and generalized anxiety disorder in Israeli civilians exposed to war trauma. Journal of Traumatic Stress, 23(3), 322–​330. Neugebauer, R., Wickramaratne, P., Svob, C., McClintock, C. H., Gameroff, M. J., Miller, L., et al. (2020). Contribution of religion/​ spirituality and major depressive disorder to altruism. Journal of Affective Disorders, 262, 16–​22. Newberg, A. (2017). The spiritual brain: science and religious experience. In Opris, I., & Casanova, M. F. (eds.), The Physics of the Mind and Brain Disorders. Cham, Switzerland: Springer International, pp. 649–​669. Newcomb, M. D. (1992). Understanding the multidimensional nature of drug use and abuse: The role of consumption, risk factors, and protective factors. In Glantz, M., & Pickens, R. (eds.), Vulnerability to Drug Abuse. Washington, DC: American Psychological Association, pp. 255–​298. Newlin, K., Melkus, G. D., & Tappen, R. (2008). Relationships of religion and spirituality to glycemic control in black women with type 2 diabetes. Nursing Research, 57(5), 331–​339. Newport, F. (2018). Church leaders and declining religious service attendance. Gallup Poll News. Retrieved on 6-​19-​2019 from https://​news.gal​ lup.com/​opin​ion/​poll​ing-​matt​ers/​242​015/​chu​ rch-​lead​ers-​declin​ing-​religi​ous-​serv​ice-​att​enda​ nce.aspx. Ng, T. P., Nyunt, M. S., Chiam, P. C., & Kua, E. H. (2011). Religion, health beliefs and the use of mental health services by the elderly. Aging & Mental Health, 15(2), 143–​149. Ngamaba, K. H., Panagioti, M., & Armitage, C. J. (2017). How strongly related are health status and subjective well-​being? European Journal of Public Health, 27(5), 879–​885. Ngamaba, K. H., & Soni, D. (2018). Are happiness and life satisfaction different across religious groups? Exploring determinants of happiness and life satisfaction. Journal of Religion and Health, 57, 2118–​2139. Ngo, S. T., Steyn, F. J., & McCombe, P. A. (2014). Gender differences in autoimmune disease.

References • 987

Frontiers in Neuroendocrinology, 35(3), 347–​369. Nguyen, A. B., Hood, K. B., & Belgrave, F. Z. (2012). The relationship between religiosity and cancer screening among Vietnamese women in the United States: the moderating role of acculturation. Women & Health, 52(3), 292–​313. NHS England (2019). Social prescribing and community-​based support: summary guide, January 31. Retrieved on 7-​21-​2021 from https://​www.engl​and.nhs.uk/​wp-​cont​ent/​uplo​ ads/​2020/​06/​soc​ial-​pres​crib​ing-​summ​ary-​guide-​ upda​ted-​june-​20.pdf. Nicholas, M. K. (2018). Why do some people develop chronic, treatment-​resistant pain and not others? Pain, 159(12), 2419–​2420. Nicholson, A., Rose, R., & Bobak, M. (2010). Associations between different dimensions of religious involvement and self-​rated health in diverse European populations. Health Psychology, 29(2), 227–​235. Nicklas, J. M., Huskey, K. W., Davis, R. B., & Wee, C. C. (2012). Successful weight loss among obese U.S. adults. American Journal of Preventive Medicine, 42(5), 481–​485. Nielsen, C. S., Stubhaug, A., Price, D. D., Vassend, O., Czajkowski, N., & Harris, J. R. (2008). Individual differences in pain sensitivity: genetic and environmental contributions. Pain, 136(1–​ 2), 21–​29. Nielsen, M. B., & Knardahl, S. (2014). Coping strategies: a prospective study of patterns, stability, and relationships with psychological distress. Scandinavian Journal of Psychology, 55(2), 142–​150. Nieman, D. C., Henson, D. A., Austin, M. D., & Sha, W. (2011). Upper respiratory tract infection is reduced in physically fit and active adults. British Journal of Sports Medicine, 45(12), 987–​992. Nieuwsma, J. A., Jackson, G. L., DeKraai, M. B., Bulling, D. J., Cantrell, W. C., Rhodes, J. E., et al. (2014). Collaborating across the departments of Veterans Affairs and defense to integrate mental health and chaplaincy services. Journal of General Internal Medicine, 29(Supp 4), 885–​894. Nieuwsma, J. A., & Rhodes, J. E. (2013). Chaplaincy and mental health in the Department of Veterans Affairs and Department of Defense. Journal of Health Care Chaplaincy, 19, 3–​21. Nieuwsma, J. A., King, H. A., Jackson, G. L., Bidassie, B., Wright, L. W., Cantrell, W. C., et al. (2017). Implementing integrated mental health and chaplain care in a national quality improvement initiative. Psychiatric Services, 68(12), 1213–​1215.

988 •  R eferences

Nikander, R., Sievänen, H., Heinonen, A., Daly, R. M., Uusi-​R asi, K., & Kannus, P. (2010). Targeted exercise against osteoporosis: a systematic review and meta-​analysis for optimizing bone strength throughout life. BMC Medicine, 8(1), 47. Nikfarjam, M., Solati, K., Heidari-​Soureshjani, S., Safavi, P., Zarean, E., Fallah, E., et al. (2018). Effect of group religious intervention on spiritual health and reduction of symptoms in patients with anxiety. Journal of Clinical & Diagnostic Research, 12(10), 1–​5. Nimgaonkar, V. L., Fujiwara, T. M., Dutta, M., Wood, J., Gentry, K., Maendel, S., et al. (2000). Low prevalence of psychoses among the Hutterites, an isolated religious community. American Journal of Psychiatry, 157(7), 1065–​1070. NIMH (2019). Prevalence of major depressive episode among adults. Retrieved on 5-​30-​2019 from https://​www.nimh.nih.gov/​hea​lth/​sta​tist​ ics/​major-​dep​ress​ion.shtml#part​_​155​029. Ninh, V. K., El Hajj, E. C., Mouton, A. J., & Gardner, J. D. (2019). Prenatal alcohol exposure causes adverse cardiac extracellular matrix changes and dysfunction in neonatal mice. Cardiovascular Toxicology, 19(5), 389–​400. Nisbet, P. A., Duberstein, P. R., Conwell, Y., & Seidlitz, L. (2000). The effect of participation in religious activities on suicide versus natural death in adults 50 and older. Journal of Nervous & Mental Disease, 188(8), 543–​546. Nishi, D., Susukida, R., Kuroda, N., & Wilcox, H. C. (2017). The association of personal importance of religion and religious service attendance with suicidal ideation by age group in the National Survey on Drug Use and Health. Psychiatry Research, 255, 321–​327. NISRA (2019). Northern Ireland Statistics and Research Agency, Census 2001 (Excel file s330_​ni_​level). Retrieved on 4-​2-​2020 from http://​www.nin​is2.nisra.gov.uk/​pub​lic/​Theme. aspx?them​eNum​ber=​135&themeN​ame=​Cen​ sus+​2001. Nkansah‐Amankra, S. (2013). Adolescent suicidal trajectories through young adulthood: Prospective assessment of religiosity and psychosocial factors among a population‐ based sample in the United States. Suicide and Life‐Threatening Behavior, 43(4), 439–​459. Noel, M., Rabbitts, J. A., Tai, G. G., & Palermo, T. M. (2015). Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children’s and parents’ recall. Pain, 156(5), 800.

Noel, P., Cork, C., & White, R. G. (2018). Social capital and mental health in post-​disaster/​ conflict contexts. Disaster Medicine and Public Health Preparedness, 12(6), 791–​802. Nonnemaker, J. M., McNeely, C. A., & Blum, R. W. (2003). Public and private domains of religiosity and adolescent health risk behaviors: evidence from the National Longitudinal Study of Adolescent Health. Social Science & Medicine, 57(11), 2049–​2054. Nonnemaker, J., McNeely, C. A., & Blum, R. W. (2006). Public and private domains of religiosity and adolescent smoking transitions. Social Science & Medicine, 62(12), 3084–​3095. Noon, A. P., Martinsen, J. I., Catto, J. W., & Pukkala, E. (2018). Occupation and bladder cancer phenotype: identification of workplace patterns that increase the risk of advanced disease beyond overall incidence. European Urology Focus, 4(5), 725–​730. Noort, A., Beekman, A. T., van Gool, A. R., & Braam, A. W. (2018). Religious delusions in older adults: diagnoses, combinations, and delusional characteristics. International Journal of Geriatric Psychiatry, 33(12), 1680–​1687. Noort, A., Beekman, A. T., & Braam, A. W. (2020). Religious hallucinations and religious delusions among older adults in treatment for psychoses in the Netherlands. Religions, 11(10), 522. Norat, T., Scoccianti, C., Boutron-​Ruault, M. C., Anderson, A., Berrino, F., Cecchini, M., et al. (2015). European code against cancer 4th edition: diet and cancer. Cancer Epidemiology, 39, S56–​S66. Nordfjærn, T. (2018). Religiosity and alcohol use: is religiosity important for abstention and consumption levels in the second half of life? Substance Use & Misuse, 53(14), 2271–​2280. Norenzayan, A., Gervais, W. M., & Trzesniewski, K. H. (2012). Mentalizing deficits constrain belief in a personal God. PLoS One, 7(4), e36880. Norman, W. T. (1963). Toward an adequate taxonomy of personality attributes: replicated factor structure in peer nomination personality ratings. Journal of Abnormal and Social Psychology, 66, 574–​583. Norman, G., & Streiner, D. (2007). Biostatistics: The Bare Essentials, 3rd ed. Beijing, China: People’s Medical Publishing House. Norton, M. C., Skoog, I., Franklin, L. M., Corcoran, C., Tschanz, J. T., Zandi, P. P., et al. (2006). Gender differences in the association between religious involvement and depression. Journals of Gerontology, 61B(3), P129–​P136. Norton, M. C., Singh, A., Skoog, I., Corcoran, C., Tschanz, J. T., Zandi, P. P., et al. (2008).

Church attendance and new episodes of major depression in a community study of older adults. Journals of Gerontology, 63B(3), P129–​P137. Novotny, P., Colligan, R. C., Szydlo, D. W., Clark, M. M., Rausch, S., Wampfler, J., et al. (2010). A pessimistic explanatory style is prognostic for poor lung cancer survival. Journal of Thoracic Oncology, 5(3), 326–​332. Nowinski, J., & Baker, S. (1992). The Twelve-​Step Facilitation Handbook: A Systematic Approach to Early Recovery from Alcoholism and Addiction. San Francisco, CA: Jossey-​Bass. Numbers, R. L., & Amundsen, D. W. (1986). Caring and Curing: Health and Medicine in the Western Religious Traditions. Baltimore, MD: Johns Hopkins University Press. O’Brien, C. (2021). Experts sound off on the media’s “negative” or absent coverage of religion: “incomplete at best.” Fox News, June 25. Retrieved on 7-​21-​2021 from https://​www.foxn​ ews.com/​media/​med​ias-​over​all-​relig​ion-​cover​ age-​pan​ned-​by-​expe​rts. O’Brien, M. E. (1982). Religious faith and adjustment to long-​term hemodialysis. Journal of Religion and Health, 21, 68–​80. O’Donnell, A. T., O’Carroll, T., & Toole, N. (2018). Internalized stigma and stigma-​related isolation predict women’s psychological distress and physical health symptoms post-​abortion. Psychology of Women Quarterly, 42(2), 220–​234. O’Donnell, M. J., Xavier, D., Liu, L., Zhang, H., Chin, S. L., Rao-​Melacini, P., et al. (2010). Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study). Lancet, 376(9735), 112–​123. O’Donnell, M. J., Chin, S. L., Rangarajan, S., Xavier, D., Liu, L., Zhang, H., et al. (2016). Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE). Lancet, 388(10046), 761–​775. O’Garo, K. G., & Koenig, H. G. (2023). Spiritually-integrated cognitive processing therapy for moral injury in the setting of PTSD: Initial evidence of therapeutic efficacy. Journal of Nervous and Mental Disease, forthcoming. O’Keefe, S. M. (2020). One in three Americans would not get COVID-​19 vaccine. Gallup Poll. Retrieved on 8-​13-​2020 from https://​news.gal​ lup.com/​poll/​317​018/​one-​three-​americ​ans-​not-​ covid-​vacc​ine.aspx. O’Neil, A., Fisher, A. J., Kibbey, K. J., Jacka, F. N., Kotowicz, M. A., Williams, L. J., et al. (2016). Depression is a risk factor for incident coronary

References • 989

heart disease in women. Journal of Affective Disorders, 196, 117–​124. O’Reilly, D., Kinnear, H., Rosato, M., Mairs, A., & Hall, C. (2013). Uptake of breast screening is influenced by current religion and religion of upbringing. Journal of Religion and Health, 52(4), 1168–​1176. Oates, G. (2013). Black-​W hite variations in the lagged reciprocal relationship between religiosity and perceived control. Mental Health, Religion & Culture, 16(6), 563–​579. Oates, G. L., & Goode, J. (2013). Racial differences in effects of religiosity and mastery on psychological distress. Society and Mental Health, 3(1), 40–​58. Obisesan, T., Livingston, I., Trulear, H. D., & Gillum, F. (2006). Frequency of attendance at religious services, cardiovascular disease, metabolic risk factors and dietary intake in Americans. International Journal of Psychiatry in Medicine, 36(4), 435–​448. Ochab, E. U. (2019). Addressing violence and persecution based on religion or belief. Journal of Christian Legal Thought, 9, 27. Ochoa-​Frongia, L., Thompson, H. S., Lewis-​ Kelly, Y., Deans-​McFarlane, T., & Jandorf, L. (2012). Breast and cervical cancer screening and health beliefs among African American women attending educational programs. Health Promotion Practice, 13(4), 447–​453. Office of the Surgeon General (2010). The surgeon general’s vision for a healthy and fit nation. Retrieved on 10-​25-​2020 from https://​www. ncbi.nlm.nih.gov/​pub​med/​20669​507. Ofori-​Atta, A., Attafuah, J., Jack, H., Baning, F., Rosenheck, R., & Joining Forces Research Consortium. (2018). Joining psychiatric care and faith healing in a prayer camp in Ghana: randomized trial. British Journal of Psychiatry, 212(1), 34–​41. Ofstedal, M. B., Chiu, C. T., Jagger, C., Saito, Y., & Zimmer, Z. (2019). Religion, life expectancy, and disability-​free life expectancy among older women and men in the United States. Journals of Gerontology, 74B(8), e107–​e118. Ogedegbe, G., & Pickering, T. (2010). Principles and techniques of blood pressure measurement. Cardiology Clinics, 28(4), 571–​586. Ogińska-​Bulik, N. (2013). Negative and positive effects of traumatic experiences in a group of emergency service workers. Medycyna Pracy, 64(4), 463–​472. Ogińska-​Bulik, N., & Kobylarczyk, M. (2015). Relation between resiliency and post-​traumatic growth in a group of paramedics. International

990 •  R eferences

Journal of Occupational Medicine & Environmental Health, 28(4), 707–​719. Ogland, C. P., Xu, X., Bartkowski, J. P., & Ogland, E. G. (2011). The association of religion and virginity status among Brazilian adolescents. Journal of Adolescent Health, 48(6), 651–​653. Ogloff, J. R., Talevski, D., Lemphers, A., Wood, M., & Simmons, M. (2015). Co-​occurring mental illness, substance use disorders, and antisocial personality disorder among clients of forensic mental health services. Psychiatric Rehabilitation Journal, 38(1), 16. Oh, A., Patel, K., Boscardin, W. J., Max, W., Stephens, C., Ritchie, C. S., & Smith, A. K. (2019). Social support and patterns of institutionalization among older adults. Journal of the American Geriatrics Society, 67(12), 2622–​2627. Oh, H., Waldman, K., & Koyanagi, A. (2018). Psychotic experiences and religiosity. Schizophrenia Research, 201, 435–​436. Oh, H., Waldman, K., Lloyd, D., & Lincoln, K. (2019). Church-​based social interactions and psychotic experiences among Black Americans. Mental Health, Religion & Culture, 22(2), 161–​170. Ohtake, F. (2012). Unemployment and happiness. Japan Labor Review, 9, 59–​74. OJJDP (2019a). Office of Juvenile Justice and Delinquency Program: juvenile arrest rate trends. Retrieved on 9-​24-​2019 from https://​ www.ojjdp.gov/​ojsta​tbb/​crime/​JAR_​Disp​lay. asp?ID=​qa05​200&selO​ffen​ses=​1. OJJDP (2019b). Office of Juvenile Justice and Delinquency Program: juvenile arrests. Retrieved on 9-​24-​2019 from https://​www.ojjdp.gov/​ojsta​ tbb/​crime/​qa05​104.asp?qaD​ate=​2017. OJJDP (2019c). Juvenile Justice Statistics: National Report Series Bulletin, August: juvenile arrests, 2017. Retrieved on 9-​24-​2019 from https://​ www.ojjdp.gov/​pubs/​252​713.pdf. Ojukwu, E., Powell, L. R., Person, S. D., Rosal, M. C., Lemon, S. C., & Allison, J. (2018). Spirituality and willingness to participate in health-​related research among African Americans. Journal of Health Care for the Poor and Underserved, 29(1), 400–​414. Okajima, S., Hirota, A., Kimura, E., Inagaki, M., Tamai, N., Iizaka, S., et al. (2013). Health‐related quality of life and associated factors in patients with primary lymphedema. Japan Journal of Nursing Science, 10(2), 202–​211. Okoro, C. A., Hollis, N. D., Cyrus, A. C., & Griffin-​ Blake, S. (2018). Prevalence of disabilities and health care access by disability status and type

among adults: United States, 2016. Morbidity and Mortality Weekly Report, 67(32), 882. Okulicz-​Kozaryn, A. (2010). Religiosity and life satisfaction across nations. Mental Health, Religion & Culture, 13(2), 155–​169. Okun, M. A., Stock, W. A., Haring, M. J., & Witter, R. A. (1984). The social activity/​subjective well-​ being relation: a quantitative synthesis. Research on Aging, 6, 45–​65. Okun, M. A., Yeung, E. W., & Brown, S. (2013). Volunteering by older adults and risk of mortality. Psychology and Aging, 28(2), 564–​577. Okun, M. A., O’Rourke, H. P., Keller, B., Johnson, K. A., & Enders, C. (2015). Value-​expressive volunteer motivation and volunteering by older adults: Relationships with religiosity and spirituality. Journals of Gerontology, 70B(6), 860–​870. Okura, M., Ogita, M., & Arai, H. (2020). Are self-​ reported masticatory ability and regular dental care related to mortality? Journal of Nutrition, Health & Aging, 24(3), 262–​268. Olagoke, A., Olagoke, O., & Hughes, A. M. (2021). Intention to vaccinate against the novel 2019 coronavirus disease: the role of health locus of control and religiosity. Journal of Religion and Health, 60(1), 65–​80. Olasky, M. (1990). Democracy and the secularization of the American press. In Q. J. Schultze (ed.), American Evangelicals and the Mass Media. Grand Rapids, MI: Academie/​Zondervan, pp. 47–​68. Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral therapy for anxiety disorders. Psychiatric Clinics, 33(3), 557–​577. Olendzki, A. (translator) (2013). King Pasenadi goes on a diet. Tipitaka, Samyutta Nikaya, Donapaka Sutta, SN 3.13. Access to Insight (Legacy Edition). Retrieved on 1-​14-​2020 from https://​www.acce​ ssto​insi​ght.org/​tipit​aka/​sn/​sn03/​sn03.013. olen.html. Olff, M., Frijling, J. L., Kubzansky, L. D., Bradley, B., Ellenbogen, M. A., Cardoso, C., et al. (2013). The role of oxytocin in social bonding, stress regulation and mental health. Psychoneuroendocrinology, 38(9), 1883–​1894. Olson, D. H. (2017). Prepare & Enrich. Retrieved on 11-​2-​2019 from https://​www.prep​are-​enr​ ich.com/​web​app/​pecv/​about/​templ​ate/​Displ​ aySe​cure​Cont​ent.vm?id=​pecv*about*resea​rch. html&xlat=​Y&repor​t_​la​ng_​c​ode=​ENGL​ISH. Olson, J. R., Marshall, J. P., Goddard, H. W., & Schramm, D. G. (2015). Shared religious beliefs, prayer, and forgiveness as predictors

of marital satisfaction. Family Relations, 64(4), 519–​533. O’Malley, P. M., Johnston, L. D., O’Malley, P. M., & Johnston, L. D. (2007). Drugs and driving by American high school seniors, 2001–​2006. Journal of Studies on Alcohol, 68(6), 834–​842. Oman, D. (2013). Defining religion and spirituality (Ch. 2). In Paloutzian, R., & Park, C. (eds.), Handbook of the Psychology of Religion and Spirituality, 2nd ed. New York, NY: Guilford Press, pp. 23–​47. Oman, D. (2018). Why Religion and Spirituality Matter for Public Health: Evidence, Implications, and Resources. New York, NY: Springer. Oman, D., & Bormann, J. E. (2015). Mantram repetition fosters self-​efficacy in veterans for managing PTSD. Psychology of Religion and Spirituality, 7(1), 34–​45. Oman, D., & Brown, T. T. (2018). Health policy and management, religion, and spirituality. In Oman, D. (ed.), Why Religion and Spirituality Matter for Public Health. New York, NY: Springer, pp. 191–​210. Oman, D., & Reed, D. (1998). Religion and mortality among the community-​dwelling elderly. American Journal of Public Health, 88, 1469–​1475. Oman, D., Thoresen, C. E., & McMahon, K. (1999). Volunteerism and mortality among the community-​dwelling elderly. Journal of Health Psychology, 4(3), 301–​316. Oman, D., Kurata, J. H., Strawbridge, W. J., & Cohen, R. D. (2002). Religious attendance and cause of death over 31 years. International Journal of Psychiatry in Medicine, 32(1), 69–​89. Oman, D., Hedberg, J., & Thoresen, C. E. (2006). Passage meditation reduces perceived stress in health professionals. Journal of Consulting & Clinical Psychology, 74(4), 714–​719. Ong, A. D., Zautra, A. J., & Reid, M. C. (2010). Psychological resilience predicts decreases in pain catastrophizing through positive emotions. Psychology and Aging, 25(3), 516–​523. Ong, A. D., Zautra, A. J., & Reid, M. C. (2015). Chronic pain and the adaptive significance of positive emotions. American Psychologist, 70(3), 283–​284. Onge, J. M. S., & Krueger, P. M. (2017). Health lifestyle behaviors among US adults. Social Sciences & Medicine-​Population Health, 3, 89–​98. Onyemah, V., Rouziès, D., & Iacobucci, D. (2018). Impact of religiosity and culture on salesperson job satisfaction and performance. International Journal of Cross Cultural Management, 18(2), 191–​219.

References • 991

Onyigbuo, C. C., Alexis-​Garsee, C., & van den Akker, O. (2018). Predicting attitudes towards seeking medical care among Nigerian immigrants in the UK. Mental Health, Religion & Culture, 21(8), 810–​824. Ooishi, Y., Mukai, H., Watanabe, K., Kawato, S., & Kashino, M. (2017). Increase in salivary oxytocin and decrease in salivary cortisol after listening to relaxing slow-​tempo and exciting fast-​tempo music. PloS One, 12(12), e0189075. Opjordsmoen, S. (1989). Delusional disorders: I. Comparative long‐term outcome. Acta Psychiatrica Scandinavica, 80(6), 603–​612. Opsahl, T., Ahrenfeldt, L. J., Möller, S., & Hvidt, N. C. (2019). Religiousness and depressive symptoms in Europeans. Public Health, 175, 111–​119. O’Reilly, D., & Rosato, M. (2008). Religious affiliation and mortality in Northern Ireland: beyond Catholic and Protestant. Social Science & Medicine, 66(7), 1637–​1645. O’Reilly, D., & Rosato, M. (2015). Religion and the risk of suicide. British Journal of Psychiatry, 206(6), 466–​470. Orji, R., Vassileva, J., & Mandryk, R. (2012). Towards an effective health interventions design: an extension of the health belief model. Online Journal of Public Health Informatics, 4(3), ojphi.v4i3.4321. Orlewska, K., Sliwczynski, A., & Orlewska, E. (2018). An ecological study of the link between the risk of most frequent types of cancer in Poland and socioeconomic variables. International Journal of Public Health, 63(7), 777–​786. Ormel, J., VonKorff, M., Ustun, T. B., Pini, S., Korten, A., & Oldehinkel, T. (1994). Common mental disorders and disability across cultures. Journal of the American Medical Association, 272(22), 1741–​1748. Orr, J., Tobin, K., Carey, D., Kenny, R. A., & McGarrigle, C. (2019). Religious attendance, religious importance, and the pathways to depressive symptoms in men and women aged 50 and over living in Ireland. Research on Aging, 41(9), 891–​911. Orr, J., Kenny, R. A., & McGarrigle, C. A. (2020). Longitudinal associations of religiosity and physical function in older Irish adults. Journal of the American Geriatrics Society, 68(9), 1998–​2005. Ortiz-​Ospina, E., & Beltekian, D. (2018). Why do women live longer than men? Our World Data. Retrieved on 7-​3-​2020 from https://​our​worl​dind​ ata.org/​why-​do-​women-​live-​lon​ger-​than-​men.

992 •  R eferences

Ortiz-​Ospina, E., & Roser, M. (2020). Marriages and divorces. Our World in Data. Oxford, UK: Oxford University. Retrieved on 9-​19-​2020 from https://​our​worl​dind​ata.org/​marria​ges-​ and-​divor​ces. Osman-​Gani, A. M., Hashim, J., & Ismail, Y. (2013). Establishing linkages between religiosity and spirituality on employee performance. Employee Relations, 35(4), 360–​376. Osmond, C., Barker, D. J., Winter, P. D., Fall, C. H., & Simmonds, S. J. (1993). Early growth and death from cardiovascular disease in women. British Medical Journal, 307(6918), 1519–​1524. Ostbye, T., Krause, K. M., Norton, M. C., Tschanz, J., Sanders, L., Hayden, K., et al. (2006). Ten dimensions of health and their relationships with overall self-​reported health and survival in a predominately religiously active elderly population. Journal of the American Geriatrics Society, 54(2), 199–​209. Osterberg, L. & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487–​497. Ostir, G. V., Berges, I. M., Markides, K. S., & Ottenbacher, K. J. (2006). Hypertension in older adults and the role of positive emotions. Psychosomatic Medicine, 68(5), 727. Ostir, G. V., Berges, I. M., Ottenbacher, M. E., Clow, A., & Ottenbacher, K. J. (2008). Associations between positive emotion and recovery of functional status following stroke. Psychosomatic Medicine, 70, 404–​409. Ouwehand, E., Braam, A. W., Renes, J., Muthert, H. J., Stolp, H. A., Garritsen, H. H., et al. (2019). Prevalence of religious and spiritual experiences and the perceived influence thereof in patients with bipolar disorder in a Dutch specialist outpatient center. Journal of Nervous and Mental Disease, 207(4), 291–​299. Ouwehand, E., Braam, A. W., Renes, J. W., Muthert, H. J., & Zock, H. T. (2020). Holy apparition or hyper-​religiosity: prevalence of explanatory models for religious and spiritual experiences in patients with bipolar disorder and their associations with religiousness. Pastoral Psychology, 69(1), 29–​45. Ovbiagele, B., Goldstein, L. B., Higashida, R. T., Howard, V. J., Johnston, S. C., Khavjou, O. A., et al. (2013). Forecasting the future of stroke in the United States. Stroke, 44(8), 2361–​2375. Overeaters Anonymous (2020). You are not alone anymore. Retrieved on 1-​10-​2020 from https://​ oa.org/​. Owen, A. D., Hayward, R. D., Koenig, H. G., Steffens, D. C., & Payne, M. E. (2011). Religious

factors and hippocampal atrophy in late life. PLoS One, 6(3), e17006. Oxhandler, H. K., Parrish, D. E., Torres, L. R., & Achenbaum, W. A. (2015). The integration of clients’ religion and spirituality in social work practice. Social Work, 60(3), 228–​237. Oxhandler, H. K., Polson, E. C., & Achenbaum, W. A. (2017). The religiosity and spiritual beliefs and practices of clinical social workers. Social Work, 63(1), 47–​56. Oxhandler, H. K., & Giardina, T. D. (2017). Social workers’ perceived barriers to and sources of support for integrating clients’ religion and spirituality in practice. Social Work, 62(4), 323–​332. Oxhandler, H. K., & Pargament, K. I. (2018). Measuring religious and spiritual competence across helping professions. Spirituality in Clinical Practice, 5(2), 120–​132. Oxhandler, H. K., & Parrish, D. E. (2018). Integrating clients’ religion/​spirituality in clinical practice: A comparison among social workers, psychologists, counselors, marriage and family therapists, and nurses. Journal of Clinical Psychology, 74(4), 680–​694. Oxman, T. E., Freeman, D. H., & Manheimer, E. D. (1995). Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosomatic Medicine, 57, 5–​15. Ozbasaran, F., Ergul, S., Temel, A. B., Aslan, G. G., & Coban, A. (2011). Turkish nurses’ perceptions of spirituality and spiritual care. Journal of Clinical Nursing, 20, 3102–​3110. Ozkan, M., Altindag, A., Oto, R., & Sentunali, E. (2006). Mental health aspects of Turkish women from polygamous versus monogamous families. International Journal of Social Psychiatry, 52(3), 214–​220. Ozmen, C. B., Brelsford, G. M., & Danieu, C. R. (2018). Political affiliation, spirituality, and religiosity: links to emerging adults’ life satisfaction and optimism. Journal of Religion and Health, 57(2), 622–​635. PA-​06-​403 (2006). The influence of religiosity and spirituality on health risk behaviors in children and adolescents (R21). Retrieved on 10-​9-​2020 from https://​gra​nts.nih.gov/​gra​nts/​guide/​pa-​ files/​pa-​06-​403.html. Pace, T. W., Negi, L. T., Adame, D. D., Cole, S. P., Sivilli, T. I., Brown, T. D., et al. (2009). Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress. Psychoneuroendocrinology, 34(1), 87–​98.

Padela, A. I., Murrar, S., Adviento, B., Liao, C., Hosseinian, Z., Peek, M., et al. (2015). Associations between religion-​related factors and breast cancer screening among American Muslims. Journal of Immigrant and Minority Health, 17(3), 660–​669. Padilla, M. E., Frietze, G., Shenberger-​Trujillo, J. M., Carrillo, M., & Loya, A. M. (2020). Influenza and intentions to vaccinate in an underserved Hispanic population. Journal of Pharmacy Practice, 33(3), 326–​333. Pagano, M. E., Zemore, S. E., Onder, C. C., & Stout, R. L. (2009). Predictors of initial AA-​related helping: findings from Project MATCH. Journal of Studies on Alcohol and Drugs, 70, 117–​124. Page, R. L., Ellison, C. G., & Lee, J. (2009). Does religiosity affect health risk behaviors in pregnant and postpartum women? Maternal Child Health Journal, 13, 621–​632. Paine, N. J., Watkins, L. L., Blumenthal, J. A., Kuhn, C. M., & Sherwood, A. (2015). Associations of depressive and anxiety symptoms with 24-​hour urinary catecholamines in individuals with untreated high blood pressure. Psychosomatic Medicine, 77(2), 136–​144. Paiva, C. E., Paiva, B. S., Yennurajalingam, S., & Hui, D. (2014). The impact of religiosity and individual prayer activities on advanced cancer patients’ health: is there any difference in function of whether or not receiving palliative anti-​neoplastic therapy? Journal of Religion and Health, 53(6), 1717–​1727. Pakhale, S., Samet, J., Folan, P., Leone, F., & White, A. (2016). The case for requiring graphic warning labels on smokeless tobacco product packages. Annals of the American Thoracic Society, 13(3), 329–​333. Palermo, T. M., & Holley, A. L. (2013). The importance of the family environment in pediatric chronic pain. JAMA Pediatrics, 167(1), 93–​94. Pallini, S., Baiocco, R., Schneider, B. H., Madigan, S., & Atkinson, L. (2014). Early child–​parent attachment and peer relations: a meta-​analysis of recent research. Journal of Family Psychology, 28(1), 118. Palma-​Gudiel, H., Córdova-​Palomera, A., Eixarch, E., Deuschle, M., & Fananas, L. (2015). Maternal psychosocial stress during pregnancy alters the epigenetic signature of the glucocorticoid receptor gene promoter in their offspring. Epigenetics, 10(10), 893–​902. Palmer, E., Leblanc-​Duchin, D., Murray, J., & Atkinson, P. (2014). Emergency department use: Is frequent use associated with a lack

References • 993

of primary care provider? Canadian Family Physician, 60(4), e223–​e229. Palmer, J. A., Howard, E. P., Bryan, M., & Mitchell, S. L. (2018). Physiological and psychosocial factors in spiritual needs attainment for community-​dwelling older adults. Archives of Gerontology and Geriatrics, 76, 1–​5. Palmier-​Claus, J. E., Berry, K., Bucci, S., Mansell, W., & Varese, F. (2016). Relationship between childhood adversity and bipolar affective disorder: a systematic review and meta-​ analysis. British Journal of Psychiatry, 209(6), 454–​459. Paloutzian, R. F., & Ellison, C. W. (1982). Loneliness, spiritual well-​being, and the quality of life. In Peplau, L. A., & Perlman, D. (eds.), Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, NY: John Wiley & Sons, pp. 224–​236. Pampel, F., & Pampel, F. (2008). Tobacco use in sub-​ Sahara Africa: estimates from the demographic health surveys. Social Science & Medicine, 66(8), 1772–​1783. Pan, X., Wang, Z., Wu, X., Wen, S. W., & Liu, A. (2018). Salivary cortisol in post-​traumatic stress disorder: a systematic review and meta-​analysis. BMC Psychiatry, 18(1), 324. Pan, Y., Cai, W., Cheng, Q., Dong, W., An, T., & Yan, J. (2015). Association between anxiety and hypertension: a systematic review and meta-​analysis of epidemiologic studies. Neuropsychiatric Disease and Treatment, 11, 1121. Panczak, R., Spoerri, A., Zwahlen, M., Bopp, M., Gutzwiller, F., & Egger, M. (2013). Religion and suicide in patients with mental illness or cancer. Suicide and Life-​Threatening Behavior, 43(2), 213–​222. Pandey, J., & Singh, M. (2019). Positive religious coping as a mechanism for enhancing job satisfaction and reducing work-​family conflict: a moderated mediation analysis. Journal of Management, Spirituality & Religion, 16(3), 314–​338. Pandya, S. P. (2020). Faith maturity and mental well-​being: a longitudinal study of Indian American followers of a guru tradition. Journal of Religion and Health, 59(2), 743–​757. Pänkäläinen, M., Kerola, T., Kampman, O., Kauppi, M., & Hintikka, J. (2016). Pessimism and risk of death from coronary heart disease among middle-​aged and older Finns: an eleven-​year follow-​up study. BMC Public Health, 16(1), 1124. Pantell, M., Rehkopf, D., Jutte, D., Syme, S. L., Balmes, J., & Adler, N. (2013). Social isolation: a predictor of mortality comparable to traditional

994 •  R eferences

clinical risk factors. American Journal of Public Health, 103(11), 2056–​2062. Papadopoulos, V., Tsakiridis, K., Filippou, D. K., Aggelopoulos, P., Nikiforidis, D., & Baltatzidis, G. (2006). Comparison of stroke among Christians and Muslims in Thrace, Greece. Rural & Remote Health, 6(2), 505. Papailou, Z., & Kiani, Q. (2016). An investigation of correlation of the physician-​patient relationship and religious orientation with adherence to treatment of adolescents with type 1 diabetes. Health, Spirituality and Medical Ethics, 3(4), 2–​9. Parati, G., & Esler, M. (2012). The human sympathetic nervous system: its relevance in hypertension and heart failure. European Heart Journal, 33(9), 1058–​1066. Pardini, D., Beardslee, J., Docherty, M., Schubert, C., & Mulvey, E. (2021). Risk and protective factors for gun violence in male juvenile offenders. Journal of Clinical Child & Adolescent Psychology, 50(3), 337–​352. Pargament, K. I. (ed.). (2013). Searching for the sacred: toward a nonreductionistic theory of spirituality. In K. I. Pargament, J. J. Exline, & J. W. Jones (eds.), APA Handbooks in Psychology. APA Handbook of Psychology, Religion, and Spirituality (Vol. 1). Washington, DC: American Psychological Association, pp. 257–​273. Pargament, K. I., Tyler, F., & Steele, R. (1979). The church/​synagogue and the psycho-​social competence of the member: an initial inquiry into a neglected dimension. American Journal of Community Psychology, 6, 649–​664. Pargament, K. I., Kennell, J., Hathaway, W., Grevengoed, N., Newman, J., & Jones, W. (1988). Religion and the problem-​solving process: three styles of coping. Journal for the Scientific Study of Religion, 27(1), 90–​104. Pargament, K. I., Olsen, H., Reilly, B., Falgout, K., & Ensing, D. S. (1992). God help me (II): The relationship of religious orientations to religious coping with negative life events. Journal for the Scientific Study of Religion, 31, 504–​513. Pargament, K. I., Smith, B. W., Koenig, H. G., & Perez, L. (1998). Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion, 37(4), 710–​724. Pargament, K. I., Koenig, H. G., & Perez, L. M. (2000). The many methods of religious coping: Development and initial validation of the RCOPE. Journal of Clinical Psychology, 56(4), 519–​543. Pargament, K. I., Koenig, H. G., Tarakeshwar, N., & Hahn, J. (2001). Religious struggle as a

predictor of mortality among medically ill elderly patients: a two-​year longitudinal study. Archives of Internal Medicine, 161, 1881–​1885. Pargament, K. I., Koenig, H. G., Tarakeshwar, N., & Hahn, J. (2004). Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: a two-​year longitudinal study. Journal of Health Psychology, 9(6), 713–​730. Pargament, K. I., Exline, J. J., & Jones, J. W. (2013a). APA Handbook of Psychology, Religion, and Spirituality (Vol 1). Washington, D.C.: American Psychological Association. Pargament, K. I., Mahoney, A. E., & Shafranske, E. P. (2013b). APA Handbook of Psychology, Religion, and Spirituality, Vol. 2: An Applied Psychology of Religion and Spirituality. Washington, DC: American Psychological Association. Park, C. L., Cohen, L. H., & Murch, R. L. (1996). Assessment and prediction of stress‐related growth. Journal of Personality, 64(1), 71–​105. Park, C. L., Malone, M. R., Suresh, D. P., Bliss, D., & Rosen, R. I. (2008). Coping, meaning in life, and quality of life in congestive heart failure patients. Quality of Life Research, 17(1), 21–​26. Park, C. L., & Sacco, S. J. (2017). Heart failure patients’ desires for spiritual care, perceived constraints, and unmet spiritual needs: relations with well-​being and health-​related quality of life. Psychology, Health & Medicine, 22(9), 1011–​1020. Park, J. I., Hong, J. P., Park, S., & Cho, M. J. (2012). The relationship between religion and mental disorders in a Korean population. Psychiatry Investigation, 9(1), 29–​35. Park, N. S., Klemmack, D. L., Roff, L. L., Parker, M. W., Koenig, H. G., Sawyer, P., et al. (2008). Religiousness and longitudinal trajectories in elders’ functional status. Research on Aging, 30(3), 279–​298. Park, N. S., Lee, B. S., Sun, F., Klemmack, D. L., Roff, L. L., & Koenig, H. G. (2013). Typologies of religiousness/​spirituality: implications for health and well-​being. Journal of Religion and Health, 52(3), 828–​839. Park, N., Peterson, C., Szvarca, D., Vander Molen, R. J., Kim, E. S., & Collon, K. (2016). Positive psychology and physical health: research and applications. American Journal of Lifestyle Medicine, 10(3), 200–​206. Park, R. M., Schulte, P. A., Bowman, J. D., Walker, J. T., Bondy, S. C., Yost, M. G., et al. (2005). Potential occupational risks for neurodegenerative diseases. American Journal of Industrial Medicine, 48(1), 63–​77.

Parke, C. (2019). Chinese officials warn Christianity is “enormous harm” to society. Fox News, May 8. Retrieved on 5-​9-​2019 from https://​www. foxn​ews.com/​world/​chin​ese-​warn-​chris​tian​ity-​ enorm​ous-​harm-​commun​ist-​soci​ety. Parker, G., McCraw, S., Tavella, G., & Hadzi-​ Pavlovic, D. (2018). Measuring the consequences of a bipolar or unipolar mood disorder and the immediate and ongoing impacts. Psychiatry Research, 269, 70–​74. Parker, M., Roff, L., Klemmack, D. L., Koenig, H. G., Baker, P., & Allman, R. M. (2003). Religiosity and mental health in southern, community-​ dwelling older adults. Aging & Mental Health, 7(5), 390–​397. Parkerson, G. R., Jr., & Gutman, R. A. (2000). Health-​related quality of life predictors of survival and hospital utilization. Health Care Financing Review, 21(3), 171–​184. Parkington, H. C., Coleman, H. A., Wintour, E. M., & Tare, M. (2010). Prenatal alcohol exposure: implications for cardiovascular function in the fetus and beyond. Clinical and Experimental Pharmacology and Physiology, 37(2), e91–​e98. Partnership Center (2020). Partnership Center, Center for Faith and Opportunity Initiatives. US Department of Health and Human Services. Retrieved on 10-​12-​2020 from https://​www. hhs.gov/​about/​agenc​ies/​iea/​partn​ersh​ips/​ index.html. Partridge, K. J., & Walker, D. F. (2015). Addressing spiritual struggles using spiritually oriented trauma-​focused cognitive behavioral therapy. Journal of Psychology and Christianity, 34(1), 84–​89. Pascal, B. (1966; 1670 per Encyclopaedia Britannica]). Pensées (translated by A. J. Krailsheimer). New York, NY: Penguin Books. Pasch, K. E., Nelson, M. C., Lytle, L. A., Moe, S. G., & Perry, C. L. (2008). Adoption of risk-​related factors through early adolescence: associations with weight status and implications for causal mechanisms. Journal of Adolescent Health, 43(4), 387–​393. Pascoe, A. E., Hill, T. D., Mossakowski, K. N., & Johnson, R. J. (2016). Religious involvement and perceptions of control: evidence from the Miami-​Dade Health Survey. Journal of Religion and Health, 55(3), 862–​873. Pascoe, E. C., & Edvardsson, D. (2016). Which coping strategies can predict beneficial feelings associated with prostate cancer? Journal of Clinical Nursing, 25(17–​18), 2569–​2578.

References • 995

Pascoe, M. C., Thompson, D. R., & Ski, C. F. (2017a). Yoga, mindfulness-​based stress reduction and stress-​related physiological measures: a meta-​ analysis. Psychoneuroendocrinology, 86, 152–​168. Pascoe, M. C., Thompson, D. R., Jenkins, Z. M., & Ski, C. F. (2017b). Mindfulness mediates the physiological markers of stress: systematic review and meta-​analysis. Journal of Psychiatric Research, 95, 156–​178. Pasupathi, P., Bakthavathsalam, G., Rao, Y. Y., & Farook, J. (2009). Cigarette smoking—​effect of metabolic health risk: a review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 3(2), 120–​127. Patel, C., & North, W. R. (1975). Randomised controlled trial of yoga and bio-​feedback in management of hypertension. Lancet 2(7925), 93–​95. Patterson, G. R., DeBaryshe, B. D., & Ramsey, E. (1989). A developmental perspective on antisocial behaviour. American Psychologist, 44, 329–​35. Patkar, A. A., Marsden, C. A., Naik, P. C., Kendall, D. A., Gopalakrishnan, R., Vergare, M. J., et al. (2004). Differences in peripheral noradrenergic function among actively drinking and abstinent alcohol-​dependent individuals. American Journal on Addictions, 13(3), 225–​235. Patnode, C. D., Perdue, L. A., Rossom, R. C., Rushkin, M. C., Redmond, N., Thomas, R. G., et al. (2020). Screening for cognitive impairment in older adults: an evidence update from the US Preventive Services Task Force. AHRQ Publication No. 19-​05257-​EF-​1. Paton, C., Crawford, M. J., Bhatti, S. F., Patel, M. X., & Barnes, T. R. (2015). The use of psychotropic medication in patients with emotionally unstable personality disorder under the care of UK mental health services. Journal of Clinical Psychiatry, 76(4), 512–​518. Patterson, R., & Price, J. (2012). Pornography, religion, and the happiness gap: does pornography impact the actively religious differently? Journal for the Scientific Study of Religion, 51(1), 79–​89. Patterson-​Buckendahl, P., Kubovcakova, L., Krizanova, O., Pohorecky, L. A., & Kvetnansky, R. (2005). Ethanol consumption increases rat stress hormones and adrenomedullary gene expression. Alcohol, 37(3), 157–​166. Paukert, A. L., Calleo, J., Kraus-​Schuman, C., Snow, L., Wilson, N., Petersen, N. J., et al. (2010). Peaceful Mind: an open trial of cognitive-​ behavioral therapy for anxiety in persons with

996 •  R eferences

dementia. International Psychogeriatrics, 22(6), 1012–​1021. Paul, C., Fitzjohn, J., Herbison, P., & Dickson, N. (2000a). The determinants of sexual intercourse before age 16. Journal of Adolescent Health, 27(2), 136–​147. Paul, C., Fitzjohn, J., Eberhart-​Phillips, J., Herbison, P., & Dickson, N. (2000b). Sexual abstinence at age 21 in New Zealand: the importance of religion. Social Science & Medicine, 51(1), 1–​10. Paul, G. S. (2010). Religiosity tied to socioeconomic status. Science, 327(5966), 642–​642. Paul-​Labrador, M., Polk, D., Dwyer, J. H., Velasquez, I., Nidich, S., Rainforth, M., et al. (2006). Effects of a randomized controlled trial of transcendental meditation on components of the metabolic syndrome in subjects with coronary heart disease. Archives of Internal Medicine, 166(11), 1218–​1224. Paulsen, A. J., Schubert, C. R., Pinto, A., Carlsson, C. M., Chappell, R. J., Fischer, M. E., et al. (2020). Neuroprotective biomarkers and cognitive function in a long-​term prospective population-​ based study of aging US adults. Alzheimer Disease & Associated Disorders, 34(1), 31–​39. Paulus, D. J., Vanwoerden, S., Norton, P. J., & Sharp, C. (2016). From neuroticism to anxiety: Examining unique contributions of three transdiagnostic vulnerability factors. Personality and Individual Differences, 94, 38–​43. Pavón, L., Sandoval-​López, G., Hernández, M. E., Loría, F., Estrada, I., Pérez, M., et al. (2006). Th2 cytokine response in major depressive disorder patients before treatment. Journal of Neuroimmunology, 172(1–​2), 156–​165. Pawlikowski, J., Białowolski, P., Węziak-​ Białowolska, D., & VanderWeele, T. J. (2019). Religious service attendance, health behaviors and well-​being: an outcome-​wide longitudinal analysis. European Journal of Public Health, 29(6), 1177–​1183. Paykel, E. S., Myers, J. K., Lindenthal, J. J., & Tanner, J. (1974). Suicidal feelings in the general population. British Journal of Psychiatry, 124, 460–​469. Payman, V., & Lim, Z. J. (2018). Do clinicians assess patients’ religiousness? Australasian Psychiatry, 26(4), 401–​404. Payman, V., & Ryburn, B. (2010). Religiousness and recovery from inpatient geriatric depression. Australian and New Zealand Journal of Psychiatry, 44(6), 560–​567. Peacock, A., Leung, J., Larney, S., Colledge, S., Hickman, M., Rehm, J., et al. (2018). Global

statistics on alcohol, tobacco and illicit drug use. Addiction, 113(10), 1905–​1926. Peake, J. (2020). Interrelations between acute and chronic exercise stress and the immune and endocrine systems. In Endocrinology of Physical Activity and Sport. Cham: Humana, pp. 249–​266. Peale, N. V. (1952). The Power of Positive Thinking. New York, NY: Prentice-​Hall. Pearce, L. D., & Haynie, D. L. (2004). Intergenerational religious dynamics and adolescent delinquency. Social Forces, 82(4), 1553–​1572. Pearce, M. J., Koenig, H. G., Robins, C. J., Nelson, B., Shaw, S. F., Cohen, H. J., et al. (2015). Religiously integrated cognitive behavioral therapy: a new method of treatment for major depression in patients with chronic medical illness. Psychotherapy, 52(1), 56–​66. Pearce, M. J., Medoff, D., Lawrence, R. E., & Dixon, L. (2016). Religious coping among adults caring for family members with serious mental illness. Community Mental Health Journal, 52(2), 194–​202. Pearce, M. J., Haynes, K., Rivera, N. R., & Koenig, H. G. (2018). Spiritually integrated cognitive processing therapy: a new treatment for post-​ traumatic stress disorder that targets moral injury. Global Advances in Health and Medicine, 7, 1–​7. Pearce, M. J., Pargament, K. I., Oxhandler, H. K., Vieten, C., & Wong, S. (2019). A novel training program for mental health providers in religious and spiritual competencies. Spirituality in Clinical Practice, 6(2), 73–​82. Pearson, C. M., Mason, T. B., Cao, L., Goldschmidt, A. B., Lavender, J. M., Crosby, R. D., et al. (2018). A test of a state-​based, self-​control theory of binge eating in adults with obesity. Eating Disorders, 26(1), 26–​38. Peck, M. S. (1978). The Road Less Traveled. New York, NY: Simon & Schuster. Peck, M. S. (1983). People of the Lie. New York, NY: Simon & Schuster. Peckham, H., de Gruijter, N. M., Raine, C., Radziszewska, A., Ciurtin, C., Wedderburn, L. R., et al. (2020). Male sex identified by global COVID-​19 meta-​analysis as a risk factor for death and ITU admission. Nature Communications, 11(1), 1–​10. Pecoraro, A., Pacciolla, A., O’Cleirigh, C., Mimiaga, M., Kwiatek, P., Blokhina, E., et al. (2016). Proactive coping and spirituality among patients who left or remained in antiretroviral treatment in St Petersburg, Russian Federation. AIDS Care, 28(3), 334–​338.

Pedersen, H. F., Birkeland, M. H., Jensen, J. S., Schnell, T., Hvidt, N. C., Sørensen, T., et al. (2018). What brings meaning to life in a highly secular society? Scandinavian Journal of Psychology, 59(6), 678–​690. Pedersen, S., & Revenson, T. A. (2005). Parental illness, family functioning, and adolescent well-​being. Journal of Family Psychology, 19(3), 404–​419. Peek, C. W., Curry, E. W., & Chalfant, H. P. (1985). Religiosity and delinqunecy over time: deviance deterrence and deviance amplification. Social Science Quarterly, 66, 120–​131. Peeri, N. C., Shrestha, N., Rahman, M. S., Zaki, R., Tan, Z., Bibi, S., et al. (2020). The SARS, MERS and novel coronavirus (COVID-​19) epidemics, the newest and biggest global health threats. International Journal of Epidemiology, 49(3), 717–​726. Pelčić, G., Karačić, S., Mikirtichan, G. L., Kubar, O. I., Leavitt, F. J., Tai, M. C., et al. (2016). Religious exception for vaccination or religious excuses for avoiding vaccination. Croatian Medical Journal, 57(5), 516–​521. Peltier, M. R., Cosgrove, S. J., Ohayagha, K., Crapanzano, K. A., & Jones, G. N. (2017). Do they see dead people? Cultural factors and sensitivity in screening for schizophrenia spectrum disorders. Ethnicity & Health, 22(2), 119–​129. Peltzer, K., & Pengpid, S. (2019). Prevalence, social and health correlates of insomnia among persons 15 years and older in Indonesia. Psychology, Health & Medicine, 24(6), 757–​768. Peltzer, K., Preez, N., Ramlagan, S., Fomundam, H., Anderson, J., & Chanetsa, L. (2011). Antiretrovirals and the use of traditional, complementary and alternative medicine by HIV patients in Kwazulu-​Natal, South Africa. African Journal of Traditional, Complementary, and Alternative Medicine, 8(4), 337–​345. Peltzer, K., Pengpid, S., Amuleru-​Marshall, O., Mufune, P., & Zeid, A. A. (2016). Religiosity and health risk behavior among university students and 26 low, middle and high income countries. Journal of Religion and Health, 55, 2131–​2140. Pence, B. W., Thielman, N. M., Whetten, K., Osterman, J., Kumar, V., & Mugavero, M. J. (2008). Coping strategies and patterns of alcohol and drug use among HIV-​infected patients in the United States southeast. AIDS Patient Care and STDs, 22, 869–​875. Pengpid, S., Peltzer, K., Kassean, H. K., Tsala, J. P., Sychareun, V., & Müller-​Riemenschneider, F. (2015). Physical inactivity and associated factors

References • 997

among university students in 23 low-​, middle-​ and high-​income countries. International Journal of Public Health, 60(5), 539–​549. Penzner, J. B., Kelly, K. V., & Sacks, M. H. (2010). Religious conversion in a psychotic individual. Journal of Religion and Health, 49(3), 351–​3 60. Perälä, J., Suvisaari, J., Saarni, S. I., Kuoppasalmi, K., Isometsä, E., Pirkola, S., et al. (2007). Lifetime prevalence of psychotic and bipolar I disorders in a general population. Archives of General Psychiatry, 64(1), 19–​28. Pereira, D. B., Christian, L. M., Patidar, S., Bishop, M. M., Dodd, S. M., Athanason, R., et al. (2010). Spiritual absence and 1-​year mortality after hematopoietic stem cell transplant. Biology of Blood and Marrow Transplantation, 16(8), 1171–​1179. Perelli‐Harris, B., Berrington, A., Gassen, N. S., Galezewska, P., & Holland, J. A. (2017). The rise in divorce and cohabitation: is there a link? Population and Development Review, 43(2), 303. Pergolizzi, J. V., Rosenblatt, M., & LeQuang, J. A. (2019). Three years down the road: the aftermath of the CDC guideline for prescribing opioids for chronic pain. Advances in Therapy, 36(6), 1235–​1240. Perk, G., Ghanem, J., Aamar, S., Ben-​Ishay, D., & Bursztyn, M. (2001). The effect of the fast of Ramadan on ambulatory blood pressure in treated hypertensives. Journal of Human Hypertension, 15(10), 723–​725. Perkins, D. F., & Jones, K. R. (2004). Risk behaviors and resiliency within physically abused adolescents. Child Abuse & Neglect, 28(5), 547–​563. Perkins, D. F., Luster, T., & Jank, W. (2002). Protective factors, physical abuse, and purging from community-​wide surveys of female adolescents. Journal of Adolescent Research, 17(4), 377–​400. Perkins, H. W. (1987). Parental religion and alcohol use problems as intergenerational predictors. Journal for the Scientific Study of Religion, 26, 340–​357. Perneger, T. V. (1998). What’s wrong with Bonferroni adjustments. British Medical Journal 316(7139), 1236–​1238. Perricone, C., Versini, M., Ben-​Ami, D., Gertel, S., Watad, A., Segel, M. J., et al. (2016). Smoke and autoimmunity: the fire behind the disease. Autoimmunity Reviews, 15(4), 354–​374. Perroud, N. (2009). Religion/​spirituality and neuropsychiatry (Ch. 5). In Huguelet, P., & Koenig, H. G. (eds.), Religion and Spirituality

998 •  R eferences

in Psychiatry. Cambridge, UK: Cambridge University Press, pp. 48–​64. Perry, S. L. (2016). From bad to worse? Pornography consumption, spousal religiosity, gender, and marital quality. Sociological Forum, 31(2), 441–​464. Perveen, A., & Malik, S. (2020). Influence of family violence on the marital quality in Pakistani Muslims. Religions, 11(9), 470. Peteet, J. R. (1993). A closer look at the role of a spiritual approach in addictions treatment. Journal of Substance Abuse Treatment, 10, 263–​267. Peteet, J. R. (1994). Approaching spiritual issues in psychotherapy. Journal of Psychotherapy Practice and Research, 3, 237–​245. Peteet, J. R. (2010). Depression and the Soul: A Guide to Spiritually Integrated Treatment. New York, NY: Routledge. Peteet, J. R. (2018). A fourth wave of psychotherapies: moving beyond recovery toward well-​being. Harvard Review of Psychiatry, 26(2), 90–​95. Peteet, J. R., Rodriguez, V., Herschkopf, M., McCarthy, A., Betts, J., & Romo S., et al. (2016). Does a therapist’s world view matter? Journal of Religion and Health, 55, 1097–​1106. Peteet, J. R., Al Zaben, F., & Koenig, H. G. (2019). Integrating spirituality into the care of older adults. International Psychogeriatrics, 31(1), 31–​38. Peter, J. (1998). Analyzing Public Policy. London, UK: Continuum. Peterman, A. H., Fitchett, G., Brady, M. J., Hernandez, L., & Cella, D. (2002). Measuring spiritual well-​being in people with cancer: The Functional Assessment of Chronic Illness Therapy–​Spiritual Well-​being Scale (FACIT-​Sp). Annals of Behavioral Medicine, 24(1), 49–​58. Peterman, J. S., LaBelle, D. R., & Steinberg, L. (2014). Devoutly anxious: The relationship between anxiety and religiosity in adolescence. Psychology of Religion and Spirituality, 6(2), 113–​122. Peters, B. G. (2015). Advanced Introduction to Public Policy. Cheltenham, UK: Edward Elgar. Peters, R. M., Aroian, K. J., & Flack, J. M. (2006). African American culture and hypertension prevention. Western Journal of Nursing Research, 28(7), 831–​854. Peters, S. A., Huxley, R. R., & Woodward, M. (2014). Diabetes as a risk factor for stroke in women compared with men. Lancet, 383(9933), 1973–​1980. Petrovic, K., Chapman, C. M., & Schofield, T. P. (2021). Religiosity and volunteering over

time: Religious service attendance is associated with the likelihood of volunteering, and religious importance with time spent volunteering. Psychology of Religion and Spirituality, 13(2), 136–​146. Petts, R. J., & Knoester, C. (2007). Parents’ religious heterogamy and children’s well-​being. Journal for the Scientific Study of Religion, 46(3), 373–​389. Pettus-​Davis, C., Brown, D., Veeh, C., & Renn, T. (2016). The Economic Burden of Incarceration in the US. Institute for Advancing Justice Research and Innovation. St. Louis, MO: Washington University. Petty, G. W., Brown, R. D., Jr., Whisnant, J. P., Sicks, J. D., O’Fallon, W. M., & Wiebers, D. O. (2000). Ischemic stroke subtypes: a population-​based study of functional outcome, survival, and recurrence. Stroke, 31(5), 1062–​1068. Pew Research Center (2012). The global religious landscape. Pew Research Center: Religion & Public Life. Retrieved on 7-​15-​2020 from https://​www.pewfo​rum.org/​2012/​12/​18/​glo​bal-​ religi​ous-​landsc​ape-​exec/​. Pew Research Center (2014). Religious Landscape Survey. Retrieved on 8-​28-​18 from http://​ www.pewfo​r um.org/​religi​ous-​landsc​ape-​ study/​. Pew Research Center (2015). The future of world religions: population growth projections, 2010–​2050: why Muslims are rising fastest and the unaffiliated are shrinking as a share of the world’s population. Retrieved on 7-​13-​2020 from https://​www.pewfo​rum.org/​2015/​04/​02/​ religi​ous-​proj​ecti​ons-​2010-​2050/​. Pew Research Center (2016). The gender gap around the world: women are generally more religious than men, particularly among Christians. Retrieved on 3-​7-​2020 from https://​www.pewfo​ rum.org/​2016/​03/​22/​the-​gen​der-​gap-​in-​relig​ ion-​aro​und-​the-​world/​. Pew Research Center (2017). The changing global religious landscape. Retrieved on 9-​ 14-​2 020 from https://​w ww.pewfo​r um.org/​ 2017/​0 4/​0 5/​t he-​chang​ing-​g lo​b al-​religi​o us-​ landsc​a pe/​. Pew Research Center (2018). Eastern and Western Europeans differ on importance of religion, views of minorities, and key social issues. Retrieved on 2-​11-​2019 from http://​ www.pewfo​r um.org/​2018/​10/​29/​east​ern-​ and-​west​ern-​europe​ans-​dif​fer-​on-​imp​orta​nce-​ of-​relig​ion-​views-​of-​min​orit​ies-​and-​key-​soc​ ial-​iss​ues/​.

Pew Research Center (2019a). A closer look at how religious restrictions have risen around the world. Retrieved on 10-​5-​2020 from https://​ www.pewfo​rum.org/​2019/​07/​15/​a-​clo​ser-​look-​ at-​how-​religi​ous-​restr​icti​ons-​have-​risen-​aro​ und-​the-​world/​. Pew Research Center (2019b). Religion in the public schools. Retrieved on 10-​3-​2020 from https://​ www.pewfo​rum.org/​2019/​10/​03/​relig​ion-​in-​ the-​pub​lic-​scho​ols-​2019-​upd​ate/​. Pew Research Center (2019c). A growing number of American teenagers—​particularly girls—​are facing depression. Retrieved on 9-​19-​2020 from https://​www.pewr​esea​rch.org/​fact-​tank/​2019/​ 07/​12/​a-​grow​ing-​num​ber-​of-​ameri​can-​teenag​ ers-​parti​cula​rly-​girls-​are-​fac​ing-​dep​ress​ion/​. Pew Research Center (2019d). In US, decline of Christianity continues at a rapid pace: an update on America’s changing religious landscape. Retrieved on 9-​14-​2020 from https://​www. pewfo​rum.org/​2019/​10/​17/​in-​u-​s-​decl​ine-​of-​ chris​tian​ity-​contin​ues-​at-​rapid-​pace/​. Phe​lps, A. C., Maciejewski, P. K., Nilsson, M., Balboni, T. A., Wright, A. A., Paulk, M. E., et al. (2009). Religious coping and use of intensive life-​prolonging care near death in patients with advanced cancer. Journal of the American Medical Association, 301(11), 1140–​1147. Phelps, A. C., Lauderdale, K. E., Alcorn, S., Dillinger, J., Balboni, M. T., Van Wert, M., et al. (2012). Addressing spirituality within the care of patients at the end of life: perspectives of patients with advanced cancer, oncologists, and oncology nurses. Journal of Clinical Oncology, 30(20), 2538. Philippus, A., Mellick, D., O’Neil-​Pirozzi, T., Bergquist, T., Guller Bodien, Y., Sander, A. M., et al. (2016). Impact of religious attendance on psychosocial outcomes for individuals with traumatic brain injury: a NIDILRR funded TBI Model Systems Study. Brain Injury, 30(13–​14), 1605–​1611. Phillips, L., Kemppainen, J. K., Mechling, B. M., MacKain, S., Kim-​Godwin, Y., & Leopard, L. (2014). Eating disorders and spirituality in college students. Journal of Psychosocial Nursing and Mental Health Services, 53(1), 30–​37. Phillips, R. E., Michelle Cheng, C., Oemig, C., Hietbrink, L., & Vonnegut, E. (2012). Validation of a Buddhist coping measure among primarily non‐Asian Buddhists in the United States. Journal for the Scientific Study of Religion, 51(1), 156–​172. Phillips, R. L., Garfinkel, L., Kuzma, J. W., Beeson, W. L., Lotz, T., & Brin, B. (1980). Mortality

References • 999

among California Seventh-​Day Adventists for selected cancer sites. Journal of the National Cancer Institute, 65, 1097–​1107. Physical Activity Guidelines Advisory Committee (2018). Physical Activity Guidelines for Americans, 2nd ed. Washington, DC: US Department of Health and Human Services (https://​hea​lth.gov/​ sites/​defa​ult/​files/​2019-​09/​Physical_​Acti​vity​_​ Gui​deli​nes_​2nd_​edit​ion.pdf). Piantadosi, S. (2005). Clinical Trials: A Methodologic Perspective, 2nd ed. New York, NY: Wiley-​Interscience. Piantadosi, S., Byar, D. P., & Green, S. B. (1988). The ecological fallacy. American Journal of Epidemiology, 127(5), 893–​904. Picco, L., Subramaniam, M., Abdin, E., Vaingankar, J. A., Zhang, Y., & Chong, S. A. (2013). Roles of religious and spiritual advisors among adults in Singapore with mental illnesses. Psychiatric Services, 64(11), 1150–​1156. Piderman, K. M., Radecki Breitkopf, C., Jenkins, S. M., Lapid, M. I., Kwete, G. M., Sytsma, T. T., et al. (2017). The impact of a spiritual legacy intervention in patients with brain cancers and other neurologic illnesses and their support persons. Psycho‐Oncology, 26(3), 346–​353. Piedmont, R. L. (1999). Does spirituality represent the sixth factor of personality? Spiritual transcendence and the five‐factor model. Journal of Personality, 67(6), 985–​1013. Piedmont, R. L. (2009). Personality, spirituality, religiousness, and the personality disorders: Predictive relations and treatment implications. In Huguelet, P., & Koenig, H. G. (eds.), Religion and Spirituality in Psychiatry. Cambridge, UK: Cambridge University Press, pp. 173–​189. Pienaar, J., Rothmann, S., & Van De Vijver, F. J. (2007). Occupational stress, personality traits, coping strategies, and suicide ideation in the South African police service. Criminal Justice and Behavior, 34(2), 246–​258. Pieper, J. (1990). The Four Cardinal Virtues: Human Agency, Intellectual Traditions, and Responsible Knowledge. Notre Dame, IN: University of Notre Dame Press. Pierre, J. M. (2001). Faith or delusion: at the crossroads of religion and psychosis. Journal of Psychiatric Practice, 7(3), 163–​172. Pignon, B., Geoffroy, P. A., Thomas, P., Roelandt, J. L., & Amad, A. (2019). Environment risk factors have different impact on bipolar and psychotic disorders: an analysis of MHGP survey. Psychological Medicine, 49(7), 1229–​1232.

1000 •  R eferences

Piko, B. F., Kovacs, E., Kriston, P., & Fitzpatrick, K. M. (2012). “To believe or not to believe?”: religiosity, spirituality, and alcohol use among Hungarian adolescents. Journal of Studies on Alcohol and Drugs, 73(4), 666–​674. Pikula, A., Beiser, A. S., Chen, T. C., Preis, S. R., Vorgias, D., DeCarli, C., et al. (2013). Serum brain–​derived neurotrophic factor and vascular endothelial growth factor levels are associated with risk of stroke and vascular brain injury. Stroke, 44(10), 2768–​2775. Pimenta, F., Maroco, J., Ramos, C., & Leal, I. (2014). Menopausal symptoms: is spirituality associated with the severity of symptoms? Journal of Religion and Health, 53(4), 1013–​1024. Pinchas-​Mizrachi, R., Solnica, A., & Daoud, N. (2021). Religiosity level and mammography performance among Arab and Jewish women in Israel. Journal of Religion and Health, 60(3), 1877–​1894. Pinchas‐Mizrachi, R., Zalcman, B. G., & Shapiro, E. (2021). Differences in mortality rates between Haredi and non‐Haredi Jews in Israel in the context of social characteristics. Journal for the Scientific Study of Religion, 60(2), 274–​290. Pinheiro, M. B., Ferreira, M. L., Refshauge, K., Ordoñana, J. R., Machado, G. C., Prado, L. R., et al. (2015). Symptoms of depression and risk of new episodes of low back pain. Arthritis Care & Research, 67(11), 1591–​1603. Pinquart, M., & Duberstein, P. R. (2010). Depression and cancer mortality. Psychological Medicine, 40(11), 1797–​1810. Pirkle, E. C., & Richter, L. (2006). Personality, attitudinal and behavioral risk profiles of young female binge drinkers and smokers. Journal of Adolescent Health, 38(1), 44–​54. Pirutinsky, S. (2013). Is the connection between religiosity and psychological functioning due to religion’s social value? A failure to replicate. Journal of Religion and Health, 52(3), 782–​784. Pirutinsky, S., & Rosmarin, D. H. (2018). Protective and harmful effects of religious practice on depression among Jewish individuals with mood disorders. Clinical Psychological Science, 6(4), 601–​609. Pirutinsky, S., Rosmarin, D. H., Holt, C. L., Feldman, R. Caplan, L., Midlarsky, E., et al. (2011). Does social support mediate the moderating effect of intrinsic religiosity on the relationship between physical health and depressive symptoms among Jews? Journal of Behavioral Medicine, 34, 489–​496. Pistoia, F., Sacco, S., Tiseo, C., Degan, D., Ornello, R., & Carolei, A. (2016). The epidemiology of

atrial fibrillation and stroke. Cardiology Clinics, 34(2), 255–​268. Pitel, L., Geckova, A. M., Kolarcik, P., Halama, P., Reijneveld, S. A., & van Dijk, J. P. (2012). Gender differences in the relationship between religiosity and health-​related behaviour among adolescents. Journal of Epidemiology and Community Health, 66, 1122–​1128. Pitt, C., & DeMaris, A. (2019). Religiosity as a buffer in the association between economic disadvantage and violence. Interdisciplinary Journal of Research on Religion, 15(1), 1–​28. Planche, K., Chan, J. F., Di Nota, P. M., Beston, B., Boychuk, E., Collins, P. I., et al. (2019). Diurnal cortisol variation according to high-​risk occupational specialty within police. Journal of Occupational and Environmental Medicine, 61(6), e260–​e265. Plans, L., Barrot, C., Nieto, E., Rios, J., Schulze, T. G., Papiol, S., et al. (2019). Association between completed suicide and bipolar disorder. Journal of Affective Disorders, 242(1), 111–​122. Plante, T. G. (2010). Contemplative Practices in Action: Spirituality, Meditation, and Health. Santa Barbara, CA: Praeger (ABC-​CLIO). Plantinga, M., Birnie, E., Abbott, K. M., Sinke, R. J., Lucassen, A. M., Schuurmans, J., et al. (2016). Population-​based preconception carrier screening. European Journal of Human Genetics, 24(10), 1417–​1423. Pohjola-​Sintonen, S., Rissanen, A., Liskola, P., & Luomanmäki, K. (1998). Family history as a risk factor of coronary heart disease in patients under 60 years of age. European Heart Journal, 19(2), 235–​239. Pöhls, K., Schlösser, T., & Fetchenhauer, D. (2020). Non-​religious identities and life satisfaction. Journal of Happiness Studies, 21(7), 2327–​2353. Poitras, V. J., Gray, C. E., Borghese, M. M., Carson, V., Chaput, J. P., Janssen, I., et al. (2016). Systematic review of the relationships between objectively measured physical activity and health indicators in school-​aged children and youth. Applied Physiology, Nutrition, and Metabolism, 41(6), S197–​S239. Pokhrel, P., Masagutov, R., Kniazev, V., & Sussman, S. (2012a). Health-​as-​a-​value, spirituality, and cigarette and alcohol use among Russian high school students. Journal of Primary Prevention, 33(5–​6), 239–​248. Pokhrel, P., Sussman, S., Regmi, S., Hallam, J. S., Kniazev, V., & Masagutov, R. (2012b). Spirituality and substance use in a sample of Russian adolescents. International Journal of Adolescent Medicine and Health, 24(2), 149–​152.

Polak, J. F., Pencina, M. J., O’Leary, D. H., & D’Agostino, R. B. (2011). Common carotid artery intima-​media thickness progression as a predictor of stroke in multi-​ethnic study of atherosclerosis. Stroke, 42(11), 3017–​3021. Polderman, T. J., Benyamin, B., De Leeuw, C. A., Sullivan, P. F., Van Bochoven, A., Visscher, P. M., et al. (2015). Meta-​analysis of the heritability of human traits based on fifty years of twin studies. Nature Genetics, 47(7), 702. Polite, B. N., Cipriano‐Steffens, T. M., Hlubocky, F. J., Jean‐Pierre, P., Cheng, Y., Brewer, K. C., et al. (2018). Association of externalizing religious and spiritual beliefs on stage of colon cancer diagnosis among black and white multicenter urban patient populations. Cancer, 124(12), 2578–​2587. Pollner, M. (1989). Divine relations, social relations, and well-​being. Journal of Health and Social Behavior, 30, 92–​104. Poole, R., & Cook, C. C. (2011). Praying with a patient constitutes a breach of professional boundaries in psychiatric practice. British Journal of Psychiatry, 199(2), 94–​98. Poole, R., & Higgo, R. (2010). Psychiatry, religion and spirituality. The Psychiatrist, 34(10), 452–​453. Poole, R., & Higgo, R. (2011). Spirituality and the threat to therapeutic boundaries in psychiatric practice. Mental Health, Religion and Culture, 14(1), 19–​29. Poole, R., Cook, C. C., & Higgo, R. (2019). Psychiatrists, spirituality and religion. British Journal of Psychiatry, 214(4), 181–​182. Poorsheikhali, F., & Alavi, H. R. (2015). Correlation of parents’ religious behavior with family’s emotional relations and students’ self-​ actualization. Journal of Religion and Health, 54(1), 235–​241. Poorthuis, M. H., Algra, A. M., Algra, A., Kappelle, L. J., & Klijn, C. J. (2017). Female-​and male-​ specific risk factors for stroke: a systematic review and meta-​analysis. JAMA Neurology, 74(1), 75–​81. Population Reference Bureau (2020). Children in single-​parent families in the United States. Kids Count Data Center [analysis of data from the US Census Bureau, Census 2000 Supplementary Survey, 2001 Supplementary Survey and 2002 through 2018 American Community Survey]. Retrieved on 9-​21-​2020 from https://​dat​acen​ter. kidsco​unt.org/​data/​tab​les/​106-​child​ren-​in-​sin​ gle-​par​ent-​famil​ies?loc=​1&loct=​1#detai​led/​1/​ any/​false/​37,871,870,573,869,36,868,867,133,3 8/​any/​429,430.

References • 1001

Porter, K. E., Brennan-​Ing, M., Burr, J. A., Dugan, E., & Karpiak, S. E. (2015). Stigma and psychological well-​being among older adults with HIV: the impact of spirituality and integrative health approaches. Gerontologist, 57(2), 219–​228. Portnoff, L., McClintock, C., Lau, E., Choi, S., & Miller, L. (2017). Spirituality cuts in half the relative risk for depression. Spirituality in Clinical Practice, 4(1), 22. Ports, K. A., Holman, D. M., Guinn, A. S., Pampati, S., Dyer, K. E., Merrick, M. T., et al. (2019). Adverse childhood experiences and the presence of cancer risk factors in adulthood. Journal of Pediatric Nursing, 44, 81–​96. Postiglione, A., Milan, G., Pappata, S., De Falco, C., Lamenza, F., Schiattarella, V., et al. (2008). Fronto-​ temporal dementia presenting as Geschwind’s syndrome. Neurocase, 14(3), 264–​270. Poteat, T., & Lassiter, J. M. (2019). Positive religious coping predicts self-​reported HIV medication adherence at baseline and twelve-​month follow-​ up among Black Americans living with HIV in the Southeastern United States. AIDS Care, 19(8), 958–​964. Powdthavee, N., Lekfuangfu, W. N., & Wooden, M. (2015). What’s the good of education on our overall quality of life? Journal of Behavioral and Experimental Economics, 54, 10–​21. Power, E. A. (2017). Social support networks and religiosity in rural South India. Nature Human Behaviour, 1(3), 0057. Power, L., & McKinney, C. (2014). The effects of religiosity on psychopathology in emerging adults. Journal of Religion and Health, 53(5), 1529–​1538. Pozueta, A., Lage, C., García-​Martínez, M., Kazimierczak, M., Bravo, M., López-​García, S., et al. (2019). Cognitive and behavioral profiles of left and right semantic dementia. Journal of Alzheimer’s Disease, 72(4), 1129–​1144. Prakhinkit, S., Suppapitiporn, S., Tanaka, H., & Suksom, D. (2014). Effects of Buddhism walking meditation on depression, functional fitness, and endothelium-​dependent vasodilation in depressed elderly. Journal of Alternative and Complementary Medicine, 20(5), 411–​416. Pramesona, B. A., & Taneepanichskul, S. (2018). The effect of religious intervention on depressive symptoms and quality of life among Indonesian elderly in nursing homes. Clinical Interventions in Aging, 13, 473–​483. Pratt, T. C., McGloin, J. M., & Fearn, N. E. (2006). Maternal cigarette smoking during pregnancy and criminal/​deviant behavior. International

1002 •  R eferences

Journal of Offender Therapy and Comparative Criminology, 50(6), 672–​690. Preau, M., Bouhnik, A. D., & Soriano, A. G. (2013). Two years after cancer diagnosis, what is the relationship between health-​ related quality of life, coping strategies and spirituality? Psychology, Health & Medicine, 18(4), 375–​386. Previti, D., & Amato, P. R. (2004). Is infidelity a cause or a consequence of poor marital quality? Journal of Social and Personal Relationships, 21, 217–​230. Prigge, R., & Jackson, C. A. (2017). The association between depression and subsequent hypertension. Journal of Epidemiology and Community Health, 71(Supp 1), A70–​A71. Primack, B. A., Mah, J., Shensa, A., Rosen, D., Yonas, M. A., & Fine, M. J. (2014). Associations between race, ethnicity, religion, and waterpipe tobacco smoking. Journal of Ethnicity in Substance Abuse, 13(1), 58–​71. Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M. R., et al. (2007). No health without mental health. Lancet, 370(9590), 859–​877. Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia. Alzheimer’s & Dementia, 9(1), 63–​75. Prom-​Wormley, E. C., Ebejer, J., Dick, D. M., & Bowers, M. S. (2017). The genetic epidemiology of substance use disorder. Drug and Alcohol Dependence, 180, 241–​259. Propst, L. R., Ostrom, R., Watkins, P., Dean, T., & Mashburn, D. (1992). Comparative efficacy of religious and nonreligious cognitive-​behavior therapy for the treatment of clinical depression in religious individuals. Journal of Consulting and Clinical Psychology, 60, 94–​103. Provencher, L., Hogue, J. C., Desbiens, C., Poirier, B., Poirier, E., Boudreau, D., et al. (2016). Is clinical breast examination important for breast cancer detection? Current Oncology, 23(4), e332. Prusak, J. (2016). Differential diagnosis of “Religious or Spiritual Problem”: possibilities and limitations implied by the V-​code 62.89 in DSM-​5. Psychiatria Polska, 50(1), 175–​186. Puchalski, C. M., & Larson, D. B. (1998). Developing curricula in spirituality and medicine. Academic Medicine, 73, 970–​974. Puchalski, C. M., Blatt, B., Kogan, M., & Butler, A. (2014a). Spirituality and health: the development of a field. Academic Medicine, 89(1), 10–​16. Puchalski, C. M., Vitillo, R., Hull, S. K., & Reller, N. (2014b). Improving the spiritual dimension

of whole person care: reaching national and international consensus. Journal of Palliative Medicine, 17(6), 642–​656. Puri, M., Tamang, J., & Shah, I. (2011). Suffering in silence: consequences of sexual violence within marriage among young women in Nepal. BMC Public Health, 11(1), 29. Purnell, M. C., Johnson, M. S., Jones, R., Calloway, E. B., Hammond, D. A., Hall, L. A., & Spadaro, D. C. (2019). Spirituality and religiosity of pharmacy students. American Journal of Pharmaceutical Education, 83(1), 6795. Putnam, R (2000). Bowling Alone: The Collapse and Revival of American Community. New York, NY: Simon & Schuster. Puzek, I., Štulhofer, A., & Božičević, I. (2012). Is religiosity a barrier to sexual and reproductive health? Archives of Sexual Behavior, 41(6), 1497–​1505. Puzzanchera, C. (2018). Juvenile arrests, 2018. Office of Juvenile Justice and Delinquency Prevention. Retrieved on 9-​19-​2020 from https://​ojjdp.ojp.gov/​libr​ary/​publi​cati​ons/​juven​ ile-​arre​sts-​2018. Pynoos, R. S., Steinberg, A. M., & Piacentini, J. C. (1999). A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46(11), 1542–​1554. Qin, P. (2011). The impact of psychiatric illness on suicide. Journal of Psychiatric Research, 45(11), 1445–​1452. Qiu, Y., & Li, S. (2008). Stroke: coping strategies and depression among Chinese caregivers of survivors during hospitalisation. Journal of Clinical Nursing, 17(12), 1563–​1573. Quinn, D. A., & Lewin, A. (2020). Family factors associated with emerging adults’ human papillomavirus vaccine behavior. Journal of American College Health, 68(5), 528–​535. Quinones, M. M., Gallegos, A. M., Lin, F. V., & Heffner, K. (2020). Dysregulation of inflammation, neurobiology, and cognitive function in PTSD: an integrative review. Cognitive, Affective, & Behavioral Neuroscience, 20(3), 455–​480. Quoidbach, J., Dunn, E. W., Petrides, K. V., & Mikolajczak, M. (2010). Money giveth, money taketh away: The dual effect of wealth on happiness. Psychological Science, 21(6), 759–​763. Quoidbach, J., Mikolajczak, M., & Gross, J. J. (2015). Positive interventions: an emotion regulation perspective. Psychological Bulletin, 141(3), 655.

Raab, K. A. (2007). Manic depression and religious experience: the use of religion in therapy. Mental Health, Religion & Culture, 10(5), 473–​487. Rabins, P. V., Fitting, M. D., Eastham, J., & Zabora, J. (1990). Emotional adaptation over time in care-​givers for chronically ill elderly people. Age and Ageing, 19, 185–​190. Racine, M. (2018). Chronic pain and suicide risk. Progress in Neuro-​Psychopharmacology and Biological Psychiatry, 87, 269–​280. Radley, J., Morilak, D., Viau, V., & Campeau, S. (2015). Chronic stress and brain plasticity: mechanisms underlying adaptive and maladaptive changes and implications for stress-​related CNS disorders. Neuroscience & Biobehavioral Reviews, 58, 79–​91. Raghavan, R., Ferlic-​Stark, L., Clarke, C., Rungta, M., & Goodgame, R. (2013). The role of patient religiosity in the evaluation and treatment outcomes from chronic HCV infection. Journal of Religion and Health, 52, 79–​90. Raglan, O., Kalliala, I., Markozannes, G., Cividini, S., Gunter, M. J., Nautiyal, J., et al. (2019). Risk factors for endometrial cancer: an umbrella review of the literature. International Journal of Cancer, 145(7), 1719–​1730. Raguram, R., Venkateswaran, A., Ramakrishna, J., & Weiss, M. G. (2002). Traditional community resources for mental health: a report of temple healing from India. British Medical Journal, 325(7354), 38–​40. Rahman, F. (1998). Health and Medicine in the Islamic Tradition. Chicago, IL: ABC International Group. Rahman, M. K., & Ali, M. A. (2018). Impact of religiosity on marital satisfaction in dual career couples. Journal of Gender and Social Issues, 17(1), 33–​44. Rainville, G., & Mehegan, L. (2019). God, purpose in life, and mental well‐being among older adults. Journal for the Scientific Study of Religion, 58(1), 287–​300. Rajagopalan, S., Al-​Kindi, S. G., & Brook, R. D. (2018). Air pollution and cardiovascular disease: JACC state-​of-​the-​art review. Journal of the American College of Cardiology, 72(17), 2054–​2070. Rajan, T. M., & Menon, V. (2017). Psychiatric disorders and obesity: a review of association studies. Journal of Postgraduate Medicine, 63(3), 182. Rajkumar, R. P. (2020). The relationship between measures of religiosity and the prevalence and outcome of COVID-​19. Research Square (https://​ doi.org/​10.21203/​rs.3.rs-​33245/​v1).

References • 1003

Rajpathak, S. N., Liu, Y., Ben‐David, O., Reddy, S., Atzmon, G., Crandall, J., et al. (2011). Lifestyle factors of people with exceptional longevity. Journal of the American Geriatrics Society, 59(8), 1509–​1512. Rakhawy, M. Y., & Hamdi, E. (2010). The attitude and use of faith healing by people with mental disorders in Upper Egypt: a community survey. Arab Journal of Psychiatry, 21(1), 29–​49. Rakrachakarn, V., Moschis, G. P., Ong, F. S., & Shannon, R. (2015). Materialism and life satisfaction: the role of religion. Journal of Religion and Health, 54(2), 413–​426. Ralston, K., Walsh, D., Feng, Z., Dibben, C., McCartney, G., & O’Reilly, D. (2017). Do differences in religious affiliation explain high levels of excess mortality in the UK? Journal of Epidemiology and Community Health, 71(5), 493–​498. Ramchandani, P. G., Psychogiou, L., Vlachos, H., Iles, J., Sethna, V., Netsi, E., et al. (2011). Paternal depression: an examination of its links with father, child and family functioning in the postnatal period. Depression and Anxiety, 28(6), 471–​477. Ramer, L., Johnson, D., Chan, L., & Barrett, M. T. (2006). The effect of HIV/​AIDS disease progression on spirituality and self-​ transcendence in a multicultural population. Journal of Transcultural Nursing, 17(3), 280–​289. Ramirez, S. P., Macêdo, D. S., Sales, P. M., Figueiredo, S. M., Daher, E. F., Araújo, S. M., et al. (2012). The relationship between religious coping, psychological distress and quality of life in hemodialysis patients. Journal of Psychosomatic Research, 72(2), 129–​1 35. Ramondetta, L., Brown, A., Richardson, G., Urbauer, D., Thaker, P. H., Koenig, H. G., et al. (2011). Religious and spiritual beliefs of gynecologic oncologists may influence medical decision making. International Journal of Gynecologic Cancer, 21(3), 573–​581. Ramón-​Jarne, F. J., Jurado, D., Jiménez-​ Fernández, S., Gutiérrez-​Rojas, L., Martínez-​Ortega, J. M., & Gurpegui, M. (2019). Disordered eating behaviors among Christian and Muslim adolescents in Ceuta, a multicultural town. Psychiatry Research, 272, 182–​189. Ramos, K., Erkanli, A., & Koenig, H. G. (2018). Effects of religious versus conventional cognitive–​behavioral therapy (CBT) on suicidal thoughts in major depression and chronic

1004 •  R eferences

medical illness. Psychology of Religion and Spirituality, 10(1), 79–​87. Rangaswamy, T. (2012). Twenty-​f ive years of schizophrenia: the Madras longitudinal study. Indian Journal of Psychiatry, 54(2), 134–​137. Rangaswamy, T., & Greeshma, M. (2012). Course and outcome of schizophrenia. International Review of Psychiatry, 24(5), 417–​422. Ransome, Y., & Gilman, S. E. (2016). The role of religious involvement in black–​w hite differences in alcohol use disorders. Journal of Studies on Alcohol and Drugs, 77(5), 792–​801. Ransome, Y., Perez, A., Strayhorn, S., Gilman, S. E., Williams, D. R., & Krause, N. (2019a). Contextual religiosity and the risk of alcohol use disorders and suicidal thoughts among adults in the United States. Journal of Affective Disorders, 250, 439–​446. Ransome, Y., Mayer, K. H., Tsuyuki, K., Mimiaga, M. J., Rodriguez-​Diaz, C. E., Srithanaviboonchai, K., et al. (2019b). The role of religious service attendance, psychosocial and behavioral determinants of antiretroviral therapy (ART) adherence: results from HPTN 063 cohort study. AIDS and Behavior, 23(2), 459–​474. Rao, A., Hickman, L. D., Phillips, J. L., & Sibbritt, D. (2016). Prevalence and characteristics of Australian women who use prayer or spiritual healing: a nationally representative cross-​ sectional study. Complementary Therapies in Medicine, 27, 35–​42. Rapee, R. M., Peters, L., Carpenter, L., & Gaston, J. E. (2015). The yin and yang of support from significant others: influence of general social support and partner support of avoidance in the context of treatment for social anxiety disorder. Behaviour Research and Therapy, 69, 40–​47. Raposeiras-​Roubín, S., Abu-​Assi, E., & Iñiguez-​ Romo, A. (2017). Tobacco, illicit drugs use and risk of cardiovascular disease in patients living with HIV. Current Opinion in HIV and AIDS, 12(6), 523–​527. Rapsomaniki, E., Timmis, A., George, J., Pujades-​ Rodriguez, M., Shah, A. D., Denaxas, S., et al. (2014). Blood pressure and incidence of twelve cardiovascular diseases. Lancet, 383(9932), 1899–​1911. Rasanen, J., Kauhanen, J., Lakka, T. A., Kaplan, G. A., & Salonen, J. T. (1996). Religious affiliation and all-​cause mortality: A prospective population study in middle-​aged men in eastern

Finland. International Journal of Epidemiology, 26, 1244–​1249. Rasic, D. T., Belik, S. L., Elias, B., Katz, L. Y., Enns, M., & Sareen, J. (2009). Spirituality, religion and suicidal behavior in a nationally representative sample. Journal of Affective Disorders, 114(1–​ 3), 32–​40. Rasic, D., Robinson, J. A., Bolton, J., Bienvenu, O. J., & Sareen, J. (2011a). Longitudinal relationships of religious worship attendance and spirituality with major depression, anxiety disorders, and suicidal ideation and attempts: findings from the Baltimore epidemiologic catchment area study. Journal of Psychiatric Research, 45(6), 848–​854. Rasic, D., Kisely, S., & Langille, D. B. (2011b). Protective associations of importance of religion and frequency of service attendance with depression risk, suicidal behaviours and substance use in adolescents in Nova Scotia, Canada. Journal of Affective Disorders, 132(3), 389–​395. Rasic, D., Asbridge, M., Kisely, S., & Langille, D. (2013). Longitudinal associations of importance of religion and frequency of service attendance with depression risk among adolescents in Nova Scotia. Canadian Journal of Psychiatry, 58(5), 291–​299. Rasinski, K. A., Kalad, Y. G., Yoon, J. D., & Curlin, F. A. (2011). An assessment of US physicians’ training in religion, spirituality, and medicine. Medical Teacher, 33(11), 944–​945. Rasinski, K. A., Lawrence, R. E., Yoon, J. D., & Curlin, F. A. (2012). A sense of calling and primary care physicians’ satisfaction in treating smoking, alcoholism, and obesity. Archives of Internal Medicine, 172(18), 1423–​1424. Rasmussen, P., Johansen, C., Hvidt, N. C., Kørup, A. K., Søndergaard, J., & Thygesen, L. C. (2017). Use of sedatives, antidepressants and antipsychotic medicine among Seventh-​Day Adventists and Baptists in Denmark. Journal of Religion and Health, 56(5), 1553–​1560. Rassoulian, A., Seidman, C., & Löffler-​Stastka, H. (2016). Transcendence, religion and spirituality in medicine: medical students’ points of view. Medicine, 95(38), e4953. Razali, S. M., Hasanah, C. I., Aminah, K., & Subramaniam, M. (1998). Religious-​ sociocultural psychotherapy in patients with anxiety and depression. Australian and New Zealand Journal of Psychiatry, 32(6), 867–​872. Razali, S. M., Aminah, K., & Khan, U. A. (2002). Religious-​cultural psychotherapy in the management of anxiety patients. Transcultural Psychiatry, 39(1), 130–​136.

Rebar, A. L., Stanton, R., Geard, D., Short, C., Duncan, M. J., & Vandelanotte, C. (2015). A meta-​meta-​analysis of the effect of physical activity on depression and anxiety in non-​ clinical adult populations. Health Psychology Review, 9(3), 366–​378. Reddy, K. J., Menon, K. R., & Hunjan, U. G. (2018). Neurobiological aspects of violent and criminal behaviour: deficits in frontal lobe function and neurotransmitters 1. International Journal of Criminal Justice Sciences, 13(1), 44. Reddy, K. K., Rao, A. P., & Reddy, T. P. (2002). Socioeconomic status and the prevalence of coronary heart disease risk factors. Asia Pacific Journal of Clinical Nutrition, 11(2), 98–​103. Redon, J., Olsen, M. H., Cooper, R. S., Zurriaga, O., Martinez-​Beneito, M. A., Laurent, S., et al. (2011). Stroke mortality and trends from 1990 to 2006 in 39 countries from Europe and Central Asia: implications for control of high blood pressure. European Heart Journal, 32(11), 1424–​1431. Reece, A. S., Norman, A., & Hulse, G. K. (2016). Cannabis exposure as an interactive cardiovascular risk factor and accelerant of organismal ageing: a longitudinal study. BMJ Open, 6(11), e011891. Reese, A. M., Thorpe, R. J., Bell, C. N., Bowie, J. V., & LaVeist, T. A. (2012). The effect of religious service attendance on race differences in depression: findings from the EHDIC-​SWB study. Journal of Urban Health, 89(3), 510–​518. Reeve, C. L., & Basalik, D. (2011). A state level investigation of the associations among intellectual capital, religiosity and reproductive health. Intelligence, 39(1), 64–​73. Reeves, R. R., Adams, C. E., Dubbert, P. M., Hickson, D. A., & Wyatt, S. B. (2012). Are religiosity and spirituality associated with obesity among African Americans in the Southeastern United States (the Jackson Heart Study)? Journal of Religion and Health, 51(1), 32–​48. Regenstein, J. M., & Chaudry, M., & Regenstein, C. (2003). The kosher and halal food laws. Comprehensive Reviews in Food Science and Food Safety, 2(3), 111–​127. Regnerus, M. D. (2000). Shaping schooling success: religious socialization and educational outcomes in metropolitan public schools. Journal for the Scientific Study of Religion, 39(3), 363–​370. Regnerus, M. D. (2003a). Moral communities and adolescent delinquency: religious contexts and community social control. Sociological Quarterly, 44(4), 523–​554.

References • 1005

Regnerus, M. D. (2003b). Linked lives, faith, and behavior: intergenerational religious influence on adolescent delinquency. Journal for the Scientific Study of Religion, 42(2), 189–​203. Regnerus, M. D., & Elder, G. H. (2003). Religion and vulnerability among low-​risk adolescents. Social Science Research, 32(4), 633–​658. Rehm, J., Hasan, O. S., Black, S. E., Shield, K. D., & Schwarzinger, M. (2019). Alcohol use and dementia: a systematic scoping review. Alzheimer’s Research & Therapy, 11(1), 1–​11. Rehm, J., & Shield, K. D. (2019). Global burden of disease and the impact of mental and addictive disorders. Current Psychiatry Reports, 21(2), 10. Reichborn-​Kjennerud, T. (2010). The genetic epidemiology of personality disorders. Dialogues in Clinical Neuroscience, 30(4), 893–​910. Reid, N., Moritz, K. M., & Akison, L. K. (2019). Adverse health outcomes associated with fetal alcohol exposure: a systematic review focused on immune-​related outcomes. Pediatric Allergy and Immunology, 30(7), 698–​707. Reif-​Lehrer, L. (2004). Grant Application Writer’s Handbook, 4th ed. Sudbury, MA: Jones and Bartlett. Reilly, J. J., Hughes, A. R., Gillespie, J., Malden, S., & Martin, A. (2019). Physical activity interventions in early life aimed at reducing later risk of obesity and related non-​communicable diseases: a rapid review of systematic reviews. Obesity Reviews, 20, 61–​73. Reimann, M., Qin, N., Gruber, M., Bornstein, S. R., Kirschbaum, C., Ziemssen, T., et al. (2017). Adrenal medullary dysfunction as a feature of obesity. International Journal of Obesity, 41(5), 714–​721. Reiner, M., Niermann, C., Jekauc, D., & Woll, A. (2013). Long-​term health benefits of physical activity—​a systematic review of longitudinal studies. BMC Public Health, 13(1), 813. Reinert, K. G., Campbell, J. C., Bandeen-​Roche, K., Lee, J. W., & Szanton, S. (2016). The role of religious involvement in the relationship between early trauma and health outcomes among adult survivors. Journal of Child & Adolescent Trauma, 9(3), 231–​241. Reinert, K. G., & Koenig, H. G. (2013). Re-​ examining definitions of spirituality in nursing research. Journal of Advanced Nursing 69(12), 2622–​2634. Reinholdsson, M., Palstam, A., & Sunnerhagen, K. S. (2018). Prestroke physical activity could influence acute stroke severity (part of PAPSIGOT). Neurology, 91(16), e1461–​e1467.

1006 •  R eferences

Reisig, M. D., Wolfe, S. E., & Pratt, T. C. (2012). Low self-​control and the religiosity-​crime relationship. Criminal Justice and Behavior, 39(9), 1172–​1191. Reiter, P. L., McRee, A. L., Gottlieb, S. L., & Brewer, N. T. (2010). HPV vaccine for adolescent males: acceptability to parents’ post-​vaccine licensure. Vaccine, 28(38), 6292–​6297. Reitsma, J., Scheepers, P., & Janssen, J. (2007). Convergent and discriminant validity of religiosity measures among church members and non-​members. Personality and Individual Differences, 42(7), 1415–​1426. Religious Freedom Restoration Act (1993). H.R. 1308—​Religious Freedom Restoration Act of 1993. Retrieved on 10-​11-​2020 from https://​ www.congr​ess.gov/​bill/​103rd-​congr​ess/​house-​ bill/​1308. Rémy, V., Zöllner, Y., & Heckmann, U. (2015). Vaccination: the cornerstone of an efficient healthcare system. Journal of Market Access & Health Policy, 3(1), 27041. Renna, M. E., O’Toole, M. S., Spaeth, P. E., Lekander, M., & Mennin, D. S. (2018). The association between anxiety, traumatic stress, and obsessive-​compulsive disorders and chronic inflammation. Depression and Anxiety, 35(11), 1081–​1094. Rentería, E., Jha, P., Forman, D., & Soerjomataram, I. (2016). The impact of cigarette smoking on life expectancy between 1980 and 2010: a global perspective. Tobacco Control, 25(5), 551–​557. Rentscher, K. E., Carroll, J. E., & Mitchell, C. (2020). Psychosocial stressors and telomere length. Annual Review of Public Health, 41, 223–​245. Renzetti, C. M., DeWall, C. N., Messer, A., & Pond, R. (2017). By the grace of God: religiosity, religious self-​regulation, and perpetration of intimate partner violence. Journal of Family Issues, 38(14), 1974–​1997. Repalust, A., Šević, S., Rihtar, S., & Štulhofer, A. (2017). Childhood vaccine refusal and hesitancy intentions in Croatia. Psychology, Health & Medicine, 22(9), 1045–​1055. Resnick, J. H. (2006). Long life through church? The effect of religious attendance on mortality. Paper presented at the annual meeting of the American Sociological Association, Montreal Convention Center, Montreal, Quebec, Canada, 8-​8-​2006. Retrieved on 8-​26-​2018 from http://​ citat​ion.alla​cade​mic.com/​.meta/​p_​ml​a_​ap​a_​re​ sear​ch_​ci​ tat​ion/​1/​0/​4/​9/​2/​page​s104​926/​p104​ 926-​1.php. Resnicow, K., Jackson, A., Blissett, D., Wang, T., McCarty, F., Rahotep, S., et al. (2005). Results

of the Healthy Body Healthy Spirit Trial. Health Psychology, 24(4), 339–​348. Reuben, D. B., Keeler, E., Seeman, T. E., Sewall, A., Hirsch, S. H., Guralnik, J. M., et al. (2002). Development of a method to identify seniors at high risk for high hospital utilization. Medical Care, 40(9), 782–​793. Rew, L., Arheart, K. L., Thompson, S., & Johnson, K. (2013). Predictors of adolescents’ health‐ promoting behaviors guided by primary socialization theory. Journal for Specialists in Pediatric Nursing, 18(4), 277–​288. Reyes-​Ortiz, C. A., Ayele, H., Mulligan, T., Espino, D. V., Berges, I. M., & Markides, K. S. (2006). Higher church attendance predicts lower fear of falling in older Mexican-​Americans. Aging and Mental Health, 10(1), 13–​18. Reyes-​Ortiz, C. A., Pelaez, M., Koenig, H. G., & Mulligan, T. (2007). Religiosity and self-​rated health among Latin American and Caribbean elders. International Journal of Psychiatry in Medicine, 37(4), 425–​443. Reyes-​Ortiz, C. A., Berges, I. M., Raji, M. A., Koenig, H. G., Kuo, Y. F., Markides, K. S., et al. (2008). Church attendance mediates the association between depressive symptoms and cognitive functioning among older Mexican Americans. Journals of Gerontology, 63A(5), M480–​486. Reynolds, D. (2014). Religiosity and parental acceptance of human papillomavirus (HPV) vaccine in 9–​18 year-​old girls. Journal of Christian Nursing, 31(3), 172–​177. Reynolds, N., Mrug, S., Britton, L., Guion, K., Wolfe, K., & Gutierrez, H. (2014a). Spiritual coping predicts 5-​year health outcomes in adolescents with cystic fibrosis. Journal of Cystic Fibrosis, 13(5), 593–​600. Reynolds, N., Mrug, S., Hensler, M., Guion, K., & Madan-​Swain, A. (2014b). Spiritual coping and adjustment in adolescents with chronic illness: a 2-​year prospective study. Journal of Pediatric Psychology, 39(5), 542–​551. Reynolds, P., & Kaplan, G. A. (1990). Social connections and risk for cancer: prospective evidence from the Alameda County Study. Behavioral Medicine, 16(3), 101–​110. Rezapour, Y., Rezai, H., Hosseini, S. A., Takalu, M., & Taghi, M. (2016). The role of faith in work, religious beliefs, and spirituality in the prediction of job satisfaction among rehabilitation experts. Iranian Rehabilitation Journal, 14(4), 217–​222. Rezende-​Pinto, A., Moreira-​Almeida, A., Ribeiro, M., Laranjeira, R., & Vallada, H. (2018). The effect of religiosity during childhood and

adolescence on drug consumption patterns in adults addicted to crack cocaine. BJPsych Open, 4(5), 324–​331. Rhee, S. H., & Waldman, I. D. (2002). Genetic and environmental influences on antisocial behavior: a meta-​analysis of twin and adoption studies. Psychological Bulletin, 128(3), 490–​529. Rhoades, G. K., Stanley, S. M., Markman, H. J. (2006). Pre-​engagement cohabitation and gender asymmetry in marital commitment. Journal of Family Psychology, 20(4), 553–​560. Rhodes, A. L., & Reiss, A. J. (1970). The “religious factor” and delinquent behavior. Journal of Research in Crime & Delinquency, 7, 83–​98. Ribeiro, C. C., Yassuda, M. S., & Neri, A. L. (2020). Purpose in life in adulthood and older adulthood: integrative review. Ciência & Saúde Coletiva, 25, 2127–​2142. Rich, T. (1996). Judaism 101: Jewish attitudes toward divorce. Retrieved on 10-​18-​2019 from http://​www.jew​faq.org/​divo​rce.htm. Richards, P. S., Berrett, M. E., Hardman, R. K., & Eggett, D. L. (2006). Comparative efficacy of spirituality, cognitive, and emotional support groups for treating eating disorder inpatients. Eating Disorders, 14(5), 401–​415. Richardson, M., Cobham, V., McDermott, B., & Murray, J. (2013). Youth mental illness and the family: parents’ loss and grief. Journal of Child and Family Studies, 22(5), 719–​736. Rico-​Uribe, L. A., Caballero, F. F., Martín-​María, N., Cabello, M., Ayuso-​Mateos, J. L., et al. (2018). Association of loneliness with all-​cause mortality: a meta-​analysis. PloS One, 13(1), e0190033. Ridge, P. G., Mukherjee, S., Crane, P. K., Kauwe, J. S., & Consortium, ASDG (2013). Alzheimer’s disease: analyzing the missing heritability. PloS One, 8(11). Ridley, N. J., Draper, B., & Withall, A. (2013). Alcohol-​related dementia: an update of the evidence. Alzheimer’s Research & Therapy, 5(1), 3. Rigotti, N. A. (2012). Strategies to help a smoker who is struggling to quit. Journal of the American Medical Association, 308(15), 1573–​1580. Ringdal, G. (1996). Religiosity, quality of life and survival in cancer patients. Social Indicators Research, 38, 193–​211. Ringdal, G., Gotestam, K., Kaasa, S., Kvinnslaud, S., & Ringdal, K. (1995). Prognostic factors and survival in a heterogeneous sample of cancer patients. British Journal of Cancer, 73, 1594–​1599. Ripke, S., Neale, B. M., Corvin, A., Walters, J. T., Farh, K. H., Holmans, P. A., et al. (2014).

References • 1007

Biological insights from 108 schizophrenia-​ associated genetic loci. Nature, 511(7510), 421–​427. Ritchie, H., & Roser, M. (2018). Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2017. Institute for Health Metrics and Evaluation (IHME). Retrieved on 11-​23-​2020 from https://​our​worl​dind​ata.org/​ men​tal-​hea​lth. Ritter, R. S., Preston, J. L., & Hernandez, I. (2014). Happy tweets: Christians are happier, more socially connected, and less analytical than atheists on Twitter. Social Psychological and Personality Science, 5(2), 243–​249. Rivera-​Hernandez, M. (2016). Religiosity, social support and care associated with health in older Mexicans with diabetes. Journal of Religion and Health, 55(4), 1394–​1410. Robbins, P. A., Scott, M. J., Conde, E., Daniel, Y., Darity, W. A., & Bentley-​Edwards, K. L. (2021). Denominational and gender differences in hypertension among African American Christian young adults. Journal of Racial and Ethnic Health Disparities, 8(5), 1332–​1343. Robert, T. E., Young, J., & Kelly, V. A. (2006). Relationships between adult workers’ spiritual well-​being and job satisfaction: a preliminary study. Counseling and Values, 50(3), 165–​175. Robert-​McComb, J. J., Tacon, A., Randolph, P., Caldera, Y. (2004). A pilot study to examine the effects of a mindfulness-​based stress-​reduction and relaxation program on levels of stress hormones, physical functioning, and submaximal exercise responses. Journal of Alternative & Complementary Medicine, 10(5), 819–​827. Roberts, B. W., Luo, J., Briley, D. A., Chow, P. I., Su, R., & Hill, P. L. (2017). A systematic review of personality trait change through intervention. Psychological Bulletin, 143(2), 117–​141. Roberts, R., & Knopman, D. S. (2013). Classification and epidemiology of MCI. Clinics in Geriatric Medicine, 29(4), 753–​772. Roberts, S., Henry, J. D., & Molenberghs, P. (2019). Immoral behaviour following brain damage: a review. Journal of Neuropsychology, 13(3), 564–​588. Robins, J. M., Hernan, M. A., & Brumback, B. (2000). Marginal structural models and causal inference in epidemiology. Epidemiology, 11, 550–​560. Robinson, J. A., Bolton, J. M., Rasic, D., & Sareen, J. (2012). Exploring the relationship between religious service attendance, mental disorders, and suicidality among different ethnic

1008 •  R eferences

groups: results from a nationally representative survey. Depression and Anxiety, 29(11), 983–​990. Robinson, K. A., Cheng, M. R., Hansen, P. D., & Gray, R. J. (2017). Religious and spiritual beliefs of physicians. Journal of Religion and Health, 56(1), 205–​225. Robinson, R., Lahti-​Pulkkinen, M., Heinonen, K., Reynolds, R. M., & Räikkönen, K. (2019). Fetal programming of neuropsychiatric disorders by maternal pregnancy depression. Pediatric Research, 85(2), 134–​145. Rodgers, J., Valuev, A. V., Hswen, Y., & Subramanian, S. V. (2019). Social capital and physical health: an updated review of the literature for 2007–​2018. Social Science & Medicine, 236, 112360. Rodin, D., Balboni, M., Mitchell, C., Smith, P. T., VanderWeele, T. J., & Balboni, T. A. (2015). Whose role? Oncology practitioners’ perceptions of their role in providing spiritual care to advanced cancer patients. Supportive Care in Cancer, 23(9), 2543–​2550. Rodriguez, L. M., Neighbors, C., & Foster, D. W. (2014). Priming effects of self-​reported drinking and religiosity. Psychology of Addictive Behaviors, 28(1), 1–​9. Rodríguez-​Martín, B. C., & Gallego-​Arjiz, B. (2018). Overeaters Anonymous: a mutual-​help fellowship for food addiction recovery. Frontiers in Psychology, 9, 1491. Rodríguez-​Monforte, M., Sánchez, E., Barrio, F., Costa, B., & Flores-​Mateo, G. (2017). Metabolic syndrome and dietary patterns: a systematic review and meta-​analysis of observational studies. European Journal of Nutrition, 56(3), 925–​947. Roelofs, K., van Peer, J., Berretty, E., de Jong, P., Spinhoven, P., & Elzinga, B. M. (2009). Hypothalamus–​pituitary–​adrenal axis hyperresponsiveness is associated with increased social avoidance behavior in social phobia. Biological Psychiatry, 65(4), 336–​343. Roest, A. M., Martens, E. J., de Jonge, P., & Denollet, J. (2010). Anxiety and risk of incident coronary heart disease: a meta-​analysis. Journal of the American College of Cardiology, 56(1), 38–​46. Rogers, N. T., Power, C., & Pinto Pereira, S. M. (2020). Birthweight, lifetime obesity and physical functioning in mid-​adulthood. International Journal of Epidemiology, 49(2), 657–​665. Rogers, R. G. (1996). The effects of family composition, health, and social support linkages

on mortality. Journal of Health and Social Behavior, 37, 326–​338. Rogers-​Sirin, L., Yanar, C., Yüksekbaş, D., Senturk, M. I., & Sirin, S. (2017). Religiosity, cultural values, and attitudes toward seeking psychological services in Turkey. Journal of Cross-​Cultural Psychology, 48(10), 1587–​1604. Roh, S., Kim, Y., Lee, K. H., Lee, Y. S., Burnette, C. E., & Lawler, M. J. (2015). Religion, social support, and life satisfaction among American Indian older adults. Journal of Religion & Spirituality in Social Work, 34(4), 414–​434. Rohani, C., Abedi, H. A., Omranipour, R., & Langius-​Eklöf, A. (2015). Health-​related quality of life and the predictive role of sense of coherence, spirituality and religious coping in a sample of Iranian women with breast cancer. Health and Quality of Life Outcomes, 13(1), 40. Rohleder, N. (2019). Stress and inflammation-​ the need to address the gap in the transition between acute and chronic stress effects. Psychoneuroendocrinology, 105, 164–​171. Rohleder, N., Chen, E., Wolf, J. M., & Miller, G. E. (2008). The psychobiology of trait shame in young women: extending the social self-​ preservation theory. Health Psychology, 27(5), 523–​532. Rohrer, J. E., Kruse, G., Borders, T., & Kupersmith, J. (2003). Realized access to physician services among the elderly in West Texas. Journal of Rural Health, 19(1), 72–​78. Rojas-​Osornio, S. A., Cruz-​Hernández, T. R., Drago-​ Serrano, M. E., & Campos-​Rodríguez, R. (2019). Immunity to influenza: impact of obesity. Obesity Research & Clinical Practice, 13(5), 419–​429. Rondó, P. H. C., Lemos, J. O., Pereira, J. A., & Souza, J. M. (2010). The relationship between cortisol concentrations in pregnancy and systemic vascular resistance in childhood. Early Human Development, 86(2), 127–​131. Ronneberg, C. R., Miller, E. A., Dugan, E., & Porell, F. (2014). The protective effects of religiosity on depression: a 2-​year prospective study. Gerontologist, 56(3), 421–​431. Rook, K. S., & Charles, S. T. (2017). Close social ties and health in later life: strengths and vulnerabilities. American Psychologist, 72(6), 567. Rosato, V., Temple, N. J., La Vecchia, C., Castellan, G., Tavani, A., & Guercio, V. (2019). Mediterranean diet and cardiovascular disease: a systematic review and meta-​analysis of observational studies. European Journal of Nutrition, 58(1), 173–​191.

Rose, A. H., Anderson, S., Miller, R., Marks, L., Hatch, T., & Card, N. (2018). Longitudinal test of forgiveness and perceived forgiveness as mediators between religiosity and marital satisfaction in long-​term marital relationships. American Journal of Family Therapy, 46(4), 356–​374. Rose, A. H., Anderson, S., Miller, R., Marks, L., Hatch, T., & Card, N. (2021). A dyadic exploration of marital satisfaction as a mediator between religiosity and depressive symptoms. Marriage & Family Review, 57(3), 243–​266. Rose, T., Shields, J., Tueller, S., & Larson, S. (2015). Religiosity and behavioral health outcomes of adolescents living in disaster-​ vulnerable areas. Journal of Religion and Health, 54(2), 480–​494. Rose, T., Hope, M. O., Thurman, D., Forrester, P., & Rose, R. (2020). Nonorganizational religious involvement and psychosocial well-​being among African American and Caribbean Black youth. Journal of Black Psychology, 46(5), 388–​422. Rosenbaum, E., & Kandel, D. B. (1990). Early onset of adolescent sexual behavior and drug involvement. Journal of Marriage and the Family, 52, 783–​798. Rosenfeld, M. J., & Roesler, K. (2019a). Cohabitation experience and cohabitation’s association with marital dissolution. Journal of Marriage and Family, 81(1), 42–​58. Rosenfeld, M. J., & Roesler, K. (2019b). Stability and change in predictors of marital dissolution in the US 1950–​2015: The rise of family inequality. Presented at the American Sociological Association Meeting, New York, NY, August. Retrieved on 10-​18-​2019 from https://​ web.stanf​ord.edu/​~mrose​nfe/​Rosenfeld_​and​_​ Roe​sler​_​div​orce​_​ine​qual​ity.pdf. Rosenfeld, R., & Lopez, E. (2020). Pandemic, social unrest, and crime in US Cities. Washington DC: Counsel on Criminal Justice. Retrieved on 9-​19-​2020 from https://​cdn.ymaws.com/​coun​ cilo​ncj.org/​resou​rce/​col​lect​ion/​D2697​4EF-​0F75-​ 4BDE-​ADE7-​86DA0​741D​C49/​Imp​act_​Repo​rt_​-​_​ Cr​ime.pdf. Rosenfeld, R., Vogel, M., & McCuddy, T. (2019). Crime and inflation in US cities. Journal of Quantitative Criminology, 35(1), 195–​210. Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4), 328–​335. Rosmarin, D. H., Pargament, K. I., Krumrei, E. J., & Flannelly, K. J. (2009). Religious coping among Jews: development and initial validation of the

References • 1009

JCOPE. Journal of Clinical Psychology, 65(7), 670–​683. Rosmarin, D. H., Pargament, K. I., Pirutinsky, S., & Mahoney, A. (2010). A randomized controlled evaluation of a spiritually integrated treatment for subclinical anxiety in the Jewish community, delivered via the Internet. Journal of Anxiety Disorders, 24(7), 799–​808. Rosmarin, D. H., Pirutinsky, S., & Pargament, K. I. (2011a). A brief measure of core religious beliefs for use in psychiatric settings. International Journal of Psychiatry in Medicine, 41(3), 253–​261. Rosmarin, D. H., Pirutinsky, S., Auerbach, R. P., Björgvinsson, T., Bigda‐Peyton, J., Andersson, G., et al. (2011b). Incorporating spiritual beliefs into a cognitive model of worry. Journal of Clinical Psychology, 67(7), 691–​700. Rosmarin, D. H., Pirutinsky, S., Cohen, A. B., Galler, Y., & Krumrei, E. J. (2011c). Grateful to God or just plain grateful? A comparison of religious and general gratitude. Journal of Positive Psychology, 6(5), 389–​396. Rosmarin, D. H., Bigda-​Peyton, J. S., Öngur, D., Pargament, K. I., & Björgvinsson, T. (2013a). Religious coping among psychotic patients: relevance to suicidality and treatment outcomes. Psychiatry Research, 210(1), 182–​187. Rosmarin, D. H., Bigda-​Peyton, J. S., Kertz, S. J., Smith, N., Rauch, S. L., & Björgvinsson, T. (2013b). A test of faith in God and treatment: The relationship of belief in God to psychiatric treatment outcomes. Journal of Affective Disorders, 146(3), 441–​446. Rosmarin, D. H., Green, D., Pirutinsky, S., & McKay, D. (2013c). Attitudes toward spirituality/​ religion among members of the Association for Behavioral and Cognitive Therapies. Professional Psychology: Research and Practice, 44(6), 424–​433. Rosmarin, D. H., Forester, B. P., Shassian, D. M., Webb, C. A., & Björgvinsson, T. (2015). Interest in spiritually integrated psychotherapy among acute psychiatric patients. Journal of Consulting and Clinical Psychology, 83(6), 1149–​1153. Rosmarin, D. H., Forester, B. P., & Bjorgvinsson, T. (2016). Spirituality and religion: Initiating a discussion with patients. Psychiatric Services, 67(3), 359. Rosmarin, D. H., Pirutinsky, S., Appel, M., Kaplan, T., & Pelcovitz, D. (2018). Childhood sexual abuse, mental health, and religion across the Jewish community. Child Abuse & Neglect, 81, 21–​28. Ross, E. J., Graham, D. L., Money, K. M., & Stanwood, G. D. (2015). Developmental

1010 •  R eferences

consequences of fetal exposure to drugs: what we know and what we still must learn. Neuropsychopharmacology, 40(1), 61. Ross, J. C., Sutfin, E. L., Suerken, C., Walker, S., Wolfson, M., & Reboussin, B. (2020). Longitudinal associations between marijuana and cigar use in young adults. Drug and Alcohol Dependence, 211, 107964. Ross, L., McSherry, W., Giske, T., van Leeuwen, R., Schep-​Akkerman, A., Koslander, T., et al. (2018). Nursing and midwifery students’ perceptions of spirituality, spiritual care, and spiritual care competency: a prospective, longitudinal, correlational European study. Nurse Education Today, 67, 64–​71. Ross, L. E., Hall, I., Fairley, T., Taylor, Y., & Howard, D. (2008). Prayer and self-​reported health among cancer survivors in the United States, National Health Interview Survey, 2002. Journal of Alternative and Complementary Medicine, 14(8), 931–​938. Rossi, B. M., Ferreira, F. O., & Toporcov, T. N. (2019). Red and processed meat consumption and cancer risk. In Ong, T. P., & Moreno, F. S. (eds.), Nutrition and Cancer Prevention. London: Royal Society of Chemistry, pp. 97–​107. Rossi, G. P., Ceolotto, G., Caroccia, B., & Lenzini, L. (2017). Genetic screening in arterial hypertension. Nature Reviews Endocrinology, 13(5), 289. Rostosky, S. S., Regnerus, M. D., & Wright, M. (2003). Coital debut: the role of religiosity and sex attitudes in the Add Health Survey. Journal of Sex Research, 40(4), 358–​367. Rostosky, S. S., Danner, F., & Riggle, E. D. (2010). Religiosity as a protective factor against heavy episodic drinking (HED) in heterosexual, bisexual, gay, and lesbian young adults. Journal of Homosexuality, 57(8), 1039–​1050. Rote, S., Hill, T. D., & Ellison, C. G. (2012). Religious attendance and loneliness in later life. Gerontologist, 53(1), 39–​50. Roth, G. A., Johnson, C., Abajobir, A., Abd-​Allah, F., Abera, S. F., Abyu, G., et al. (2017). Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. Journal of the American College of Cardiology, 70(1), 1–​25. Rothblum, E. D. (2018). Slim chance for permanent weight loss. Archives of Scientific Psychology, 6(1), 63–​69. Rothman, K. J., Greenland, S., & Lash, T. L. (eds.). (2008). Modern Epidemiology. Philadelphia, PA: Lippincott Williams & Wilkins. Rouholamini, M., Kalantarkousheh, S. M., & Sharifi, E. (2017). Effectiveness of spiritual components

training on life satisfaction of Persian orphan adolescents. Journal of Religion and Health, 56(6), 1895–​1902. Rounding, K., Lee, A., Jacobson, J. A., & Ji, L. J. (2012). Religion replenishes self-​control. Psychological Science, 23(6), 635–​642. Rousset-​Jablonski, C., & Gompel, A. (2017). Screening for familial cancer risk: focus on breast cancer. Maturitas, 105, 69–​77. Roved, J., Westerdahl, H., & Hasselquist, D. (2017). Sex differences in immune responses. Hormones and Behavior, 88, 95–​105. Rowatt, W. C., & Kirkpatrick, L. (2002). Two dimensions of attachment to God and their relation to affect, religiosity, and personality constructs. Journal for the Scientific Study of Religion, 41(4), 637–​651. Roy, R. (1985). Engel’s pain-​prone disorder patient: 25 years after. Psychotherapy and Psychosomatics, 43(3), 126–​135. Rozanski, A., Blumenthal, J. A., & Kaplan, J. (1999). Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation, 99(16), 2192–​2217. Rozanski, A., Bavishi, C., Kubzansky, L. D., & Cohen, R. (2019). Association of optimism with cardiovascular events and all-​cause mortality. JAMA Network Open, 2(9), e1912200–​e1912200. Rozenfeld, Y., Beam, J., Maier, H., Haggerson, W., Boudreau, K., Carlson, J., et al. (2020). A model of disparities: risk factors associated with COVID-​19 infection. International Journal for Equity in Health, 19(1), 1–​10. RPHC (2022). About Us. Retrieved on 7-​22-​22 from http://​www.rphcem​ory.org/​about-​us/​. Rubin, R. (2019). Task force to prevent veteran suicides. Journal of the American Medical Association, 322(4), 295. Rudolph, L., Caplan, J., Ben-​Moshe, K., & Dillon, L. (2013). Health in All Policies: A Guide for State and Local Governments. Washington, DC: American Public Health Association. Ruijs, W. L., Hautvast, J. L., van der Velden, K., de Vos, S., Knippenberg, H., & Hulscher, M. E. (2011). Religious subgroups influencing vaccination coverage in the Dutch Bible belt: an ecological study. BMC Public Health, 11(1), 102. Ruiz, A. L., & Acevedo, G. A. (2015). True believers? Religion, physiology, and perceived body weight in Texas. Journal of Religion and Health, 54(4), 1221–​1237. Ruiz, J. M., Hamann, H. A., Mehl, M. R., & O’Connor, M. F. (2016). The Hispanic health paradox: from epidemiological phenomenon to

contribution opportunities for psychological science. Group Processes & Intergroup Relations, 19(4), 462–​476. Russ, T. C., Stamatakis, E., Hamer, M., Starr, J. M., Kivimäki, M., & Batty, G. D. (2012). Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies. British Medical Journal, 345, e4933. Russell, C. (2016). Religion in the classroom: how other countries in the EU deal with it. TheJournal.ie. Retrieved on 10-​3-​2020 from https://​www.the​jour​nal.ie/​relig​ion-​classr​ oom-​eu-​examp​les-​prim​ary-​div​estm​ent-​2887​ 905-​Aug2​016/​. Russo, N. R., & Dabul, A. J. (1997). The relationship of abortion to well-​being: do race and religion make a difference? Professional Psychology: Research and Practice, 28, 23–​31. Ruttle, P. L., Javaras, K. N., Klein, M. H., Armstrong, J. M., Burk, L. R., & Essex, M. J. (2013). Concurrent and longitudinal associations between diurnal cortisol and body mass index across adolescence. Journal of Adolescent Health, 52(6), 731–​737. Rye, M. S., & Pargament, K. I. (2002). Forgiveness and romantic relationships in college: can it heal the wounded heart? Journal of Clinical Psychology, 58(4), 419–​441. Rye, M. S., Pargament, K. I., Ali, M. A., Beck, G. L., Dorff, E. N., Hallisey, C., et al. (2000). Religious perspectives on forgiveness. In McCullough, M. E., Pargament, K. I., & Thoresen, C. E. (eds.), Forgiveness: Theory, Research, and Practice. New York, NY: Guilford Press, pp. 17–​40. Rye, M. S., Pargament, K. I., Pan, W., Yingling, D. W., Shogren, K. A., & Ito, M. (2005). Can group interventions facilitate forgiveness of an ex-​ spouse? A randomized clinical trial. Journal of Consulting & Clinical Psychology, 73(5), 880–​892. Sá, K. N., Moreira, L., Baptista, A. F., Yeng, L. T., Teixeira, M. J., Galhardoni, R., et al. (2019). Prevalence of chronic pain in developing countries: systematic review and meta-​analysis. Pain Reports, 4(6), e779. Saavedra-​Rodríguez, L., & Feig, L. A. (2013). Chronic social instability induces anxiety and defective social interactions across generations. Biological Psychiatry, 73(1), 44–​53. Sacks, O. (1985). The Man Who Mistook His Wife for a Hat. New York, NY: Simon & Schuster. Sadeghi, M., Ghaderijavid, S., & Shalani, B. (2019). Prediction of marital commitment based on personality traits, attachment styles, and

References • 1011

religious orientation in married students. Journal of Research on Religion & Health, 5(3), 18–​31. Sadigh, G., Dempsey, A. F., Ruffin, M., Resnicow, K., & Carlos, R. C. (2012). National patterns in human papillomavirus vaccination. Human Vaccines & Immunotherapeutics, 8(2), 234–​242. Saeaib, N., Sriplung, H., Pichatechaiyoot, A., & Bilheem, S. (2019). Trends in incidence of uterine cancer in Songkhla, Southern Thailand. Journal of Gynecologic Oncology, 30(2), e22. Saeed, O., Malik, A. A., & Qureshi, A. I. (2018). Abstract TP207: the effect of religion on risk of incident cardiovascular events in post-​ menopausal women. Stroke, 49(Supp 1), ATP207–​ATP207. Saffari, M., Lin, C. Y., Chen, H., & Pakpour, A. H. (2019). The role of religious coping and social support on medication adherence and quality of life among the elderly with type 2 diabetes. Quality of Life Research, 28(8), 2183–​2 193. Sahin, I., & Unlu, A. (2021). The effect of Muslim religiosity on youth delinquency. Criminal Justice Review, 46(3), 361–​381. Şahin, Z. A., & Kardaş Özdemir, F. (2016). Spirituality and spiritual care: a descriptive survey of nursing practices in Turkey. Contemporary Nurse, 52(4), 454–​461. Sahmeddini, M. A., Zamani Lari, M., Nabi Rahimian, M., Danaei, L., Beigi, N., & Habibi, H. (2014). The effect of listening to the Quran on serum cortisol levels and anxiety in primiparous women during the first stage of labor. Iranian Journal of Obstetrics, Gynecology and Infertility, 17(99), 1–​7. Saint Onge, J. M., & Krueger, P. M. (2017). Health lifestyle behaviors among US adults. Social Sciences in Medicine-​Population Health, 3, 89–​98. Saint-​Jean, G., Martinez, C. A., & Crandall, L. A. (2008). Psychosocial mediators of the impact of acculturation on adolescent substance abuse. Journal of Immigrant & Minority Health, 10(2), 187–​195. Saito, I., Yamagishi, K., Kokubo, Y., Yatsuya, H., Iso, H., Sawada, N., et al. (2019). Non-​high-​ density lipoprotein cholesterol and risk of stroke subtypes and coronary heart disease. Journal of Atherosclerosis and Thrombosis, 27(4), 1–​12. Sajadi, M., Niazi, N., Khosravi, S., Yaghobi, A., Rezaei, M., & Koenig, H. G. (2018). Effect of spiritual counseling on spiritual well-​being in Iranian women with cancer: A randomized clinical trial. Complementary Therapies in Clinical Practice, 30, 79–​84.

1012 •  R eferences

Salander, P. (2006). Who needs the concept of “spirituality”? Psycho-​Oncology, 15(7), 647–​649. Salander, P. (2012). The emperor’s new clothes: spirituality. A concept based on questionable ontology and circular findings. Archive for the Psychology of Religion, 34(1), 17–​32. Salas-​Wright, C. P., Vaughn, M., Hodge, D. R., & Perron, B. (2012). Religiosity profiles of American youth in relation to substance use, violence, and delinquency. Journal of Youth and Adolescence, 41(12), 1560–​1575. Salas-​Wright, C. P., Vaughn, M., & Maynard, B. (2014a). Buffering effects of religiosity on crime: Testing the invariance hypothesis across gender and developmental period. Criminal Justice and Behavior, 41(6), 673–​691. Salas-​Wright, C. P., Vaughn, M., & Maynard, B. (2014b). Religiosity and violence among adolescents in the United States: findings from the National Survey on Drug Use and Health 2006–​2010. Journal of Interpersonal Violence, 29(7), 1178–​1200. Salas-​Wright, C. P., Vaughn, M., & Maynard, B. (2015). Profiles of religiosity and their association with risk behavior among emerging adults in the United States. Emerging Adulthood, 3(2), 67–​84. Salas-​Wright, C. P., Vaughn, M., Maynard, B., Clark, T., & Snyder, S. (2017). Public or private religiosity: which is protective for adolescent substance use and by what pathways? Youth & Society, 49(2), 228–​253. Saleem, S., & Saleem, T. (2017). Role of religiosity in psychological well-​being among medical and non-​medical students. Journal of Religion and Health, 56(4), 1180–​1190. Salgado, H., Haviland, I., Hernandez, M., Lozano, D., Osoria, R., Keyes, D., et al. (2014). Perceived discrimination and religiosity as potential mediating factors between migration and depressive symptoms: a transnational study of an indigenous Mayan population. Journal of Immigrant and Minority Health, 16(3), 340–​347. Salicru, A. N., Sams, C. F., & Marshall, G. D. (2007). Cooperative effects of corticosteroids and catecholamines upon immune deviation of the type-​1/​type-​2 cytokine balance in favor of type-​2 expression in human peripheral blood mononuclear cells. Brain, Behavior, and Immunity, 21(7), 913–​920. Salinas, J., Beiser, A., Himali, J. J., Satizabal, C. L., Aparicio, H. J., Weinstein, G., et al. 2017). Associations between social relationship measures, serum brain-​derived neurotrophic

factor, and risk of stroke and dementia. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 3(2), 229–​237. Salmoirago-​Blotcher, E., Fitchett, G., Ockene, J. K., Schnall, E., Crawford, S., Granek, I., et al. (2011). Religion and healthy lifestyle behaviors among postmenopausal women: the Women’s Health Initiative. Journal of Behavioral Medicine, 34(5), 360–​371. Salmoirago-​Blotcher, E., Fitchett, G., Hovey, K., Schnall, E., Thomson, C., Andrews, C., et al. (2013). Frequency of private spiritual activity and cardiovascular risk in postmenopausal women: The Women’s Health Initiative. Annals of Epidemiology, 23, 239–​245. Salmoirago-​Blotcher, E., Fitchett, G., Leung, K., Volturo, G., Boudreaux, E., Crawford, S., et al. (2016). An exploration of the role of religion/​ spirituality in the promotion of physicians’ wellbeing in Emergency Medicine. Preventive Medicine Reports, 3, 189–​195. Salmon, D. A., Haber, M., Gangarosa, E. J., Phillips, L., Smith, N. J., & Chen, R. T. (1999). Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles. Journal of the American Medical Association, 282, 47–​53. Salsman, J. M., Pustejovsky, J. E., Jim, H. S., Munoz, A. R., Merluzzi, T. V., George, L., et al. (2015). A meta‐analytic approach to examining the correlation between religion/​spirituality and mental health in cancer. Cancer, 121(21), 3769–​3778. Salti, I., Benard, E., Detournay, B., Bianchi-​Biscay, M., Le Brigand, C., Voinet, C., et al. (2004). A population-​based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries. Diabetes Care, 27(10), 2306–​2311. Sameem, S., & Buryi, P. (2019). Impact of unemployment on happiness in the United States. Applied Economics Letters, 26(12), 1049–​1052. Samsudin, A., Yahya, N., Wan Mat, W. R., Masdar, A., Liu, C., & Izaham, A. (2019). Listening to Islamic praises (Dzikr) is more effective in reducing perioperative anxiety levels when compared to nature-​based sounds in Muslim patients undergoing surgery under regional anaesthesia. International Medical Journal Malaysia, 18(3), 31–​39. Samuel-​Hodge, C. D., Headen, S. W., Skelly, A. H., Ingram, A. F., Keyserling, T. C., Jackson, E. J., et al. (2000). Influences on day-​to-​day self-​management of type 2 diabetes among

African-​American women: spirituality, the multi-​caregiver role, and other social context factors. Diabetes Care, 23(7), 928–​933. Samuel-​Hodge, C. D., Keyserling, T. C., Park, S., Johnston, L. F., Gizlice, Z., Bangdiwala, S. I., et al. (2009). A randomized trial of a church-​ based diabetes self-​management program for African Americans with type 2 diabetes. Diabetes Educator, 35(3), 439–​454. SAMHSA (2019). Substance Abuse and Mental Health Services Administration. Results from the 2018 national survey on drug use and health: detailed tables. Rockville, MD: Center for Behavioral Statistics and Quality. Retrieved on 11-​27-​2020 from https://​www.sam​hsa.gov/​data/​. Sanada, K., Montero-​Marin, J., Alda Díez, M., Salas-​Valero, M., Pérez-​Yus, M. C., Morillo, H., et al. (2016). Effects of mindfulness-​based interventions on salivary cortisol in healthy adults: a meta-​analytical review. Frontiers in Physiology, 7, 471. Sanaeinasab, H., Saffari, M., Sheykh-​Oliya, Z., Khalaji, K., Laluie, A., Al Zaben, F., et al. (2021). A spiritual intervention to reduce stress, anxiety and depression in pregnant women: Randomized controlled trial. Health Care for Women International, 42(12), 1340–​1357. Sandberg, J. G., Bradford, A. B., & Brown, A. P. (2017). Differentiating between attachment styles and behaviors and their association with marital quality. Family Process, 56(2), 518–​531. Sandfort, V., Bluemke, D. A., Vargas, J., Brinker, J. A., Gerstenblith, G., Kickler, T., et al. (2017). Coronary plaque progression and regression in asymptomatic African American chronic cocaine users with obstructive coronary stenoses. Journal of Addiction Medicine, 11(2), 126. Sandhu, R. S., Ghosh, S., & Dellenbaugh, T. (2016). Association between dysthymic disorder and disability, with religiosity as moderator. Activitas Nervosa Superior, 58(1–​2), 13–​19. Sands, A., Thompson, E. J., & Gaysina, D. (2017). Long-​term influences of parental divorce on offspring affective disorders. Journal of Affective Disorders, 218, 105–​114. Sanford, J. R. (2016). Facing our demons: psychiatric perspectives on exorcism rituals. The Hilltop Review, 8(2), 87–​93. Sara, J. D., Prasad, M., Eleid, M. F., Zhang, M., Widmer, R. J., & Lerman, A. (2018). Association between work‐related stress and coronary heart disease. Journal of the American Heart Association, 7(9), e008073. Sarathchandra, D., Navin, M. C., Largent, M. A., & McCright, A. M. (2018). A survey instrument

References • 1013

for measuring vaccine acceptance. Preventive Medicine, 109, 1–​7. Sarkar, S., Germeraad, W. T., Rouschop, K. M., Steeghs, E. M., Gelder, M. V., Bos, G. M., et al. (2013). Hypoxia induced impairment of NK cell cytotoxicity against multiple myeloma can be overcome by IL-​2 activation of the NK cells. PloS one, 8(5), e64835. Sarma, E. A., Kawachi, I., Poole, E. M., Tworoger, S. S., Giovannucci, E. L., Fuchs, C. S., et al. (2018). Social integration and survival after diagnosis of colorectal cancer. Cancer, 124(4), 833–​840. Saroglou, V. (2002). Religion and the five factors of personality: a meta-​analytic review. Personality and Individual Differences, 32(1), 15–​25. Saroglou, V., Pichon, I., Trompette, L., Verschueren, M., & Dernelle, R. (2005). Prosocial behavior and religion: new evidence based on projective measures and peer ratings. Journal for the Scientific Study of Religion, 44(3), 323–​348. Saroglou, V., Karim, M., & Day, J. (2020). Personality and values of deconverts: A function of current nonbelief or prior religious socialization? Mental Health, Religion & Culture, 23(2), 139–​152. Sarri, K. O., Tzanakis, N. E., Linardakis, M. K., Mamalakis, G. D., & Kafatos, A. G. (2003). Effects of Greek Orthodox Christian Church fasting on serum lipids and obesity. BMC Public Health, 3(1), 16. Sartor, C. E., Lynskey, M. T., Heath, A. C., Jacob, T., & True, W. (2007). The role of childhood risk factors in initiation of alcohol use and progression to alcohol dependence. Addiction, 102(2), 216–​225. Sartor, C. E., Hipwell, A. E., & Chung, T. (2020). Public and private religious involvement and initiation of alcohol, cigarette, and marijuana use in Black and White adolescent girls. Social Psychiatry and Psychiatric Epidemiology, 55, 447–​456. Sarwar, N., Gao, P., Kondapally Seshasai, S. R., Gobin, R., Kaptoge, S., Di Angelantonio, E., et al. (2010). Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease. Lancet, 375(9733), 2215–​2222. Sasaki, J. Y., Kim, H. S., & Xu, J. (2011). Religion and well-​being: the moderating role of culture and the oxytocin receptor (OXTR) gene. Journal of Cross-​Cultural Psychology, 42(8), 1394–​1405. Sasaki, J. Y., Kim, H. S., Mojaverian, T., Kelley, L. D., Park, I. Y., & Janušonis, S. (2013). Religion priming differentially increases prosocial behavior among variants of the dopamine D4

1014 •  R eferences

receptor (DRD4) gene. Social Cognitive and Affective Neuroscience, 8(2), 209–​215. Sasaki, J. Y., Mojaverian, T., & Kim, H. S. (2015). Religion priming and an oxytocin receptor gene (OXTR) polymorphism interact to affect self-​ control in a social context. Development and Psychopathology, 27(1), 97–​109. Sattelmair, J., Pertman, J., Ding, E. L., Kohl, H. W., III, Haskell, W., & Lee, I. M. (2011). Dose response between physical activity and risk of coronary heart disease: a meta-​analysis. Circulation, 124(7), 789–​795. Sattin, R. W., Williams, L. B., Dias, J., Garvin, J. T., Marion, L., Joshua, T. V., et al. (2016). Community trial of a faith-​based lifestyle intervention to prevent diabetes among African-​Americans. Journal of Community Health, 41(1), 87–​96. Sauer, A. G., Siegel, R. L., Jemal, A., & Fedewa, S. A. (2017). Updated review of prevalence of major risk factors and use of screening tests for cancer in the United States. Cancer Epidemiology and Prevention Biomarkers, 26(8), 1192–​1208. Sauer, A. G., Siegel, R. L., Jemal, A., & Fedewa, S. A. (2019). Current prevalence of major cancer risk factors and screening test use in the United States. Cancer Epidemiology and Prevention Biomarkers, 28(4), 629–​642. Saveanu, R. V., & Nemeroff, C. B. (2012). Etiology of depression: genetic and environmental factors. Psychiatric Clinics, 35(1), 51–​71. Sax, W. (2014). Ritual healing and mental health in India. Transcultural Psychiatry, 51(6), 829–​849. Saxena, P. P., Unnikrishnan, B., Rathi, P., Kotian, H., & Reshmi, B. (2019). Survival analysis of head and neck cancer: results from a hospital-​based cancer registry in southern Karnataka. Clinical Epidemiology and Global Health, 7(3), 346–​350. Scarmeas, N., Stern, Y., Mayeux, R., & Luchsinger, J. A. (2006). Mediterranean diet, Alzheimer disease, and vascular mediation. Archives of Neurology, 63(12), 1709–​1717. Schaal, M. D., Sephton, S. E., Thoreson, C., Koopman, C., & Spiegel, D. (1998). Religious expression and immune competence in women with advanced cancer. In Proceedings of the Meeting of the American Psychological Association, August, San Francisco, CA. Schafer, R. M., Handal, P. J., Brawer, P. A., & Ubinger, M. (2011). Training and education in religion/​spirituality within APA-​accredited clinical psychology programs: 8 years later. Journal of Religion and Health, 50(2), 232–​239. Schak, D. C. (2008). Gender and Buddhism in Taiwan. Hsuan Chuang Journal of Buddhist Studies, 9, 145–​174.

Scheier, M. F., & Carver, C. S. (1993). On the power of positive thinking: The benefits of being optimistic. Current Directions in Psychological Science, 2(1), 26–​30. Scheitle, C. P., & Adamczyk, A. (2010). High-​cost religion, religious switching, and health. Journal of Health and Social Behavior, 51(3), 325–​342. Schettino, J. R., Olmos, N. T., Myers, H. F., Joseph, N. T., Poland, R. E., & Lesser, I. M. (2011). Religiosity and treatment response to antidepressant medication. Mental Health, Religion & Culture, 14(8), 805–​818. Schick-​Makaroff, K. (2018). Symptoms, coping, and quality of life of people with chronic kidney disease. Nephrology Nursing Journal, 45(4), 339–​355. Schieman, S., Van Gundy, K., & Taylor, J. (2002). The relationship between age and depressive symptoms. Journal of Aging & Health, 14(2), 260–​285. Schilling, R. (2019). The Most Addictive Drugs. Retrieved on 12-​19-​2019 from https://​www. askdr​ray.com/​the-​most-​addict​ive-​drugs/​. Schnall, E. (2016). Social support: a role for social work in the treatment and prevention of hypertension. Einstein Journal of Biology and Medicine, 21(2), 50–​56. Schnall, E., Wassertheil-​Smoller, S., Swencionis, C., Zemon, V., Tinker, L., O’Sullivan, M. J. (2010). The relationship between religion and cardiovascular outcomes and all-​cause mortality in the women’s health initiative observational study. Psychology and Health, 25(2), 249–​263. Schnall, E., Kalkstein, S., Fitchett, G., Salmoirago-​ Blotcher, E., Ockene, J., Tindle, H. A., et al. (2012). Psychological and social characteristics associated with religiosity in women’s health initiative participants. Journal of Religion and Health, 51(1), 20–​31. Schneider, R. H., Staggers, F., Alexander, C., Sheppard, W., Rainforth, M., Kondwani, K., et al. (1995). A randomized controlled trial of stress reduction for hypertension in older African Americans. Hypertension, 26, 820–​829. Schneider, R. H., Alexander, C. N., Staggers, F., Orme-​Johnson, D. W., Rainforth, M., Salerno, J. W., et al. (2005). A randomized controlled trial of stress reduction in African Americans treated for hypertension for over one year. American Journal of Hypertension, 18(1), 88–​98. Schnell, T., Fuchs, D., & Hefti, R. (2020). Worldview under stress: preliminary findings on cardiovascular and cortisol stress responses predicted by secularity, religiosity, spirituality,

and existential search. Journal of Religion and Health, 59(6), 2969–​2989. Schnitker, S. A., & Emmons, R. A. (2017). The psychology of virtue: Integrating positive psychology and the psychology of religion. Psychology of Religion and Spirituality, 9(3), 239. Schnitker, S. A., Felke, T. J., Barrett, J. L., & Emmons, R. A. (2014). Longitudinal study of religious and spiritual transformation in adolescents attending young life summer camp. Psychology of Religion and Spirituality, 6(2), 83. Schnitker, S., Shubert, J., Houltberg, B., & Fernandez, N. (2020). Bidirectional associations across time between entitativity, positive affect, generosity, and religiousness in adolescents training with a religiously affiliated charity marathon team. International Journal of Environmental Research and Public Health, 17(3), 686. Schnittker, J. (2019). Religion, social integration, and depression in Europe: evidence from the European Social Survey. Social Science & Medicine, 267, 112376. Schoenbach, V. J., Kaplan, B., Fredman, L., & Kleinbaum, D. G. (1986). Social ties and mortality in Evans County, Georgia. American Journal of Epidemiology, 123, 577–​591. Schoenfeld, G. (2004). The Return of Anti-​Semitism. San Francisco, CA: Encounter Books. Schoenfeld, T. J., & Gould, E. (2012). Stress, stress hormones, and adult neurogenesis. Experimental Neurology, 233(1), 12–​21. Scholte, W. F., Olff, M., Ventevogel, P., de Vries, G.-​ J., Jansveld, E., Lopes Cardozo, B., et al. (2004). Mental health symptoms following war and repression in Eastern Afghanistan. Journal of the American Medical Association, 292(5), 585–​593. Schröder, S. L., Richter, M., Schröder, J., Frantz, S., & Fink, A. (2016). Socioeconomic inequalities in access to treatment for coronary heart disease: a systematic review. International Journal of Cardiology, 219, 70–​78. Schroeder, R. D., & Frana, J. F. (2009). Spirituality and religion, emotional coping, and criminal desistance: a qualitative study of men undergoing change. Sociological Spectrum, 29(6), 718–​741. Schroeder, R. D., Broadus, E. J., & Bradley, C. (2018). Religiosity and crime revisited: accounting for non-​believers. Deviant Behavior, 39(5), 632–​647. Schuler, A., Ferentzy, P., Turner, N. E., Skinner, W., McIsaac, K. E., Ziegler, C. P., et al. (2016). Gamblers Anonymous as a recovery pathway: a scoping review. Journal of Gambling Studies, 32(4), 1261–​1278.

References • 1015

Schumer, M. C., Lindsay, E. K., & Creswell, J. D. (2018). Brief mindfulness training for negative affectivity: a systematic review and meta-​ analysis. Journal of Consulting and Clinical Psychology, 86(7), 569. Schuster, I., & Krahé, B. (2019). Predictors of sexual aggression perpetration among male and female college students. Sexual Abuse, 31(3), 318–​343. Schuster, M. A., Stein, B. D., Jaycox, L., Collins, R. L., Marshall, G. N., Elliott, M. N., et al. (2001). A national survey of stress reactions after the September 11, 2001, terrorist attacks. New England Journal of Medicine, 345(20), 1507–​1512. Schuurmans-​Stekhoven, J. B. (2019). Auspicious or suspicious—​does religiosity really promote elder well-​being? Examining the belief-​as-​ benefit effect among older Japanese. Archives of Gerontology and Geriatrics, 81, 129–​135. Schwanke, E. R. (1986) Providing pastoral care for the elderly in long term care facilities without a chaplain utilizing coordinated congregational resources. Journal of Religion & Aging, 2(3), 57–​64. Schwartz, C., Meisenhelder, J. B., Ma, Y., & Reed, G. (2003). Altruistic social interest behaviors are associated with better mental health. Psychosomatic Medicine, 65(5), 778–​785. Schwartz, J. E., Fennig, S., Tanenberg-​Karant, M., Carlson, G., Craig, T., Galambos, N., et al. (2000). Congruence of diagnoses 2 years after a first-​ admission diagnosis of psychosis. Archives of General Psychiatry, 57(6), 593–​600. Schwingshackl, L., Schwedhelm, C., Hoffmann, G., Lampousi, A. M., Knüppel, S., Iqbal, K., et al. (2017). Food groups and risk of all-​cause mortality. American Journal of Clinical Nutrition, 105(6), 1462–​1473. Scott, K. M., Wells, J. E., Angermeyer, M., Brugha, T. S., Bromet, E., Demyttenaere, K., et al. (2010). Gender and the relationship between marital status and first onset of mood, anxiety and substance use disorders. Psychological Medicine, 40(9), 1495–​1505. Scott, K. M., Lim, C., Al-​Hamzawi, A., Alonso, J., Bruffaerts, R., Caldas-​de-​Almeida, J. M., et al. (2016). Association of mental disorders with subsequent chronic physical conditions: world mental health surveys from 17 countries. JAMA Psychiatry, 73(2), 150–​158. SCP (2019). Long-​term trends in deaths of despair. Social Capital Project, Report Number 4-​19. Retrieved on 7-​14-​2020 from https://​www.jec. sen​ate.gov/​pub​lic/​index.cfm/​repu​blic​ans/​2019/​ 9/​long-​term-​tre​nds-​in-​dea​ths-​of-​desp​air.

1016 •  R eferences

Scrutton, A. P. (2015). Schizophrenia or possession? A reply to Kemal Irmak and Nuray Karanci. Journal of Religion and Health, 54, 1963–​68. Sebena, R., El Ansari, W., Stock, C., Orosova, O., & Mikolajczyk, R. T. (2012). Are perceived stress, depressive symptoms and religiosity associated with alcohol consumption? A survey of freshmen university students across five European countries. Substance Abuse Treatment, Prevention, and Policy, 7(1), 21. Secinti, E., Thompson, E. J., Richards, M., & Gaysina, D. (2017). Research review: childhood chronic physical illness and adult emotional health—​a systematic review and meta-​analysis. Journal of Child Psychology and Psychiatry, 58(7), 753–​769. Seeman, T. E., Kaplan, G. A., Knudsen, L., Cohen, R., & Guralnik, J. (1987). Social network ties and mortality among the elderly in the Alameda County study. American Journal of Epidemiology, 126, 714–​723. Segerstrom, S. C., & Sephton, S. E. (2010). Optimistic expectancies and cell-​mediated immunity: The role of positive affect. Psychological Science, 21(3), 448–​455. Seidell, J. C., Cigolini, M., Charzewska, J., Ellsinger, B. M., & Biase, G. D. (1990). Fat distribution in European women: a comparison of anthropometric measurements in relation to cardiovascular risk factors. International Journal of Epidemiology, 19(2), 303–​308. Seidman, S. N., Mosher, W. D., & Aral, S. O. (1992). Women with multiple sexual partners: United States, 1988. American Journal of Public Health, 82, 1388–​1394. Seirmarco, G., Neria, Y., Insel, B., Kiper, D., Doruk, A., Gross, R., et al. (2012). Religiosity and mental health: changes in religious beliefs, complicated grief, posttraumatic stress disorder, and major depression following the September 11, 2001 attacks. Psychology of Religion and Spirituality, 4(1), 10–​18. Selmi, C., Leung, P. S., Sherr, D. H., Diaz, M., Nyland, J. F., Monestier, M., et al. (2012). Mechanisms of environmental influence on human autoimmunity. Journal of Autoimmunity, 39(4), 272–​284. Selten, J. P., Booij, J., Buwalda, B., & Meyer-​ Lindenberg, A. (2017). Biological mechanisms whereby social exclusion may contribute to the etiology of psychosis: a narrative review. Schizophrenia Bulletin, 43(2), 287–​292. Selye, H. (1956). The Stress of Life. New York, NY: McGraw-​Hill.

Semplonius, T., Good, M., & Willoughby, T. (2015). Religious and non-​religious activity engagement as assets in promoting social ties throughout university: the role of emotion regulation. Journal of Youth and Adolescence, 44(8), 1592–​1606. Sen, C. K., & Kumkale, G. T. (2016). Who does not get screened? A simple model of the complex relationships in mammogram non-​attendance. Journal of Health Psychology, 21(12), 2838–​2850. Seow, L. S., Ong, C., Mahesh, M. V., Sagayadevan, V., Shafie, S., Chong, S. A., et al. (2016). A systematic review on comorbid post-​traumatic stress disorder in schizophrenia. Schizophrenia Research, 176(2–​3), 441–​451. Sephton, S. E., Koopman, C., Schaal, M., Thoresen, C., & Spiegel, D. (2001). Spiritual expression and immune status in women with metastatic breast cancer: an exploratory study. Breast Journal, 7(5), 345–​353. Sephton, S. E., Dhabhar, F. S., Keuroghlian, A. S., Giese-​Davis, J., McEwen, B. S., Ionan, A. C., et al. (2009). Depression, cortisol, and suppressed cell-​mediated immunity in metastatic breast cancer. Brain, Behavior, and Immunity, 23(8), 1148–​1155. Seyedfatemi, N., Zeinali, E., Bahremand, M., Mehran, A., & Zeinali, M. (2019). The relationship between medication adherence and coping skills in patients with heart failure. Avicenna Journal of Nursing and Midwifery Care, 27(2), 89–​96. Sperber, A. D., Peleg, A., Friger, M., & Shvartzman, P. (2001). Factors associated with daily smoking among Israeli adolescents: a prospective cohort study with a 3-​year follow-​up. Preventive Medicine, 33(2 Pt 1), 73–​81. Serfaty, D. R., Cherniak, A. D., & Strous, R. D. (2020). How are psychotic symptoms and treatment factors affected by religion? Psychiatry Research, 293, 113349. Seshadri, S., Beiser, A., Pikula, A., Himali, J., Kelly-​ Hayes, M., Debette, S., et al. (2010). Parental occurrence of stroke and risk of stroke in their children. Circulation, 121(11), 1304–​1312. Sethi, S., & Bhargava, S. C. (2003). Relationship of meditation and psychosis: case studies. Australian and New Zealand Journal of Psychiatry, 37(3), 382–​382. Severaid, K. B., Osborne, K. J., & Mittal, V. A. (2019). Implications of religious and spiritual practices for youth at clinical high risk for psychosis. Schizophrenia Research, 208, 481–​482. Shab-​Bidar, S., Golzarand, M., Hajimohammadi, M., & Mansouri, S. (2018). A posteriori

dietary patterns and metabolic syndrome in adults: a systematic review and meta-​analysis of observational studies. Public Health Nutrition, 21(9), 1681–​1692. Shafer, K., Petts, R. J., & Renick, A. J. (2019). Religious variability in the relationship between masculinity and father involvement. Journal for the Scientific Study of Religion, 58(2), 378–​397. Shah, A. D., Langenberg, C., Rapsomaniki, E., Denaxas, S., Pujades-​Rodriguez, M., Gale, C. P., et al. (2015). Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1.9 million people. Lancet Diabetes & Endocrinology, 3(2), 105–​113. Shah, R. S., & Cole, J. W. (2010). Smoking and stroke: the more you smoke the more you stroke. Expert Review of Cardiovascular Therapy, 8(7), 917–​932. Shalit, N., Rehm, J., & Lev-​R an, S. (2019). Epidemiology of hallucinogen use in the US results from the National epidemiologic survey on alcohol and related conditions III. Addictive Behaviors, 89, 35–​43. Shamsipour, H. S., Mohammadi, H., Azari, E., & Norouzi, M. (2018). The effect of emotion-​ focused couple therapy based on religious teachings on social compatibility and marital conflicts. Journal of Research on Religion & Health, 4(4), 44–​58. Shapero, B. G., Black, S. K., Liu, R. T., Klugman, J., Bender, R. E., Abramson, L. Y., et al. (2014). Stressful life events and depression symptoms: the effect of childhood emotional abuse on stress reactivity. Journal of Clinical Psychology, 70(3), 209–​223. Shapiro, S., Strax, P., & Venet, L. (1971). Periodic breast cancer screening in reducing mortality from breast cancer. Journal of the American Medical Association, 215(11), 1777–​1785. Sharara, E., Akik, C., Ghattas, H., & Obermeyer, C. M. (2018). Physical inactivity, gender and culture in Arab countries: a systematic assessment of the literature. BMC Public Health, 18(1), 639. Sharif, S. P., Ahadzadeh, A. S., & Ong, F. S. (2019). The effect of religiosity on the relationship between BMI and body image among Iranian women. Psychology of Religion and Spirituality, 11(2), 168. Shariff, A. F., Willard, A. K., Andersen, T., & Norenzayan, A. (2016). Religious priming: a meta-​analysis with a focus on prosociality. Personality and Social Psychology Review, 20(1), 27–​48.

References • 1017

Sharma, I., Pandit, B., Pathak, A., & Sharma, R. (2013). Hinduism, marriage and mental illness. Indian Journal of Psychiatry, 55(Supp 2), S243. Sharma, M., Fine, S. L., Brennan, R. T., & Betancourt, T. S. (2017). Coping and mental health outcomes among Sierra Leonean war-​ affected youth: results from a longitudinal study. Development and Psychopathology, 29(1), 11–​23. Sharma, R. K., & Dash, B. (2008). Caraka Samhita (Vol. I). Varanasi, India: Chowkhamba Sanskrit Bhawan. Sharma, S., Mustanski, B., Dick, D., Bolland, J., & Kertes, D. A. (2019). Protective factors buffer life stress and behavioral health outcomes among high-​risk youth. Journal of Abnormal Child Psychology, 47(8), 1289–​1301. Sharma, S., & Singh, K. (2019). Religion and well-​ being: the mediating role of positive virtues. Journal of Religion and Health, 58(1), 119–​131. Sharma, V., Marin, D. B., Koenig, H. G., Feder, A., Iacoviello, B. M., Southwick, S. M., et al. (2017). Religion, spirituality, and mental health of US military veterans. Journal of Affective Disorders, 217, 197–​204. Shastri, V. (2012). History of asana and exercise in India. Fountainhead of Yoga. Retrieved on 12-​ 26-​2019 from https://​www.hindu​hist​ory.info/​ hist​ory-​of-​asana-​and-​exerc​ise-​in-​india/​. Shavelle, R. M., Paculdo, D. R., Strauss, D. J., & Kush, S. J. (2008). Smoking habit and mortality a meta-​analysis. Journal of Insurance Medicine, 40(3–​4), 170–​178. Shaw, S. A., Mergenova, G., & El-​Bassel, N. (2020). Religion and HIV risk among male market vendors in Kazakhstan. Journal of Religion and Health, 59, 2019–​2031. Shehan, C. L., Bock, E. W., & Lee, G. R. (1990). Religious heterogamy, religiosity, and marital happiness. Journal of Marriage and the Family, 52, 73–​79. Sheldrake, P. (2007). A Brief History of Spirituality. Boston, MA: Blackwell. Shelton, R. C., Snavely, A. C., De Jesus, M., Othus, M. D., & Allen, J. D. (2013). HPV vaccine decision-​making and acceptance. Journal of Religion and Health, 52(4), 1120–​1130. Shen, A. (2019). Religious attendance, healthy lifestyles, and perceived health. Journal of Religion and Health, 58(4), 1235–​1245. Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The link between depression and chronic pain: neural mechanisms in the brain. Neural Plasticity, 9724371. Shepherd, A. M., Schnitker, S. S., Leffel, G. M., Oakes Mueller, R. A., Curlin, F. A., Yoon,

1018 •  R eferences

J. D., et al. (2018). Developing the good physician: Spirituality affects the development of virtues and moral intuitions in medical students. Journal of Positive Psychology, 13(2), 143–​154. Sherill, K., & Larson, D. B. (1994). The anti-​ tenure factor in religious research in clinical epidemiology and aging. In J. Levin (ed.), Religion in Aging and Health: Theoretical Foundations and Methodological Frontiers. Thousand Oaks, CA: SAGE Publications, pp. 149–​177. Sherk, A., Thomas, G., Churchill, S., & Stockwell, T. (2020). Does drinking within low-​risk guidelines prevent harm? Implications for high-​income countries using the international model of alcohol harms and policies. Journal of Studies on Alcohol and Drugs, 81(3), 352–​361. Sherman, A. C., Plante, T. G., Simonton, S., Latif, U., & Anaissie, E. J. (2009). Prospective study of religious coping among patients undergoing autologous stem cell transplantation. Journal of Behavioral Medicine, 32(1), 118–​128. Shi, L., Zhang, D., Wang, L., Zhuang, J., Cook, R., & Chen, L. (2017). Meditation and blood pressure: a meta-​analysis of randomized clinical trials. Journal of Hypertension, 35(4), 696–​706. Shi, W., Neubeck, L., & Gallagher, R. (2017). Measurement matters: A systematic review of waist measurement sites for determining central adiposity. Collegian, 24(5), 513–​523. Shiah, Y. J., Chang, F., Chiang, S. K., Lin, I. M., & Tam, W. C. (2015). Religion and health: anxiety, religiosity, meaning of life and mental health. Journal of Religion and Health, 54(1), 35–​45. Shields, A. (2016–​2019). National spirituality and health consortium. Retrieved on 4-​30-​2019 from https://​www.temple​ton.org/​grant/​natio​nal-​spiri​ tual​ity-​and-​hea​lth-​con​sort​ium. Shields, A. (2019). R/​S Atlas: mapping religion & spirituality in US cohorts. Retrieved on 4-​30-​ 2019 from https://​atlas.mgh.harv​ard.edu/​. Shilo, G., & Savaya, R. (2012). Mental health of lesbian, gay, and bisexual youth and young adults: Differential effects of age, gender, religiosity, and sexual orientation. Journal of Research on Adolescence, 22(2), 310–​325. Shim, E. J., Lee, J. W., Cho, J., Jung, H. K., Kim, N. H., Lee, J. E., et al. (2020). Association of depression and anxiety disorder with the risk of mortality in breast cancer. Breast Cancer Research and Treatment, 179(2), 491–​498. Shimada‐Sugimoto, M., Otowa, T., & Hettema, J. M. (2015). Genetics of anxiety disorders: genetic epidemiological and molecular studies in

humans. Psychiatry and Clinical Neurosciences, 69(7), 388–​401. Shin, D. W., Suh, S. Y., Sun-​Hyun, K., Park, J., Yoon, S. J., Kim, Y. J., et al. (2018). Is spirituality related to survival in advanced cancer inpatients in Korea? Palliative & Supportive Care, 16(6), 669. Shin, J., Yang, S., Park, D. H., Ryu, S. H., Ha, J. H., Kim, J. W., et al. (2020). Predictors of psychiatric outpatient adherence after an emergency room visit for a suicide attempt. Psychiatry Investigation, 17(9), 896. Shin, L. M., & Liberzon, I. (2010). The neurocircuitry of fear, stress, and anxiety disorders. Neuropsychopharmacology, 35(1), 169–​191. Shiota, M. N., & Levenson, R. W. (2007). Birds of a feather don’t always fly farthest: similarity in Big Five personality predicts more negative marital satisfaction trajectories in long-​term marriages. Psychology and Aging, 22(4), 666–​675. Shirneshan, E. (2013). Cost of illness study of anxiety disorders for the ambulatory adult population of the United States. University of Tennessee Health Science Center UTHSC Digital Commons. Retrieved on 11-​24-​2020 from https://​dc.uthsc.edu/​disser​tati​ons/​370/​. Shmueli, A. (2003). Socio-​economic and demographic variation in health and in its measures: the issue of reporting heterogeneity. Social Science & Medicine, 57(1), 125–​134. Shmueli, A. (2007). Health and religiosity among Israeli Jews. European Journal of Public Health, 17(1), 104–​111. Shor, E., Roelfs, D. J., Bugyi, P., & Schwartz, J. E. (2012). Meta-​analysis of marital dissolution and mortality. Social Science & Medicine, 75(1), 46–​59. Shor, E., Roelfs, D. J., & Yogev, T. (2013). The strength of family ties: a meta-​analysis and meta-​regression of self-​reported social support and mortality. Social Networks, 35(4), 626–​638. Shorey, R. C., Elmquist, J., Anderson, S., & Stuart, G. L. (2016). The relationship between spirituality and aggression in a sample of men in residential substance use treatment. International Journal of Mental Health and Addiction, 14(1), 23–​30. Short, M. B., Kasper, T. E., & Wetterneck, C. T. (2015). The relationship between religiosity and internet pornography use. Journal of Religion and Health, 54(2), 571–​583. Shorter, R. L., & Elledge, L. C. (2020). Family functioning and adjustment in Appalachian

youth. Journal of Child and Family Studies, 29(10), 2745–​2758. Shrout, P. E., & Fleiss, J. L (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin 86, 420–​428. Shrum, W. (1980). Religion and marital instability: change in the 1970’s? Review of Religious Research, 21, 135–​147. Shultz, R., Bookwala, J., Knapp, J., Scheier, M., & Williamson, G. (1996). Pessimism, age, and cancer mortality. Psychology and Aging, 11, 304–​309. Siahpush, M., Spittal, M., & Singh, G. K. (2008). Happiness and life satisfaction prospectively predict self-​rated health, physical health, and the presence of limiting, long-​term health conditions. American Journal of Health Promotion, 23(1), 18–​26. Siddle, R., Haddock, G., Tarrier, N., & Faragher, E. (2002a). Religious delusions in patients admitted to hospital with schizophrenia. Social Psychiatry & Psychiatric Epidemiology, 37(3), 130–​138. Siddle, R., Haddock, G., Tarrier, N., & Faragher, E. (2002b). The validation of a religiosity measure for individuals with schizophrenia. Mental Health, Religion & Culture, 5(3), 267–​284. Siddle, R., Haddock, G., Tarrier, N., & Faragher, E. (2004). Religious beliefs and religious delusions: Response to treatment in schizophrenia. Mental Health, Religion & Culture, 7(3), 211–​223. Siedlecki, K. L., Salthouse, T. A., Oishi, S., & Jeswani, S. (2014). The relationship between social support and subjective well-​being across age. Social Indicators Research, 117(2), 561–​576. Siegel, M. D. (2018). To Comfort Always [commentary on saying by 19th century American physician Edward Livingston Trudeau, founder of the famed tuberculosis sanitarium at Saranac Lake in New York’s Adirondacks]. Yale School of Medicine News. Retrieved on 7-​31-​22 from https://​medic​ine.yale.edu/​news-​arti​cle/​to-​ comf​ort-​alw​ays/​. Siegel, R., DeSantis, C., & Jemal, A. (2014). Colorectal cancer statistics, 2014. CA: A Cancer Journal for Clinicians, 64(2), 104–​117. Siegel, R. L., Miller, K. D., Fedewa, S. A., Ahnen, D. J., Meester, R. G., Barzi, A., et al. (2017). Colorectal cancer statistics, 2017. CA: A Cancer Journal for Clinicians, 67(3), 177–​193. Siegel, R. L., Miller, K. D., & Jemal, A. (2019). Cancer statistics, 2019. CA: A Cancer Journal for Clinicians, 69(1), 7–​34.

References • 1019

Siegrist, M. (1996). Church attendance, denomination, and suicide ideology. Journal of Social Psychology, 136(5), 559–​566. Sigurvinsdottir, R., Asgeirsdottir, B., Ullman, S., & Sigfusdottir, I. (2021). The impact of sexual abuse, family violence/​conflict, spirituality, and religion on anger and depressed mood among adolescents. Journal of Interpersonal Violence, 36(1–​2), NP577–​NP597. Silva, A. N., Moratelli, L., Tavares, P. L., Marsicano, E. D., Pinhati, R. R., Colugnati, F. A., et al. (2016). Self‐efficacy beliefs, locus of control, religiosity and non‐adherence to immunosuppressive medications in kidney transplant patients. Nephrology, 21(11), 938–​943. Silverman, M. G., Ference, B. A., Im, K., Wiviott, S. D., Giugliano, R. P., Grundy, S. M., et al. (2016). Association between lowering LDL-​ C and cardiovascular risk reduction among different therapeutic interventions. Journal of the American Medical Association, 316(12), 1289–​1297. Silverstein, M., & Bengtson, V. L. (2018). Return to religion? Predictors of religious change among Baby-​Boomers in their transition to later life. Journal of Population Ageing, 11(1), 7–​21. Silverstein, M., Zuo, D., Wang, J., & Bengtson, V. L. (2019). Intergenerational religious participation in adolescence and provision of assistance to older mothers. Journal of Marriage and Family, 81(5), 1206–​1220. Simmonds, M., Llewellyn, A., Owen, C. G., & Woolacott, N. (2016). Predicting adult obesity from childhood obesity: a systematic review and meta-​analysis. Obesity Reviews, 17(2), 95–​107. Simons, R. L., Lei, M. K., Carter, S., Beach, S. R., Gibbons, F. X., Gerrard, M., et al. (2019). Inflammation mediates the effect of discrimination, religiosity, and friendship network on expression of the Tp53 cancer suppressor gene. Social Sciences and Medicine (Population Health), 7, 100389 (https://​doi.org/​ 10.1016/​j.ssmph.2019.100​389). Simpson, M. E., & Conklin, G. H. (1989). Socioeconomic development, suicide, and religion. Social Forces, 67(4), 945–​964. Simpson, R. J., Campbell, J. P., Gleeson, M., Krüger, K., Nieman, D. C., Pyne, D. B., et al. (2020). Can exercise affect immune function to increase susceptibility to infection? Exercise Immunology Review, 26, 8–​22. Simpson, W. F. (1989). Comparative longevity in a college cohort of Christian Scientists. Journal of the American Medical Association, 262, 1657–​1658.

1020 •  R eferences

Sims, M., Diez-​Roux, A. V., Dudley, A., Gebreab, S., Wyatt, S. B., Bruce, M. A., et al. (2012). Perceived discrimination and hypertension among African Americans in the Jackson Heart Study. American Journal of Public Health, 102(S2), S258–​S265. Sin, N. L., Ong, A. D., Stawski, R. S., & Almeida, D. M. (2017). Daily positive events and diurnal cortisol rhythms. Psychoneuroendocrinology, 83, 91–​100. Singh, B. K. (1979). Correlates of attitudes toward euthanasia. Social Biology, 26, 247–​254. Singh, B. K., & Williams, J. S. (1982). Satisfaction with health and physical condition among the elderly. Journal of Psychiatric Treatment and Evaluation, 4, 403–​408. Singh, B. K., Williams, J. S., & Ryther, B. J. (1986). Public approval of suicide: a situational analysis. Suicide and Life-​Threatening Behavior, 16, 409–​417. Singh, G. M., Danaei, G., Farzadfar, F., Stevens, G. A., Woodward, M., Wormser, D., et al. (2013). The age-​specific quantitative effects of metabolic risk factors on cardiovascular diseases and diabetes. PloS One, 8(7), e65174. Singh, K. (2016). Nutrient and stress management. Journal of Nutrition and Food Sciences, 6(4), https://​doi.org/​10.4172/​2155-​9600.1000​528. Sinha, D. N., Suliankatchi, R. A., Gupta, P. C., Thamarangsi, T., Agarwal, N., Parascandola, M., et al. (2018). Global burden of all-​cause and cause-​specific mortality due to smokeless tobacco use: systematic review and meta-​ analysis. Tobacco Control, 27(1), 35–​42. Sinha, J. W., Cnaan, R. A., & Gelles, R. J. (2007). Adolescent risk behaviors and religion: findings from a national study. Journal of Adolescence, 30(2), 231–​249. Sipilä, P., Harrasova, G., Mustelin, L., Rose, R. J., Kaprio, J., & Keski‐Rahkonen, A. (2017). “Holy anorexia”—​relevant or relic? Religiosity and anorexia nervosa among Finnish women. International Journal of Eating Disorders, 50(4), 406–​414. Sippel, L. M., Allington, C. E., Pietrzak, R. H., Harpaz-​Rotem, I., Mayes, L. C., & Olff, M. (2017). Oxytocin and stress-​related disorders: neurobiological mechanisms and treatment opportunities. Chronic Stress, 1, 1–​15. Siracusa, F., Schaltenberg, N., Villablanca, E. J., Huber, S., & Gagliani, N. (2019). Dietary habits and intestinal immunity: from food intake to CD4+​TH cells. Frontiers in Immunology, 9, 3177. Sisask, M., Värnik, A., K[otilde]lves, K., Bertolote, J. M., Bolhari, J., Botega, N. J., et al. (2010). Is religiosity a protective factor against attempted

suicide: a cross-​cultural case-​control study. Archives of Suicide Research, 14(1), 44–​55. Sithey, G., Li, M., Wen, L. M., Kelly, P. J., & Clarke, K. (2018). Socioeconomic, religious, spiritual and health factors associated with symptoms of common mental disorders: a cross-​sectional secondary analysis of data from Bhutan’s Gross National Happiness Study, 2015. BMJ Open, 8(2), e018202. Sivan, Y., Reisner, S., Amitai, Y., Wasser, J., Nehama, H., & Tauman, R. (2004). Effect of religious observance on infants’ sleep position in the Jewish population. Journal of Paediatrics and Child Health, 40(9–​10), 534–​539. Sivasankaran, S., Pollard-​Quintner, S., Sachdeva, R., Pugeda, J., Hoq, S. M., Zarich, S. W., et al. (2006). The effect of a six-​week program of yoga and meditation on brachial artery reactivity: do psychosocial interventions affect vascular tone? Clinical Cardiology, 29(9), 393–​398. Skarupski, K. A., Fitchett, G., Evans, D. A., & Mendes de Leon, C. (2013). Race differences in the association of spiritual experiences and life satisfaction in older age. Aging & Mental Health, 17(7), 888–​895. Skodol, A. E., & Shrout, P. E. (1989). Use of DSM-​III in Axis IV in clinical practice: Rating etiologically significant stressors. American Journal of Psychiatry, 146(1), 61–​66. Skolarus, L. E., Lisabeth, L. D., Sánchez, B. N., Smith, M. A., Garcia, N. M., Risser, J. M., et al. (2012). The prevalence of spirituality, optimism, depression, and fatalism in a bi-​ethnic stroke population. Journal of Religion and Health, 51(4), 1293–​1305. Skolasky, R. L., MacKenzie, E., Wegener, S., & Riley, L. (2008). Patient activation and adherence to physical therapy in persons undergoing spine surgery. Spine, 33, E784–​E791. Skotsimara, G., Antonopoulos, A., Oikonomou, E., Ioakeimidis, N., Tsalamandris, S., Georgakopoulos, C., et al. (2018). Exposure to e-​cigarette adversely affects blood pressure and heart rate in healthy individuals. Circulation, 138(Supp 1), A11507–​A11507. Skovlund, C. W., Kessing, L. V., Mørch, L. S., & Lidegaard, Ø. (2017). Increase in depression diagnoses and prescribed antidepressants among young girls. Nordic Journal of Psychiatry, 71(5), 378–​385. Skrabski, A., Kopp, M., Rozsa, S., Rethelyi, J., & Rahe, R. H. (2005). Life meaning: an important correlate of health in the Hungarian population. International Journal of Behavioral Medicine, 12(2), 78–​85.

Sladek, M. R., Doane, L. D., Gonzales, N. A., Grimm, K. J., & Luecken, L. J. (2019). Latino adolescents’ cultural values associated with diurnal cortisol activity. Psychoneuroendocrinology, 109, 104403. Slatcher, R. B., & Schoebi, D. (2017). Protective processes underlying the links between marital quality and physical health. Current Opinion in Psychology, 13, 148–​152. Sleiman, D., Al-​Badri, M. R., & Azar, S. T. (2015). Effect of Mediterranean diet in diabetes control and cardiovascular risk modification. Frontiers in Public Health, 3, 69. Slentz, C. A., Houmard, J. A., & Kraus, W. E. (2009). Exercise, abdominal obesity, skeletal muscle, and metabolic risk: evidence for a dose response. Obesity, 17(S3), S27–​S33. Sloan, R. P., Bagiella, E., & Powell, T. (1999). Religion, spirituality, and medicine. Lancet, 353(9153), 664–​667. Sloan, R. P., Bagiella, E., VandeCreek, L., Hover, M., Casalone, C., Hirsch, T. J., et al. (2000). Should physicians prescribe religious activities? New England Journal of Medicine, 342(25), 1913–​1916. Sloane, D. M., & Potvin, R. H. (1986). Religion and delinquency: cutting through the maze. Social Forces, 65(1), 87–​105. Smidowicz, A., & Regula, J. (2015). Effect of nutritional status and dietary patterns on human serum C-​reactive protein and interleukin-​6 concentrations. Advances in Nutrition, 6(6), 738–​747. Smit, H. F., Cuijpers, P., Oostenbrink, J., Batelaan, N. M., de Graaf, R., et al. (2006). Costs of nine common mental disorders. Journal of Mental Health Policy and Economics, 9(4), 193–​200. Smith, A. P. (2002). Stress, breakfast cereal consumption and cortisol. Nutritional Neuroscience, 5(2), 141–​144. Smith, B. W., & Zautra, A. J. (2004). The role of purpose in life in recovery from knee surgery. International Journal of Behavioral Medicine, 11, 197–​202. Smith, D. T., Attwell, K., & Evers, U. (2020). Majority acceptance of vaccination and mandates across the political spectrum in Australia. Politics, 40(2), 189–​206. Smith, K. E., Porges, E. C., Norman, G. J., Connelly, J. J., & Decety, J. (2014). Oxytocin receptor gene variation predicts empathic concern and autonomic arousal while perceiving harm to others. Social Neuroscience, 9(1), 1–​9. Smith, K. R., Mineau, G., Garibotti, G., & Kerber, R. (2009). Effects of childhood and middle-​ adulthood family conditions on later-​life

References • 1021

mortality. Social Science & Medicine, 68, 1649–​1658. Smith, L. G. (2008). P2-​262: prayer as an intervention for agitated dementia residents. Alzheimer’s & Dementia, 4(4), T448. Smith, L. H., & VanderWeele, T. J. (2019). Bounding bias due to selection. Epidemiology, 30(4), 509–​516. Smith, S. (2019). Religious “nones” now as big as evangelicals in the US, new data shows. Christian Post. Retrieved on 4-​19-​2019 from https://​ www.christ​ianp​ost.com/​news/​religi​ous-​nones-​ now-​as-​big-​as-​evang​elic​als-​in-​the-​us-​new-​data-​ shows.html. Smith, S. J. (2015). Risky sexual behavior among young adult Latinas: are acculturation and religiosity protective? Journal of Sex Research, 52(1), 43–​54. Smith, T. B., Bartz, J., & Scott Richards, P. (2007). Outcomes of religious and spiritual adaptations to psychotherapy. Psychotherapy Research, 17(6), 643–​655. Smyre, C. L., Tak, H. J., Dang, A. P., Curlin, F. A., & Yoon, J. D. (2018). Physicians’ opinions on engaging patients’ religious and spiritual concerns. Journal of Pain and Symptom Management, 55(3), 897–​905. Snowden, A., Fitchett, G., Grossoehme, D. H., Handzo, G., Kelly, E., King, S. D., et al. (2017). International study of chaplains’ attitudes about research. Journal of Health Care Chaplaincy, 23(1), 34–​43. Soeteman, D. I., Roijen, L. H., Verheul, R., & Busschbach, J. J. (2008). The economic burden of personality disorders in mental health care. Journal of Clinical Psychiatry, 69(2), 259–​265. Soetrisno, S., Sulistyowati, S., Ardhianto, A., & Hadi, S. (2017). The effect of logotherapy on the expressions of cortisol, HSP70, Beck Depression Inventory (BDI), and pain scales in advanced cervical cancer patients. Health Care for Women International, 38(2), 91–​99. Solanke, B. L., Oladosu, O. A., Akinlo, A., & Olanisebe, S. O. (2015). Religion as a social determinant of maternal health care service utilisation in Nigeria. African Population Studies, 29(2), 1868–​1881. Sollgruber, A., Bornemann-​Cimenti, H., Szilagyi, I. S., & Sandner-​Kiesling, A. (2018). Spirituality in pain medicine: a randomized experiment of pain perception, heart rate and religious spiritual well-​being by using a single session meditation methodology. PloS One, 13(9), e0203336.

1022 •  R eferences

Son, J., & Wilson, J. (2011). Religiosity, psychological resources, and physical health. Journal for the Scientific Study of Religion, 50(3), 588–​603. Song, J., & Fan, H. (2013). A meta-​analysis of the relationship between social support and subjective well-​being. Advances in Psychological Science, 21(8), 1357–​1370. Sordo, L., Barrio, G., Bravo, M. J., Indave, B. I., Degenhardt, L., Wiessing, L., et al. (2017). Mortality risk during and after opioid substitution treatment. British Medical Journal, 357, j1550. Sorensen, T., Danbolt, Lien, L. J., Koenig, H. G., & Holmen, J. (2011). The relationship between religious attendance and blood pressure: the HUNT Study, Norway. International Journal of Psychiatry in Medicine, 42(1), 13–​28. Sorensen, T., Dahl, A., Fossa, S., Holmen, J., Lien, L., & Danbolt, L. (2012). Is “seeking God’s help” associated with life satisfaction and disease-​ specific quality of life in cancer patients? The HUNT study. Archive for the Psychology of Religion, 34, 191–​213. Sorge, R. E., & Totsch, S. K. (2017). Sex differences in pain. Journal of Neuroscience Research, 95(6), 1271–​1281. South, S. C., & DeYoung, N. J. (2013). Behavior genetics of personality disorders: informing classification and conceptualization in DSM-​5. Personality Disorders, 4(3), 270–​283. Sowa, A., Golinowska, S., Deeg, D., Principi, A., Casanova, G., Schulmann, K., et al. (2016). Predictors of religious participation of older Europeans in good and poor health. European Journal of Ageing, 13(2), 145–​157. Speed, D. (2017). Unbelievable?! Theistic/​ epistemological viewpoint affects religion-​health relationship. Journal of Religion and Health, 56(1), 238–​257. Speed, D. (2018). Mixed blessings? Religion/​ spirituality predicts better and worse screening behaviours. Journal of Religion and Health, 57(1), 366–​383. Speed, D., & Fowler, K. (2016). What’s God got to do with it? How religiosity predicts atheists’ health. Journal of Religion and Health, 55, 296–​308. Speed, D., & Fowler, K. (2017). Good for all? Hardly! Attending church does not benefit religiously unaffiliated. Journal of Religion and Health, 56(3), 986–​1002. Speer, M. E., & Delgado, M. R. (2017). Reminiscing about positive memories buffers acute stress responses. Nature Human Behaviour, 1(5), 1–​9. Spence, C., Danielson, T. S., & Kaunitz, W. M. (1984). The Faith Assembly: a study of perinatal

and maternal mortality. Indiana Medicine, March, 180–​183. Spence, C., & Danielson, T. (1987). The Faith Assembly: a follow-​up study of faith healing and mortality. Indiana Medicine, 80(3), 238–​240. Spence, N. D., Farvid, M. S., Warner, E. T., VanderWeele, T. J., Tworoger, S. S., Argentieri, M. A., et al. (2020). Religious service attendance, religious coping, and risk of hypertension in women participating in the Nurses’ Health Study II. American Journal of Epidemiology, 189(3), 193–​203. Spencer, R. J., Ray, A., Pirl, W. F., & Prigerson, H. G. (2012). Clinical correlates of suicidal thoughts in patients with advanced cancer. American Journal of Geriatric Psychiatry, 20(4), 327–​336. Spilman, S. K., Neppl, T., Donnellan, M., Schofield, T., & Conger, R. (2013). Incorporating religiosity into a developmental model of positive family functioning across generations. Developmental Psychology, 49(4), 762–​774. Spoerri, A., Zwahlen, M., Bopp, M., Gutzwiller, F., & Egger, M. (2010). Religion and assisted and non-​ assisted suicide in Switzerland: National Cohort Study. International Journal of Epidemiology, 39(6), 1486–​1494. Spreitzer, E., & Snyder, E. (1974). Correlates of life satisfaction among the aged. Journal of Gerontology, 29, 454–​458. Sproston, N. R., & Ashworth, J. J. (2018). Role of C-​reactive protein at sites of inflammation and infection. Frontiers in Immunology, 9, 754. Sprung, C. L., Maia, P., Bulow, H. H., Ricou, B., Armaganidis, A., Baras, M., et al. (2007). The importance of religious affiliation and culture on end-​of-​life decisions in European intensive care units. Intensive Care Medicine, 33(10), 1732–​1739. Sprung, J. M., Sliter, M. T., & Jex, S. M. (2012). Spirituality as a moderator of the relationship between workplace aggression and employee outcomes. Personality and Individual Differences, 53(7), 930–​934. Squires, N. (2014). Pope Frances praises exorcists for combating “the Devil’s works.” The Telegraph, October 28. Retrieved on 7-​18-​2019 from http://​www.telegr​aph.co.uk/​news/​worldn​ews/​ the-​pope/​11193​681/​Pope-​Fran​cis-​prai​ses-​exorci​ sts-​for-​combat​ing-​the-​Dev​ils-​works.html. Sri Dhammananda, V. K. (2005). A happy married life: a Buddhist perspective. Retrieved on 10-​18-​ 2019 from https://​www.acce​ssto​insi​ght.org/​lib/​ auth​ors/​dham​mana​nda/​marri​age.html. Srivastava, A., & Mohanty, S. K. (2013). Age and sex pattern of cardiovascular mortality,

hospitalisation and associated cost in India. PloS One, 8(5), e62134. St. George, A., & McNamara, P. (1984). Religion, race and psychological well-​being. Journal for the Scientific Study of Religion, 23, 351–​363. Stack, S. (1983a). The effect of religious commitment on suicide: a cross-​national analysis. Journal of Health and Social Behavior, 24(4), 362–​374. Stack, S. (1983b). A comparative analysis of suicide and religiosity. Journal of Social Psychology, 119(2), 285–​286. Stack, S. (1998). Heavy metal, religiosity, and suicide acceptability. Suicide & Life-​threatening Behavior, 28, 388–​394. Stack, S. (2000). Blues fans and suicide acceptability. Death Studies, 24(3), 223–​231. Stack, S. (2002). Opera subculture and suicide for honor. Death Studies, 26(5), 431–​437. Stack, S., & Kposowa, A. (2006). The effect of religiosity on tax fraud acceptability. Journal for the Scientific Study of Religion, 45(3), 325–​351. Stack, S., & Kposowa, A. J. (2008). The association of suicide rates with individual-​level suicide attitudes: a cross-​national analysis. Social Science Quarterly, 89(1), 39–​59. Stack, S., & Kposowa, A. J. (2011). Religion and suicide acceptability: a cross-​national analysis. Journal for the Scientific Study of Religion, 50(2), 289–​306. Stack, S., & Wasserman, I. (1992). The effect of religion on suicide ideology: an analysis of the networks perspective. Journal for the Scientific Study of Religion, 31(4), 457–​466. Stack, S., & Wasserman, I. (1995). The effect of marriage, family, and religious ties on African American suicide ideology. Journal of Marriage and the Family, 57(1), 215–​222. Stack, S., Wasserman, I. M., & Kposowa, A. (1994). The effects of religion and feminism on suicide ideology: an analysis of national survey data. Journal for the Scientific Study of Religion, 33(2), 110–​121. Stadlbauer, V., Horvath, A., Komarova, I., Schmerboeck, B., Feldbacher, N., Wurm, S., et al. (2019). A single alcohol binge impacts on neutrophil function without changes in gut barrier function and gut microbiome composition in healthy volunteers. PloS One, 14(2), e0211703. Stahl, E. A., Breen, G., Forstner, A. J., McQuillin, A., Ripke, S., Trubetskoy, V., et al. (2019). Genome-​wide association study identifies 30 loci

References • 1023

associated with bipolar disorder. Nature Genetics, 51(5), 793–​803. Stahler, G. J., Shipley, T. E., Jr., Kirby, K. C., Godboldte, C., Kerwin, M. E., Shandler, I., et al. (2005). Development and initial demonstration of a community-​based intervention for homeless, cocaine-​using, African-​American Women. Journal of Substance Abuse Treatment, 28(2), 171–​179. Stahler, G. J., Kirby, K. C., & Kerwin, M. E. (2007). A faith-​based intervention for cocaine-​dependent Black women. Journal of Psychoactive Drugs, 39(2), 183–​190. Stamatakis, E., Gale, J., Bauman, A., Ekelund, U., Hamer, M., & Ding, D. (2019). Sitting time, physical activity, and risk of mortality in adults. Journal of the American College of Cardiology, 73(16), 2062–​2072. Stampfer, M. J., Hu, F., Manson, J., Rimm, E., & Willett, W. (2000). Primary prevention of coronary heart disease in women through diet and lifestyle. New England Journal of Medicine, 343, 16–​22. Stanley, M. A., Bush, A. L., Camp, M. E., Jameson, J. P., Phillips, L. L., Barber, C. R., et al. (2011). Older adults’ preferences for religion/​spirituality in treatment for anxiety and depression. Aging & Mental Health, 15(3), 334–​343. Stanley, S. M., Markman, H. J., & Whitton, S. W. (2002). Communication, conflict and commitment: insights on the foundations of relationship success from a national survey. Family Process, 41, 659–​675. Stansfield, R. (2018). Religion and desistance from substance use among adolescent offenders: the role of cognitive functioning. Criminal Behaviour and Mental Health, 28(4), 350–​360. Stansfield, R., Mowen, T. J., O’Connor, T., & Boman, J. H. (2017). The role of religious support in reentry: evidence from the SVORI data. Journal of Research in Crime and Delinquency, 54(1), 111–​145. Stansfield, R., O’Connor, T., & Duncan, J. (2019). Religious identity and the long-​term effects of religious involvement, orientation, and coping in prison. Criminal Justice and Behavior, 46(2), 337–​354. Stansfield, R., O’Connor, T., Duncan, J., & Hall, S. (2020). Comparing recidivism of sexual and nonsexual offenders. Sexual Abuse, 32(6), 634–​656. Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Quarterly, 83(3), 457–​502.

1024 •  R eferences

Stark, R. (1996). Religion as context: hellfire and delinquency one more time. Sociology of Religion, 57, 163–​173. Stark, R., Kent, L., & Doyle, D. P. (1982). Religion and delinquency: the ecology of a “lost” relationship. Journal of Research in Crime & Delinquency, 19, 4–​24. Stavig, G. R., Igra, A., & Leonard, A. R. (1984). Hypertension among Asians and Pacific Islanders in California. American Journal of Epidemiology, 119, 677–​691. Stavrova, O. (2015). Religion, self-​rated heatlh, and mortality: whether religiosity delays death depends on the cultural context. Social Psychological and Personality Science, 6(8), 911–​922. Stavrova, O., Fetchenhauer, D., & Schlösser, T. (2013). Why are religious people happy? The effect of the social norm of religiosity across countries. Social Science Research, 42(1), 90–​105. Stearns, M., & McKinney, C. (2020). Conflict associated with stronger parent-​child religiosity in emerging adults, especially for sons. Psychology of Religion and Spirituality, 12(2), 149–​156. Stecula, D. A., Kuru, O., Albarracin, D., & Jamieson, K. H. (2020). Policy views and negative beliefs about vaccines in the United States, 2019. American Journal of Public Health, 110(10), 1561–​1563. Stecz, P., & Kocur, J. (2015). Religiousness, religious coping with illness, and psychological function among Polish elderly patients with osteoarthritis undergoing arthroplasty. Journal of Religion and Health, 54(2), 554–​570. Stecz, P., Wrzesińska, M., Tabała, K., & Nowakowska-​Domagała, K. (2017). Emotional distress associated with surgical treatment and its relationship with coping profiles among chronically ill older patients. Current Psychology, 36(1), 174–​183. Steeds, C. E. (2016). The anatomy and physiology of pain. Surgery, 34(2), 55–​59. Steel, A. J., & Eslick, G. D. (2015). Herpes viruses increase the risk of Alzheimer’s disease: a meta-​ analysis. Journal of Alzheimer’s Disease, 47(2), 351–​364. Steel, J. L., Antoni, M., Pathak, R., Butterfield, L. H., Vodovotz, Y., Savkova, A., et al. (2020). Adverse childhood experiences (ACEs), cell-​mediated immunity, and survival in the context of cancer. Brain, Behavior, and Immunity, 88, 566–​572. Steel, Z., Marnane, C., Iranpour, C., Chey, T., Jackson, J. W., Patel, V., et al. (2014). The

global prevalence of common mental disorders. International Journal of Epidemiology, 43(2), 476–​493. Steenhuis, L. A., Bartels-​Velthuis, A. A., Jenner, J. A., Aleman, A., Bruggeman, R., Nauta, M. H., et al. (2016). Religiosity in young adolescents with auditory vocal hallucinations. Psychiatry Research, 236, 158–​164. Steensland, B., Robinson, L. D., Wilcox, W. B., Park, J. Z., Regnerus, M. D., & Woodberry, R. D. (2000). The measure of American religion. Social Forces, 79(1), 291–​318. Stefanac, N., Hetrick, S., Hulbert, C., Spittal, M. J., Witt, K., & Robinson, J. (2019). Are young female suicides increasing? A comparison of sex-​specific rates and characteristics of youth suicides in Australia over 2004-​2014. BMC Public Health, 19(1), 1389. Stefanidis, K. B., Askew, C. D., Greaves, K., & Summers, M. J. (2018). The effect of non-​ stroke cardiovascular disease states on risk for cognitive decline and dementia. Neuropsychology Review, 28(1), 1–​15. Steffen, P. R., Masters, K. S., & Baldwin, S. (2017). What mediates the relationship between religious service attendance and aspects of well-​being? Journal of Religion and Health, 56(1), 158–​170. Stegenga, B. T., Nazareth, I., Torres-​González, F., Xavier, M., Švab, I., Geerlings, M. I., et al. (2012). Depression, anxiety and physical function. Journal of Epidemiology and Community Health, 66(7), e25–​e25. Steingrímsdóttir, Ó. A., Landmark, T., Macfarlane, G. J., & Nielsen, C. S. (2017). Defining chronic pain in epidemiological studies. Pain, 158(11), 2092–​2107. Steinman, K. J. (2005). Drug selling among high school students. Journal of Adolescent Health, 36(1), 71e1–​71e8. Steinman, K. J., Ferketich, A., & Sahr, T. (2008). The dose-​response relationship of adolescent religious activity and substance use: variation across demographic groups. Health Education & Behavior, 35(1), 22–​43. Steinman, K. J., & Zimmerman, M. A. (2004). Religious activity and risk behavior among African American adolescents. American Journal of Community Psychology, 33(3–​4), 151–​161. Stellar, J. E., John-​Henderson, N., Anderson, C. L., Gordon, A. M., McNeil, G. D., et al. (2015). Positive affect and markers of inflammation: discrete positive emotions predict lower levels of inflammatory cytokines. Emotion, 15(2), 129.

Stenholm, S., Koster, A., Valkeinen, H., Patel, K. V., Bandinelli, S., Guralnik, J. M., et al. (2016). Association of physical activity history with physical function and mortality in old age. Journals of Gerontology, 71B(4), M496–​501. Stephen, R., Hongisto, K., Solomon, A., & Lönnroos, E. (2017). Physical activity and Alzheimer’s disease. Journals of Gerontology, 72A(6), M733–​739. Steptoe, A. (2019). Happiness and health. Annual Review of Public Health, 40, 339–​359. Steptoe, A., & Ussher, M. (2006). Smoking, cortisol, and nicotine. International Journal of Psychophysiology, 59, 228–​235. Steptoe, A., & Kivimäki, M. (2013). Stress and cardiovascular disease: an update on current knowledge. Annual Review of Public Health, 34, 337–​354. Stern, R. M., Rasinski, K. A., & Curlin, F. A. (2011). Jewish physicians’ beliefs and practices regarding religion/​spirituality in the clinical encounter. Journal of Religion and Health, 50(4), 806–​817. Sternfeld, B., Colvin, A., Stewart, A., Dugan, S., Nackers, L., El Khoudary, S. R., et al. (2017). The impact of a healthy lifestyle on future physical functioning in midlife women. Medicine and Science in Sports and Exercise, 49(2), 274. Sternthal, M. J., Williams, D. R., Musick, M. A., & Buck, A. C. (2010). Depression, anxiety, and religious life: a search for mediators. Journal of Health and Social Behavior, 51(3), 343–​359. Sternthal, M. J., Williams, D. R., Musick, M. A., & Buck, A. C. (2012). Religious practices, beliefs, and mental health: variations across ethnicity. Ethnicity & Health, 17(1–​2), 171–​185. Stetler, C., & Miller, G. E. (2011). Depression and hypothalamic-​pituitary-​adrenal activation. Psychosomatic Medicine, 73(2), 114–​126. Stevens-​Watkins, D., & Rostosky, S. (2010). Binge drinking in African American males from adolescence to young adulthood. Substance Use & Misuse, 45(10), 1435–​1451. Steverman, B. (2018). The latest thing millennials are being blamed for killing? Divorce. Time Magazine, September 25. Retrieved on 12-​3-​ 2020 from https://​time.com/​5405​757/​mill​enni​ als-​us-​divo​rce-​rate-​decl​ine/​. Stewart, D. E., & Yuen, T. (2011). A systematic review of resilience in the physically ill. Psychosomatics, 52(3), 199–​209. Stewart, O., Yamarat, K., Neeser, K. J., Lertmaharit, S., & Holroyd, E. (2014). Buddhist religious practices and blood pressure among elderly in rural Uttaradit Province, northern Thailand. Nursing & Health Sciences, 16(1), 119–​125.

References • 1025

Stier, H., & Kaplan, A. (2020). Are children a joy or a burden? European Journal of Population, 36, 387–​413. Stockdale, S. E., Wells, K., Tang, L., Belin, T. R., Zhang, L., & Sherbourne, C. (2007). The importance of social context: neighborhood stressors, stress-​buffering mechanisms, and alcohol, drug, and mental health disorders. Social Science & Medicine, 65(9), 1867–​1881. Stocks, P. (1930). A biometric investigation of twins and their brothers and sisters. Annals of Eugenics, 4(1–​2), 49–​108. Stockwell, T., Zhao, J., Panwar, S., Roemer, A., Naimi, T., & Chikritzhs, T. (2016). Do “moderate” drinkers have reduced mortality risk? A systematic review and meta-​analysis of alcohol consumption and all-​cause mortality. Journal of Studies on Alcohol and Drugs, 77(2), 185–​198. Stoddard-​Dare, P., Tedor, M. F., Quinn, L., & Mallett, C. (2014). An assessment of risk factors for early death among a sample of previously incarcerated youth. Criminal Justice Studies, 27(2), 191–​209. Straight, C. R., Brady, A. O., & Evans, E. (2015). Sex-​ specific relationships of physical activity, body composition, and muscle quality with lower-​ extremity physical function in older men and women. Menopause, 22(3), 297–​303. Strang, S., & Strang, P. (2001). Spiritual thoughts, coping and “sense of coherence” in brain tumour patients and their spouses. Palliative Medicine, 15(2), 127–​134. Strawbridge, W. J., Cohen, R. D., Shema, S. J., & Kaplan, G. A. (1997). Frequent attendance at religious services and mortality over 28 years. American Journal of Public Health, 87, 957–​961. Strawbridge, W. J., Shema, S. J., Cohen, R. D., Roberts, R. E., & Kaplan, G. A. (1998). Religiosity buffers effects of some stressors on depression but exacerbates others. Journal of Gerontology, 53(3), S118–​S126. Strawbridge, W. J., Shema, S. J., Cohen, R. D., & Kaplan, G. A. (2001). Religious attendance increases survival by improving and maintaining good health behaviors, mental health, and social relationships. Annals of Behavioral Medicine, 23(1), 68–​74. Strawn, J. R., & Geracioti, T. D., Jr. (2008). Noradrenergic dysfunction and the psychopharmacology of posttraumatic stress disorder. Depression and Anxiety, 25(3), 260–​271. Strazzullo, P., D'Elia, L., Cairella, G., Garbagnati, F., Cappuccio, F. P., & Scalfi, L. (2010). Excess body weight and incidence of stroke: meta-​analysis of

1026 •  R eferences

prospective studies with 2 million participants. Stroke, 41(5), e418–​e426. Streubert-​Speziale, H. J., & Carpenter, D. R. (2006). Qualitative Research in Nursing: Advancing the Humanistic Imperative, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins. Strielkowski, W. (2018). Predatory publishing: what are the alternatives to Beall’s list? American Journal of Medicine, 131(4), 333–​334. Stringhini, S., Carmeli, C., Jokela, M., Avendaño, M., Muennig, P., Guida, F., et al. (2017). Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-​ analysis of 1.7 million men and women. The Lancet, 389(10075), 1229–​1237. Strobbe, S., Cranford, J., Wojnar, M., & Brower, K. (2013). Spiritual awakening predicts improved drinking outcomes in a Polish treatment sample. Journal of Addiction Nursing, 24(4), 209–​216. Strogatz, D. S., & James, S. A. (1986). Social support and hypertension among Blacks and Whites in a rural, southern community. American Journal of Epidemiology, 124(6), 949–​956. Stroope, S., & Baker, J. O. (2018). Whose moral community? Religiosity, secularity, and self-​ rated health across communal religious contexts. Journal of Health and Social Behavior, 59(2), 185–​199. Stroppa, A., & Moreira‐Almeida, A. (2013). Religiosity, mood symptoms, and quality of life in bipolar disorder. Bipolar Disorders, 15(4), 385–​393. Stroppa, A., Colugnati, F. A., Koenig, H. G., & Moreira-​Almeida, A. (2018). Religiosity, depression, and quality of life in bipolar disorder: a two-​year prospective study. Brazilian Journal of Psychiatry, 40(3), 238–​243. Strote, J., Lee, J., & Wechsler, H. (2002). Increasing MDMA use among college students: results from a national survey. Journal of Adolescent Health, 30(1), 64–​72. Stroud, C. B., Davila, J., & Moyer, A. (2008). The relationship between stress and depression in first onsets versus recurrences: a meta-​analytic review. Journal of Abnormal Psychology, 117(1), 206–​213. Struthers, R., Eschiti, V. S., & Patchell, B. (2004). Traditional indigenous healing: Part I. Complementary Therapies in Nursing and Midwifery, 10(3), 141–​149. Stuck, C., Campbell, N., Bragg, J., & Moran, R. (2012). Psychiatry in the Deep South: a pilot study of integrated training for psychiatry

residents and seminary students. Academic Psychiatry, 36(1), 51–​55. Štulhofer, A., Šoh, D., Jelaska, N., Baćak, V., & Landripet, I. (2011). Religiosity and sexual risk behavior among Croatian college students, 1998–​2008. Journal of Sex Research, 48(4), 360–​371. Stunkard, A., & McLaren-​Hume, M. (1959). The results of treatment for obesity. Archives of Internal Medicine, 103(1), 79–​85. Stupiansky, N. W., Rosenthal, S. L., Wiehe, S. E., & Zimet, G. D. (2010). Human papillomavirus vaccine acceptability among a national sample of adult women in the USA. Sexual Health, 7(3), 304–​309. Stutzer, A., & Frey, B. S. (2006). Does marriage make people happy, or do happy people get married? Journal of Socio-​Economics, 35(2), 326–​347. Su, X., Huang, X., Jin, Y., Wan, S., & Han, Z. (2018). The relationship of individual social activity and cognitive function of community Chinese elderly: a cross-​sectional study. Neuropsychiatric Disease and Treatment, 14, 2149–​2157. Su, X. Y., Lau, J. T., Mak, W. W., Choi, K. C., Feng, T. J., Chen, X., et al. (2015). A preliminary validation of the Brief COPE instrument for assessing coping strategies among people living with HIV in China. Infectious Diseases of Poverty, 4(1), 41. Subramuniyaswami, S. (1992). Let’s talk about suicide. Hinduism Today, December. Retrieved on 6-​10-​2019 from https://​www.hindui​smto​ day.com/​modu​les/​smart​sect​ion/​item.php?ite​ mid=​985. Suh, H., Hill, T. D., & Koenig, H. G. (2019). Religious attendance and biological risk: A national longitudinal study of older adults. Journal of Religion and Health, 58(4), 1188–​1202. Suhail, K., & Chaudhry, H. R. (2004). Predictors of subjective well-​being in an Eastern Muslim culture. Journal of Social & Clinical Psychology, 23(3), 359–​376. Suhail, K., & Ghauri, S. (2010). Phenomenology of delusions and hallucinations in schizophrenia by religious convictions. Mental Health, Religion & Culture, 13(3), 245–​259. Sujoldzic, A., Peternel, L., Kulenovic, T., & Terzic, R. (2006). Social determinants of health-​-​a comparative study of Bosnian adolescents in different cultural contexts. Collegium Antropologicum, 30, 703–​711. Sullins, D. P. (2006). Gender and religion: deconstructing universality,

constructing complexity. American Journal of Sociology, 112(3), 838–​880. Sullivan, A. R. (2010). Mortality differentials and religion in the United States: Religious affiliation and attendance. Journal for the Scientific Study of Religion, 49(4), 740–​753. Sullivan, P. F., Kendler, K. S., & Neale, M. C. (2003). Schizophrenia as a complex trait. Archives of General Psychiatry, 60(12), 1187–​1192. Sullivan, P. F., Neale, M. C., & Kendler, K. S. (2000). Genetic epidemiology of major depression: review and meta-​analysis. American Journal of Psychiatry, 157(10), 1552–​1562. Suls, J. (2018). Toxic affect: are anger, anxiety, and depression independent risk factors for cardiovascular disease? Emotion Review, 10(1), 6–​17. Suls, J. E., & Wills, T. (1991). Social Comparison: Contemporary Theory and Research. Mahwah, NJ: Lawrence Erlbaum Associates. Sultan, S., Kanwal, F., & Hussain, I. (2020). Moderating effects of personality traits in relationship between religious practices and mental health of university students. Journal of Religion and Health, 59, 2458–​2468. Sun, F., Park, N. S., Roff, L., Klemmack, D., Parker, M., & Koenig, H. G., et al. (2012). Predicting the trajectories of depressive symptoms among southern community-​dwelling older adults: the role of religiosity. Aging and Mental Health, 16(2), 189–​198. Sun, Y., Ma, W., Wu, Y., Koenig, H. G., & Wang, Z. (2018). The mediating effect of depression in religiosity and cognitive function among Chinese Muslim elderly. Neuropsychiatry, 8(3), 1046–​1053. Sundquist, J., Johansson, S. E., Yang, M., & Sundquist, K. (2006). Low linking social capital as a predictor of coronary heart disease in Sweden: a cohort study of 2.8 million people. Social Science & Medicine, 62(4), 954–​963. Sundström, A., Westerlund, O., & Kotyrlo, E. (2016). Marital status and risk of dementia: a nationwide population-​based prospective study from Sweden. BMJ Open, 6(1), e008565. Sundt, J. L., Dammer, H. R., & Cullen, F. T. (2002). The role of the prison chaplain in rehabilitation. Journal of Offender Rehabilitation, 35(3–​ 4), 59–​86. Superville, D. J., Pargament, K., & Lee, J. (2014). Sabbath keeping and its relationships to health and well-​being: a mediational analysis. International Journal for the Psychology of Religion, 24, 241–​256.

References • 1027

Suris, J. C., Nebot, M., & Parera, N., (2005). Behaviour evaluation for risk-​taking adolescents (BERTA): an easy to use and assess instrument to detect adolescent risky behaviors in a clinical setting. European Journal of Pediatrics, 164(6), 371–​376. Sutantoputri, N., & Watt, H. (2012). Attribution and motivation: a cultural study among Indonesian university students. International Journal of Higher Education, 1(2), 118–​129. Sutherland, I., & Shepherd, J. P. (2001). Social dimensions of adolescent substance use. Addiction, 96(3), 445–​458. Sutin, A. R., Stephan, Y., & Terracciano, A. (2018). Psychological well‐being and risk of dementia. International Journal of Geriatric Psychiatry, 33(5), 743–​747. Svensson, N. H., Hvidt, N. C., Nissen, S. P., Storsveen, M. M., Hvidt, E. A., Søndergaard, J., et al. (2020). Religiosity and health-​related risk behaviours in a secular culture—​is there a correlation? Journal of Religion and Health, 59(5), 2381–​2396. Svob, C., & Weissman, M. (2019). The role of religiosity in families at high-​risk for depression. Ethics, Medicine and Public Health, 9, 1–​6. Svob, C., Wickramaratne, P. J., Reich, L., Zhao, R., Talati, A., Gameroff, M. J., et al. (2018). Association of parent and offspring religiosity with offspring suicide ideation and attempts. JAMA Psychiatry, 75(10), 1062–​1070. Swainson, M. G., Batterham, A. M., Tsakirides, C., Rutherford, Z. H., & Hind, K. (2017). Prediction of whole-​body fat percentage and visceral adipose tissue mass from five anthropometric variables. PloS One, 12(5), e0177175. Swanson, J. W., Holzer, C. E., III, Ganju, V. K., & Jono, R. T. (1990). Violence and psychiatric disorder in the community. Psychiatric Services, 41(7), 761–​770. Szaflarski, M. (2001). Gender, self-​reported health and health-​related lifestyles in Poland. Health Care for Women International, 22(3), 207–​227. Tabriz, E. R., Mohammadi, R., Roshandel, G., Talebi, R., & Khorshidi, M. (2018). Pain coping strategies and their relationship with unpleasant emotions (anxiety, stress, and depression) and religious coping in cancer patients. Middle East Journal of Cancer, 9(3), 208–​216. Tabrizi, R., Akbari, M., Lankarani, K. B., Heydari, S. T., Masoudi, A., Shams, A. H., et al. (2017). Relationship between religion and school students’ road behavior in southern Iran. Chinese Journal of Traumatology, 20(5), 264–​269.

1028 •  R eferences

Tafazoli, M., Nameni, F., Mazloom, S. R., & Mirteymori, M. (2019). The relationship between spiritual health and the intensity of post-​cesarean section pain. Journal of Midwifery and Reproductive Health, 7(2), 1655–​1661. Taggart, T., Gottfredson, N., Powell, W., Ennett, S., Chatters, L., Carter-​Edwards, L., et al. (2018). The role of religious socialization and religiosity in African American and Caribbean Black adolescents’ sexual initiation. Journal of Religion and Health, 57(5), 1889–​1904. Tajadini, H., Zangiabadi, N., Divsalar, K., Safizadeh, H., Esmaili, Z., & Raiei, H. (2017). Effective prayer on intensity of migraine headache: a randomized clinical trial. Journal of Evidence-​ Based Complementarity & Alternative Medicine, 22(1), 37–​40. Takagi, H., Ando, T., Umemoto, T., & ALICE Group. (2017). Perioperative depression or anxiety and postoperative mortality in cardiac surgery. Heart and Vessels, 32(12), 1458–​1468. Talati, A., Bao, Y., Kaufman, J., Shen, L., Schaefer, C. A., & Brown, A. S. (2013). Maternal smoking during pregnancy and bipolar disorder in offspring. American Journal of Psychiatry, 170(10), 1178–​1185. Talib, M. A., & Abdollahi, A. (2017). Spirituality moderates hopelessness, depression, and suicidal behavior among Malaysian adolescents. Journal of Religion and Health, 56(3), 784–​795. Talley, J. A., & Magie, R. (2014). The integration of the “Spirituality in Medicine” curriculum into the osteopathic communication curriculum at Kansas City University of Medicine and Biosciences. Academic Medicine, 89(1), 43–​47. Tan, E. Y., Köhler, S., Hamel, R. E., Muñoz-​ Sánchez, J. L., Verhey, F. R., & Ramakers, I. H. (2019). Depressive symptoms in mild cognitive impairment and the risk of dementia. Journal of Alzheimer’s Disease, 67(4), 1319–​1329. Tan, H. L., Kheirandish-​Gozal, L., & Gozal, D. (2019). Sleep, sleep disorders, and immune function. In Fishbein, A., & Sheldon, S. H. (eds.), Allergy and Sleep. Cham, Switzerland: Springer, pp. 3–​15. Tan, M. M., Chan, C. K., & Reidpath, D. D. (2016). Religiosity, dietary habit, intake of fruit and vegetable, and vegetarian status among Seventh-​ Day Adventists in West Malaysia. Journal of Behavioral Medicine, 39(4), 675–​686. Tan, S. Y. (2011). Mindfulness and acceptance-​ based cognitive behavioral therapies: Empirical evidence and clinical applications from a Christian perspective. Journal of Psychology and Christianity, 30(3), 243.

Tang, M., Maestre, G., Tsai, W. Y., Liu, X., Feng, L., Chung, W. Y., et al. (1996). Effect of age, ethnicity, and head injury on the association between APOE genotypes and Alzheimer’s disease. Annals of New York Academy of Sciences, 802, 6–​15. Taniguchi, H., & Thomas, L. D. (2011). The influences of religious attitudes on volunteering. International Journal of Voluntary and Nonprofit Organizations, 22(2), 335–​355. Tarakeshwar, N., Pargament, K. I., & Mahoney, A. (2003). Initial development of a measure of religious coping among Hindus. Journal of Community Psychology, 31(6), 607–​628. Tarelho, A., Duarte, M., Melim, J., Batista, A., & Almeida, S. (2016). Dietary pattern and mental health: review of literature. European Psychiatry, 33, S517. Tarry, H., & Emler, N. (2007). Attitudes, values and moral reasoning as predictors of delinquency. British Journal of Developmental Psychology, 25(2), 169–​183. Tateyama, M., Asai, M., Kamisada, M., Hashimoto, M., Bartels, M., & Heimann, H. (1993). Comparison of schizophrenic delusions between Japan and Germany. Psychopathology, 26(3–​4), 151–​158. Tavares, B. F., Béria, J. U., & Lima, M. S. D. (2004). Factors associated with drug use among adolescent students in southern Brazil. Revista de Saude Publica, 38(6), 787–​796. Tavares, J. L., Ronneberg, C. R., Miller, E. A., & Burr, J. A. (2019). Stress and inflammation among older adults: the moderating role of religiosity. Journal of Religion, Spirituality & Aging, 31(2), 187–​202. Taylor, B. D., Buckner, A. V., Walker, C. D., & Blumenthal, D. S. (2011). Faith-​based partnerships in graduate medical education: the experience of the Morehouse School of Medicine public health/​preventive medicine residency program. American Journal of Preventive Medicine, 41(4), S283–​S289. Taylor, C. (2007). A Secular Age. Cambridge, MA: Harvard University Press. Taylor, D., Mulekar, M., Luterman, A., Meyer, F., Richards, W., & Rodning, C. (2011). Spirituality within the patient-​surgeon relationship. Journal of Surgical Education, 68(1), 36–​43. Taylor, E. J., Mamier, I., Ricci-​Allegra, P., & Foith, J. (2017). Self-​reported frequency of nurse-​ provided spiritual care. Applied Nursing Research, 35, 30–​35. Taylor, E. J., Gober‐Park, C., Schoonover‐Shoffner, K., Mamier, I., Somaiya, C. K., & Bahjri, K.

(2018). Nurse opinions about initiating spiritual conversation and prayer in patient care. Journal of Advanced Nursing, 74(10), 2381–​2392. Taylor, J. L., Zimet, G. D., Donahue, K. L., Alexander, A. B., Shew, M. L., & Stupiansky, N. W. (2014). Vaccinating sons against HPV: results from a US national survey of parents. PLoS One, 9(12), e115154. Taylor, R. J., & Chatters, L. (1988). Church members as a source of informal social support. Review of Religious Research, 30, 193–​203. Taylor, R. J., & Chatters, L. M. (2010). Importance of religion and spirituality in the lives of African Americans, Caribbean Blacks and non-​Hispanic Whites. Journal of Negro Education, 79(3), 280–​294. Taylor, R. J., Mattis, J., & Chatters, L. M. (1999). Subjective religiosity among African Americans: a synthesis of findings from five national samples. Journal of Black Psychology, 25(4), 524–​543. Taylor, R. J., Chatters, L. M., & Joe, S. (2011). Non-​ organizational religious participation, subjective religiosity, and spirituality among older African Americans and Black Caribbeans. Journal of Religion and Health, 50(3), 623–​645. Taylor, S., Khan, M., Muhammad, A., Akpala, O., van Strien, M., Morry, C., et al. (2017). Understanding vaccine hesitancy in polio eradication in northern Nigeria. Vaccine, 35(47), 6438–​6443. Tchernof, A., & Després, J. P. (2013). Pathophysiology of human visceral obesity: an update. Physiological Reviews, https://​doi.org/​ 10.1152/​phys​rev.00033.2011. TCJA (2017). Tax Cut and Jobs Act. Tax Reform: U.S. Internal Review Service. Retrieved on 10-​9-​2020 from https://​www.irs.gov/​tax-​ ref​orm. te Nijenhuis, J., Dutton, E., Choi, K., Choi, Y., Lee, J., Seo, E., et al. (2021). Do elderly religious people in South Korea have lower mean IQ than elderly non-​religious people? Personality and Individual Differences, 168, 110298. Teachman, J. D. (2002). Stability across cohorts in divorce risk factors. Demography, 39(2), 331–​351. Teachman, J. D. (2003). Premarital sex, premarital cohabitation, and the risk of subsequent marital dissolution among women. Journal of Marriage and Family, 65(2), 444–​455. Teasdale, J. D., Segal, Z. V., Williams, J., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/​recurrence in major depression by mindfulness-​based cognitive

References • 1029

therapy. Journal of Consulting and Clinical Psychology, 68(4), 615–​623. Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. Journal of Traumatic Stress, 9(3), 455–​471. Tedrus, G. M., Fonseca, L., & Hoehr, G. (2014). Spirituality aspects in patients with epilepsy. Seizure, 23, 25–​28. Tedstone, J. E., & Tarrier, N. (2003). Posttraumatic stress disorder following medical illness and treatment. Clinical Psychology Review, 23(3), 409–​448. Teel, K. S., Verdeli, H., Wickramaratne, P., Warner, V., Vousoura, E., Haroz, E. E., et al. (2016). Impact of a father figure’s presence in the household on children’s psychiatric diagnoses and functioning in families at high risk for depression. Journal of Child and Family Studies, 25(2), 588–​597. Teferra, S., Shibre, T., Fekadu, A., Medhin, G., Wakwoya, A., Alem, A., et al. (2012). Five-​year clinical course and outcome of schizophrenia in Ethiopia. Schizophrenia Research, 136(1–​3), 137–​142. Teinonen, T., Vahlberg, T., Isoaho, R., & Kivela, S. L. (2005). Religious attendance and 12-​year survival in older persons. Age & Ageing, 34(4), 406–​409. Tekur, P., Singphow, C., Nagendra, H., & Raghuram, N. (2008). Effect of short-​term intensive yoga program on pain, functional disability and spinal flexibility in chronic low back pain: a randomized control study. Journal of Alternative and Complementary Medicine, 14(6), 637–​644. Telman, M. D., Overbeek, M. M., de Schipper, J. C., Lamers-​Winkelman, F., Finkenauer, C., et al. (2016). Family functioning and children’s post-​ traumatic stress symptoms in a referred sample exposed to interparental violence. Journal of Family Violence, 331(1), 127–​136. Tenke, C. E., Kayser, J., Miller, L., Warner, V., Wickramaratne, P., Weissman, M., et al. (2013). Neuronal generators of posterior EEG alpha reflect individual differences in prioritizing personal spirituality. Biological Psychology, 94, 426–​432. Tenke, C. E., Kayser, J., Svob, C., Miller, L., Alvarenga, J. E., Abraham, K., et al. (2017). Association of posterior EEG alpha with prioritization of religion or spirituality: a replication and extension at 20-​year follow-​up. Biological Psychology, 124, 79–​86. Teplin, L. A., McClelland, G. M., Abram, K. M., & Mileusnic, D. (2005). Early violent death among

1030 •  R eferences

delinquent youth: a prospective longitudinal study. Pediatrics, 115(6), 1586–​1593. Terracciano, A., Sutin, A. R., An, Y., O’Brien, R. J., Ferrucci, L., Zonderman, A. B., et al. (2014). Personality and risk of Alzheimer’s disease: new data and meta-​analysis. Alzheimer’s & Dementia, 10(2), 179–​186. Terry-​McElrath, Y. M., O’Malley, P. M., Johnston, L. D., Bray, B. C., Patrick, M. E., & Schulenberg, J. E. (2017). Longitudinal patterns of marijuana use across ages 18–​50 in a US national sample. Drug and Alcohol Dependence, 171, 70–​83. Teteh, D. K., Lee, J. W., Montgomery, S. B., & Wilson, C. M. (2020). Working together with God: religious coping, perceived discrimination, and hypertension. Journal of Religion and Health, 59(1), 40–​58. Tettey, N. S., Duran, P. A., Andersen, H. S., & Boutin-​Foster, C. (2017). Evaluation of HeartSmarts, a faith-​based cardiovascular health education program. Journal of Religion and Health, 56(1), 320–​328. Tew, J., Ramon, S., Slade, M., Bird, V., Melton, J., & Le Boutillier, C. (2012). Social factors and recovery from mental health difficulties: a review of the evidence. British Journal of Social Work, 42(3), 443–​460. Thanissaro, P. N. (2011). Measuring attitude towards Buddhism and Sikhism: internal consistency reliability for two new instruments. Mental Health, Religion & Culture, 14(8), 797–​803. Thayer, J. F., Yamamoto, S. S., & Brosschot, J. F. (2010). The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors. International Journal of Cardiology, 141(2), 122–​131. Thege, B. K., Pilling, J., Székely, A., & Kopp, M. S. (2013). Relationship between religiosity and health: Evidence from a post-​communist country. International Journal of Behavioral Medicine, 20(4), 477–​486. Theorell, T., Jood, K., Järvholm, L. S., Vingård, E., Perk, J., Östergren, P. O., et al. (2016). A systematic review of studies in the contributions of the work environment to ischaemic heart disease development. European Journal of Public Health, 26(3), 470–​477. Thera, V. N. (2017). Buddha and His Teachings. Onalaska, WA: Pariyatti. Theunissen, M., Peters, M. L., Bruce, J., Gramke, H. F., & Marcus, M. A. (2012). Preoperative anxiety and catastrophizing. Clinical Journal of Pain, 28(9), 819–​841. Thind, A. (2005). Analysis of health services use for respiratory illness in Indonesian

children: implications for policy. Journal of Biosocial Science, 37(2), 129–​142. Thoits, P. A. (2011). Mechanisms linking social ties and support to physical and mental health. Journal of Health and Social Behavior, 52(2), 145–​161. Thomas, A., & Chess, S. (1977). Temperament and Development. Oxford, UK: Brunner/​Mazel. Thomas, N., & Humphrey, C. (Eds.). (1996). Shamanism, History, and the State. Ann Arbor, MI: University of Michigan Press. Thomas, C. R., Russell, W., Robert, R. S., Holzer, C. E., Blakeney, P., & Meyer, W. J. (2012). Personality disorders in young adult survivors of pediatric burn injury. Journal of Personality Disorders, 26(2), 255–​266. Thomas, J., O’Hara, L., Tahboub-​Schulte, S., Grey, I., & Chowdhury, N. (2018). Holy anorexia: eating disorders symptomatology and religiosity among Muslim women in the United Arab Emirates. Psychiatry Research, 260, 495–​499. Thomas, M. E., & Holmes, B. (1992). Determinants of satisfaction for Blacks and Whites. Sociological Quarterly, 33, 459–​472. Thomas, M. L., Kaufmann, C. N., Palmer, B. W., Depp, C. A., Martin, A. S., Glorioso, D. K., et al. (2016). Paradoxical trend for improvement in mental health with aging. Journal of Clinical Psychiatry, 77(8), e1019. Thompson, A. E. (2015). The immune system. Journal of the American Medical Association, 313(16), 1686–​1686. Thompson, B., Coronado, G., Chen, L., Thompson, L. A., Halperin, A., Jaffe, R., et al. (2007). Prevalence and characteristics of smokers at 30 Pacific Northwest colleges and universities. Nicotine & Tobacco Research, 9(3), 429–​438. Thompson, C. A., Yost, K. J., Maurer, M. J., Allmer, C., Farooq, U., Habermann, T. M., et al. (2018). Quality of life at diagnosis predicts overall survival in patients with aggressive lymphoma. Hematological Oncology, 36(5), 749–​756. Thompson, K., Tak, H. J., El-​Din, M., Madani, S., Brauer, S. G., & Yoon, J. D. (2019). Physicians’ religious characteristics and their perceptions of the psychological impact of patient prayer and beliefs at the end of life. American Journal of Hospice and Palliative Medicine, 36(2), 116–​122. Thompson, M. P., Ho, C. H., & Kingree, J. B. (2007). Prospective associations between delinquency and suicidal behaviors in a nationally representative sample. Journal of Adolescent Health, 40(3), 232–​237. Thompson, T., Pérez, M., Kreuter, M., Margenthaler, J., Colditz, G., & Jeffe, D. B. (2017). Perceived

social support in African American breast cancer patients: predictors and effects. Social Science & Medicine, 192, 134–​142. Thompson, V. L., Arnold, L. D., & Notaro, S. R. (2011). African American parents’ attitudes toward HPV vaccination. Ethnicity & Disease, 21(3), 335. Thorndike, A. N. (2019). E-​cigarette use by young adult nonsmokers: next-​generation nicotine dependence? Annals of Internal Medicine, 170(1), 70–​71. Thornton, A., & Camburn, D. (1989). Religious participation and adolescent sexual behavior and attitudes. Journal of Marriage and the Family, 51, 641–​653. Thornton, E. E. (1970). Professional Education for Ministry: A History of Clinical Pastoral Education. Nashville, TN: Abingdon Press. Thuné‐Boyle, I. C., Stygall, J., Keshtgar, M. R., Davidson, T. I., & Newman, S. P. (2011). Religious coping strategies in patients diagnosed with breast cancer in the UK. Psycho‐oncology, 20(7), 771–​782. Thurstone, L. L., & Chave, E. J. (1929). The Measurement of Attitude: A Psychophysical Method and Some Experiments with a Scale for Measuring Attitude toward the Church. Chicago, IL: University of Chicago Press. Thygesen, L. C., Dalton, S., Johansen, C., Ross, L., Kessing, L., & Hvidt, N. (2013). Psychiatric disease incidence among Danish Seventh-​Day Adventists and Baptists. Social Psychiatry and Psychiatric Epidemiology, 48, 1583–​1590. Tibbetts, S. G., & Gibson, C. L. (2002). Individual propensities and rational decision-​ making: recent findings and promising approaches (Ch. 1). In Piquero, A. R., & Tibbetts, S. G. (eds.), Rational Choice and Criminal Behavior: Recent Research and Future Challenges. London: Routledge, pp. 3–​24. Tillich, P. (1957). Dynamics of Faith. New York, NY: Harper Torchbooks. Timberlake, D. S., Rhee, S. H., Haberstick, B. C., Hopfer, C., Ehringer, M., Lessem, J. M., et al. (2006). The moderating effects of religiosity on the genetic and environmental determinants of smoking initiation. Nicotine and Tobacco Research, 8(1), 123–​133. Timio, M., Verdecchia, P., Venanzi, S., Gentili, S., Ronconi, M., Francucci, B., et al. (1988). Age and blood pressure changes: a 20-​year follow-​up study in nuns in a secluded order. Hypertension, 12, 457–​461. Timio, M., Saronio, P., Verdura, C., Schiaroli, M., Timio, F., & Monarca, C. (2001). A link between

References • 1031

psychosocial factors and blood pressure trend in women. Physiology & Behavior, 73(3), 359–​363. Timmins, F., Neill, F., Murphy, M., Begley, T., & Sheaf, G. (2015). Spiritual care competence for contemporary nursing practice: a quantitative exploration of the guidance provided by fundamental nursing textbooks. Nurse Education in Practice, 15(6), 485–​491. Timmins, F., Caldeira, S., Murphy, M., Pujol, N., Sheaf, G., Weathers, E., et al. (2018). The role of the healthcare chaplain. Journal of Health Care Chaplaincy, 24(3), 87–​106. Tindle, H. A., Chang, Y., Kuller, L., Manson, J., Robinson, J., Rosal, M., et al. (2009). Optimism, cynical hostility, and incident coronary heart disease and mortality in the women’s health initiative. Circulation, 120, 656–​662. Tinetti, M. E., McAvay, G. J., Murphy, T. E., Gross, C. P., Lin, H., & Allore, H. G. (2012). Contribution of individual diseases to death in older adults with multiple diseases. Journal of the American Geriatrics Society, 60(8), 1448–​1456. Tirosh, A., Shai, I., Afek, A., Dubnov-​R az, G., Ayalon, N., Gordon, B., et al. (2011). Adolescent BMI trajectory and risk of diabetes versus coronary disease. New England Journal of Medicine, 364(14), 1315–​1325. Tirrell, J. M., Geldhof, G. J., King, P. E., Dowling, E. M., Sim, A. T., Williams, K., et al. (2019). Measuring spirituality, hope, and thriving among Salvadoran youth. Child & Youth Care Forum, 48(2), 241–​268. Tiwari, K. N. (1998). Classical Indian Ethical Thought: A Philosophical Study of Hindu, Jaina, and Buddhist Morals. New Delhi, India: Motilal Banarsidass Publishers, pp. 52–​55. Tix, A. P., & Frazier, P. A. (1998). The use of religious coping during stressful life events: main effects, moderation, and mediation. Journal of Consulting and Clinical Psychology, 66(2), 411. Tobin, E. T., & Slatcher, R. B. (2016). Religious participation predicts diurnal cortisol profiles 10 years later via lower levels of religious struggle. Health Psychology, 35(12), 1356–​1363. Toh, Y. M., & Tan, S. (1997). The effectiveness of church-​based lay counselors: a controlled outcome study. Journal of Psychology and Christianity, 16, 260–​267. Tohen, M., Greenfield, S. F., Weiss, R. D., Zarate, C. A., & Vagge, L. M. (1998). The effect of comorbid substance use disorders on the course of bipolar disorder: a review. Harvard Review of Psychiatry, 6(3), 133–​141.

1032 •  R eferences

Tolppanen, A. M., Ngandu, T., Kåreholt, I., Laatikainen, T., Rusanen, M., Soininen, H., et al. (2014). Midlife and late-​life body mass index and late-​life dementia. Journal of Alzheimer’s Disease, 38(1), 201–​209. Toma, A., Paré, G., & Leong, D. P. (2017). Alcohol and cardiovascular disease: how much is too much? Current Atherosclerosis Reports, 19(3), 13. Tomaszewska, P., & Krahé, B. (2018). Predictors of sexual aggression victimization and perpetration among Polish university students: a longitudinal study. Archives of Sexual Behavior, 47(2), 493–​505. Tomić, T., Domínguez-​López, S., & Barrios-​ Rodríguez, R. (2019). Non-​aspirin non-​steroidal anti-​inflammatory drugs in prevention of colorectal cancer in people aged 40 or older. Cancer Epidemiology, 58, 52–​62. Tomita, A., & Ramlall, S. (2018). A nationwide panel study on religious involvement and depression in South Africa. Journal of Religion and Health, 57(6), 2279–​2289. Tonga, J. B., Arnevik, E. A., Werheid, K., & Ulstein, I. D. (2016). Manual-​based cognitive behavioral and cognitive rehabilitation therapy for young-​ onset dementia: a case report. International Psychogeriatrics, 28(3), 519–​522. Tonigan, J. S., Miller, W. R., & Schermer, C. (2002). Atheists, agnostics and Alcoholics Anonymous. Journal of Studies on Alcohol, 63(5), 534–​541. Tonigan, J. S., Rynes, K. N., & McCrady, B. S. (2013). Spirituality as a change mechanism in 12-​step programs: a replication, extension, and refinement. Substance Use & Misuse, 48(12), 1161–​1173. Tonigan, J. S., Pearson, M. R., Magill, M., & Hagler, K. J. (2018). AA attendance and abstinence for dually diagnosed patients: a meta-​analytic review. Addiction, 113(11), 1970–​1981. Tønnesen, M. T., Miani, A., Pedersen, A. S., Mitkidis, P., Zak, P. J., & Winterdahl, M. (2019). Neuropeptide Y and religious commitment in healthy young women. Acta Neuropsychiatrica, 31(2), 106–​112. Topiwala, A., Allan, C. L., Valkanova, V., Zsoldos, E., Filippini, N., Sexton, C., et al. (2017). Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline. British Medical Journal, 357, j2353. TOPS (2020). Real people: real weight loss. TOPS Club, Inc. Retrieved on 1-​10-​2020 from https://​ www.tops.org/​. Torgler, B. (2006). The importance of faith: tax morale and religiosity. Journal of Economic Behavior & Organization, 61(1), 81–​109.

Tort, L., & Teles, M. (2011). The endocrine response to stress-​a comparative view. Basic and Clinical Endocrinology Up-​To-​Date, 263–​286 (https://​www.int​echo​pen.com/​books/​basic-​and-​ clini​cal-​endocr​inol​ogy-​up-​to-​date/​the-​endocr​ ine-​respo​nse-​to-​str​ess-​a-​comp​arat​ive-​view). Toussa​int, L. L., Owen, A. D., & Cheadle, A. (2012). Forgive to live: forgiveness, health, and longevity. Journal of Behavioral Medicine, 35(4), 375–​386. Toussaint, L. L., Wilson, C. M., Wilson, L. C., & Williams, D. R. (2015a). Religiousness and suicide in a nationally representative sample of Trinidad and Tobago adolescents and young adults. Social Psychiatry and Psychiatric Epidemiology, 50(9), 1441–​1450. Toussaint, L. L., Worthington, E. L., Jr., & Williams, D. R. (2015b). Forgiveness and Health: Scientific Evidence and Theories Relating Forgiveness to Better Health. New York, NY: Springer. Toussaint, L. L., Shields, G. S., Dorn, G., & Slavich, G. M. (2016). Effects of lifetime stress exposure on mental and physical health in young adulthood: How stress degrades and forgiveness protects health. Journal of Health Psychology, 21(6), 1004–​1014. Toussaint, L. L., & Williams, D. R. (2008). National survey results for Protestant, Catholic, and nonreligious experiences of seeking forgiveness and of forgiveness of self, of others, and by God. Journal of Psychology and Christianity, 27(2), 120–​130. Towfighi, A., Zheng, L., & Ovbiagele, B. (2009). Sex-​ specific trends in midlife coronary heart disease risk and prevalence. Archives of Internal Medicine, 169(19), 1762–​1766. Tracey, T. J., Ryan, J. M., & Jaschik-​Herman, B. (2001). Complementarity of interpersonal circumplex traits. Personality and Social Psychology Bulletin, 27(7), 786–​797. Tran, C. T., Kuhn, E., Walser, R. D., & Drescher, K. D. (2012). The relationship between religiosity, PTSD, and depressive symptoms in veterans in PTSD residential treatment. Journal of Psychology and Theology, 40(4), 313–​322. Tran, N. T., Najman, J. M., & Hayatbakhsh, R. (2015). Predictors of maternal drinking trajectories before and after pregnancy. Australian and New Zealand Journal of Obstetrics and Gynaecology, 55(2), 123–​130. Travers, J. L., Hirschman, K. B., Hanlon, A. L., Huang, L., & Naylor, M. D. (2020). Factors associated with perceived worsened physical health among older adults who are newly enrolled long-​term services and supports

recipients. INQUIRY: Journal of Health Care Organization, Provision, and Financing, 57, 1–​10 (https://​doi.org/​10.1177/​00469​5801​9900​835). Treede, R. D. (2018). The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. Pain Reports, 3(2), e643. Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., et al. (2015). A classification of chronic pain for ICD-​11. Pain, 156(6), 1003. Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., et al. (2019). Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-​11). Pain, 160(1), 19–​27. Trevino, K. M., Pargament, K. I., Cotton, S., Leonard, A. C., Hahn, J., Caprini-​Faigin, C. A., et al. (2010). Religious coping and physiological, psychological, social, and spiritual outcomes in patients with HIV/​AIDS: cross-​sectional and longitudinal findings. AIDS & Behavior, 14(2), 379–​389. Trevino, K. M., Balboni, M., Zollfrank, A., Balboni, T., & Prigerson, H. G. (2014). Negative religious coping as a correlate of suicidal ideation in patients with advanced cancer. Psycho‐Oncology, 23(8), 936–​945. Trevino, K. M., Naik, A. D., & Moye, J. (2016). Perceived and actual change in religion/​spirituality in cancer survivors: longitudinal relationships with distress and perceived growth. Psychology of Religion and Spirituality, 8(3), 195–​205. Trinitapoli, J. (2009). Religious teachings and influences on the ABCs of HIV prevention in Malawi. Social Science & Medicine, 69(2), 199–​209. Trinitapoli, J., & Regnerus, M. D. (2006). Religion and HIV risk behaviors among married men: Initial results from a study in rural Sub-​ Saharan Africa. Journal for the Scientific Study of Religion, 45(4), 505–​528. Trinity Lutheran Church of Columbia, Inc., v. Comer (2017). 137 S. Ct. 2012. Retrieved on 10-​11-​ 2020 from https://​www.supre​meco​urt.gov/​opini​ ons/​16pdf/​15-​577_​k​hlp.pdf. Tritter, J. (1992). An educated change in moral values: Some effects of religious and state schools on their students. Oxford Review of Education, 18(1), 29–​43. Tronvik, E., Sorensen, T., Linde, M., Bendtsen, L., Artto, V., Laurell, K., et al. (2014). The relationship between headache and religious attendance (the Nord-​Trondelag health study—​ HUNT). Journal of Headache and Pain, 15(1), 1–​7. Troutman, A., & Benjamin, G. (2013). Preface. In Rudolph, L., Caplan, J., Ben-​Moshe, K., Dillon, L. (eds.), Health in All Policies: A Guide

References • 1033

for State and Local Governments. Washington, DC, and Oakland, CA: American Public Health Association and Public Health Institute, p. 1. Troxel, W. M., Lee, L., Hall, M., & Matthews, K. A. (2014). Single-​parent family structure and sleep problems in black and white adolescents. Sleep Medicine, 15(2), 255–​261. Trudel-​Fitzgerald, C., Boehm, J. K., Kivimaki, M., & Kubzansky, L. D. (2014). Taking the tension out of hypertension: a prospective study of psychological well-​being and hypertension. Journal of Hypertension, 32(6), 1222–​1228. Trudel-​Fitzgerald, C., Millstein, R. A., von Hippel, C., Howe, C. J., Tomasso, L. P., Wagner, G. R., et al. (2019). Psychological well-​being as part of the public health debate? BMC Public Health, 19(1), 1–​11. Trudel-​Fitzgerald, C., Zevon, E. S., Kawachi, I., Tucker-​Seeley, R. D., Grodstein, F., & Kubzansky, L. D. (2020). The prospective association of social integration with life span and exceptional longevity in women. Journals of Gerontology, 75B(10), 2132–​2141. Truett, K., Eaves, L., Meyer, J., Heath, A., & Martin, N. (1992). Religion and education as mediators of attitudes: a multivariate analysis. Behavior Genetics, 22, 43–​62. Trzebiatowska, M., & Bruce, S. (2012). Why Are Women More Religious Than Men? New York, NY: Oxford University Press. Tsai, J., & Pietrzak, R. H. (2017). Trajectories of posttraumatic growth among US military veterans: a 4-​year nationally representative, prospective cohort study. Acta Psychiatrica Scandinavica, 136(5), 483–​492. Tsai, J., & Rosenheck, R. A. (2011). Religiosity among adults who are chronically homeless: association with clinical and psychosocial outcomes. Psychiatric Services, 62(10), 1222–​1224. Tsai, A. G., & Wadden, T. A. (2005). Systematic review: an evaluation of major commercial weight loss programs in the United States. Annals of Internal Medicine, 142(1), 56–​66. Tsai, J., Rosenheck, R. A., Kasprow, W. J., & McGuire, J. F. (2012). Do faith-​based residential care services affect the religious faith and clinical outcomes of homeless veterans? Community Mental Health Journal, 48(6), 682–​691. Tsai, J., El-​Gabalawy, R., Sledge, W., Southwick, S., & Pietrzak, R. (2015). Post-​traumatic growth among veterans in the USA. Psychological Medicine, 45, 165–​179. Tsai, J., Sippel, L., Mota, N., Southwick, S., & Pietrzak, R. (2016). Longitudinal course of

1034 •  R eferences

posttraumatic growth among US military veterans: results from the National Health and Resilience in Veterans Study. Depression and Anxiety, 33(1), 9–​18. Tsang, J. A., McCullough, M. E., & Hoyt, W. T. (2005). Psychometric and rationalization accounts of the religion‐forgiveness discrepancy. Journal of Social Issues, 61(4), 785–​805. Tsang, J. A., Carlisle, R. D., & Al-​Kire, R. L. (2020). Forgive and remember: The relationship between religion and the recollection of transgressions. International Journal for the Psychology of Religion, 30(1), 35–​47. Tsuang, M. T., & Simpson, J. C. (2008). Commentary on Koenig (2008): “Concerns about measuring ‘spirituality’ in research.” Journal of Nervous & Mental Disease, 196(8), 647–​649. Tsuchiya, K. J., Byrne, M., & Mortensen, P. B. (2003). Risk factors in relation to an emergence of bipolar disorder: a systematic review. Bipolar Disorders, 5(4), 231–​242. Tsukayama, H. (2015). Teens spend nearly nine hours every day consuming media. Washington Post. Accessed on 8-​24-​2019 from https://​www. was​hing​tonp​ost.com/​news/​the-​swi​tch/​wp/​ 2015/​11/​03/​teens-​spend-​nea​rly-​nine-​hours-​ every-​day-​consum​ing-​media/​?nor​edir​ect=​on. Tuck, A., Robinson, M., Agic, B., Ialomiteanu, A. R., & Mann, R. E. (2017). Religion, alcohol use and risk drinking among Canadian adults living in Ontario. Journal of Religion and Health, 56(6), 2023–​2038. Tucker, R. (2019). A threat to end tax exemption for churches and non-​profits. Church Alliance: Alliance Defending Freedom. Retrieved on 10-​3-​2020 from https://​www.adfchu​rcha​llia​nce. org/​post/​a-​thr​eat-​to-​end-​tax-​exempt​ion-​for-​ churc​hes-​and-​non-​prof​i ts. Tugade, M. M., & Fredrickson, B. L. (2004). Resilient individuals use positive emotions to bounce back from negative emotional experiences. Journal of Personality and Social Psychology, 86(2), 320–​333. Tully, J., Viner, R. M., Coen, P. G., Stuart, J. M., Zambon, M., Peckham, C., et al. (2006). Risk and protective factors for meningococcal disease in adolescents: matched cohort study. British Medical Journal, 332(7539), 445–​450. Tully, P. J., Harrison, N. J., Cheung, P., & Cosh, S. (2016). Anxiety and cardiovascular disease risk: a review. Current Cardiology Reports, 18(12), 120. Tumwesigye, N. M., Atuyambe, L., Kibira, S. P., Wabwire-​Mangen, F., Tushemerirwe, F., & Wagner, G. J. (2013). Do religion and religiosity

have anything to do with alcohol consumption patterns? Evidence from two fishing landing sites on Lake Victoria, Uganda. Substance Use & Misuse, 48(12), 1130–​1137. Tuncay, T., Musabak, I., Gok, D., & Kutlu, M. (2008). The relationship between anxiety, coping strategies, and characteristics of patients with diabetes. Health and Quality of Life Outcomes, 6, 79. Turecki, G., & Brent, D. A. (2016). Suicide and suicidal behaviour. Lancet, 387(10024), 1227–​1239. Turner, H., & Cook, C. C. (2016). Perceptions of physiotherapists in relation to spiritual care. Journal for the Study of Spirituality, 6(1), 58–​77. Turner, H. A., Finkelhor, D., Hamby, S. L., & Shattuck, A. (2013). Family structure, victimization, and child mental health in a nationally representative sample. Social Science & Medicine, 87, 39–​51. Turner, J. A., & Clancy, S. (1986). Strategies for coping with chronic low back pain: relationship to pain and disability. Pain, 24(3), 355–​364. Turner, M. D., Nedjai, B., Hurst, T., & Pennington, D. J. (2014). Cytokines and chemokines: at the crossroads of cell signaling and inflammatory disease. Biochimica et Biophysica Acta (BBA), 1843(11), 2563–​2582. Turner, N., Hastings, J. F., & Neighbors, H. W. (2019). Mental health care treatment seeking among African Americans and Caribbean Blacks: what is the role of religiosity/​spirituality? Aging & Mental Health, 23(7), 905–​911. Turner-​Cobb, J. M., Palmer, J., Aronson, D., Russell, L., Purnell, S., Osborn, M., et al. (2010). Diurnal cortisol and coping responses in close relatives of persons with acquired brain injury: a longitudinal mixed methods study. Brain Injury, 24(6), 893–​903. Tuttle, J. D., & Davis, S. N. (2015). Religion, infidelity, and divorce: Reexamining the effect of religious behavior on divorce among long-​married couples. Journal of Divorce & Remarriage, 56(6), 475–​489. Tuvblad, C., & Beaver, K. M. (2013). Genetic and environmental influences on antisocial behavior. Journal of Criminal Justice, 41(5), 273–​276. Twenge, J. M., Exline, J. J., Grubbs, J. B., Sastry, R., & Campbell, W. K. (2015). Generational and time period differences in American adolescents’ religious orientation, 1966–​2014. PloS One, 10(5), e0121454. Twenge, J. M., Joiner, T. E., Rogers, M. L., & Martin, G. N. (2018). Increases in depressive symptoms, suicide-​related outcomes, and suicide rates among US adolescents after 2010 and links

to increased new media screen time. Clinical Psychological Science, 6(1), 3–​17. Twenge, J. M., Cooper, A. B., Joiner, T. E., Duffy, M. E., & Binau, S. G. (2019). Age, period, and cohort trends in mood disorder indicators and suicide-​ related outcomes in a nationally representative dataset, 2005–​2017. Journal of Abnormal Psychology, 128(3), 185. Twig, G., Yaniv, G., Levine, H., Leiba, A., Goldberger, N., Derazne, E., et al. (2016). Body-​mass index in 2.3 million adolescents and cardiovascular death in adulthood. New England Journal of Medicine, 374(25), 2430–​2440. Tyrer, P., Reed, G. M., & Crawford, M. J. (2015). Classification, assessment, prevalence, and effect of personality disorder. Lancet, 385(9969), 717–​726. Tyrka, A. R., Wyche, M. C., Kelly, M. M., Price, L. H., & Carpenter, L. L. (2009). Childhood maltreatment and adult personality disorder symptoms. Psychiatry Research, 165(3), 281–​287. Tzeng, H. J., & Lee, M. C. (2017). Multifaceted changes and mortality in older people: a longitudinal study in Taiwan. Geriatrics & Gerontology International, 17(6), 959–​966. Tzeng, N. S., & Liu, Y. P. (2019). Amphetamine exposure and dementia–​A hypothesis of the long-​term sequelae of cognitive enhancers based on opponent process theory. Medical Hypotheses, 132, 109327. Tzoumakis, S., Burton, M., Carr, V. J., Dean, K., Laurens, K. R., & Green, M. J. (2019). The intergenerational transmission of criminal offending behaviours. Retrieved on 9-​27-​2019 from https://​epri​nts.qut.edu.au/​127​298/​1/​tzou​ maki​s19-​1415-​Fina​lRep​ort.pdf. US Bureau of Justice Statistics (2019). Number of arrests for all offenses in the United States from 1990 to 2020. Retrieved on 8-​9-​2022 from https://​www.stati​sta.com/​sta​tist​ics/​191​261/​ num​ber-​of-​arre​sts-​for-​all-​offen​ses-​in-​the-​us-​ since-​1990/​. US Bureau of Justice Statistics (2020). Selected findings from the FBI’s Uniform Crime Reporting Program. Retrieved on 9-​21-​2020 fromhttps://​www.bjs.gov/​index.cfm?ty=​pbdet​ ail&iid=​6929. US Census (2016). The majority of children live with two parents, Census Bureau reports. Retrieved on 10-​19-​2019 from https://​www. cen​sus.gov/​newsr​oom/​press-​relea​ses/​2016/​ cb16-​192.html. US News & World Report (2020). Best diets overall. Retrieved on 1-​5-​2020 from https://​hea​lth. usn​ews.com/​best-​diet/​best-​diets-​over​all (for

References • 1035

methodology, see https://​hea​lth.usn​ews.com/​ best-​diet/​expe​rts). Uch​ino, B. N., Bowen, K., de Grey, R. K., Mikel, J., & Fisher, E. B. (2018a). Social support and physical health. In Fisher, E., et al. (eds.), Principles and Concepts of Behavioral Medicine. New York, NY: Springer, pp. 341–​372. Uchino, B. N., Trettevik, R., Kent de Grey, R. G., Cronan, S., Hogan, J., & Baucom, B. R. (2018b). Social support, social integration, and inflammatory cytokine. Health Psychology, 37(5), 462–​471. Uchino, B. N., & Way, B. M. (2017). Integrative pathways linking close family ties to health: a neurochemical perspective. American Psychologist, 72(6), 590. Uecker, J. E. (2008). Religion, pledging, and the premarital sexual behavior of married young adults. Journal of Marriage and the Family, 70(3), 728–​744. Uecker, J. E. (2012). Marriage and mental health among young adults. Journal of Health and Social Behavior, 53, 67–​83. Uecker, J. E., Mayrl, D., & Stroope, S. (2016). Family formation and returning to institutional religion in young adulthood. Journal for the Scientific Study of Religion, 55(2), 384–​406. Uher, R., & Weaver, I. C. (2014). Epigenetic traces of childhood maltreatment in peripheral blood: a new strategy to explore gene-​environment interactions. British Journal of Psychiatry, 204(1), 3–​5. Ulloa, B. F. L., Møller, V., & Sousa-​Poza, A. (2013). How does subjective well-​being evolve with age? A literature review. Journal of Population Ageing, 6(3), 227–​246. Underwood, L., & Washington, A. (2016). Mental illness and juvenile offenders. International Journal of Environmental Research and Public Health, 13(2), 228. Underwood, L. G., & Teresi, J. A. (2002). The Daily Spiritual Experience Scale. Annals of Behavioral Medicine, 24(1), 22–​33. UNESCO (2020). Routes of Santiago de Compostela: Camino Francés and Routes of Northern Spain, UNESCO World Heritage Center. Retrieved on 1-​4-​2020 from https://​whc. une​sco.org/​en/​list/​669. United Nations (2019a). United Nations Office on Drugs and Crime: World Drug Report 2019, United Nations publication Sales No. E. 19.XI.8. Retrieved on 11-​27-​2020 from https://​wdr. unodc.org/​wdr2​019/​. United Nations (2019b). United Nations Office of Drug Control and Crime Prevention (UNODC).

1036 •  R eferences

Executive Summary: 2019 World Drug Report. United Nations publication, Sales No. E.19.XI.8. Retrieved on 8-​8-​2022 from https://​wdr.unodc. org/​wdr2​019/​prelau​nch/​WDR19_​Book​let_​1_​EX​ ECUT​IVE_​SUMM​ARY.pdf. United Nations Children’s Fund (2007). Child Poverty in Perspective: An Overview of Child-​Well-​ Being in Rich Countries. Florence, Italy: UNICEF Innocent Research Centre. University of Michigan (2018). National poll on healthy aging, October. Retrieved on 5-​8-​2020 from https://​ihpi.umich.edu/​sites/​defa​ult/​files/​ 2019-​03/​NPHA​_​Lon​elin​ess-​Repor​t_​FI​NAL-​022​ 619.pdf. Unseen Japan (2018). Why are the Japanese not religious? Retrieved on 10-​28-​2020 from https://​med​ium.com/​@unse​enja​pan/​why-​are-​ the-​japan​ese-​not-​religi​ous-​b4787​79b6​6be. Unterrainer, H. F., Lukanz, M., Pilch, M., Scharf, S., Glawischnig-​Goschnik, M., Wutte, N., et al. (2016). Spirituality and mood pathology in severe skin conditions: a prospective observational study. Archives of Dermatological Research, 308(7), 521–​525. Upchurch, D., Dye, C., Chyu, L., Gold, E., & Greendale, G. (2010). Demographic, behavioral, and health correlates of complementary and alternative medicine and prayer use among midlife women: 2002. Journal of Women’s Health, 19(1), 23–​30. Upenieks, L., & Schafer, M. H. (2020). Religious attendance and physical health in later life. Journal of Health and Social Behavior, 61(4), 486–​502. Upenieks, L., Schafer, M. H., & Mogosanu, A. (2021). Does childhood religiosity delay death? Journal of Religion and Health, 60, 420–​443. Uppal, S. (2006). Impact of the timing, type and severity of disability on the subjective well-​being of individuals with disabilities. Social Science & Medicine, 63(2), 525–​539. US Bureau of Labor Statistics (2019). Databases, tables & calculators by subject. Retrieved on 11-​ 16-​2019 from https://​data.bls.gov/​tim​eser​ies/​ LNS1​4000​000. Vaccarino, V., Goldberg, J., Magruder, K. M., Forsberg, C. W., Friedman, M. J., Litz, B. T., et al. (2014). Posttraumatic stress disorder and incidence of type-​2 diabetes: a prospective twin study. Journal of Psychiatric Research, 56, 158–​164. Vahia, I. V., Depp, C. A., Palmer, B. W., Fellows, I., Golshan, S., Thompson, W., et al. (2011). Correlates of spirituality in older women. Aging & Mental Health, 15(1), 97–​102.

Vaidya, D., Yanek, L., Moy, T., Pearson, T., Becker, L., & Becker, D. M. (2007). Incidence of coronary artery disease in siblings of patients with premature coronary artery disease: 10 years of follow-​up. American Journal of Cardiology, 100(9), 1410–​1415. Vaillant, G. E. (1975). Sociopathy as a human process. Archives of General Psychiatry, 32, 173–​183. Vaillant, G. E., & Milofsky, E. S. (1982). Natural history of male alcoholism: IV. Paths to recovery. Archives of General Psychiatry, 39(2), 127–​133. Valdimarsdottir, H. B., & Bovbjerg, D. H. (1997). Positive and negative mood: Association with natural killer cell activity. Psychology and Health, 12(3), 319–​327. Valkanova, V., Ebmeier, K. P., & Allan, C. L. (2013). CRP, IL-​6 and depression: a systematic review and meta-​analysis of longitudinal studies. Journal of Affective Disorders, 150(3), 736–​744. Valtorta, N. K., Kanaan, M., Gilbody, S., Ronzi, S., & Hanratty, B. (2016). Loneliness and social isolation as risk factors for coronary heart disease and stroke. Heart, 102(13), 1009–​1016. Van Assche, L., Morrens, M., Luyten, P., Van de Ven, L., & Vandenbulcke, M. (2017). The neuropsychology and neurobiology of late-​ onset schizophrenia and very-​late-​onset schizophrenia-​like psychosis. Neuroscience & Biobehavioral Reviews, 83, 604–​621. Van Cappellen, P., Way, B. M., Isgett, S. F., & Fredrickson, B. L. (2016). Effects of oxytocin administration on spirituality and emotional responses to meditation. Social Cognitive and Affective Neuroscience, 11(10), 1579–​1 587. Van Dam, N. T., Rando, K., Potenza, M. N., Tuit, K., & Sinha, R. (2014). Childhood maltreatment, altered limbic neurobiology, and substance use relapse severity via trauma-​specific reductions in limbic gray matter volume. JAMA Psychiatry, 71(8), 917–​925. Van de Velde, S., Van der Bracht, K., & Buffel, V. (2017). The relation between religion and depression in Europe: the moderating role of the religious context. International Journal of Comparative Sociology, 58(6), 515–​532. Van Den Bree, M. B., Whitmer, M. D., & Pickworth, W. B. (2004). Predictors of smoking development in a population-​based sample of adolescents: A prospective study. Journal of Adolescent Health, 35(3), 172–​181. Van der Hooft, M. P., Hoogendoorn, A. W., van Balkom, A. J., Schaap-​Jonker, H., van Oppen, P., van Megen, H. J., et al. (2018). Influence

of religion on obsessive–​compulsive disorder: Comparisons between Dutch nonreligious, Roman Catholic, and Protestant patients. Psychology of Religion and Spirituality, 10(4), 327–​333. Van der Valk, E. S., Savas, M., & van Rossum, E. F. (2018). Stress and obesity: are there more susceptible individuals? Current Obesity Reports, 7(2), 193–​203. Van Dooren, F. E., Schram, M. T., Schalkwijk, C. G., Stehouwer, C. D., Henry, R. M., Dagnelie, P. C., et al. (2016). Associations of low grade inflammation and endothelial dysfunction with depression: The Maastricht Study. Brain, Behavior, and Immunity, 56, 390–​396. Van Dyke, M., Greer, S., Odom, E., Schieb, L., Vaughan, A., Kramer, M., et al. (2018). Heart disease death rates among blacks and whites aged ≥ 35 years: United States, 1968–​2015. MMWR Surveillance Summaries, 67(5), 1–​11. Van Gelder, J. L., & De Vries, R. E. (2012). Traits and states: Integrating personality and affect into a model of criminal decision making. Criminology, 50(3), 637–​671. Van Lenthe, F. J., Droomers, M., Schrijvers, C. T., & Mackenbach, J. P. (2000). Socio-​demographic variables and 6 year change in body mass index. International Journal of Obesity & Related Metabolic Disorders, 24(8), 1077–​1084. Van Ness, P. H., & Kasl, S. V. (2003a). Religion and cognitive dysfunction in an elderly cohort. Journals of Gerontology, 58B(1), S21–​S29. Van Ness, P. H., Kasl, S. V., & Jones, B. A. (2003b). Religion, race, and breast cancer survival. International Journal of Psychiatry in Medicine, 33(4), 357–​375. Van Os, J., Kenis, G., & Rutten, B. P. (2010). The environment and schizophrenia. Nature, 468(7321), 203–​212. Van Olphen, J., Schulz, A., Israel, B., Chatters, L., Klem, L., Parker, E., et al. (2003). Religious involvement, social support, and health among African-​American women on the east side of Detroit. Journal of General Internal Medicine, 18(7), 549–​557. Van Randwijk, C. B., Opsahl, T., Hvidt, E. A., Kørup, A. K., Bjerrum, L., Thomsen, K. F., et al. (2019). Characteristics of religious and spiritual beliefs of Danish physicians and likelihood of addressing religious and spiritual issues with patients. Journal of Religion and Health, 58(1), 333–​342. Van Tongeren, D. R., Hill, P. C., Krause, N., Ironson, G. H., & Pargament, K. I. (2017). The mediating role of meaning in the association between

References • 1037

stress and health. Annals of Behavioral Medicine, 51(5), 775–​781. Van Voorhees, B. W., Paunesku, D., Kuwabara, S. A., Basu, A., Gollan, J., Hankin, B. L., et al. (2008). Protective and vulnerability factors predicting new-​onset depressive episode in a representative of US adolescents. Journal of Adolescent Health, 42(6), 605–​616. Van Wagoner, N., Elopre, L., Westfall, A. O., Mugavero, M. J., Turan, J., & Hook EW (2016). Reported church attendance at the time of entry into HIV care is associated with viral load suppression at 12 months. AIDS and Behavior, 20(8), 1706–​1712. Vancampfort, D., Vansteelandt, K., Correll, C. U., Mitchell, A. J., De Herdt, A., Sienaert, P., et al. (2013). Metabolic syndrome and metabolic abnormalities in bipolar disorder. American Journal of Psychiatry, 170(3), 265–​274. Vance, T., Maes, H. H., & Kendler, K. S. (2014). A multivariate twin study of the dimensions of religiosity and common psychiatric and substance use disorders. Journal of Nervous and Mental Disease, 202, 360–​367. Van der Valk, E. S., Savas, M., & van Rossum, E. F. (2018). Stress and obesity: are there more susceptible individuals? Current Obesity Reports, 7(2), 193–​203. VanderWeele, T. J. (2009). Marginal structural models for the estimation of direct and indirect effects. Epidemiology, 20(1), 18–​26. VanderWeele, T. J. (2012). Invited commentary: structural equation models and epidemiologic analysis. American Journal of Epidemiology, 176(7), 608–​612. VanderWeele, T. J. (2013). Re: “Religious service attendance and major depression: A case of reverse causality?” American Journal of Epidemiology, 177(3), 275–​277. VanderWeele, T. J. (2015). Explanation in Causal Inference: Methods for Mediation and Interaction. New York, NY: Oxford University Press. VanderWeele, T. J. (2017a). On the promotion of human flourishing. Proceedings of the National Academy of Sciences, 114(31), 8148–​8156. VanderWeele, T. J. (2017b). Religious communities and human flourishing. Current Directions in Psychological Science, 26(5), 476–​481. VanderWeele, T. J. (2017c). Outcome-​wide epidemiology. Epidemiology, 28, 399–​402. VanderWeele, T. J. (2017d). Religion and health: a synthesis. In Balboni, M. J., & Peteet, J. R. (eds.), Spirituality and Religion within the Culture of Medicine: From Evidence to Practice. New York, NY: Oxford University Press, pp. 357–​401.

1038 •  R eferences

VanderWeele, T. J. (2018). Is forgiveness a public health issue? American Journal of Public Health, 108(2), 189–​190. VanderWeele, T. J. (2019a). Suffering and response: directions in empirical research. Social Science and Medicine, 224, 58–​66. VanderWeele, T. J. (2019b/2020). Spiritual well-​ being and human flourishing: conceptual, causal, and policy relations. In A. Cohen (ed.), Religion and Human Flourishing. Waco, TX: Baylor University Press. VanderWeele, T. J. (2019c). Measures of community well-​being: a template. International Journal of Community Well-​Being, 2, 253–​275. VanderWeele, T. J. (2020b). Activities for flourishing: an evidence-​based guide. Journal of Positive Psychology and Wellbeing, 4, 79–​91. VanderWeele, T. J. (2021a). Effects of religious service attendance and religious importance on depression: examining the meta-​analytic evidence. International Journal for the Psychology of Religion, 31(1), 21–​26. VanderWeele, T. J. (2021b). Can sophisticated study designs with regression analyses of observational data provide causal inferences? JAMA Psychiatry, 78(3), 244–​246. VanderWeele, T. J. (2022). Constructed measures and causal inference: towards a new model of measurement for psychosocial constructs. Epidemiology, 33(1), 141–​151. VanderWeele, T. J., Jackson, J. W., & Li, S. (2016a). Causal inference and longitudinal data: a case study of religion and mental health. Social Psychiatry and Psychiatric Epidemiology, 51(11), 1457–​1466. VanderWeele, T. J., Li, S., Tsai, A. C., & Kawachi, I. (2016b). Association between religious service attendance and lower suicide rates among US women. JAMA Psychiatry, 73(8), 845–​851. VanderWeele, T. J., & Shields, A. E. (2016c). Religiosity and telomere length: One step forward, one step back. Social Science and Medicine, 163, 176–​178. VanderWeele, T. J., & Koenig, H. G. (2017). A course on religion and public health at Harvard. American Journal of Public Health, 107(1), 47–​49. VanderWeele, T. J., Yu, J., Cozier, Y. C., Wise, L., Argentieri, M. A., Rosenberg, L., et al. (2017a). Attendance at religious services, prayer, religious coping, and religious/​spiritual identity as predictors of all-​cause mortality in the Black Women’s Health Study. American Journal of Epidemiology, 185(7), 515–​522.

VanderWeele, T. J., Balboni, T. A., & Koh, H. K. (2017b). Health and spirituality. Journal of the American Medical Association, 318(6), 519–​520. VanderWeele, T. J., & Ding, P. (2017c). Sensitivity analysis in observational research: introducing the E-​value. Annals of Internal Medicine, 167(4), 268–​274. VanderWeele, T. J., Li, S., & Kawachi, I. (2017d). Religious service attendance and suicide rates. JAMA Psychiatry, 74(2), 197–​198. VanderWeele, T. J., McNeely, E., & Koh, H. K. (2019). Reimagining health—​flourishing. Journal of the American Medical Association, 321(17), 1667–​1668. VanderWeele, T. J., & Chen, Y. (2020a). Religion as a social determinant of health. American Journal of Epidemiology, 189, 1464–​1466. VanderWeele, T. J., Mathur, M. B., & Chen, Y. (2020b). Outcome-​wide longitudinal designs for causal inference. Statistical Science, 35(3), 437–​466. VanderWeele, T. J., Long, K., & Balboni, M. J. (2020c/2021). On tradition-specific measures of spiritual well-​being. In Lee, M., Kubzansky, L. D., and VanderWeele, T. J. (eds.), Measuring Wellbeing: Interdisciplinary Perspectives from the Social Sciences and the Humanities. New York, NY: Oxford University Press, Chapter 16, pp. 482–​498. VanderWeele, T. J., Chen. Y., Long, K. N., Kim, E. S., Trudel-​Fitzgerald, C., & Kubzansky, L. D. (2020d). Positive epidemiology? Epidemiology, 31, 189–​193. VanderWeele, T. J., Balboni, T. A., & Koh, H. K. (2022). Religious service attendance and implications for clinical care, community participation and public health. American Journal of Epidemiology, 191(1), 31–​35. Vang, Z. M., Hou, F., & Elder, K. (2019). Perceived religious discrimination, religiosity, and life satisfaction. Journal of Happiness Studies, 20(6), 1913–​1932. Varella, A. C., Bensenor, I. M., Griep, R., Fonseca, M. J., Pereira, A. C., & Lotufo, P. A. (2019). Religious attendance, educational attainment, and hypertension. Circulation, 139(Supp 1), AP355. Varella, A. C., Benseñor, I. M., Fonseca, M. J., Griep, R. H., Pereira, A. C., & Lotufo, P. A. (2020). Religious service attendance, educational attainment, and hypertension at baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-​Brasil). American Journal of Hypertension, 33(5), 452–​457. Varma, V. R., Tan, E. J., Gross, A. L., Harris, G., Romani, W., Fried, L. P., et al. (2016). Effect of

community volunteering on physical activity: a randomized controlled trial. American Journal of Preventive Medicine, 50(1), 106–​110. Varshney, M., Mahapatra, A., Krishnan, V., Gupta, R., & Deb, K. S. (2016). Violence and mental illness: what is the true story? Journal of Epidemiology and Community Health, 70(3), 223–​225. Vasigh, A., Tarjoman, A., & Borji, M. (2018). The effect of spiritual-​religious interventions on patients’ pain status: systematic review. Anaesthesia, Pain & Intensive Care, 22(4), 499–​505. Vasigh, A., Tarjoman, A., & Borji, M. (2020). Relationship between spiritual health and pain self-​efficacy in patients with chronic pain: a cross-​sectional study in west of Iran. Journal of Religion and Health, 59(2), 1115–​1125. Vaughan, E. L., de Dios, M. A., Steinfeldt, J. A., & Kratz, L. M. (2011). Religiosity, alcohol use attitudes, and alcohol use in a national sample of adolescents. Psychology of Addictive Behaviors, 25(3), 547. Vaughn, M. G., Salas-​Wright, C. P., & Piquero, A. R. (2012). Buckle up: non-​seat belt use and antisocial behavior in the United States. Annals of Epidemiology, 22(12), 825–​831. Veasley, C., Clare, D., Clauw, D. J., Cowley, T., Nguyen, R. H. N., Reinecke, P., et al. (2015). Impact of chronic overlapping pain conditions on public health and the urgent need for safe and effective treatment: 2015 analysis and policy recommendations. Chronic Pain Research Alliance, 2016, 5. Vehmeijer, F. O., Guxens, M., Duijts, L., & El Marroun, H. (2019). Maternal psychological distress during pregnancy and childhood health outcomes: a narrative review. Journal of Developmental Origins of Health and Disease, 10(3), 274–​285. Veith, R. C., Lewis, N., Linares, O. A., Barnes, R. F., Raskind, M. A., Villacres, E. C., et al. (1994). Sympathetic nervous system activity in major depression: basal and desipramine-​ induced alterations in plasma norepinephrine kinetics. Archives of General Psychiatry, 51(5), 411–​422. Velleman, R., & Templeton, L. J. (2016). Impact of parents’ substance misuse on children: An update. British Journal of Psychiatry Advances, 22(2), 108–​117. Velthorst, E., Koeter, M., Van Der Gaag, M., Nieman, D. H., Fett, A. K., Smit, F., et al. (2015). Adapted cognitive–​behavioural therapy required for targeting negative symptoms in

References • 1039

schizophrenia. Psychological Medicine, 45(3), 453–​465. Veluchamy, A., Hebert, H. L., Meng, W., Palmer, C. N., & Smith, B. H. (2018). Systematic review and meta-​analysis of genetic risk factors for neuropathic pain. Pain, 159(5), 825–​848. Ventura, M. T., Casciaro, M., Gangemi, S., & Buquicchio, R. (2017). Immunosenescence in aging: between immune cells depletion and cytokines up-​regulation. Clinical and Molecular Allergy, 15(1), 21. Verbakel, E., & Jaspers, E. (2010). A comparative study on permissiveness toward euthanasia: Religiosity, slippery slope, autonomy, and death with dignity. Public Opinion Quarterly, 74(1), 109–​139. Verbrugge, L. M. (1979). Marital status and health. Journal of Marriage and the Family, 41(2), 267–​285. Verghese, A., John, J. K., Rajkumar, S., Richard, J., Sethi, B. B., & Trivedi, J. K. (1989). Factors associated with the course and outcome of schizophrenia in India: results of a two-​year multicentre follow-​up study. British Journal of Psychiatry, 154(4), 499–​503. Verma, R. (2009). Faith & Philosophy of Hinduism. Delhi, India: Kalpaz Publications. Vermandere, M., Warmenhoven, F., Van Severen, E., De Lepeleire, J., & Aertgeerts, B. (2016). Spiritual history taking in palliative home care: a cluster randomized controlled trial. Palliative Medicine, 30(4), 338–​350. Veronelli, L., Makaretz, S. J., Quimby, M., Dickerson, B. C., & Collins, J. A. (2017). Geschwind Syndrome in frontotemporal lobar degeneration: neuroanatomical and neuropsychological features over 9 years. Cortex, 94, 27–​38. Vespa, J., Armstrong, D. M., & Medina, L. (2018). Demographic turning points for the United States: population projections for 2020 to 2060. Washington, DC: US Department of Commerce, Economics and Statistics Administration, US Census Bureau. Vicennati, V., Garelli, S., Rinaldi, E., Di Dalmazi, G., Pagotto, U., & Pasquali, R. (2014). Cross-​ talk between adipose tissue and the HPA axis in obesity and overt hypercortisolemic states. Hormone Molecular Biology and Clinical Investigation, 17(2), 63–​77. Vicente, A. R. T., Castro-​Costa, É., Firmo, J. D. O. A., Lima-​Costa, M. F., & Loyola Filho, A. I. D. (2018). Religiousness, social support and the use of antidepressants among the elderly: a population-​based study. Ciencia & Saude Coletiva, 23, 963–​971.

1040 •  R eferences

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., et al. (2018). Bipolar disorders. Nature Reviews Disease Primers, 4, 18008, 1–​16. Vigo, D., Thornicroft, G., & Atun, R. (2016). Estimating the true global burden of mental illness. Lancet Psychiatry, 3(2), 171–​178. Vile, J. R. (2009). Illinois ex rel. McCollum v. Board of Education (1948). The Amendment Encyclopedia. Retrieved on 7-​31-​2022 from https://​mtsu.edu/​first-​amendm​ent/​arti​cle/​668/​ illin​ois-​ex-​rel-​mccol​lum-​v-​board-​of-​educat​ion. Viner, R. M., Haines, M. M., Head, J. A., Bhui, K., Taylor, S., Stansfeld, S. A., et al. (2006). Variations in associations of health risk behaviors among ethnic minority early adolescents. Journal of Adolescent Health, 38(1), 55.e15–​55e.23. Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., et al. (2012). Adolescence and the social determinants of health. Lancet, 379(9826), 1641–​1652. Virani, S., Wetzel, E. C., Laohawiriyakamol, S., Boonyaphiphat, P., Geater, A., Kleer, C. G., et al. (2018). Ethnic disparity in breast cancer survival in southern Thai women. Cancer Epidemiology, 54, 82–​89. Virdis, A., Giannarelli, C., Fritsch Neves, M., Taddei, S., & Ghiadoni, L. (2010). Cigarette smoking and hypertension. Current Pharmaceutical Design, 16(23), 2518–​2525. Vita, A., & Barlati, S. (2018). Recovery from schizophrenia: is it possible? Current Opinion in Psychiatry, 31(3), 246–​255. Vittengl, J. R. (2018). A lonely search? Risk for depression when spirituality exceeds religiosity. Journal of Nervous and Mental Disease, 206(5), 386–​389. Voas, D., & Chaves, M. (2018). Even intense religiosity is declining in the United States: Comment. Sociological Science, 5, 694–​710. Vogel, R. A. (2019). Alcohol, heart disease, and mortality: a review. Reviews in Cardiovascular Medicine, 3(1), 7–​13. Volk, F., & Koenig, H. G. (2019). Moral injury and religiosity in active duty US military with PTSD symptoms. Military Behavioral Health, 7(1), 64–​72. Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiologic advances from the brain disease model of addiction. New England Journal of Medicine, 374(4), 363–​371. von Lengerke, T., & Krauth, C. (2011). Economic costs of adult obesity: a review of recent European studies with a focus on

subgroup-​specific costs. Maturitas, 69(3), 220–​229. Vos, T., Barber, R. M., Bell, B., Bertozzi-​Villa, A., Biryukov, S., Bolliger, I., et al. (2015). Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–​2013. Lancet, 386(9995), 743–​800. Vos, T., Abajobir, A. A., Abate, K. H., Abbafati, C., Abbas, K. M., Abd-​Allah, F., et al. (2017). Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–​2016. Lancet, 390(10100), 1211–​1259. Votaw, V. R., Geyer, R., Rieselbach, M. M., & McHugh, R. K. (2019). The epidemiology of benzodiazepine misuse: a systematic review. Drug and Alcohol Dependence, 200, 95–​114. Vu, M., Azmat, A., Radejko, T., & Padela, A. I. (2016). Predictors of delayed healthcare seeking among American Muslim women. Journal of Women’s Health, 25(6), 586–​593. Vukasović, T., & Bratko, D. (2015). Heritability of personality: a meta-​analysis of behavior genetic studies. Psychological Bulletin, 141(4), 769–​785. Wachholtz, A. B., & Pargament, K. I. (2005). Is spirituality a critical ingredient of meditation? Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. Journal of Behavioral Medicine, 28, 369–​384. Wachholtz, A. B., & Pargament, K. I. (2008). Migraines and meditation: does spirituality matter? Journal of Behavioral Medicine, 31(4), 351–​366. Wachholtz, A. B., & Rogoff, M. (2013). The relationship between spirituality and burnout among medical students. Journal of Contemporary Medical Education, 1(2), 83–​91. Wachholtz, A. B., & Sambamthoori, U. (2013). National trends in prayer use as a coping mechanism for depression: Changes from 2002 to 2007. Journal of Religion and Health, 52(4), 1356–​1368. Wachholtz, A., & Fitch, C. E. (2018). The effects of religious and spiritual interventions on pain. In Plante, T. G. (ed.), Healing with Spiritual Practices: Proven Techniques for Disorders from Addictions and Anxiety to Cancer and Chronic Pain. Santa Barbara, CA: Praeger, pp. 168–​183. Wade, N. G., Worthington Jr, E. L., & Vogel, D. L. (2007). Effectiveness of religiously tailored interventions in Christian therapy. Psychotherapy Research, 17(1), 91–​105.

Wade, N. G., Hoyt, W. T., Kidwell, J. E., & Worthington, E. L., Jr. (2014). Efficacy of psychotherapeutic interventions to promote forgiveness: a meta-​analysis. Journal of Consulting and Clinical Psychology, 82(1), 154. Wade, T. J., Veldhuizen, S., & Cairney, J. (2011). Prevalence of psychiatric disorder in lone fathers and mothers: examining the intersection of gender and family structure on mental health. Canadian Journal of Psychiatry, 56(9), 567–​573. Walker, E. R., McGee, R. E., & Druss, B. G. (2015). Mortality in mental disorders and global disease burden implications: a systematic review and meta-​analysis. JAMA Psychiatry, 72(4), 334–​341. Walker, R. J., Garacci, E., Palatnik, A., Ozieh, M. N., & Egede, L. E. (2020). The longitudinal influence of social determinants of health on glycemic control in elderly adults with diabetes. Diabetes Care, 43(4), 759–​766. Wallace v. Jaffree (1984). Then-​Justice Rehnquist dissenting. 472 U.S. 38, 91. Retrieved on 10-​8-​ 2020 from https://​case​law.find​law.com/​us-​supr​ eme-​court/​472/​38.html#91. Wallace, J. G. (1972). Drinkers and abstainers in Norway. Quarterly Journal of Studies on Alcohol, Supp 6, 129–​151. Wallace, J. M., Jr., & Forman, T. A. (1998). Religion’s role in promoting health and reducing the risk among American youth. Health Education and Behavior, 25, 721–​741. Wallace, J. M., Jr., Brown, T. N., Bachman, J. G., & Laveist, T. A. (2003). The influence of race and religion on abstinence from alcohol, cigarettes and marijuana among adolescents. Journal of Studies on Alcohol, 64(6), 843–​848. Wallace, J. M., Jr., Yamaguchi, R., Bachman, J. G., O’Malley, P. M., Schulenberg, J. E., & Johnston, L. D. (2007). Religiosity and adolescent substance use: The role of individual and contextual influences. Social Problems, 54(2), 308–​327. Wallace, L. E., Anthony, R., End, C. M., & Way, B. M. (2019). Does religion stave off the grave? Religious affiliation in one’s obituary and longevity. Social Psychological and Personality Science, 10(5), 662–​670. Wallack, E. M., Wiseman, H. D., & Ploughman, M. (2016). Healthy aging from the perspectives of 683 older people with multiple sclerosis. Multiple Sclerosis International, 2016: article ID 1845720. Walls, C. T., & Zarit, S. H. (1991). Informal support from black churches and the well-​being of elderly blacks. Gerontologist, 31, 490–​495. Walseth, K., & Fasting, K. (2003). Islam’s view on physical activity and sport: Egyptian women

References • 1041

interpreting Islam. International Review for the Sociology of Sport, 38(1), 45–​60. Walsh, A., & Ellis, L. (1999). Political ideology and American criminologists’ explanations for criminal behavior. The Criminologist, 24(6), 1–​27. Walsh, E., Blake, Y., Donati, A., Stoop, R., & von Gunten, A. (2019). Early secure attachment as a protective factor against later cognitive decline and dementia. Frontiers in Aging Neuroscience, 11, 161. Walsh, K., McCormack, C. A., Webster, R., Pinto, A., Lee, S., Feng, T., et al. (2019). Maternal prenatal stress phenotypes associate with fetal neurodevelopment and birth outcomes. Proceedings of the National Academy of Sciences, 116(48), 23996–​24005. Walter-​Ginzburg, A., Shmotkin, D., Blumstein, T., & Shorek, A. (2005). A gender-​based dynamic multidimensional longitudinal analysis of resilience and mortality in the old-​old in Israel. Social Science & Medicine, 60(8), 1705–​1715. Wang, D., Li, W., Cui, X., Meng, Y., Zhou, M., Xiao, L., et al. (2016). Sleep duration and risk of coronary heart disease: a systematic review and meta-​analysis of prospective cohort studies. International Journal of Cardiology, 219, 231–​239. Wang, H. R., Woo, Y. S., & Bahk, W. M. (2015). Caffeine-​induced psychiatric manifestations: a review. International Clinical Psychopharmacology, 30(4), 179–​182. Wang, K., Li, F., Chen, L., Lai, Y. M., Zhang, X., & Li, H. Y. (2017). Change in risk of breast cancer after receiving hormone replacement therapy by considering effect-​modifiers. Oncotarget, 8(46), 81109–​81124. Wang, L., Wang Z., Koenig, H. G., & Alshohaib, S. (2017). Interactions between apolipoprotein E genes and religiosity in relation to mild cognitive impairment. Neuropsychiatry, 7(5), 659–​666. Wang, L., Wang, R., Liu, L., Qiao, D., Baldwin, D. S., & Hou, R. (2019). Effects of SSRIs on peripheral inflammatory markers in patients with major depressive disorder. Brain, Behavior, and Immunity, 79, 24–​38. Wang, L., Koenig, H. G., Al Shohaib, S., & Wang, Z. (2020). Religiosity, depression and telomere length in Chinese older adults. Journal of Affective Disorders, 260, 624–​628. Wang, P., Sun, J., Xie, T., & Lv, S. (2018). Serum non-​high-​density lipoprotein cholesterol and risk of stroke in the general population. International Journal of Clinical and Experimental Medicine, 11(3), 1467–​1474. Wang, T., Huang, X., Bi, C. (2014). Relationship between physical health and happiness in

1042 •  R eferences

China: the moderating effect of religiosity. Chinese Journal of Clinical Psychology, 22(6), 1053–​1056. Wang, T. W., Gentzke, A. S., Creamer, M. R., Cullen, K. A., Holder-​Hayes, E., Sawdey, M. D., et al. (2019). Tobacco product use and associated factors among middle and high school students: United States, 2019. Mortality and Morbidity Weekly Report, 68 (No. SS-​12), 1–​22. Wang, Y. H., Li, J. Q., Shi, J. F., Que, J. Y., Liu, J. J., Lappin, J. M., et al. (2020). Depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-​analysis of cohort studies. Molecular Psychiatry, 25(7), 1487–​1499. Wang, Z., Koenig, H. G., Zhang, Y., Ma, W., & Huang, Y. (2015). Religious involvement and mental disorders in mainland China. PloS One, 10(6), e0128800. Wang, Z., Ma, H., Rong, Y., & Koenig, H. G. (2016a). Psychometric properties of Belief into Action Scale among university students in China. International Journal of Social Science Studies, 4(3), 83–​93. Wang, Z., Koenig, H. G., Ma, H., & Al Shohaib, S. (2016b). Religion, purpose in life, social support, and psychological distress in Chinese university students. Journal of Religion and Health, 55(3), 1055–​1064. Wansink, B., & Wansink, C. S. (2013). Are there atheists in foxholes? Combat intensity and religious behavior. Journal of Religion and Health, 52(3), 768–​779. Warburton, J., & Stirling, C. (2007). Factors affecting volunteering among older rural and city dwelling adults in Australia. Educational Gerontology, 33(1), 23–​43. Ward, B. W., Allen, A., & Gryczynski, J. (2014). Racial/​ethnic differences in the relationship among cigarette use, religiosity, and social norms for US adolescents. Journal of Ethnicity in Substance Abuse, 13(4), 337–​361. Ward, E., Jemal, A., Cokkinides, V., Singh, G. K., Cardinez, C., Ghafoor, A., et al. (2004). Cancer disparities by race/​ethnicity and socioeconomic status. CA: A Cancer Journal for Clinicians, 54(2), 78–​93. Ward, R. (1980). Age and acceptance of euthanasia. Journal of Gerontology, 35(3), 421–​431. Ward, P. (2018). Trust and communication in a doctor-​patient relationship: a literature review. Journal of Healthcare Communications, 3(3), 36. Ward, Z. J., Bleich, S. N., Cradock, A. L., Barrett, J. L., Giles, C. M., Flax, C., et al. (2019). Projected us state-​level prevalence of adult obesity and

severe obesity. New England Journal of Medicine, 381(25), 2440–​2450. Warnock, C. J. P. (2009). Who pays for providing spiritual care in healthcare settings? The ethical dilemma of taxpayers funding holistic healthcare and the first amendment requirement for separation of church and state. Journal of Religion and Health, 48(4), 468–​481. Warraich, H. J. (2009). Religious opposition to polio vaccination. Emerging Infectious Diseases, 15(6), 978. Warren, P., Van Eck, K., Townley, G., & Kloos, B. (2015). Relationships among religious coping, optimism, and outcomes for persons with psychiatric disabilities. Psychology of Religion and Spirituality, 7(2), 91–​99. Wasson, D. H. (2003). A qualitative investigation of the relapse experiences of women with bulimia nervosa. Eating Disorders, 11(2), 73–​88. WatchBlog (2017). How much does crime cost? US Government Accountability Office, November 29. Retrieved on 9-​27-​2019 from https://​blog. gao.gov/​2017/​11/​29/​how-​much-​does-​crime-​ cost/​. Waters, E. K., Millard, H. M., & Doyle, Z. (2015). Losing hope: mental health and religious service non-​attendance in Australia. Mental Health, Religion & Culture, 18(2), 114–​122. Watkins, K. L., Reitzel, L. R., Wetter, D. W., & McNeill, L. H. (2015). HPV awareness, knowledge and attitudes among older African-​ American women. American Journal of Health Behavior, 39(2), 205–​211. Watkins, Y. J., Quinn, L. T., Ruggiero, L., Quinn, M. T., & Choi, Y. K. (2013). Spiritual and religious beliefs and practices and social support’s relationship to diabetes self-​care activities in African Americans. Diabetes Educator, 39(2), 231–​239. Watson, M., Homewood, J., Haviland, J., & Bliss, J. M. (2005). Influence of psychological response on breast cancer survival: 10-​year follow-​up of a population-​based cohort. European Journal of Cancer, 41, 1710–​1714. Watson, M., Homewood, J., & Haviland, J. (2012). Coping response and survival in breast cancer patients: a new analysis. Stress and Health, 28(5), 376–​380. Watson, R. J., Allen, A., Pollitt, A. M., & Eaton, L. A. (2019). Risk and protective factors for sexual health outcomes among black bisexual men in the US. Archives of Sexual Behavior, 48(1), 243–​253. Watterson, K., & Giesler, R. B. (2012). Religiosity and self-​control: When the going gets tough,

the religious get self-​regulating. Psychology of Religion and Spirituality, 4(3), 193–​205. Watts, S. J. (2017). The link between child abuse and neglect and delinquency. Victims & Offenders, 12(5), 700–​717. Watts, S. J. (2018). When does religion matter with regard to crime? Criminal Justice and Behavior, 45(8), 1192–​1212. Weaver, A. J. (1995). Has there been a failure to prepare and support Parish-​based clergy in their role as front-​line community mental health workers? Journal of Pastoral Care, 49, 129–​149. Weaver, A. J., Hosenfeld, C., & Koenig, H. G. (2007). Counseling Persons with Addictions and Compulsions: A Handbook of Pastors and Other Helping Professionals. Cleveland, OH: Pilgrim Press. Weaver, A. J., & Koenig, H. G. (2009). Pastoral Care of Alcohol Abusers. Minneapolis, MN: Fortress Press. Webb, B. L., & Bopp, M. J. (2017). Results of walking in faith: a faith-​based physical activity program for clergy. Journal of Religion and Health, 56(2), 561–​574. Wei, J., Hou, R., Zhang, X., Xu, H., Xie, L., Chandrasekar, E. K., et al. (2019). The association of late-​life depression with all-​ cause and cardiovascular mortality among community-​dwelling older adults. British Journal of Psychiatry, 215(2), 449–​455. Weinberger, A. H., Gbedemah, M., Martinez, A. M., Nash, D., Galea, S., & Goodwin, R. D. (2018). Trends in depression prevalence in the USA from 2005 to 2015: widening disparities in vulnerable groups. Psychological Medicine, 48(8), 1308–​1315. Weiss, B., Lavner, J. A., & Miller, J. D. (2018). Self-​and partner-​reported psychopathic traits’ relations with couples’ communication, marital satisfaction trajectories, and divorce in a longitudinal sample. Personality Disorders: Theory, Research, and Treatment, 9(3), 239–​249. Weiss, R. D., Griffin, M. L., Gallop, R., Luborsky, L., Siqueland, L., Frank, A., et al. (2000). Predictors of self-​help group attendance in cocaine dependent patients. Journal of Studies on Alcohol, 61(5), 714–​719. Wellman, R. J., Dugas, E. N., Dutczak, H., O’Loughlin, E. K., Datta, G. D., Lauzon, B., et al. (2016). Predictors of the onset of cigarette smoking: a systematic review of longitudinal population-​based studies in youth. American Journal of Preventive Medicine, 51(5), 767–​778.

References • 1043

Welte, J. W., Barnes, G. M., Tidwell, M. C. O., Hoffman, J. H., & Wieczorek, W. F. (2015). Gambling and problem gambling in the United States: Changes between 1999 and 2013. Journal of Gambling Studies, 31(3), 695–​715. Wen, H., & Wang, L. (2017). Reducing effect of aerobic exercise on blood pressure of essential hypertensive patients: a meta-​analysis. Medicine, 96(11), e6150. Wen, M. (2014). Parental participation in religious services and parent and child well-​ being: Findings from the National Survey of America’s families. Journal of Religion and Health, 53, 1539–​1561. Wen, W., Schlundt, D., Andersen, S. W., Blot, W. J., & Zheng, W. (2019). Does religious involvement affect mortality in low-​income Americans? BMJ Open, 9(7), e028200. Wennerblom, B., Lurje, L., Solem, J., Tygesen, H., Udén, M., Vahisalo, R., et al. (2000). Reduced heart rate variability in ischemic heart disease is only partially caused by ischemia. Cardiology, 94(3), 146–​151. West, S. G., & Graziano, W. G. (1989). Long‐ term stability and change in personality: an introduction. Journal of Personality, 57(2), 175–​193. Wȩziak-​Białowolska, D., McNeely, E., & VanderWeele, T. J. (2019). Human flourishing in cross cultural settings: evidence from the United States, China, Sri Lanka, Cambodia, and Mexico. Frontiers in Psychology, 10, 1269. Wheeler, M. A., McGrath, M. J., & Haslam, N. (2019). Twentieth century morality: The rise and fall of moral concepts from 1900 to 2007. PLoS One, 14(2), e0212267. Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., et al. (2018). 2017 ACC/​AHA/​AAPA/​ABC/​ACPM/​ AGS/​APhA/​ASH/​ASPC/​NMA/​PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/​American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127–​e248. Whisman, M. A., Gordon, K. C., & Chatav, Y. (2007). Predicting sexual infidelity in a population-​based sample of married individuals. Journal of Family Psychology, 21(2), 320–​324. White, A. M., Castle, I. J., Hingson, R. W., & Powell, P. A. (2020). Using death certificates to explore changes in alcohol‐related mortality in the

1044 •  R eferences

United States, 1999 to 2017. Alcoholism: Clinical and Experimental Research, 44(1), 178–​187. White, H. R., McMorris, B. J., Catalano, R. F., Fleming, C. B., Haggerty, K. P., & Abbott, R. D. (2006). Increases in alcohol and marijuana use during the transition out of high school into emerging adulthood: the effects of leaving home, going to college, and high school protective factors. Journal of Studies on Alcohol, 67(6), 810–​822. White, J., Xu, X., Ellison, C. G., DeAngelis, R. T., & Sunil, T. (2018). Religion, combat casualty exposure, and sleep disturbance in the US military. Journal of Religion and Health, 57(6), 2362–​2377. White, R. L., Babic, M. J., Parker, P. D., Lubans, D. R., Astell-​Burt, T., & Lonsdale, C. (2017). Domain-​specific physical activity and mental health. American Journal of Preventive Medicine, 52(5), 653–​666. White, T. J., Duncan, S., Yorgason, J., James, S., & Holmes, E. (2020). Marital interventions. Family Relations, 69(1), 125–​137. Whitehead, A. L. (2018). Religion and disability: variation in religious service attendance rates for children with chronic health conditions. Journal for the Scientific Study of Religion, 57(2), 377–​395. Whitehead, B. R., & Bergeman, C. S. (2011). Coping with daily stress: Differential role of spiritual experience on daily positive and negative affect. Journals of Gerontology, 67(4), 456–​459. Whitehead, B. R., & Bergeman, C. S. (2020). Daily religious coping buffers the stress–​effect relationship and benefits overall metabolic health in older adults. Psychology of Religion and Spirituality, 12(4), 393–​399. Whitehouse, H., & Lanman, J. A. (2014). The ties that bind us: ritual, fusion, and identification. Current Anthropology, 55, 674–​695. WHO (1946). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York: World Health Organization, 19–​22 June. Retrieved on 7-​31-​2022 from https://​ apps.who.int/​iris/​han​dle/​10665/​268​691. WHO (2011). World report on disability 2011 (full report). World Health Organization. Retrieved on 7-​18-​2020 from https://​www.who.int/​disab​ ilit​ies/​world​_​rep​ort/​2011/​rep​ort/​en/​. WHO (2017a). Depression and other common mental disorders: global health estimates. World Health Organization. Retrieved on 9-​7-​2019 from https://​apps.who.int/​iris/​bitstr​eam/​han​

dle/​10665/​254​610/​WHO-​MSD-​MER-​2017.2-​ eng.pdf. WHO (2017b). Top 10 causes of death. Data, Global Health Observatory (GHO), World Health Organization. Retrieved on 6-​8-​2019 from http://​www.who.int/​gho/​morta​lity​_​bur​den_​dise​ ase/​cause​s_​de​ath/​top​_​10/​en/​. WHO (2018a). World Health Statistics data visualizations dashboard: suicide. World Health Organization. Retrieved on 6-​8-​2019 from http://​apps.who.int/​gho/​data/​node.sdg.3-​4-​viz-​ 2?lang=​en. WHO (2018b). Prevalence of insufficient physical activity among adults. World Health Organization. Retrieved on 12-​23-​2019 from http://​apps.who. int/​gho/​data/​node.main.A893?lang=​en. WHO (2019). Global strategy on diet, physical activity and health: physical activity and adults. World Health Organization. Retrieved on 12-​31-​ 2019 from https://​www.who.int/​dietp​hysi​cala​ ctiv​ity/​facts​heet​_​adu​lts/​en/​. WHO (2020). Health policy. World Health Organization. Retrieved on 10-​1-​2020 from https://​www.who.int/​top​ics/​health​_​pol​icy/​en/​. Whooley, M. A., Boyd, A. L., Gardin, J. M., & Williams, D. R. (2002). Religious involvement and cigarette smoking in young adults: the CARDIA study (Coronary Artery Risk Development in Young Adults) study. Archives of Internal Medicine, 162(14), 1604–​1610. Whooley, M. A., De Jonge, P., Vittinghoff, E., Otte, C., Moos, R., Carney, R. M., et al. (2008). Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. Journal of the American Medical Association, 300(20), 2379–​2388. WHOQOL-​SRPB (2006). A cross-​cultural study of spirituality, religion, and personal beliefs as components of quality of life. Social Science & Medicine, 62(6), 1486–​1497. Widmer, R. J., Flammer, A. J., Lerman, L. O., & Lerman, A. (2015). The Mediterranean diet, its components, and cardiovascular disease. American Journal of Medicine, 128(3), 229–​238. Wiech, K., Farias, M., Kahan, G., Shackel, N., Tiede, W., & Tracey, I. (2008). An fMRI study measuring analgesia enhanced by religion as a belief system. Pain, 139(2), 467–​476. Wilcox, B., & Wilson, R. F. (2014). One way to end violence against women? Married dads. Washington Post, June 10. Retrieved on 12-​27-​ 2019 from https://​www.was​hing​tonp​ost.com/​ pos​teve​r yth​ing/​wp/​2014/​06/​10/​the-​best-​way-​ to-​end-​viole​nce-​agai​nst-​women-​stop-​tak​ing-​lov​ ers-​and-​get-​marr​ied/​.

Wilcox, S., Parrott, A., Baruth, M., Laken, M., Condrasky, M., Saunders, R., et al. (2013). The Faith, Activity, and Nutrition program: A randomized controlled trial in African-​American churches. American Journal of Preventive Medicine, 44(2), 122–​131. Wilcox, W. B. (2011). Why Marriage Matters: 30 Conclusions from the Social Sciences, 3rd ed. New York, NY: Institute for American Values/​ National Marriage Project. Wilcox, W. B., & Wolfinger, N. H. (2007). Then comes marriage? Religion, race, and marriage in urban America. Social Science Research, 36(2), 569–​589. Wild, D., Grove, A., Martin, M., Eremenco, S., McElory, S., Verjee-​Lorenz, A., et al. (2005). Principles of good practice for the translation and cultural adaptation process for Patient-​ Reported Outcomes (PRO) measures. Value in Health, 8(2), 94–​104. Wilkinson, J. E., Saper, R. B., Rosen, A. K., Welles, S. L., Culpepper, L. (2008). Prayer for health and primary care. Family Medicine, 40(9), 638–​644. Williams, B. R., Wang, M. Q., Holt, C. L., Schulz, E., & Clark, E. M. (2015). Social integration and health insurance status among African American men and women. Journal of Women & Aging, 27(3), 195–​215. Williams, D. R., Larson, D. B., Buckler, R. E., Heckmann, R. C., & Pyle, C. M. (1991). Religion and psychological distress in a community sample. Social Science & Medicine, 32(11), 1257–​1262. Williams, D. R., Priest, N., & Anderson, N. B. (2016). Understanding associations among race, socioeconomic status, and health: Patterns and prospects. Health Psychology, 35(4), 407–​411. Williams, E., Francis, L., & Village, A. (2010). Marriage, religion and human flourishing: how sustainable is the classic Durkheim thesis in contemporary Europe? Mental Health, Religion and Culture, 13(1), 93–​104. Williams, J. A., Meltzer, D., Arora, V., Chung, G., & Curlin, F. A. (2011). Attention to inpatients’ religious and spiritual concerns: predictors and association with patient satisfaction. Journal of General Internal Medicine, 26(11), 1265–​1271. Williams, S. L., & Cabrera-​Nguyen, E. P. (2016). Impact of lifetime evaluated need on mental health service use among African American emerging adults. Cultural Diversity and Ethnic Minority Psychology, 22(2), 205–​214. Williamson, I., & Gonzales, M. H. (2007). The subjective experience of forgiveness: Positive

References • 1045

construals of the forgiveness experience. Journal of Social and Clinical Psychology, 26(4), 407–​446. Willits, F. K., & Crider, D. M. (1988). Religion and well-​being: men and women in the middle years. Review of Religious Research, 29, 281–​294. Wills, T. A., Yaeger, A. M., & Sandy, J. M. (2003). Buffering effect of religiosity for adolescent substance use. Psychology of Addictive Behaviors, 17(1), 24–​31. Wilson, C. (2006). Public Policy: Continuity and Change. Long Grove, IL: Waveland Press, p. 16. Wilson, J. (1978). The measurement of religiosity. In Wilson, J. (ed.), Religion in American Society. Englewood Cliffs, NJ: Prentice-​Hall. Wilson, J., & Musick, M. (1996). Religion and marital dependency. Journal for the Scientific Study of Religion, 35(1), 30–​40. Wilson, J. M., & Jungner, G. (1968). Principles and Practice of Screening for Disease. Geneva, Switzerland: World Health Organization. Wilson, L. (2004). Body, perspectives on the. In Buswell, R. E., Jr. (ed.), Macmillan Encyclopedia of Buddhism. New York, NY: Macmillan Reference, pp. 63–​66. Wilson, W. (1967). Correlates of avowed happiness. Psychological Bulletin, 67, 294–​306. Wilson, W. P. (1998). Religion and the psychoses (ch 11). In Koenig, H. G. (ed.), Handbook of Mental Health and Religion. San Diego, CA: Academic Press, pp. 161–​172. Wilt, J. A., Exline, J. J., Grubbs, J. B., Park, C. L., & Pargament, K. I. (2016). God’s role in suffering. Psychology of Religion and Spirituality, 8(4), 352. Wilt, J. A., Grubbs, J. B., Pargament, K. I., & Exline, J. J. (2017). Religious and spiritual struggles, past and present. International Journal for the Psychology of Religion, 27(1), 51–​64. Windle, M., Mun, E. Y., & Windle, R. C. (2005). Adolescent-​to-​young adulthood heavy drinking trajectories and their prospective predictors. Journal of Studies on Alcohol, 66(3), 313–​322. Wineberg, H. (1994). Marital reconciliation in the United States: which couples are successful? Journal of Marriage and the Family, 56, 80–​88. Winett, R. A., Anderson, E. S., Wojcik, J. R., Winett, S. G., & Bowden, T. (2007). Guide to health: nutrition and physical activity outcomes of a group-​randomized trial of an Internet-​based intervention in churches. Annals of Behavioral Medicine, 33(3), 251–​261. Wing, R. R., & Phelan, S. (2005). Long-​term weight loss maintenance. American Journal of Clinical Nutrition, 82(1), 222S–​225S.

1046 •  R eferences

Wingard, E. B. (1982). The sex differential in mortality rates. American Journal of Epidemiology, 115, 205–​216. Wingood, G. M., Robinson, L. R., Braxton, N. D., Er, D. L., Conner, A. C., Renfro, T. L., et al. (2013). Comparative effectiveness of a faith-​ based HIV intervention for African American women: importance of enhancing religious social capital. American Journal of Public Health, 103(12), 2226–​2233. Wink, P., & Dillon, M. (2003). Religiousness, spirituality, and psychosocial functioning in late adulthood: findings from a longitudinal study. Psychology and Aging, 18(4), 916–​924. Wink, P., & Scott, J. (2005). Does religiousness buffer against the fear of death and dying in late adulthood? Findings from a longitudinal study. Journals of Gerontology, 60B(4), P207–​P214. Winslow, C. E. (1920). The untilled field of public health. Science, 51(1306), 23–​33. Winter, D. (1971). Closer Than a Brother. Wheaton, IL: Harold Shaw. Winter, L., Moriarty, H. J., Atte, F., & Gitlin, L. N. (2015). Depressed affect and dimensions of religiosity in family caregivers of individuals with dementia. Journal of Religion and Health, 54(4), 1490–​1502. Winter, T., Karvonen, S., & Rose, R. J. (2002). Does religiousness explain regional differences in alcohol use in Finland? Alcohol & Alcoholism, 37(4), 330–​339. Winter, T., Karvonen, S., & Rose, R. J. (2014). Associations between sexual abstinence ideals, religiosity, and alcohol abstinence: a longitudinal study of Finnish twins. Journal of Sex Research, 51(2), 197–​207. Winzer, L., & Gray, R. S. (2019). The role of Buddhist practices in happiness and health in Thailand: a structural equation model. Journal of Happiness Studies, 20(2), 411–​425. Wirtz, P. H., Redwine, L. S., Ehlert, U., & von Kanel, R. (2009). Independent association between lower level of social support and higher coagulation activity before and after acute psychosocial stress. Psychosomatic Medicine, 71(1), 30–​37. Wirtz, P. H., & von Känel, R. (2017). Psychological stress, inflammation, and coronary heart disease. Current Cardiology Reports, 19(11), 111. Wirtz, P. H., von Kanel, R., Mohiyeddini, C., Emini, L., Ruedisueli, K., & Groessbauer, S. (2006). Low social support and poor emotional regulation are associated with increased stress hormone reactivity to mental stress in systemic

hypertension. Journal of Clinical Endocrinology & Metabolism, 91(10), 3857–​3865. Witek-​Janusek, L., Albuquerque, K., Chroniak, K. R., Chroniak, C., Durazo-​Arvizu, R., & Mathews, H. L. (2008). Effect of mindfulness-​based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain, Behavior, and Immunity, 22, 969–​981. Witter, R. A., Okun, M. A., Stock, W. A., & Haring, M. J. (1984). Education and subjective well-​ being: A meta-​analysis. Educational Evaluation and Policy Analysis, 6(2), 165–​173. Witvliet, C. V., Hinze, S., & Worthington, E. L. (2008). Unresolved justice: Christian commitment, forgiveness, emotion, and cardiovascular responding. Journal of Psychology and Christianity, 29, 212–​224. Witzke, J., Rhone, R. A., Backhaus, D., & Shaver, N. A. (2008). How sweet the sound: research evidence for the use of music in Alzheimer’s dementia. Journal of Gerontological Nursing, 34(10), 45–​52. Witztum, E., & Stein, D. (2012). Suicide in Judaism with a special emphasis on modern Israel. Religions, 3(3), 725–​738. Witztum, E., Greenberg, D., & Dasberg, H. (1990). Mental illness and religious change. British Journal of Medical Psychology, 63(1), 33–​41. Włodarska, A., Gujski, M., Pinkas, J., & Raciborski, F. (2021). The influence of socio-​demographic characteristics on attitudes towards prophylactic vaccination in Poland. International Journal of Occupational Medicine and Environmental Health, 34(1), 121–​132. Wolf, J. P., & Kepple, N. J. (2019). Individual-​and county-​level religious participation, corporal punishment, and physical abuse of children. Journal of Interpersonal Violence, 34(19), 3983–​3994. Wolfe, C. D. A., Rudd, A. G., Howard, R., Coshall, C., Stewart, J., Lawrence, E., et al. (2002). Incidence and case fatality rates of stroke subtypes in a multiethnic population. Journal of Neurology, Neurosurgery, and Psychiatry, 72(2), 211–​216. Wolinsky, F. D., & Stump, T. E. (1996). Age and the sense of control among older adults. Journal of Gerontology, 51B, S217–​S220. Wombwell, E., Fangman, M. T., Yoder, A. K., & Spero, D. L. (2015). Religious barriers to measles vaccination. Journal of Community Health, 40(3), 597–​604. Wong, J. A., Pickworth, W. B., Waters, A. J., al’Absi, M., & Leventhal, A. M. (2014).

Cortisol levels decrease after acute tobacco abstinence in regular smokers. Human Psychopharmacology: Clinical and Experimental, 29(2), 152–​162. Wood, A. M., Froh, J. J., & Geraghty, A. W. (2010). Gratitude and well-​being. Clinical Psychology Review, 30(7), 890–​905. Wood, J. E., Jr. (1986). Tax exemption of religion and the separation of church and state. Review & Expositor, 83(2), 235–​258. Woods, J. L., & Hensel, D. J. (2018). Religious affiliation, religiosity, and spirituality in pediatric residents. Journal of Religion and Health, 57(2), 636–​648. Woods, T. E., Antoni, M. H., Ironson, G. H., & Kling, D. W. (1999). Religiosity is associated with affective and immune status in symptomatic HIV-​infected gay men. Journal of Psychosomatic Research, 46, 165–​176. Woolf, S. H., Chapman, D. A., & Lee, J. H. (2021). COVID-​19 as the leading cause of death in the United States. Journal of the American Medical Association, 325(2), 123–​124. Woolf, S. H., & Schoomaker, H. (2019). Life expectancy and mortality rates in the United States, 1959–​2017. Journal of the American Medical Association, 322(20), 1996–​2016. World Christian Database (2019). Retrieved on 4-​19-​2019 from https://​wor​ldch​rist​iand​atab​ ase.org/​. World Health Organization (2003). Adherence to Long Term Therapies. Geneva, Switzerland: WHO, p. 22. World Health Organization (2011). Declaration at the World Conference on Social Determinants of Health, October 19–​21, Rio de Janeiro, Brazil. World Health Organization (2014). World health statistics 2014. Retrieved on 12-​19-​2019 from http://​apps.who.int/​iris/​bitstr​eam/​10665/​112​ 738/​1/​978924​0692​671_​eng.pdf. World Health Organization (2017). Mental health of older adults. Retrieved on 5-​8-​2020 from https://​www.who.int/​news-​room/​fact-​she​ets/​ det​ail/​men​tal-​hea​lth-​of-​older-​adu​lts. World Health Organization (2018). Global health estimates 2016: deaths by cause, age, sex, by country and by region, 2000–​2016. World Health Organization. Retrieved on 1-​17-​2020 from http://​www.who.int/​hea​lthi​nfo/​global​_​bur​ den_​dise​ase/​estima​tes/​en/​. World Population Review (2019). Divorce rates by country 2019. Retrieved on 10-​19-​2019 from http://​worldp​opul​atio​nrev​iew.com/​countr​ies/​ divo​rce-​rates-​by-​coun​try/​

References • 1047

World Values Survey (2010–​2014a). Based on codebook of results, Wave 6. Retrieved on 5-​9-​ 2019 from http://​www.worldv​alue​ssur​vey.org/​ WVSD​ocum​enta​tion​WV6.jsp. World Values Survey (2010–​2014b). Results: “Independently of whether you attend religious services or not, would you say you are . . .” (V147), p. 349. Retrieved on 5-​4-​2019 from http://​www.worldv​alue​ssur​vey.org/​WVSD​ ocum​enta​tion​WV6.jsp. World Values Survey (2017). Happiness and life satisfaction. Retrieved on 9-​19-​2020 from https://​our​worl​dind​ata.org/​happin​ess-​and-​life-​ satis​fact​ion. Worthington, E. L., Wade, N. G., Hight, T. L., Ripley, J. S., McCullough, M. E., Berry, J. W., et al. (2003). The Religious Commitment Inventory—​10. Journal of Counseling Psychology 50(1), 84–​96. Worthington, E. L., Hook, J. N., Davis, D. E., & McDaniel, M. A. (2011). Religion and spirituality. Journal of Clinical Psychology, 67(2), 204–​214. WPR (2019). Most obese countries 2019. World Population Review. Retrieved on 12-​24-​2019 from http://​worldp​opul​atio​nrev​iew.com/​countr​ ies/​most-​obese-​countr​ies/​. Wray, N. R., Ripke, S., Mattheisen, M., Trzaskowski, M., Byrne, E. M., Abdellaoui, A., et al. (2018). Genome-​wide association analyses identify 44 risk variants and refine the genetic architecture of major depression. Nature Genetics, 50(5), 668. Wright, J. P., Dietrich, K. N., Ris, M. D., Hornung, R. W., Wessel, S. D., Lanphear, B. P., et al. (2008). Association of prenatal and childhood blood lead concentrations with criminal arrests in early adulthood. PLoS Medicine, 5(5), e101. Wrona, S., & Wrona, K. (2016). Coping with stress and social network among parents participating in the process of early intervention. Psychiatria Psychologia Kliniczna, 16(4), 217–​224. Wu, E. Q., Shi, L., Birnbaum, H., Hudson, T., & Kessler, R. (2006). Annual prevalence of diagnosed schizophrenia in the USA: a claims data analysis approach. Psychological Medicine, 36(11), 1535–​1540. Wu, L. F., & Koo, M. (2016). Randomized controlled trial of a six‐week spiritual reminiscence intervention on hope, life satisfaction, and spiritual well‐being in elderly with mild and moderate dementia. International Journal of Geriatric Psychiatry, 31(2), 120–​127. Wu, Y. T., Kralj, C., Acosta, D., Guerra, M., Huang, Y., Jotheeswaran, A. T., et al. (2020). The

1048 •  R eferences

association between, depression, anxiety, and mortality in older people across eight low‐and middle‐income countries. International Journal of Geriatric Psychiatry, 35(1), 29–​36. Wuerfel, J., Krishnamoorthy, E. S., Brown, R. J., Lemieux, L., Koepp, M., Van Elst, L. T., et al. (2004). Religiosity is associated with hippocampal but not amygdala volumes in patients with refractory epilepsy. Journal of Neurology, Neurosurgery & Psychiatry, 75(4), 640–​642. Wuthnow, R. (2002). Religious involvement and status-​bridging social capital. Journal for the Scientific Study of Religion, 41(4), 669–​684. Wyshak, G. (2016). Income and subjective well-​ being: new insights from relatively healthy American women, ages 49–​79. PLoS One, 11(2), e0146303. Xi, B., Veeranki, S. P., Zhao, M., Ma, C., Yan, Y., & Mi, J. (2017). Relationship of alcohol consumption to all-​cause, cardiovascular, and cancer-​related mortality in US adults. Journal of the American College of Cardiology, 70(8), 913–​922. Xing, G. (2016). The teaching and practice of filial piety in Buddhism. Journal of Law and Religion, 31(2), 212–​226. Xing, L., Guo, X., Bai, L., Qian, J., & Chen, J. (2018). Are spiritual interventions beneficial to patients with cancer? A meta-​analysis of randomized controlled trials following PRISMA. Medicine, 97(35), e11948. Xu, J., McClintock, C. H., Balodis, I. M., Miller, L., & Potenza, M. N. (2018). Openness to changing religious views is related to radial diffusivity in the genu of the corpus callosum in an initial study of healthy young adults. Frontiers in Psychology, 9, 330. Xu, J. Q., Murphy, S. L., Kochanek, K. D., & Arias, E. (2020). Mortality in the United States, 2018. NCHS Data Brief, no 355. Retrieved on 7-​3-​2020 from https://​www.cdc.gov/​nchs/​produ​cts/​dat​ abri​efs/​db355.htm. Xu, K., Soucat, A., & Kutzin, J. (2018). Public spending on health: a closer look at global trends. 2018. World Health Organization. Retrieved on 9-​21-​2020 from https://​www. who.int/​healt​h_​fi​nanc​ing/​docume​nts/​hea​lth-​ expe​ndit​ure-​rep​ort-​2018/​en/​. Xu, X., Bishop, E. E., Kennedy, S. M., Simpson, S. A., & Pechacek, T. F. (2015). Annual healthcare spending attributable to cigarette smoking: an update. American Journal of Preventive Medicine, 48(3), 326–​333.

Xu, X., Ou, M., Xie, C., Cheng, Q., & Chen, Y. (2019). Pain acceptance and its associated factors among cancer patients in mainland China: a cross-​ sectional study. Pain Research and Management, 2019, 9458683. Yaden, D. B., Eichstaedt, J. C., Kern, M. L., Smith, L. K., Buffone, A., Stillwell, D. J., et al. (2018). The language of religious affiliation: social, emotional, and cognitive differences. Social Psychological and Personality Science, 9(4), 444–​452. Yahaya, N., Momtaz, Y. A., Othman, M., Sulaiman, N., & Mat, F. (2012). Spiritual well-​being and mental health among Malaysian adolescents. Life Science Journal, 9(1), 440–​448. Yahaya, N. A., Subramanian, P., Bustam, A. Z., & Taib, N. A. (2015). Symptom experiences and coping strategies among multi-​ethnic solid tumor patients undergoing chemotherapy in Malaysia. Asian Pacific Journal of Cancer Prevention, 16(2), 723–​730. Yalcin, I. (2015). Relationships between well-​ being and social support: a meta-​analysis of studies conducted in Turkey. Turkish Journal of Psychiatry, 26(1), 21–​32. Yamada, A. M., Subica, A. M., Kim, M. A., Van Nguyen, K., Lim, C. S., & Mancuso, L. L. (2014). State of spirituality-​infused mental health services in Los Angeles County wellness and client-​run centers. Administration and Policy in Mental Health and Mental Health Services Research, 41(6), 835–​844. Yamada, N., Nakajima, S., & Noguchi, T. (1998). Age at onset of delusional disorder is dependent on the delusional theme. Acta Psychiatrica Scandinavica, 97(2), 122–​124. Yamaoka, K. (2008). Social capital and health and well-​being in East Asia: a population-​based study. Social Science & Medicine, 66(4), 885–​899. Yan, H (2020). 200,000 people have died from Covid-​19 in the US. That’s more than the US battle deaths from 5 wars combined. Cable Network News (CNN), September 22. Retrieved on 9-​24-​2020 from https://​www.cnn.com/​2020/​ 09/​22/​hea​lth/​us-​coro​navi​rus-​dea​ths-​200k/​ index.html. Yang, H. J., Mao, C. L., Wei, C. Y., & Huang, S. S. (2017). Religious characteristics, spirituality, and depressive symptoms among 10th-​to 12th-​ graders living in a Buddhist or Daoist culture: a short-​term longitudinal study. International Journal for the Psychology of Religion, 27(1), 14–​25. Yang, L., Zhao, M., Magnussen, C. G., Veeranki, S. P., & Xi, B. (2020). Psychological distress

and mortality among US adults: prospective cohort study of 330 367 individuals. Journal of Epidemiology and Community Health, 74(4), 384–​390. Yang, Y. C., Boen, C., Gerken, K., Li, T., Schorpp, K., & Harris, K. M. (2016). Social relationships and physiological determinants of longevity across the human life span. Proceedings of the National Academy of Sciences, 113(3), 578–​583. Yanovitzky, I. (2005). Sensation seeking and adolescent drug use: the mediating role of association with deviant peers and pro-​ drug discussions. Health Communication, 17(1), 67–​89. Yeager, D., Glei, D. A., Au, M., Lin, H.-​S., Sloan, R. P., & Weinstein, M. (2006). Religious involvement and health outcomes among older persons in Taiwan. Social Science & Medicine, 63(8), 2228–​2241. Yehuda, R., Siever, L. J., Teicher, M. H., Levengood, R. A., Gerber, D. K., Schmeidler, J., et al. (1998). Plasma norepinephrine and 3-​methoxy-​4-​ hydroxyphenylglycol concentrations and severity of depression in combat posttraumatic stress disorder and major depressive disorder. Biological Psychiatry, 44(1), 56–​63. Yen, S. T., & Zampelli, E. M. (2014). What drives charitable donations of time and money? The roles of political ideology, religiosity, and involvement. Journal of Behavioral and Experimental Economics, 50, 58–​67. Yeo, K. K., Wijetunga, M., Ito, H., Efird, J. T., Tay, K., Seto, T. B., et al. (2007). The association of methamphetamine use and cardiomyopathy in young patients. American Journal of Medicine, 120(2), 165–​171. Yeung, J. W. (2018). Religion, volunteerism and health: are religious people really doing well by doing good? Social Indicators Research 138(2), 809–​828. Yilmaz, F. T., Sabanciogullari, S., & Karabey, G. (2019). The effect of hajj pilgrimage on treatment compliance in individuals with chronic diseases. Journal of Religion and Health, 58(2), 599–​611. Yilmaz, S., Kart-​Koseoglu, H., Guler, O., & Yucel, E. (2008). Effect of prayer on osteoarthritis and osteoporosis. Rheumatology International, 28(5), 429–​436. Yip, K. (2003). Traditional Chinese religious beliefs and superstitions in delusions and hallucinations of Chinese schizophrenic patients. International Journal of Social Psychiatry, 49(2), 97–​111. Yogman, M., Garfield, C. F., & Committee on Psychosocial Aspects of Child and Family

References • 1049

Health. (2016). Fathers’ roles in the care and development of their children: the role of pediatricians. Pediatrics, 138(1), e20161128. Yong, H. H., Hamann, S. L., Borland, R., Fong, G. T., & Omar, M. (2009). Adult smokers’ perception of the role of religion and religious leadership on smoking and association with quitting: a comparison between Thai Buddhists and Malaysian Muslims. Social Science & Medicine, 69(7), 1025–​1031. Yoon, J. D., Shin, J. H., Nian, A. L., & Curlin, F. A. (2015). Religion, sense of calling, and the practice of medicine: findings from a national survey of primary care physicians and psychiatrists. Southern Medical Journal, 108(3), 189–​195. Yoon, K. H., Moon, Y. S., Lee, Y., Choi, S. H., Moon, S. Y., Seo, S. W., et al. (2018). The moderating effect of religiosity on caregiving burden and depressive symptoms in caregivers of patients with dementia. Aging & Mental Health, 22(1), 141–​147. Yoon, S. S., Dillon, C. F., Illoh, K., & Carroll, M. (2016). Trends in the prevalence of coronary heart disease in the US: National Health and Nutrition Examination Survey, 2001–​2012. American Journal of Preventive Medicine, 51(4), 437–​445. Yorston, G. A. (2001). Mania precipitated by meditation: A case report and literature review. Mental Health, Religion & Culture, 4(2), 209–​213. You, L. F., Yeh, J. R., & Su, M. C. (2014). Expression profiles of loneliness-​associated genes for survival prediction in cancer patients. Asian Pacific Journal of Cancer Prevention, 15(1), 185–​190. Younis, M., Sasikala, K., Anand, A. V., Iqbal, J., Kailash, S., & Hura, M. U. D. (2018). Genetic analysis, health issues and consanguineous marriage in Muslim community. International Journal of Scientific Research in Science and Technology, 4(2), 100–​107. Youssef, N. A., Boswell, E., Fiedler, S., Jump, R., Lee, E., Yassa, M., et al. (2018). Moral injury, posttraumatic stress disorder, and religious involvement among US veterans. Annals of Clinical Psychiatry, 30(2), 113–​121. Ysseldyk, R., Haslam, S. A., & Morton, T. A. (2016). Stairway to heaven? (Ir)religious identity moderates the effects of immersion in religious spaces on self-​esteem and self-​perceived physical health. Journal of Environmental Psychology, 47, 14–​21. Yu, B., & Chen, X. (2019). Age and birth cohort–​ adjusted rates of suicide mortality among US

1050 •  R eferences

male and female youths aged 10 to 19 years from 1999 to 2017. JAMA Network Open, 2(9), e1911383. Yu, B., Steptoe, A., Chen, Y., & Jia, X. (2021). Social isolation, rather than loneliness, is associated with cognitive decline in older adults. Psychological Medicine, 51(14), 2414–​2421. Yu, C. H., Trier, H., & Slama, M. (2019). A data mining and data visualization approach to examine the interrelationships between life satisfaction, secularization and religiosity. Journal of Religion and Health, 58(1), 271–​288. Yucel, D. (2015). What predicts egalitarian attitudes towards marriage and children: Evidence from the European values study. Social Indicators Research, 120(1), 213–​228. Yun, Y. H., Lee, M. K., Park, S. M., Kim, Y. A., Lee, W. J., Lee, K. S., et al. (2012). Effect of complementary and alternative medicine on the survival and health-​related quality of life among terminally ill cancer patients. Annals of Oncology, 24(2), 489–​494. Yunanto, R. A., Susanto, T., Rasni, H., Susumaningrum, L. A., & Nur, K. R. M. (2020). The prevalence of hypertension and related factors among older people in nursing home of Jember, East Java, Indonesia. NurseLine Journal, 4(2), 146–​153. Yusoff, N., Low, W. Y., & Yip, C. H. (2010). Reliability and validity of the Brief COPE Scale (English version) among women with breast cancer undergoing treatment of adjuvant chemotherapy. Medical Journal of Malaysia, 65(1), 41–​44. Zahl, D. (2019). Seculosity: How Career, Parenting, Technology, Food, Politics, and Romance Became Our New Religion and What to Do about It. Minneapolis, MN: Augsburg. Zahl, D. (2020). Replacement Religion and the “Seculosity of Busyness.” Retrieved on 7-​22-​ 2022 from https://​modern​refo​rmat​ion.org/​ resou​rce-​libr​ary/​artic​les/​repl​acem​ent-​relig​ ion-​and-​the-​%CB%9Dsec​ulos​ity-​of-​busyn​ ess%CB%9D/​. Zahrah, N., Norasyikin, S., Abdul, B., Binti, S. H., Rani, A., Akmal, B., et al. (2016). The relationship between Islamic religiosity, Islamic work ethics and job performance. European Proceedings of Social & Behavioural Sciences, 710–​716. Zaidi, M. B., & Flores-​R omo, L (2020). The growing threat of vaccine resistance. Current Treatment Options in Infectious Diseases, 12, 122–​134.

Zaidi, S., & Brueckner, M. (2017). Genetics and genomics of congenital heart disease. Circulation Research, 120(6), 923–​940. Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M., et al. (2016). Suicide prevention strategies revisited: 10-​year systematic review. The Lancet Psychiatry, 3(7), 646–​659. Zangeneh, F., Abedinia, N., Naghizadeh, M. M., Yazdi, R. S., & Madani, T. (2014). The effect of Ramadan fasting on hypothalamic pituitary ovarian (HPO) axis in women with Polycystic Ovary syndrome. Women’s Health Bulletin, 1(1), 1–​6. Zanuso, S., Jimenez, A., Pugliese, G., Corigliano, G., & Balducci, S. (2010). Exercise for the management of type 2 diabetes. Acta Diabetologica, 47(1), 15–​22. Zare, B. (2011). Review of studies on infidelity. International Proceedings of Economics Development and Research, 19(2), 182–​186. Zautra, A. J., Johnson, L. M., & Davis, M. C. (2005). Positive affect as a source of resilience for women in chronic pain. Journal of Consulting and Clinical Psychology, 73(2), 212–​220. Zehnder, D., Prchal, A., Vollrath, M., & Landolt, M. A. (2006). Prospective study of the effectiveness of coping in pediatric patients. Child Psychiatry & Human Development, 36(3), 351–​368. Zemore, S. E., & Zemore, S. E. (2007). A role for spiritual change in the benefits of 12-​step involvement. Alcoholism: Clinical & Experimental Research, 31(10 Supp), 76s–​79s. Zeng, R., & Greenfield, P. M. (2015). Cultural evolution over the last 40 years in China: Using the Google Ngram Viewer to study implications of social and political change for cultural values. International Journal of Psychology, 50(1), 47–​55. Zeng, Y., Gu, D., & George, L. K. (2011). Association of religious participation with mortality among Chinese old adults. Research on Aging, 33(1), 51–​83. Zhang, C., Qin, Y. Y., Chen, Q., Jiang, H., Chen, X. Z., Xu, C. L., et al. (2014). Alcohol intake and risk of stroke. International Journal of Cardiology, 174(3), 669–​677. Zhang, C., Brook, J. S., Leukefeld, C. G., & Brook, D. W. (2021). Developmental trajectories of religious service attendance: predictors of nicotine dependence and alcohol dependence/​ abuse in early midlife. Journal of Religion and Health, 60(3), 1766–​1779. Zhang, J., Wieczorek, W. F., Conwell, Y., & Ming Tu, X. (2011). Psychological strains and youth

suicide in rural China. Social Sciences & Medicine, 72(12), 2003–​2010. Zhang, J., O’Leary, A., Jemmott III, J. B., Icard, L. D., & Rutledge, S. E. (2019). Syndemic conditions predict lower levels of physical activity among African American men who have sex with men. PloS One, 14(3), e0213439. Zhang, W. (2008). Religious participation and mortality risk among the oldest old in China. Journals of Gerontology, 63B(5), S293–​297. Zhang, W. (2010). Religious participation, gender differences, and cognitive impairment among the oldest old in China. Journal of Aging Research, 2010, 160294. Zhang, Y. (2018). Family functioning in the context of an adult family member with illness. Journal of Clinical Nursing, 27(15–​16), 3205–​3224. Zhang, Y., & Han, B. (2016). Positive affect and mortality risk in older adults: A meta‐analysis. Psych Journal, 5(2), 125–​138. Zhao, D., Post, W. S., Blasco-​Colmenares, E., Cheng, A., Zhang, Y., Deo, R., et al. (2019). Racial differences in sudden cardiac death. Circulation, 139(14), 1688–​1697. Zheng, X., Song, M., & Chen, H. (2020). Could wealth make religiosity less needed for subjective well-​being? Frontiers in Psychology, 11, 1636. Zhu, T., Xue, J., & Chen, S. (2019). Social support and depression related to older adults’ hypertension control in rural China. American Journal of Geriatric Psychiatry, 27(11), 1268–​1276. Zidkova, R., Glogar, P., Polackova Solcova, I., P van Dijk, J., Kalman, M., Tavel, P., et al. (2020). Spirituality, religious attendance and health complaints in Czech adolescents. International Journal of Environmental Research and Public Health, 17(7), 2339. Zill, N., Morrison, D. R., & Coiro, M. J. (1993). Long-​term effects of parental divorce on parent-​child relationships, adjustment, and achievement in young adulthood. Journal of Family Psychology, 7(1), 91. Zimmer, Z., Chiu, C. T., Saito, Y., Jagger, C., Ofsteda, M. B., & Lin, Y. H. (2019). Religiosity dimensions and disability-​free life expectancy in Taiwan. Journal of Aging and Health, 32(7–​8), 627–​641. Zimmer, Z., Chiu, C. T., Saito, Y., Lin, Y. H., Ofstedal, M. B., & Jagger, C. (2020). Does religious activity distinguish the mortality experiences of older Taiwanese? Journal of Religion and Health, 59(1), 289–​308.

References • 1051

Zimpel, R. R., Panzini, R. G., Bandeira, D. R., Heldt, E., Manfro, G. G., Fleck, M. P., et al. (2018). Can religious coping and depressive symptoms predict clinical outcome and quality of life in panic disorder? Journal of Nervous and Mental Disease, 206(7), 544–​548. Zini, A., Sgan-​Cohen, H. D., & Marcenes, W. (2012a). Is religiosity related to periodontal health among the adult Jewish population in Jerusalem? Journal of Periodontal Research, 47(4), 418–​425. Zini, A., Sgan-​Cohen, H. D., & Marcenes, W. (2012b). Religiosity, spirituality, social support, health behavior and dental caries among 35-​44-​ year-​old Jerusalem adults. Caries Research, 46, 368–​375. Ziv, I., Lubin, O. B. H., & Asher, S. (2018). “I swear I will never betray you.” Journal of Sex Research, 55(2), 236–​251. Zollinger, T. W., Phillips, R. L., & Kuzman, J. W. (1984). Breast cancer survival rates among Seventh-​Day Adventists and non-​Seventh-​Day Adventists. American Journal of Epidemiology, 119, 503–​509.

1052 •  R eferences

Zoni-​Berisso, M., Lercari, F., Carazza, T., & Domenicucci, S. (2014). Epidemiology of atrial fibrillation: European perspective. Clinical Epidemiology, 6, 213–​220. Zorn, J. V., Schür, R. R., Boks, M. P., Kahn, R. S., Joëls, M., & Vinkers, C. H. (2017). Cortisol stress reactivity across psychiatric disorders. Psychoneuroendocrinology, 77, 25–​3 6. Zou, J., Huang, Y., Maldonado, L., Kasen, S., Cohen, P., & Chen, H. (2014). The efficacy of religious service attendance in reducing depressive symptoms. Social Psychiatry & Psychiatric Epidemiology, 49, 911–​918. Zouhal, H., Lemoine-​Morel, S., Mathieu, M. E., Casazza, G. A., & Jabbour, G. (2013). Catecholamines and obesity: effects of exercise and training. Sports Medicine, 43(7), 591–​600. Zuckerman, M., Li, C., & Diener, E. F. (2017). Societal conditions and the gender difference in well-​being. Personality and Social Psychology Bulletin, 43(3), 329–​336.

Index

Tables and figures are indicated by t and f following the page number AA. See Alcoholics Anonymous AAMI (age-​associated memory impairment), 440 Abarca-​Gomez, L., 347 Abdi, A., 222 Abel, W. M., 412 Aberer, E., 559 Abu, H. O., 386 abuse. See also child abuse depression and, 70 emotional, 70, 171, 195, 258 physical, 171, 195, 258–​259, 508, 569 sexual, 70, 148, 171, 195, 569 academic performance. See also education cigarette smoking and, 318 divorce and, 256 family environment and, 153 literature review, 764t psychological well-​being and, 214 religiosity and, 293–​294 acceptance and commitment therapy (ACT), 187, 571 ACS (Attitude toward Church Scale), 24 activities of daily living (ADLs) cognitive impairment and, 438 drug use and, 551 instrumental, 545, 555–​558 life strain and, 59 physical disability and, 545–​547

stroke and, 418, 429 volunteering and, 550 addiction. See also substance use disorders causes of, 170 defined, 164–​165 food, 185, 363, 734–​735t gambling, 185–​186, 735t Internet gaming, 186, 736t nicotine, 317 opioid, 168–​169 religiosity and, 174, 182, 183 suicide/​suicidal ideation and, 119 Addison's disease, 486 Adekeye, O. B., 182–​183 ADHD. See attention deficit and hyperactivity disorder adherence to treatment. See compliance with treatment adjustment disorders (ADs), 68, 125 ADLs. See activities of daily living adrenaline. See epinephrine adultery. See infidelity Afghanistan depressive disorders in, 69 religious coping in, 51–​52 stress levels in, 46 Afhami, R., 201, 202

 • 1053

Africa. See also specific countries anxiety disorders in, 127 chronic pain in, 567 depressive disorders in, 69 hypertension in, 398 psychotic disorders in, 144 religious coping in, 52, 64 substance use disorders in, 165 African Americans bipolar disorder and, 90 cancer and, 507, 510 chronic pain and, 569 cigarette smoking and, 322–​323, 423 delinquency/​crime and, 238–​239 dementia and, 440 depressive disorders and, 69, 75 diet and nutrition, 351 domestic violence and, 276 education and, 637 heart disease and, 372, 385–​386 hypertension and, 398, 400, 402, 405–​410, 414 life expectancy for, 525 obesity and, 347, 359–​360, 362, 424, 635 physical activity and, 337, 339 physical disability and, 546, 547 psychological well-​being and, 215 psychotic disorders and, 155 religious coping among, 52 sexual activity and, 270 stress hormones and, 485 stroke and, 419, 425 substance use disorders and, 166, 176–​177, 179 suicide/​suicidal ideation and, 105 age anxiety disorders and, 128 cancer and, 506–​507 chronic pain and, 568–​569 cigarette smoking and, 318 cognitive impairment and, 119, 440 depression and, 69, 71 heart disease and, 369, 371, 371t hypertension and, 399, 402 immune function and, 460–​461 inactivity rates and, 330, 331, 334 mortality risk and, 524, 533 personality formation and, 189 physical disability and, 547, 548 psychological well-​being and, 213 psychotic disorders and, 145 stress hormones and, 485–​486 stroke and, 419, 425 substance use disorders and, 166–​169 suicide/​suicidal ideation and, 96, 103–​104, 115, 634 age-​associated memory impairment (AAMI), 440 Age Universal Religious Orientation Scale, 248 Aghababaei, N., 201, 202 Agnew, R., 251 agnosticism, 9, 18, 116, 449 agoraphobia, 124, 126–​127, 375 agreeableness characteristics of, 191t family stability and, 267 heart disease and, 375 marital satisfaction and, 257 religiosity and, 198, 202–​203, 207 sociability and, 285

1054 •  I N D E X

Ahrenfeldt, L. J., 79–​80, 336–​337, 357–​358, 386–​387, 408, 432, 516, 556–​557 Ai, A. L., 58 AIDS. See HIV/​AIDS Akbari, M. E., 152 Akrawi, D., 185 Alam, I., 406 Alcaraz, K. I., 518 Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), 323 Alcohol and Smoking Cessation Self-​Efficacy (ASE) scale, 182–​183 Alcoholics Anonymous (AA), 141, 165, 183–​185, 187, 392, 599 alcohol-​related dementia, 439 alcohol use disorder (AUD) anxiety disorders and, 131 bipolar disorder and, 94 cancer and, 511, 513 causes of, 170–​172, 244 chronic pain and, 572, 575 as coping strategy, 49 delinquency/​crime and, 239–​240 dementia and, 443, 445 depression and, 68, 71 drug use and, 167 heart disease and, 377 hypertension and, 400 immune function and, 465–​466 interventions for, 172, 182–​183 mortality and, 530 physical disability and, 551, 553 prevalence of, 165, 634–​635 religiosity and, 174–​178, 183 stress hormones and, 489, 492 stroke and, 423, 427 suicide/​suicidal ideation and, 105, 119 Al-​Hazzaa, H. M., 331 Alicandro, G., 104 Allah, 135, 137, 410, 562, 596. See also Islam and Muslims Allen, J. O., 494 Allen, K. D., 494 Allison, P. J., 510 allocative health policy, 646, 647t Allport, Gordon, 20, 189 Allport Intrinsic Religiosity Scale, 292 alternative medicine, 517, 577 altruism dementia and, 443 emotional stability and, 197 genetic influences on, 153 literature review, 774–​776t physical disability and, 550, 553 religiosity and, 197, 198, 294 religious education on, 243 as virtue, 208 Alzheimer's disease causes of, 441–​443 clinical presentation, 438 literature review, 449–​451, 800–​801t obesity and, 348 physical activity and, 329 psychotic disorders and, 148 religiosity and, 449–​451 American Academy of Pediatricians, 259 American Heart Association, 345, 376, 397, 398, 424 American Indians. See Native Americans American Psychiatric Association, xx, 86, 657

Amish communities, 355, 597, 613–​614 Amjadian, M., 388–​389 amphetamines, 68, 165, 166, 423, 443 ancestral worship, 265–​266 Anderson, K. L., 275–​276 Anderson, M. R., 498–​499 Anderson, N., 85 answerability of research questions, 31 Antisocial Behavior Questionnaire, 205 antisocial personality disorder, 192t, 193–​195, 198, 204–​209, 252 Antoni, M. H., 508–​509 anxiety disorders, 123–​142. See also specific disorders adjustment disorders and, 68 bipolar disorder and, 91, 127 cancer and, 509 case study, 129–​130 causes of, 128–​129, 303 chronic diseases and, 127–​129, 131 chronic pain and, 571 consequences of, 127–​128 dementia and, 441, 442 depression and, 127 diagnosis of, 123–​126 economic burden of, 127 in family environment, 131, 258 future research needs, 139–​140 heart disease and, 375 hypertension and, 399–​400 immune function and, 463 interventions for, 135–​141 literature review, 131–​139, 711–​717t moral injury and, 126 mortality and, 528 personality disorders and, 193, 195 physical activity and, 329 physical disability and, 127, 549 prevalence of, 126–​127 religiosity and, 119, 129–​140, 175, 302 religious coping and, 78, 132, 133, 139, 156, 158 schizophrenia and, 127 spirituality and, 134 stress hormones and, 487, 491–​492 stroke and, 421, 427 substance use disorders and, 129–​131, 139, 171–​172 suicide/​suicidal ideation and, 103, 105, 119, 127 anxiolytics, 169 Anyfantakis, D., 430, 494 Apel, M. D., 597 ARDA (Association of Religion Data Archives), 40 Argentina, obesity in, 347 Aristotle, 211, 369 Arredondo, E., 340–​341 arthritis anxiety disorders and, 127 osteoarthritis, 53, 347, 548, 559, 570, 818t physical disability and, 548 religious coping and, 53 rheumatoid, 548, 570, 818t ASE (Alcohol and Smoking Cessation Self-​Efficacy) scale, 182–​183 Asia. See also specific countries chronic pain in, 567 depressive disorders in, 69, 549 heart disease in, 370 hypertension in, 398 psychotic disorders in, 144 religious coping in, 51–​52, 54–​55

stroke in, 419, 422 substance use disorders in, 166, 168 Asian Americans bipolar disorder and, 90 delinquency/​crime and, 238 depressive disorders and, 69 education and, 637 hypertension and, 398, 400 meaning and purpose in life for, 223 physical disability and, 546 Asmand, P., 410–​411 Assari, S., 495 assault physical, 148, 252, 553, 614 sexual, 59, 126, 136, 148, 304, 633 Assemie, M. A., 602 assessment. See measurement Assiri, H. M., 331 ASSIST (Alcohol, Smoking and Substance Involvement Screening Test), 323 Association of Religion Data Archives (ARDA), 40 atheism, 9, 18, 54, 62, 116, 229–​230 atrial fibrillation, 420 attachment security, 258, 266, 271, 272, 278, 281 Attachment to God Inventory, 21 Attachment to God Scale, 21, 623 attachment to religion, 21, 231 attendance at religious services anxiety disorders and, 132–​135, 139 bipolar disorder and, 95, 98, 100 body weight and, 356–​359 cancer and, 514–​518 chronic pain and, 578–​579 cigarette smoking and, 321–​324 cognitive function and, 447–​448, 452 during COVID-​19 pandemic, 650 delinquency/​crime and, 245–​248, 250 depression and, 36–​38, 74–​81, 133 diet and, 353 disease prevention and, 597 domestic violence and, 276 family functioning and, 272 forgiveness and, 292 heart disease and, 382–​385, 387 hypertension and, 407–​409 immune function and, 471–​475 marital stability and, 268, 271 mortality risk and, 536–​539 personality traits and, 199–​200 physical activity and, 333, 335–​336, 338 physical disability and, 554–​559 positive emotions and, 223, 225, 226, 229 psychological well-​being and, 215, 218–​221 psychotic disorders and, 155, 156 religious coping and, 58–​61 sexual activity and, 269, 270 single-​item measures of, 18–​19, 665 social capital and, 294 social support and, 289, 290, 295, 296 stroke and, 428–​432 substance use disorders and, 174, 176–​181 suicide/​suicidal ideation and, 98, 114–​117, 121 variations across religions, 668 volunteering and, 294 attention deficit and hyperactivity disorder (ADHD), 129, 171–​172, 175, 241 Attitude toward Buddhism Scale, 23–​24

Index • 1055

Attitude toward Christianity Scale, 272 Attitude toward Church Scale (ACS), 24 Attitude toward Sikhism Scale, 23 AUD. See alcohol use disorder Auditory Vocal Hallucination Rating Scale, 157 Augustine of Hippo: City of God, 108 Aune, D., 532 Australia anxiety disorders in, 136–​137 depressive disorders in, 69, 76, 84 heart disease in, 374 obesity in, 347 physical activity in, 531 physical disability in, 550 religiosity in, 54, 201 religious coping in, 54 substance use disorders in, 169, 603 suicide/​suicidal ideation in, 104 Austria bipolar disorder in, 98, 100 chronic pain in, 580 depressive disorders in, 79 autonomic nervous system, 392, 422, 612 avoidant personality disorder, 192t, 194, 199, 206–​207, 209 Ayazi, M., 388, 409–​410 Ayling, K., 464 Azorin, J. M., 97 Bachhuber, M. A., 169 Baetz, M., 95 Bahri, N., 508 BAI (Beck Anxiety Inventory), 124 Bailey, Z. D., 322 Balboni, Michael and Tracy, xviii Balbuena, L., 77 Bandelow, B., 127 Bangladesh religiosity in, 47 stress levels in, 46 Baptists, 156–​158 Barbados, hypertension in, 397–​398 Barlati, S., 145 Barr, T., 465–​466 Basinski, A., 578 Bastida, E., 289 Batz, C., 214–​215 Baxter, A. J., 127 B-​COPE. See Brief COPE Bear, U. R., 24 Beaver, K. M., 244 Beck Anxiety Inventory (BAI), 124 Beck Depression Inventory (BDI), 69, 75, 81–​83 Beeri, M. S., 447, 449 Behavioral Religiosity Scale (BRS), 449 behavioral risk factors bipolar disorder and, 92 cancer and, 510–​513 chronic pain and, 572, 575 dementia and, 442–​444 heart disease and, 372t, 376–​377, 381 hypertension and, 400, 403–​404 immune function and, 464–​466, 468 mental health and, 305, 310 mortality and, 530–​532, 534 obesity and, 348 physical disability and, 550–​551, 553–​554 physical health and, 613, 615

1056 •  I N D E X

psychotic disorders and, 154 stroke and, 423–​424, 427 Behavioral Risk Factor Surveillance System (BRFSS), 546 Beiranvand, S., 410 Belgium chronic pain in, 577 depressive disorders in, 79 personality disorders in, 193 Belief into Action Scale (BIAC), 20, 23, 25, 121, 477 Bellinger, D. L., 494 Benda, B. B., 155–​156 Beneitez, I., 566 Benin, hypertension in, 406 Benjamins, M. R., 507, 598, 604 Ben-​Meir, Y., 23 Benzies, K., 260, 267 benzodiazepines, 135, 138, 169, 187, 551 bereavement, 68–​69, 106 Bergeman, C. S., 284, 358 Berges, I. M., 429 Berk, L. S., 495, 497, 502 Bert, S. C., 228–​229, 274 Best, J. B., 118 BIAC. See Belief into Action Scale biases. See also discrimination recall, 32 researcher, 16–​17 selection, 96, 668 Bible. See also Christianity delinquency/​crime and, 249–​250 on diet and nutrition, 350 on family unit, 264 on forgiveness, 288 on heart health, 393t immune function and, 479t on mortality, 523–​524 on physical body, 320, 332, 561–​562 psychotic disorders and, 156, 157, 159 religious coping and, 58, 61 on social support, 287 on suffering, 562 suicide prohibitions in, 108 Bierman, A., 60 Big Five model, 190, 191t, 197, 202–​203 binge eating disorder, 185 biological risk factors. See also genetic influences anxiety disorders and, 129, 131 bipolar disorder and, 91–​92 cancer and, 507–​508 chronic pain and, 570, 574 delinquency/​crime and, 239–​240, 243 depression and, 71–​72 heart disease and, 371t, 372–​373, 379–​380 immune function disorders and, 461, 467 mental health and, 305–​306, 310 mortality and, 526, 533 personality disorders and, 195 physical health and, 612, 614 psychotic disorders and, 153 stroke and, 420–​421, 426 suicide/​suicidal ideation and, 105 bipolar disorder (BPD), 89–​102 anxiety disorders and, 91, 127 case study, 92–​93 causes of, 91–​92, 303 consequences of, 91 depression and, 90–​101 diagnosis of, 89–​90

economic burden of, 91 future research needs, 100 literature review, 95–​100, 704–​705t mania and, 89–​90, 92–​101, 147 prevalence of, 90–​91 psychotherapy for, 101 with psychotic features, 143, 145, 147, 151 religiosity and, 89, 92–​100, 102 religious coping and, 89, 99 spirituality and, 95 substance use disorders and, 91–​94 suicide/​suicidal ideation and, 91, 96, 101, 103, 105 Black, N., 167 Black Americans. See African Americans Blanchflower, D. G., 213–​214 Blazer, D. G., 529 Blazer, Dan G., xvii Bleuler, Eugene, 148 BMMRS. See Brief Multidimensional Measure of Religiousness/​Spirituality body mass index (BMI), 346–​347 body weight, 344–​365. See also diet and nutrition; obesity adipose tissue and, 348 cancer and, 511 chronic pain and, 572 dementia and, 443, 446 future research needs, 361–​362 immune function and, 465 interventions for, 362–​365, 364t literature review, 355–​361, 784–​786t measurement of, 346–​347 mental health and, 67, 105, 348 mortality risk and, 532 physical activity and, 329 religiosity and, 352, 355–​361 stress hormones and, 490 stroke and, 424, 427 Book of Common Prayer, wedding vows in, 254 Bopp, M. J., 339–​340 borderline personality disorder, 192t, 194–​195, 198, 204–​205, 207, 209–​210 Bormann, J. E., 137, 206 Borsook, D., 568 Botswana, depressive disorders in, 69 BPD. See bipolar disorder BPRS (Brief Psychiatric Rating Scale), 158 Braam, A.W., 75, 81 Bradshaw, M., 60–​61, 133–​134, 219, 228 brain structure and function alcohol use and, 551 bipolar disorder and, 92 literature review, 802–​803t personality disorder and, 195 religiosity and, 453–​454 stroke and, 423 Brammli-​Greenberg, S., 578 Brandt, M. J., 403 Brazil bipolar disorder in, 97, 99, 100 cigarette smoking in, 323 personality disorders in, 204 psychotic disorders in, 155 substance use disorders in, 169 suicide/​suicidal ideation in, 104 Brent, D. A., 106 Breslin, M. J., 203 BRFSS (Behavioral Risk Factor Surveillance System), 546 Brief COPE (B-​COPE), 20, 48, 49t, 51–​54

Brief Multidimensional Measure of Religiousness/​Spirituality (BMMRS), 22, 24, 25, 134, 408, 473 Brief Psychiatric Rating Scale (BPRS), 158 brief psychotic disorder, 143, 146 Brief RCOPE, 20–​22, 24–​25, 58, 78, 96, 99, 133, 156 Brief Religious History scale (BRH), 21 Brief Symptom Inventory, 61, 82, 498 Brown, C., 598 Brown, E., 268–​269 Brown, S. L., 529–​530 Brown, T. L., 178–​179 Brown, W. M., 550 Browne, M., 201 BRS (Behavioral Religiosity Scale), 449 Bruininks, P., 226 Brummet, B. H., 487–​488 BSS (Building Spiritual Strengths intervention), 138, 140 Bücker, S., 214 Buddhism branches of, 18, 55, 500 cancer and, 517 chanting and, 388 chronic pain and, 585 on diet and nutrition, 351 Eastern model and, 620 Eightfold Path in, 84, 136, 263, 265, 287–​288, 320, 620 on exercise, 333 on family unit, 265–​266 Five Moral Precepts in, 351 on forgiveness, 288 Four Noble Truths in, 320, 620 on heart health, 394t immune function and, 480t on marriage and divorce, 263 measurement scales for, 23–​24 mindfulness-​based therapies and, 84, 136–​137, 210, 453, 488, 494, 579, 585 non-​attachment principle in, 62, 320 on physical body, 320, 562, 595, 596, 606 on social support, 287–​288 Spiritual Self–​Schema and, 182 on suicide, 108 walking meditation, 360, 389, 396, 410 Buddhist Beliefs and Practices Scale, 19, 23 Buddhist COPE, 23 Building Spiritual Strengths intervention (BSS), 138, 140 bulimia nervosa, 185 Burke, A., 577 Burshtein, S., 115–​116 Buzdar, M. A., 205–​206 Byrnes, M. D., 510 Cadet, T., 601 caffeine, 129, 166 CA-​IMT (carotid artery intima-​media thickness), 420, 426–​431, 433–​434 Calati, R., 106 Call, V. R. A., 268 Callen, B. L., 473, 477 CAM (complementary and alternative medicine), 517, 577 Canada bipolar disorder in, 95, 99, 100 cancer in, 506, 512, 515 chronic pain in, 576 cognitive function in, 448 depressive disorders in, 77, 84 obesity in, 347 personality disorders in, 204, 205

Index • 1057

Canada (cont.) psychotic disorders in, 144 religiosity in, 53, 289 religious coping in, 53–​54 stroke in, 432 cancer, 505–​522 anxiety disorders and, 128, 136–​137 case study, 512 depression and, 75, 82, 84 determinants of, 318, 345–​346, 506–​512 economic burden of, 506 future research needs, 518–​520 interventions for, 520–​521 literature review, 513–​518, 815–​817t mortality and, 505–​506, 516–​518, 593 obesity and, 346, 347, 511 physical activity and, 329 prevalence and survival rates, 505–​506, 506t, 593 psychological well-​being and, 219–​220, 222 psychotic disorders and, 152 religiosity and, 512–​518 religious coping and, 51–​54 screenings for, 511–​513, 532, 593–​594 social support and, 289–​290 stress hormones and, 501, 508 cannabis use bipolar disorder and, 92, 93 dementia and, 443 heart disease and, 377 immune function and, 466 prevalence of, 166–​167, 169, 635 psychotic disorders and, 154 religiosity and, 174, 176–​182 schizophrenia and, 148 CAPI (Child Abuse Potential Inventory), 274 Caplan, L. S., 556 Cappuccio, F. P., 377 CAPS (Clinician Administered PTSD Scale), 137, 138 Captari, L. E., 85–​86 cardiovascular disease (CVD). See also heart disease anxiety disorders and, 131 bipolar disorder and, 93, 94 cigarette smoking and, 318 dementia and, 441 diet and, 344–​345 economic burden of, 370 health consequences of, 370 personality disorders and, 193 physical activity and, 329 physical disability and, 548 prevalence of, 370 psychotic disorders and, 148, 153 Caribbean. See Latin America and Caribbean Caribe, A. C., 97 Carlson, S. A., 330 carotid artery intima-​media thickness (CA-​IMT), 420, 426–​431, 433–​434 Carvalho, L. D., 204 Carver, Charles, 48, 63, 65 Caspi, A., 71, 128, 239 Castillo-​Richmond, A., 429–​430, 434 catecholamines. See epinephrine; norepinephrine Catholicism on attendance at services, 668 body weight and, 359 Catechism of the Catholic Church, 108, 119, 264, 359 denominations within, 18 on diet and nutrition, 349–​350

1058 •  I N D E X

exorcisms and, 150–​151, 161 on family unit, 263–​264 longevity of believers, 535 on marriage and divorce, 261–​262 personality disorders and, 207 physical activity during Mass, 333 pilgrimages in, 334 religious coping and, 62 rituals for atonement in, 521 sexual activity and, 270 on social support, 287 stroke and, 431, 432 substance use disorders and, 177 on suffering, 584 suicide/​suicidal ideation and, 108, 114–​120 CBT. See cognitive behavioral therapy CBVD. See cerebrovascular disease Center for Epidemiologic Studies–​Depression scale (CES-​D), 69, 74, 75, 78–​80, 221, 448 Centers for Disease Control (CDC) on healthcare expenditures, 636 on health policy, 646 on marriage and divorce rates, 255 on physical disability, 546 on suicide rates, 121 on tobacco use, 318 vaccination recommendations, 589, 589t Centers for Faith-​Based and Neighborhood Partnerships (CFNPs), 657 Centers for Medicare and Medicaid Services (CMS), xx, 654, 659 Central America. See Latin America and Caribbean Centrality of Religiosity Scale (CRS), 20, 204, 477 central nervous system, 195, 303, 482, 489, 500, 566, 612 cerebrovascular disease (CBVD). See also stroke anxiety disorders and, 131 bipolar disorder and, 91–​93 dementia and, 441 diet and, 344–​345 literature review, 799–​800t prevalence of, 370 religiosity and, 416 types of, 417 CES-​D. See Center for Epidemiologic Studies–​Depression scale CFNPs (Centers for Faith-​Based and Neighborhood Partnerships), 657 Chad, depressive disorders in, 69 Chan, C. S., 58 Chan, J. Y., 441 Chan, M. Y., 528 Chang, B. H., 59 character traits. See also specific traits decision-​making and, 615 mental health and, 7, 306, 311 model of, 190, 191t personality vs., 189 physical health and, 614 religious education and, 243 virtues, 207–​208, 306, 311, 632, 639, 740–​741t Charlemagne-​Badal, S. J., 407 Chastin, S. F., 531 Chaves, Mark, 667 CHD. See coronary heart disease Chen, R., 419 Chen, Y., 80–​81, 117, 134–​136, 177, 178, 180, 220, 221, 223, 226, 229, 290–​292, 294, 322, 338, 357, 358, 387, 409, 432, 474, 515–​516, 604–​605 Chida, Y., 508

child abuse cancer and, 508 chronic pain and, 569 delinquency/​crime and, 238, 240 depression and, 70 emotional, 70, 171, 195 literature review, 274–​275, 769–​770t mortality risk and, 527 physical, 171, 195, 508, 569 psychological well-​being and, 220 religiosity and, 60, 274–​275, 278 sexual, 70, 171, 195, 569 substance use disorders and, 170–​171 Child Abuse Potential Inventory (CAPI), 274 Child Behavior Checklist, 132, 134 child offenders. See delinquency and crime Child Post-​Traumatic Stress Reactions scale, 132 Chile bipolar disorder in, 90–​91 depressive disorders in, 77 obesity in, 347 religious coping in, 52 China ancestral worship in, 266 anxiety disorders in, 127 bipolar disorder in, 90–​91 chronic pain in, 577 cognitive function in, 450–​452 depressive disorders in, 69 obesity in, 347 personality disorders in, 193 psychotic disorders in, 144, 152, 155 religious coping in, 54, 64 religious persecution in, 54, 540 social unrest in, 634 stroke in, 422 cholesterol diet and, 345–​346 heart disease and, 372 physical inactivity and, 331 stroke and, 420–​421, 426 Chou, A. F., 510 Christ, A., 465 Christian-​accommodative mindfulness training (CMT), 85 Christianity. See also Bible; Catholicism; God; Protestantism anxiety disorders and, 140 ascetic practices within, 596 cancer and, 517 chronic pain and, 585 cognitive behavioral therapy and, 85 denominations within, 18 depression and, 83–​85 on forgiveness, 288 forgiveness interventions and, 135–​136 on heart health, 393t immune function and, 479t mindfulness-​based therapies and, 85, 210 on physical body, 320, 332, 342, 561–​562, 595, 606 religious coping and, 52, 59 self-​esteem and, 229–​230 on social support, 287 on suffering, 562, 584 on suicide, 108, 119 Christian Scientists, 535 chronic diseases. See also disease prevention; specific conditions anxiety disorders and, 127–​129, 131 economic burden of, xxii physical disability and, 546, 548

prevalence of, 310, 635 religiosity and, 54, 119 religious coping and, 54 stress associated with, 47 suicide/​suicidal ideation and, 105, 118, 119 chronic obstructive pulmonary disease (COPD), 129, 318, 548 chronic pain, 565–​586 anxiety disorders and, 127 case study, 573 definitions of, 567 determinants of, 568–​572 economic burden of, 568 future research needs, 581–​583 interventions for, 583–​585 literature review, 576–​581, 835–​837t mortality risk and, 527 prevalence of, 567–​568 religiosity and, 572–​583, 575f, 582f religious coping and, 53–​54, 576 spirituality and, 576, 580–​581 suicide/​suicidal ideation and, 105, 582 Chu, P. S., 216 CIDI. See Composite International Diagnostic Interview cigarette smoking, 317–​327. See also tobacco use disorder bipolar disorder and, 92–​94 cancer and, 511, 513 case study, 319 chronic pain and, 572, 575 delinquency/​crime and, 239–​240 dementia and, 443, 445 e-​cigarettes, 318, 319, 326, 400 economic burden of, 325 future research needs, 324–​326 health consequences of, 193, 318–​319, 376, 423, 427 immune function and, 465 interventions for, 326–​327 literature review, 321–​324, 776–​781t mortality and, 318, 325, 530 nicotine addiction and, 317 physical disability and, 546, 551, 553 predictors of, 318 prevalence of, 317–​318, 423, 635 religiosity and, 119, 154, 174, 176, 182–​183, 320–​324, 666 spirituality and, 325–​326 stress hormones and, 489, 492 Civil Rights Act of 1964, 654 Clancy, S., 576 Clinical Global Impressions Scale, 17 Clinician Administered PTSD Scale (CAPS), 137, 138 Cloninger, Robert, 190 CMS (Centers for Medicare and Medicaid Services), xx, 654, 659 CMT (Christian-​accommodative mindfulness training), 85 cocaine, 68, 165–​167, 170, 178, 186, 377, 423 codeine, 168, 182 cognitive behavioral therapy (CBT). See also religious cognitive behavioral therapy anxiety disorders and, 141 bipolar disorder and, 101 delinquency/​crime and, 252–​253 depression and, 81–​85, 87 psychotic disorders and, 159–​161 stress hormones and, 495–​497 substance use disorders and, 173, 182–​183, 187 suicidal ideation and, 106, 118, 122 cognitive impairment. See also dementia age-​related, 119, 440 causes of, 441–​444

Index • 1059

cognitive impairment (cont.) future research needs, 454–​455 interventions for, 455–​457 mild, 440–​442, 450–​451, 453, 456 religiosity and, 444–​454 spirituality and, 448 stroke and, 417 cohabitation, 255, 260, 262, 266, 269, 278, 637 Cohen, Harvey Jay, xvii Cohen, L., 576 Cohen, S., 477 Cohen-​Mansfield, J., 290–​291, 451, 556 Coherence, defined, 611 Cohon, Samuel S., 563 cohort studies. See prospective studies Coin, A., 449 Colantonio, A., 428–​429 collectivism vs. individualism, 633 Colombia, mental health disorders in, 155, 193 Comings, D. E., 150 commitment to religion anxiety disorders and, 134 cognitive appraisals and, 62 eating disorders and, 185 immune function and, 476 multi-​item measures of, 20, 477 personality disorders and, 205, 207 stress hormones and, 500 substance use disorders and, 179–​180 complementary and alternative medicine (CAM), 517, 577 compliance with treatment anxiety disorders and, 141, 143 bipolar disorder and, 93, 94 depression and, 86 disease prevention and, 594 heart disease and, 370, 377 hypertension and, 411–​412, 415 literature review, 843–​846t psychotic disorders and, 145, 151, 160 religiosity and, 599–​600, 602–​603 substance use disorders and, 182 suicide prevention and, 106 Composite International Diagnostic Interview (CIDI), 76, 77, 95, 124, 127 Comstock, G. W., 598 concurrent validity, 4, 27, 28 conduct disorder, 171–​172, 175 Confucianism, 108, 620 conscientiousness characteristics of, 191t dementia and, 442 family stability and, 267 heart disease and, 375 immune function and, 464 marital satisfaction and, 257 mortality risk and, 527–​528 personality disorders and, 192t religiosity and, 198, 202, 207 construct validity, 4, 27 content validity, 27 convenience sampling, 34 convergent validity, 4, 20, 27, 28 Cook, Christopher, xix cooperativeness, 190, 191t, 208, 252 COPD (chronic obstructive pulmonary disease), 129, 318, 548 COPE scale, 20, 24–​25, 48, 60, 63, 220, 412, 475, 576–​577 coping resources

1060 •  I N D E X

availability of, 48, 62 delinquency/​crime and, 241, 243–​244 eustress in development of, 47 family stability and, 260 psychological well-​being and, 214 psychotic disorders and, 154 religion and, 62–​64, 154 stress buffering and, 129 coping strategies. See also religious coping adaptive, 48–​49, 49t, 64, 65, 73, 143, 154 cigarette smoking, 321 emotion-​focused, 48, 49, 63 maladaptive, 48–​49, 49t, 64, 305 problem-​focused, 48, 49, 63 psychotic disorders and, 143 reappraisals, 48, 49, 63, 305, 577, 583, 584 reframing, 49, 64, 65, 309, 584, 585 social support, 49, 60, 63, 64 substance use disorders and, 49, 51, 53–​55 Cordonnier, C., 419 coronary heart disease (CHD) diet and, 344–​346 economic burden of, 370 future research needs, 390–​391 health consequences of, 370 prevalence of, 369, 370 religiosity and, 379–​390, 382f risk factors for, 371–​378 Corsentino, E. A., 448–​449 Cortes, D. S., 500 cortisol in acute stress response, 482, 483 in chronic stress response, 482, 484 cytokines and, 460 factors affecting, 441, 485–​490, 508 fetal development and, 303, 373 fight-​flight response and, 463, 482 immune function and, 484 physical effects of, 482 religiosity and, 360, 492–​496 Costello, H., 463 Costello and Comrey Anxiety Scale, 136 Coughlin, S. S., 510 COVID-​19 pandemic attendance at religious services during, 650 clerical sacrifices during, 655 long-​term care settings and, 658 mask mandates during, 646 mortality in, 461, 526, 635–​636 PTSD during, 126 religiosity and, 605 shelter-​in-​place directives during, 602 vaccinations and, 589–​590, 601 Cozier, Y. C., 407–​408 Cozma, S., 350 Crank, B. R., 181, 223 Cranmer, Thoms, 254 Crawford, M. J., 106 C-​reactive protein (CRP), 377, 460, 463–​465, 468, 470–​472, 476 Crespi, B., 204 crime. See delinquency and crime criterion validity, 4, 27, 28 Croezen, S., 79 Cronan, T. A., 581 cross-​sectional studies on bipolar disorder, 95–​99

on chronic pain, 577–​578 on cognitive impairment, 446, 450–​451 description of, 32 on diet, 353–​355 on family functioning, 272–​273, 275–​276 on hypertension, 406 levels of evidence and, 36, 36t on personality disorders, 203–​207 on physical health and religiosity, 624 on psychotic disorders, 154–​155, 158 recommendations for, 35 on religious coping, 57, 59, 61 sample size and selection methods, 33 on stroke, 428, 430 on suicide/​suicidal ideation, 119 CRP. See C-​reactive protein CRS (Centrality of Religiosity Scale), 20, 204, 477 Cruz, M., 96 cultural diversity. See race and ethnicity Curlin, Farr, xviii Currier, J. M., 134 Cushing's disease, 486 CVD. See cardiovascular disease cytokines cancer and, 509, 510 cognitive function and, 441–​442 heart disease and, 372–​373 immune function and, 459–​472, 476 stress hormones and, 484–​485, 509 Czech Republic, cognitive impairment in, 453 Daghigh, A., 206 Daily Spiritual Experiences Scale (DSES), 21, 24, 57, 406 Daniels, N. A., 598 DASH (Dietary Approaches to Stop Hypertension) diet, 345, 346, 354 DASS (Depression Anxiety and Stress Scale), 85, 136–​137, 323 Davidson, M., 449 Davis, D. E., 292 Davis, R. F., 223 DBT (dialectical behavior therapy), 106, 208–​209 DDMC (depressive disorder due to a medical condition), 68 Deane, F. P., 603 death and dying. See mortality decision-​making character traits and, 615 delinquency/​crime and, 241, 244 literature review, 852t mental health and, 305, 306, 311 patient-​physician sharing of, 593 religious-​based, 155, 244, 322, 353, 588, 658, 670 De Feudis, R., 52 definitions in religion-​health relationship, 3–​14 in clinical practice, 5, 13–​14 literature review, 678t mapping of constructs, 5–​10 recommendations for, 12–​14 religion and religiosity, 10–​11, 673 in research, 3–​6, 13 secular humanism, 11 spirituality, 11–​12, 664–​665 DeFranza, D., 603 De La Rosa, M. R., 172 De Leeuw, E., 646 delinquency and crime, 237–​253 case study, 241–​242 consequences of, 238

definitions of, 237–​238 determinants of, 239–​241, 259 economic burden of, 238, 239, 636 future research needs, 250–​251 human flourishing and, 632–​633 interventions for, 251–​253 literature review, 244–​250, 760–​763t personality disorders and, 195, 241, 251–​252 prevalence of, 238–​239 religiosity and, 242–​250 spirituality and, 248–​249 substance use disorders and, 180 violence and, 161, 238–​239 delirium, 144, 146, 147, 539–​540 delusional disorder, 143–​146 delusions bipolar disorder and, 93, 99, 100 dementia and, 456 psychotic disorders and, 144–​146, 151–​152, 154, 157, 160 dementia, 437–​457. See also specific conditions case study, 444 causes of, 441–​444 diagnosis of, 438 economic burden of, 440 future research needs, 454–​455 interventions for, 455–​457 literature review, 446–​454, 800–​801t obesity and, 348 physical activity and, 329 physical disability and, 548 prevalence of, 440 psychotic disorders and, 148, 153 religiosity and, 444–​454 types of, 437–​440 demonic possession, 150–​151 Denmark depressive disorders in, 79 divorce rates in, 255 psychotic disorders in, 156–​158 religiosity in, 54 religious coping in, 54 dental care, 351–​352, 377, 532, 590–​591, 818t dependent personality disorder, 192t, 194, 199, 206–​207, 209 depression, 66–​88. See also specific depressive disorders adjustment disorders and, 68 antidepressants, 55, 71, 79, 82, 101 anxiety disorders and, 127 attendance at religious services and, 36–​38 bereavement and, 68–​69 bipolar disorder and, 90–​101 cancer and, 509 case study, 72–​73 causes of, 70–​72, 302–​303 chronic pain and, 571 dementia and, 441–​442 diagnosis of, 67–​69 disabling effects of, 66, 67t, 69–​70, 549 disease prevention and, 595 divorce and, 256 economic burden of, 70 in family environment, 258 future research needs, 86 heart disease and, 374–​375 hypertension and, 399 immune function and, 463 interventions for, 81–​88 literature review, 73–​86, 689–​704t

Index • 1061

depression (cont.) moral injury and, 126 mortality and, 70, 528 personality disorders and, 77, 193, 195 physical activity and, 329 postpartum, 52, 258 prevalence of, 69–​70, 91, 549, 634 religiosity and, 61, 72–​86, 119, 133, 301–​302, 639–​640 religious coping and, 52–​54, 59–​61, 74, 78, 156, 158 spirituality and, 76–​78, 81 stress hormones and, 441, 486–​487, 491–​492 stroke and, 421–​422, 427, 435 substance use disorders and, 82–​83, 167 suicide/​suicidal ideation and, 67, 70, 103–​105, 118, 119 Depression Anxiety and Stress Scale (DASS), 85, 136–​137, 323 depressive disorder due to a medical condition (DDMC), 68 Dervic, K., 96 DeSantis, C. E., 507 Dew, R. E., 173–​174, 307 DeYoung, N. J., 194 Dezutter, J., 577 Dhabhar, F. S., 462, 508–​509 Dhammananda, Sri, 263 diabetes anxiety disorders and, 128 body weight and, 347, 360 dementia and, 441 diet and, 346 economic burden of, 70 epinephrine and, 482 immune function and, 461 neuropathic pain and, 566 physical activity and, 329 physical disability and, 546, 548 prevalence of, 421 religious coping and, 59–​60 screenings for, 592 stroke and, 421, 426 Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-​IV), 164 Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-​5) on anxiety disorders, 124–​126 on bipolar disorder, 89–​90 on cognitive impairment, 438, 440 on depressive disorders, 67–​69 on eating disorders, 185 on gambling disorder, 185 on Internet gaming disorder, 186 on personality disorders, 190–​191, 192t, 195 on psychotic disorders, 144–​146 on substance use disorders, 164, 166 dialectical behavior therapy (DBT), 106, 208–​209 Di Angelantonio, E., 532 Diener, Edward, 211–​212, 214, 528 diet and nutrition, 344–​365. See also body weight cancer and, 345, 346, 511, 513 case study, 349 chronic pain and, 575 dementia and, 443, 446 depression and, 71 eating disorders, 185, 363, 365, 734–​735t future research needs, 361–​362 healthy diet, benefits of, 344–​346 heart disease and, 376

1062 •  I N D E X

hypertension and, 400, 406 immune function and, 465 interventions for, 362–​365, 364t literature review, 352–​355, 783–​784t mortality risk and, 531–​532 physical health and, 613 psychotic disorders and, 157, 159 religion-​specific views of, 349–​351, 403–​404 religiosity and, 119, 351–​355 stress hormones and, 490, 492 stroke and, 424, 427, 435 Dietary Approaches to Stop Hypertension (DASH) diet, 345, 346, 354 Dima-​Cozma, C., 350 Ding, D., 330 disability. See physical disability discriminant validity, 4, 5, 20, 27, 28 discrimination delinquency/​crime and, 251 eating habits and, 362 heart disease and, 380 hypertension and, 399, 401, 404–​405 public policy and, 649 religious coping and, 60, 491 social determinants of health and, 288 disease prevention, 587–​607. See also compliance with treatment; screenings case study, 595 education and, 590 factors affecting, 594–​595 future research needs, 604–​605 healthy habits and behaviors for, 590 Healthy People 2020 on, 588, 588t importance of, 587, 635–​636 interventions for, 605–​607 literature review, 838–​846t medical and dental care for, 590–​591 pro-​social community involvement in, 590 public policy and, 590 religiosity and, 595–​604 vaccinations and, 589–​590 diseases. See chronic diseases dissociative identity disorder, 151 diversity. See race and ethnicity divorce anxiety disorders and, 130 consequences of, 256 depression and, 70, 71, 82 personality disorders and, 195 predictors of, 255–​256, 266 prevalence of, 254–​255, 637 religion-​specific views of, 262–​263 religiosity and, 266, 269–​271, 278 religious coping and, 52, 60 stroke and, 422 substance use disorders and, 171 Djibouti, depressive disorders in, 69 domestic violence family stability and, 259 prevalence of, 263 psychotic disorders and, 148, 153 religiosity and, 275–​276, 278 substance use disorders and, 259, 266 Doody, M. M., 428 Doolittle, Benjamin, xix dopamine-​β-​hydroxylase deficiency, 486 doubt, 22, 206, 224

Dowlati, Y., 476 drug use disorders. See also specific substances anxiety disorders and, 129–​131 bipolar disorder and, 92–​94 causes of, 170–​172 chronic pain and, 572, 575 cigarette smoking and, 318 as coping strategy, 49 dementia and, 443, 445 depression and, 71 heart disease and, 377 immune function and, 466 interventions for, 172–​173, 182–​183 mortality and, 530–​531, 635 physical disability and, 551, 553 prevalence of, 165–​169 religiosity and, 173–​182 stroke and, 423, 427 suicide/​suicidal ideation and, 105, 119 DSES (Daily Spiritual Experiences Scale), 21, 24, 57, 406 DSM-​IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition), 164 DSM-​5. See Diagnostic and Statistical Manual of Mental Disorders, 5th edition Duberstein, P. R., 509 Duke University Religion Index (DUREL), 20, 24–​25, 58, 96–​ 99, 121, 201, 205, 323, 408, 412, 450–​451, 556, 559, 602 Dunn, E. W., 71–​72 Dunne, Finley Peter, 123 Dupre, M. E., 422 Durkheim, Emile Elementary Forms of Religious Life, 11 on religion and mental health, xvii on suicide, 108, 114 Duru, O. K., 339 Dwidiyanti, M., 158 Dzivakwe, V. G., 59–​60 Eastern model of physical health, 619–​621, 619f eating disorders, 185, 363, 365, 734–​735t Eating for a Healthy Life (EHL) intervention, 353 eating habits. See diet and nutrition ecological fallacy, 46, 109, 638 Edgren, G., 507 education. See also academic performance; religious education bipolar disorder and, 90, 91 dementia and, 440 disease prevention and, 590 divorce rates and, 254, 255 of healthcare professionals, 860–​862t health policy recommendations, 653–​654 heart disease and, 372 human flourishing and, 637, 641–​642 hypertension and, 409–​410 immune function and, 461 physical disability and, 547–​548 psychological well-​being and, 214 public vs. private schools, 653–​654 substance use disorders and, 168 Egypt obesity in, 347 religious coping in, 52 EHL (Eating for a Healthy Life) intervention, 353 Eilat-​Adar, S., 385 Ekelund, U., 531 Elder, G. H., 246 electronic cigarettes (e-​cigarettes), 318, 319, 326, 400

Ellingson, L., 330, 331 Ellis, L., 241 Ellison, C. G., 274–​276 Ellison, C. W., 22 El Salvador, positive emotions in, 46 Emavardhana, T., 23 emotional abuse, 70, 171, 195, 258 emotional pain, 161, 302 emotional well-​being, 212, 221, 291, 294, 307, 338, 555 employment chronic pain and, 569 delinquency/​crime and, 241 health policy recommendations, 654 heart disease and, 372 human flourishing and, 637, 642 psychological well-​being and, 214, 219 suicide/​suicidal ideation and, 115 Enard, D., 462 Engel, George, 571 Enright, R. D., 285–​286 environmental risk factors. See also epigenetics anxiety disorders and, 128–​131 bipolar disorder and, 92 cancer and, 508, 512–​513 chronic pain and, 569, 574 delinquency/​crime and, 240, 243 dementia and, 442, 445 depression and, 70–​72 heart disease and, 371t, 373, 380 hypertension and, 400–​401, 404–​405 immune function disorders and, 462 inactivity and, 330, 334–​335 mental health and, 304, 308–​309 mortality and, 526, 533–​534 obesity and, 348–​349 personality disorders and, 194–​195 physical health and, 612, 614 psychotic disorders and, 147–​148, 153 substance use disorders and, 170–​171, 175 epigenetics anxiety disorders and, 128–​130 cancer and, 508 delinquency/​crime and, 241, 243 dementia and, 441, 444 depression and, 71–​72 heart disease and, 372, 379 hypertension and, 402 immune function disorders and, 462 mental health and, 304–​308 mortality risk and, 526 personality disorders and, 195 psychotic disorders and, 148, 151 stroke and, 424–​425 substance use disorders and, 171, 174 suicide/​suicidal ideation and, 105 epinephrine (adrenaline) in acute stress response, 483 in chronic stress response, 484 factors affecting, 485–​490 fight-​flight response and, 463 immune function and, 485 physical effects of, 482 religiosity and, 493, 496–​497 EPQ (Eysenck Personality Questionnaire), 199, 200 ER. See extrinsic religiosity Establishment Clause, 649–​650 ethical research questions, 31

Index • 1063

Ethiopia depressive disorders in, 69 happiness in, 631 HIV/​AIDS in, 602 psychotic disorders in, 145 religiosity in, 47 religious coping in, 52 ethnicity. See race and ethnicity Europe. See also specific countries anxiety disorders in, 549 chronic pain in, 567 depressive disorders in, 69, 77 heart disease in, 370 hypertension in, 398 inactivity rates in, 330, 635 obesity in, 347, 348 personality disorders in, 193 psychotic disorders in, 144, 155 religiosity in, 52–​53 religious coping in, 52–​53, 64 stroke in, 419, 422, 432 substance use disorders in, 165, 166, 168, 169 suicide/​suicidal ideation in, 104, 105 eustress, 47 evaluation. See measurement evangelicals, 150, 157, 270, 333, 350 Everson, S. A., 509 Everson v. Board of Education (1947), 649 EWB. See existential well-​being exercise and physical activity, 328–​343 cancer and, 511, 513 case study, 331 chronic pain and, 572, 575 as coping resource, 48 costs of inactivity, 329–​330 dementia and, 443, 445 future research needs, 341 health benefits of, 329, 376 hypertension and, 400 immune function and, 464–​465 inactivity risk factors, 330–​331, 334–​335 interventions for, 342 literature review, 335–​341, 781–​782t mortality risk and, 329, 336, 531 physical disability and, 551 physical health and, 329, 613 recommended levels of, 328–​329 religiosity and, 119, 331–​341, 666 stress hormones and, 489–​490, 492 stroke and, 423–​424, 427 existential well-​being (EWB), 21, 136, 177, 204, 221–​222, 617 Exline, Julie, 22 exorcisms, 150–​151, 161 experimental studies. See also randomized controlled trials on cognitive impairment, 449, 453 description of, 34–​35 on diet, 355 on heart disease, 387–​389 on hypertension, 409–​410 on physical disability, 559 on physical health and religiosity, 625–​626 on suicide/​suicidal ideation, 118 exploratory analysis, 38 extramarital sex. See infidelity extraversion characteristics of, 191t marital satisfaction and, 257

1064 •  I N D E X

personality disorders and, 192t religiosity and, 197–​198, 201, 207 sociability and, 285 extrinsic religiosity (ER) characteristics of, 19–​20 heart disease and, 388, 390 measurement of, 20 multi-​item measures of, 20 personality disorders and, 206 personality traits and, 201, 202 Eysenck, Hans, 239 Eysenck Personality Questionnaire (EPQ), 199, 200 face validity, 27 FACIT-​Sp (Functional Assessment of Chronic Illness Therapy Spiritual Well-​being), 24 factor analytic validity, 20 faith-​adapted CBT. See religious cognitive behavioral therapy Faith Assembly, 535, 650 family environment, 254–​281. See also divorce; domestic violence; marriage; parental religiosity academic performance and, 153 anxiety disorders in, 131, 258 bipolar disorder and, 92, 93 body weight and, 358 chronic pain and, 572 delinquency/​crime and, 240, 243, 259 dementia and, 442 depression in, 258 future research needs, 279 health policy recommendations, 651–​653 heart disease and, 379 household composition, 259, 267, 637 human flourishing and, 636–​637, 641 interventions for, 279–​280 literature review, 267–​279, 768–​770t obesity and, 348 personality disorders and, 194–​195 physical health issues in, 259 protective factors for, 259–​260 psychological well-​being and, 215 psychotic disorders in, 148, 153, 258 religion-​specific views of, 263–​266 religiosity and, 94, 266–​279 social support and, 285 substance use disorders in, 171, 172, 258 suicide/​suicidal ideation and, 105 Family Environment Scale, 272 Fan, H., 216 Fancourt, D., 80, 220–​221 Farzanegan, B., 539–​540 Fauth, R. C., 132, 246–​247 feasibility of research questions, 31 Feinstein, M., 428, 429, 431 fentanyl, 168 Ferraro, K. F., 471 fetal alcohol syndrome (FAS), 373 Feuille, M., 579–​580 FFM (Five Factor Model), 197, 199–​201, 207 Fiala, W. E., 22 FI (Flourishing Index), 643 fight-​flight response, 463, 482 Fikriana, R., 412 Finland age-​associated memory impairment in, 440 cancer in, 517–​518 divorce rates in, 255

heart disease in, 375 physical disability in, 548 suicide/​suicidal ideation in, 105, 106 First Amendment, 649, 651 Fishbain, D., 571 Fisher, H. E., 499 Fitchett, G., 406 Five Factor Model (FFM), 197, 199–​201, 207 Floud, S., 384 Flourishing Index (FI), 643 Foley, E., 84, 136–​137 Folkman, Susan, 48, 62–​65, 573 food intake. See diet and nutrition Foong, H. F., 451 Ford, K., 85 forgiveness diet and, 354 emotional stability and, 197 by God, 220, 221, 225, 229, 539 group therapy and, 135–​136 health effects of, 285–​286 literature review, 772–​773t mortality risk and, 539 psychological well-​being and, 221 religion-​specific views on, 288 religiosity and, 291–​293, 295 religious education on, 243, 266 self-​forgiveness, 291, 292, 354 spousal, 82, 258, 270–​271, 277–​278 transactional, 220, 225, 229, 293 as trauma response, 138 as virtue, 208 Foster, Richard, 82, 182 Fox, S. A., 598 France bipolar disorder in, 97, 99, 100 depressive disorders in, 79 personality disorders in, 193 religiosity in, 53 religious coping in, 53 suicide/​suicidal ideation in, 116 Francis, L. J., 199–​200 Frankl, Victor: Man’s Search for Meaning, 638 Frazier, P. A., 61–​62 French, D. C., 291 Freud, Sigmund, 46, 131, 151, 161, 638–​639 Fromm, Eric, 252 frontotemporal dementia (FTD), 148, 439, 441, 453 Functional Assessment of Chronic Illness Therapy Spiritual Well-​being (FACIT-​Sp), 24 functional (psychogenic) pain, 566–​567, 571 GAD. See generalized anxiety disorder GAD-​7 (Generalized Anxiety Disorder-​7), 124 Gafarova, V. V., 422–​423 Gainey, A., 360, 389, 410 GALI (Global Activity Limitations Index), 557 Gallemore, J. L., Jr., 94 Galton, Francis, xvi Gambler's Anonymous, 186, 187 gambling disorder, 185–​186, 735t Gandhi, Mahatma, 639 Gao, J., 388 Garcini, L. M., 472 Garssen, B., 81 Garzon, F., 85 gate theory of pain, 570

Gawad, N. A., 98 GDS. See Geriatric Depression Scale gender differences anxiety disorders and, 127, 128 bipolar disorder and, 90 cancer and, 507 chronic pain and, 569 cigarette smoking and, 317–​318 delinquency/​crime and, 238, 239 dementia and, 440 depressive disorders and, 69, 71 divorce consequences and, 256 heart disease and, 371–​372, 371t hypertension and, 398, 402 immune function and, 461 inactivity rates and, 330, 334 mortality risk and, 524, 533 obesity and, 347, 348 physical disability and, 546, 547 psychological well-​being and, 214–​215 psychotic disorders and, 145, 156–​157 religious coping and, 52 stress hormones and, 485–​486 stroke and, 419, 421, 425 substance use disorders and, 163, 168, 169, 181 suicide/​suicidal ideation and, 104, 105, 117, 634 gene-​environment interactions. See epigenetics General Health Questionnaire (GHQ), 183 generalized anxiety disorder (GAD) causes of, 128, 129 comorbidities and, 127, 128 diagnosis of, 124 heart disease and, 375 immune function and, 463 prevalence of, 126 religiosity and, 131, 135, 139 stress hormones and, 487 substance use disorders and, 172 Generalized Anxiety Disorder-​7 (GAD-​7), 124 General Social Survey (GSS), 18, 528, 538 genetic influences. See also epigenetics anxiety disorders and, 128, 130, 303 bipolar disorder and, 91, 303 cancer and, 507 chronic pain and, 569–​570 delinquency/​crime and, 239, 243 dementia and, 441, 444 depression and, 71–​72, 302–​303 heart disease and, 371t, 372 hypertension and, 398–​399, 402 immune function disorders and, 461–​462 mental health and, 302–​303, 306–​308 mortality risk and, 526, 533 obesity and, 348, 352 personality disorders and, 193–​194 physical disability and, 547, 548 physical health and, 612–​614 psychological well-​being and, 212 psychotic disorders and, 91, 147, 150, 152–​153, 303 social support and, 284–​285 stroke and, 419–​420, 425–​426 substance use disorders and, 170, 173–​174, 244 suicide/​suicidal ideation and, 105 temperament and, 212 geopolitical conflicts, 634, 639 George, Linda, xvii Geriatric Depression Scale (GDS), 59, 61, 76, 79, 451

Index • 1065

Germany depressive disorders in, 79 personality disorders in, 193, 204 psychological well-​being in, 219 psychotic disorders in, 152 religiosity in, 53 religious coping in, 53 Getz, G. E., 152 Ghafoor, H., 207 Ghana hypertension in, 411–​412 inactivity rates in, 334 psychotic disorders in, 157–​159 Ghauri, S., 152 GHQ (General Health Questionnaire), 183 Gilani, T. M., 308 giving to religious causes. See also altruism; volunteering literature review, 774–​776t physical disability and, 550 single-​item measures of, 19 social determinants of health and, 283 tax exemptions for, 655 Glanville, J. L., 247, 293–​294 Global Activity Limitations Index (GALI), 557 Global Physical Activity Questionnaire, 334, 339, 340 Glover-​Graf, N. M., 581 God attachment to, 21, 60–​62, 204, 220, 225, 229, 616, 623 forgiveness by, 220, 221, 225, 229, 539 gratitude to, 59 Goeke-​Morey, M. C., 272 Goldbourt, U., 385 Good, M., 205 Goodman, G., 209 Gorsuch, Richard, 20 Gottfredson, M. R., 241 Graham, E. K., 527–​528 Graham, John, xviii gratitude to God, 59 religiosity and, 227–​228, 230 spiritual exercises and, 82, 83, 137 as virtue, 207–​208 Greece body weight in, 356 psychological well-​being in, 219–​220 stress levels in, 46 stroke in, 432 suicide/​suicidal ideation in, 104 Green, K. M., 179 Greer, D. B., 412 Greeshma, M., 145 Grewen, K. M., 488 grief, 68–​69 Gross, C.: The Developmental Origins of Anxiety, 128 Grosso, G., 345 group therapy anxiety disorders and, 135, 138 depression and, 82 eating disorders and, 185 personality disorders and, 209–​210 psychotic disorders and, 156 suicide/​suicidal ideation and, 106 Grover, S., 97–​98 GSS (General Social Survey), 18, 528, 538 Guarnaccia, C., 59–​60

1066 •  I N D E X

Guatemala depressive disorders in, 69 positive emotions in, 46 Guide to Health (GTH) program, 353 Guo, S., 177–​178, 180, 248 Gurak, K. K., 603 Gurin Symptoms Checklist, 132 Haber, J. R., 176, 177 HADS (Hospital Anxiety and Depression Scale), 124 Hafizi, S., 205 Hai, A. H., 184 hallucinations bipolar disorder and, 99 dementia and, 456 psychotic disorders and, 144, 146, 151, 154, 157–​160 hallucinogens, 68, 167 Hamil-​Luker, J., 178 Hamilton Anxiety Rating Scale (HARS), 124, 135–​137 Hamilton Rating Scale for Depression (HRSD), 17, 81–​82, 84 Han, B., 529 Hanel, P. H., 204 Hank, K., 61 happiness. See also life satisfaction Aristotle on, 211 characteristics of, 212 human flourishing and, 630–​631, 638 manic episodes and, 100 physical disability and, 550 physical health and, 613 predictors of, 212–​216 religiosity and, 221, 492 theories of, 212–​213 Hardt Spirituality Questionnaire, 204 harm avoidance, 190, 191–​192t, 571 Harrell, Z. A., 179 Harris, J. I., 138, 584 HARS (Hamilton Anxiety Rating Scale), 124, 135–​137 Hatoum, H. T., 547 Hawton, K., 105 Haynie, D. L., 246 Hayward, R. D., 223, 225, 229, 555–​556 health, defined, 629–​630, 672. See also mental health; physical health; public health; religion-​health relationship Health Beliefs Model, 594 healthcare costs anxiety disorders, 127 bipolar disorder, 91 cancer, 506 chronic diseases, xxii, 70 chronic pain, 568 cigarette smoking, 325 dementia, 440 depressive disorders, 70 heart disease, 370 hypertension, 398 literature review, 846–​850t obesity, 348 personality disorders, 193 physical disability, 547 stroke, 418 health-​in-​all policies approach, 646–​648, 648t health insurance, 590–​591 health knowledge, 594 health policy, 646–​660 defined, 646 on education, 653–​654

on employment, 654 on marriage and family life, 651–​653 on media portrayals of religion, 654–​655 recommendations for, 650–​660, 652t, 671–​672 on religious community-​based health programs, 656–​658 on religious expression and participation, 651 on research on religion-​health relationship, 655–​656 on spirituality integration into healthcare, 658–​659 on suicide prevention, 660 on tax exemptions, 655 types of, 646–​648, 647–​648t Healthy People 2020 (ODPHP), 282, 588, 588t heart attack diet and, 344–​345 epinephrine and, 482 prevalence of, 369, 370 religious coping and, 54 risk factors for, 377, 398 heart disease, 369–​396. See also coronary heart disease anxiety disorders and, 127 case study, 378–​379 economic burden of, 370 future research needs, 390–​391 health consequences of, 370, 426 interventions for, 391–​395, 393–​395t literature review, 381–​390, 792–​795t obesity and, 347 prevalence of, 369–​370 religiosity and, 379–​390, 382f risk factors for, 371–​372t, 371–​378, 397 heart rate variability (HRV), 375, 383, 388–​390, 487 Heaton, T. B., 268 Hefti, Rene, xix Helms, S. W., 60 Hen, R.: The Developmental Origins of Anxiety, 128 Henry, P. J., 403 Hermstad, A., 355 Herndon, C. N., 462 heroin, 168 Herold, S. C., 338 Herr, N. R., 258 Herth Hope Scale (HHS), 226–​227 Herzog, A. R., 550 Hess, Catherine, 249 HEXACO Personality Inventory, 202 Hicks, B. M., 170 hierarchy of needs (Maslow), 631 high blood pressure. See hypertension Hill, A. B., 611 Hill, T. D., 290, 356–​357, 387, 407, 447, 470, 473–​474, 539, 556 Hinduism Bhagavad Gita, 288, 351, 394t bipolar disorder and, 97–​98 branches of, 18 chronic pain and, 584–​585 on diet and nutrition, 351 Eastern model and, 620 on exercise, 332–​333 on family unit, 265 on forgiveness, 288 immune function and, 479–​480t on marriage and divorce, 263 measurement scales for, 23 meditation and, 210, 433, 493, 494, 497 on physical body, 320, 606 pilgrimages in, 334

psychotic disorders and, 158 on social support, 287 on suicide, 108 Hindu RCOPE, 23 Hirschi, T., 241 Hispanics. See Latinos/​Latinas history, religious, 5, 21, 561 histrionic personality disorder, 192t, 194, 198, 204–​205, 207, 209 HIV/​AIDS cancer and, 511 compliance with treatment for, 602–​603 dementia and, 443 immune function and, 461, 469–​470, 472–​475 neuropathic pain and, 566 religious coping and, 53, 54, 58, 60 risk-​prevention behavior and, 182 Hodge, D. R., 321–​322 Hoge, Dean, 20 Holbrook, C., 499 Holt-​Lunstad, J., 284, 374 Hoover, J. Edgar, 237 hope cancer and, 509–​510 chronic pain and, 572 optimism vs., 225–​226 physical disability and, 549, 550, 553 physical health and, 613 religiosity and, 161, 225–​227, 230 Hopkins System Checklist-​90, 78 hormones. See stress hormones; specific hormones Horton, E. G., 204–​206 Hospital Anxiety and Depression Scale (HADS), 124 Hosseini, M., 137 House, J. S., 284 Howard, V., 419 HRSD (Hamilton Rating Scale for Depression), 17, 81–​82, 84 HRV. See heart rate variability Huguelet, P., 603 Hui, C. H., 200–​203 Hulett, J. M., 494 Hülür, G., 529 human flourishing, 630–​644 defined, 630 delinquency/​crime and, 632–​633 education and, 637, 641–​642 employment and, 637, 642 family environment and, 636–​637, 641 financial/​material stability and, 636, 640–​641 future research needs, 643–​644 geopolitical conflicts and, 634, 639 happiness and, 630–​631, 638 individualism vs. collectivism and, 633 life satisfaction and, 630–​631, 638 literature review, 851t meaning and purpose in life and, 631–​632, 638–​639 mental health and, 634–​635, 639–​640 physical health and, 635–​636, 640 religion and, 631f, 638–​642, 671 social unrest and, 633–​634, 639 virtue/​character and, 632–​633, 639 humanism. See secular humanism Hungary, bipolar disorder in, 91 Hunt, B. R., 518 Hutterites, 154–​155, 158 Hwang, J., 452 Hybels, C. F., 471

Index • 1067

hypertension, 397–​415 anti-​hypertensives, 411–​412 anxiety disorders and, 127–​128 case study, 401 causes of, 398–​401 diagnosis of, 397 economic burden of, 398 epinephrine and, 482 future research needs, 412–​414 health consequences of, 372, 397, 398, 420, 426 interventions for, 414–​415 literature review, 405–​412, 795–​799t physical disability and, 546 prevalence of, 398 psychotic disorders and, 148 religiosity and, 358–​359, 401–​412 screenings for, 591 spirituality and, 408, 412 hypnotics, 169 hypomania, 90, 93, 97 hypotheses, 30, 31, 38 Ibn Khattab, Umar, 332 Iceland, J., 215 Idler, Ellen, xviii, 73–​74, 537 IFI (InnerChange Freedom Initiative), 250, 253 IGD (Internet gaming disorder), 186, 736t Imamura, Y., 496–​497, 499 immune cells, 459, 460, 463, 472–​473, 484 immune function, 458–​480 adaptive, 458, 459, 462–​465, 476 case study, 466–​467 determinants of, 47, 460–​466 future research needs, 476–​478 immune system overview, 458–​460 innate, 458–​459, 463, 465, 476 interventions for, 478–​479, 479–​480t literature review, 468–​476, 803–​810t religiosity and, 467–​476 spirituality and, 469–​470, 473, 475 stress hormones and, 484–​485 susceptibility to infection and, 461–​462, 465, 469, 473–​474 viral load and, 464, 465, 469, 473–​475 immunizations. See vaccinations Impact of Events Scale-​Revised, 136 incarceration. See delinquency and crime income level. See socioeconomic status Index of Core Spiritual Experiences, 21 India bipolar disorder in, 93, 97–​98, 100 cancer in, 517 depressive disorders in, 69 domestic violence in, 263 happiness in, 631 heart disease in, 370 obesity in, 347 psychotic disorders in, 144, 145, 157 religious coping in, 51 stress hormone studies in, 496 Indians. See Native Americans individualism vs. collectivism, 633 Indonesia psychotic disorders in, 144, 158 stress hormone studies in, 496 infertility, 488, 497, 818t infidelity, 257–​258, 262, 266, 270, 666 Inglehart, R., 214

1068 •  I N D E X

inhalants, 68, 167, 187 InnerChange Freedom Initiative (IFI), 250, 253 Inozu, M., 207 insurance coverage, 590–​591 intercessory prayer, xvi, 184, 386, 390, 410, 677 internal reliability, 20, 27, 28 Internet gaming disorder (IGD), 186, 736t Interpretation of Intrusions Inventory, 206 intrinsic religiosity (IR) anxiety disorders and, 133 bipolar disorder and, 96–​99 brain function and, 454 characteristics of, 6, 19 cognitive function and, 451 delinquency/​crime and, 249 depression and, 61, 74, 76, 78 forgiveness and, 292 heart disease and, 388, 390 hypertension and, 410 measurement of, 20, 23, 25, 96 multi-​item measures of, 20 personality disorders and, 205, 206 personality traits and, 201, 202 physical disability and, 556, 559 stress buffering and, 60 stress hormones and, 497 substance use disorders and, 181 suicide/​suicidal ideation and, 109, 114 Intrinsic Religiosity Scale (IRS), 477 Intrinsic Religious Motivation Scale (IRMS), 20, 24, 25 Inventory of Statements about SelfInjury (ISAS), 205 IR. See intrinsic religiosity Iran anxiety disorders in, 137, 138 chronic pain in, 579–​581 heart disease in, 388–​389 hypertension in, 410–​411 personality disorders in, 205 psychological well-​being in, 221–​222 religiosity in, 201, 202 religious coping in, 51 stress hormone studies in, 495 substance use disorders in, 183 Iraq, psychotic disorders in, 155 Ireland personality disorders in, 203 religiosity in, 52, 290 IRMS (Intrinsic Religious Motivation Scale), 20, 24, 25 Ironson, G., 60, 471–​475 IRS (Intrinsic Religiosity Scale), 477 ISAS (Inventory of Statements about SelfInjury), 205 Islam and Muslims. See also Qur'an Allah and, 135, 137, 410, 562, 596 anxiety disorders and, 135, 137, 140 on ascetic practices, 596 on attendance at services, 668 branches of, 18 cancer and, 517 chronic pain and, 579–​580, 585 cognitive behavioral therapy and, 85 cognitive impairment and, 450–​451 daily prayers in, 333 depression and, 82, 85 on diet and nutrition, 350–​351, 354 discrimination against, 405 disease prevention and, 597, 600 on family unit, 265

on forgiveness, 288 giving to religious causes, 19 Hajj (pilgrimage) in, 334, 602 on heart health, 393t hypertension and, 406, 410 immune function and, 479t on marriage and divorce, 262–​263 measurement scales for, 23 meditation and, 210 Muhammad and, 108, 135, 287, 332, 596 personality disorders and, 205–​207 on physical body, 320, 332, 562, 595, 606 psychological well-​being and, 221–​222 religious coping and, 51, 52, 291 on social support, 287 spiritual therapy intervention and, 183 stroke and, 432, 433 on suffering, 562–​563, 584 suicide/​suicidal ideation and, 108, 109, 116, 118–​120 Islami, F., 511 isolation. See social isolation Israel anxiety disorders in, 127 bipolar disorder in, 91 body weight in, 356 chronic pain in, 578 cognitive impairment and, 449, 451–​452 heart disease in, 382, 385 loneliness in, 290–​291 religious coping in, 51 suicide/​suicidal ideation in, 109, 115–​116 Italy Alzheimer's disease in, 449 bipolar disorder in, 91 depressive disorders in, 79 personality disorders in, 193 religiosity in, 52 religious coping in, 52 Jackson, K. M., 176 Jacob, T., 176 James, William, xvii, 21, 211 Jang, S. J., 181 Japan bipolar disorder in, 98–​100 obesity in, 347 psychotic disorders in, 144, 152 religiosity in, 54 religious coping in, 54–​55 stress hormone studies in, 496–​497, 499, 500 suicide/​suicidal ideation in, 104 JCAHO (Joint Commission for the Accreditation of Hospital Organizations), xix–​xx, 646, 658–​659 Jennings, R. G., 462 Jewish COPE (JCOPE), 23 Jewish Religiosity Scale, 23 Jews. See Judaism and Jews; Torah Jin, P., 493 jobs. See employment John Henryism Active Coping (JHAC), 388, 409–​410 Johnson, B. R., 245, 249–​250 Johnson, J., 527 Joint Commission for the Accreditation of Hospital Organizations (JCAHO), xix–​xx, 646, 658–​659 Jokela, M., 528 Jones, T. M., 172 Judaism and Jews. See also Torah

anxiety disorders and, 137 on ascetic practices, 596 cancer and, 514, 516, 533, 613 chronic pain and, 585 cognitive impairment and, 449, 451–​452 on diet and nutrition, 350, 404 on family unit, 264–​265 on forgiveness, 288 on heart health, 393t immune function and, 479t longevity of, 535 on marriage and divorce, 263 measurement scales for, 23 meditation and, 210 on physical body, 320, 332, 562, 595, 606 religious coping and, 51 on social support, 287 stroke and, 431–​432 subgroups within, 18 on suffering, 563 suicide/​suicidal ideation and, 108, 109, 116, 120 Talmud, 108, 263, 606 Jung, J., 60, 220, 451 juvenile delinquency. See delinquency and crime Kabat-​Zinn, J., 579 Kagan, Israel Meir, 332 Kahan, D., 332, 338 Kaliampos, A., 219–​220 Kaplan, A., 272–​273 Kaplan, B. H., 21, 623 Kaplan, G. A., 514 Kashdan, T. B., 219, 223 Kasl, S. V., 73–​74, 446–​447, 449, 605 Katerndahl, D., 276 Kaufman, Y., 448 Kearney, P. M., 397–​398 Kedem, P., 23 Keivan, N., 580–​581 Kelly, J. F., 184–​185 Kelly-​Hayes, M., 419 Kelsch, C. B., 499 Kemp, B. R., 508 Kendler, K. S., 70, 71, 284–​285 Kennedy, G. J., 74 Kent, B. V., 220, 225, 229 Kerksieck, P., 201, 202 Kesebir, P., 632 Kesebir, S., 632 Khaledian, M., 183 Kiang, L., 223 kidney disease, 54, 461, 526, 588, 817t Kim, E. S., 336, 358, 538, 558 Kim, S., 471 King, D. E., 597 King, Martin Luther, Jr., 639 King, Valerie, 27, 271 Kinghorn, Warren, xviii Kiran, U., 496 Kiribati, depressive disorders in, 69 Kirk, W. G., 118 Kitano, A., 54 Kleiman, E. M., 106, 115 Knestel, A., 388 Kobayashi, D., 336, 356, 406–​407 Koenig, Harold, xvii–​xviii, 61, 74, 81, 83, 84, 173–​174, 203, 225, 307, 405–​406

Index • 1069

Koop, Everett, 594 Koopmans, J. R., 244 Kovess-​Masfety, V., 155 Kraal, A. Z., 452 Kraepelin, Emil, 145 Krause, Neal, 22, 26, 59, 223–​225, 229, 289, 292, 294, 470–​ 471, 474, 555–​556 Kremer, H., 473, 475 Kretchy, I., 411–​412 Kristeller, J. L., 82 Kroenke, C. H., 515 Krukowski, R. A., 359 Kuemmerer, J. M., 598 Kunto, Y. S., 354 Kurita, A., 388, 470 Kushner, Harold, 56, 638 Kuwait, religious coping in, 51 Kyrgyzstan, inactivity rates in, 330 Lake, B., 53 Lambert, N. M., 183 Lamers, S. M., 216, 550 Lanman, J. A., 287 Lariscy, J. T., 530 Larson, David B., xvii, xix, 250 Latham-​Mintus, K., 557–​558 Latin America and Caribbean. See also specific countries anxiety disorders in, 549 chronic pain in, 567 depressive disorders in, 69 inactivity rates in, 330, 635 obesity in, 347, 362 positive emotions in, 46, 47 psychotic disorders in, 144 religious coping in, 52 substance use disorders in, 166, 168 suicide/​suicidal ideation in, 104 Latinos/​Latinas bipolar disorder and, 90 cigarette smoking and, 321–​323, 423 cognitive function and, 447, 448 diet and nutrition, 351 domestic violence and, 276 education and, 637 hypertension and, 398 life expectancy for, 525–​526 obesity and, 347, 424, 635 physical activity and, 339 physical disability and, 546, 547 psychotic disorders and, 155, 158 religious coping among, 52, 155 sexual activity and, 270 substance use disorders and, 172 Laurenceau, J. P., 277 Lawrence, E. M., 528, 538 Lawrence, G. M., 472 Lazarus, Richard, 48, 62–​65, 573 Lazzarino, A. I., 422 LBD (Lewy body dementia), 439 Lebanon, mental health disorders in, 155, 193 Lechner, C. M., 219 Lee, D. C., 330, 331 Lee, J. L., 322–​323 Lee, Y. R., 285–​286 Lehto, U. S., 510 Lekhak, N., 452–​453 Lenze, E. J., 549

1070 •  I N D E X

Leopold, T., 219, 256 Leurent, B., 77–​78 Levenson, R. W., 257 Levin, Jeff, xvi–​xvii, 21, 623 Levinson, N. P., 563 Lewis-​Fernandez, R., 155 Lewy body dementia (LBD), 148, 439 Li, P., 508, 509 Li, S., 37, 79, 86, 271, 384–​385, 431, 517, 536–​537, 541, 542, 557 Liberia, depressive disorders in, 69 life expectancy. See mortality life satisfaction. See also happiness human flourishing and, 630–​631, 638 mortality risk and, 529 physical disability and, 550, 553 physical health and, 613 predictors of, 212–​216 religiosity and, 134, 218–​222, 232, 492 religious coping and, 61–​62 Lim, C., 218–​219 Lithuania religious coping in, 53 suicide/​suicidal ideation in, 104 Liu, J., 399 Liu, R. T., 115 Liu, X., 577 loneliness. See also social isolation cancer and, 510 dementia and, 442 divorce and, 256 health effects of, 284 heart disease and, 374 interventions for, 296 literature review, 772t mortality risk and, 529 psychotic disorders and, 154 religiosity and, 290–​291 stress hormones and, 488 suicide/​suicidal ideation and, 106, 119 Long, K. N., 221, 291, 354 Longest, Beauford, 646 longitudinal studies. See prospective studies Love of God scales, 21 Lubin, G., 109 Luca, S. A., 420 Ludwig-​Dehm, S., 215 lung disease anxiety disorders and, 128, 131 cigarette smoking and, 131, 318 COPD, 129, 318, 548 literature review, 818t suicide/​suicidal ideation and, 106 Luoh, M. C., 550 Luszczynska, A., 53 Lyons, H. A., 269–​270 MacArthur, A. C., 515 Macfarlane, G. J., 527 Machida, S., 500 Maimonides, Moses: Mishneh Torah, 332 major depressive disorder (MDD) anxiety disorders and, 127 bereavement and, 69 bipolar disorder and, 90, 91, 97 causes of, 70–​71 diagnosis of, 67

economic burden of, 70 heart disease and, 374 prevalence of, 69, 634 with psychotic features, 143, 145, 147, 152 religiosity and, 76–​78, 82–​84 suicide/​suicidal ideation and, 103, 118 Maksuti, E., 399 Malaysia anxiety disorders in, 135 cognitive function in, 451 depressive disorders in, 82 religious coping in, 51 malignant narcissism, 252 Malle, B. F., 226 Malouff, J. M., 257 Malta, religiosity in, 52 Mandemakers, J. J., 354 Mandhouj, O., 116 Manfredini, R., 374 mania, 89–​90, 92–​101, 145, 147 Manierre, A., 209 Mann, J. J., 106 Mao, C., 452 Marciniak, R., 453 Margolin, A., 182 marijuana. See cannabis Marital Adjustment Test, 277 marriage, 254–​281. See also divorce; family environment anxiety disorders and, 131 assortative mating, 240, 243 bipolar disorder and, 92 cancer and, 510 case study, 260–​261 conflict and commitment in, 257, 266 counseling prior to, 277, 280 delinquency/​crime and, 240, 243 forgiveness in, 82, 258, 270–​271, 277–​278 future research needs, 279 health policy recommendations, 651–​653 heart disease and, 374 infidelity in, 257–​258, 262, 266, 270, 666 interventions for, 279–​280 literature review, 267–​279, 765–​768t physical disability and, 550, 553 polygamous, 262–​263 prevalence of, 255, 636–​637 psychological well-​being and, 215 religion-​specific views of, 261–​263 religiosity and, 94, 266–​279 satisfaction during, 256–​258, 266, 277 sex prior to, 255–​256, 266, 269, 278 suicide/​suicidal ideation and, 106, 115 wedding vows, 254 Martin, J. L., 323 Martinez, S. M., 339 Martín-​María, N., 529 Marx, Karl, 153, 266, 379 Maselko, J., 76–​77, 86 Maslow's hierarchy of needs, 631 Masters, K. S., 388, 390 Matthews, Dale, xvii, xix Matthews, G. A., 489 McAll, Kenneth, 150 McCain, N. L., 469–​470 McCallum, T. J., 494 McCollum v. Board of Education (1948), 653 McCord, J., 240

McCullough, Michael, xvii, 200–​203 McDougle, L., 537 McFarland, M. J., 224, 228 McGill Pain Questionnaire, 576 MCI. See mild cognitive impairment McIntosh, D. N., 133 McKee-​Ryan, F., 214 MDD. See major depressive disorder Meador, Keith, xvii, xviii meaning and purpose in life dementia and, 442 heart disease and, 375–​376 human flourishing and, 631–​632, 638–​639 immune function and, 464 physical disability and, 549, 553 physical health and, 613 religiosity and, 119, 222–​224, 230, 492 religious coping and, 63 spirituality and, 95, 219, 223 stroke and, 435, 436 measurement, 15–​29. See also specific measurement instruments correlation vs. causation, 73, 119–​120 data collection methods, 17–​18 literature review, 678–​680t mixed methods approach to, 17 multi-​item measures, 19–​22, 24 new scale development, 26 qualitative (see qualitative measurement) quality of, 667–​668 quantitative (see quantitative measurement) reliability and, 16, 17, 20, 23, 26–​28 religion-​specific scales, 22–​24 single-​item measures, 18–​19, 665 translation of scales, 28 validity and, 4–​5, 16, 17, 20, 23, 26–​28 media portrayals of religion, 654–​655 medical-​induced psychosis, 143, 147 medical insurance, 590–​591 meditation. See also mindfulness-​based therapies anxiety disorders and, 134, 136 chronic pain and, 575, 577, 580 cigarette smoking and, 322, 326 cognitive function and, 452–​453 depression and, 84–​85 exercise programs and, 360 forgiveness and, 292 hypertension and, 406, 410, 411, 414 immune function and, 478 passage meditation, 58 personality disorders and, 210 positive emotions and, 229 psychological well-​being and, 220 psychotic disorders and, 150 Rajyoga, 496 religious coping and, 52, 54, 58, 63 stress hormones and, 493–​497, 503 stroke and, 433 substance use disorders and, 177, 180 tai chi, 493 transcendental, 210, 383, 390, 411, 429, 433, 497, 535, 584–​585 walking, 360, 389, 410, 496 yogic, 493 Mediterranean diet, 345–​346, 376, 424, 435, 443, 465, 478, 531–​532 Mehr, S. S., 501 Meints, S. M., 580

Index • 1071

Melzack, Ronald, 570 men. See gender differences Mennonites, 432, 433 mental health, 301–​313. See also specific conditions body weight and, 67, 105, 348 cigarette smoking and, 193, 318 delinquency/​crime and, 241 determinants of, 7, 302–​306, 303t family stability and, 256, 258 future research needs, 311–​312 human flourishing and, 634–​635, 639–​640 interventions for, 312–​313 physical activity and, 329 positive emotions and, 211, 309 religiosity and, 301–​302, 306–​311, 307t, 665–​666 religious coping and, 55–​65, 78, 94 religious struggles and, 22, 302 screenings for, 594 social factors related to, 284–​286 spirituality and, 6–​10, 7–​9f, 13f, 21, 133 stress in relation to, 47 mental state theory, 213 Merritt, M. M., 494 metabolic disorders, 71, 345–​346, 372, 465, 813–​815t Metcalfe, C., 177–​178, 180, 248 methadone, 168, 172, 182, 183 methamphetamines, 68, 166, 186, 377, 423 methylphenidate, 68, 165 Mexico hypertension in, 397, 407 obesity in, 347, 362 personality disorders in, 193 positive emotions in, 46 psychotic disorders in, 144, 155 religious coping in, 52 substance use disorders in, 168 suicide/​suicidal ideation in, 104 Michaelis, S., 127 Michaelson, V., 353–​354 Middle East. See also specific countries inactivity rates in, 330, 635 obesity in, 347, 362 psychotic disorders in, 144 religious coping in, 51, 64 social unrest in, 634 stroke in, 422 substance use disorders in, 165 suicide/​suicidal ideation in, 104 mild cognitive impairment (MCI), 440–​442, 450–​451, 453, 456 Miller, Lisa, xviii, 76 Miller, T., 247–​248 Miller, W. R., 82–​83, 138–​139, 182 Mills, K. T., 398 Milofsky, Eva, 196–​197 MI (moral injury), 126, 127, 141 mindfulness-​based therapies anxiety disorders and, 136–​137 chronic pain and, 572, 579–​580, 585 cognitive impairment and, 453 depression and, 84–​85 personality disorders and, 210 schizophrenia and, 158 stress hormones and, 488, 494 Mini-​Mental State Exam (MMSE), 440, 447–​450, 452 minor depressive disorder, 68 MI-​RSWB (Multidimensional Inventory of Religious/​Spiritual Well-​Being), 559

1072 •  I N D E X

Mishra, A., 157 Misiak, B., 148 Mitchell, J., 59 mixed methods measurement, 17 Mizuno, Y., 98 Moberg, David O., xvii Moeini, M., 221–​222 Mohanty, S. K., 370 monotheistic model of physical health, 616–​619, 616f Montgomery-​Asberg Depression Rating Scale, 99 Montréal Cognitive Assessment (MOCA), 451 Moradi, Z., 603 moral injury (MI), 126, 127, 141 Moreira-​Almeida, A., 96–​97 Morgenstern, L. B., 430–​431 Morisky Medication Adherence Scale, 412 Mormons body weight and, 355 cancer and, 514 cerebrovascular disease and, 432–​433 on diet, 349 longevity of, 535 on physical body, 320 reward center in brain, 168–​169 sexual activity and, 269 Morocco, religious coping in, 52 Morrow-​Howell, N., 550 mortality, 523–​544 anxiety disorders and, 528 average life span, 523–​524, 525t bipolar disorder and, 91 cancer and, 505–​506, 516–​518, 593 case study, 532–​533 chronic pain and, 582 cigarette smoking and, 318, 325, 530 in COVID-​19 pandemic, 461, 526, 635–​636 delinquency/​crime and, 238 depression and, 70, 528 future research needs, 541–​542 heart disease and, 370, 375, 384–​385 hypertension and, 398 interventions for, 542–​543 literature review, 534–​541, 819–​826t personality disorders and, 193 physical activity and, 329, 336, 531 psychological well-​being and, 216 religiosity and, 354, 358, 533–​541 risk factors for, 524–​532 social support and, 284, 529–​530 stroke and, 418, 419 substance use disorders and, 165, 167, 169, 635 suicide and, 104, 106, 114–​116, 127 Mosqueiro, B. P., 454 motivational interviewing, 326, 340 Moutinho, I. L., 323 Muhammad (prophet), 108, 135, 287, 332, 596 multiculturalism. See race and ethnicity Multidimensional Inventory of Religious/​Spiritual Well-​Being (MI-​RSWB), 559 multiple sclerosis, 802t Multiple Visual Analog Scales of Bipolarity (MVAS-​BP), 97 Murphy, G. E., 105 muscle relaxation, 137 music. See religious music Musick, M. A., 75 Muslim Religiosity Scale, 23 Muslims. See Islam and Muslims

mutism, 125 Mychasuk, R., 260, 267 Myers, David: The Pursuit of Happiness, 211 Myint, A. M., 476 myocardial infarction. See heart attack Mysticism Scale, 21 Nadal, A. R., 205 Nam, S., 359–​360 NAOS (New Age Orientation Scale), 24 narcissistic personality disorder, 192t, 193, 194, 198, 204–​ 208, 252 Narcissistic Personality Inventory, 206 Narcotics Anonymous, 141, 169, 187, 392, 599 National Center for Health Statistics (NCHS), 40 Native Americans bipolar disorder and, 90 cigarette smoking and, 423 delinquency/​crime and, 238 measurement scales for, 24 physical disability and, 546 Native American Spirituality Scale, 24 Naylor, B., 571 Nedderman, A. B., 226–​227 negative religious coping (NRC), 25, 78, 96–​97, 99, 133, 584 NEO Five Factor Inventory, 199 Nepal depressive disorders in, 69 domestic violence in, 263 nervous system. See also brain structure and function autonomic, 392, 422, 612 central, 195, 303, 482, 489, 500, 566, 612 fetal development of, 308 genetic influences on, 618 literature review, 802–​803t parasympathetic, 463, 482 sensitization to pain, 569 sympathetic, 392, 460, 463, 481–​482 Netherlands anxiety disorders in, 127 bipolar disorder in, 98–​100 depressive disorders in, 75, 79 disease prevention in, 597 personality disorders in, 193, 206–​207 psychotic disorders in, 152, 157 suicide/​suicidal ideation in, 104 networking, 161–​162 Neugebauer, R., 294 neurocognitive disorders. See dementia neuropathic pain, 566, 567, 569, 570, 573 neurosis, 46, 131 neuroticism characteristics of, 191t depression and, 70 marital satisfaction and, 257 mortality risk and, 527–​528 personality disorders and, 192t physical disability and, 548 religiosity and, 197, 199–​201, 207 New Age Orientation Scale (NAOS), 24 New Zealand, anxiety disorders in, 127 Nezlek, J. B., 219 Ngamaba, K. H., 216 Nicaise, V., 338 nicotine. See cigarette smoking; tobacco use disorder Nicotine Anonymous, 326–​327 Nieto, R., 566

Niger, religiosity in, 47 Nigeria, mental health disorders in, 155, 182, 193 Nikfarjam, M., 138 Nimgaonkar, V. L., 154–​155 Nkansah-​Amankra, S., 114–​115 nociceptive (physiologic) pain, 565–​567 Noel, P., 286 non-​organizational religiosity, 6, 23, 25, 96, 205, 224–​225, 228, 323 nonrandomized controlled trials, 34–​35 Noon, A. P., 517–​518 Nordfjaern, T., 177 norepinephrine (noradrenaline) in acute stress response, 483 in chronic stress response, 484 depression and, 71 factors affecting, 485–​490 fight-​flight response and, 463 immune function and, 485 personality disorders and, 194 physical effects of, 482–​483 religiosity and, 493, 496–​497 Northern Ireland family functioning in, 272 religiosity in, 52 stroke in, 429 suicide/​suicidal ideation in, 115, 118 Norway anxiety disorders in, 127 cancer in, 514 psychotic disorders in, 146 religious coping in, 54 substance use disorders in, 177 novelty of research questions, 31 novelty seeking, 190, 191–​192t Novotny, P., 510 NRC. See negative religious coping nutrition. See diet and nutrition OA (Overeaters Anonymous), 362–​365 obesity chronic pain and, 572 criteria for, 347 economic burden of, 348 health consequences of, 346–​348, 376, 511 immune function and, 465 inactivity rates and, 329–​331 interventions for, 362–​365 physical disability and, 546, 551, 553–​554 predictors of, 348–​349, 352 prevalence of, 347, 424, 635 religiosity and, 356–​360 screenings for, 592 stress hormones and, 490 Obisesan, T., 428 observational research design, 32–​37, 39 obsessional neurosis, 46, 131 obsessive-​compulsive disorder (OCD), 97, 125–​128, 140, 302 obsessive-​compulsive personality disorder, 192t, 194, 199, 206–​207, 209 O'Donnell, M. J., 421–​422 Office of Disease Prevention and Health Promotion (ODPHP), 588 Ofori-​Atta, A., 157–​158 Okun, M. A., 215–​216, 530 Oman, D., 3, 137, 514–​515 OMCT (Orientation-​Memory-​Concentration Test), 451

Index • 1073

Ong, A. D., 572 openness to experience characteristics of, 191t personality disorders and, 192t religiosity and, 198, 201–​202, 207 sociability and, 285 opioids, 68, 167–​170, 173, 186, 377, 530, 551, 635 Opsahl, T., 226 optimism cancer and, 509, 510 chronic pain and, 572 hope vs., 225–​226 hypertension and, 400 immune function and, 464 physical disability and, 549, 553 physical health and, 613 religiosity and, 60, 224–​225, 230, 492 stroke and, 435, 436 O'Reilly, D., 115, 429 organizational religiosity, 6, 23, 25, 96, 205, 224–​225, 228 Orientation-​Memory-​Concentration Test (OMCT), 451 Orr, J., 290, 558–​559 osteoarthritis, 53, 347, 548, 559, 570, 818t Ostir, G. V., 550 Oswald, A. J., 213–​214 Ouwehand, E., 98–​99 Overeaters Anonymous (OA), 362–​365 overweight, 347–​348. See also obesity oxytocin anxiety disorders and, 129 factors affecting, 488–​489 physical effects of, 483 religiosity and, 494, 498–​501 pain. See also chronic pain defined, 565 emotional, 161, 302 gate theory of, 570 neuropathic, 566, 567, 569, 570, 573 physiologic, 565–​567 psychogenic, 566–​567, 571 Pain Coping Skills Training (PCST) intervention, 559 Pakistan hypertension in, 406 inactivity rates in, 330 personality disorders in, 205–​207 psychotic disorders in, 144, 151–​152 religious coping in, 51, 52 Paloutzian, R. F., 22 Panama, positive emotions in, 46 PANAS (Positive and Negative Affect Schedule), 83, 84 pandemic. See COVID-​19 pandemic panic disorder, 124, 126–​129, 139, 375, 463 Pantell, M., 536 Papua New Guinea, depressive disorders in, 69 Paraguay depressive disorders in, 69 positive emotions in, 46 paranoid personality disorder, 192t, 194, 198, 203–​204 paranoid schizophrenia, 98 parasympathetic nervous system (PNS), 463, 482 parental religiosity. See also family environment anxiety disorders and, 130 body weight and, 358 child abuse and, 274–​275 cigarette smoking and, 320–​321 delinquency/​crime and, 243, 245–​246, 250

1074 •  I N D E X

family functioning and, 272–​274, 278 immune function and, 472 mental health and, 308 personality disorders and, 198, 208 physical disability and, 555 physical health and, 614 sexual activity and, 269 substance use disorders and, 175, 176, 180–​181 suicide/​suicidal ideation and, 117 Parent Attachment Security Scale, 272 Pargament, Ken, xvii, 12, 20, 22, 135–​136, 292–​293, 579–​580 Parker, G., 91 Parkinson's disease dementia (PDD), 439, 441 Pascal, Blaise, 218 pastoral care/​counseling anxiety disorders and, 126, 140–​141 chronic pain, 584 depression and, 81–​82, 87–​88 heart disease and, 392 interventions and, 233 personality disorders and, 209, 210 physical disability and, 563–​564 premarital, 280 psychotic disorders and, 161 stress hormones and, 503 substance use disorders and, 187 Patient Health Questionnaire-​9 (PHQ-​9), 69 Pawlikowski, J., 178, 221, 294, 323, 337–​338 Payman, V., 76 PCGT (Present-​Centered Group Therapy), 138 PCP (phencyclidine), 68, 167 PCPs (primary care providers), 590–​592 PCST (Pain Coping Skills Training) intervention, 559 PDD (Parkinson's disease dementia), 439, 441 PDD (persistent depressive disorder), 68 PDs. See personality disorders Peale, Norman Vincent: The Power of Positive Thinking, 309 Pearce, L. D., 246 Pearson, W. S., 597 Peck, M. Scott People of the Lie, 252 The Road Less Traveled, 45 peer groups anxiety disorders and, 129, 131 cigarette smoking and, 320 commitment to religion and, 250 delinquency/​crime and, 240–​241, 243, 249, 252 depression and, 60 family stability and, 260 parental religiosity and, 175 personality disorders and, 193, 195 religious coping and, 51 social support from, 106 substance use disorders and, 170–​172, 175, 187 Peltzer, K., 602 Pengpid, S., 330 Penn State Worry Questionnaire, 133, 137 Pentecostals, 157, 513, 606 perceived stress, 57–​58, 65 Perceived Stress Scale (PSS), 57–​58, 85, 137 Performance Oriented Mobility Assessment (POMA) scale, 556 persistence, 190, 191t, 570 persistent complex bereavement disorder, 68–​69 persistent depressive disorder (PDD), 68 personality, defined, 189 personality disorders (PDs), 190–​210. See also specific disorders

anxiety disorders and, 193, 195 bipolar disorder and, 91 case study, 196 categorization of, 191, 192t causes of, 193–​195 characteristics of, 190 consequences of, 193 delinquency/​crime and, 195, 241, 251–​252 depression and, 77, 193, 195 diagnosis of, 190–​191 economic burden of, 193 future research needs, 208 interventions for, 208–​210 literature review, 199–​207, 743–​745t prevalence of, 193 religiosity and, 195–​199, 203–​207 spirituality and, 204, 205, 209 substance use disorders and, 167, 171, 193 suicide/​suicidal ideation and, 105, 193 personality traits. See also specific traits Big Five model, 190, 191t, 197, 202–​203 changes associated with, 190, 203 character traits and, 189, 190, 191t chronic pain and, 571 family stability and, 267 Five Factor Model, 197, 199–​201, 207 heart disease and, 375 literature review, 197–​203, 207, 736–​742t marital satisfaction and, 257 mortality risk and, 527–​528 religiosity and, 195–​203, 207 stress hormones and, 499 temperament and, 189, 190, 191t Peru, psychotic disorders in, 155 Peteet, John, xviii Peterman, J. S., 134 Peters, B. G., 646 Peters, S. A., 421 PF (Prison Fellowship) program, 249–​250, 253 phencyclidine (PCP), 68, 167 pheochromocytoma, 486, 487 Philippines stress levels in, 46 suicide/​suicidal ideation in, 104 phobias, 124–​128, 463 PHQ-​9 (Patient Health Questionnaire-​9), 69 physical abuse cancer and, 508 chronic pain and, 569 domestic violence and, 259 personality disorders and, 195 substance use disorders and, 171, 258 physical activity. See exercise and physical activity physical assault, 148, 252, 553, 614 physical disability, 545–​564 anxiety disorders and, 127, 549 bipolar disorder and, 91 case study, 552 clinical interventions, 561–​564 continuum of, 545 depression and, 66, 67t, 69–​70, 549 economic burden of, 547 future research needs, 560–​561 literature review, 554–​560, 826–​834t prevalence of, 546–​547 religiosity and, 552–​560 risk factors for, 547–​552

spirituality and, 559 stress in relation to, 47 stroke and, 417–​418 subjective perceptions of, 545–​546 suicide/​suicidal ideation and, 105, 119 YLD, 66, 67t, 69–​70, 91, 127, 546, 567 physical health, 611–​626. See also specific health issues cigarette smoking and, 318, 613 depression and, 68, 70, 71 determinants of, 303t, 304, 612–​613 divorce and, 256 Eastern model of, 619–​621, 619f family stability and, 259 future research needs, 623–​626 human flourishing and, 635–​636, 640 monotheistic model of, 616–​619, 616f personality disorders and, 195 physical activity and, 329, 613 positive emotions and, 216, 612 psychological well-​being and, 216–​217, 612 religiosity and, 613–​621, 616f, 619f, 665, 666 religious struggles and, 22 secular humanism and, 621–​622, 621f social factors related to, 284–​286, 613–​615 spirituality and, 7–​9f, 9–​10, 13f stress in relation to, 47 substance use disorders and, 169 physical risk factors. See biological risk factors physiologic (nociceptive) pain, 565–​567 Pick's disease, 439 Piedmont, R. L., 209 Pienaar, J., 57 Pierre, J. M., 160 Pinheiro, M. B., 571 Pinquart, M., 509 Plausibility, defined, 611 PMR (progressive muscle relaxation), 137 PNS (parasympathetic nervous system), 463, 482 Poland chronic pain in, 578 cigarette smoking in, 323 loneliness in, 291 religiosity in, 52, 201, 202 religious coping in, 53 social capital in, 294 polygamy, 262–​263 POMA (Performance Oriented Mobility Assessment) scale, 556 POMS (Profile of Mood States), 220 Poorthuis, M. H., 421 pornography, 258, 260, 266, 281, 363, 790t Portugal, religiosity in, 52 Positive and Negative Affect Schedule (PANAS), 83, 84 positive emotions, 211–​233. See also well-​being; specific emotions cancer and, 509–​510, 513 case study, 217 chronic pain and, 571–​572 future research needs, 230–​232 immune function and, 463–​464 interventions and, 232–​233 literature review, 218–​230, 745–​760t mental health and, 211, 309 in monotheistic model, 617 mortality risk and, 528–​529 physical disability and, 549–​550, 553 physical health and, 216, 612

Index • 1075

positive emotions (cont.) protective nature of, 211 regional variations, 46, 47 religiosity and, 217–​232 spirituality and, 7, 24 stress hormones and, 487–​488, 492 positive psychology, 212, 311, 617 positive religious coping (PRC) bipolar disorder and, 96–​97, 99, 100 infections and, 473 loneliness and, 291 measurement of, 25, 58, 78, 96, 133 medication compliance and, 602 stress-​related growth and, 58 postpartum depression, 52, 258 post-​traumatic growth (PTG), 58 post-​traumatic stress disorder (PTSD) causes of, 47, 64, 129 chronic pain and, 571 consequences of, 127, 128 coping strategies for, 49 diagnosis of, 125–​126 immune function and, 463 interventions for, 136–​141 mortality and, 528 prevalence of, 126–​127 religiosity and, 133, 134 religious coping and, 132 social support and, 131 spirituality and, 134 stress hormones and, 482, 484, 487 Poteat, T., 602 poverty. See socioeconomic status Power, E. A., 287 Prakhinkit, S., 389 prayer anxiety disorders and, 134, 139, 140 cancer and, 516, 517 chronic pain and, 575, 577, 579–​580, 585 cigarette smoking and, 322, 326 cognitive function and, 449, 450, 452–​453 delinquency/​crime and, 248 depression and, 75–​76, 78, 80 forgiveness and, 277, 292 heart disease and, 383, 386–​388 hypertension and, 408, 414 immune function and, 470, 478 intercessory, xvi, 184, 386, 390, 410, 677 Islamic requirements for, 333 mortality risk and, 537, 538 personality disorders and, 203 physical activity and, 338, 342 physical disability and, 554 positive emotions and, 223–​226, 229 psychological well-​being and, 220 psychotic disorders and, 156–​159 religious coping and, 52, 54, 60–​61, 63 in schools, 653 sexual activity and, 270 single-​item measures for, 19 stress hormones and, 503 substance use disorders and, 174–​177, 179, 180, 183 suicide/​suicidal ideation and, 115, 121 PRC. See positive religious coping predictive validity, 4, 27–​28 premarital counseling, 277, 280 premarital sex, 255–​256, 266, 269, 278

1076 •  I N D E X

prenatal period Faith Assembly and, 650 maternal fasting during, 354 maternal substance use in, 373 mental health and, 303–​304, 303t, 308 mortality risk and, 532 physical health and, 303t, 304 Present-​Centered Group Therapy (PCGT), 138 Prevention and Relationship Enhancement Program (PREP), 277 primary care providers (PCPs), 590–​592 Prison Fellowship (PF) program, 249–​250, 253 prison population. See delinquency and crime Profile of Mood States (POMS), 220 progressive muscle relaxation (PMR), 137 Prom-​Wormley, E. C., 170 Propst, L. R., 81–​82 prospective studies advantages of, 33, 665 on anxiety disorders, 132–​135, 139 on bipolar disorder, 99, 100 on body weight, 355–​360 on chronic pain, 578–​579 on cognitive impairment, 446–​449, 451–​453 on depression, 73–​81, 86 description of, 32 on diet, 353–​355 on heart disease, 382–​387, 389–​390 on hypertension, 407–​409 levels of evidence and, 36–​37, 36t, 73 on marital and family stability, 267–​276 on personality disorders, 204–​205 on physical disability, 555–​559 on physical health and religiosity, 624–​625 on positive emotions, 218–​221 on psychotic disorders, 155–​159 public-​use data sets and, 40 on religious coping, 56–​62 sample size and, 34 on stroke, 428–​432 on substance use disorders, 176–​182 on suicide/​suicidal ideation, 109, 114–​117, 119, 120 Protestantism. See also specific denominations on attendance at services, 668 delinquency/​crime and, 245–​246 denominations within, 18 on diet and nutrition, 349–​350 on family unit, 263–​264 on marriage and divorce, 262 personality disorders and, 207 religious coping and, 62 sexual activity and, 270 suicide/​suicidal ideation and, 108, 114–​116, 118–​120 PSS (Perceived Stress Scale), 57–​58, 85, 137 psychogenic (functional) pain, 566–​567, 571 psychological autopsies, 120–​121 psychological risk factors anxiety disorders and, 129, 131 cancer and, 508–​510, 513 chronic pain and, 570–​572, 574–​575 delinquency/​crime and, 241, 243–​244 dementia and, 441–​442, 444–​445 heart disease and, 371t, 374–​376, 381 hypertension and, 399–​400, 403 immune function disorders and, 462–​464, 467 inactivity and, 330

mental health and, 305, 309 mortality and, 526–​529, 534 obesity and, 348 physical disability and, 548–​550, 553 physical health and, 612, 614 psychotic disorders and, 154 stroke and, 421–​422, 427 substance use disorders and, 171–​172, 175 suicide/​suicidal ideation and, 104–​105 psychological well-​being continuum of, 211 dementia and, 442 divorce and, 256 hypertension and, 400 interventions for, 232–​233 personality disorders and, 190 physical disability and, 550, 553 physical health and, 216–​217, 612 predictors of, 212–​216 religiosity and, 215, 217–​222, 230, 232, 492 religious coping and, 60–​61, 78, 156, 158, 219–​220 spirituality and, 219 theories of, 212–​213 psychometric properties. See reliability; validity psychosis, defined, 144 psychotic disorders, 143–​162. See also specific disorders case study, 148–​149 causes of, 143, 147–​148, 303 delinquency/​crime and, 241 diagnosis of, 144–​147 differentiating from religion, 151–​152, 160 in family environment, 148, 153, 258 future research needs, 159 interventions for, 159–​162 literature review, 154–​159, 717–​719t precipitation or exacerbation of, 149–​151 prevalence of, 144–​147 religiosity and, 149–​159 religious coping and, 155, 156, 159, 161 suicide/​suicidal ideation and, 103, 154 violence and, 161–​162 PTG (post-​traumatic growth), 58 PTSD. See post-​traumatic stress disorder PTSD Symptom Checklist (PCL), 137, 138 public health. See also disease prevention; health policy; human flourishing defined, 629 geopolitical conflicts and, 634 literature review, 851t religion and, 631f, 641, 642, 671 social support and, 296 suicide rates and, 121 public policy. See also health policy definitions of, 646 as determinant of health, 587 disease prevention and, 590 evidence-​based, 646 religion and, 649–​650 Puchalski, Christian, xix, 12 pulmonary disease. See lung disease purpose in life. See meaning and purpose in life Putnam, Robert, 218–​219, 286 Puzek, I., 473 Qatar, depressive disorders in, 69 QRO (Quest Religious Orientation) scale, 206 QST (Quantitative Sensory Testing), 580

qualitative measurement characteristics of, 16–​17 definitions of constructs in, 5, 14 in mixed methods approach, 17 of physical health and religiosity, 624 research designs for, 32 quantitative measurement characteristics of, 15–​16 data collection methods, 17–​18 definitions of constructs in, 4–​6, 13, 14 in mixed methods approach, 17 research designs for, 32 Quantitative Sensory Testing (QST), 580 Quest Religious Orientation (QRO) scale, 206 Qur'an. See also Islam and Muslims on diet and nutrition, 350–​351 on family unit, 265 on forgiveness, 288 on heart health, 393t immune function and, 479t interventions involving, 135, 137, 138, 183, 222 on marriage and divorce, 262 on physical body, 320, 332, 562 religious coping and, 58 on social support, 287 stress hormones and, 495 suicide prohibitions in, 108 race and ethnicity. See also specific racial and ethnic groups bipolar disorder and, 90 cancer and, 507 chronic pain and, 569 delinquency/​crime and, 238–​239 dementia and, 440 depressive disorders and, 69, 71, 75 divorce rates and, 255 domestic violence and, 276 heart disease and, 371t, 372 hypertension and, 398 immune function and, 461 inactivity rates and, 330, 334 mortality risk and, 525–​526, 533 physical disability and, 546, 547 psychological well-​being and, 215 religious coping and, 52 stress hormones and, 485–​486 stroke and, 419, 425 Raghavan, R., 474 Raguram, R., 158 Rahman, Fazlur, 562–​563 Ramos, K., 118 randomized controlled trials (RCTs) advantages of, 33, 665 on anxiety disorders, 135–​140 on bipolar disorder, 100 on body weight, 356, 359–​361 on chronic pain, 579–​581 on depression, 81–​86 description of, 35 on diet, 353, 355 on hypertension, 410–​411 levels of evidence and, 36t, 37, 38, 81 on marital and family stability, 276–​278 on personality disorders, 206 on positive emotions, 221–​222 on psychotic disorders, 157–​159 on religious coping, 56–​58

Index • 1077

randomized controlled trials (RCTs) (cont.) on stroke, 429–​430 on substance use disorders, 182–​186 on suicide/​suicidal ideation, 118–​120 random sampling, 33, 34 Rangaswamy, T., 145 rape. See sexual assault Rasic, D., 76, 114, 132–​133 Rational Choice Theory, 646 Razali, S. M., 82, 135 RC. See religious coping RCBT. See religious cognitive behavioral therapy RCI. See Religious Commitment Inventory; Religious Coping Index RCOPE scale, 21, 24 RCTs. See randomized controlled trials recall bias, 32 Redon, J., 419 referrals delinquency/​crime and, 253 depression and, 87–​88 heart disease and, 392 psychotic disorders and, 161 substance use disorders and, 187 Regnerus, M. D., 245–​246 regulatory health policy, 646, 647t Reichborn-​Kjennerud, T., 194 Reiner, M., 329 relational spirituality, 22 relevance of research questions, 31 reliability, 16, 17, 20, 23, 26–​28 religion and religiosity. See also specific religions anxiety disorders and, 119, 129–​140, 175, 302 attachment to, 21, 231 attending services (see attendance at religious services) bipolar disorder and, 89, 92–​100, 102 body weight and, 352, 355–​361 cancer and, 512–​518 chronic pain and, 572–​583, 575f, 582f cigarette smoking and, 119, 154, 174, 176, 182–​183, 320–​324, 666 commitment to (see commitment to religion) coping resources and, 62–​64, 154 decision-​making and, 155, 244, 322, 353, 588, 658, 670 definitions of, 10–​11, 673 delinquency/​crime and, 242–​250 dementia and, 444–​454 depression and, 61, 72–​86, 119, 133, 301–​302, 639–​640 diet and, 119, 351–​355 dimensions of, 5–​6, 18–​25 disease prevention and, 595–​604 eating disorders and, 185 extrinsic (see extrinsic religiosity) family environment and, 94, 266–​279 First Amendment on, 649 gambling disorder and, 185–​186 health and (see religion-​health relationship) heart disease and, 379–​390, 382f human flourishing and, 631f, 638–​642, 671 hyper-​religiosity, 89, 95, 453–​454 hypertension and, 358–​359, 401–​412 immune function and, 467–​476 importance of (see salience of religion) Internet gaming disorder and, 186 intrinsic (see intrinsic religiosity) marriage and, 94, 266–​279 media portrayals of, 654–​655

1078 •  I N D E X

mental health and, 301–​302, 306–​311, 307t, 665–​666 mortality and, 354, 358, 533–​541 multi-​item measures of, 19–​22, 24 non-​organizational, 6, 23, 25, 96, 205, 224–​225, 228, 323 as obsessional neurosis, 46, 131 organizational, 6, 23, 25, 96, 205, 224–​225, 228 parental (see parental religiosity) persecution of, 54, 540 personality disorders and, 195–​199, 203–​207 personality traits and, 195–​203, 207 physical activity and, 119, 331–​341, 666 physical disability and, 552–​560 physical health and, 613–​621, 616f, 619f, 665, 666 positive emotions and, 217–​232 psychological well-​being and, 215, 217–​222, 230, 232, 492 psychotic disorders and, 149–​159 public health and, 631f, 641, 642, 671 public policy and, 649–​650 regional variations, 46–​47, 52–​54 single-​item measures of, 18–​19, 665 social support and, 288, 293–​295, 639, 666 stress hormones and, 491–​501 stroke and, 416, 425–​433 substance use disorders and, 94, 173–​186, 640 suicide/​suicidal ideation and, 97–​100, 108–​121, 110–​113t virtues and, 207–​208 religion-​health relationship clinical implications of, 670–​671 complexity of, 668–​669 cumulative effects in, 669 definitions in (see definitions in religion-​health relationship) design of studies on (see research design) future research needs, 672 history of scientific exploration, xvi–​xix mainstream acceptance of, xxiii, 40, 622, 663, 664 measurement of (see measurement) mental health (see mental health) physical health (see physical health) public health and policy implications of, 671–​672 quality of research on, 667–​670 scales recommended for study of, 24–​26 social determinants of, 282–​289, 283t support for research on, 86, 655–​656 religious affiliation anxiety disorders and, 132 bipolar disorder and, 96 cancer and, 515 child abuse and, 275 chronic pain and, 577, 578 cognitive function and, 447 decline in, 638 depression and, 75, 76, 80 disease prevention and, 597, 599 mortality risk and, 535 physical disability and, 558–​559 psychotic disorders and, 153, 155 religious coping and, 59 sexual activity and, 269, 270 single-​item measures of, 18 stroke and, 429, 430 substance use disorders and, 176, 177 suicide/​suicidal ideation and, 96, 115 Religious and Spiritual Struggles Scale (RSSS), 22, 200 Religious Belief Salience Scale, 200 religious but not spiritual, 6–​7, 12, 98, 205, 248

religious cognitive behavioral therapy (RCBT) anxiety disorders and, 141 bipolar disorder and, 101 cognitive impairment and, 456 delinquency/​crime and, 252–​253 depression and, 81–​85, 87 positive emotions and, 223–​225 psychotic disorders and, 159–​161 stress hormones and, 495–​497 substance use disorders and, 187 suicidal ideation and, 118, 122 Religious Commitment Inventory (RCI), 20, 24, 25, 205, 477, 498, 500 religious coping (RC) anxiety disorders and, 78, 132, 133, 139, 156, 158 bipolar disorder and, 89, 99 case study, 49–​50 chronic pain and, 53–​54, 576 defined, 50 depression and, 52–​54, 59–​61, 74, 78, 156, 158 domestic violence and, 276 frequency of, 46, 50–​55, 64 hypertension and, 408 literature review, 57–​62, 681–​688t mental health and, 55–​65, 78, 94 mortality risk and, 537, 538 multi-​item measures of, 20–​21, 24 negative, 25, 78, 96–​97, 99, 133, 584 outcomes of, 55–​62 perceived stress and, 57–​58, 65 physical disability and, 554–​555 positive (see positive religious coping) psychological well-​being and, 60–​61, 78, 156, 158, 219–​220 psychotic disorders and, 155, 156, 159, 161 regional variations, 46, 51–​55, 64 single-​item measures of, 19 stress buffering and, 57–​61, 65 stress-​related growth and, 58, 63, 65 volunteering and, 48, 50, 63, 244, 290 Religious Coping Index (RCI), 17, 24, 61, 74 religious doubt, 22, 206, 224 religious education on cancer, 521 character traits and, 243 on dementia, 449 family functioning and, 280 on forgiveness, 243, 266 on heart disease, 392, 395 on hypertension, 414–​415 immune function and, 478, 479 mental health and, 308–​309, 311 on mortality, 543 physical activity and, 337, 338 positive emotions and, 226, 232 on stroke, 435 substance use disorders and, 175 Religious Experience Questionnaire, 21 religious experiences anxiety disorders and, 134 attachment to God and, 616 bipolar disorder and, 94, 98–​99 delusion or hallucinations in, 456 in Eastern model, 620 multi-​item measures of, 21 psychotic disorders and, 149–​151, 158–​159, 169 Religious Freedom Restoration Act of 2017, 649 religious healing practices, 513, 518, 554, 596, 606

religious history, 5, 21, 561 religious music anxiety disorders and, 133–​134 dementia and, 456 immune function and, 476 positive emotions and, 225, 228 psychological well-​being and, 219 Religious Orientation Scale (ROS), 20, 24, 206 Religious Orientation Scale-​Revised (ROS-​R), 20, 24, 25 religious quests, 6, 22, 206 religious-​sociocultural psychotherapy, 82, 135 religious struggles chronic pain and, 583–​584 mental health and, 22, 302 moral injury and, 126 multi-​item measures of, 22 pastoral counseling for, 563 personality traits and, 200–​202 physical health and, 22 religious support. See also pastoral care/​counseling bipolar disorder and, 101 delinquency/​crime and, 252 forgiveness interventions and, 293 multi-​item measures of, 22 personality disorders and, 209 Religious Support Scale (RSS), 22, 25 religious trauma writing (RTW), 136, 140 religious well-​being (RWB), 21–​22, 204–​206, 222 research design, 30–​41 analysis plans, 38–​39, 670 collaboration and, 40 cross-​sectional (see cross-​sectional studies) experimental (see experimental studies) levels of evidence and, 36–​38, 36t, 73, 81 literature review, 680–​681t nonrandomized controlled trials, 34–​35 observational, 32–​37, 39 prospective (see prospective studies) public-​use data sets and, 39–​40 publishing considerations, 40–​41 quality of, 669–​670 RCTs (see randomized controlled trials) recommendations for, 35–​38 research questions influencing, 30–​32, 665 response rate identification, 34 retrospective cohort, 32–​33, 356, 406–​407, 428 sample selection methods, 33–​34 sample sizes, 33–​35, 670 researcher bias, 16–​17 research questions, 30–​32, 665 resource theory, 212 retrospective cohort studies, 32–​33, 356, 406–​407, 428 reward dependence, 190, 191t Reyes-​Ortiz, C. A., 448 Reynolds, P., 514 rheumatoid arthritis, 548, 570, 818t Rhodes, J. E., 58 Richards, P. S., 185 Rico-​Uribe, L. A., 529 Ringdal, G., 514 Robins, E., 105 Rodriguez-​Monteforte, M., 345 Roesler, K., 255 Roest, A. M., 375 Romania, psychotic disorders in, 155 Ronneberg, C. R., 78 Rosato, M., 115

Index • 1079

Rose, A. H., 270–​271 Rosenfeld, M. J., 255 Rosmarin, David, 21, 23, 78, 133, 137, 156, 623 ROS (Religious Orientation Scale), 20, 24, 206 ROS-​R (Religious Orientation Scale-​Revised), 20, 24, 25 Rostosky, S., 176–​177 Rouholamini, M., 222 Roussi, P., 219–​220 Royal College of Psychiatrists, xx, 86, 150 Royal Free Interview for Spiritual and Religious Beliefs (RFI-​SRB), 77, 430, 494 Rozanski, A., 528 RSS (Religious Support Scale), 22, 25 RSSS (Religious and Spiritual Struggles Scale), 22, 200 RTW (religious trauma writing), 136, 140 Russ, T. C., 527 Russia cigarette smoking in, 325 divorce rates in, 255 psychotic disorders in, 144 religious coping in, 53 stroke in, 422–​423 suicide/​suicidal ideation in, 104 RWB (religious well-​being), 21–​22, 204–​206, 222 Ryburn, B., 76 Rye, M. S., 82, 135–​136, 277, 292–​293 Saeed, O., 431–​432 Saffari, M., 602 Sahmeddini, M. A., 495 Sajadi, M., 222 Salas-​Wright, C. P., 206 salience of religion bipolar disorder and, 98 cigarette smoking and, 322 delinquency/​crime and, 246–​248 depression and, 75–​76 mortality risk and, 537 personality disorders and, 206 psychological well-​being and, 220 sexual activity and, 270 single-​item measures of, 19 social support and, 290 stress-​related growth and, 58 substance use disorders and, 174 suicide/​suicidal ideation and, 114, 115, 117 Salmoirago-​Blotcher, E., 353, 383–​384 sample size and selection methods, 33–​35, 670 Sanaeinasab, H., 410 Sandberg, J. G., 258 Santosh-​Frances Attitude toward Hinduism Scale, 23 Sarma, E. A., 517 Saroglou, V., 199, 201, 202 Sarwar, N., 421 Sasaki, J. Y., 498 satisfaction of goals theory, 212–​213 Satisfaction with Life Scale, 61, 221, 222 Saudi Arabia cancer in, 506 Hajj (pilgrimage) to, 334 obesity in, 331, 352 Schaal, M. D., 493 Schaan, B., 61 schizoaffective disorder, 143–​145, 152 schizoid personality disorder, 144, 192t, 198, 203–​204 schizophrenia anxiety disorders and, 127

1080 •  I N D E X

causes of, 91, 147–​148, 303 delusions and hallucinations in, 144, 151–​152 diagnosis of, 144 interventions for, 150, 158, 159, 161 outcomes related to, 145 paranoid, 98 prevalence of, 144, 154–​155 religiosity and, 150–​159 suicide/​suicidal ideation and, 103, 154 violence and, 161–​162 schizophreniform disorder, 144 schizotypal personality disorder, 144, 192t, 194, 198, 203–​204, 209 Schizotypal Personality Questionnaire-​Brief (SPQ-​B), 204 Schnall, E., 430, 515 Scholte, W. F., 51–​52 school. See academic performance; education Schwingshackl, L., 531 SCID-​5 (Structured Clinical Interview for DSM-​5), 17, 124, 138 Scott, K. M., 127 screenings for infections, 591 literature review, 841–​843t for loneliness, 296 for medical conditions, 511–​513, 532, 591–​594 for mental health, 594 recommendations for, 591, 592t religiosity and, 598–​599, 601–​602 scripture reading. See also Bible; Qur'an; Torah anxiety disorders and, 140 cigarette smoking and, 326 delinquency/​crime and, 249–​250 immune function and, 479, 480t religious coping and, 58, 61 sexual activity and, 270 single-​item measures of, 19 stress hormones and, 495 SDHs (social determinants of health), 282–​289, 283t secular humanism. See also agnosticism; atheism defined, 11 immanent frame of, 6, 11 physical health and, 621–​622, 621f Secure Flourishing Index (SFI), 643 sedatives, 167, 169 selective mutism, 125 self-​directedness, 190, 191t self-​esteem bipolar disorder and, 89 cigarette smoking and, 318 depression and, 68 personality disorders and, 199 psychotic disorders and, 156 religiosity and, 60, 83–​84, 134, 228–​230 spiritual interventions and, 183, 219 Self-​Esteem Inventory (SEI), 229 self-​transcendence, 190, 191–​192t Semplonius, T., 289 separation anxiety disorder, 125, 126, 128, 140 SES. See socioeconomic status set-​point theory, 212 Seventh-​Day Adventists body weight and, 355 cancer and, 514 cerebrovascular disease and, 432 on diet, 349, 352–​353

hypertension and, 404, 407 longevity of, 535 on physical body, 320 psychotic disorders and, 156–​158 sexual abuse chronic pain and, 569 depression and, 70 personality disorders and, 195 psychotic disorders and, 148 substance use disorders and, 171 sexual activity high-​risk, 63, 318, 443, 445, 511 infidelity, 257–​258, 262, 266, 270, 666 literature review, 787–​789t physical health and, 613 premarital, 255–​256, 266, 269, 278 religiosity and, 94, 269, 270, 278 sexual assault, 59, 126, 136, 148, 304, 633 sexually transmitted diseases (STDs), 92–​94, 443, 474, 511 SFI (Secure Flourishing Index), 643 SG (Spiritual Guidance) intervention, 182 Shab-​Bidhar, S., 345 Shah, A. D., 421 Shapero, B. G., 70 Shavelle, R. M., 530 Sheikh, T. L., 182–​183 Shields, Alexandra, 40 Shin, J., 603 Shinto Buddhism, 55 Shiota, M. N., 257 Shirneshan, E., 127 Shor, E., 529 Short Portable Mental Status Questionnaire (SPMSQ), 447, 448 SHS (Spiritual History Scale), 21 Shultz, R., 510 SICPT (spiritually integrated cognitive processing therapy), 141 SIDD (substance-​induced depressive disorder), 68 Sierra Leone, religious coping in, 52 Sikhism, 23, 97–​98 Silverstein, M., 273–​274 Simons, R. L., 471–​472, 516 single-​group experimental design, 34, 35 Siracusa, F., 465 Skolasky, R. L., 549 Slatcher, R. B., 495 sleep anxiety disorders and, 124 bipolar disorder and, 90 chronic pain and, 572, 575 depression and, 67, 68 family environment and, 259 heart disease and, 377 literature review, 791t religious coping and, 60 stress hormones and, 490 Sleiman, D., 346 Smith, L. G., 449 Smith, S. J., 269–​270 Smoker's Anonymous, 326–​327 smoking. See cigarette smoking SNS. See sympathetic nervous system social anxiety disorder, 125–​127, 129, 131, 139–​140, 487 social capital. See also altruism; volunteering health effects of, 284, 286 heart disease and, 374

literature review, 773–​774t religiosity and, 288, 293–​295, 639, 666 social determinants of health (SDHs), 282–​289, 283t social epidemiology, 284 social integration cancer and, 510, 517 health effects of, 284–​285 heart disease and, 374 immune function and, 464, 467 mortality risk and, 529 stress hormones and, 488 suicide/​suicidal ideation and, 116, 117 social isolation. See also loneliness cancer and, 510, 517 delinquency/​crime and, 240 dementia and, 442 health effects of, 284 interventions for, 296 psychotic disorders and, 154, 160 stress hormones and, 488 stroke and, 422, 427 suicide/​suicidal ideation and, 106, 119, 121 social phobia. See social anxiety disorder social prescribing, 651 social risk factors anxiety disorders and, 129, 131 bipolar disorder and, 92 cancer and, 510, 513 chronic pain and, 572, 575 delinquency/​crime and, 240–​241, 243 dementia and, 442, 445 heart disease and, 371t, 374, 380–​381 hypertension and, 400, 403 immune function disorders and, 464 mental health and, 305, 309–​310 mortality and, 529–​530, 534 obesity and, 348 physical disability and, 550, 553 physical health and, 284–​286, 613–​615 psychotic disorders and, 153–​154 stroke and, 422–​423, 427 substance use disorders and, 172, 175–​176 suicide/​suicidal ideation and, 105–​106 social support, 284–​297 anxiety disorders and, 129, 131 bipolar disorder and, 92–​94 cancer and, 510, 513 case study, 286 chronic pain and, 572, 575 as coping strategy, 49, 60, 63, 64 delinquency/​crime and, 241, 243 disease prevention and, 594 factors influencing need for, 284–​285 family stability and, 260, 267 future research needs, 295–​296 health effects of, 284–​285 heart disease and, 374 hypertension and, 400, 407 immune function and, 464, 467 interventions for, 296–​297 literature review, 289–​295, 770–​772t in monotheistic model, 617 mortality risk and, 284, 529–​530 physical disability and, 550, 553 physical health and, 613 psychological well-​being and, 215–​216 psychotic disorders and, 143, 153, 158, 160

Index • 1081

social support (cont.) religion-​specific views of, 287–​288 religiosity and, 94, 153, 287–​296 stress buffering and, 131, 153 stress hormones and, 488–​489, 492 stroke and, 422–​423, 427, 436 substance use disorders and, 172 suicide/​suicidal ideation and, 105, 106, 121 social unrest, 633–​634, 639 social well-​being, x, 290, 555, 629 socioeconomic status (SES) bipolar disorder and, 90 cancer and, 507 chronic pain and, 569, 574 cigarette smoking and, 318 delinquency/​crime and, 240 depressive disorders and, 71 diet and, 351–​352 divorce rates and, 255 heart disease and, 371t, 372, 379 hypertension and, 399, 402–​403 immune function and, 461 inactivity rates and, 330, 331, 335 mortality risk and, 525, 533 obesity and, 348, 352 personality disorders and, 195 physical disability and, 546–​548 psychotic disorders and, 147–​148, 153 stress hormones and, 485–​486 stroke and, 419, 422, 425 suicide/​suicidal ideation and, 106 Sollgruber, A., 580 Solomon Islands, depressive disorders in, 69 Somalia depressive disorders in, 69 religiosity in, 47 somatization, 131, 146, 259, 837t Son, J., 555 Song, J., 216 South, S. C., 194 South Africa HIV/​AIDS in, 602 obesity in, 347 personality disorders in, 193 psychotic disorders in, 151 religious coping in, 52, 57 South America. See Latin America and Caribbean South Korea cancer in, 517 cognitive function in, 451, 452 hypertension in, 397–​398 stress hormone studies in, 498 Sowa, A., 450 Spain Catholic pilgrimages in, 334 depressive disorders in, 79 personality disorders in, 193 religiosity in, 52 religious coping in, 53 stress hormone studies in, 497 Spence, N. D., 358–​359, 409 Spilman, S. K., 273 Spiritual Assessment Inventory, 205 spiritual but not religious, 6–​7, 11, 98, 205, 248–​249, 499 Spiritual Guidance (SG) intervention, 182 spiritual histories anxiety disorders and, 140

1082 •  I N D E X

bipolar disorder and, 100–​101 cancer and, 520 chronic pain, 583 delinquency/​crime and, 251 dementia and, 455 depression and, 82, 86–​87 diet and weight, 362 disease prevention and, 606 heart disease and, 391 hypertension and, 414 immune function and, 478 mortality and, 543 personality disorders and, 209 physical disability and, 561 positive emotions and, 232 psychotic disorders and, 159–​160 stress hormones and, 503 stroke and, 434–​435 substance use disorders and, xx, 186 Spiritual History Scale (SHS), 21 spirituality anxiety disorders and, 134 bipolar disorder and, 95 chronic pain and, 576, 580–​581 cigarette smoking and, 325–​326 in clinical setting, 9f, 12–​14 cognitive impairment and, 448 defined, 11–​12, 664–​665 delinquency/​crime and, 248–​249 depression and, 76–​78, 81 hypertension and, 408, 412 immune function and, 469–​470, 473, 475 integration into healthcare, 658–​659, 852–​860t meaning and purpose in life and, 95, 219, 223 mental health and, 6–​10, 7–​9f, 13f, 21, 133 modern understanding of, 6–​10, 8–​9f multi-​item measures of, 24 non-​contaminated, 12, 13 personality disorders and, 204, 205, 209 physical disability and, 559 physical health and, 7–​9f, 9–​10, 13f positive emotions and, 7, 24 psychological well-​being and, 219 relational, 22 for research purposes, 13, 13f stress hormones and, 499, 500 traditional understanding of, 6, 7f, 11 spiritually integrated cognitive processing therapy (SICPT), 141 Spiritual Perspective Scale (SPS), 411–​412 Spiritual Self–​Schema (SSS), 182 spiritual struggles, 200–​202, 253, 521, 584 Spiritual Transcendence Scale (STS), 24, 500 spiritual well-​being, x, 22, 177, 204, 673 Spiritual Well-​Being Scale (SWBS), 21, 24, 204, 222 SPMSQ (Short Portable Mental Status Questionnaire), 447, 448 Spoerri, A., 114 SPQ-​B (Schizotypal Personality Questionnaire-​Brief), 204 SRG (stress-​related growth), 58, 63, 65 SRGS (Stress-​Related Growth Scale), 58 Srivastava, A., 370 Stahler, G. J., 599 Stampfer, M. J., 344 Stanley, S. M., 257 Stansfield, R., 180, 248, 249, 252 State-​Trait Anxiety Inventory (STAI), 124, 136, 138

STDs. See sexually transmitted diseases Steenhuis, L. A., 157 Stegenga, B. T., 549 Steptoe, A., 80, 220–​221 Sternfeld, B., 551 Stevens-​Watkins, D., 176–​177 Stier, H., 272–​273 stimulants, 165–​167. See also specific stimulants Strawbridge, W. J., 75, 176, 268, 289, 321, 335 stress, 45–​65. See also coping resources; coping strategies adjustment disorders and, 68, 125 anxiety disorders and, 129, 131 appraisal of, 48, 62, 573–​574 bipolar disorder and, 92–​94 buffering, 57–​61, 65, 129, 131, 153 cancer and, 508–​509, 513 defined, 47 dementia and, 442 depression and, 70–​72 divorce and, 256 eustress, 47 heart disease and, 374 hypertension and, 399 immune function and, 462–​463 mortality risk and, 527 perceived, 57–​58, 65 physical disability and, 548 psychotic disorders and, 143 PTSD (see post-​traumatic stress disorder) stroke and, 421 substance use disorders and, 171 transactional theory of, 48, 62, 573 in United States, 46, 52, 64, 635 stress hormones, 481–​504. See also specific hormones in acute stress response, 482, 483 case study, 491 in chronic stress response, 482–​484 factors affecting, 485–​490 fight-​flight response and, 463, 482 future research needs, 501–​502 immune function and, 484–​485 interventions for, 502–​503 literature review, 492–​501, 810–​813t religiosity and, 491–​501 spirituality and, 499, 500 stress-​related growth (SRG), 58, 63, 65 Stress-​Related Growth Scale (SRGS), 58 stroke, 416–​436 anxiety disorders and, 127 bipolar disorder and, 92 case study, 424–​425 consequences of, 417–​418 diet and, 345 economic burden of, 418 epinephrine and, 482 future research needs, 433–​434 interventions for, 434–​436 literature review, 427–​433 prevalence of, 416, 417 psychotic disorders and, 148, 153 religiosity and, 416, 425–​433 religious coping and, 54 risk factors for, 347, 398, 418–​424 types of, 417 Stroppa, A., 96–​97, 99 Structured Clinical Interview for DSM-​5 (SCID-​5), 17, 124, 138 struggles. See religious struggles; spiritual struggles

STS (Spiritual Transcendence Scale), 24, 500 Su, X. Y., 54 subjective religiosity. See intrinsic religiosity substance abuse, defined, 164. See also substance use disorders substance dependence, defined, 164. See also addiction substance-​induced depressive disorder (SIDD), 68 substance-​induced psychosis, 143, 146–​147 substance use disorders (SUDs), 163–​188. See also addiction; withdrawal; specific substances and conditions anxiety disorders and, 129–​131, 139, 171–​172 bipolar disorder and, 91–​94 case study, 173 causes of, 170–​172, 244 as coping strategy, 49, 51, 53–​55 delinquency/​crime and, 241 depression and, 82–​83, 167 diagnosis of, 164 disease prevention and, 595 domestic violence and, 259, 266 in family environment, 171, 172, 258 future research needs, 186 heart disease and, 373, 377 interventions for, 172–​173, 182–​188 literature review, 176–​185, 719–​734t marital satisfaction and, 258 personality disorders and, 167, 171, 193 prevalence of, 163, 165–​170, 634–​635 religiosity and, 94, 173–​186, 640 suicide/​suicidal ideation and, 103, 105, 169 types of, 165–​170 Suh, H., 387, 408, 471–​472 Suhail, K., 152 suicide and suicidal ideation, 103–​122 anxiety disorders and, 103, 105, 119, 127 bipolar disorder and, 91, 96, 101, 103, 105 case study, 107 causes of, 104–​106 chronic diseases and, 105, 118, 119 chronic pain and, 105, 582 cigarette smoking and, 318 depression and, 67, 70, 103–​105, 118, 119 divorce and, 256 future research needs, 120–​121 interventions for, 121–​122 literature review, 108–​109, 114–​119, 705–​711t moral injury and, 126 personality disorders and, 105, 193 prevalence of, 103–​104, 634 prevention strategies, 106–​107, 660 psychotherapy for, 106, 118, 122 psychotic disorders and, 103, 154 public health implications, 121 religion-​specific views of, 107–​108, 119 religiosity and, 97–​100, 108–​121, 110–​113t religious coping and, 57, 63 substance use disorders and, 103, 105, 169 underreporting of, 120 Sulmasy, Daniel, xviii Sun, Y., 450–​451 Sundquist, J., 374 support. See religious support Svob, C., 117 SWBS. See Spiritual Well-​Being Scale Sweden cancer in, 506 depressive disorders in, 79 divorce rates in, 255

Index • 1083

Sweden (cont.) religiosity in, 54 religious coping in, 54 stress hormone studies in, 500 substance use disorders in, 169 suicide/​suicidal ideation in, 106 Switzerland anxiety disorders in, 132 depressive disorders in, 79 suicide/​suicidal ideation in, 114, 119 sympathetic nervous system (SNS), 392, 460, 463, 481–​482 systematic sampling, 34 Taiwan bipolar disorder in, 91 cognitive function in, 447–​448 hypertension in, 406 Tajikistan anxiety disorders in, 127 depressive disorders in, 69 Take Off Pounds Sensibly (TOPS), 363–​365 Talmud, 108, 263, 606. See also Judaism and Jews Tanzania, stress levels in, 46 Taoism, 108, 620 Tavares, J. L., 471 Tax Cut and Jobs Act of 2017 (TCJA), 655 tax exemptions, 655 Tay, L., 214–​215 Taylor, Charles, 6 Teasdale, B., 181 Teasdale, J. D., 84 temperament. See also specific traits bipolar disorder and, 97 family stability and, 260 genetic influences on, 212 model of, 190, 191t personality vs., 189 Temperament and Character Trait Model, 190, 191t Templeton Foundation, xvii–​xix, 40, 231, 655 Teplin, L. A., 238 Terry-​McElrath, Y. M., 179–​180 test-​retest reliability, 20, 27, 28 Tew, J., 284 Thailand cancer in, 517 hypertension in, 410 substance use disorders in, 169 Thanissaro, P. N., 23 theodicy, 56, 138 Theunissen, M., 571 Thompson, B., 109, 114 Thompson, T., 289–​290 Thygesen, L. C., 156–​157 TIAs (transient ischemic attack), 417, 420, 429 Tillich, Paul, 19 Timed Up and Go (TUG) test, 558 Timor-​Leste, depressive disorders in, 69 Tindle, H. A., 375, 510 Title VII (Civil Rights Act of 1964), 654 Tix, A. P., 61–​62 tobacco use disorder (TUD). See also cigarette smoking causes of, 170 health consequences of, 318–​319 interventions for, 173 prevalence of, 167–​168, 318 religiosity and, 175, 178 Tobin, E. T., 495

1084 •  I N D E X

Tønnesen, M. T., 499–​500 TOPS (Take Off Pounds Sensibly), 363–​365 Torah. See also Judaism and Jews on family unit, 264–​265 on forgiveness, 288 on physical body, 320, 332 on social support, 287 suicide prohibitions in, 108 Tori, C. D., 23 Toussaint, L. L., 285, 539 tranquilizers. See sedatives Transactional Theory of Stress and Coping (TTSC), 48, 62, 573 Transgression-​Related Interpersonal Motivations Inventory, 292 transient ischemic attack (TIAs), 417, 420, 429 translational validity, 27 translation of scales, 28 trauma. See also post-​traumatic stress disorder delinquency/​crime and, 240 depression and, 70, 71 heart disease and, 374 immune function and, 461 mortality risk and, 527 personality disorders and, 195 psychotic disorders and, 148, 153 traumatic brain injury, 195, 240, 243, 306 trauma writing, 136, 140 treatment compliance. See compliance with treatment Tronvik, E., 578–​579 Trust in God scales, 21 Tsai, A. G., 365 Tsai, J., 58 Tsang, J. A., 292 TSF (Twelve-​Step Facilitation) therapy, 183–​185, 187 TTSC (Transactional Theory of Stress and Coping), 48, 62, 573 Tuck, Inez, 469 TUD. See tobacco use disorder TUG (Timed Up and Go) test, 558 Turecki, G., 106 Turkey personality disorders in, 207 psychological well-​being in, 216 religious coping in, 58 Turner, J. A., 576 Turner-​Cobb, J. M., 495 Tuttle, J. D., 270 Twelve-​Step Facilitation (TSF) therapy, 183–​185, 187 12-​step programs cigarette smoking and, 326–​327 delinquency/​crime and, 253 obesity and, 362–​365 substance use disorders and, 169, 172–​173, 183–​188, 184t Tye, K. M., 489 type I and type II errors, 35, 38, 670 Uecker, J. E., 269 Uganda, depressive disorders in, 69 Ukraine, depressive disorders in, 69 underweight, 347, 355 United Arab Emirates cancer in, 506 depressive disorders in, 69 eating disorders in, 185 religious coping in, 51 United Kingdom chronic pain in, 569 cigarette smoking in, 323

depressive disorders in, 77, 84 eating disorders in, 185 heart disease in, 384 personality disorders in, 193, 209 religiosity in, 53, 199–​200 religious coping in, 53 social prescribing in, 651 social unrest in, 633–​634 stress hormone studies in, 495 stroke in, 418 suicide/​suicidal ideation in, 104, 634 United States anxiety disorders in, 123, 125–​127, 133, 137–​138 bipolar disorder in, 90, 91, 96, 99, 100 cancer in, 505–​506, 514–​515, 518 chronic diseases in, xxii, 310 chronic pain in, 567, 568, 580 church-​state separation in, 650 cigarette smoking in, 317, 318, 321–​324, 325 delinquency/​crime in, 238, 246–​250 dementia in, 440 depressive disorders in, 69, 70, 78, 634 gambling disorder in, 185 happiness in, 630–​631 heart disease in, 369, 370 household composition in, 259 hypertension in, 398, 420 inactivity rates in, 329–​330, 635 Internet gaming disorder in, 186 life expectancy in, 524 marriage and divorce rates in, 254–​255, 636–​637 obesity in, 347, 348, 635 personality disorders in, 193, 204–​206 physical disability in, 546 psychological well-​being in, 212, 214–​215, 220–​221 psychotic disorders in, 144, 147, 152, 155 religiosity in, 46–​47, 200 religious coping in, 46, 52, 57–​60 social unrest in, 633–​634 spiritual but not religious persons in, 7 stress levels in, 46, 52, 64, 635 stroke in, 417–​419 substance use disorders in, 163, 165–​170, 176–​177, 179 suicide/​suicidal ideation in, 103–​104, 119, 121, 634 vaccinations cortisol and, 484 literature review, 838–​841t mortality risk and, 532 recommendations for, 589, 589t religiosity and, 597–​598, 600–​601 religious exemptions from, 650 resistance to, 590 VaD (vascular dementia), 148, 417, 438–​439 Vaidya, D., 372 Vaillant, George, 196–​197, 208 validity, 4–​5, 16, 17, 20, 23, 26–​28 Van Cappellen, P., 500 Van der Hooft, M. P., 206–​207 VanderWeele, Tyler, xviii–​xix, 36, 116–​117, 121, 134–​135, 177, 180, 220, 223, 229, 292, 294, 322, 336, 354, 357, 474, 515–​516, 537–​538, 558, 630 Van Ness, P. H., 446–​447, 449, 514, 605 Van Voorhees, B. W., 75–​76 Van Wagoner, N., 475 vascular dementia (VaD), 148, 417, 438–​439 Vaupel, James, 526

Vedic martial arts, 333 Verbrugge, L. M., 256 Vietnam, anxiety disorders in, 127 violence. See also abuse; assault; domestic violence crime-​related, 161, 238–​239 personality disorders and, 206 psychotic disorders and, 161–​162 virtues, 207–​208, 306, 311, 632, 639, 740–​741t Vita, A., 145 volunteering anxiety disorders and, 140 dementia and, 443, 445–​446, 456 depression and, 87 genetic influences on, 152 heart disease and, 374 immune function and, 478 literature review, 774–​776t mortality risk and, 530 psychological well-​being and, 232 religiosity and, 283, 294, 297 religious coping and, 48, 50, 63, 244, 290 Vu, M., 600 Vuolo, M., 247–​248 Wachholtz, A. B., 136 Wadden, T. A., 365 Walking in Faith intervention, 339–​340 Walsh, A., 241 Wang, D., 377 Wang, L., 450, 509 Watson, M., 509–​510 Watts, S. J., 275 Ways of Coping Questionnaire, 48, 63 Webb, B. L., 339–​340 wedding vows, 254. See also marriage weight. See body weight Weiss, B., 257 well-​being. See also human flourishing; psychological well-​being emotional, 212, 221, 291, 294, 307, 338, 555 existential, 21, 136, 177, 204, 221–​222, 617 religious, 21–​22, 204–​206, 222 social, x, 290, 555, 629 spiritual, x, 22, 177, 204, 673 Wen, W., 385–​386 Wheeler, M. A., 632 White, M. S., 172 White Americans bipolar disorder and, 90 cigarette smoking and, 423 delinquency/​crime and, 238 dementia and, 440 depressive disorders and, 69, 71, 75 domestic violence and, 276 education and, 637 hypertension and, 398 life expectancy for, 525 physical disability and, 546 psychological well-​being and, 215 psychotic disorders and, 155 sexual activity and, 270 stroke and, 419, 425 substance use disorders and, 166, 168, 179 Whitehead, B. R., 57, 358 Whitehouse, H., 287 WHO. See World Health Organization Wilcox, W. B., 268 Williams, David R., 59, 132

Index • 1085

Wilson, Bill, 165 Wilson, J., 555 Wilson, Warner, 212, 213 Wilson, William P., xvii, 150 Wilt, J. A., 201–​202 Wink, P., 204–​205 Winslow, C. E., 629 Wirtz, P. H., 488 withdrawal alcohol and, 439, 489 cannabis and, 167 defined, 164 depression and, 68 psychosis and, 146 Wolfinger, N. H., 268 Wombwell, E., 601 women. See gender differences work. See employment World Health Organization (WHO) on dementia prevalence, 440 on depressive disorders, 549 Global Burden of Disease Study, 66, 69, 91, 127, 165, 418, 546, 567 Global Physical Activity Questionnaire, 334, 339, 340 health as defined by, 629–​630 Physical Activity Guidelines, 328–​329, 341 Quality of Life-​Spirituality, Religiousness, and Personal Beliefs scale, 24, 116 on suicide prevalence, 103, 104 on treatment compliance, 594 World Mental Health Surveys, 127

1086 •  I N D E X

World Psychiatric Association, xx, 86 worry. See anxiety disorders Wu, Y. T., 528 Yalcin, I., 216 Yang, Y. C., 529 Yeager, D., 406, 447–​448 years lived with disability (YLD), 66, 67t, 69–​70, 91, 127, 546, 567 Yemen religiosity in, 47 stress levels in, 46 yoga, 332–​333, 383, 493, 494, 497, 584–​585 You, L. F., 510 Young Mania Rating Scale, 98, 99 Ysseldyk, R., 83–​84, 229–​230 Yun, Y. H., 517 Zahl, D., 12 Zalsman, G., 106 Zangeneh, F., 497 Zehnder, D., 132 Zeng, Y., 536 Zhang, C., 323–​324, 423 Zhang, J., 33 7 Zhang, W., 446 Zhang, Y., 529 Zimmer, Z., 538–​539 Zou, J., 78 Zuckerman, M., 215 Zung Depression Scale, 69