Religion, health and mortality among elderly population in Mexico and Puerto Rico
Kenya Noronha
Department of Economics
Federal Univeristy of Minas Gerais
Alberto Palloni
Center for Demography and Ecology
University of Wisconsin-Madison
FIRST DRAFT
1. Introduction
While studies of the relationship between religion and health are quite abundant in developed countries, they are remarkably scarce in low income countries in general and Latin America in particular (Levin and Markides 1985, Ferraro and Albrecht-Jensen 1991,
Idler and Kasl 1997a, Idler and Kasl 1997b, Oman and Reed 1998, Ellison and Levin 1998, Chatters 2000, King, Mainous, and Pearson 2002, Fredrickson 2002, George, Ellison and Larson 2002, Regnerus and Smith 2005, Lee and Newberg 2005, Benjamins and Buck 2008, McCullough and Willoughby 2009, Zhang 2008, Kim 2007). This is regrettable because at least Latin America societies have become the bedrock of renewed religious fervor through the massive spread of protestant denominations that may eventually supplant the century long domination of the Catholic Church. Since the evidence gathered elsewhere suggests that, by and large, individual religious beliefs and practices have important beneficial effects on health and survivorship (Blanchard et al 2008, Williams and Sternthal 2007, Dupre, Franzese and Parrado 2006, Benjamins 2004, Hummer et al 1999), it is natural to ask if and to what an extent the emergence of new forms of religiosity in a rapidly aging context such as that pervasive in LAC countries may actually engender positive spillovers manifesting themselves in decreased morbidity and mortality. This highlights the importance of extending the study of the relationship between health and religion beyond the boundaries of developed countries.
The objective of this paper is to provide a preliminary assessment of the relationship between individual religious beliefs and practices and individual health and mortality among elderly in Mexico and Puerto Rico. We use data from MHAS (Mexican
Health and Aging Survey) and PREHCO (Puerto Rican Elderly Health Conditions. Both data sets are two wave panels and contain rich information on health status and short term mortality as well as information on religious beliefs and practices. Strict comparability between the two countries is difficult because the information of religious beliefs and practices differ across surveys and also because the health indicators are dependent on information elicited through questions that are not strictly comparable and are also subject to culturally dependent biases.
We estimate effects of religious beliefs and practices measured at baseline on survival and health status assessed at the time of second wave. In particular, we choose four health outcomes: (a) self reported heart diseases, (b) self reported diabetes, (c) functional disability measured as difficult to perform at least one activity of daily life (ADL) and (d) mortality.
If preliminary assessments suggest more than trivial associations, our next aim is to identify the main mechanisms through which religion may influences health status and survival. In particular, we focus on two of the three main mechanisms identified in the literature: (a) adherence to religious beliefs could promote behavioral practices that have well established beneficial health effects and (b) religious practices encourage formation of and participation in social networks with all their machinery of social and emotional support. We also examine albeit less thoroughly than would be desired an additional conjecture that invokes the neurophysiological effects of transcendental beliefs and practices that involve meditation and prayer.
Paramount in our analysis is a defensive stance to prevent misinterpretations that plague studies of this type. Indeed, any inference about the health effects of religion faces
three serious challenges. The first is that there are individual traits (usually unmeasured) that increase the likelihood of both adherence to religious beliefs and aversion of risky behavior. The second is that health status by itself may limit (enhance) participation in religious practices or promote (deter) acceptance of religious beliefs. Third, unmeasured predispositions toward particular types of behaviors with non trivial health impact may actually increase the probability of abandoning religious beliefs and/or defect from religiously based groups.
The paper is organized as follows. In Section II we describe the data sets for Mexico and Puerto Rico and formulate the estimation procedures. In Section III we discuss preliminary results.
2. Material and Methods
Data sources
The data used were from the Mexican Health and Aging Study (MHAS) and Puerto Rican Elderly: Health Conditions (PREHCO). Both surveys are two-wave panels of nationally representative samples of non-institutionalized elderly individuals. The interviews were conducted with elderly adults including those with cognitive limitations who required the presence of a proxy to provide information and with their surviving spouses regardless of age.
The PREHCO study is a panel study of a nationally representative sample of Puerto Rican adults over 60 years old.1 A total of 4,291 in-home face-to-face target interviews were conducted between May 2002 and May 2003. In addition 1,442 spouses
1
The study, a joint venture between the Center for Demography and Ecology of the University of Wisconsin-Madison and the Graduate School of Public Health of the University of Puerto Rico, funded by the National Institute on Aging and supported by the Legislature of Puerto Rico, is the largest ever about the elderly population in Puerto Rico.
were interviewed, 1,042 of them 60 or older. The follow up interview of targets and spouses took place between June of 2006 and November of 2007. A total of 3,891 interviews of targets and 1,260 spouses were carried out for an overall response rate of 90.6% for targets and 89.61% for spouses. Among targets and spouses over 60, there were 867 individuals who had died and 55 who were institutionalized in the inter-wave period, whose interviews were completed using a proxy. Four hundred and two targets and spouses over 60 were assigned a non-response code: 142 of them refused to be interviewed and most of the remaining 260 could not be located or moved to the mainland.2
MHAS is a nationally representative, prospective panel study of Mexicans aged 50 and over as in 2000 funded by the National Institute on Aging. Baseline interviews were completed in the summer of 2001 with about 15,000 respondents, including target and spouses. The individual non-response rate of 10.5% for a population based survey is very low. The second wave of MHAS was successfully fielded in 2003. An exit-interview was sought in 2003 with a next-of-kin of deceased persons; about 540 next of kin interviews were obtained, a number consistent with expectations given the mortality levels in Mexico. Sample attrition was small (7% at the individual level) for a total of about 12,000 follow-ups with surviving individuals who were age 50 or older at the baseline. All data files for MHAS 2001 and the 2003 follow-up are now public use3.
2 For more information on PREHCO see the study website http://prehco.rcm.upr.edu/ 3
For details on the study and access to the data, see the study website at www.mhas.pop.upenn.edu.
Our analyses includes all elderly who are above 60 years old (except spouses) including those who responded via proxies.
Dependent Variables Health Outcomes
We define four health indicators measured at the time of the second wave. The first variable is a dummy that equals one if the individual died during the inter-wave period. Considering only target individuals, around 7% of the interviewed elderly (349 observations) died between 2001 and 2003 in Mexico and around 17% (678 observations) died in Puerto Rico between 2002 and 2006.
The second and third health outcomes refer to two self-reported chronic diseases: diabetes and heart diseases (including hypertension, heart attack, heart conditions and stroke). These are the most common chronic conditions experienced by elderly in Latin America. Around 34% and 76% of the elderly people in Puerto Rico reported having suffered of diabetes and heart diseases in 2006. For Mexico 2003 the figures are 16% and 41% respectively.
Finally, the fourth health outcome is a measure of functional disability. We classify as disabled all individuals who self-report at least one limitation in Activities of Daily Life (ADL). The ADLs considered were the standard ones, namely, moving across the room, dressing oneself, taking a shower, eating, going to bed, and using the toilet. According to these definitions, the proportion of individuals older than 60 years with a limitation in at least one ADL is 20% in Puerto Rico, and 19% in Mexico.
Religion Variables
The indicators to evaluate religious beliefs and practices are not strictly comparable between the two countries. In the case of Puerto Rico we are able to construct two indicators. The first one is more objective and evaluates attendance to religious services. Individuals were asked how often have you attended religious services? (no attendance, once a month, 2 or 3 times a month, once a week, 2 or 3 times a week and everyday). The obvious difficulty with this variable is that some individuals may not be able to attend religious services due to poor health conditions. While one could address the endogeneity problem using a variety of techniques, we chose instead to use an alternative indicator which is less contaminated by potential endogeneity. It is a more subjective measure of religiosity and was obtained by eliciting a rank of individuals’ own religiosity (very religious, somewhat religious or not at all religious).
In the case of Mexico we were able to employ only a single subjective indicator of the importance of religion for individuals’ lives (very important, somewhat important and not important). Even though this indicator is a more subjective measure of religiosity, it is not quite comparable to the one available to Puerto Rico.
Other controls
Besides the indicator of religious practices and beliefs, all models include controls for age, gender, educational level, lifestyle, social network and health status measured at the baseline survey. In both countries lifestyle indicators include physical activities practices, smoking and alcohol intake, and body mass index (included as continuous variable). In PREHCO social network indicators available to us include participation in social activities, availability of help with household tasks, when dealing with sickness
and of casual but frequent contacts. In MHAS, only information on social activities participation is available.
3. Preliminary Results
We estimate a series of logistic models for each of the health outcomes defined before. In Puerto Rico there are significant effects of church attendance on mortality, functional disability and diabetes (Tables 1-3). The effect of religious attendance on the probability of experiencing heart disease is not statistically significant (Table 4). Among Puerto Rican elderly who attend religious services either 2-3 times a month, once a month or 2-3 times a week, the probability of dying is lower than those who do not attend religious services. However, those at the extremes, namely attending once per day or once per month, experience mortality risks that are not statistically different from those who do not attend at all. The probability of having difficulty to perform at least one ADL is lower among those who attend church more than once a week. In the case of diabetes, the estimated effect of religious attendance for Puerto Rico is a function of how often individuals go to church. The probability of experiencing diabetes is significantly higher among those who attend everyday than among those who do not attend but it is lower among those who attend once a month. After controlling for lifestyle and social network variables, the effect of religious attendance on all health outcomes is attenuated as has been found in previous studies (Williams and Sternthal 2007, Dupre, Franzese and Parrado 2006, Hummer et al 1999).
We found that the effect of subjectivity religiosity has no effects on any of the health outcomes analyzed in either country (Tables 5-12).
Table 1. Estimated effects of religious attendance on mortality
Puerto Rico (2002-2006).
Variables Model 1 Model 2 Model 3 Model 4
once/mo -0.25 ns -0.21 ns -0.07 ns -0.09 ns 2-3 times/mo -0.46 * -0.52 ** -0.29 ns -0.29 ns once/week -0.27 * -0.26 * -0.13 ns -0.14 Ns 2-3 times/week -0.88 *** -0.82 *** -0.64 *** -0.64 *** every day -0.50 ns -0.45 ns -0.24 ns -0.24 Ns sexo 0.52 *** 0.56 *** 0.37 *** 0.43 *** age_2002 0.07 *** 0.07 *** 0.07 *** 0.07 *** household size -0.03 ns -0.05 ns -0.07 ns -0.09 * school -0.05 *** -0.05 *** -0.04 *** -0.03 ** heart_2002 0.13 ns 0.27 ** 0.25 * diab_2002 0.51 *** 0.62 *** 0.60 *** CDa_2002 -0.08 ns -0.10 ns -0.13 Ns adl_2002 0.41 *** 0.33 * 0.29 * depress_2002 0.18 ns 0.17 ns 0.15 Ns physica~2002 -0.22 ns -0.24 Ns bmi_2002 -0.07 *** -0.07 *** smoked 0.43 *** 0.43 *** smoke 0.59 *** 0.61 *** heavy drink -0.14 ns -0.10 Ns social activities -0.07 Ns
help with tasks 0.24 Ns
help when sick 0.16 Ns
people visiting 0.01 Ns
_cons -6.38 *** -7.13 *** -5.57 *** -5.58 *** Source: PREHCO 2002-2006
Table 2. Estimated effects of religious attendance on the probability of having diabetes - Puerto Rico (2002-2006).
Variables Model 1 Model 2 Model 3
once/mo -0.28 ** -0.26 * -0.29 ** 2-3 times/mo 0.21 ns 0.17 ns 0.18 ns once/week -0.08 ns -0.06 ns -0.07 ns 2-3 times/week -0.05 ns -0.04 ns -0.06 ns every day 0.42 ** 0.45 ** 0.42 ** sexo -0.03 ns 0.09 ns 0.15 ns age_2002 -0.01 *** -0.01 * -0.01 ** household size 0.06 * 0.04 ns 0.03 ns escolar -0.02 ** -0.02 ** -0.02 ** physica~2002 -0.13 ns -0.14 ns bmi_2002 0.06 *** 0.06 *** smoked -0.12 ns -0.13 ns smoke 0.01 ns 0.00 ns heavy drink -0.29 ns -0.27 ns social activities 0.06 ns
help with tasks 0.16 ns
help when sick 0.03 ns
people visiting 0.03 ns
_cons 0.49 ns -1.48 *** -1.61 ***
Source: PREHCO 2002-2006
Table 3. Estimated effects of religious attendance on Functional Limitation - Puerto Rico (2002-2006).
Variables Model 1 Model 2 Model 3 Model 4
once/mo -0.07 ns -0.12 ns -0.08 ns -0.08 ns 2-3 times/mo -0.34 ns -0.27 ns -0.18 ns -0.16 ns once/week -0.51 *** -0.48 *** -0.31 * -0.32 ** 2-3 times/week -0.37 ** -0.39 ** -0.22 ns -0.21 ns every day -0.54 * -0.66 ** -0.53 * -0.48 ns sexo -0.75 *** -0.50 *** -0.43 *** -0.35 ** Age 0.03 *** 0.04 *** 0.04 *** 0.04 *** Household size 0.04 ns 0.02 ns 0.01 ns -0.01 ns Yrs schooling -0.05 *** -0.04 *** -0.03 *** -0.03 ** Heart 0.44 *** 0.33 ** 0.31 ** Diabetes 0.27 ** 0.22 * 0.22 *
Other Chronic diseases 0.62 *** 0.65 *** 0.61 ***
Depression 0.63 *** 0.68 *** 0.64 *** ADL 1.45 *** 1.19 *** 1.15 *** Physical activities -0.40 ** -0.43 ** Bmi 0.04 *** 0.05 *** Smoked 0.20 ns 0.19 ns Smoke 0.49 ** 0.47 ** Alcohol -0.35 ns -0.28 ns Social activities -0.19 ns
Help with tasks 0.37 ***
Help when sick -0.14 ns
People visiting 0.14 ns
_cons -2.91 *** -4.85 *** -6.38 *** -6.30 ***
Source: PREHCO 2002-2006
Table 2. Estimated effects of religious attendance on the probability of having heart diseases - Puerto Rico (2002-2006).
Variables Model 1 Model 2 Model 3
once/mo -0.05 ns -0.07 ns -0.09 ns 2-3 times/mo 0.00 ns -0.05 ns -0.06 ns once/week 0.04 ns 0.10 ns 0.09 ns 2-3 times/week 0.17 ns 0.16 ns 0.16 ns every day -0.02 ns -0.01 ns -0.01 ns sexo -0.34 *** -0.33 *** -0.28 ** age_2002 0.01 ** 0.02 *** 0.02 *** Household size 0.03 ns 0.03 ns -0.02 ns escolar -0.03 *** -0.03 *** -0.02 ** Diabetes 2002 1.03 *** 0.93 *** 0.89 *** Physical activites -0.03 ns -0.03 ns Bmi 2002 0.09 *** 0.09 *** Smoked 0.12 ns 0.11 ns Smoke -0.19 ns -0.17 ns Alcohol 0.21 ns 0.21 ns Social activities -0.11 Ns
Help with tasks 0.25 **
Help when sick 0.40 ***
People visting -0.08 ns
_cons 0.30 ns -2.74 *** -2.82 ***
Source: PREHCO 2002-2006
Table 5. Estimated effects of subjective religiousity on mortality
Puerto Rico (2002-2006).
Variables Model 1 Model 2 Model 3 Model 4
very religious 0.06 ns 0.04 ns 0.08 ns 0.07 ns sexo 0.59 *** 0.62 *** 0.42 *** 0.48 *** age_2002 0.07 *** 0.07 *** 0.07 *** 0.07 *** household size -0.03 ns -0.05 ns -0.07 ns -0.09 * school -0.05 ns -0.05 *** -0.04 *** -0.04 ** heart_2002 0.15 ns 0.31 ** 0.28 ** diab_2002 0.51 *** 0.62 *** 0.60 *** CDa_2002 -0.12 ns -0.13 ns -0.16 ns adl_2002 0.49 *** 0.38 ** 0.34 ** depress_2002 0.18 ns 0.17 ns 0.15 ns physica~2002 -0.24 ns -0.25 ns bmi_2002 -0.07 *** -0.07 *** smoked 0.44 *** 0.44 *** smoke 0.66 *** 0.67 *** heavy drink -0.05 ns 0.00 ns social activities -0.10 ns
help with tasks 0.27 *
help when sick 0.19 ns
people visiting -0.04 ns
_cons -6.78 ns -7.50 *** -5.76 *** -5.74 ***
Source: PREHCO 2002-2006
Table 6. Estimated effects of subjective religiosity on diabetes -Puerto Rico (2002-2006).
Variables Model1 Model2 Model3
very religious -0.03 ns -0.02 ns -0.03 ns sexo -0.04 ns 0.09 ns 0.14 ns age_2002 -0.01 *** -0.01 * -0.01 * household size 0.06 * 0.04 ns 0.03 ns escolar -0.03 *** -0.03 *** -0.03 *** physica~2002 -0.12 ns -0.13 Ns bmi_2002 0.06 *** 0.06 *** smoked -0.11 ns -0.12 Ns smoke -0.06 ns -0.07 Ns heavy drink -0.29 ns -0.27 Ns social activities 0.07 Ns
help with tasks 0.17 *
help when sick 0.02 Ns
people visiting 0.04 Ns
_cons 0.48 ns -1.43 *** -1.57 ***
Source: PREHCO 2002-2006
Table 7. Estimated effects of subjective religiosity on heart diseases -Puerto Rico (2002-2006).
Variables Model 1 Model 2 Model 3
very religious -0.11 ns -0.07 ns -0.06 ns sexo -0.35 *** -0.34 *** -0.28 ** age_2002 0.01 ** 0.02 *** 0.02 ** c1num 0.04 ns 0.03 ns -0.01 Ns escolar -0.03 *** -0.03 *** -0.02 ** diab_2002 0.99 *** 0.90 *** 0.86 *** Physical Activities -0.07 ns -0.08 Ns Bmi 0.09 *** 0.09 *** Smoked 0.13 ns 0.11 Ns Smoke -0.27 ns -0.27 Ns Alcohol 0.22 ns 0.23 Ns Social activities -0.06 Ns Help tasks 0.29 ***
Help when sick 0.39 ***
People visiting -0.09 Ns
_cons 0.42 ns -2.50 *** -2.55 ***
Source: PREHCO 2002-2006
Table 8. Estimated effects of subjective religiosity on Functional Limitation-Puerto Rico (2002-2006).
Variables Model 1 Model 2 Model 3 Model 4
very religious 0.07 ns 0.05 ns 0.11 ns 0.14 ns sexo -0.70 *** -0.45 *** -0.40 *** -0.31 ** age_2002 0.03 *** 0.04 *** 0.04 *** 0.04 *** household size 0.04 ns 0.02 ns 0.01 ns -0.02 ns School -0.05 *** -0.04 *** -0.03 ** -0.03 ** Heart diseases 0.44 *** 0.34 ** 0.31 ** Diabetes 0.25 ** 0.21 ns 0.20 ns
Other Chronic Diseases 0.60 *** 0.65 *** 0.61 ***
depression 0.59 *** 0.66 *** 0.62 *** ADL 1.47 *** 1.19 *** 1.15 *** Physical activities -0.39 ** -0.42 ** Bmi 0.05 *** 0.05 *** Smoked 0.21 ns 0.20 ns Smoke 0.57 ** 0.51 ** heavy drink -0.29 ns -0.19 ns social activities -0.24 * help tasks 0.42 ***
health when sick -0.16 ns
visitors 0.17 ns
_cons -3.33 *** -5.21 *** -6.73 *** -6.65 ***
Source: PREHCO 2002-2006
Table 9. Estimated effects of subjective religiosity on Mortality-Mexico - (2001-2003).
Variables Model 1 Model 2 Model 3 Model 4
somewhat important -0.07 ns -0.19 ns -0.14 ns 0.00 ns very important -0.01 ns -0.20 ns -0.28 ns -0.13 ns Sexo -0.25 * -0.41 ** -0.39 ** -0.37 ** age_2001 0.08 *** 0.08 *** 0.07 *** 0.07 *** household size -0.03 ns -0.05 ns -0.07 ns -0.07 ns years school -0.03 ns -0.02 ns -0.05 ** -0.04 * heart diseases (2001) 0.35 ** 0.29 * 0.31 * Diabestes (2001) 0.58 *** 0.47 ** 0.44 ** Other CD (2001) 0.08 ns 0.25 ns 0.27 ns ADL (2001) 0.74 *** 0.35 * 0.37 * Physical activities (2001) -0.59 *** -0.55 ** BMI (2001) 0.01 ns 0.01 ns smoked 0.04 ns 0.05 ns smoke 0.42 * 0.44 * heavy drink 0.11 ns 0.12 ns social_2001 -0.22 ns _cons -8.17 *** -7.64 *** -6.97 *** -7.11 *** Source: MHAS 2001-2003
Table 10. Estimated effects of subjective religiosity on Diabetes-Mexico - (2001-2003).
Variables Model 1 Model 3 Model 4
somewhat important -0.03 ns -0.08 ns -0.09 ns very important 0.03 ns 0.09 ns 0.09 ns Sexo 0.31 *** 0.11 ns 0.11 ns age_2001 -0.03 *** -0.03 *** -0.03 *** household size 0.04 ** 0.04 * 0.04 * years school -0.02 ns -0.02 ** -0.02 ** Physical activities (2001) -0.33 *** -0.33 *** BMI (2001) 0.04 *** 0.04 *** Smoked -0.05 ns -0.05 ns smoke -0.32 ** -0.32 ** heavy drink -0.26 ns -0.26 ns social_2001 -0.03 ns _cons -0.22 ns -0.55 ns -0.53 ns Source: MHAS 2001-2003
Table 11. Estimated effects of subjective religiosity on Heart Diseases-Mexico - (2001-2003).
Variables Model 1 Model 3 Model 4
somewhat important 0.06 ns -0.02 ns -0.03 ns very important 0.13 ns 0.01 ns 0.00 ns sexo 0.61 *** 0.53 *** 0.53 *** age_2001 0.00 ns 0.00 ns 0.00 ns household size 0.01 ns 0.01 ns 0.01 ns years school 0.00 ns 0.00 ns 0.00 ns Physical activities (2001) 0.45 *** 0.31 *** 0.31 *** BMI (2001) -0.07 ns -0.07 ns smoked 0.04 *** 0.04 *** smoke 0.05 ns 0.05 ns heavy drink -0.30 ** -0.30 ** social_2001 0.26 ns 0.26 ns social_2001 0.00 ns _cons -1.49 *** -2.52 *** -2.50 *** Source: MHAS 2001-2003
Table 12. Estimated effects of subjective religiosity on Functional Limitation-Mexico - (2001-2003).
Variables Model 1 Model 2 Model 3 Model 4
somewhat important 0.39 ns 0.36 ns 0.27 ns 0.27 ns very important 0.43 ns 0.35 ns 0.28 ns 0.28 ns sexo 0.41 *** 0.24 ** 0.15 ns 0.15 ns age_2001 0.07 *** 0.06 *** 0.06 *** 0.06 *** household size 0.01 ns 0.00 ns 0.02 ns 0.02 ns years school -0.06 *** -0.06 *** -0.06 *** -0.06 *** heart diseases (2001) 0.30 *** 0.19 * 0.18 * Diabestes (2001) 0.58 *** 0.58 *** 0.57 *** Other CD (2001) 0.39 *** 0.45 *** 0.45 *** ADL (2001) 1.56 *** 1.59 *** 1.59 *** Physical activities (2001) -0.58 *** -0.58 *** BMI (2001) -0.01 ns -0.01 ns smoked -0.05 ns -0.05 ns smoke -0.26 ns -0.26 ns heavy drink 0.10 ns 0.10 ns social_2001 -0.06 ns _cons -7.31 *** -6.99 *** -6.55 *** -6.52 *** Source: MHAS 2001-2003
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