Aksoy, O

Bann, D

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American Journal of Epidemiology© The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School ofPublic Health. This is an Open Access article distributed under the terms of the Creative Commons AttributionLicense (http://creativecommons.org/licenses/by/4.0), which permits unrestricted reuse, distribution, andreproduction in any medium, provided the original work is properly cited.Vol. 00, No. 00https://doi.org/10.1093/aje/kwab135Advance Access publication:Response to Invited CommentaryBann and Aksoy Respond to “Religious Service Attendance and Public Health”David Bann∗ and Ozan Aksoy∗∗ Correspondence to Ozan Aksoy, Social Research Institute, University College London, 55-59 Gordon Square, London WC1H0AA, United Kingdom (e-mail: ozan.aksoy@ucl.ac.uk); or David Bann, Social Research Institute, University College London,55-59 Gordon Square, London WC1H 0AA, United Kingdom (e-mail: david.bann@ucl.ac.uk).Initially submitted April 23, 2021; accepted for publication May 3, 2021.Estimating the causal effect of religiosity on health is chal-lenging. Even for service attendance, for which evidence isstrongest as VanderWeele et al (1) elegantly summarize, the“exposure” itself and likely its effects are enormously variedacross and within religious traditions. An effect of a giventype of attendance may also differ in direction and magni-tude by context—cross-sectional analysis notwithstanding,associations seemingly range from negative in China toparticularly positive in the United States (2). Prior findings(1, 3) that do suggest, in a given context, beneficial effectson certain health outcomes should also be interpreted withcaution: What may have been the case in the past does notnecessarily determine what could or indeed should be thecase in the future. The somewhat acerbic reactions to pastwork on this topic (4–6) perhaps highlight the polarizingviews on the net benefit to individuals and society thatreligious institutions bring (7, 8). A robust link betweenservice attendance and health could, however, have impli-cations for both religious and secular societies. This broaderutilitarian ground may bridge opposing views and be mostfruitful in terms of etiology and translation. Building on priordiscussion (9), we pose 2 sets of questions that could aid suchunderstanding.Assuming a causal link exists, why is religious serviceattendance beneficial for health? What elements of atten-dance are most beneficial? How can those elements be trans-ferred to other domains? Addressing these questions willnot only improve the causal credibility of earlier findingsbut also help to improve the transferability of inferences tointervention or policy. It would also help to incorporate such“exposures” in broader environments than the US-focusedcontext discussed by VanderWeele et al. For instance, wherereligious attendance may attract ostracization or hostility(10), population wellbeing could be similarly improved ifnonreligious community participation is facilitated. Suchalternatives will also be important given the increasing sec-ularization observed nearly globally (11, 12). Investigatingemerging secular alternatives (e.g., the Sunday Assembly)and contrasting them with religious attendance could be afirst step to addressing the above questions, though suchinitiatives are still in their infancy (3). New data collec-tions on secular alternatives may be warranted alongsideanalysis of prominent nonreligious community participa-tion activities that are more tractably investigated in exist-ing epidemiologic studies (e.g., sports teams and volunteergroups).Assuming a robust set of exposures is extracted fromreligious service attendance, the second set of questionsconcerns the identification of policy levers through whichthese exposures could be implemented and evaluated in aninclusive way. VanderWeele et al. (1) focused on clinician-patient interactions; yet, despite their apparent neutral char-acter, the proposed questions on religion/spirituality mightbe interpreted as inappropriate or even proselytization inroutine care, given the clinician-patient power dynamic. Amore inclusive approach could be to focus on communityparticipation, inclusive of religious service attendance. Thiscould be empirically tested as a form of social prescrib-ing. More broadly, interventions focusing on such clinicalinteractions are likely less suitable to contexts with limitedpatient-clinician interactions or when such interactions nec-essarily focus on active treatment rather than prevention.There may be other possible upstream public health targetsto improve community participation that are more effectiveand equitable than those operating at the individual levelvia activity promotion (13, 14). Epidemiologic findings thusmotivate a need to better understand the determinants ofand possible policy tools for facilitating community par-ticipation. Although US society has become increasinglyindividualized (from 1960 to 2020), a contrasting trendtowards increased community involvement occurred pre-viously (from 1900 to 1960) (15). Such shifts illustratethe potential modifiability of community participation andthe possibility of incorporating the beneficial componentsof religious attendance in broader (religious and secular)society.1 Am J Epidemiol. 2021;00(00):1–2Downloaded from https://academic.oup.com/aje/advance-article/doi/10.1093/aje/kwab135/6274217 by guest on 19 November 20212 Bann and AksoyACKNOWLEDGMENTSAuthor affiliations: Centre for Longitudinal Studies, TheSocial Research Institute, University College London,London, United Kingdom (David Bann); and Centre forQuantitative Social Science, The Social Research Institute,University College London, London, United Kingdom(Ozan Aksoy).Both authors contributed equally to this work.D.B. is supported by the Economic and Social ResearchCouncil (grant number ES/M001660/1), the MedicalResearch Council (grant number MR/V002147/1), and TheAcademy of Medical Sciences/Wellcome Trust(“Springboard Health of the Public in 2040” award:HOP001/1025).The authors thank David Voas and Dingeman Wiertz forcomments.Conflict of interest: none declared.REFERENCES1. VanderWeele TJ, Balboni TA, Koh HK. Invited commentary:religious service attendance and implications for clinical care,community participation, and public health. Am J Epidemiol.2021;190(XXX):XXX–XXX.2. Zimmer Z, Rojo F, Ofstedal MB, et al. Religiosity and health:a global comparative study. SSM Popul Health. 2018;7, 006.3. Aksoy O, Bann D, Fluharty ME, et al. Religiosity and mentalwellbeing among members of majority and minorityreligions: findings from Understanding Society: The UKHousehold Longitudinal Study. Am J Epidemiol. 2021;190(XXX):XXX–XXX.4. Krieger N. Religious service attendance and suicide rates.JAMA Psychiat. 2017;74(2):197–198.5. Davey Smith G. Post–modern epidemiology: when methodsmeet matter. Am J Epidemiol. 2019;188(8):1410–1419.6. Re PF. Positive epidemiology? Epidemiology. 2020;31(5):e37.7. Hitchens C. God Is Not Great: How Religion PoisonsEverything. New York, NY: Little, Brown & Company; 2008.8. Harris S. Letter to a Christian Nation. New York, NY:Vintage; 2008.9. Kawachi I. Invited commentary: religion as a socialdeterminant of health. Am J Epidemiol. 2020;189(12):1461–1463.10. Pew Research Center. A Closer Look at How ReligiousRestrictions Have Risen Around the World: Tenth AnnualReport Dives Deeper Into the Ways Government Restrictionson Religion and Social Hostilities Involving Religion HaveChanged, From 2007 to 2017. Washington, DC: PewResearch Center; 2019. https://www.pewforum.org/2019/07/15/a-closer-look-at-how-religious-restrictions-have-risen-around-the-world/. Accessed April 23, 2021.11. Voas D. The continuing secular transition. In: Pollack D,Olson DVA, eds. The Role of Religion in Modern Societies.Taylor and Frances: Milton Park, UK; 2008:25–48.12. Stolz J. Secularization theories in the twenty-first century:ideas, evidence, and problems. Presidential address. SocialCompass. 2020;67(2):282–308.13. Lorenc T, Petticrew M, Welch V, et al. What types ofinterventions generate inequalities? Evidence from systematicreviews. J Epidemiol Community Health. 2013;67(2):190–193.14. Jebb SA, Aveyard P, Hawkes C. The evolution of policy andactions to tackle obesity in England. Obes Rev. 2013;14(S2):42–59.15. Putnam RD. The Upswing: How America Came Together aCentury Ago and How We Can Do It Again. New York, NY:Simon & Schuster; 2020.Am J Epidemiol. 2021;00(00):1–2Downloaded from https://academic.oup.com/aje/advance-article/doi/10.1093/aje/kwab135/6274217 by guest on 19 November 2021

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