Religion, a social determinant of mortality? A 10-year follow-up of the Health and Retirement Study

<div><p>The social determinants of health framework has brought a recognition of the primary importance of social forces in determining population health. Research using this framework to understand the health and mortality impact of social, economic, and political conditions, however, has rarely included religious institutions and ties. We investigate a well-measured set of social and economic determinants along with several measures of religious participation as predictors of adult mortality. Respondents (N = 18,370) aged 50 and older to the Health and Retirement Study were interviewed in 2004 and followed for all-cause mortality to 2014. Exposure variables were religious attendance, importance, and affiliation. Other social determinants of health included gender, race/ethnicity, education, household income, and net worth measured at baseline. Confounders included physical and mental health. Health behaviors and social ties were included as potential explanatory variables. Cox proportional hazards regressions were adjusted for complex sample design. After adjustment for confounders, attendance at religious services had a dose-response relationship with mortality, such that respondents who attended frequently had a 40% lower hazard of mortality (HR = 0.60, 95% CI 0.53–0.68) compared with those who never attended. Those for whom religion was “very important” had a 4% higher hazard (HR = 1.04, 95% CI 1.01–1.07); religious affiliation was not associated with risk of mortality. Higher income and net worth were associated with a reduced hazard of mortality as were female gender, Latino ethnicity, and native birth. Religious participation is multi-faceted and shows both lower and higher hazards of mortality in an adult US sample in the context of a comprehensive set of other social and economic determinants of health.</p></div

Descriptive statistics, Health and Retirement Study 2004, weighted and adjusted for complex sample design.

<p>Descriptive statistics, Health and Retirement Study 2004, weighted and adjusted for complex sample design.</p

Mortality hazard ratios from Cox proportional hazard models for religion measures, before and after inclusion of other social determinants, potential confounders, and potential mediators, with adjustment for complex sample design, Health and Retirement Study, 2004–14.

<p>Mortality hazard ratios from Cox proportional hazard models for religion measures, before and after inclusion of other social determinants, potential confounders, and potential mediators, with adjustment for complex sample design, Health and Retirement Study, 2004–14.</p

Modeling steps of the Cox proportional hazard regressions, Health and Retirement Study 2004–2014.

<p>Modeling steps of the Cox proportional hazard regressions, Health and Retirement Study 2004–2014.</p

Individual-level factors of study population by prevalence of iron and folic acid receipt and consumption.

<p>^a It should be noted that all women in the study population received at least one ANC visit. Those who did not attend ANC were not asked about IFA receipt or consumption;</p><p>^b Early enrollment: 1^st trimester, Late enrollment: 2^nd-3^rd trimester; ANC: Antenatal care; IFA: Iron and Folic Acid</p><p>Individual-level factors of study population by prevalence of iron and folic acid receipt and consumption.</p

Characteristics and rotated factor loadings for Health Sub-Center factors^a^a.

<p>^a Factor loadings ≤|0.35| are not shown;</p><p>HSC: Health Sub-Center; PHC: Primary Health Center; VHSC: Village Health and Sanitation Committee</p><p>Characteristics and rotated factor loadings for Health Sub-Center factors^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0120404#t002fn001" target="_blank">a</a>}^a.</p

Characteristics and rotated factor loadings for antenatal care factors^a^a.

<p>^a Factor loadings ≤|0.5| are not shown; ANC: Antenatal care</p><p>Characteristics and rotated factor loadings for antenatal care factors^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0120404#t001fn001" target="_blank">a</a>}^a.</p

Flowchart of Health Sub-Center exclusions and final sample.

<p>Flowchart of exclusions and final sample of health sub-centers surveyed in Bihar through DLHS-3. HSC: Health Sub-Center; DLHS: District Level Household Survey; PSU: Primary Sampling Unit; IFA: iron and folic acid tablets or syrup.</p

Multilevel modeling of iron and folic acid consumption for ≥90 days during last pregnancy.

<p>^a Early enrollment:</p><p>1^st trimester, Late enrollment: 2^nd-3^rd trimester; AIC: Akaike Information Criterion; ANC: Antenatal care; HSC: Health Sub-Center; IFA: iron and folic acid; PHC: Primary Health Center</p><p>Multilevel modeling of iron and folic acid consumption for ≥90 days during last pregnancy.</p

Variable definitions included in multilevel modeling of IFA receipt and consumption.

<p>^a Early enrollment:</p><p>1^st trimester, Late enrollment: 2^nd–3^rd trimester; ANC: Antenatal Care; HSC: Health Sub-Center; IFA: Iron and Folic Acid; PHC: Primary Health Center; PSU: Primary Sampling Unit; Ref.: Reference Value; WHO: World Health Organization</p><p>Variable definitions included in multilevel modeling of IFA receipt and consumption.</p