Patterns of religious practice and belief in the last year of life.

OBJECTIVES: Although it is frequently assumed that issues of religious faith become more salient at the end of life, there is little or no population-based empirical evidence testing this assumption. METHODS: Using data from the New Haven site of the Established Populations for Epidemiologic Studies of the Elderly (N = 2,812), the authors examined self-reports of attendance at services, self-ratings of religiousness, and strength and comfort felt from religion for respondents who did and did not die within 12 months following an interview. Religiousness was assessed at baseline (1982) and in follow-up interviews in 1985, 1988, and 1994. Cross-sectional comparisons of levels of religiousness were made among persons in their last 6 months of life, persons in their last 12 months of life, and persons who survived 12 months, and longitudinal comparisons were made with religiousness at the previous wave. RESULTS: After adjusting for age, sex, education, marital status, religious affiliation, and a set of health status measures, the authors found that although attendance at religious services declined among the near-deceased, this group showed either stability or a small increase in feelings of religiousness and strength/comfort received from religion. Overall levels of attendance and religious feelings were high for this religiously diverse sample. DISCUSSION: Community studies of respondents in their last year of life are rare. In this sample, religious involvement appears to continue throughout the last months of life.

Survival, functional limitations, and self-rated health in the NHANES I Epidemiologic Follow-up Study, 1992. First National Health and Nutrition Examination Survey.

This study examined relative hazards for mortality and functional limitations according to poor self-ratings of health using prospective data from the NHANES I Epidemiologic Follow-up Study, a representative sample of US adults aged 25-74 years that has been followed since the First National Health and Nutrition Examination Survey (NHANES I) was conducted in 1971-1975. Follow-up data were taken from death records and from the 1982 and 1992 reinterviews. Respondents (n = 6,913) provided extensive baseline data through physician examinations, laboratory testing, and self-reports of conditions, symptoms, and risk behaviors. Functional limitations were assessed among survivors in 1982 and 1992. Cox regression models accounting for sample design indicated that baseline self-rated health was associated with a significantly reduced hazard of mortality for males but not for females through 1992; adjusted hazards ratios for excellent health as compared with poor health were 0.52 for males (95% confidence interval: 0.36, 0.73) and 0.80 for females (95% confidence interval: 0.51, 1.23). Self-rated health also predicted 1982 and 1992 functional limitation for both men and women and 1992 function net of 1982 function for men only. Self-rated health contributes unique information to epidemiologic studies that is not captured by standard clinical assessments or self-reported histories, but evidence suggests that the effect may be stronger for men than for women.

Positive affect and function as influences on self-assessments of health: expanding our view beyond illness and disability.

Longitudinal data from 851 elderly residents of a retirement community (mean age = 73 years) were used to examine the correlates of self-assessments of health (SAH) and the predictors of changes in SAH over several follow-up periods ranging from 1 to 5 years. The authors hypothesized that indicators of positive health, including feelings of energy and positive mood, social support, and active functioning, are as important in determining current and future SAH as negative indicators such as disease history, disability, medication, and negative mood. Results of cross-sectional and longitudinal analyses showed that functional ability, medication use, and negative affect were salient to people judging their health, but positive indicators of activity and mood had an even stronger, independent effect. These findings show the importance of attending to the full illness-wellness continuum in studying people's perceptions of health.

Religion among disabled and nondisabled persons I: cross-sectional patterns in health practices, social activities, and well-being.

What is the relationship between religious involvement and functional disability among elderly people? Is being disabled different for those who frequently attend religious services? Does religious involvement have an effect on subsequent change in disability? Deriving our hypotheses from traditional theories in the sociology of religion, these questions are explored in these two related articles. Both employ data from the New Haven site of the Established Populations for the Epidemiologic Study of the Elderly (N = 2812). In the first, cross-sectional correlates of religious involvement and disability are examined at the baseline of the study, including multiple indicators of health practices, social activities, and subjective well-being. We test for interactions between religious attendance and disability. Findings are (a) that religious involvement in 1982 is tied to a broad array of behavioral and psychosocial resources, (b) that these resources are associated primarily with attendance at services, and not with subjective feelings of religiousness, and (c) that some of these associations are especially pronounced among disabled respondents.

Religion among disabled and nondisabled persons II: attendance at religious services as a predictor of the course of disability.

Does religious involvement influence changes in physical health? We perform a longitudinal analysis of the effect of religious participation on functioning over a 12-year follow-up period, in a large, prospective, representative sample of elderly persons from New Haven, Connecticut, a religiously diverse community. To examine the possibility that disability or changes in disability may be affecting religious involvement, we perform a second longitudinal analysis of changes in religious practices. Finally, we ask whether psychosocial correlates explain the effect of religious involvement on disability. Findings are (a) that attendance at services is a strong predictor of better functioning, even when intermediate changes in functioning are included, (b) that health practices, social ties, and indicators of well-being reduce, but do not eliminate these effects, and (c) that disability has minimal effects on subsequent attendance. The findings illustrate the short- and long-term importance of religious participation to the health and well-being of elderly people, and suggest a particular significance for religious participation in the lives of disabled elders.

Self-rated health and mortality: a review of twenty-seven community studies.

We examine the growing number of studies of survey respondents' global self-ratings of health as predictors of mortality in longitudinal studies of representative community samples. Twenty-seven studies in U.S. and international journals show impressively consistent findings. Global self-rated health is an independent predictor of mortality in nearly all of the studies, despite the inclusion of numerous specific health status indicators and other relevant covariates known to predict mortality. We summarize and review these studies, consider various interpretations which could account for the association, and suggest several approaches to the next stage of research in this field.

Self-rated health and physical disability in elderly survivors of a major medical event.

This article describes change and stability in self-rated health after a major medical event. Using a prospective design, it examines the ability of premorbid and post-illness health perceptions to predict physical disability independently of medical, psychosocial, and behavioral variables. Participants (N=254) were a subsample of the New Haven cohort of the Established Populations for Epidemiologic Studies of the Elderly (EPESE) project who had survived hospitalization for stroke, myocardial infarction, or hip fracture. Data came from premorbid EPESE interviews, medical records, and interviews at 6 weeks and at 6 months after hospitalization. Health perceptions did not universally decline after the illness. Self-rated health at 6 weeks predicted disability at 6 months, but premorbid self-rated health did not, suggesting that illness-related changes in health perceptions influenced the recovery process. The effects of 6-week self-rated health on disability were independent of physical inactivity. The mechanisms by which health perceptions influence recovery are unclear.

Self-ratings of health: do they also predict change in functional ability?

Self-ratings of health by individuals responding to surveys have shown themselves to be potent predictors of mortality in a growing number of studies; they appear to contribute significant additional independent information to health status indicators gathered through self-reported health histories or medical examinations. A key question raised by these studies is: What are the mediating processes involved in the association? Specifically, do poor self-ratings increase the risk of disability and morbidity, and are these outcomes intervening steps in the link to mortality? In this report we address the first question, of self-ratings predicting future levels of functional disability, our choice of an index of overall impact of morbidity. Data come from the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE) site (N = 2,812). Results show that self-ratings of health in 1982, net of baseline functional ability, health and sociodemographic status, are associated with changes in functional ability over periods of one through six years. These findings extend our understanding of the meaning of excellent, good, fair, and poor ratings of health, and that they have implications not just for survival but for the loss or maintenance of functional ability in daily life.

Age differences in self-assessments of health: age changes, cohort differences, or survivorship?

Do older people tend to exaggerate their health problems? Or do they downplay them? Do such tendencies change as people age? Are they a function of cohort membership? Or are differences in health perceptions among elderly people due to differences in survivorship within the elderly cohorts? These questions are examined with longitudinal data from the Yale Health and Aging Project, a stratified probability sample of elderly persons in New Haven, Connecticut. Complete health assessments are available for 2,583 community residents 65 and older in 1982, and complete follow-up date are available for 1,319 respondents in 1988. Multivariate regressions of self-assessed health on concurrent 1982 and 1988 objective health status and longitudinal analysis of residual values from these equations show that: (a) older survey respondents gave disproportionately positive health assessments, and (b) processes of aging, selective survivorship, and cohort differences all appear to play a role in creating this pattern.

Health perceptions and survival: do global evaluations of health status really predict mortality?

Self-evaluations of health status have been shown to predict mortality, above and beyond the contribution to prediction made by indices based on the presence of health problems, physical disability, and biological or life-style risk factors. Several possible reasons for this association are discussed: (a) methodological shortcomings of previous studies render the association spurious; (b) other psychosocial influences on mortality are involved and explain the association; and (c) self-evaluations of health status have a direct and independent effect of their own. Four-year follow-up mortality data from the Yale Health and Aging Project (N = 2812) are used to explore these possibilities. The analysis controls for the contribution of numerous indicators of health problems, disability and risk factors, and also makes adjustments of standard errors for the complex sample design. The findings favor the third possibility, an independent effect, to the extent that the particular set of psychosocial factors examined did not explain the basic association, and to the extent that the control variables were an adequately comprehensive set.

PIP: Researchers evaluated data from a prospective study begun in 1982 of the health of 2812 elderly people in New Haven, Connecticut to determine the extent self perceptions of health have on predicting mortality. The results demonstrated that men who rated their health as bad or poor were 6.75 times at risk of death than those who rated it as excellent. In addition, women who reported their health as bad or poor were 3.12 times more likely to die than those who claimed to be in excellent health. Both of these results were statistically significant. Nevertheless age was the best predictor of mortality for both sexes. For men, self assessed health followed age then the Roscow score (a health scale for the aged), smoking, and diabetes. For women, diabetes followed age then self assessed health, the Roscow score, body mass index, and smoking. Further poor and fair self assessed health statuses correctly predicted both early and late deaths for both sexes. Additional analyses showed that the association between self assessed health and mortality existed only for women living in the community and not for those in public or private housing for the elderly. Moreover this analysis indicated an excess number of expected deaths among women living in public housing who claimed to be in excellent health. Medical care utilization, presence of external social resources (e.g., close friends), and presence of internal emotional resources (e.g. religiosity) had little to no direct effect on mortality. These results indicated that self rated health has a unique, predictive, and, at the present time, inexplicable association with mortality. Further research on possible contributing variables is needed.

Self-rated health and mortality in the NHANES-I Epidemiologic Follow-up Study.

The ability of self-rated health status to predict mortality was tested with data from the National Health and Nutrition Examination Survey (NHANES-I) Epidemiologic Follow-Up Study (NHEFS), conducted from 1971-84. The sample consists of adult NHANES-I respondents ages 25-74 years (N = 6,440) for whom data from a comprehensive physical examination at the initial interview and survival status at follow-up are available. Self-rated health consists of the response to the single item, "Would you say your health in general is excellent, very good, good, fair, or poor?" Proportional hazards analyses indicated that, net of its association with medical diagnoses given in the physical examination, demographic factors, and health related behaviors, self-rated health at Time 1 is associated with mortality over the 12-year follow-up period among middle-aged males, but not among elderly males or females of any age.

Self-evaluated health and mortality among the elderly in New Haven, Connecticut, and Iowa and Washington counties, Iowa, 1982-1986.

The ability of global self-evaluations of health to predict survival in follow-up studies is tested in two samples of elderly, noninstitutionalized adults. Data from the Yale Health and Aging Project, New Haven, Connecticut (n = 2,812), and the 65+ Rural Health Study, Iowa and Washington counties, Iowa (n = 3,673), were used to investigate the association between 1982 self-evaluated global health status (excellent, good, fair, poor) and survivorship from 1982 to 1986. Despite extensive controls for physical health status in the form of measures of disabilities and chronic conditions, sociodemographic characteristics, and health risk behaviors at the beginning of the follow-up period, and the use of analytic techniques which take into account the stratified sample design of the New Haven data, poor self-perceptions of health significantly increase the risk of mortality. Adjusted odds ratios for the extreme categories ("poor" as compared with "excellent") for New Haven men and women were 5.33 (95% confidence interval (CI) 1.93-14.75) and 2.99 (95% CI 1.30-6.91), respectively; for Iowa men and women they were 4.84 (95% CI 2.22-10.57) and 3.16 (95% CI 1.49-6.71). Respondents reporting "fair" and "good" health also show elevated risks of mortality in dose-response fashion. Self-perceptions of health status appear to be a factor of unique prospective significance in mortality studies.

Moral medicine: symbolic content in 19th century Shaker therapeutics.

This paper presents an analysis of the symbolic meanings implicit in an ostensibly empirical therapeutic system. The Shakers, a celibate communal religious order founded in New York State in the mid 1770s, were practitioners of botanic medicine, as were many other Americans in the nineteenth century. This study analyzes the therapeutic properties of the herbs they produced (such as diuretic, stimulant, narcotic, emetic, astringent), using a classification scheme based on the location of the botanical substance's effect vis-à-vis body boundaries and surfaces. The Shakers' beliefs about the therapeutic properties of their herbs are compared with similar analyses of the properties given by two contemporary nineteenth century New England proponents of herbal medicine, botanist Constantine Rafinesque and sectarian practitioner Samuel Thomson. The comparison shows systematic variation in emphasis given to herbs which regulate internal body processes, or act through the openings of the body or on its surface. In this context Shaker medicine can be characterized as quickening, internal, and purifying in its effects on body processes, effects which are highly consistent with Shaker religious beliefs in active, physical worship, selflessness and spiritual purification by confession.