Is there a religious factor in health?

J o u r n a l of Religion and Health, Vol. 26, No. 1, Spring 1987

Is T h e r e a R e l i g i o u s F a c t o r in H e a l t h ? J E F F R E Y S. LEVIN and PRESTON L. SCHILLER A B S T R A C T : This paper reviews epidemiologic studies employing religion as a n independent construct, and finds t h a t most epidemiologists have a n extremely limited appreciation of religion. After a historical overview of empirical religion and health research, some theoretical considerations are offered, followed by clarification of several operational and methodological issues. Next, well over 200 studies are reviewed from nine health-related areas: cardiovascular disease, hypertension and stroke, colitis and enteritis, general h e a l t h status, general mortality, cancer of the uterine corpus and cervix, all other non-uterine cancers, morbidity and mortality in the clergy, and cancer in India. Finally, an agenda for further research is proposed.

Historical background It has been nearly 150 years since Benjamin Travers remarked t h a t he had never seen a case of cancer of the penis in a Jew, 1 and almost t h a t long since Rigoni-Stern first observed t h a t Catholic nuns in Verona, Italy, were at significant risk for breast cancer yet significantly protected against uterine cancer. 2 Half a century later, in 1891, John Shaw Billings first considered religious affiliation to be a potential factor in the study of differential rates of morbidity and mortality among social groups2 Three-quarters of a century have now elapsed since William Osler broached the issue of a "faith t h a t heals, TM a sentiment recently echoed by Frank, ~ and nearly sixty years have passed since Paulsen reviewed "religious healing" movements in JAMA.8 Over a quarter of a century has gone by since White expounded upon the interactions between the psyche and the soma, 7 and it has been more t h a n a decade since several influential researchers attempted to stimulate research into the effects of illness behavior on religious beliefs 8 and the relations between religious institution attendance and mortality2 Finally, nearly another decade has elapsed since Vaux attempted to promote research into the "intersection of religion and health behavior in order to better delineate their contribution to American life ''1~ and since Vanderpool asserted the "therapeutic significance" of religion. 1~ Although m a n y epidemiologists continue to collect some information about subjects' religious preference, background, or practice as part of their inquirJeffrey S. Levin, M.P.H., is with the Division of Sociomedical Sciences, D e p a r t m e n t of Preventive Medicine and Community Health, at The University of Texas Medical Branch in Galveston, Texas. Preston L. Schiller, Ph.D., is with the RDI: Research/Development/Information, 6502 106th Ave., N.E., Kirkland, WA 98033. The authors wish to t h a n k Dr. C. David J e n k i n s for his comments on a n earlier draft of this manuscript. 9

9 1987 Institute of Religionand Health

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Journal of Religion and Health

ies, next to nothing has been accomplished in terms of the refinement of concepts or measures. Nor has there been much in the way of a synthesis of findings which might establish this area as one for legitimate epidemiologic research in the m a n n e r in which earlier advocates had proposed. And yet the b e l i e f - - o r s u s p i c i o n - - t h a t some relationship might be operant here seems to h a u n t the minds of scholars. Indeed, this issue has formed part of the folklore of discussion on the fringes of the research community ever since before the t u r n of the century when scientists first took note of the relative risk of certain forms of cancer among Jews. 12 In this paper we shall review empirical findings plus m a n y of the more influential theoretical discussions in this vitally important y e t - - p a r a d o x i c a l l y - - n e g l e c t e d area. Sociologists have long considered the relation between religion and other social factors to be of considerable importance in understanding complex social phenomena. Religion, treated as belief, background (socialization), practice (cultic ritual), or commitment, has been commonly assumed to be both a reflection of a group's general situation (or indicator thereof) relative to other groups in a society, as well as a phenomenon with important consequences in the daily lives of adherents and those close to them. Typically, researchers in these areas have tended to focus on the extremes of the spectrum of religious commitment, studying either the consequences of exaggerated "religiosity" or the consequences of a lack of religious commitment or orientation. An over-comm i t m e n t to a religious outlook or way of life as manifest in millenarian groups or religious communal groups may have serious consequences for t h a t group in re its relations with the social world beyond the boundaries of t h a t group, especially when t h a t social world is undergoing rapid social and technological change. Such an over-commitment, especially when coupled with harsh socialization and buttressed by communal norms, may make it impossible for one raised within those confines to live outside of such a community. On the other hand, social scientists from Durkheim forward have demonstrated the consequences for both the individual and the social collectivity of a weakening or lack of religious commitments. 13 Researchers focusing upon this aspect of the impact of religion upon society have cited the association of weak or no religious commitment with anomie, marginalization, secularization (as in the early twentieth century when there was a flow of former ministers and ministers' children into sociology and social work), and differential rates of deviance--especially suicide. One of the chronic problems readers of this literature encounter is the difficulty in establishing just what is conceptually meant by constructs such as religious affiliation and religious institution attendance. It is rarely clear just what underlying processes are actually being reflected: the effects of early childhood socialization (that is, parental religious affiliation) or a rather passively accepted social convention (for example, "Well, my family went to the such-and-such church and so do I"); or, in terms of frequency of attendance, it is rarely distinguished whether what is being measured is a normative pattern within a religion (for example, weekly communion), a normative social convention (for example, rural people attend church more frequently t h a n do urban people), an indicator of behavioral tendencies (for example, "She attends

Jeffrey S. Levin and Preston L. Schiller

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church religiously") or of personality organization, a voluntary associational activity TM (explained by a set of social factors similar to, say, going to an Elks' Club meeting), or, as has recently been suggested, ~5among other things, a desire to please one's m o t h e r - - o r an interaction between these and other factors. However, it is true of all epidemiologic indices from occupational status to ponderosity t h a t the same index may well reflect different combinations of things in different individuals. Among social scientists, sociologists are not alone in considering religion to be a salient influence upon h u m a n affairs. Psychologists, too, have provided conceptual clarification of the nature of religiosity. In considering the impact of religion upon the beliefs, attitudes, and behavior of individuals, the term "religiosity" is often used synonymously with r e l i g i o u s n e s s ; in other words, religion is viewed as an innate characteristic of individual persons. In this vein, yet influenced by sociologists such as Durkheim, Gordon Allport has posited two types of religiosity: "institutionalized" and "interiorized" religious outlooks which "have opposite effects in the personality. '''~ Institutionalized religiosity is a collectively-experienced and objectively-observable phenomenon, and can be characterized by patterns of behavior such as affiliating with a particular denomination or frequently attending church. Interiorized religiosity is an individually-experienced and subjectively-interpreted phenomenon, and can be characterized by cognitive and affective traits, such as "faith" or the particular salient beliefs held by an individual.

Theoretical considerations

How then might one characterize the relation between religion and health? The convergence of healing and the supernatural has been taken for granted, in m a n y quarters, for millenia, '7 and much discussion of a positive relationship between religious participation and health status has begun to appear recently in professional discourse on health. Several writers have argued from the perspective of "holistic health" t h a t religiosity is promotive of health and "wellness. ''I8 Other scholars, apparently sympathetic to the notion of a positive relationship between religion and h e a l t h - - b u t tempered by their schooling in the social sciences--have been more modest in their proposals, and have even pointed to possibly deleterious effects t h a t r e l i g i o n - - o r an exaggeration of religious p r a c t i c e - - m i g h t have upon health. ~9 Kaplan, for instance, has noted t h a t "religious behavior can also be a risk factor" for stress-related diseases such as coronary heart disease or hypertension, in t h a t certain religious adherences or traditions may create or lead to high levels of guilt or anxiety in their practitioners owing to the imposition of excessive affective demands. S~ Overall, there seem to be several salient dimensions to the discussion of religion and health, including: 1. The convergence of religious practices, rituals, and beliefs and "scientifically"-validated techniques and therapeutic systems:


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a. the oft-discussed identity of the physical examination and the religious "laying-on-of-hands"; b. discussions of the much-documented "placebo"--and "nocebo"~l--effects (that it is the belief in the power of the healer, or the self, that counts most); c. prayer as autogenic therapy and/or the converse; and, d. the syncretization of folk beliefs of disease etiology and scientific explanations of disease into a new, operative overall belief system. 22 2. The healthfulness of many habits, practices, or taboos dictated by religious prescription or proscription: a. the post-hoc wisdom of religious codes (such as the Mosaic code) as public health codes (avoidance of pork lessens trichinosis, circumcision lessens cervical cancer, etc.); b. abstention from stimulants (as among Mormons) and meat (as among Seventh-Day Adventists) leads to a longer and healthier life; and, c. holistic health techniques derived from religious practices (for example, superconscious or "transcendental" meditation) may lead to certain healthrelated outcomes. 23 3. The inclusion of questions about religious affiliation and behavior in national health surveys may indicate that some scientists believe religion influences health care utilization: 24 more than thirty published health services studies have included religion variables, 25although the weight of evidence seems to show that "[r]eligious preference does not predict the use of health services. ''~ This dimension of the religion and health discussion has been influenced by the work of Zborowski 27 and Zola ~ on cultural differences in the experience of pain, as well as by the work of Mechanic 29on the relation between illness behavior and religion. 4. The so-called "medical church" metaphor: Pitts and Schiller, 3~ Levin, ~ Szasz, 32 Mendelsohn, ~3 and several others 3~ have noted similarities between the institution of religion and the institution of medicine: surgery as initiation, hospitals as churches, medication as communion, suffering as sacrifice, 3~anaesthetization as ecstasy, the physician-patient transaction as informed by lay acknowledgement of"apostolic" authority, 36etc. 5. The relations between clergy and religious institutions and medical practice: a growing literature purports that the clergy may have a positive effect upon the therapeutic process and should be considered as necessary adjuncts to medical, hospital, community mental health, and public health practice. 37

Operational and methodological issues W h i l e the p h e n o m e n o n of religion r e p r e s e n t s a conceptually u n d e r d e v e l o p e d a r e a in epidemiology, some n a r r o w a r e a s h a v e been r e a s o n a b l y studied. Several studies h a v e reported on religious differences in responses to psychological b a t t e r i e s (such as the MMPI), 38 on the p s y c h o p a t h o l o g y of t h e a d h e r e n t s of m a j o r d e n o m i n a t i o n s , 39 and on the m e n t a l h e a l t h of m e m b e r s of p a r t i c u l a r religious sects (for example, Spencer on the J e h o v a h ' s Witnesses 4~ a n d B e n y o n


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on Negro religious cult adherents), 41 of the clergy, 4~ and of immigrants. 43 In addition, chronic disease has been studied in several religious groups (such as Mormons, Seventh-Day Adventists, Parsis, and Jews). Those epidemiologic studies which have treated religion as an independent construct have tended, for the most part, to measure religion only as a matter of either affiliation or attendance. However, both of these constructs are inherently limited as indicators of religion, since each corresponds to Allport's "institutionalized" category of religiosity. Furthermore, the usual measures of each of these constructs suffer from certain methodological flaws threatening their validity. R e l i g i o u s affiliation. Religious affiliation, as an operational construct, has confined itself almost exclusively to either Protestant versus Catholic versus Jewish or Jewish versus Gentile distinctions and, thus, may be little more than a proxy for socioeconomic status (SES) or ethnicity. Furthermore, this religious affiliation literature is characterized by a lack of sensitivity to the heterogeneous nature of Protestant Christianity. This could be merely a result of having to aggregate religious affiliation owing to small sample sizes, or it could indicate that religion variables are often included in epidemiologic surveys only to permit verification of religious homogeneity among subgroups in case-control studies, after which religion is not used in subsequent analyses." In other words, it may be wrong to expect methodological sophistication in a field in which religion has made only rare 45"guest appearances." Nevertheless, important distinctions among Protestants must be made. The work of King and associates 4~is unique in consistently attending to the multidenominationality of Protestantism. H u l k a ~7 and others 48 have already focused some of their work upon adherents of sectarian Christian traditions, and there is now information available on the health of Amish, Hutterites (including L-leut, S-leut, and D-leut varieties), Mormons (both LDS and RLDS varieties), and Seventh-Day Adventists, especially the latter two groups. However, epidemiologists have thus far overlooked Quakers, Jehovah's Witnesses, Christian Scientists, Mennonites, the prominent black denominations and established sects, and the "new religions ''~9 imported from the East. Protestants, though, hardly have a monopoly on heterogeneity. Jews can be expanded into Reform, Conservative, and Orthodox classifications, as well as Reconstructionist and even Messianic, and, ethnically, can be separated into Ashkenazim, Sephardim, and Mizrahi Sephardim (Oriental Jews), an imporrant distinction if one intends to investigate potential hereditary explanations for significant religious factors2 ~ And Roman Catholics might be considered heterogeneous according to European nation of ancestry, and perhaps even generationally (that is, whether their religious formation was pre- or postVatican II). F i n a l l y - - a n d this comment is relevant to all religious g r o u p s - - p e r h a p s degree of faith, pattern of practice (for example, charismatic versus non-charismatic), or theological orientation (for example, fundamentalist versus conservative versus liberal) might represent more fruitful indicators of individual differences in religiosity--"interiorized" r e l i g i o s i t y - - t h a n the typical indicators of "institutionalized" religiosity--namely, churchgoing behavior and

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affiliational membership. For example, classifying Protestants into Wesleyan or Calvinist groups might reveal significant differences in health outcomes. The relevant hypothesis here could be that health status might vary by whether one believes in free will or has a much more deterministic understanding of life; indeed, such a distinction is not unlike that of the health locus of control construct?' In any event, these sorts of issues may be critical because, if significant health-related differences do exist between religious groups, then a trichotomous (Protestant versus Catholic versus Jewish) or dichotomous (Jewish versus Gentile) independent variable could possibly suppress these differences2 2 Religious institution attendance. Religious institution attendance is an operational construct made popular chiefly in the past fifteen years or so, perhaps because it may be viewed as intertwined with issues of social support or socialization effects, and perhaps because of the curiosity stimulated by the seminal work of George Comstock and his associates in Washington County, Maryland2 3 In this literature of over two dozen articles, 54 the independent variable is usually dichotomized. However, if health status variations by attendance actually exist, one critical distinction m a y be between weekly attenders and those who go to church even more often. A "once per week or more" versus "less than once weekly" comparison (the conventional approach) obscures this discrimination by assuming homogeneity for Sunday-only Protestants and those attending Wednesday night prayer services and by making no distinctions between Catholics by frequency of going to Mass (for example, weekly versus daily communicants). In light of the possible therapeutic role of "healing charisma" in prayer services ~5 and the lower mortality among clergymen regardless of denomination, ~6the issue of "hyperattendance" ought to be given serious consideration. On the other hand, very recent findings reported by Levin and Markides in the J o u r n a l of Religion a n d Health 57 suggest that a statistically insignificant association between attendance and chronic disease prevalence is likely to remain insignificant regardless of the particular configuration of the categories of the attendance variable. In defense of those who have employed dichotomous variables, a religious attendance item may initially have included five or six response categories, yet small cell sizes may have necessitated its collapse in order to conduct meaningful analyses. The work of Comstock and Partridge ~8 provides a good example of this sort of analytically-necessitated collapsing of a church attendance variable. Like the affiliation literature, the attendance literature is actually a few, separate clusters of articles organized about particular disease entities or health-related topics. Much of this literature has focused upon heart disease and has been reviewed on a few occasions, 59 most notably by Kaplan, G~who provided an especially thoughtful, theoretically-oriented discussion of the relevance of religious beliefs to the work of epidemiologists. This paper represented a major contribution, especially since Hinkle, several years earlier, had cautioned epidemiologists about drawing conclusions regarding a potential religion/heart disease relationship until further "intellectual interchanges" had occurred21


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Review of empirical findings While it is impossible to claim that what follows is an absolutely complete listing of every single use of a religion variable in epidemiologic r e s e a r c h - - i n fact, we located a number of additional studies in foreign-language journals which were inaccessible to us 62 or available only as pre-publication abstracts in English-language journals63--this literature has never before been reviewed. In fact, it is very likely that most epidemiologists--and most religion scholars as w e l l - - a r e entirely unaware that such an enormous body of data even exists. Therefore, statistically significant (as well as significant statistically insignificant) findings of differences between categories of religion variables for various health-related outcomes are reviewed, although, admittedly, a few pages can hardly do justice to well over 200 very dissimilar articles. This discussion is organized around the several divergent health-related areas into which these studies seem to fall. These include cardiovascular disease, hypertension and stroke, colitis and enteritis, general health status, general mortality, cancer of the uterine corpus and cervix, all other non-uterine cancers, morbidity and mortality in the clergy, and cancer in India. This review does not include studies in psychiatric epidemiology. Cardiovascular disease. Over two dozen published studies have examined religious differences in cardiovascular morbidity and mortality. This literature includes several measures of religion (affiliation, attendance, Jewish ethnicity, parental affiliation and attendance, importance of religion, religious homogeneity of marriage, and self-rated religiosity), and a wide variety of dependent variables, including mortality because of circulatory system diseases; arteriosclerotic heart disease (ASHD) and arteriosclerotic and degenerative heart disease (ASDHD) incidence and mortality; myocardial infarction (MI) incidence and mortality; coronary artery disease (CAD) prevalence; atherosclerosis prevalence; coronary heart disease (CHD) incidence, prevalence, and mortality; cardiovascular reaction; rheumatic, non-rheumatic, and hypertensive heart disease mortality; angina pectoris (AP) incidence; aortic calcification prevalence; chronic endocarditis mortality; and the incidences of various risk factors including high cholesterol, lipids, caloric and fat intake, and triglycerides. Clearly, this area of empirical religion and health investigation alone would benefit greatly from a thorough review on a scale much more comprehensive than is possible here. With regard to MI incidence, Jews are at increased risk relative to Gentiles, ~4 with Ashkenazim and non-Mizrahi Sephardim especially at risk; 65 Protestants are at greater risk than Catholics; 6~ and "degree of religiosity" is inversely associated with MI incidence, ~7 as is being born of a religiously homogeneous marriage28 For AP, Gentiles seem to be protected with respect to Jews29 Incidence of CHD is greater among both Jews 7~ and children of mothers with high SES religious affiliations and fathers with low SES affiliations, 71 and is more prevalent among Jews than among Catholics, 72 Protestants, 73 and Gentiles as a wholeY 4 It is also more prevalent in those Japanese-Americans who acknowledge the "importance of religion. ''7~ CHD mortality is less common among Mormons 76 and Seventh-Day Adventists 77

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than among the general population, and mortality due to MI is less common among Mizrahi Sephardim TM than among other Jews. Atherosclerosis, aortic calcification, and CAD are more prevalent in Jews than in Catholics, who are protected against ASHD relative to Protestants. 79 Mortality due to ASHD, ASDHD, chronic endocarditis, and myocardial degeneration does not differ greatly by affiliation, 8~but regular religious attenders are significantly protected. 81 For mortality due to circulatory system diseases in general, Gentiles s2 and the Amish 83seem to be particularly protected. High serum cholesterol is more common in Jews than in Gentiles, ~4 although Italian Catholics have been found to have higher cholesterols than New York Jews, ~5 despite the fact that CHD mortality is lower in Catholics than in Jews. Hypercholesterolemia is also highly incident among members of the Reformed Church, ~6 but quite uncommon in Seventh-Day Adventists, ~ especially those who maintain strictly vegetarian dietary regimes2 8 Finally, a classic study by King and Funkenstein s9 found an association between a norepinephrine-like cardiovascular reaction (as measured by a ballistocardiograph) and both regular religious attendance and high religious conventionalism. However, in the past quarter century, no other researchers have followed up on these intriguing findings. Hypertension and stroke. If a single statement were to be proffered characterizing the literature on religion and blood pressure, it would be that high religiosity (whether frequent attendance or high self-rating) is associated with lower pressures. However, this statement cannot be generalized, because these findings are inconclusive and require qualification. In an interesting study in North Carolina, 9~ frequent religious attendance was associated with lower systolic blood pressure, but this relationship was largely (though not totally) explained by Quetelet Index, or body mass. Scotch's influential study of Zulus ~1found an association between attendance and normotension, but only in rural areas, and between church membership and normotension, but only among urban-dwelling females. However, the implications of this study are unclear, as is the denominational meaning of the label "Christian" applied to the study's subjects. In a study of Catholic immigrants to Toledo, Ohio, ~ anomie was associated inversely with religious attendance and positively with blood pressure, suggesting "a prophylactic effect of religion on blood pressure." Several studies have revealed a number of protected and corresponding higher-risk populations, including Buddhists with respect to non-Buddhists, ~8 the unaffiliated with respect to the affiliated, 94 the less religious with respect to the highly religious, 9~ Yemenite Jews with respect to Gentiles, 96 Protestant females with respect to non-Protestant females, 97 and Seventh-Day Adventists with respect to both non-Adventists 98 and Mormons2 9 Finally, in a sample of Cleveland lawyers, Gentiles were at greater risk than Jews for a family history of stroke. '| In sum, there appears to be a tendency for the more strictly delimited group to have less pathology than the heterogeneous "all other" comparison group, although exceptions are evident. Colitis and enteritis. This tiny portion of the epidemiologic spectrum merits a separate section because of its consistent attention to religion as well as the


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consistency of findings throughout the years. This literature consists, primarily, of contrasts between Jews and Gentiles, and reports on the incidence and prevalence of both ulcerative colitis and regional enteritis. Briefly, Jews are at increased risk for both diseases, TM a finding replicated in a variety of settings in the United States, 1~ the United Kingdom, 1~ and Israel. TM Among Jews, Ashkenazim and non-Mizrahi Sephardim are at heightened risk relative to Mizrahim. ~~ Furthermore, this relative Jewish risk withstands controlling for military officership, residence, and occupation; '~ SES, marital status, and birthplace; 1~ and for life stress, number of residences, birth order, and a whole host of endogenous psychological factors.'~ General health status. This catch-all category includes indicators of health and illness along with miscellaneous causes of morbidity excluding cancer, heart disease, hypertension, and colitis and enteritis. This collection of studies is divisible into three categories: those dealing with illness symptoms, with (self-)ratings of health, and with various causes of acute and chronic morbidity. A handful of interesting studies has explored differences in symptomatology by categories of several religion variables, including affiliation, church membership, attendance, and religious beliefs. On the Cornell Medical Index, Jews score higher than Gentiles even after controlling for educational attainment, 1~ and other studies confirm an inverse association between attendance and symptomatology, ~1~whether physical, mental, or social, and regardless of affiliation. H' One recent study presents strong evidence of an inverse relationship between pain level in cancer patients and church membership, attendance, belief in the importance of church, and feelings of closeness to God. 1~2 The few studies of religion and self-rated health are limited to samples of elderly subjects, in which infrequent religious attendance may be more an indicator of activity limitation than of declining religiosity. H3 Significant findings include associations between satisfaction with health and the strength of one's religious affiliation; H' between religious attendance and self-rated health status in Mexican Americans; H5 and between self-rated religiosity ("How religious would you say you are?") and health status, but only among Anglos. H~ Finally, several religion and health studies have focused upon a number of miscellaneous causes of morbidity. Regular religious attendance has been associated with a low prevalence of trichomoniasis, H7 a low tuberculosis total case rate over five years, H8and a low sensitivity to large reactions to tuberculin skin tests. 1'9 Affiliation with the Seventh-Day Adventist Church offers protection against a history of persistent cough, sinusitis, pneumonia, and influenza, ~2~and increases the risk of hay fever, backache, pain, and asthma, ~ while affiliation with Mormonism decreases the risk of early menopause. '~2 History of an X-ray or radium t r e a t m e n t is most common in Jews, then Protestants, then Catholics, in both sexes; and the annual incidence of a diagnostic X-ray exam is highest in Jews of both sexes2 23 Finally, a couple of recent studies have determined that Gentiles exceed J e w s in frequent m o u t h w a s h use, '24 and that coffee-drinking Adventists have higher cancer rates than

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their non-coffee-drinking compatriots. 1'~5 However, in the former study, the religious differences were not linked to differences in morbidity, and, in the latter study, the morbidity differences were not linked to religious differences. General mortality. This category includes all causes of mortality except cancer, heart disease, and hypertension. The independent religion variables used in these studies include affiliation, attendance, church membership, length of affiliation, and self-rated religiosity, and this extremely large class of healthrelated outcomes probably warrants a separate review article. Religious affiliation studies typically contrast members and non-members of a particular faith across several causes of death. Most of these studies focus upon Seventh-Day Adventists, who are at less risk than non-Adventists for overall mortality '2~ and for mortality due to respiratory diseases 127 such as tuberculosis, emphysema, bronchitis, asthma, and pneumonia. 128 Strictly vegetarian Adventists have an even more favorable mortality profile. '29 This pattern of decreased mortality in Protestant sects making strong behavioral demands on their constituent members holds also for the Amish 13~as well as for the Reorganized Latter-Day Saints. TM Finally, Jews are protected relative to Gentiles for overall mortality, 132infant mortality, and mortality due to accidents, liver disease, respiratory diseases, tuberculosis, pneumonia, and syphilis, and are at higher risk for mortality due to digestive system diseases, diabetes mellitus, and diseases of the central nervous system.133 Religious attendance has been associated with a decreased risk of mortality due to emphysema and cirrhosis of the liver, TM but it has been suggested t h a t these findings are explained by educational attainment. '35 Infrequent maternal attendance has been associated with high neonatal mortality, ~38but this is not a consistent finding. '~7 Frequent attendance has also been associated with decreased overall mortality, a finding which persists even after controlling for age and various risk factors. '38 Finally, church membership has been very strongly associated with lower mortality, in both sexes and at all ages, 1~9 although a very recent study identified high self-rated religiosity as a significant risk factor. '4~ Cancer of the uterine corpus and cervix. This topic represents by far the largest set of studies to be reviewed h e r e - - i n excess of fifty published articles. However, most of these contrast Jewish and Gentile cervical cancer incidence, the subject of nearly all of the early studies mentioned briefly at the outset of this paper. In sum, religious groups characterized by greater behavioral conformity and/or doctrinal orthodoxy have less uterine cancer morbidity and mortality. However, t h a t this signifies an actual "religious" factor is highly uncertain, considering the propensity of some groups, such as Jews ~4~ and Mormons, '42 to engage in cervical cancer preventive behaviors (for example, use of diaphragms, circumcision of males, later age of first intercourse, and fewer sexual partners). No doubt, this explains the low rates of mortality due to such cancers in Mormons, ~4~L- and S-leut Hutterites, 14~ regular religious attenders, ~4~and Jews. '~6 A similar pattern is found for uterine cancer morbidity, where a large number of studies identifies Jews as strongly protected for cancer of both corpus and cervix. '47 Within Judaism, Ashkenazim are at heightened risk, ~48 as


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are Conservative and Orthodox Jews, synogogue members, Passover non-observers, and children of Reform Jewish fathers. 149 Other protected groups include Mormons,159 Hutterites, TM Seventh-Day Adventists,~52 the Amish, ~53 Muslims, TM Parsis, 1~ and frequently churchgoing Christians. 1~6 Non-uterine cancer. Around forty published studies of religion and nonuterine cancer have appeared through the years, with somewhat more attention paid to mortality than to incidence. As with m a n y of the other healthrelated topics already reviewed, Jews and members of behaviorally strict denominations have a more favorable profile, although there are exceptions. With respect to cancer incidence, Mormons, ~7 Seventh-Day Adventists, ~58 and Hindus 15~are significantly protected overall and at many sites. Jews are at increased risk overall, and are either protected ~6~ or at risk ~61 with respect to Gentiles, depending upon the sites in question. In examining cancer mortality, this pattern reappears. While results vary across specific sites, significant protection overall is found among Hutterites, ~62 the Amish, 1~3 Mormons, TM the RLDS, ~6~ and Seventh-Day Adventists. '66 Jewish overall cancer mortality falls somewhere below t h a t of Catholics and above t h a t of Protestants, ~67 although there is some evidence to the contrary. 1~8 Although such all-sites cancer mortality rates are amalgamations, they may provide a more accurate picture t h a n examination of individual cancer sites, where there are Jewish deficits at some sites and Gentile deficits at others. However, the possibility of misclassification of the primary cancer site may render these findings less t h a n reliable. Nevertheless, some of the more persistent findings include a deficit in lung cancer mortality among Jewish males and Gentile females, '69 and an increased Jewish risk of leukemia ~7~and breast cancer. 17~ Morbidity and mortality in the clergy. While these studies overlap the previous topical sub-areas, these articles are being reviewed separately because of the homogeneous nature of their independent religion variables. In each of these investigations, health-related differences are explored across categories of variables such as clerical status, religious order, Mormon lay priesthood level, denomination of Protestant ministry, and missionary experience. These studies are classifiable into three types: comparisons within Mormonism, comparisons within the Protestant clergy, and Catholic-oriented investigations comparing nuns, priests, monks, and missionaries to laypeople and to one another. Much of the pioneering work in this area was reviewed by Fecher ~72 and King ~73about fifteen years ago. All of the Mormon studies pertain to cancer, whether incidence, ~7' mortality, 175 or risk factors. "~ Mormon lay priesthood level (ranging from the Aaronic priesthood and moving upward through the Melchizedek elder, the Melchizedek Seventy, and the Melchizedek High Priesthood) is inversely related to morbidity and mortality. In other words, the higher the authority of the priesthood, the healthier is the Mormon. The subjects of the Protestant clergy studies include Episcopal, Anglican, L u t h e r a n Church of America, United Presbyterian, Lutheran-Missouri Synod, and American Baptist Convention ministers, in various combinations, and contrasted with respect to a variety of specific causes of mortality. 177 Most of

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the groups are variously at-risk or protected, depending upon the disease in question. The Catholic studies are of four types. Several studies show nuns to be protected against cervical cancer, I~8 and variously better- or worse-off than laypeople with respect to various specific causes of mortality. 17~ Second, two studies of priests 18~ paint for them a favorable mortality picture overall, which is perhaps attributable, say the authors, to high role satisfactions. A third set of studies TM examines the health of monks, who appear to be healthier than non-monks, although there are distinct differences between orders, such as between Trappists and Benedictines, owing in part to diet. Fourth, a study published sixty years ago ls~ found that overall mortality was higher among missionaries than among laypeople, as was increased mortality due to a variety of causes. However, this may be due to a heightened exposure to communicable diseases in and around mission settings. Finally, one very recent study fits into none of the above categories. The mortality patterns of a cohort of Japanese Rinzai Zen Buddhist priests were studied over a quarter of a century283 The subjects were significantly protected overall and for mortality due to tuberculosis, cerebrovascular disease, hypertension, pneumonia, bronchitis, peptic ulcer, cirrhosis of the liver, and cancer of the lung and other respiratory organs. Cancer in India. The final health-related topic to be reviewed is cancer in India. As with the previous topic, these studies could have been considered earlier, but are instead grouped together here by virtue of their comprising a rather homogeneous set of study populations and findings. These studies fall into three groups on the basis of authorship and chronology: three seminal articles by Nath and Grewal from nearly half a century ago, TM a follow-up of these conducted by Khanolkar in 1950, ~85 and the excellent recent work of Jussawalla and his associates in Bombay. ~s6 Taken as a whole, these studies compare Muslims, Christians, Buddhists, Jains, Parsis, Sikhs, and Hindus across almost every cancer site imaginable at three points in time. Two findings stand out. First, P a r s i s - - a n extant group of Z o r o a s t r i a n s - - h a v e the most favorable health profile. They are a highly cohesive, inbred, late-marrying population observing favorable dietary and sexual norms. Second, Muslims have low rates of cancer of the penis and female reproductive organs. This is most likely consequent to their practice of male circumcision2 ~7

Discussion

The most immediately striking characteristic of this literature is the relative preponderance of investigations using a religious affiliation variable versus those addressing religious institution attendance. This is especially curious since it is when addressing the issue of attendance that hypotheses regarding the nature of a relationship between religion and health could be readily informed by creative speculation in currently popular topics. While differences in health status by affiliation may well be explained by sociodemographic or


21

behavioral traits or by the cultic components (rituals, myths, symbols) inherent in particular religions, the explanation of differences in health by frequency of churchgoing behavior (after controlling for the usual array of sociodemographic background variables as well as for affiliation) may require engaging such popular issues as social support, the effectiveness of coping behavior, the probability or intensity of behavioral adherence, health locus of control, the increasing "medicalization" of nonmedical social institutions, 188 and the therapeutic correlates of self-help and self-care. '89 One might also consider Turner's thought-provoking comments suggesting that the "rationalisation of the body i s . . . a significant dimension of the secularisation of society," in his outstanding reconciliation of medical sociology and the sociology of religion. 1~~ Other notable aspects of this literature include: 1. Cross-cultural investigation was recommended in 1948 in Kennaway's superb review of uterine cancer, 191 yet has been kept alive primarily by the work of Jussawalla and his associates in India, ~'92who have examined health status across numerous religious traditions. For the most part, though, medical researchers interested in religion have tended toward an ethnocentric emphasis upon the United States, with occasional forays into Israel. Perhaps with the advent of interest in this field among the growing ranks of "applied medical sociologists '~9~ (prominent among the ranks of those who call themselves social epidemiotogists) and "culturally-sensitive" (that is, nonethnocentric) public health professionals, this situation m a y soon improve. 2. Many of these epidemiologic investigations--especially those concentrating on Jewish/Gentile differences--are set in New York City. No doubt, this is due, in large part, to the high concentration of Jews (and epidemiologic investigators) living there. 3. All of the studies concerned only with women focus upon their reproductive systems and sexual behavior (and that of their sexual partners)294 Surely, in this enlightened age, the empirical study of religion and health in women can go beyond these apparently redundant examinations of their nether organs. 4. Not one single study has focused exclusively upon black Americans. The black experience in the United States is a unique and critically important phenomenon. 195Controlling for race among Christians does black religion no justice, nor do studies of Africans, such as Scotch's classic but very limited work on Zulus over twenty years ago. ~96 Since blacks are also present in substantial numbers in a variety of white sects, it is surprising that the plethora of epidemiologic studies of Mormons, for example, has so far overlooked the fascihating black Mormon population297 Furthermore, with the growing popularity of basing community medicine interventions in black churches, 1~ one would expect the beginnings of an accumulation of data addressing the association between health status and the black experience in religion, but this has not yet occurred. 5. There appears to be a relative lack of interest in the investigation of religion as a factor in health behavior, whether illness behavior (excepting the work of Zborowski ~99 and Mechanic), ~~176preventive behavior (excepting

22


Hendershot's article in 1983 ~~ and the work of Suchman2~ or sick-role behavior (excepting O'Brien's article in 1982). 203 Since religious denominations vary in the extent to which their adherents perceive (deviant) behaviors to be illnesses, 2~ it is unfortunate indeed t h a t this aspect of the religion/health dialogue has been ignored. However, judging from the recency of the Hendershot and O'Brien studies, this trend is apparently changing. 6. Finally, there appears to be a widespread disinterest in studying religion and health directly. That is, in most of these studies, religion was only tangentially related to the m a t t e r at h a n d - - j u s t another variable to " c r u n c h " - - and "religiosity," per se, left undefined, was not the primary focus of the investigation. This is especially apparent in those studies examining religious differences in cervical cancer. 2~

An agenda for the empirical study of religious factors in health Despite the lack of precision in specifying just what it is about religion t h a t one is measuring and just what effect or effects it has on health, the notion of an influence of religion upon health animates both public discussion and the research imagination to the extent t h a t one's voice may safely be added to the previously heard pleas for more attention to this area. It would appear that at this moment the following items must head the agenda for empirical inquiry into religion and health: 1. This field calls for the development of a paradigm hypothesizing how and why religion affects health, and guiding research in this area. Philipp, a physician, has noted t h a t the "solution of religious beliefs is the core of h u m a n stability, ''2~ and even the usually staid British Medical Journal editorialized not too long ago (perhaps with tongue in cheek) on the impact of spiritual "rebirth" upon life expectancy. 2~ Given all this, along with the recent willingness of some scholars to propose actual direct therapeutic sequelae of being religious, 2~ certain questions arise: Is it the socialization process concomitant to a religious orientation which is promotive of healing? Does religion as a force for social control canalize otherwise harmful behavior into healthful catharsis? Or is it t h a t religious commitment is identical to other forms of enhancement of social support and solidarity? Finally, is it the structure of religion as a social institution t h a t affects health (that is, the comforting belief t h a t one is among "God's people" and, therefore, according to the Prophet Isaiah, t h a t "no weapon t h a t is formed against thee shall prosper")? 2~ Or, conversely, is it the resemblance of health and its attendant institutions to a medicalized religious institution 21~(~ la the medical church thesis)? 2. Empirical studies informed by such a paradigm should be launched. One would hope they do more t h a n merely measure religious institution attendance dichotomously or religious affiliation in the same old limited manners. What is particularly called for is the use of indicators of Allport's "interiorized" religiosity. The literatures of the sociology and psychology of religion are replete with measures of religion far broader in scope t h a n just affiliation and attendance. Glock and Stark's 21~ scale addressing the five dimensions of religi-


23

osity or McCready and Greeley's 212 "ultimate values" typology are good examples, and these multidimensional measures certainly could serve epidemiologists as useful and meaningful variables. However, as Gorsuch recently warned, 213 the use of scales in empirical investigations of religion introduces all sorts of measurement dilemmas in need of resolution. Such scales might only add confusion, unless accompanied by paradigmatic-based selection of variables and psychometrically-based selection of measures. Clearly, as readers of the Journal of Religion and Health appreciate, religion is a most complex issue; and if epidemiologists aim to uncover meaningful relationships between religion and health, then they simply must engage these epistemological issues before proceeding. 3. The nature of religion as an independent variable must be explored. Is it a proxy for socioeconomic status? for ethnicity? for personality formation? for attitudes toward adversity? for symptomatology? or, as the findings regarding Mormons and Seventh-Day Adventists suggest, for some set of behavioral factors? In a similar vein, if it were possible to control for every confounding, intervening, and effect-modifying variable ostensibly related to religion, and a "religious factor ''~4 still remained, what would be the nature of this factor? Would it be some outcome of the belief system? ~'5 of religious practice? of interaction within the cult fellowship? o r - - a s some of the religious themselves might c l a i m - - o f some supernatural influence? 4. Finally, there is the altogether different issue of what might be appropriate health-related independent variables to be employed with religion as a dependent variable. Here the crucial query is whether or not religion is better off conceived as an intervening or dependent variable. For example, an inverse association between religion and health in the elderly may, in fact, indicate that older people who get sick subsequently become more religious. Alternatively, a positive association between religion and health might obtain because people who are in poor health may, ipso facto, be social isolates unable to participate in religion, or, if not isolated, may be restricted in their activity owing to limitations placed upon them by their infirmity} ~6notwithstanding monks, who lead socially isolated lives, as well as the many bedridden elderly who listen to religious radio or watch religious television all day. Or, following certain scholarly traditions, religion m a y be only a reflection of political economy ~17 and, thus, not itself a true independent or dependent variable. Consequently, studies of the relation between health status and changes in religious affiliation or attendance may be more to the point than just using inherited denominational markers or routinized patterns of religious behavior, in that the convert m a y be seen as taking his or her religion more "seriously" than the person maintaining inherited religious ties.

Summary

In this paper, we have demonstrated that consideration of religious factors has been a major focus of epidemiologic research for going on two centuries. Well over two hundred empirical studies in epidemiology have included religion

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variables and have obtained positive findings associating religion and health. Nonetheless, statements such as, "There has been a paucity of studies examining the epidemiological effects of religion and health ''218 are unfortunately commonplace, and most epidemiologists would probably be more than mildly surprised to be confronted with such a positively enormous body of data of which they were previously unaware. Indeed, the epidemiology of religious factors, if considered as a single entity, may actually be larger than any content-specific subdiscipline in the entire field. Therefore, in attempting both to synthesize findings and to organize this field of research, we pursued several tasks. First, we traced empirical investigation into religion and health back to several studies in the early nineteenth century. Second, we considered some theoretical issues, in particular the possibility that there are several salient dimensions to discussion of religion and health. Third, we moved from the epistemological level of the conceptual to that of the operational, treating several major methodological issues. Fourth, we summarized the empirical findings associating religion and health, reviewing studies from several health-related areas. Fifth, we offered a critical discussion of several notable aspects of this literature. Finally, we set an agenda for the study of religious factors in health. In closing, the unspoken, underlying thesis tested in the studies we reviewed - - t h e notion that religious faith might reduce fear and provide comfort when stress o c c u r s - - m a y be related to consideration of the central nervous system as a mediator of health and illness. Perhaps the nervous system represents the locus of a mechanism by which religious faith or religious beliefs (not merely overt affiliational or behavioral tendencies) promotes well-being. 2'9 This would account for why some studies show religious adherents to have less hypertension and also lower rates of some cancers. Perhaps with this or something similar in mind, a recent article proposed the new field of "neurotheology. ''22~Of course, the operation of things religious must never be exclusively treated so reductionistically. As it is axiomatic in many quarters that God intervenes in the affairs of men, then the effects of God's healing grace should be demonstrable, even if many disbelieving scientists might debate the source. Finally, just because religion is a humanistic, imponderable issue does not render it "soft." If religious factors are indeed associated with h e a l t h - - a n d we have presented overwhelming evidence suggestive of t h i s - - p e r h a p s the next question researchers should ask is, "Why?" Up to now, empirical research into religion and health has consisted primarily of epidemiologic surveys, accompanied by very little biomedical research. It would appear that such a line of investigation is strongly indicated by the publication of well over two hundred primarily non-biomedical studies. In other words, if the empirical study of religion and health represents "soft science," it is not because it cannot necessarily be "hardened." If the creation of research teams comprising epidemiologists, psychiatrists, psychoneuroimmunologists, physicians, sociologists and psychologists of religion, church historians, theologians, and historians of religions seems utopian, one should recall Jerome Frank's assertion that the "world is full of phenomena that cannot be explained by our present cosmologies. '2~1 Perhaps such interdisciplinary consultation will be required to conduct the sorts of studies that can determine the nature of the relationship be-


25

tween religion and health. If there truly is a religious factor in health, then this is where the "experiment" should begin.

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17. Merrill, G.G., "Health, Healing and Religion," Maryland State Medical J., 1981, 30, 12, 4547. 18. Wilson, R.W., "Religiosity and Health," Health Values, 1978, 2, 144-146; Schlosser, C., "Health in a New Key," Health Values, 1977, 6, 258-261; Harmon, Y., "The Relationship Between Religiosity and Health," Health Values, 1985, 9, 323-25. 19. MacDonald, C.B., and Luckett, J.B., "Religious Affiliation and Psychiatric Diagnoses," J. Scientific Study of Religion, 1983, 22, 15-37; Cavenar, J.O., and Spaulding, J., "Depressive Disorders and Religious Conversions," J. Nervous and Mental Disease, 1977, 165, 209-212; Eick, J.J.; Williams, R.E.; and Kaye, J.J., "Incidental Roetgenographic Demonstration of Multiple Metallic Foreign Bodies with an Unusual Etiology," J. Louisiana State Medical Society, 1982, 134, 10-11. 20. Kaplan, B.H., "A Note on Religious Beliefs and Coronary Heart Disease," J. South Carolina Medical Association, 1976, Feb. (supplement), 60-64. 21. Kissel, P., and Barrucand, D., Placebos etEffet--Placebos en Mddicine. Paris, Mason, 1964. 22. Primack, A., "Cultural Background and Medical Care," Urban Health, 1984, 13, 22-28. 23. Barnard, D., "Religion and Religious Studies in Health Care and Health Education," J. Allied Health, 1983, 12, 192-201. 24. NORC, National Data Program for the Social Sciences. Codebook for the Spring 1972 General Social Survey. Chicago, University of Chicago Press, 1972. 25. Levin, J.S., and Schiller, P.L., "Religious Factors in Health Services Utilization: A Review of the Literature and New Findings from an Appalachian Self-Care Program," presented at the Medical Sociology sessions of the Annual Meeting of the Southwestern Social Science Association, Houston, March 1985. 26. Maurana, C.A.; Eichhorn, R.L.; and Lonnquist, L.E., The Use of Health Services: Indices and Correlates, A Research Bibliography, 1981, NCHSR 82-65. Washington, D.C., U.S. Government Printing Office, 1981. 27. Zborowski, M., "Cultural Components in Responses to Pain," J. Social Issues, 1952, 8, 16-30. 28. Zola, I.K., "Culture and Symptoms,"Amer. SociologicalReview, 1966, 31,615-630. 29. Mechanic, D., "Religion, Religiosity, and Illness Behavior," Human Organization, 1963, 22, 202 -208. 30. Pitts, J.R., and Schiller, P.L., "Marginality, Structural Differentiation, and Professionalization," presented at the Annual Meeting of the American Sociological Association, 1978. 31. Levin, J.S., "Medicalization and Religion," M.P.H. Thesis, University of North Carolina School of Public Health, 1983. 32. Szasz, T.S., The Theology of Medicine. Baton Rouge, Louisiana State University Press, 1977; "The Theology of Therapy: The Breach of the First Amendment through the Medicalization of Morals," N Y U Review of Law and Social Change, 1975, 5, 127-135; The Manufacture of Madness. New York, Harper & Row, 1970. 33. Mendelsohn, R.S., Confessions of a Medical Heretic. New York, Warren Books, 1979; MalePractice: How Doctors Manipulate Women. Chicago, Contemporary Books, 1981. 34. Wooten, B. (The Baroness of Abinger), "The Law, the Doctor, and the Deviant," British Med. J., 1963, 2, 197; Freidson, E., Professional Dominance. Chicago, Aldine Publishing Company, 1970; Neaman, J.S., Suggestion of the Devil. Garden City, N.Y., Anchor Books, 1975; Kittrie, N.N., The Right to Be Different. Baltimore, The Johns Hopkins Press, 1971; Rotenberg, M., Damnation and Deviance. New York, The Free Press, 1978. 35. Sevensky, R.L., "Religion and Illness: An Outline of Their Relationship," Southern Medical J. 1981, 74, 745-750. 36. Balint, M., TheDoctor, His Patient, and the Illness. New York, International University Press, 1957. 37. Levin, J.S., "The Role of the Black Church in Community Medicine," J. National Medical Association, 1984, 76, 477-483. 38. Gr•esch• S.J.• and Davis• w.E.• ``Psychiatric Patients• Religi•n and MMPI Resp•nses•'• J. Clinical Psychology, 1977, 33, 168-171; Bohrnstedt, G.W., Borgata, E.F., and Evans, R.R., "Religious Affiliation, Religiosity, and MMPI Scores," J. Scientific Study of Religion, 1968, 7, 255-258. 39. Srole, L., and Langner, T., "Religious Origin." In Srole, L.; Langner, T.S.; Michael, S.T.; Opler, M.K.; and Rennie, T.A., eds., Mental Health in the Metropolis: The Midtown Manhattan Study. New York, McGraw-Hill, 1962, pp. 300-324; Carr, L.G., and Hauser, W.J., "Class, Religious Participation, and Psychiatric Symptomatology," International J. Social Psychiatry, 1981, 27, 133-142. 40. Spencer, J., "The Mental Health of Jehovah's Witnesses," British J. Psychiatry, 1975, 126, 556-559.


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41. Jones, R.J., "A Comparative Study of Religious Cult Behavior among Negroes with Special Reference to Emotional Group Conditioning." Washington, D.C., Howard University Graduate School, 1939. 42. McAllister, R.J., and Vander Veldt, A.J., "Factors in Mental Illness among Hospitalized Clergy," J. Nervous and Mental Diseases, 1961, 132, 80-88; "Psychiatric Illness in Hospitalized Catholic Religious," Amer. J. Psychiatry, 1965,121,881-884; McAllister, R.J., "The Mental Health of Members of Religious Communities," International Psychiatric Clinics, 1969, 211-222; Vander Veldt, A.J., and McAllister, R.J., "Psychiatric Illness in Hospitalized Clergy: Alcoholism," Quarterly J. Stud. Alcohol, 1962, 23, 124-130; Moore, T.V., "Insanity in Priests and Religious. Part 1. The Rate of Insanity in Priests and Religious," Ecclesiastical Review, 1936, Nov., 485-498. 43. Roberts, B.H., and Myers, J.K., "Religion, National Origin, Immigration, and Mental Illness," Amer. J. Psychiatry, 1954, 110, 759-764. 44. Strayhorn, G., "Transcutaneous Electrical Nerve Stimulation and Postoperative Use of Narcotic Analgesics," J. National Medical Association, 1983, 75, 811-816; Winkelstein, W.; Stenchever, M.A.; and Lilienfeld, A.M., "Occurrence of Pregnancy, Abortion, and Artificial Menopause among Women with Coronary Artery Disease," J. Chronic Disease, 1958, 7, 273-286; Helsing, K.J., and Szklo, M., "Mortality after Bereavement," Amer. J. Epidemiology, 1981, 114, 41 - 52; Boas, E.P., and Epstein, F.H., "Prevalence of Manifest Atherosclerosis in a Working Population: Preliminary Report," AMA Archives of Internal Medicine, 1954, 94, 94-101; Brown, R.C., and Ritzmann, L., "Some Factors Associated with Absence of Heart Disease in Persons Aged 65 or Older," J. Amer. Geriatric Society, 1967, 15, 239-250; Billings, A.G., and Moos, R.H., "The Role of Coping Resources in Attenuating the Stress of Life Events," J. Behavioral Medicine, 1981, 4, 139-157; Gaines, M.J.; Wilson, M.A.; Redican, K.J.; and Baffi, C.R., "The Effects of Cult Membership on the Health Status of Adults and Children, Health Values, 1984, 8, 2, 13-17. 45. Jenkins, C.D., "Psychologic and Social Precursors of Coronary Disease," New England J. Medicine, 1971, 284, 244-255,307-317. 46. King, H., "Clerical Mortality Patterns of the Anglican Communion," Social Biology, 1971, 18, 164-177; "Health in the Medical and Other Learned Professions," J. Chronic Disease, 1970, 23,257-281; "What We Do and Don't Know About the Health of the Clergymen." In Nix, J.T., and Fecher, C.J., eds., Stamina for the Apostolate, Washington, D.C., Center for Applied Research in the Apostolate, 1970, pp. 98-116; King, H., and Bailar, J.C., "The Health of the Clergy: A Review of Demographic Literature," Demography, 1969, 6, 27-43; "Mortality among Lutheran Clergymen," Milbank Memorial Fund Quarterly, 1968, 46, 527-548; King, H., and Locke, F.B., "American White Protestant Clergy as a Low-Risk Population for Mortality Research," J. National Cancer Institute, 1980, 65, 1115-1124; King, H.; Zafros, G.; and Haas, R., "Further Inquiry into Protestant Clerical Mortality Patterns," J. Biosocial Science, 1975, 7, 243-254; Locke, F.B., and King, H., "Mortality among Baptist Clergymen," J. Chronic Disease, 1980, 33, 581-590. 47. Hulka, B.S., "Risk Factors for Cervical Cancer," J. Chronic Disease, 1982, 35, 3-11. 48. Walker, A.R.P., "Cancer and Religion," S. African Medical J., 1981, 60, 405-60; Editorial, "Church Attendance and Coronary Heart Disease," S. African Medical J., 1973, 47, 1267-1268. 49. Nelson, G.K., "The Spiritualist Movement and the Need for a Redefinition of Cult," J. Scientific Study of Religion, 1969, 8, 152-160. 50. Groen, J., and Vander Heide, R.M., "Atherosclerosis and Coronary Thrombosis," Medicine, 1959, 38, 1-23. 51. Rotter, J.B., "Some Problems and Misconceptions Related to the Construct of Internal vs. External Control of Reinforcement," J. Consulting and Clinical Psychology, 1975, 43, 56-57; Wallston, K.A., and Wallston, B.S., "Who Is Responsible for Your Health?: The Concept of Health Locus of Control," In Sanders, G., and Suls, J., eds., SocialPsychology of Health andlllness. Hillsdale, NJ, Lawrence Erlbaum and Associates, 1981. 52. Rosenberg, M., "The Logical Status of Suppressor Variables,"Public Opinion Quarterly, 1973, 37, 359-372. 53. Comstock, G.W., and Tonascia, J.A., "Education and Mortality in Washington County, Maryland," J. Health and Social Behavior, 1977, 18, 54-61; Naguib, S.M.; Comstock, G.W.; and Davis, H.D., "Epidemiologic Study of Trichomoniasis in Normal Women," Obstetrics and Gynecology, 1966, 27, 607-616; Comstock and Partridge, op. cit. 54. Many recent studies are reviewed in: Levin, J.S., and Markides, K.S., "Religion and Health in Mexican Americans," J. Religion and Health, 1985, 24, 1, 60-69. Other studies include: Comstock, G.W.; Abbey, H.; and Lundin, F.E., "The Non-Official Census as a Basic Tool for

28

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Religion and Health, 1982, 21, 1, 68-80; Markides, K.S., and Martin, H.W., with Gomez, E., Older Mexican Americans: A Study in an Urban Barrio. Austin, University of Texas Press, 1983; West, D.W.; Lyon, J.L.; and Gardner, J.W., "Cancer Risk Factors: An Analysis of Utah Mormons and Non-Mormons," J. National Cancer Institute, 1980, 65, 1083-1095; Steinitz, L.Y., "Religiosity, Well-Being, and Weltanschauung among the Elderly," J. Scientific Study of Religion, 1980, 19, 60-67; Croog, S.H., and Levine, S., The Heart Patient Recovers. New York, Human Sciences Press, 1977; Zuckerman, D.M.; Kasl, S.V.; and Ostfeld, A.M., "Psychological Predictors of Mortality among the Elderly Poor: The Role of Religion, Well-Being, and Social Contacts," Amer. J. Epidemiology, 1984, 119, 410-423; Enstr0m, J.E., "Cancer Mortality among Mormons," Cancer, 1975, 36, 825-841; West, D.W., "An Assessment of Cancer Risk Factors in Latter-day Saints and NonLatter-day Saints in Utah." In Cairns, J.; Lyon, J.L; and Skolnick, M., eds., Cancerlncidence in Defined Populations, Banbury Report 4. Cold Spring Harbor Laboratory, 1980, pp. 31-49; Gardner, J.W., and Lyon, J.L., "Cancer in Utah Mormon Women by Church Activity Level," Amer. J. Epidemiology, 1982, 116, 258-65; House, J.S.; Robbins, C.; and Metzner, H.L., "The Association of Social Relationships and Activities with Mortality," Amer. J. Epidemiology, 1982, 116, 123-140; Naguib, S.M.; Lundin, F.E.; and Davis, H.D., "Relation of Various Epidemiologic Factors to Cervical Cancer as Determinants of a Screening Program," Obstetrics and Gynecology, 1966, 28,451-459; Cleary, P.D., and Houts, P.S., "The Psychological Impact of the Three Mile Island Incident," J. Human Stress, 1984, Spring, 28-34; Comstock and Partridge, op. cir.; Comstock and Tonascia, op. cit; Naguib; Comstock; and Davis, op. cir. Griffith, E.E.H., and Mathewson, M.A., "Communitas and Charisma in a Black Church Service," J. 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Alg~rien de Carcinologie, 1951; Messerschmidt, R., Bull. Algdrien de Carcinologie, 1951; Montpellier, J.M., and Vial, Cahiers Mdd. Union Franc., 1947, 2,449; Mussini-Montpellier, J., "Cancer in North Africa" (Abstract), J. National Cancer Institute, 1950, 11,645-652 (Originally published in Bull. Alg~rien de Carcinologie, 1951). Runge, H., and Zeitz, H., "Gestationsvorgfinge und Carcinoma Colli Uteri," Geburtshilfe und


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Frauenheilkunde, 1955, 15, 877-885; Kouwenaar, W., "On Cancer Incidence in Indonesia" (Abstract), J. National Cancer Institute, 1950, 11, 645-652 (Originally published in Documenta Neerlandica et Indonesia de Morbis Tropicis, 1951). Shapiro, S.; Weinblatt, E.; Frank, C.W.; and Sager, R.V., "Incidence of Coronary Heart Disease in a Population Insured for Medical Care (HIP): Myocardial Infarction, Angina Pectoris, and Possible Myocardial Infarction. Amer. J. Public Health, 1969, 59 (supplement 2), 1-101. Dreyfuss, F., "The Incidence of Myocardial Infarctions in Various Communities in Israel," Amer. Heart J., 1953, 45, 749-755. Winkelstein, W., and Rekate, A.C., "Age Trend of Mortality from Coronary Artery Disease in Women and Observations on the Reproductive Pattern of Those Affected," Amer. Heart J., 1964, April, 481-488; Wardwell, W.I.; Bahnson, C.B.; and Caron, H.S., "Social and Psychological Factors in Coronary Heart Disease," J. Health and Human Behavior, 1963, 4, 154-165. Medalie, J.H.; Kahn, H.A.; Neufeld, H.N.; Riss, E.; and Goldbourt, U., "Five-Year Myocardial Infarction Incidence--II. Association of Single Variables to Age and Birthplace," J. Chronic Disease, 1973, 26, 329-349. Wardwell; Bahnson; and Caron, op. cir. Epstein, F.H.; Simpson, R.; and Boas, E.P., "The Epidemiology of Atherosclerosis among a Random Sample of Clothing Workers of Different Ethnic Origins in New York City, II. Associations Between Manifest Atherosclerosis, Serum Lipid Levels, Blood Pressure, Overweight, and Some Other Variables," J. Chronic Disease, 1957, 5, 329-341; Shapiro; Weinblatt; Frank; and Sager, op cit. Wardwell, W.I., and Bahnson, C.B., "Behavioral Variables and Myocardial Infarction in the Southeastern Connecticut Study," J. Chronic Disease, 1973, 26, 447-461. Lehr, I.; Messinger, H.B.; and Rosenman, R.H., "A Sociobiological Approach to the Study of Coronary Heart Disease," J. Chronic Disease, 1973, 26, 13-30. Epstein, F.H.; Boas, E.P.; and Simpson, R., "The Epidemiology of Atherosclerosis among a Random Sample of Clothing Workers of Different Ethnic Origins in New York City, I. Prevalence of Atherosclerosis and Some Associated Characteristics," J. Chronic Disease, 1957, 5, 300-328. Wardwell, W.I.; Hyman, M.; and Bahnson, C.B., "Socio-Environmental Antecedents to Coronary Heart Disease in 87 White Males," Social Science and Medicine, 1968, 2, 165-183. Friedman, E.H., and Hellerstein, H.K., "Occupational Stress, Law School Hierarchy, and Coronary Artery Disease in Cleveland Attorneys," Psychosomatic Medicine, 1968, 30, 72-86. Marmot, M.G., and Syme, S.L., "Acculturation and Coronary Heart Disease in JapaneseAmericans," Amer. J. Epidemiology, 1976, 104, 225-247. Lyon, J.L.; Wetzler, H.P.; Gardner, J.W.; Klauber, M.R.; and Williams, R.R., "Cardiovascular Mortality in Mormons and Non-Mormons in Utah, 1969-71," Amer. J. Epidemiology, 1978, 108, 357-366. Phillips, R.L.; Lemon, F.R.; Beeson, W.L.; and Kuzma, J.W., "Coronary Heart Disease Mortality among Seventh-Day Adventists with Differing Dietary Habits: A Preliminary Report," Amer. J. Clinical Nutrition, 1978, 31, S191-S198; Jarvis, G.K., "Mormon Mortality Rates in Canada," Social Biology, 1977, 24, 294-302. Medalie, J.H.; Kahn, H.A.; Neufeld, H.N.; Riss, E.; Goldbourt, U.; Perlstein, T.; and Oron, D., "Myocardial Infarction over a Five-Year Period--I. Prevalence, Incidence and Mortality Experience," J. Chronic Disease, 1973, 26, 63-84. Epstein, F.H.; Simpson, R.; and Boas, E.P., "Relations Between Diet and Atherosclerosis among a Working Population of Different Ethnic Groups," Amer. J. Clinical Nutrition, 1956, 4, 10-19; Epstein, F.H., and Boas, E.P., "The Prevalence of Manifest Athersclerosis among Randomly Chosen Italian and Jewish Garment Workers: A Preliminary Report," J. Gerontology, 1955, 10, 331-337; Epstein, F.H., and Boas, E.P., "The Prevalence of Coronary Artery Disease among Randomly Chosen Men of Italian and Jewish Origin," Circulation, 1955, 12, 493; Wardwell, W.I.; Hyman, M.; and Bahnson, C.B., "Stress and Coronary Heart Disease in Three Field Studies," J. Chronic Disease, 1964, 17, 73-84; Epstein; Simpson; and Boas, J. Chronic Disease, op. cir. Skyring, A.; Modan, B.; Crocetti, A.; and Hammerstrom, C., "Some Epidemiological and Familial Aspects of Coronary Heart Disease: Report of a Pilot Study," J. Chronic Disease, 1963, 16, 1267-1279; Comstock, op. cit. Comstock, op. cir. Liberson, D.M., "Causes of Death among Jews in New York City in 1953," Jewish Social Studies, 1956, 18, 83-117. Hamman, R.F.; Barancik, J.I.; and Lilienfeld, A.M., "Patterns of Mortality in Old Order Amish. I. Background and Major Causes of Death," Amer. J. Epidemiology, 1981, 114, 845-861.

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84. Schaefer, L.E.; Drachman, S.R.; Steinberg, A.G.; and Adlersberg, D., "Genetic Studies on Hypercholesteremia," Amer. Heart J., 1953, 46, 99-116; Adlersberg, D.; Schaefer, L.E.; and Drachman, S.R., "The Incidence of Hereditary Hypercholesteremia," J. Laboratory and Clinical Medicine, 1952, 39, 237-245. 85. Epstein, F.H.; Carol, R.; and Simpson, R., "Estimation of Caloric Intake from Dietary Histories among Population Groups," Amer. J. Clinical Nutrition, 1956, 4, 1-9. 86. Torrington, M., and Botha, J.L., "Familial Hypercholesterolaemia and Church Affiliation," Lancet, 1981, Nov. 14, 1120. 87. Walden, R.T.; Schaefer, L.E.; Lemon, F.t~.; Sunshine, A.; and Wynder, E., "Effect of Environment on the Serum Cholesterol-Trigylceride Distribution among Seventh-day Adventists," Amer. J. Medicine, 1964, 36, 269-276. 88. West, R.O., and Hayes, O.B., "Diet and Serum Cholesterol Levels. A Comparison between Vegetarians and Nonvegetarians in a Seventh-day Adventist Group," Amer. J. Clinical Nutrition, 1968, 21,853-862. 89. King and Funkenstein, op. cit. 90. Graham; Kaplan; Cornoni-Huntley;et al., Ol9. cit. 91. Scotch, op. cir. 92. Walsh, op. cit. 93. Stavig, G.R.; Igra, A.; and Leonard, A.R., "Hypertension among Asians and Pacific Islanders in California," Amer. J. Epidemiology, 1984, 119, 677-691. 94. Ibid. 95. Levin and Markides, op. cit. 96. Toor, M.; Agmon, J.; and Allalouf, D., "Changes of Serum Total Lipids, Total Cholesterol and Lipid-Phosphorous in Jewish Yemenite Immigrants after 20 Years in Israel," Bull. Research Council of Israel, 1954, 4, 202-203. 97. Ross, D.C., and Thomas, C.B., "Precursors of Hypertension and Coronary Disease among Healthy Medical Students: Discriminant Function Analysis. III. Using Ethnic Origin as the Criterion, with Observations on Parental Hypertension and Coronary Disease on Religion," Bull. Johns Hopkins Hospital, 1967, 117, 37-57. 98. Armstrong, B.; Van Merwyck, A.J.; and Coates, H., "Blood Pressure in Seventh-Day Adventist Vegetarians," Amer. J. Epidemiology, 1977, 105, 444-449. 99. Rouse, I.L.; Armstrong, B.K.; and Beilin, L.J., "Vegetarian Diet, Lifestyle and Blood Pressure in Two Religious Populations," Clinical and Experimental Pharmacology and Physiology, 1982, 9, 327-330. 100. Friedman and Hellerstein, o19.cit. 101. Acheson, E.D., "The Distribution of Ulcerative Colitis and Regional Enteritis in United States Veterans with Particular Reference to the Jewish Religion," Gut, 1960, 1,291-293; "The Epidemiology of Ulcerative Colitis and Regional Enteritis." In Badenoch, J., and Brooke, B.N., eds., Recent Advances in Gastroenterology. Boston, Little Brown and Co., 1965, pp. 202-226; Boyce, F.F., Regional Enteritis, Diagnostic and Therapeutic Considerations. Philadelphia, J.B. Lippincott, 1955, p. 62; Paulley, J.W., "Ulcerative Colitis: A Study of 173 Cases," Gastroenterology, 1950, 16, 566. 102. Monk, M.; Mendeloff, A.I.; Siegel, C.I.; and Lilienfeld, A., "An Epidemiological Study of Ulcerative Colitis and Regional Enteritis among Adults in Baltimore--I. Hospital Incidence and Prevalence, 1960 to 1963," Gastroenterology, 1967, 53, 198-210. 103. Melrose, A.G., "The Geographical Incidence of Chronic Ulcerative Colitis in Britain," Gastroenterology, 1955, 29, 1055. 104. Weiner, H.A., and Lewis, C.M., "Some Notes on the Epidemiology of Non-Specific Ulcerative Colitis: An Apparent Increase in Incidence in Jews," Amer. J. Digestive Diseases, 1960, 5, 406-418. 105. Birnbaum, D.; Groen, J.J.; and Kallner, G., "Ulcerative Colitis among the Ethnic Groups in Israel," AMA Archives of Internal Medicine, 1960, 105, 843-848. 106. Acheson, E.D., and Nefzger, D., "Ulcerative Colitis in the United States Army in 1944: Epidemiology," Gastroenterology, 1963, 44, 7-19. 107. Monk, M.; Mendeloff, A.I.; Siegel, C.I.; and Lilienfeld, A., "An Epidemiological Study of Ulcerative Colitis and Regional Enteritis among Adults in Baltimore--II. Social and Demographic Factors," Gastroenterology, 1969, 56, 847-857. 108. Monk, M.; Mendeloff, A.I.; Siegel, C.I.; and Lilienfeld, A., "An Epidemiological Study of Ulcerative Colitis and Regional Enteritis among Adults in Baltimore--III. Psychological and Possible Stress-Precipitating Factors," J. Chronic Disease, 1970, 22, 565-578. 109. Croog, S.H., "Ethnic Origins, Educational Level, and Responses to a Health Questionnaire," Human Organization, 1961, 20, 65-69.


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32


Groups in New York City," Environmental Research, 1970, 3, 234-250; Seidman, H., "Cancer Mortality in New York City for Country of Birth, Religions, and Socioeconomic Groups," Environmental Research, 1971, 4, 390-429; Versluys, J.J., "Cancer and Occupation in the Netherlands," Brit. J. Cancer, 1949, 3, 161-185; Greenwald, P.; Korns, R.F.; Nasca, P.C.; and Wolfgang, P.E., "Cancer in United States Jews," Cancer Research, 1975, 35, 3507-3512; Haenszel, W., "Cancer Mortality among U.S. Jews," Israel J. Medical Science, 1971, 7, 1437-1450; Lombard, H.L., and Doering, C.R., "Cancer Studies in Massachusetts: 3. Cancer Mortality in Nativity Groups," J. Preventive Medicine, 1929, 3, 343-361. 147. Casper, J., "Incidence of Uterine Cancer among Different Ethnic Groups," SchweizerishceZ. Pathologie und Bakteriologie, 1955, 18, 764-774; Dorn, H.F., "Some Problems Arising in Prospective and Retrospective Studies of the Etiology of Disease," New England J. 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33

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[Public health research: Is there a pilot?].

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Is there a case for mental health promotion in the primary care setting? A systematic review.

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cultural procedure, not a medical procedure.

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Is there a visual dyslexia.

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