Sot. Sci’.Med. Vol. 38, Nell, pp.

1475-1482, 1994
Copyright 0 Elsevier ScienceLtd
1994
Pergamon Printed-in Great Britain. All rights reserved
0277-9536/94$7.09+ 0.00

RELIGION AND HEALTH: IS THERE AN ASSOCIATION,

IS IT VALID, AND IS IT CAUSAL?
JEFFREYS. LEVIN
Department of Family and Community Medicine, Eastern Virginia Medical School, P.O. Box 1980,
Norfolk, VA 23501, U.S.A.

Abstract-This paper reviews evidence for a relationship between religion and health. Hundreds of
epidemiologic studies have reported statistically significant, salutary effects of religious indicators on
morbidity and mortality. However, this does not necessarily imply that religion influences health; three
questions must first be answered: “Is there an association?‘, “Is it valid?‘, and, “Is it causal?” Evidence
presented in this paper suggests that the answers to these respective questions are “yes,” “probably,” and
“maybe.” In answering these questions, several issues are addressed. First, key reviews and studies are
discussed. Second, the problems of chance, bias, and confounding are examined. Third, alternative
explanations for observed associations between religion and health are described. Fourth, these issues are
carefully explored in the context of Hill’s well-known features of a causal relationship. Despite the
inconclusiveness of empirical evidence and the controversial and epistemologically complex nature of
religion as an epidemiologic construct, this area is worthy of additional investigation. Further research
can help to clarify these provocative findings.

Key wor&--causation, epidemiology, health, religion

INTRODUCTION These sentiments, justified or not, are certainly

Over the past several years, comprehensive reviews
of epidemiologic and medical studies of the
health effects of religiosity have begun to appear.
In the first of these reviews [1], the authors were
surprised to uncover over 250 published empirical
studies dating back to the 19th Century. Why did it
take so long for this body of findings to be discov-
ered?
First, these hundreds of studies do not truly
represent a ‘literature,’ in the usual sense of
the term. Few of these studies set out explicitly to
study religion. Rather, in studies of various health
outcomes and causes of morbidity or mortality
(e.g. cardiovascular disease, uterine cancer, colitis,
symptomatology), one or more religious indicators
made a serendipitous ‘guest appearance’ alongside
of scores of other psychosocial measures [2]. Find-
ings bearing on religion-health linkages were then
buried in tables, often without comment in either
text or abstract, and usually without reference
to similar findings from other studies. Indeed,
most of these researchers may have been unaware of
these studies’ existence [3]. This has worked against
the collation of such findings, such as in review
articles.
Second, salient idealogical and institutional bar-
riers within academic medicine have discouraged
the dissemination of positive findings. These
barriers include beliefs or attitudes such as, “Reli-
gion is unimportant,” “Religion is not real,” “This
is bad science,” “This goes against my training,”
and, “This will only encourage the clergy” [4].
understandable. As was noted several years ago,
“Western biomedicine, of which epidemiology is
a part, is still wrestling with a body-mind dualism
that defies consensus; thus, for most epidemiologists
any resolution of a body-mind-spirit pluralism is
simply beyond consideration” [5, pp. 590-5911. As a
result, the idea that one’s religious background or
experiences might in some way influence one’s health
has remained “part of the folklore of discussion on
the fringes of the research community” [1, p. lo].
Apparently, several of the seminal figures of mod-
ern medicine would have hoped otherwise [6]. For
example, Sir William Osler [7], writing in the British
Medical Journal in 1910, spoke of “the faith that
heals,” sentiments echoed 65 years later by Jerome
Frank [8]. According to Osler, this faith can be in
the efficacy of drugs, in the capabilities of the
physician, or in the workings of God, but, regard-
less, “faith is the most precious commodity without
which we should be very badly off” [8, p. 1271. Over
100 years ago, John Shaw Billings [9] spoke of
religious affiliation as a potential factor in the study
of differential rates of morbidity and mortality
among social groups, a fact soon thereafter demon-
strated by the French sociologist Emile Durkheim
[lo]. Durkheim’s famous study systematically
identified differences in suicide rates among Protes-
tants, Catholics, and Jews, which he attributed to a
variety of extrinsic (e.g. social alienation) and intrin-
sic (e.g. self-discipline, free-thinking) causes [IO].
Other key figures, from Maimonides and Wesley to
contemporaries such as James, Freud, Jung,
Maslow, Allport, even Bertrand Russell and Albert
 1476 JEFFREYS. LEVIN
Ellis, have all spoken of religion as a force which,
for better or worse, influences human health and
well-being and deserves careful scutiny [ll]. James
[12], for one, used a medical metaphor to distinguish
between “healthy-minded” and “sick” religious ex-
pression, and he attributed beneficial and dire effects
of these respective types of religion to their emotional
sequelae.
More recently, notable reviews and orginal
studies have appeared, and in the most mainstream
of scientific journals. In his classic review of psycho-
social factors in the etiology of coronary disease
published in the New England Journal of Medicine,
Jenkins [ 131 reviewed several epidemiologic studies
of religious differences in morbidity. Comstock and
associates at Johns Hopkins have published nearly
a dozen epidemiologic papers which present
positive findings linking measures of religiosity to
various health outcomes, including a much-cited
study in the Journal of Chronic Diseases which re-
vealed that infrequent church attendance is a
risk factor for several causes of mortality [14]. Byrd
[15] published results of a double-blind, randomized,
controlled clinical trial of the effects of prayer on
coronary care outcomes in Southern Medical Journal.
This study was so provocative that it led to an
editoral. Other editorals or special essays discussing
this subject have appeared in The Journal of
Family Practice, Journal of the National Medical
Association, Milbank Memorial Fund Quarterly,
The Johns Hopkins Medical Journal, and espec-
ially Social Science & Medicine, as well as in the
official journals of numerous state and foreign
medical societies. Further, the hundreds of empirical
studies which have presented data on religion have
appeared in most of the leading medical journals in
the world [l], including JAMA, Lancet, American
Journal of Public Health, and American Journal of
Epidemiology.
In light of this seeming goldmine of information,
only recently unearthed and collated and not fully
synthesized or critiqued, this paper intends to criti-
cally assess the possibility of a religion-health re-
lationship as suggested by the accumulation of over
a century of empirical data. This paper will make no
judgements as to the existence of spiritual or divine
or supernatural realities; in fact, such speculation has
no bearing on this discussion. The task is much
simpler: confronted with hundreds of studies whose
findings are mostly in accord, there is a need to
systematically examine the evidence that something
known popularly as religiosity or religiousness, how-
ever conceived, is related to health. This can be done
in much the same way that any other newly discov-
ered risk factor or protective factor is examined in the
absence of either an established etiology or a theoreti-
cally based expectation. In epidemiologic fashion
[la], this task will consist of answering three ques-
tions: (a) “Is there an association?“, and if so, (b) “Is
it valid?“, and if so, (c) “Is it causal?”
IS THERE AN ASSOCIATION?
In their initial review of published findings, Levin
and Schiller [1] found that, generally speaking, reli-
giosity, however operationalized, seems to exert a
salutary effect on health, regardless of the outcomes
or diseases or types of rates which are examined.
While there were exceptions and while many of these
studies had not been designed to focus specifically on
religion, this summary finding emerged in one of two
forms.
First, when comparing religious groups, there ap-
pears to be relatively lower risk in more behaviorally
strict religions or denominations (e.g. Mormons,
Seventh-day Adventists, Orthodox Jews, clergy of all
faiths). This is true for cardiovascular disease, hyper-
tension, stroke, uterine and cervical cancer, numerous
other cancer sites, colitis and enteritis, general health
status indicators, and overall and cause-specific mor-
tality [l]. A subsequent review [17], which focused
specifically on studies of cancer in Mormons, Adven-
tists, Amish and Hutterites, came to the same general
conclusion. A third review [18], which gave careful
scrutiny to that subset of studies dealing with religion
and mortality rates, also concurred. Some evidence
also exists that even within such behaviorally strict
religious groups there may be a health-related gradi-
ent on the basis of religious involvement. For
example, a study of Mormons [19] found that the
age-standardized incidence of lung cancer was con-
siderably lower in women with strong adherence to
church doctrines relative to religiously inactive
women. Similar results were found for Mormon men
with respect to lay priesthood level and several cancer
sites [20]. This study found that the higher the level
of priesthood attained, the lower the incidence of
cancerdespite the fact that priesthood level rises
with age, a known correlate of increased cancer
incidence.
Second, when ordinal-level indicators of religious
behaviors or attitudes or experiences are used in
analyses, there is a trend toward better health and less
morbidity and mortality, across the board, in the
presence of higher levels of religiosity. For example,
in a review of 27 studies of the effects of the most
popularly used religious indicator, frequency of reli-
gious attendance, 22 of the studies revealed a positive
and statistically significant relationship with health
(51. Outcomes included hypertension, trichomoniasis,
cervical cancer incidence, tuberculosis case rate,
atherosclerotic and degenerative heart disease, neo-
natal mortality, subjective health, overall mortality,
and many other disease entities and conditions. These
findings were so striking that the authors of the
review proposed the development of an “epidemiol-
ogy of religion” [5].
More specialized reviews, focusing on studies of
specific diseases, have supported both of these general
findings. For example, a review of studies of religious
effects on hypertension [21] found relatively lower
 Religion and health
rates among groups such as observant Sephardic
Jews, Benedictine Monks, Adventists, Mormons,
Baptist clergy, and Zen Buddhist priests. It also
found that the greater the level of religiosity, the
lower the blood pressure-regardless of how religios-
ity was operationalized (e.g. religious attendance,
church membership, subjective self-ratings of religios-
ity, father’s years of Yeshiva). Several reviews have
documented similar findings in relation to other
health problems, notably affective states related to
the psychological well-being of the elderly [22-241.
In summary, the question, “Is there an associ-
ation?‘, can be answered with a guarded “yes.” This
implies no endorsement of an as yet unidentified
explanatory mechanism. Nor does this even imply
that this summary finding is methologically valid (i.e.
not due solely to chance, bias, and/or confounding).
However, the presence of hundreds of published
studies which, collectively, have examined scores of
diseases and types of rates; have used a variety of
religious indicators; have occured in settings through-
out the world and throughout the past century, to the
present day; have included subjects of both genders
and of nearly all racial and ethnic groups, from
infants to the elderly; and consistently have pointed
to a salutary effect of religion provides substantial
empirical evidence for an association between religion
and health.
IS IT VALID?
Once an association is identified, it must then be
determined whether or not it is valid-that is,
whether the association is real as opposed to merely
an artifact due to chance or bias or confounding.
Only if these can be confidently ruled out is validity
proposed for an epidemiologic association [ 161.
Whether or not a valid association is ‘causal’ is a
separate matter altogether.
It is difficult to accurately assess the validity of the
apparent association between religion and health.
Hundreds of studies are involved and there is great
diversity in their designs, sampling frames, settings
and populations, as well as in health indicators and
religious measures. Further, as epidemiologists are
aware, null results from one good study generally
outweigh positive findings from 100 poorly designed
and executed studies.
Chance and bias
In ruling out chance and bias, however, this diver-
sity and the sheer volume of studies may actually
work to the advantage of validity. Since so many
hundreds of studies have been published, and these
overwhelmingly report statistically significant, posi-
tive religion-health associations or health differences
across religious groups, and since most of these
studies were epidemiologic censuses of entire popu-
lations or surveys of randomized samples, it is un-
likely that this summary result is due solely to chance.
1477
At the level of individual studies, these results can
probably be trusted, for the most part; at a literature-
wide level, it would require thousands of unpublished
null findings to produce anything like a ‘file-drawer’
problem.
This diversity in studies suggests that bias may also
be safely ruled out. A significant, positive religious
effect on health was found in prospective and retro-
spective studies; in cohort and case-control studies; in
studies of children and of older adults; in studies of
U.S. White and Black Protestants, European
Catholics, Parsis from India, Zulus from South
Africa, Japanese Buddhists and Israeli Jews, among
others; in studies from the 1930s and studies from the
1980s; and in studies of self-limiting acute conditions,
of fatal chronic diseases and of illnesses with lengthy,
brief, or absent latency periods between exposure and
diagnosis and mortality.
Confounding
Confounding is more difficult to assess. This in-
volves determing whether or not the observed associ-
ation between religion and health is spurious due to
its being explained by one or more unaccounted for
variables which do not represent functions or charac-
teristics of religion. ‘Explanation’ is a loaded term,
and raises interesting epistemological issues. While
the influence of psychosocial factors, generally, can
be understood in terms of biological processes or
mechanisms [25], this does not imply that psychoso-
cial variables are not meaningfully related to health.
For example, while there is greater mortality among
lonely widows and single men, it is hardly sufficient
to say that this is fully explained by psychoneuro-
immunologic factors, even though the process of
mortality is reducible to certain physiological and
biochemical events. Granting explanatory primacy to
one particular level of the human system (cultural,
social, psychological, organ systems, cellular, molecu-
lar, etc.) is arbitrary; human biology is itself ‘ex-
plained’ by the activity of molecules and, ultimately,
to paraphase Democritus, everything is just atoms
and empty space. Yet no one would suggest that
research in subatomic physics will yield the best
approach for improving the life expectancy of lonely
or bereaved people.
In order to more fully understand these anomalous
findings linking measures of religion and health, a list
of alternative hypotheses or explanations was devel-
oped [21]. They seek to account for observed associ-
ations which are presumed to be due to the effects of
characteristics or functions of religion, and not to
chance or bias. These hypotheses are meant to ex-
plain the effects of religion and health in the sense of
elucidating its pathways and mechanisms of influ-
ence, not in the sense of ‘explaining it away.’ Reli-
gion, as a social institution, and religiosity, as a
component or dimension of our psychological make-
up and interpersonal life, are real phenomena-or
at least as real as any other psychosocial construct. It
1478 JEFFREYS. LEVIN
would be reductionistic to define as a religious effect
only something of a mystical or supernatural nature
which, depending upon one’s scientific perspective, is
either nonexistent or must logically be explained
away by a natural mechanism. The following alterna-
tive hypotheses are summarized in greater detail
elsewhere [4, 211.
Behavior. Certain health-promotive life styles or
health-related behaviors are sanctioned by particular
religions or religious denominaticns. These proscrip-
tions and prescriptions govern alcohol, tobacco,
drugs, diet, exercise, and general hygiene [26], and
help to explain why morbidity and mortality rates are
lower among certain religious groups (e.g. Mormons,
Seventh-day Adventists). The holding of particular
religious beliefs or practice of particular religious
behaviors thus directly leads to adoption of health-
promoting behaviors. Indeed, the congruence of
many religious and health-related behaviors [26]
suggests that the conceptual compartmentalization of
certain behaviors as ‘religious’ or ‘health-related’ may
be artificial.
Heredity. Morbidity and mortality might be higher
(or lower) in a particular religious group due to
genetic risk (or protection) for certain diseases. For
example, Tay Sachs disease seems to be most incident
among Ashkenazi Jews; hypercholesterolemia dispro-
portionately strikes Dutch Reformed Afrikaaners;
and sickle cell anemia is likely to be more prevalent
among members of the National Baptist Convention
of America (which is predominantly Black) than
among members of the Southern Baptist Convention
(which is predominantly White). While these findings
are distinctly religious in origin in that they are
attributable to genetic characteristics of religious
group membership, they are clearly not due to, say,
religious differences in theology or polity or worship
practices. In such studies, reported religious differ-
ences are best understood in terms of those
geographic, biological, ethnic, and cultural character-
istics of people which happen to vary by religious
group membership.
Psychosociaf effects. Frequent religious involve-
ment and greater intensity of religious experience
may be associated with better health due to religion’s
promotion of social support, a sense of belonging,
and convivial fellowship. A long tradition of research
in social epidemiology has demonstrated the salutary
nature of these psychosocial influences [27] which
serve to buffer the adverse effects of stress and anger,
perhaps via psychoneuroimmunologic pathways.
Religious activity or commitment thus may trigger a
multifactorial sequence of biological processes [28]
leading to better health.
Psychodynamics of belief systems. The salient be-
liefs of particular religious traditions may engender
peacefulness, self-confidence, and a sense of purpose;
alternatively, they may produce guilt, self-doubt,
shame, and low self-esteem. Such feelings, in turn,
have been shown to be related to health beliefs and,
thus indirectly, to subjective perceptions of health.
Certain religious beliefs or theological worldviews
even seem to converge with respective health beliefs
or personality styles. For example, descriptions of the
well-known Protestant work ethic are quite similar to
descriptions of the Type A behavioral pattern, and
the distinction between the psychological constructs
of internal and external locus of control appears to
mirror the distinction between free-will and more
Calvinistic theological perspectives. Both Type A and
locus of control have been found in numerous studies
to modify risk for certain health outcomes.
Psychodynamics of religious rites. The public and
private cultic rituals of religious worship and spiritual
practice may serve to ease anxiety and dread, defeat
loneliness, and establish a sense of being loved and
appreciated. These psychological outcomes of reli-
gious practice, as well as the actual physiological
markers of emotional arousal during worship and
prayer, are believed to be associated with healing and
health and well-being. These salutary effects have
been characterized as psychic beta-blockers or
emotional placebos [21].
Psychodynamics offaith. The mere belief that reli-
gion or God is health-enhancing may be enough to
produce salutary effects. That is, significant associ-
ation between measures of religion and health, es-
pecially in prospective studies, may, in part, present
evidence akin to a placebo effect. Various scriptures
promise health and healing to the faithful, and the
physiological effects of expectant beliefs such as this
are now being documented by mind-body researchers
[29, 301.
Multifactorial explanation. It is possible that a
combination of some or all of the above explanations
best explains statistically significant associations be-
tween religion and health. For example, many studies
show that Seventh-day Adventists are considerably
healthier than the members of other religious groups,
especially with regard to hypertension. Taking into
account the previous explanations, in order, this
religious effect may be attributable to the following
confluence of factors:
. the avoidance of meat (leading to low levels of dietary
fat and cholesterol); the discouragement of intermarriage
(supporting a trend toward selecting out of the population
those persons predisposed to hypertension); an emphasis on
family solidarity and religious fellowship (buffering the
adverse physiological consequences of life stress and
anxiety); a theological emphasis on self-responsibility and
positive health-directedness (encouraging self-care and ben-
eficial health-related behavior); a sense of trust and peace
engendered both through expectations of God’s directly
transforming the world and through ritual experience of
transformation through divine power (preventing or amelio-
rating state anxiety, hassles and uplifts, anger, etc.); and a
sense of purpose and well-being because the worldview and
piety of Adventists is believed to be promotive of health
(reinforced by the relative lack of hypertension-related
morbidity among co-religionists) [21, p. 751.
Superempirical force. While the previous expla-
nations engage social, psychological, and biological
 Religion and health
phenomena or processes generally accepted by scien-
tists, this explanation suggests that religious practice
or belief or worship in some way taps or accesses a
pantheistic, discarnate force or power. The term
“superempirical” is used to distinguish it from the
supernatural, which by definition cannot be measured
by scientists since it is outside of nature. Superempir-
ical is used to denote those phenomena which, ulti-
mately, may not be supernatural at all, but which are
currently subject to controversy or mystery. Such a
force or power goes by various names (prana, chi,
orgone, life force, etc.) and its operation is central to
health-related claims made by proponents of New
Age healing [31] or other unconventional forms of
medicine which postulate the existence of nadis (or
acupuncture meridians) and chukrus (or etheric en-
ergy centers), as well as the efficacy of pranuyumu (or
yogic breathing exercises), Reiki healing, and various
types of “vibrational medicine” [32]. These types of
practices [33] may not be as principally health-related
as they might appear. They are often embedded
within a religious context, and thus the practice of a
particular holistic technique seeking to balance or
control this superempirical force may be conceived of
as part of a spiritual quest (see Ref. [34]). Some
scientists [35] claim recent success in measuring this
force, so perhaps in the near future it will no longer
be considered superempirical but empirical-a natu-
ral force or energy tapped or triggered by religious
pursuits.
In summary, the question, “Is it valid?‘, can be
answered with a “probably.” That is to say, accord-
ing to current evidence and the nature of existing
data, it appears that the observed association between
religious and health indicators is not solely due to
chance or to biased studies. Further, the possibility of
an effect of religion on health seems to make sense in
light of the known health-relatedness of several
characteristics and functions of religion. However, a
disappointing aspect of validity is that one can rarely
be certain on the basis of observational research;
some as yet undiscovered construct or mechanism,
neither a characteristic nor function of religion, may
fully account for the positive associations revealed in
the studies in this literature. Thus, confounding is an
unlikely but still real possibility. Because hardly any
of these studies are based on experimental designs,
but are instead observational studies, this cannot be
ruled out.
IS IT CAUSAL?
To summarize, research has established a religion-
health association, and it is probably, although not
definitely, valid. Is it casual? That is, do religious
experiences or the practice of religion lead to or
‘cause’ salutary outcomes? Since the concept of cau-
sation as used in epidemiology is controversial and
there is no true consensus [36], it is possible that this
question cannot be answered, or at least answered to
1479
universal satisfaction. There appear to be two schools
of thought, and in certain ways they are diametrically
opposed.
Falsificationists, in the tradition of Popper, do not
accept that causal inference is logically possible;
hypotheses can be refuted but never definitively
proven [371. Verificationists, in the tradition of Hill,
seek to build a case of supporting evidence on the
basis of a study or studies which report an association
possessing certain characteristics or qualities that one
would expect to find in cause-and-effect relationships
[38]. Hill [39] proposed a list of nine such qualities,
often wrongly referred to as criteria, but actually
different bases or viewpoints for considering cau-
sation. According to Hill, “None of my nine view-
points can bring indisputable evidence for or against
the cause-and-effect hypothesis and none can be
required as a sine qua non” [39, p. 2991. The practical
application of either of these two approaches to
causality is challenging, but required, because the
interplay of modern chronic diseases and their many
biopsychosocial precursors point to a multifactorial
web of causation, and the application of older, more
deterministic approaches to causality such as Koch’s
postulates is thus not entirely helpful.
Causal evidence
Keeping in mind the falsificationist caveat that
causation cannot be completely established, Hill’s
causal characteristics will be used as rough guidelines
to assess the available evidence for a cause-and-effect
relationship between religion and health. Hill’s nine
causal features, familiar to epidemiologists, include
strength, consistency, specificity, temporality, bio-
logical gradient, plausibility, coherence, experiment,
and analogy.
Strengrh. There is no single meta-analytic review
available for all of the hundreds of published studies
in this area. Furthermore, too few epidemiologic
studies have been designed to focus explicitly on the
effect of religion for this overview to reliably gauge its
magnitude. However, moderate to strong associ-
ations have been found in several studies. For
example, Comstock and Partridge [14] examined the
relative risk of infrequent church attendance for
cause-specific mortality and found significant risk
ratios as high as 3.9 for certain diseases. King and
Locke [40], in a series of studies comparing the health
of clergy and lay people, found significant standard-
ized mortality ratios for clergy as low as 9 for certain
causes of death. Levin and associates [41] found that
particular dimensions of religious involvement ex-
erted significant standardized regression effects on a
composite health status measure as high as 0.419.
Consistency. According to Hill, consistency ad-
dresses whether an association has “been repeatedly
observed by different persons, in different places,
circumstances and times” [39, p. 2961. On this point,
there can be no argument. As noted earlier, a positive
association between religion and health has been
1480 JEFFREYS. LEVIN
observed in hundreds of studies of various designs,
conducted by scores of researchers in different
countries, at different times throughout this century,
using a multiplicity of independent and dependent
variables, and including subjects exhibiting great
diversity by race, ethnicity, gender, age, social class,
nationality, religious affiliation, and disease status.
SpeciJicity. This refers to whether or not an ex-
posure or independent variable (e.g. religion) has
effects specific to just one disease, and whether rates
of this disease vary only by that exposure. Clearly,
this is not the case for religion and health. The
literature reveals significant religious effects on scores
of indicators of both morbidity and mortality. There-
fore, the religion-health association does not exhibit
specificity. According to Hill, “We must not, how-
ever, over-emphasize the importance of [this] charac-
teristic” [39, p. 2971. In dealing with chronic diseases,
multiple causation is common (e.g. for heart disease),
and certain causal factors (e.g. tobacco smoking) are
common to multiple disease outcomes.
Temporality. Most of the studies reporting signifi-
cant associations between religion and health are
retrospective or cross-sectional in design. Fewer are
prospective, and fewer still are panel studies. The
provocative Byrd [ 151study provides rare experimen-
tal evidence. Therefore, it has not been conclusively
demonstrated that cause (religion) precedes effect
(health). For example, until recently, most studies
reporting positive associations between religious at-
tendance and functional health (i.e. lack of disability)
in the elderly had been based on cross-
sectional surveys. Thus, some believed, it could be
that increased disability leads to declines in religious
attendance, rather than higher attendance leading to
better health. If so, then frequency of attendance in
disabled elders, rather than being a religious indi-
cator, may be a defacto proxy measure of functional
health; therefore, correlations between attendance
and disability are really correlations between disabil-
ity and disability, and positive associations are thus
spurious. In recent years, however, a series of multi-
wave studies in older populations (see Ref. [5]) has
begun to disentangle these effects and provide better
evidence of temporality.
Biological gradient. This refers to the existence of
a dose-response curve. The Mormon studies dis-
cussed earlier [19,20] suggest such a gradient, but no
one has yet examined all of the existing literature with
this in mind. A careful meta-analysis was conducted
several years ago of a subset of this literature dealing
with older adults [ZO]. However, it is uncertain
whether a dose-response relationship can be directly
inferred from these analyses.
Plausibility. The alternative explanations described
earlier demonstrate that the idea of a religious factor
in health is biologically plausible. That is, it is
consonant with current knowledge in human physi-
ology and health, especially with findings from
behavioral medicine, social epidemiology, and psy-
choneuroimmunology. While an explanation based
on an unproven ‘superempirical’ force was broached,
this was done more for the sake of completeness; an
understanding of religion-health associations does
not hang on this hypothesis.
Coherence. According to Hill, a causal interpret-
ation of an association “should not seriously conflict
with the generally known facts of the natural history
and biology of the disease” [39, p. 2981. Because of
the multiplicity of diseases and health outcomes for
which a significant religious factor has been ident-
ified, it is barely possible to assess this feature as a
causal criterion for this literature. Nevertheless, per-
haps coherence is partly supported by research which
suggests that elements of the proposed explanations
(e.g. health behaviors, social support, health beliefs,
emotional arousal) are associated with many of the
disease outcomes examined in this literature in terms
of risk, etiology, pathogenesis, and prognosis.
Experiment. The Byrd [15] study offers striking
experimental evidence of a religiously oriented effect
on health. However, the nature of the exposure
variable he studied (distant prayer) is substantively
quite different from the other religious variables
considered in this literature, namely public and pri-
vate religious behaviors, attitudes, and affiliations.
For these measures, no experimental evidence exists.
Analogy. A causal relationship between religion
and health is supported by other research which
shows that psychosocial constructs in general vari-
ously increase or decrease risk for many of the
diseases examined throughout the religion and health
literature. For example, Type A behavior is believed
to be related to heart disease (or at least it used to be),
so why not religion? Both are psychosocial variables.
According to Hill, this reasoning by analogy provides
the weakest evidence for causation.
In summary, the question, “Is it causal?‘, can be
answered with a “maybe.” Notwithstanding the fal-
sificationist assertion that the answer, by definition,
cannot ever be yes, examining the evidence in light of
Hill’s guidelines is inconclusive, but promising. Judg-
ing this literature in terms of consistency, plausibility,
and analogy, the answer is yes. In terms of coherence,
the answer is probably yes, but one cannot be certain.
In terms of temporality and biological gradient, there
is insufficient evidence, but recent gerontological find-
ings may change this to a yes. In terms of strength
and experiment, there is insufficient evidence. Finally,
specificity does not seem to be applicable.
CONCLUSION
In sum, hundreds of published empirical studies
have reported findings bearing on a possible relation-
ship between religion and health. On the basis of the
critique presented here, there does appear to be an
association, this association is probably but not
definitely valid, and there is only mixed evidence at
the present time that this relationship is ‘causal.’
 Religion and health
A fourth question can now be posed: “Is this area
worthy of further scientific inquiry?’ This answer to
this question is a confident “yes.” However, one
reservation should be noted. It is important that
investigation into these issues be conducted with care
and with emphasis on the limitations of findings. Too
often, partisans have trumpeted particular findings as
‘proof’ that religious practice causes better health.
This does a disservice to scientists and physicians
who are interested in this area yet are put off by
claims that are based more on extrapolation and
wishful thinking than on systematic research using
representative samples, prospective designs, reliable
and meaningful measures, and a hypothesis-testing
approach.
Finally, the approach taken in this review can
be-and probably should be-applied by researchers
when writing up results of individual studies. In order
for this subject to be intelligently explored, re-
searchers need to carefully scrutinize associations
suggestive of a religious effect. Chance, bias, and
confounding ought to be discussed explicitly, and an
attempt made to rule them out. Alternative expla-
nations ought to be proposed for positive findings,
and some effort ought to be made to address the issue
of causality, such as by stepping through Hill’s
guidelines. Further, this field must begin to take a
more multidisciplinary approach to what is clearly a
multifactoral issue. As Vaux [42] encouraged many
years ago, empirical studies of religion and health
need to better account for the interaction and inter-
play of biochemical, endocrinological, metabolic,
hormonal, and immunologic processes with social,
behavioral, and psychological pattern-a complex
but intrinsic characteristic of human beings. Finally,
little attention has been given to delineating the
clinical and public health applications of these find-
ings (e.g. Ref. [6]). Without such careful scrutiny of
findings and discussion of their therapeutic relevance,
the exploration of potential religious factors in health
will remain and should remain, a marginal issue for
epidemiology and medicine.
Acknowledgements-This work was supported by the
National Institute on Aging under NIH FIRST Award
(R29) Grant No. AGO9462 and NIH Research Project
(ROl) Grant No. AGl0135. The author would like to thank
two anonymous reviewers for their helpful comments.
REFERENCES
1. Levin J. S. and Schiller P. L. Is there a religious factor
in health? J. Religion Hith 26, 9-36, 1987.
2. Schiller P. L. and Levin J. S. Is there a religious factor
in health care utilization?: A review. Sot. Sci. Med. 27,
1369-1379, 1988.
3. Byrne J. T. and Price J. H. In sickness and in health: The
effects of religion. HZth Educ. 10. 6-10. 1979.
4. Levin J. S. Investigating the epidemiologic effects of
religious experience: Findings, explanations, and bar-
riers. In Religion in Aging and Health: Theoretical
Foundations and Methodological Frontiers (Edited by
Levin J. S.). Sage, Thousand Oaks, CA, 1994.
1481
5. Levin J. S. and Vanderpool H. Y. Is frequent religious
attendance really conducive to better health?: Toward
an epidemiology of religion. Sot. Sci. Med. 24,589-600,
1989.
6. Levin J. S. and Vanderpool H. Y. Religious factors in
physical health and the prevention of illness. In Religion
and Prevention in Mental Health: Research, Vision, and
Action (Edited by Pargament K. I., Maton K. I. and
Hess R. E.), pp. 83-103. The Haworth Press, New York,
1992.
7. Osler W. The faith that heals. Er. Med. J. 18,
147&1472, 1910.
8. Frank J. D. The faith that heals. Johns Hopkins Med.
J. 137, 127-131, 1975.
9. Billings J. S. Vital statistics of the Jews. N. Am. Rev.
153, 70-84, 1891.
10. Durkheim E. La Suicide. Alcan, Paris, 1897.
11. Vanderpool H. Y. and Levin J. S. Religion and medi-
cine: How are they related? J. Religion Hlth 29, 9-20,
1990.
12. James W. The Varieties of Religious Experience: A Study
in Human Nature (1902). Longmans, Green, New York,
1917.
13. Jenkins C D. Psychologic and social precursors of
coronary disease. N. Engl. J. Med. 284, 244-255,
307-317, 1971.
14. Comstock G. W. and Partridge K. B. Church attend-
ance and health. J. Chron. Dis. 25, 665672, 1972.
15. Byrd R. C. Positive therapeutic effects of intercessory
prayer in a coronary care unit population. S. Med. J.
81, 826829, 1988.
16. Fletcher R. H., Fletcher S. W. and Wagner E. H.
Clinical Epidemiology: The Essentials, 2nd edn. Williams
& Wilkins, Baltimore, 1988.
17. Troyer H. Review of cancer among 4 religious sects:
Evidence that life-styles are distinctive sets of risk
factors. Sot. Sci. Med. 26, 1007-1017, 1988.
18. Jarvis G. K. and Northcutt H. C. Religion and differ-
ences in morbidity and mortality. SocT Sci. Med. 25,
813-824, 1987.
19. Gardner J. W. and Lyon J. L. Cancer in Utah Mormon
women by church activity level. Am. J. Epidemiol. 116,
258-265, 1982.
20. Gardner J. W. and Lyon J. L. Cancer in Utah Mormon
men by lay priesthood level. Am. J. Epidemiol. 116,
243-257, 1982.
21. Levin J. S. and Vanderpool H. Y. Is religion therapeuti-
cally significant for hypertension? Socl Sci. Med. 29,
69-78, 1989.
22. Levin J. S. Religious factors in aging, adjustment, and
health: A theoretical overview. In Religion, Aging and
Health:A GlobalPerspective (Edited by Clements W. M.),
pp. 133-146. The Haworth Press, New York, 1989.
23. Witter R. A., Stock W. A., Okun M. A. and Haring
M. J. Religion and subjective well-being in adulthood:
A quantitative synthesis. Rev. Religious Res. 26,
332-342, 1985.
24. Koenig H. G. Research on religion and mental health
in later life: A review and commentary. J. Geriutric
Psychiat. 23, 23-53, 1990.
25. Angel1 M. Disease as a reflection of the psyche. N. Engl.
J. Med. 3t2, 1570-1572, 1985.
26. Spector R. E. Cultural Diversity in Health and Illness.
Appleton-Century-Crofts, New York, 1979.
27. House J. S., Landis K. R. and Umberson D. Social
relationships and health. Science 241, 54&545, 1988.
28. Henry J. P. The relation of social to biological processes
in disease. Sot. Sci. Med. 16, 369-380, 1982.
29. Dossey L. Meaning and Medicine: A Doctor’s Tales of
Breakthrough und Healing. Bantam Books, New York,
1991.
30. Frank J. D. Mind-body relationships in illness and
healing. J. Int. Acad. Prevent. Med. 2, 4659, 1975.
1482 JEFFREYS. LEVIN
31. Levin J. S. and Coreil J. “New Age” healing in the U.S.
Sot. Sci. Med. 23, 8899897, 1986.
32. Gerber R. Vibrational Medicine: New Choices for Heal-
ing Ourselves. Bear & Company, Santa Fe, NM, 1988.
33. English-Lueck J. A. Health in the New Age: A Study in
California Holistic Practices. University of New Mexico
Press, Albuquerque, 1990.
34. McGuire M. Health and spirituality as contemporary
concerns. Annls Am. Acad. polit. sot. Sci. 521, 144-154,
1993.
35. Motoyama H. The Correlation Between Psi Energy and
Ki: Unification of Religion and Science. Human Science
Press, Tokyo, 1991.
36. Rothman K. J. Inferring causal connections-habit,
faith or logic? In Causal Inference (Edited by Rothman
K. J.), pp. 3-12. Epidemiology Resources, Chestnut
Hill, MA, 1988.
37. Susser M. Falsification, verification and casual inference
in epidemiology: Reconsideration in the light of Sir Karl
Popper’s philosophy. In Causal Inference (Edited by
Rothman K. J.), pp. 33-57. Epidemiology Resources,
Chestnut Hill, MA, 1988.
38. Labarthe D. R. and Stallones R. A. Epidemiologic
inference. In Causal Inference (Edited by Rothman
K. J.);pp. 119-129. Epidemiology Resources, Chestnut
Hill, MA, 1988.
39. Hill A. B. The environment and disease: Association
or causation? Proc. R. Sot. Med. 58, 1217-1219,
1965.
40. King H. and Locke F. B. American White Protestant
clergy as a low-risk population for mortality research.
J. n%. Cancer Inst.-65, I1 15-1124, 1980.
41. Levin J. S., Chatters L. M., Taylor R. J. and Jackson
J. S. Religiosity, health and life satisfaction in Black
Americans. Presented at the Symposium on Religion
and Mental Health: Current Empirical Research, at the
Annual Meeting of the American Psychological Associ-
ation, New Orleans, July 13, 1989.
42. Vaux K. Religion and health. Prevent. Med. S,522-536,
1976.