Religious and Spiritual Coping and Risk of Incident Hypertension in the Black Women's Health Study

Religious and Spiritual Coping and Risk of Incident Hypertension in the Black Women's Health Study Abstract Background The few studies of the relationship between religion and/or spirituality (R/S) and hypertension are conflicting. We hypothesized that R/S may reduce the risk of hypertension by buffering adverse physiological effects of stress. Methods We prospectively assessed the association of R/S with hypertension within the Black Women’s Health Study (BWHS), a cohort study initiated in 1995 that follows participants through biennial questionnaires. The 2005 questionnaire included four R/S questions: (i) extent to which one’s R/S is involved in coping with stressful situations, (ii) self-identification as a religious/spiritual person, (iii) frequency of attending religious services, and (iv) frequency of prayer. Incidence rate ratios (IRRs) and 95% confidence intervals were calculated for each R/S variable in relation to incident hypertension using Cox proportional hazards regression models, controlling for demographics, known hypertension risk factors, psychosocial factors, and other R/S variables. Results During 2005–2013, 5,194 incident cases of hypertension were identified. High involvement of R/S in coping with stressful events compared with no involvement was associated with reduced risk of hypertension (IRR: 0.87; 95% CI: 0.75, 1.00). The association was strongest among women reporting greater levels of perceived stress (IRR: 0.77; 95% CI: 0.61, 0.98; p interaction = .01). More frequent prayer was associated with increased risk of hypertension (IRR: 1.12; 95% CI: 0.99, 1.27). No association was observed for the other R/S measures. Conclusion R/S coping was associated with decreased risk of hypertension in African American women, especially among those reporting higher levels of stress. Further research is needed to understand the mechanistic pathways through which R/S coping may affect health. Religiosity, Spirituality, Psychosocial stress, Coping, Black women, Hypertension Background Hypertension remains one of the leading risk factors for cardiovascular disease and stroke, and a leading cause of death in the USA [1–3]. Hypertension is also a condition marked by dramatic racial/ethnic disparities. In the years 2011–2014, the prevalence of hypertension among adults aged 18 years and older was 41% for African Americans and 28% for White Americans [4]. African American women are diagnosed with hypertension, on average, a decade earlier than their white counterparts [1, 5]. Numerous randomized controlled trials have demonstrated the clinical benefit of antihypertensive regimens [6–8], now codified in clinical guidelines [9, 10]. However, a comprehensive strategy to reduce morbidity and mortality from hypertension must include patient-centered prevention and treatment strategies [11, 12]. A growing body of research suggests that psychosocial stress is a risk factor involved in the etiology of clinical hypertension [13]. For example, prospective studies have associated occupational stress [14–18], low wages [19], social isolation and lack of support [20, 21], and poor sleep quality [22, 23] with increased risk of incident hypertension. African Americans experience higher burdens of all of these psychosocial stressors relative to White Americans. The disproportionate experience of psychosocial stress may therefore be one pathway through which racial disparities in hypertension are created and sustained. Psychosocial stress has been shown to lead to dysregulation of the neuroendocrine, autonomic, and immune systems within the stress pathway [24, 25], but positive moderating influences, such as coping skills, social support, and religious coping, have also been shown to mitigate the deleterious effects of stress [26–31]. Positive religious and spiritual (R/S) coping—the constructive use of religious and spiritual resources to cope with and adapt to stressful life circumstances [32]—may buffer the adverse impact of stress by providing internal resources for coping, resiliency, and inner peace [33, 34]. Given that Africans Americans are more likely than Whites to indicate that religion is important in their daily lives (90% vs. 75%) [35], and that African American patients are 37% more likely than White patients to rely on their faith to cope with serious illness [36], the potential buffering effects of R/S as they relate to risk of incident hypertension may be especially pronounced among African Americans—the precise population experiencing the highest burden of hypertension. The literature on R/S coping and health is mixed [37–43]. No prospective study to date has investigated the relationship between R/S coping and risk of incident hypertension in a U.S. population. We assessed the association of religion and spirituality with risk of incident hypertension in the Black Women’s Health Study (BWHS), the largest prospective study of African American women in the USA. Specifically, we assessed the relationship of positive R/S coping, as well as three additional R/S measures (self-described religiosity or spirituality, frequency of religious service attendance, and frequency of prayer) with risk of incident hypertension. We hypothesized that religion and spirituality may operate through the stress pathway to influence risk of hypertension by buffering the effects of stress on the body, and thus will have the greatest protective effect among women experiencing the highest levels of stress. Methods The BWHS is an ongoing prospective follow-up of 59,000 self-identified Black women from throughout the USA. The aim of the study, which began in 1995, is to assess risk factors for breast cancer and other illnesses. Participants enrolled through postal health questionnaires; >95% were recruited from subscribers of Essence magazine, with the remainder from selected Black women’s professional organizations. Informed consent was indicated by participants’ completion of the questionnaire. More than 80% of respondents were from California, Georgia, Illinois, Indiana, Louisiana, Maryland, Massachusetts, Michigan, New Jersey, New York, South Carolina, Virginia, and the District of Columbia. On the 1995 baseline questionnaire, BWHS participants provided data on demographic characteristics, medical and reproductive history, smoking and alcohol use, physical activity, anthropometric measures (e.g., height, weight), and other factors. At baseline, participants were aged 21–69 years (median, 38 years); 97% had completed high school, and 44% had completed college. Participants update their health information every two years via biennial questionnaires [44]. Over nine questionnaire cycles, follow-up of the baseline cohort has been completed for 88% of potential person-years. The Boston University Medical Center Institutional Review Board approved the human subjects’ protocol for the study. Study Population The start of follow-up for the current analysis was 2005, when the religiosity and spirituality (R/S) questions described below were asked on the 2005 BWHS questionnaire, completed by 43,179 participants. We excluded women with a history of hypertension or a history of hypertensive medications (n = 17,685), and women who did not complete all R/S questions (n = 3,808), leaving an analytic sample of 21,686 (Fig. 1). Women who did not complete all four R/S questions were similar to those included in the analytic sample on key hypertension risk factors: age (mean = 45.8 vs 45.4 years) and body mass index (mean = 28.9 vs 28.7 kg/m2). The geographic distribution was also similar in the two groups, although those in the analytic sample were slightly more educated than those who did not complete all R/S questions (≥16 years of education: 64.2% vs 54.0%). Compared to the analytic sample, women excluded due to prevalent hypertension were similar in terms of geographic distribution, but were older (mean age = 54.3 vs 45.8 years), heavier (mean body mass index = 32.2 vs 28.9 kg/m2), reported more type 2 diabetes (22% vs 6%), and were more likely to attend religious services several times/week (20% vs 16%) and to pray several times/day (41% vs 35%). Fig. 1 View largeDownload slide Flowchart of study population and exclusions, Black Women's Health Study. Fig. 1 View largeDownload slide Flowchart of study population and exclusions, Black Women's Health Study. Religion/Spirituality The 2005 follow-up questionnaire contained four R/S questions. Two questions were drawn from the Fetzer Institute’s Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) [45]. The first addressed positive religious coping (as distinct from negative religious coping) [32]: “To what extent is your religion or spirituality involved in understanding or dealing with stressful situations in any way?” (religious or spiritual coping), with four response categories from “not involved at all” to “very involved.” The second question assessed individuals’ assessment of themselves as religious or spiritual persons: “To what extent do you consider yourself a religious or spiritual person?” (religious/spiritual person) with response options ranging from “not religious/spiritual” to “very religious/spiritual.” Two questions, drawn from the Duke University Religion Index [46], included: “How often do you attend religious services?” (service attendance), with response options ranging from “never” to “several times a day,” and “How often do you pray?” (frequency of prayer), with response options ranging from “rarely or never” to “many times a day.” Incident Hypertension Incident hypertension cases were identified through self-report on the 2007 through 2013 questionnaires. Women were asked to indicate the calendar year of their diagnosis. Cases were defined as women who reported physician-diagnosed hypertension with use of either antihypertensive medications or diuretics. In a BWHS validation study, 99% of self-reported cases were confirmed by medical records and/or physician checklists [47]. Covariates Selection of potential confounders was based on the existing literature [10] as well as their association with hypertension in previous analyses within the BWHS [48]. Data on age, smoking status, alcohol consumption, weight, and geographic region of residence were obtained from the 2005 questionnaire. Data on height were collected in 1995; years of education in 1995 and 2003; and vigorous exercise and walking for exercise in 2001. Prevalent diagnoses of myocardial infarction, stroke, cancer, or type 2 diabetes were obtained from questionnaires preceding the start of our analysis (1995 through 2005 questionnaires). The short-form National Cancer Institute-Block food frequency questionnaire [49] was included on the 2001 questionnaire; from these data, we calculated the DASH dietary pattern [50]. Higher scores indicate healthier diet. The 2005 questionnaire included the four-item Perceived Stress Scale developed by Cohen et al. [51], which measures the degree to which respondents found their lives “unpredictable, uncontrollable, and overloading” in the past month. Perceived stress has been positively associated with incident high blood pressure [52]. We derived a variable for neighborhood socioeconomic status at the Census block level. Specifically, BWHS participant residential addresses from 2005 were geocoded and linked to the American Community Survey data at the block group level. Factor analysis was used to create an index of neighborhood socioeconomic status (SES) that included six U.S. census variables (median household income; median housing value; percent of households receiving interest; dividend or net rental income; percent of adults aged ≥ 25 years who completed college; percent of families with children not headed by a single female; and percent of population not living below the poverty level). Regression coefficients from the factor analysis were used to weight the variables for a combined neighborhood score [53]. Higher scores indicate higher neighborhood SES. Neighborhood SES has been inversely associated with hypertention in the BWHS [48]. Other factors, including depressive symptoms (CES-D scale), experiences and perceptions of racism [47], childhood abuse victimization, country of birth, insurance status, and physical exam in past 2 years, were considered as potential confounders but were not included in the final models because their inclusion did not change risk estimates by more than 10%. In fact, inclusion of these variables changed estimates by less than 1%. Data Analysis Person-years were calculated from March 2005 to the midpoint of the calendar year of diagnosis of hypertension, loss to follow-up, death, or the end of follow-up (March 2013), whichever occurred first. Incidence rate ratios (IRRs) and 95% confidence intervals (CI) were estimated for each of the R/S variables in relation to hypertension using Cox proportional hazard models. With respect to R/S coping, the reference category was that a person’s religion or spirituality was “not involved at all” in coping with stressful situations. For self-identification as a religious or spiritual person, the reference category was “not or slightly.” For frequency of attendance at religious services, the reference category was “≤1 /month” rather than “never” because only 366 women in our sample selected “never,” and these women may differ in unknown ways from most BWHS participants who reported attending religious services at least occasionally. Similarly, for frequency of prayer, “≤1 /week” was the reference category rather than the small group of women (n = 281) who rarely or never prayed. For each R/S measure, Model 1 was adjusted for age (1-year intervals) and 2-year questionnaire cycle. Model 2 additionally included terms for perceived stress (below median, above median), education (≤12, 13–15, 16, ≥17 years), body mass index (weight (kg)/height (m2); < 25, 25–29, 30–34, 35–39, ≥40), pack-years of smoking (never, <5, 5–9, 10–19, ≥20), alcohol consumption (never, past, 1–3, 4–6, ≥7 drinks/week), neighborhood SES score (in quintiles), vigorous exercise (none, <1, 1–2, or ≥3 hr/week), walking for exercise (none, <1, 1–2, or ≥3 hr/week), DASH diet score (quintiles), geographic region (Northeast, South, Midwest, West), and history of myocardial infarction, stroke, cancer, or type 2 diabetes. Model 3 was adjusted simulaneously for all R/S measures in addition to the Model 2 covariates. Indicator variables were used to account for missing covariate data. Tests of trend were performed by modeling R/S variables as ordinal variables. p Values are two-sided. All analyses were performed using SAS version 9.3, software (SAS Institute, Inc., Cary, North Carolina). We assessed the presence of collinearity between R/S variables using the variance components method [54]. Results Table 1 presents selected characteristics of study participants according to each R/S measure. Women who reported higher levels on all or most of the R/S variables were older, more educated, and less likely to smoke or to drink heavily. They also were less likely to score high on the perceived stress scale. However, they were more likely to live in a disadvantaged neighborhood. Table 1 Baseline characteristics according to lower and upper categories of religion/spirituality questions, Black Women’s Health Study, 2005 To what extent is religion involved in coping? To what extent are you a religious or spiritual person? How often do you attend religious services? How often do you pray? Characteristic Not involved Very involved Not/slightly Very ≤1/month Several times/ week Rarely/never Several times/ day (n = 1,514) (n = 15,095) (n = 2,449) (n = 8,805) (n = 6,168) (n = 3,474) (n = 910) (n = 7,679) Age (years) (mean [SD]) 45.0 (9.6) 46.2 (9.4) 43.5 (8.8) 46.6 (9.3) 44.4 (8.7) 47.6 (9.8) 44.5 (9.4) 47.3 (9.5) Body mass index (≥30 kg/m2), % 35 35 33 35 35 39 32 35 Education (≤12 years), % 16 9 14 9 11 11 10 11 Smoking (≥10 pack- years), % 16 12 17 12 16 10 21 13 Alcohol (≥4 drinks/ week), % 14 7 13 7 12 3 17 7 Vigorous exercise (≥3 hours/week), % 21 21 20 21 20 19 23 21 Walking (≥3 hours/ week), % 26 29 26 29 27 30 24 30 DASH dietary pattern (quintile 5) (high), % 19 18 18 19 18 17 20 19 Neighborhood SES (quintile 5) (high), % 22 17 21 17 20 12 26 14 Perceived stress (above median), % 53 48 56 45 51 48 53 49 Myocardial infarction, % 1 1 1 1 1 1 1 1 Stroke, % 1 1 1 1 1 1 1 1 Type 2 diabetes, % 6 6 6 6 6 6 5 6 To what extent is religion involved in coping? To what extent are you a religious or spiritual person? How often do you attend religious services? How often do you pray? Characteristic Not involved Very involved Not/slightly Very ≤1/month Several times/ week Rarely/never Several times/ day (n = 1,514) (n = 15,095) (n = 2,449) (n = 8,805) (n = 6,168) (n = 3,474) (n = 910) (n = 7,679) Age (years) (mean [SD]) 45.0 (9.6) 46.2 (9.4) 43.5 (8.8) 46.6 (9.3) 44.4 (8.7) 47.6 (9.8) 44.5 (9.4) 47.3 (9.5) Body mass index (≥30 kg/m2), % 35 35 33 35 35 39 32 35 Education (≤12 years), % 16 9 14 9 11 11 10 11 Smoking (≥10 pack- years), % 16 12 17 12 16 10 21 13 Alcohol (≥4 drinks/ week), % 14 7 13 7 12 3 17 7 Vigorous exercise (≥3 hours/week), % 21 21 20 21 20 19 23 21 Walking (≥3 hours/ week), % 26 29 26 29 27 30 24 30 DASH dietary pattern (quintile 5) (high), % 19 18 18 19 18 17 20 19 Neighborhood SES (quintile 5) (high), % 22 17 21 17 20 12 26 14 Perceived stress (above median), % 53 48 56 45 51 48 53 49 Myocardial infarction, % 1 1 1 1 1 1 1 1 Stroke, % 1 1 1 1 1 1 1 1 Type 2 diabetes, % 6 6 6 6 6 6 5 6 Values are standardized to the 2005 age distribution. SES socioeconomic status. View Large Table 1 Baseline characteristics according to lower and upper categories of religion/spirituality questions, Black Women’s Health Study, 2005 To what extent is religion involved in coping? To what extent are you a religious or spiritual person? How often do you attend religious services? How often do you pray? Characteristic Not involved Very involved Not/slightly Very ≤1/month Several times/ week Rarely/never Several times/ day (n = 1,514) (n = 15,095) (n = 2,449) (n = 8,805) (n = 6,168) (n = 3,474) (n = 910) (n = 7,679) Age (years) (mean [SD]) 45.0 (9.6) 46.2 (9.4) 43.5 (8.8) 46.6 (9.3) 44.4 (8.7) 47.6 (9.8) 44.5 (9.4) 47.3 (9.5) Body mass index (≥30 kg/m2), % 35 35 33 35 35 39 32 35 Education (≤12 years), % 16 9 14 9 11 11 10 11 Smoking (≥10 pack- years), % 16 12 17 12 16 10 21 13 Alcohol (≥4 drinks/ week), % 14 7 13 7 12 3 17 7 Vigorous exercise (≥3 hours/week), % 21 21 20 21 20 19 23 21 Walking (≥3 hours/ week), % 26 29 26 29 27 30 24 30 DASH dietary pattern (quintile 5) (high), % 19 18 18 19 18 17 20 19 Neighborhood SES (quintile 5) (high), % 22 17 21 17 20 12 26 14 Perceived stress (above median), % 53 48 56 45 51 48 53 49 Myocardial infarction, % 1 1 1 1 1 1 1 1 Stroke, % 1 1 1 1 1 1 1 1 Type 2 diabetes, % 6 6 6 6 6 6 5 6 To what extent is religion involved in coping? To what extent are you a religious or spiritual person? How often do you attend religious services? How often do you pray? Characteristic Not involved Very involved Not/slightly Very ≤1/month Several times/ week Rarely/never Several times/ day (n = 1,514) (n = 15,095) (n = 2,449) (n = 8,805) (n = 6,168) (n = 3,474) (n = 910) (n = 7,679) Age (years) (mean [SD]) 45.0 (9.6) 46.2 (9.4) 43.5 (8.8) 46.6 (9.3) 44.4 (8.7) 47.6 (9.8) 44.5 (9.4) 47.3 (9.5) Body mass index (≥30 kg/m2), % 35 35 33 35 35 39 32 35 Education (≤12 years), % 16 9 14 9 11 11 10 11 Smoking (≥10 pack- years), % 16 12 17 12 16 10 21 13 Alcohol (≥4 drinks/ week), % 14 7 13 7 12 3 17 7 Vigorous exercise (≥3 hours/week), % 21 21 20 21 20 19 23 21 Walking (≥3 hours/ week), % 26 29 26 29 27 30 24 30 DASH dietary pattern (quintile 5) (high), % 19 18 18 19 18 17 20 19 Neighborhood SES (quintile 5) (high), % 22 17 21 17 20 12 26 14 Perceived stress (above median), % 53 48 56 45 51 48 53 49 Myocardial infarction, % 1 1 1 1 1 1 1 1 Stroke, % 1 1 1 1 1 1 1 1 Type 2 diabetes, % 6 6 6 6 6 6 5 6 Values are standardized to the 2005 age distribution. SES socioeconomic status. View Large Over the follow-up period, 5,194 incident cases of hypertension occurred during 137,590 person-years, with a mean duration of follow-up of 6.5 years (SD = 2.4; range = 1–8). Findings on the relation of R/S variables to hypertension incidence are presented in Table 2. R/S coping was not associated with risk of hypertension in the age-adjusted model (Model 1) or in the multivariable model that adjusted for all covariates except the other R/S variables (Model 2). However, after further adjustment for the other R/S variables (Model 3), the IRR for the highest level of R/S coping compared with none was 0.87 (95% CI: 0.75, 1.00; p trend = .02). We repeated the analysis adjusting for individual R/S measures one at time and found that “prayer” produced the largest change in the effect estimate. Table 2 Self-reported religious coping, religiosity/spirituality, service attendance, and prayer in relation to incident hypertension in the Black Women’s Health Study, 2005–2013 Exposure Cases Person-years Incidence Rate Ratio (95% CI) Model 1a Model 2b Model 3c Religious or spiritual coping  Not involved 337 9,543 Reference Reference Reference  Somewhat involved 1,240 32,205 1.08 (0.96, 1.22) 1.05 (0.93, 1.18) 0.94 (0.82, 1.08)  Very involved 3,617 95,842 1.01 (0.90, 1.13) 0.98 (0.88, 1.10) 0.87 (0.75, 1.00)  p trend .26 .18 .02 Religious/spiritual person  Not/slightly 512 15,700 Reference Reference Reference  Moderately 2,593 65,946 1.11 (1.01, 1.22) 1.08 (0.98, 1.19) 1.05 (0.93, 1.17)  Very 2,089 55,944 1.02 (0.93, 1.13) 1.01 (0.92, 1.12) 1.01 (0.89, 1.15)  p trend .31 .40 .65 Service attendance  Never 446 13,895 0.88 (0.80, 0.98) 0.89 (0.80, 0.99) 0.91 (0.82, 1.02)  ≤1/month 1,426 39,231 Reference Reference Reference  2–3 times/month 1,026 26,148 1.03 (0.95, 1.12) 1.04 (0.96, 1.13) 1.05 (0.96, 1.14)  1/week 1,405 36,505 0.98 (0.91, 1.05) 0.99 (0.92, 1.07) 1.01 (0.93, 1.09)  Several times/week 891 21,810 1.01 (0.93, 1.10) 0.95 (0.88, 1.04) 0.99 (0.90, 1.09)  p trend .22 .85 .53 Frequency of prayer  Rarely/Never 170 5,869 0.89 (0.75, 1.07) 0.94 (0.78, 1.13) 0.96 (0.79, 1.16)  ≤1/week 375 11,927 Reference Reference Reference  Several times/week 1,027 26,619 1.18 (1.05, 1.33) 1.16 (1.03, 1.31) 1.19 (1.05, 1.34)  1–2 times/day 1,713 45,113 1.11 (0.99, 1.24) 1.10 (0.99, 1.24) 1.14 (1.01, 1.29)  Several times/day 1,909 48,062 1.10 (0.98, 1.23) 1.06 (0.95, 1.19) 1.12 (0.99, 1.27)  p trend .12 .71 .42 Exposure Cases Person-years Incidence Rate Ratio (95% CI) Model 1a Model 2b Model 3c Religious or spiritual coping  Not involved 337 9,543 Reference Reference Reference  Somewhat involved 1,240 32,205 1.08 (0.96, 1.22) 1.05 (0.93, 1.18) 0.94 (0.82, 1.08)  Very involved 3,617 95,842 1.01 (0.90, 1.13) 0.98 (0.88, 1.10) 0.87 (0.75, 1.00)  p trend .26 .18 .02 Religious/spiritual person  Not/slightly 512 15,700 Reference Reference Reference  Moderately 2,593 65,946 1.11 (1.01, 1.22) 1.08 (0.98, 1.19) 1.05 (0.93, 1.17)  Very 2,089 55,944 1.02 (0.93, 1.13) 1.01 (0.92, 1.12) 1.01 (0.89, 1.15)  p trend .31 .40 .65 Service attendance  Never 446 13,895 0.88 (0.80, 0.98) 0.89 (0.80, 0.99) 0.91 (0.82, 1.02)  ≤1/month 1,426 39,231 Reference Reference Reference  2–3 times/month 1,026 26,148 1.03 (0.95, 1.12) 1.04 (0.96, 1.13) 1.05 (0.96, 1.14)  1/week 1,405 36,505 0.98 (0.91, 1.05) 0.99 (0.92, 1.07) 1.01 (0.93, 1.09)  Several times/week 891 21,810 1.01 (0.93, 1.10) 0.95 (0.88, 1.04) 0.99 (0.90, 1.09)  p trend .22 .85 .53 Frequency of prayer  Rarely/Never 170 5,869 0.89 (0.75, 1.07) 0.94 (0.78, 1.13) 0.96 (0.79, 1.16)  ≤1/week 375 11,927 Reference Reference Reference  Several times/week 1,027 26,619 1.18 (1.05, 1.33) 1.16 (1.03, 1.31) 1.19 (1.05, 1.34)  1–2 times/day 1,713 45,113 1.11 (0.99, 1.24) 1.10 (0.99, 1.24) 1.14 (1.01, 1.29)  Several times/day 1,909 48,062 1.10 (0.98, 1.23) 1.06 (0.95, 1.19) 1.12 (0.99, 1.27)  p trend .12 .71 .42 CI confidence interval. aModel 1 adjusts for age and questionnaire cycle. bModel 2 adjusts for model 1 variables and BMI, neighborhood SES, vigorous exercise, walking for exercise, DASH diet, education, smoking, alcohol consumption, perceived stress, geographic region, MI, stroke, and diabetes. cModel 3 adjusts for model 2 variables plus simultaneous adjustment for other r/s questions. View Large Table 2 Self-reported religious coping, religiosity/spirituality, service attendance, and prayer in relation to incident hypertension in the Black Women’s Health Study, 2005–2013 Exposure Cases Person-years Incidence Rate Ratio (95% CI) Model 1a Model 2b Model 3c Religious or spiritual coping  Not involved 337 9,543 Reference Reference Reference  Somewhat involved 1,240 32,205 1.08 (0.96, 1.22) 1.05 (0.93, 1.18) 0.94 (0.82, 1.08)  Very involved 3,617 95,842 1.01 (0.90, 1.13) 0.98 (0.88, 1.10) 0.87 (0.75, 1.00)  p trend .26 .18 .02 Religious/spiritual person  Not/slightly 512 15,700 Reference Reference Reference  Moderately 2,593 65,946 1.11 (1.01, 1.22) 1.08 (0.98, 1.19) 1.05 (0.93, 1.17)  Very 2,089 55,944 1.02 (0.93, 1.13) 1.01 (0.92, 1.12) 1.01 (0.89, 1.15)  p trend .31 .40 .65 Service attendance  Never 446 13,895 0.88 (0.80, 0.98) 0.89 (0.80, 0.99) 0.91 (0.82, 1.02)  ≤1/month 1,426 39,231 Reference Reference Reference  2–3 times/month 1,026 26,148 1.03 (0.95, 1.12) 1.04 (0.96, 1.13) 1.05 (0.96, 1.14)  1/week 1,405 36,505 0.98 (0.91, 1.05) 0.99 (0.92, 1.07) 1.01 (0.93, 1.09)  Several times/week 891 21,810 1.01 (0.93, 1.10) 0.95 (0.88, 1.04) 0.99 (0.90, 1.09)  p trend .22 .85 .53 Frequency of prayer  Rarely/Never 170 5,869 0.89 (0.75, 1.07) 0.94 (0.78, 1.13) 0.96 (0.79, 1.16)  ≤1/week 375 11,927 Reference Reference Reference  Several times/week 1,027 26,619 1.18 (1.05, 1.33) 1.16 (1.03, 1.31) 1.19 (1.05, 1.34)  1–2 times/day 1,713 45,113 1.11 (0.99, 1.24) 1.10 (0.99, 1.24) 1.14 (1.01, 1.29)  Several times/day 1,909 48,062 1.10 (0.98, 1.23) 1.06 (0.95, 1.19) 1.12 (0.99, 1.27)  p trend .12 .71 .42 Exposure Cases Person-years Incidence Rate Ratio (95% CI) Model 1a Model 2b Model 3c Religious or spiritual coping  Not involved 337 9,543 Reference Reference Reference  Somewhat involved 1,240 32,205 1.08 (0.96, 1.22) 1.05 (0.93, 1.18) 0.94 (0.82, 1.08)  Very involved 3,617 95,842 1.01 (0.90, 1.13) 0.98 (0.88, 1.10) 0.87 (0.75, 1.00)  p trend .26 .18 .02 Religious/spiritual person  Not/slightly 512 15,700 Reference Reference Reference  Moderately 2,593 65,946 1.11 (1.01, 1.22) 1.08 (0.98, 1.19) 1.05 (0.93, 1.17)  Very 2,089 55,944 1.02 (0.93, 1.13) 1.01 (0.92, 1.12) 1.01 (0.89, 1.15)  p trend .31 .40 .65 Service attendance  Never 446 13,895 0.88 (0.80, 0.98) 0.89 (0.80, 0.99) 0.91 (0.82, 1.02)  ≤1/month 1,426 39,231 Reference Reference Reference  2–3 times/month 1,026 26,148 1.03 (0.95, 1.12) 1.04 (0.96, 1.13) 1.05 (0.96, 1.14)  1/week 1,405 36,505 0.98 (0.91, 1.05) 0.99 (0.92, 1.07) 1.01 (0.93, 1.09)  Several times/week 891 21,810 1.01 (0.93, 1.10) 0.95 (0.88, 1.04) 0.99 (0.90, 1.09)  p trend .22 .85 .53 Frequency of prayer  Rarely/Never 170 5,869 0.89 (0.75, 1.07) 0.94 (0.78, 1.13) 0.96 (0.79, 1.16)  ≤1/week 375 11,927 Reference Reference Reference  Several times/week 1,027 26,619 1.18 (1.05, 1.33) 1.16 (1.03, 1.31) 1.19 (1.05, 1.34)  1–2 times/day 1,713 45,113 1.11 (0.99, 1.24) 1.10 (0.99, 1.24) 1.14 (1.01, 1.29)  Several times/day 1,909 48,062 1.10 (0.98, 1.23) 1.06 (0.95, 1.19) 1.12 (0.99, 1.27)  p trend .12 .71 .42 CI confidence interval. aModel 1 adjusts for age and questionnaire cycle. bModel 2 adjusts for model 1 variables and BMI, neighborhood SES, vigorous exercise, walking for exercise, DASH diet, education, smoking, alcohol consumption, perceived stress, geographic region, MI, stroke, and diabetes. cModel 3 adjusts for model 2 variables plus simultaneous adjustment for other r/s questions. View Large Self-identification as a religious/spiritual person and higher levels of attendance at religious services were not appreciably associated with incidence of hypertension (Table 2), although those who reported never attending religious services had a slightly lower incidence of hypertension (IRR: 0.91; 95% CI: 0.82, 1.02). Praying more frequently was associated with a small increased incidence of hypertension (IRR: 1.14; 95% CI: 1.01, 1.29 for prayer one to two times a day, and IRR: 1.12; 95% CI: 0.99, 1.27 for several times a day). Using the variance components method [54], we assessed the presence of collinearity between the R/S variables. Based on a condition index cut-off of ≥ 3.0, we found that only the top four indices exceeded the threshold value, with the largest taking a value of 6.2. Despite this, none of the variables in the model loaded onto the same indices, providing little evidence for collinearity between our R/S variables. To explore the relationship between R/S coping and risk of hypertension further, we assessed associations within tertiles of perceived stress scores. As seen in Table 3, the inverse association between R/S coping and hypertension incidence was strongest among women with the highest level of perceived stress (IRR: 0.77; 95% CI: 0.61, 0.98; p for interaction: .01). Table 3 R/S coping in relation to incidence of hypertension according to perceived stress in the Black Women’s Health Study (2005–2013) Religious or spiritual coping Perceived Stress Scale Score Tertile 1 (low) Tertile 2 Tertile 3 (high) Cases HR (95% CI) Cases HR (95% CI) Cases HR (95% CI) Not involved 84 Reference 108 Reference 129 Reference Somewhat involved 360 1.32 (1.00, 1.72) 414 0.89 (0.70, 1.12) 435 0.77 (0.61, 0.97) Very involved 1374 1.13 (0.86, 1.50) 1120 0.81 (0.63, 1.03) 1032 0.77 (0.61, 0.98) p trend .51 .06 .19 p interaction .01 Religious or spiritual coping Perceived Stress Scale Score Tertile 1 (low) Tertile 2 Tertile 3 (high) Cases HR (95% CI) Cases HR (95% CI) Cases HR (95% CI) Not involved 84 Reference 108 Reference 129 Reference Somewhat involved 360 1.32 (1.00, 1.72) 414 0.89 (0.70, 1.12) 435 0.77 (0.61, 0.97) Very involved 1374 1.13 (0.86, 1.50) 1120 0.81 (0.63, 1.03) 1032 0.77 (0.61, 0.98) p trend .51 .06 .19 p interaction .01 CI confidence interval; HR hazard ratio. IRRs are adjusted for age, questionnaire cycle, BMI, neighborhood SES, vigorous exercise, walking for exercise, DASH diet, education, pack years of smoking, alcohol consumption, geographic region, prevalent MI, stroke, diabetes, and simultaneous adjustment for other r/s questions. View Large Table 3 R/S coping in relation to incidence of hypertension according to perceived stress in the Black Women’s Health Study (2005–2013) Religious or spiritual coping Perceived Stress Scale Score Tertile 1 (low) Tertile 2 Tertile 3 (high) Cases HR (95% CI) Cases HR (95% CI) Cases HR (95% CI) Not involved 84 Reference 108 Reference 129 Reference Somewhat involved 360 1.32 (1.00, 1.72) 414 0.89 (0.70, 1.12) 435 0.77 (0.61, 0.97) Very involved 1374 1.13 (0.86, 1.50) 1120 0.81 (0.63, 1.03) 1032 0.77 (0.61, 0.98) p trend .51 .06 .19 p interaction .01 Religious or spiritual coping Perceived Stress Scale Score Tertile 1 (low) Tertile 2 Tertile 3 (high) Cases HR (95% CI) Cases HR (95% CI) Cases HR (95% CI) Not involved 84 Reference 108 Reference 129 Reference Somewhat involved 360 1.32 (1.00, 1.72) 414 0.89 (0.70, 1.12) 435 0.77 (0.61, 0.97) Very involved 1374 1.13 (0.86, 1.50) 1120 0.81 (0.63, 1.03) 1032 0.77 (0.61, 0.98) p trend .51 .06 .19 p interaction .01 CI confidence interval; HR hazard ratio. IRRs are adjusted for age, questionnaire cycle, BMI, neighborhood SES, vigorous exercise, walking for exercise, DASH diet, education, pack years of smoking, alcohol consumption, geographic region, prevalent MI, stroke, diabetes, and simultaneous adjustment for other r/s questions. View Large Discussion In this first national prospective study investigating the relationship of religion and spirituality (R/S) to incidence of hypertension in African American women, we found that the extent to which a woman reported that her religion was involved in dealing with stressful situations (i.e., positive coping), was associated with a 13% reduction in the risk of hypertension. The association only became apparent after control for other R/S measures, in particular, frequency of prayer; women who reported praying more frequently were estimated to have an increased incidence of hypertension. The observed inverse association of R/S coping with hypertension incidence was strongest among women reporting the highest levels of stress, lending support to our hypothesis that R/S coping serves as a buffer against the adverse impacts of stress. Self-identification as a religious/spiritual person and higher levels of attendance at religious services were not associated with hypertension incidence. While there have been no previous U.S. studies of R/S coping in relation to incident hypertension, three cross-sectional studies demonstrated an association between R/S coping and lower blood pressure among white female college alumni [41], black female University students [42], and black (but not white) North Carolina adults enrolled in the Duke Biobehavioral Investigation of Hypertension study [43]. Our results also converge with findings from other prospective studies that have found a protective clinical effect of R/S coping in relation to other conditions. These include studies documenting association between R/S coping and weight management among cardiac rehabilitation patients [55]; glycemic control among diabetics [56]; and mortality following surgery [30]. In contrast to our findings, three prospective studies on R/S coping reported null results [37, 57, 58]. R/S coping was not associated with self-reported hypertension in a prospective analysis of Japanese adults [37]; nor was it associated with all-cause mortality in adult women from the Women’s Health Initiative (WHI)[57] or survival patterns among U.S. hemodialysis patients [58]. These studies each differed in terms of demographics, cultural approach to religion and spirituality, and importantly, how coping was assessed. The Krause study focused on a specific stressor—death of a loved one—and found that belief in a good afterlife, rather than seeking help from a deity (religious coping), influenced hypertension risk [37]. The study by Schnall and colleagues assessed the “level of strength and comfort provided by religion” rather than directly measuring coping [57]. Spinale et al. measured “religious feelings as coping mechanisms” specific to those experiencing kidney disease (“ . . . in adjusting to my kidney disease/failure . . .”) [58]. On the other hand, negative religious coping, which reflects an insecure relationship with God [59], has consistently been found to be associated with poorer mental and physical health [60]. We did not collect measures of negative coping in the BWHS. Our results provide preliminary evidence that positive R/S coping meaningfully reduces stress and has a tangible impact on risk of a critically important clinical outcome—hypertension. This growing body of research warrants further investigation to understand the underlying biological mechanisms—such as epigenetic regulation or functional dynamics—through which R/S coping may operate to affect a wide range of clinical outcomes. Shifting the focus to more functional aspects of R/S as it relates to biologically resonant and disease-relevant exposures, such as stress [61], may prove more successful in elucidating these biological mechanisms and pathways [33]. To date, few prospective studies have investigated such functional dimensions of R/S. Rather, prior literature has largely focused on general R/S service attendance, due to its consistent (but poorly understood) relationship to decreased risk of mortality [62, 63]. Frequent prayer was associated with a somewhat increased risk of hypertension. Existing prospective literature is mixed on the relationship between prayer and hypertension or blood pressure, with studies showing more frequent prayer to be associated with both increased risk of hypertension [38], and decreased risk of high blood pressure [64]. Despite the prospective design of our study, it is possible that aspects of religiosity and spirituality could already have been manifested prior to our analysis. In addition, over 30 percent of hypertensive adults are unaware that they have the condition [65], and such persons may experience mild symptoms such as headaches should their blood pressure enter the “severe” range (i.e., ≥180/≥120 mmHg) [66]. Experiencing even mild symptoms may prompt religiously inclined individuals to pray rather than seek medical evaluation. In our analysis, neither attending religious services nor identity as a religious or spiritual person was associated with a reduced risk of hypertension. As with prayer, the literature on attendance is mixed with studies reporting increased weekly attendance to be associated with a lower odds of hypertension [39, 40], while another found no association [38]. Spirituality was associated with a significantly increased diastolic blood pressure, and a nonsignificant increase in hypertension [38]. As one would expect, the women excluded from our analysis who had already been diagnosed with hypertension were older and more often affected by obesity and diabetes than those who were unaffected by hypertension at the start of our follow-up in 2005. On the other hand, the differences in the religious practices of the excluded and included were relatively small, which we take as some reassurance that our analytic population was not markedly different in religious practices from those excluded. Our investigation was limited by the fact that participants in the BWHS under-represent the approximately 15% of U.S. African American women from the same birth cohorts who did not graduate from high school [67]. In addition, 44% of BWHS participants had graduated college which over-represents that educational stratum among black women nationally. Our analyses were also limited to the four dimensions of R/S assessed. Further, religious coping was assessed using a single item from the BMMRS, which may not capture the full complexity of this construct. Although we had to rely on measures of R/S at a single point in time, we recognize that individuals’ R/S beliefs and practices are dynamic and fluid. There also could have been residual confounding as well as other unmeasured confounders including family history of hypertension. In addition, the inclusion of women only in our study limits the generalizability of the findings. Despite these limitations, however, our study has a number of strengths. This study is the first prospective study of R/S coping in relationship to incident hypertension conducted within a large, established U.S. cohort. The BWHS does represent the 85% of U.S. African American women who have completed 12 or more years of education, and BWHS participants reside in all regions of the continental USA. Our data on R/S were collected before the occurrence of incident hypertension, thereby clarifying the temporality of associations. Our validation of self-reported hypertension indicated a high level of accuracy. The methodological literature also indicates a high degree of accuracy of self-reported physician diagnosed hypertension [68, 69]. The robustness of data available to us also allowed us to control for a large number of known risk factors for hypertension, collinearity between variables of interest, as well as other potential confounders. The results from our study also raise clinically important questions with respect to providing patient-centered primary care for individuals at risk of hypertension. A key component of patient-centered care is helping patients develop the confidence and skills needed to achieve optimal health [12]. In this regard, it is important for clinicians serving the African American community to recognize that African American patients rely on their religion/spirituality to cope with stressful life situations more often than patients from other communities [36]. Indeed, an awareness of the role of spirituality in patients’ lives, and in particular how it might bear on their health and healthcare decision-making, should be seen as an essential component of providing patient-centered primary care regardless of the cultural community that patients come from [70]. However, this is even more the case when serving a patient population known to be highly religious, and the results of our study may well pertain to other highly religious populations (e.g., Hispanics/Latinos). Concrete examples of how the role of spirituality in patients’ lives could be useful in tailoring care might include referring religious or spiritual patients experiencing stressful life situations to psychotherapists equipped to provide culturally-competent [71], spiritually integrated psychotherapy [72]. Although taking a spiritual history has become a standard component of comprehensive palliative care [73, 74], this has not yet become part of routine primary care, despite recommendations from some that taking a spiritual history become a part of providing quality, patient-centered primary care [75]. Creative, culturally-tailored interventions that draw on African American spirituality as a resource for resiliency to combat the adverse impact of stress on health may also provide new opportunities to reduce racial disparities in the burden of hypertension. Acknowledgments This paper was a collaborative effort. Each author had access to the data, contributed to the analysis and interpretation of the data and writing of the manuscript. The idea for assessing this topic came from Drs. Shields, Palmer, Rosenberg, and Cozier. The design of the data collection came from Drs. Rosenberg, Palmer, and Cozier. Each author has approved the final version and will take public responsibility. This manuscript and the data have not been published, either in whole or in part, nor is it being considered elsewhere. We gratefully acknowledge the contributions of all BWHS participants. We also thank Ken Pargament for his helpful comments on an earlier draft of this paper. 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Religious and Spiritual Coping and Risk of Incident Hypertension in the Black Women's Health Study

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Abstract

Abstract Background The few studies of the relationship between religion and/or spirituality (R/S) and hypertension are conflicting. We hypothesized that R/S may reduce the risk of hypertension by buffering adverse physiological effects of stress. Methods We prospectively assessed the association of R/S with hypertension within the Black Women’s Health Study (BWHS), a cohort study initiated in 1995 that follows participants through biennial questionnaires. The 2005 questionnaire included four R/S questions: (i) extent to which one’s R/S is involved in coping with stressful situations, (ii) self-identification as a religious/spiritual person, (iii) frequency of attending religious services, and (iv) frequency of prayer. Incidence rate ratios (IRRs) and 95% confidence intervals were calculated for each R/S variable in relation to incident hypertension using Cox proportional hazards regression models, controlling for demographics, known hypertension risk factors, psychosocial factors, and other R/S variables. Results During 2005–2013, 5,194 incident cases of hypertension were identified. High involvement of R/S in coping with stressful events compared with no involvement was associated with reduced risk of hypertension (IRR: 0.87; 95% CI: 0.75, 1.00). The association was strongest among women reporting greater levels of perceived stress (IRR: 0.77; 95% CI: 0.61, 0.98; p interaction = .01). More frequent prayer was associated with increased risk of hypertension (IRR: 1.12; 95% CI: 0.99, 1.27). No association was observed for the other R/S measures. Conclusion R/S coping was associated with decreased risk of hypertension in African American women, especially among those reporting higher levels of stress. Further research is needed to understand the mechanistic pathways through which R/S coping may affect health. Religiosity, Spirituality, Psychosocial stress, Coping, Black women, Hypertension Background Hypertension remains one of the leading risk factors for cardiovascular disease and stroke, and a leading cause of death in the USA [1–3]. Hypertension is also a condition marked by dramatic racial/ethnic disparities. In the years 2011–2014, the prevalence of hypertension among adults aged 18 years and older was 41% for African Americans and 28% for White Americans [4]. African American women are diagnosed with hypertension, on average, a decade earlier than their white counterparts [1, 5]. Numerous randomized controlled trials have demonstrated the clinical benefit of antihypertensive regimens [6–8], now codified in clinical guidelines [9, 10]. However, a comprehensive strategy to reduce morbidity and mortality from hypertension must include patient-centered prevention and treatment strategies [11, 12]. A growing body of research suggests that psychosocial stress is a risk factor involved in the etiology of clinical hypertension [13]. For example, prospective studies have associated occupational stress [14–18], low wages [19], social isolation and lack of support [20, 21], and poor sleep quality [22, 23] with increased risk of incident hypertension. African Americans experience higher burdens of all of these psychosocial stressors relative to White Americans. The disproportionate experience of psychosocial stress may therefore be one pathway through which racial disparities in hypertension are created and sustained. Psychosocial stress has been shown to lead to dysregulation of the neuroendocrine, autonomic, and immune systems within the stress pathway [24, 25], but positive moderating influences, such as coping skills, social support, and religious coping, have also been shown to mitigate the deleterious effects of stress [26–31]. Positive religious and spiritual (R/S) coping—the constructive use of religious and spiritual resources to cope with and adapt to stressful life circumstances [32]—may buffer the adverse impact of stress by providing internal resources for coping, resiliency, and inner peace [33, 34]. Given that Africans Americans are more likely than Whites to indicate that religion is important in their daily lives (90% vs. 75%) [35], and that African American patients are 37% more likely than White patients to rely on their faith to cope with serious illness [36], the potential buffering effects of R/S as they relate to risk of incident hypertension may be especially pronounced among African Americans—the precise population experiencing the highest burden of hypertension. The literature on R/S coping and health is mixed [37–43]. No prospective study to date has investigated the relationship between R/S coping and risk of incident hypertension in a U.S. population. We assessed the association of religion and spirituality with risk of incident hypertension in the Black Women’s Health Study (BWHS), the largest prospective study of African American women in the USA. Specifically, we assessed the relationship of positive R/S coping, as well as three additional R/S measures (self-described religiosity or spirituality, frequency of religious service attendance, and frequency of prayer) with risk of incident hypertension. We hypothesized that religion and spirituality may operate through the stress pathway to influence risk of hypertension by buffering the effects of stress on the body, and thus will have the greatest protective effect among women experiencing the highest levels of stress. Methods The BWHS is an ongoing prospective follow-up of 59,000 self-identified Black women from throughout the USA. The aim of the study, which began in 1995, is to assess risk factors for breast cancer and other illnesses. Participants enrolled through postal health questionnaires; >95% were recruited from subscribers of Essence magazine, with the remainder from selected Black women’s professional organizations. Informed consent was indicated by participants’ completion of the questionnaire. More than 80% of respondents were from California, Georgia, Illinois, Indiana, Louisiana, Maryland, Massachusetts, Michigan, New Jersey, New York, South Carolina, Virginia, and the District of Columbia. On the 1995 baseline questionnaire, BWHS participants provided data on demographic characteristics, medical and reproductive history, smoking and alcohol use, physical activity, anthropometric measures (e.g., height, weight), and other factors. At baseline, participants were aged 21–69 years (median, 38 years); 97% had completed high school, and 44% had completed college. Participants update their health information every two years via biennial questionnaires [44]. Over nine questionnaire cycles, follow-up of the baseline cohort has been completed for 88% of potential person-years. The Boston University Medical Center Institutional Review Board approved the human subjects’ protocol for the study. Study Population The start of follow-up for the current analysis was 2005, when the religiosity and spirituality (R/S) questions described below were asked on the 2005 BWHS questionnaire, completed by 43,179 participants. We excluded women with a history of hypertension or a history of hypertensive medications (n = 17,685), and women who did not complete all R/S questions (n = 3,808), leaving an analytic sample of 21,686 (Fig. 1). Women who did not complete all four R/S questions were similar to those included in the analytic sample on key hypertension risk factors: age (mean = 45.8 vs 45.4 years) and body mass index (mean = 28.9 vs 28.7 kg/m2). The geographic distribution was also similar in the two groups, although those in the analytic sample were slightly more educated than those who did not complete all R/S questions (≥16 years of education: 64.2% vs 54.0%). Compared to the analytic sample, women excluded due to prevalent hypertension were similar in terms of geographic distribution, but were older (mean age = 54.3 vs 45.8 years), heavier (mean body mass index = 32.2 vs 28.9 kg/m2), reported more type 2 diabetes (22% vs 6%), and were more likely to attend religious services several times/week (20% vs 16%) and to pray several times/day (41% vs 35%). Fig. 1 View largeDownload slide Flowchart of study population and exclusions, Black Women's Health Study. Fig. 1 View largeDownload slide Flowchart of study population and exclusions, Black Women's Health Study. Religion/Spirituality The 2005 follow-up questionnaire contained four R/S questions. Two questions were drawn from the Fetzer Institute’s Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) [45]. The first addressed positive religious coping (as distinct from negative religious coping) [32]: “To what extent is your religion or spirituality involved in understanding or dealing with stressful situations in any way?” (religious or spiritual coping), with four response categories from “not involved at all” to “very involved.” The second question assessed individuals’ assessment of themselves as religious or spiritual persons: “To what extent do you consider yourself a religious or spiritual person?” (religious/spiritual person) with response options ranging from “not religious/spiritual” to “very religious/spiritual.” Two questions, drawn from the Duke University Religion Index [46], included: “How often do you attend religious services?” (service attendance), with response options ranging from “never” to “several times a day,” and “How often do you pray?” (frequency of prayer), with response options ranging from “rarely or never” to “many times a day.” Incident Hypertension Incident hypertension cases were identified through self-report on the 2007 through 2013 questionnaires. Women were asked to indicate the calendar year of their diagnosis. Cases were defined as women who reported physician-diagnosed hypertension with use of either antihypertensive medications or diuretics. In a BWHS validation study, 99% of self-reported cases were confirmed by medical records and/or physician checklists [47]. Covariates Selection of potential confounders was based on the existing literature [10] as well as their association with hypertension in previous analyses within the BWHS [48]. Data on age, smoking status, alcohol consumption, weight, and geographic region of residence were obtained from the 2005 questionnaire. Data on height were collected in 1995; years of education in 1995 and 2003; and vigorous exercise and walking for exercise in 2001. Prevalent diagnoses of myocardial infarction, stroke, cancer, or type 2 diabetes were obtained from questionnaires preceding the start of our analysis (1995 through 2005 questionnaires). The short-form National Cancer Institute-Block food frequency questionnaire [49] was included on the 2001 questionnaire; from these data, we calculated the DASH dietary pattern [50]. Higher scores indicate healthier diet. The 2005 questionnaire included the four-item Perceived Stress Scale developed by Cohen et al. [51], which measures the degree to which respondents found their lives “unpredictable, uncontrollable, and overloading” in the past month. Perceived stress has been positively associated with incident high blood pressure [52]. We derived a variable for neighborhood socioeconomic status at the Census block level. Specifically, BWHS participant residential addresses from 2005 were geocoded and linked to the American Community Survey data at the block group level. Factor analysis was used to create an index of neighborhood socioeconomic status (SES) that included six U.S. census variables (median household income; median housing value; percent of households receiving interest; dividend or net rental income; percent of adults aged ≥ 25 years who completed college; percent of families with children not headed by a single female; and percent of population not living below the poverty level). Regression coefficients from the factor analysis were used to weight the variables for a combined neighborhood score [53]. Higher scores indicate higher neighborhood SES. Neighborhood SES has been inversely associated with hypertention in the BWHS [48]. Other factors, including depressive symptoms (CES-D scale), experiences and perceptions of racism [47], childhood abuse victimization, country of birth, insurance status, and physical exam in past 2 years, were considered as potential confounders but were not included in the final models because their inclusion did not change risk estimates by more than 10%. In fact, inclusion of these variables changed estimates by less than 1%. Data Analysis Person-years were calculated from March 2005 to the midpoint of the calendar year of diagnosis of hypertension, loss to follow-up, death, or the end of follow-up (March 2013), whichever occurred first. Incidence rate ratios (IRRs) and 95% confidence intervals (CI) were estimated for each of the R/S variables in relation to hypertension using Cox proportional hazard models. With respect to R/S coping, the reference category was that a person’s religion or spirituality was “not involved at all” in coping with stressful situations. For self-identification as a religious or spiritual person, the reference category was “not or slightly.” For frequency of attendance at religious services, the reference category was “≤1 /month” rather than “never” because only 366 women in our sample selected “never,” and these women may differ in unknown ways from most BWHS participants who reported attending religious services at least occasionally. Similarly, for frequency of prayer, “≤1 /week” was the reference category rather than the small group of women (n = 281) who rarely or never prayed. For each R/S measure, Model 1 was adjusted for age (1-year intervals) and 2-year questionnaire cycle. Model 2 additionally included terms for perceived stress (below median, above median), education (≤12, 13–15, 16, ≥17 years), body mass index (weight (kg)/height (m2); < 25, 25–29, 30–34, 35–39, ≥40), pack-years of smoking (never, <5, 5–9, 10–19, ≥20), alcohol consumption (never, past, 1–3, 4–6, ≥7 drinks/week), neighborhood SES score (in quintiles), vigorous exercise (none, <1, 1–2, or ≥3 hr/week), walking for exercise (none, <1, 1–2, or ≥3 hr/week), DASH diet score (quintiles), geographic region (Northeast, South, Midwest, West), and history of myocardial infarction, stroke, cancer, or type 2 diabetes. Model 3 was adjusted simulaneously for all R/S measures in addition to the Model 2 covariates. Indicator variables were used to account for missing covariate data. Tests of trend were performed by modeling R/S variables as ordinal variables. p Values are two-sided. All analyses were performed using SAS version 9.3, software (SAS Institute, Inc., Cary, North Carolina). We assessed the presence of collinearity between R/S variables using the variance components method [54]. Results Table 1 presents selected characteristics of study participants according to each R/S measure. Women who reported higher levels on all or most of the R/S variables were older, more educated, and less likely to smoke or to drink heavily. They also were less likely to score high on the perceived stress scale. However, they were more likely to live in a disadvantaged neighborhood. Table 1 Baseline characteristics according to lower and upper categories of religion/spirituality questions, Black Women’s Health Study, 2005 To what extent is religion involved in coping? To what extent are you a religious or spiritual person? How often do you attend religious services? How often do you pray? Characteristic Not involved Very involved Not/slightly Very ≤1/month Several times/ week Rarely/never Several times/ day (n = 1,514) (n = 15,095) (n = 2,449) (n = 8,805) (n = 6,168) (n = 3,474) (n = 910) (n = 7,679) Age (years) (mean [SD]) 45.0 (9.6) 46.2 (9.4) 43.5 (8.8) 46.6 (9.3) 44.4 (8.7) 47.6 (9.8) 44.5 (9.4) 47.3 (9.5) Body mass index (≥30 kg/m2), % 35 35 33 35 35 39 32 35 Education (≤12 years), % 16 9 14 9 11 11 10 11 Smoking (≥10 pack- years), % 16 12 17 12 16 10 21 13 Alcohol (≥4 drinks/ week), % 14 7 13 7 12 3 17 7 Vigorous exercise (≥3 hours/week), % 21 21 20 21 20 19 23 21 Walking (≥3 hours/ week), % 26 29 26 29 27 30 24 30 DASH dietary pattern (quintile 5) (high), % 19 18 18 19 18 17 20 19 Neighborhood SES (quintile 5) (high), % 22 17 21 17 20 12 26 14 Perceived stress (above median), % 53 48 56 45 51 48 53 49 Myocardial infarction, % 1 1 1 1 1 1 1 1 Stroke, % 1 1 1 1 1 1 1 1 Type 2 diabetes, % 6 6 6 6 6 6 5 6 To what extent is religion involved in coping? To what extent are you a religious or spiritual person? How often do you attend religious services? How often do you pray? Characteristic Not involved Very involved Not/slightly Very ≤1/month Several times/ week Rarely/never Several times/ day (n = 1,514) (n = 15,095) (n = 2,449) (n = 8,805) (n = 6,168) (n = 3,474) (n = 910) (n = 7,679) Age (years) (mean [SD]) 45.0 (9.6) 46.2 (9.4) 43.5 (8.8) 46.6 (9.3) 44.4 (8.7) 47.6 (9.8) 44.5 (9.4) 47.3 (9.5) Body mass index (≥30 kg/m2), % 35 35 33 35 35 39 32 35 Education (≤12 years), % 16 9 14 9 11 11 10 11 Smoking (≥10 pack- years), % 16 12 17 12 16 10 21 13 Alcohol (≥4 drinks/ week), % 14 7 13 7 12 3 17 7 Vigorous exercise (≥3 hours/week), % 21 21 20 21 20 19 23 21 Walking (≥3 hours/ week), % 26 29 26 29 27 30 24 30 DASH dietary pattern (quintile 5) (high), % 19 18 18 19 18 17 20 19 Neighborhood SES (quintile 5) (high), % 22 17 21 17 20 12 26 14 Perceived stress (above median), % 53 48 56 45 51 48 53 49 Myocardial infarction, % 1 1 1 1 1 1 1 1 Stroke, % 1 1 1 1 1 1 1 1 Type 2 diabetes, % 6 6 6 6 6 6 5 6 Values are standardized to the 2005 age distribution. SES socioeconomic status. View Large Table 1 Baseline characteristics according to lower and upper categories of religion/spirituality questions, Black Women’s Health Study, 2005 To what extent is religion involved in coping? To what extent are you a religious or spiritual person? How often do you attend religious services? How often do you pray? Characteristic Not involved Very involved Not/slightly Very ≤1/month Several times/ week Rarely/never Several times/ day (n = 1,514) (n = 15,095) (n = 2,449) (n = 8,805) (n = 6,168) (n = 3,474) (n = 910) (n = 7,679) Age (years) (mean [SD]) 45.0 (9.6) 46.2 (9.4) 43.5 (8.8) 46.6 (9.3) 44.4 (8.7) 47.6 (9.8) 44.5 (9.4) 47.3 (9.5) Body mass index (≥30 kg/m2), % 35 35 33 35 35 39 32 35 Education (≤12 years), % 16 9 14 9 11 11 10 11 Smoking (≥10 pack- years), % 16 12 17 12 16 10 21 13 Alcohol (≥4 drinks/ week), % 14 7 13 7 12 3 17 7 Vigorous exercise (≥3 hours/week), % 21 21 20 21 20 19 23 21 Walking (≥3 hours/ week), % 26 29 26 29 27 30 24 30 DASH dietary pattern (quintile 5) (high), % 19 18 18 19 18 17 20 19 Neighborhood SES (quintile 5) (high), % 22 17 21 17 20 12 26 14 Perceived stress (above median), % 53 48 56 45 51 48 53 49 Myocardial infarction, % 1 1 1 1 1 1 1 1 Stroke, % 1 1 1 1 1 1 1 1 Type 2 diabetes, % 6 6 6 6 6 6 5 6 To what extent is religion involved in coping? To what extent are you a religious or spiritual person? How often do you attend religious services? How often do you pray? Characteristic Not involved Very involved Not/slightly Very ≤1/month Several times/ week Rarely/never Several times/ day (n = 1,514) (n = 15,095) (n = 2,449) (n = 8,805) (n = 6,168) (n = 3,474) (n = 910) (n = 7,679) Age (years) (mean [SD]) 45.0 (9.6) 46.2 (9.4) 43.5 (8.8) 46.6 (9.3) 44.4 (8.7) 47.6 (9.8) 44.5 (9.4) 47.3 (9.5) Body mass index (≥30 kg/m2), % 35 35 33 35 35 39 32 35 Education (≤12 years), % 16 9 14 9 11 11 10 11 Smoking (≥10 pack- years), % 16 12 17 12 16 10 21 13 Alcohol (≥4 drinks/ week), % 14 7 13 7 12 3 17 7 Vigorous exercise (≥3 hours/week), % 21 21 20 21 20 19 23 21 Walking (≥3 hours/ week), % 26 29 26 29 27 30 24 30 DASH dietary pattern (quintile 5) (high), % 19 18 18 19 18 17 20 19 Neighborhood SES (quintile 5) (high), % 22 17 21 17 20 12 26 14 Perceived stress (above median), % 53 48 56 45 51 48 53 49 Myocardial infarction, % 1 1 1 1 1 1 1 1 Stroke, % 1 1 1 1 1 1 1 1 Type 2 diabetes, % 6 6 6 6 6 6 5 6 Values are standardized to the 2005 age distribution. SES socioeconomic status. View Large Over the follow-up period, 5,194 incident cases of hypertension occurred during 137,590 person-years, with a mean duration of follow-up of 6.5 years (SD = 2.4; range = 1–8). Findings on the relation of R/S variables to hypertension incidence are presented in Table 2. R/S coping was not associated with risk of hypertension in the age-adjusted model (Model 1) or in the multivariable model that adjusted for all covariates except the other R/S variables (Model 2). However, after further adjustment for the other R/S variables (Model 3), the IRR for the highest level of R/S coping compared with none was 0.87 (95% CI: 0.75, 1.00; p trend = .02). We repeated the analysis adjusting for individual R/S measures one at time and found that “prayer” produced the largest change in the effect estimate. Table 2 Self-reported religious coping, religiosity/spirituality, service attendance, and prayer in relation to incident hypertension in the Black Women’s Health Study, 2005–2013 Exposure Cases Person-years Incidence Rate Ratio (95% CI) Model 1a Model 2b Model 3c Religious or spiritual coping  Not involved 337 9,543 Reference Reference Reference  Somewhat involved 1,240 32,205 1.08 (0.96, 1.22) 1.05 (0.93, 1.18) 0.94 (0.82, 1.08)  Very involved 3,617 95,842 1.01 (0.90, 1.13) 0.98 (0.88, 1.10) 0.87 (0.75, 1.00)  p trend .26 .18 .02 Religious/spiritual person  Not/slightly 512 15,700 Reference Reference Reference  Moderately 2,593 65,946 1.11 (1.01, 1.22) 1.08 (0.98, 1.19) 1.05 (0.93, 1.17)  Very 2,089 55,944 1.02 (0.93, 1.13) 1.01 (0.92, 1.12) 1.01 (0.89, 1.15)  p trend .31 .40 .65 Service attendance  Never 446 13,895 0.88 (0.80, 0.98) 0.89 (0.80, 0.99) 0.91 (0.82, 1.02)  ≤1/month 1,426 39,231 Reference Reference Reference  2–3 times/month 1,026 26,148 1.03 (0.95, 1.12) 1.04 (0.96, 1.13) 1.05 (0.96, 1.14)  1/week 1,405 36,505 0.98 (0.91, 1.05) 0.99 (0.92, 1.07) 1.01 (0.93, 1.09)  Several times/week 891 21,810 1.01 (0.93, 1.10) 0.95 (0.88, 1.04) 0.99 (0.90, 1.09)  p trend .22 .85 .53 Frequency of prayer  Rarely/Never 170 5,869 0.89 (0.75, 1.07) 0.94 (0.78, 1.13) 0.96 (0.79, 1.16)  ≤1/week 375 11,927 Reference Reference Reference  Several times/week 1,027 26,619 1.18 (1.05, 1.33) 1.16 (1.03, 1.31) 1.19 (1.05, 1.34)  1–2 times/day 1,713 45,113 1.11 (0.99, 1.24) 1.10 (0.99, 1.24) 1.14 (1.01, 1.29)  Several times/day 1,909 48,062 1.10 (0.98, 1.23) 1.06 (0.95, 1.19) 1.12 (0.99, 1.27)  p trend .12 .71 .42 Exposure Cases Person-years Incidence Rate Ratio (95% CI) Model 1a Model 2b Model 3c Religious or spiritual coping  Not involved 337 9,543 Reference Reference Reference  Somewhat involved 1,240 32,205 1.08 (0.96, 1.22) 1.05 (0.93, 1.18) 0.94 (0.82, 1.08)  Very involved 3,617 95,842 1.01 (0.90, 1.13) 0.98 (0.88, 1.10) 0.87 (0.75, 1.00)  p trend .26 .18 .02 Religious/spiritual person  Not/slightly 512 15,700 Reference Reference Reference  Moderately 2,593 65,946 1.11 (1.01, 1.22) 1.08 (0.98, 1.19) 1.05 (0.93, 1.17)  Very 2,089 55,944 1.02 (0.93, 1.13) 1.01 (0.92, 1.12) 1.01 (0.89, 1.15)  p trend .31 .40 .65 Service attendance  Never 446 13,895 0.88 (0.80, 0.98) 0.89 (0.80, 0.99) 0.91 (0.82, 1.02)  ≤1/month 1,426 39,231 Reference Reference Reference  2–3 times/month 1,026 26,148 1.03 (0.95, 1.12) 1.04 (0.96, 1.13) 1.05 (0.96, 1.14)  1/week 1,405 36,505 0.98 (0.91, 1.05) 0.99 (0.92, 1.07) 1.01 (0.93, 1.09)  Several times/week 891 21,810 1.01 (0.93, 1.10) 0.95 (0.88, 1.04) 0.99 (0.90, 1.09)  p trend .22 .85 .53 Frequency of prayer  Rarely/Never 170 5,869 0.89 (0.75, 1.07) 0.94 (0.78, 1.13) 0.96 (0.79, 1.16)  ≤1/week 375 11,927 Reference Reference Reference  Several times/week 1,027 26,619 1.18 (1.05, 1.33) 1.16 (1.03, 1.31) 1.19 (1.05, 1.34)  1–2 times/day 1,713 45,113 1.11 (0.99, 1.24) 1.10 (0.99, 1.24) 1.14 (1.01, 1.29)  Several times/day 1,909 48,062 1.10 (0.98, 1.23) 1.06 (0.95, 1.19) 1.12 (0.99, 1.27)  p trend .12 .71 .42 CI confidence interval. aModel 1 adjusts for age and questionnaire cycle. bModel 2 adjusts for model 1 variables and BMI, neighborhood SES, vigorous exercise, walking for exercise, DASH diet, education, smoking, alcohol consumption, perceived stress, geographic region, MI, stroke, and diabetes. cModel 3 adjusts for model 2 variables plus simultaneous adjustment for other r/s questions. View Large Table 2 Self-reported religious coping, religiosity/spirituality, service attendance, and prayer in relation to incident hypertension in the Black Women’s Health Study, 2005–2013 Exposure Cases Person-years Incidence Rate Ratio (95% CI) Model 1a Model 2b Model 3c Religious or spiritual coping  Not involved 337 9,543 Reference Reference Reference  Somewhat involved 1,240 32,205 1.08 (0.96, 1.22) 1.05 (0.93, 1.18) 0.94 (0.82, 1.08)  Very involved 3,617 95,842 1.01 (0.90, 1.13) 0.98 (0.88, 1.10) 0.87 (0.75, 1.00)  p trend .26 .18 .02 Religious/spiritual person  Not/slightly 512 15,700 Reference Reference Reference  Moderately 2,593 65,946 1.11 (1.01, 1.22) 1.08 (0.98, 1.19) 1.05 (0.93, 1.17)  Very 2,089 55,944 1.02 (0.93, 1.13) 1.01 (0.92, 1.12) 1.01 (0.89, 1.15)  p trend .31 .40 .65 Service attendance  Never 446 13,895 0.88 (0.80, 0.98) 0.89 (0.80, 0.99) 0.91 (0.82, 1.02)  ≤1/month 1,426 39,231 Reference Reference Reference  2–3 times/month 1,026 26,148 1.03 (0.95, 1.12) 1.04 (0.96, 1.13) 1.05 (0.96, 1.14)  1/week 1,405 36,505 0.98 (0.91, 1.05) 0.99 (0.92, 1.07) 1.01 (0.93, 1.09)  Several times/week 891 21,810 1.01 (0.93, 1.10) 0.95 (0.88, 1.04) 0.99 (0.90, 1.09)  p trend .22 .85 .53 Frequency of prayer  Rarely/Never 170 5,869 0.89 (0.75, 1.07) 0.94 (0.78, 1.13) 0.96 (0.79, 1.16)  ≤1/week 375 11,927 Reference Reference Reference  Several times/week 1,027 26,619 1.18 (1.05, 1.33) 1.16 (1.03, 1.31) 1.19 (1.05, 1.34)  1–2 times/day 1,713 45,113 1.11 (0.99, 1.24) 1.10 (0.99, 1.24) 1.14 (1.01, 1.29)  Several times/day 1,909 48,062 1.10 (0.98, 1.23) 1.06 (0.95, 1.19) 1.12 (0.99, 1.27)  p trend .12 .71 .42 Exposure Cases Person-years Incidence Rate Ratio (95% CI) Model 1a Model 2b Model 3c Religious or spiritual coping  Not involved 337 9,543 Reference Reference Reference  Somewhat involved 1,240 32,205 1.08 (0.96, 1.22) 1.05 (0.93, 1.18) 0.94 (0.82, 1.08)  Very involved 3,617 95,842 1.01 (0.90, 1.13) 0.98 (0.88, 1.10) 0.87 (0.75, 1.00)  p trend .26 .18 .02 Religious/spiritual person  Not/slightly 512 15,700 Reference Reference Reference  Moderately 2,593 65,946 1.11 (1.01, 1.22) 1.08 (0.98, 1.19) 1.05 (0.93, 1.17)  Very 2,089 55,944 1.02 (0.93, 1.13) 1.01 (0.92, 1.12) 1.01 (0.89, 1.15)  p trend .31 .40 .65 Service attendance  Never 446 13,895 0.88 (0.80, 0.98) 0.89 (0.80, 0.99) 0.91 (0.82, 1.02)  ≤1/month 1,426 39,231 Reference Reference Reference  2–3 times/month 1,026 26,148 1.03 (0.95, 1.12) 1.04 (0.96, 1.13) 1.05 (0.96, 1.14)  1/week 1,405 36,505 0.98 (0.91, 1.05) 0.99 (0.92, 1.07) 1.01 (0.93, 1.09)  Several times/week 891 21,810 1.01 (0.93, 1.10) 0.95 (0.88, 1.04) 0.99 (0.90, 1.09)  p trend .22 .85 .53 Frequency of prayer  Rarely/Never 170 5,869 0.89 (0.75, 1.07) 0.94 (0.78, 1.13) 0.96 (0.79, 1.16)  ≤1/week 375 11,927 Reference Reference Reference  Several times/week 1,027 26,619 1.18 (1.05, 1.33) 1.16 (1.03, 1.31) 1.19 (1.05, 1.34)  1–2 times/day 1,713 45,113 1.11 (0.99, 1.24) 1.10 (0.99, 1.24) 1.14 (1.01, 1.29)  Several times/day 1,909 48,062 1.10 (0.98, 1.23) 1.06 (0.95, 1.19) 1.12 (0.99, 1.27)  p trend .12 .71 .42 CI confidence interval. aModel 1 adjusts for age and questionnaire cycle. bModel 2 adjusts for model 1 variables and BMI, neighborhood SES, vigorous exercise, walking for exercise, DASH diet, education, smoking, alcohol consumption, perceived stress, geographic region, MI, stroke, and diabetes. cModel 3 adjusts for model 2 variables plus simultaneous adjustment for other r/s questions. View Large Self-identification as a religious/spiritual person and higher levels of attendance at religious services were not appreciably associated with incidence of hypertension (Table 2), although those who reported never attending religious services had a slightly lower incidence of hypertension (IRR: 0.91; 95% CI: 0.82, 1.02). Praying more frequently was associated with a small increased incidence of hypertension (IRR: 1.14; 95% CI: 1.01, 1.29 for prayer one to two times a day, and IRR: 1.12; 95% CI: 0.99, 1.27 for several times a day). Using the variance components method [54], we assessed the presence of collinearity between the R/S variables. Based on a condition index cut-off of ≥ 3.0, we found that only the top four indices exceeded the threshold value, with the largest taking a value of 6.2. Despite this, none of the variables in the model loaded onto the same indices, providing little evidence for collinearity between our R/S variables. To explore the relationship between R/S coping and risk of hypertension further, we assessed associations within tertiles of perceived stress scores. As seen in Table 3, the inverse association between R/S coping and hypertension incidence was strongest among women with the highest level of perceived stress (IRR: 0.77; 95% CI: 0.61, 0.98; p for interaction: .01). Table 3 R/S coping in relation to incidence of hypertension according to perceived stress in the Black Women’s Health Study (2005–2013) Religious or spiritual coping Perceived Stress Scale Score Tertile 1 (low) Tertile 2 Tertile 3 (high) Cases HR (95% CI) Cases HR (95% CI) Cases HR (95% CI) Not involved 84 Reference 108 Reference 129 Reference Somewhat involved 360 1.32 (1.00, 1.72) 414 0.89 (0.70, 1.12) 435 0.77 (0.61, 0.97) Very involved 1374 1.13 (0.86, 1.50) 1120 0.81 (0.63, 1.03) 1032 0.77 (0.61, 0.98) p trend .51 .06 .19 p interaction .01 Religious or spiritual coping Perceived Stress Scale Score Tertile 1 (low) Tertile 2 Tertile 3 (high) Cases HR (95% CI) Cases HR (95% CI) Cases HR (95% CI) Not involved 84 Reference 108 Reference 129 Reference Somewhat involved 360 1.32 (1.00, 1.72) 414 0.89 (0.70, 1.12) 435 0.77 (0.61, 0.97) Very involved 1374 1.13 (0.86, 1.50) 1120 0.81 (0.63, 1.03) 1032 0.77 (0.61, 0.98) p trend .51 .06 .19 p interaction .01 CI confidence interval; HR hazard ratio. IRRs are adjusted for age, questionnaire cycle, BMI, neighborhood SES, vigorous exercise, walking for exercise, DASH diet, education, pack years of smoking, alcohol consumption, geographic region, prevalent MI, stroke, diabetes, and simultaneous adjustment for other r/s questions. View Large Table 3 R/S coping in relation to incidence of hypertension according to perceived stress in the Black Women’s Health Study (2005–2013) Religious or spiritual coping Perceived Stress Scale Score Tertile 1 (low) Tertile 2 Tertile 3 (high) Cases HR (95% CI) Cases HR (95% CI) Cases HR (95% CI) Not involved 84 Reference 108 Reference 129 Reference Somewhat involved 360 1.32 (1.00, 1.72) 414 0.89 (0.70, 1.12) 435 0.77 (0.61, 0.97) Very involved 1374 1.13 (0.86, 1.50) 1120 0.81 (0.63, 1.03) 1032 0.77 (0.61, 0.98) p trend .51 .06 .19 p interaction .01 Religious or spiritual coping Perceived Stress Scale Score Tertile 1 (low) Tertile 2 Tertile 3 (high) Cases HR (95% CI) Cases HR (95% CI) Cases HR (95% CI) Not involved 84 Reference 108 Reference 129 Reference Somewhat involved 360 1.32 (1.00, 1.72) 414 0.89 (0.70, 1.12) 435 0.77 (0.61, 0.97) Very involved 1374 1.13 (0.86, 1.50) 1120 0.81 (0.63, 1.03) 1032 0.77 (0.61, 0.98) p trend .51 .06 .19 p interaction .01 CI confidence interval; HR hazard ratio. IRRs are adjusted for age, questionnaire cycle, BMI, neighborhood SES, vigorous exercise, walking for exercise, DASH diet, education, pack years of smoking, alcohol consumption, geographic region, prevalent MI, stroke, diabetes, and simultaneous adjustment for other r/s questions. View Large Discussion In this first national prospective study investigating the relationship of religion and spirituality (R/S) to incidence of hypertension in African American women, we found that the extent to which a woman reported that her religion was involved in dealing with stressful situations (i.e., positive coping), was associated with a 13% reduction in the risk of hypertension. The association only became apparent after control for other R/S measures, in particular, frequency of prayer; women who reported praying more frequently were estimated to have an increased incidence of hypertension. The observed inverse association of R/S coping with hypertension incidence was strongest among women reporting the highest levels of stress, lending support to our hypothesis that R/S coping serves as a buffer against the adverse impacts of stress. Self-identification as a religious/spiritual person and higher levels of attendance at religious services were not associated with hypertension incidence. While there have been no previous U.S. studies of R/S coping in relation to incident hypertension, three cross-sectional studies demonstrated an association between R/S coping and lower blood pressure among white female college alumni [41], black female University students [42], and black (but not white) North Carolina adults enrolled in the Duke Biobehavioral Investigation of Hypertension study [43]. Our results also converge with findings from other prospective studies that have found a protective clinical effect of R/S coping in relation to other conditions. These include studies documenting association between R/S coping and weight management among cardiac rehabilitation patients [55]; glycemic control among diabetics [56]; and mortality following surgery [30]. In contrast to our findings, three prospective studies on R/S coping reported null results [37, 57, 58]. R/S coping was not associated with self-reported hypertension in a prospective analysis of Japanese adults [37]; nor was it associated with all-cause mortality in adult women from the Women’s Health Initiative (WHI)[57] or survival patterns among U.S. hemodialysis patients [58]. These studies each differed in terms of demographics, cultural approach to religion and spirituality, and importantly, how coping was assessed. The Krause study focused on a specific stressor—death of a loved one—and found that belief in a good afterlife, rather than seeking help from a deity (religious coping), influenced hypertension risk [37]. The study by Schnall and colleagues assessed the “level of strength and comfort provided by religion” rather than directly measuring coping [57]. Spinale et al. measured “religious feelings as coping mechanisms” specific to those experiencing kidney disease (“ . . . in adjusting to my kidney disease/failure . . .”) [58]. On the other hand, negative religious coping, which reflects an insecure relationship with God [59], has consistently been found to be associated with poorer mental and physical health [60]. We did not collect measures of negative coping in the BWHS. Our results provide preliminary evidence that positive R/S coping meaningfully reduces stress and has a tangible impact on risk of a critically important clinical outcome—hypertension. This growing body of research warrants further investigation to understand the underlying biological mechanisms—such as epigenetic regulation or functional dynamics—through which R/S coping may operate to affect a wide range of clinical outcomes. Shifting the focus to more functional aspects of R/S as it relates to biologically resonant and disease-relevant exposures, such as stress [61], may prove more successful in elucidating these biological mechanisms and pathways [33]. To date, few prospective studies have investigated such functional dimensions of R/S. Rather, prior literature has largely focused on general R/S service attendance, due to its consistent (but poorly understood) relationship to decreased risk of mortality [62, 63]. Frequent prayer was associated with a somewhat increased risk of hypertension. Existing prospective literature is mixed on the relationship between prayer and hypertension or blood pressure, with studies showing more frequent prayer to be associated with both increased risk of hypertension [38], and decreased risk of high blood pressure [64]. Despite the prospective design of our study, it is possible that aspects of religiosity and spirituality could already have been manifested prior to our analysis. In addition, over 30 percent of hypertensive adults are unaware that they have the condition [65], and such persons may experience mild symptoms such as headaches should their blood pressure enter the “severe” range (i.e., ≥180/≥120 mmHg) [66]. Experiencing even mild symptoms may prompt religiously inclined individuals to pray rather than seek medical evaluation. In our analysis, neither attending religious services nor identity as a religious or spiritual person was associated with a reduced risk of hypertension. As with prayer, the literature on attendance is mixed with studies reporting increased weekly attendance to be associated with a lower odds of hypertension [39, 40], while another found no association [38]. Spirituality was associated with a significantly increased diastolic blood pressure, and a nonsignificant increase in hypertension [38]. As one would expect, the women excluded from our analysis who had already been diagnosed with hypertension were older and more often affected by obesity and diabetes than those who were unaffected by hypertension at the start of our follow-up in 2005. On the other hand, the differences in the religious practices of the excluded and included were relatively small, which we take as some reassurance that our analytic population was not markedly different in religious practices from those excluded. Our investigation was limited by the fact that participants in the BWHS under-represent the approximately 15% of U.S. African American women from the same birth cohorts who did not graduate from high school [67]. In addition, 44% of BWHS participants had graduated college which over-represents that educational stratum among black women nationally. Our analyses were also limited to the four dimensions of R/S assessed. Further, religious coping was assessed using a single item from the BMMRS, which may not capture the full complexity of this construct. Although we had to rely on measures of R/S at a single point in time, we recognize that individuals’ R/S beliefs and practices are dynamic and fluid. There also could have been residual confounding as well as other unmeasured confounders including family history of hypertension. In addition, the inclusion of women only in our study limits the generalizability of the findings. Despite these limitations, however, our study has a number of strengths. This study is the first prospective study of R/S coping in relationship to incident hypertension conducted within a large, established U.S. cohort. The BWHS does represent the 85% of U.S. African American women who have completed 12 or more years of education, and BWHS participants reside in all regions of the continental USA. Our data on R/S were collected before the occurrence of incident hypertension, thereby clarifying the temporality of associations. Our validation of self-reported hypertension indicated a high level of accuracy. The methodological literature also indicates a high degree of accuracy of self-reported physician diagnosed hypertension [68, 69]. The robustness of data available to us also allowed us to control for a large number of known risk factors for hypertension, collinearity between variables of interest, as well as other potential confounders. The results from our study also raise clinically important questions with respect to providing patient-centered primary care for individuals at risk of hypertension. A key component of patient-centered care is helping patients develop the confidence and skills needed to achieve optimal health [12]. In this regard, it is important for clinicians serving the African American community to recognize that African American patients rely on their religion/spirituality to cope with stressful life situations more often than patients from other communities [36]. Indeed, an awareness of the role of spirituality in patients’ lives, and in particular how it might bear on their health and healthcare decision-making, should be seen as an essential component of providing patient-centered primary care regardless of the cultural community that patients come from [70]. However, this is even more the case when serving a patient population known to be highly religious, and the results of our study may well pertain to other highly religious populations (e.g., Hispanics/Latinos). Concrete examples of how the role of spirituality in patients’ lives could be useful in tailoring care might include referring religious or spiritual patients experiencing stressful life situations to psychotherapists equipped to provide culturally-competent [71], spiritually integrated psychotherapy [72]. Although taking a spiritual history has become a standard component of comprehensive palliative care [73, 74], this has not yet become part of routine primary care, despite recommendations from some that taking a spiritual history become a part of providing quality, patient-centered primary care [75]. Creative, culturally-tailored interventions that draw on African American spirituality as a resource for resiliency to combat the adverse impact of stress on health may also provide new opportunities to reduce racial disparities in the burden of hypertension. Acknowledgments This paper was a collaborative effort. Each author had access to the data, contributed to the analysis and interpretation of the data and writing of the manuscript. The idea for assessing this topic came from Drs. Shields, Palmer, Rosenberg, and Cozier. The design of the data collection came from Drs. Rosenberg, Palmer, and Cozier. Each author has approved the final version and will take public responsibility. This manuscript and the data have not been published, either in whole or in part, nor is it being considered elsewhere. We gratefully acknowledge the contributions of all BWHS participants. We also thank Ken Pargament for his helpful comments on an earlier draft of this paper. 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Journal

Annals of Behavioral MedicineOxford University Press

Published: Nov 12, 2018

References

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