Spirituality in Medicine- An examination of religious service attendance and overall mortality among a cohort of female nurses

Whether by pure coincidence or divine action, within minutes of posting my last article regarding the imagery of an interconnected world existing amidst a “vibrational bowl” of love and the implications for those, like myself, wishing to practice medicine focusing on the spiritual being, I was “sent” a notification email from JAMA Internal Medicine informing me of a newly accessible, online first study entitled: Association of Religious Service Attendance With Mortality Among Women.

Already intrigued by the title I began reading through the abstract, and within minutes was already immersed in the body of the paper, piecing apart the intricacies of the statistical results and reflecting upon the ideas described in the thoughtful discussion. In an attempt to make the statistics a little more user-friendly I have presented the results of the study below as well as my own personal interpretation of the author’s conclusions.

Cohort Studied: “Attendance at religious services was assessed from the first questionnaire in 1992 through June 2012, be a self-reported question asked of 74,534 women in the Nurses’ Health Study who were free of cardiovascular disease and cancer at baseline. Data Analysis was conducted from return of the 1996 questionnaire through June 2012.”

1. A 33% decrease in all cause mortality for those individuals who attended one or more religious services a week versus those who did not attend any religious functions.

2. Decreased likelihood of dying from cardiovascular disease as determined by a hazard ratio (HR 0.79). A hazard ratio is basically the ratio of the likelihood of an event occurring for two different groups as defined by a single variable (in this case dying from cardiovascular disease for those who attended one or more religious services per week vs. those who did not attend any religious functions). A HR of less than 1 (such as the HR of 0.79 in this study) when combined with a predetermined p-value to show a “significant” likelihood of a true effect essentially means that the group of regular religious attendees were less likely to die from cardiovascular disease (CVD) than those who did not attend a religious service. Generally speaking, the smaller the hazard ratio (for example 0.35) the less likely the specified group with the defined variable (religious attendance) would suffer the measured effect (death related to CVD). It is important to note, however, that the researchers only found a significant decreased likelihood of death related to CVD as it pertained specifically to cerebrovascular disease (stroke) and other cardiovascular diseases (such as congestive heart failure) – but no such association with ischemic heart disease [heart attacks or in more medical jargon- dysregulated coronary vasculature (blood flow to the heart)]. 

Summary

The weekly religious attendees had a 0.79X less chance of dying from stroke and cardiovascular disease- but not ischemic heart disease, when compared to those who did not attend religious services.

3. Decreased likelihood of dying from cancer as determined by a hazard ratio (HR of 0.73). Sparing you a further “rabbit hole” description of a hazard ratio, I will simply share that the researchers also found a site specific cancer mortality effect for breast cancer (as this cohort was of female nurses) and colorectal cancer but not for any other forms of cancer.

What the researchers DID NOT find

1. Spirituality as a whole, if describable, had an effect on any other domain of health besides total mortality, mortality from cancer, and mortality from cardiovascular disease (excluding ischemic heart disease).

2. Populations outside of female health care workers- predominantly, white, middle class Christians did or would receive a benefit in regards to mortality as related to regular religious attendance.

3. Associations (as they were not directly measured) for quality of life across mental, emotional and physical domains for the regular religious service attendees compared to those who did not attend religious functions.

4. Specific mechanisms or pathways (outside of the associated mediators described below) for how religious attendance could cause the observed affects for decreased mortality. 

5. Spiritual practice, outside of regular attendance to a specific religious function, could not also give potential benefits as they relate to decreased total mortality and mortality from cardiovascular disease and cancer.

Addressing the practical question: How was the observed effect of decreased mortality mediated? 

One of the strengths of this study was the numerous confounding variables controlled for with regards to the primary variable analyzed (religious attendance) These variables included diet and exercise patterns, smoking, depressive symptoms, multivitamin use, medical diagnosis- comorbid disease and numerous demographic variables. Through all of this covariate analysis the researchers were able to isolate four primary mediators that likely contributed to the observed primary endpoints of decreased mortality.

1. Optimism 

2. Smoking Status

3. Depressive Symptoms

4. Social Support/Social Integration

Smoking was found to “explain” 22% of the observed effect, Social Support 23%, Depressive Symptoms 11%, and Optimism 9%. Additional mediators examined that did not show a significant mediating effect included: alcohol use, diet quality, and phobia related anxiety. The researchers calculated the “Social Support” score from multiple longitudinal surveys in the specified cohort and attempted to create a final score independent of social support associated with religious service attendance.

Summary

 No one mediator was found to strongly correlate with the observed effect of decreased mortality, however, it appears that non-smoking individuals with a self-reported positive outlook, minimal depressive symptoms and supportive social structures were the least likely to die during the time period of this study. Whether or not regular religious service attendance added a significant “value” for an individual outside of the mediators discussed is open for debate and certainly would be an area worthy of further study.

Implications and Ideas

Author’s Conclusion: “Religion and spirituality may be an under appreciated resource that physicians could explore with their patients, as appropriate.”

Personal Conclusion: Spirituality is a complex description of one’s personal beliefs, faith in a greater energy, being, or creator, as well as a motivating sense of purpose, connectedness with others/ the natural world and cannot simply be “quantified” by regular religious service attendance. This specific study provides some evidence that cultivating a positive social support network through regular attendance to religious functions (a “surrogate” for spirituality) can be a means to maintain health and avoid premature death. In the end, quantifying one’s own sense of spirituality is not likely possible with a single measure or combined variable, and the scientific method/ study through traditional clinical research designs does not provide a realistic means to determine the relative importance of spiritual practice to any one individual.

References

Li S, Stampfer MJ, Williams DR, VanderWeele TJ. Association of Religious Service Attendance With Mortality Among Women. JAMA Intern Med. 2016 May 16. 

Koenig HG. Religion, spirituality, and health: the research and clinical implications. ISRN Psychiatry. 2012 Dec 16;2012:278730.