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In this issue of JAMA Internal Medicine, Li et al1 report a clear and moderately strong association between attendance at religious services and decreased mortality during a 16-year follow-up of a subgroup from the Nurses’ Health Study. The study by Li et al1 includes baseline and follow-up data from 74 534 participants and documented 13 537 deaths. The inverse association of attendance at religious services and adverse health outcomes has been studied extensively, with most results in concert with the study by Li et al, so the results are primarily confirmatory. However, this study is a major contribution to the literature.2 A particular strength of the study, in addition to the large sample size and excellent participation over time by the enrolled women, is the ability to test the temporal association between the independent variable and the outcome variable at multiple time points as well as the use of time-varying covariates to control for confounding, especially by social support and functional status. A favorable distribution of participants across the different categories of attendance at religious services, from almost never to more than once per week, provides ample numbers for comparison. Even so, the study exhibits limitations in terms of generalizability, many of which are acknowledged by the authors yet should be highlighted. Before addressing these limitations, however, we may ask, “What is the rationale for publishing studies about religion in a medical journal focused on documenting empirical evidence related to health and health care?” First, readers and investigators must, as do these authors, focus on the data, no more and no less, and not attempt to generalize beyond the evidence. The study by Li et al does not address philosophical or theological questions such as, “Does God (or any higher being) exist?” The data do not validate claims made about some of the positive benefits of specific religious experiences, claims made even by medical professionals.3 Nor do the data address a biological mechanism by which the religion or spirituality variable enhances health, as do Miller et al4 in their study of the importance of spiritual experience in protecting against the onset of depression, with cortical thickening being associated with spirituality in certain regions of the brain, suggesting a possible mechanism. Finally, the data do not suggest that medical professionals should recommend attendance at religious services. In other words, the data cannot be taken even as proof of concept for intervention. For such an intervention to be validated, a randomized clinical trial would be required, which is almost certainly unethical, as emphasized by the authors.1 Second, readers must recognize that studies of religion and spirituality have proliferated dramatically for the past 20 to 30 years.2 Investigators have answered this question positively, given the significant increase in publications exploring the association of religion or spirituality and health that have entered the mainstream of scientific reports. Therefore, such studies should be evaluated using the same criteria with which any published empirical study are evaluated. Despite the obvious strengths of the study by Li et al, there are clear limitations, which are basically embedded in the nature of the sample itself and faced by all investigators who perform secondary data analysis. These limitations, in my view, primarily constrict our ability to generalize from the data presented to the population in general. What are these limitations? The study addresses only one aspect of religion and spirituality, namely, attendance at religious services. Reasons for attendance at religious services may vary appreciably across individuals, such as religious devotion, lifelong habits, social pressures, and perhaps simple loneliness causing individuals to search for a support group with which to connect. One of the strengths of the study is that the investigators explore extensively the role of social supports as a confounding variable in their longitudinal analyses and the explanatory power of attendance at religious services remains robust in these controlled analyses. However, we have no assurance that attendance at religious services is a marker of the strength of one’s religion or spiritualty and no description of the extent of private practices of spirituality, such as prayer, or perceptions of spiritual well-being among the participants. In addition, the sample is derived from female nurses who volunteered to participate in the study. These women are therefore better educated than the general population, more willing to participate in activities that are of value to the larger community given their volunteer status, and informed about health and health care in general. The mean baseline age of the participants is 60 years or older and therefore the study cannot be generalized to men or to young adults. This limitation is important when we consider that religious service attendance is higher among women and higher among persons who are older.5 Even the nature of religion and spirituality may vary by age. Smith and Snell,6 in a survey of religious attitudes among young adults, found them to be less active in structured religious activities, such as attendance at religious services, but nevertheless continuing to view their spirituality as important although different than that in older adults. They described the emerging religious attitudes among these young adults as moral (being good and nice) therapeutic (primarily concerned with one’s own happiness) deism (a higher being distant and not normally involved in one’s life), a viewpoint that is a far cry from typical Protestant and Catholic beliefs that service attendance is an important marker of religion or spirituality. The participants in the study by Li et al1 are primarily Christian (Protestant or Catholic); therefore, we cannot generalize the study’s findings to other religious groups, such as Jews, Buddhists, Muslims, and Hindus. The only religious group in the study that included enough participants overall to study beyond Christians is Ashkenazi Jews. However, their attendance at religious services is significantly skewed toward less frequency than in the Christian groups, which are much more widely distributed in terms of attendance. Attendance at religious services is usually associated with overall religion and spirituality among most Christian and Muslim groups (Muslims make up too few participants in this sample for generalization). However, attendance at religious services may not be a marker for religion or spirituality for Jews, Hindus, and Buddhists. The United States, although predominantly Christian, is becoming much more religiously diverse; therefore, readers should avoid conflating religion and spirituality with the beliefs and practices of Christians. In addition, the association is stronger for African American than white women. Other ethnic groups, which are becoming much more frequent within the health care professions, such as nursing, not to mention the public at large, are not represented in the sample, specifically persons of Asian and Middle Eastern origins (regardless of their religious affiliations). So what can we learn from this study? In this well-designed secondary data analysis, attendance at religious services is clearly associated with lower risk of mortality. This finding should not be ignored but rather explored in more depth. Are there confounding variables of importance not available to the investigators in this study? What possible mechanism may contribute to this association? Is attendance at religious services in some way associated with health habits critical to longevity that are not considered in this study? In other words, the study invites additional investigation, as the iterative nature of epidemiology so often does. Back to top Article Information Corresponding Author: Dan German Blazer II, MD, MPH, PhD, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, PO Box 3003, Durham, NC 27710 (email@example.com). Published Online: May 16, 2016. doi:10.1001/jamainternmed.2016.1626. Conflict of Interest Disclosures: None reported. References 1. Li S, Stampfer MJ, Williams DR, VanderWeele TJ. Association of religious service attendance with mortality among women [published online May 15, 2016]. JAMA Intern Med. doi:10.1001/jamainternmed.2016.1615.Google Scholar 2. Koenig HG, King D, Carson VB. Handbook of Religion and Health. New York, NY: Oxford University Press; 2012. 3. Alexander E. Proof of Heaven. New York, NY: Simon and Schuster; 2012. 4. Miller L, Bansal R, Wickramaratne P, et al. Neuroanatomical correlates of religiosity and spirituality: a study in adults at high and low familial risk for depression. JAMA Psychiatry. 2014;71(2):128-135.PubMedGoogle ScholarCrossref 5. Pew Research Center. Attendence at religious services. http://www.pewforum.org/religious-landscape-study/attendance-at-religious-services/. Accessed March 9, 2016. 6. Smith C, Snell P. Souls in Transition: The Religious Lives of Young Adults in America. New York, NY: Oxford University Press; 2009.
JAMA Internal Medicine – American Medical Association
Published: Jun 1, 2016
Keywords: health status indicators,longevity,religion,spirituality,women's health,christianity,mortality,social support,biopsychosocial disease model,interpretation of findings,nurses' health study,ashkenazi jew,roman catholicism
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