Epidemiological studies of religious behaviours and health in the Nord-Trøndelag Health Study (HUNT 3), Norway

Torgeir Sørensen Epidemiological studies of religious behaviours and health in the Nord-Trøndelag Health Study (HUNT 3), Norway PhD Thesis MF Norwegian School of Theology, Oslo 2012

Contents Acknowledgements 5 List of papers 7 Summary 9 1. Background 13 A personal approach 13 Religion and health as a theme of interest throughout the centuries 14 Religion and health research 15 In the beginning 15 The Allport tradition 16 Religious coping 17 The emerging era from 1980 19 Norwegian religion and health research 21 Possible explanations for relationships between religion and health 22 Religion and physical health 24 Religion, cancer and quality of life 26 Religion and mental health 28 Objective(s) 31 2. Material and Methods 32 Concepts 32 Religion 32 Health 34 Epidemiology informed by and relevant to psychology of religion 36 Theory of science 37 Normative aspects 40 Ethics 41 Material 42 Environment religiousness in Nord-Trøndelag County, Norway 42 Data source the HUNT Study 46 Samples Paper I, II and IV 46 Samples Paper III 47 Variables 48 Assessment of items applicability and choice of exposure variables (independent) 48

The relationship between the exposure variables 51 Dependent variables (Paper II-IV) 52 Other variables 53 Methods 55 Qualitative approach (Paper I) 55 Quantitative approach (Paper I-IV) 56 3. Results/Review of Paper I-IV 57 Paper I 58 Paper II 59 Paper III 60 Paper IV 61 4. General discussion 62 Discussion of methods 63 The researcher 63 Design 63 Precision 64 Internal validity 65 External validity 67 The papers juxtaposed 68 Attendance at church/prayer house and seeking God s help as religion 69 The contextual factor 71 Inverse relationships 74 Humour and receptive/creative culture 76 Gender differences 76 Conclusions 79 Implications 80 Research proposals 80 Clinical practice 81 Contributions to practical theology 82 5. References 85 Paper I-IV Appendix

Acknowledgements I am sitting on the veranda of our cabin in Vera at spring time writing these first (or last) lines of my thesis. The snow is about to melt and the small stream murmurs. As the landscape emerges from a long, cold and dark winter, the sun heats me up and sheds light on this scenery of Nord-Trøndelag. I am thinking that the delivery is close - in several ways. Later on, maybe a red tractor will stop by with my good friend Arve coming out for a cup of coffee, reminding me of the 50.000 other inhabitants in this county participating in the HUNT 3 Study. What would my thesis be if not all of these people had shared their time and sincerity regarding a huge amount of personal sensitive information? Thanks to HUNT Research Centre and all staff there for including the religiousness items in the HUNT 3 Study, for hosting me in the three months period when my project protocol was written, for awakening the interest for research in me, and last but not least for providing data for my project. Thanks to MF Norwegian School of Theology for funding four years of research, hosting me in its PhD-programme, accommodating me with an excellent office, exceptional IT-resources, and an outstanding library. Thanks to the department of research at Innlandet Hospital Trust for giving me a 20% position in three years at Centre for Psychology of Religion, Sanderud, and granting me funding for publication of data. Thanks also to Eckbo s legater for financial support. I have always considered this interdisciplinary project as a team work. I am very grateful to my supervisor prof. Lars Johan Danbolt, PhD (Centre for Psychology of Religion, and MF Norwegian School of Theology) for his continues encouragements and for his view that everything will turn out just fine. To co-supervisor prof. Jostein Holmen, MD, PhD (HUNT Research Centre, NTNU), for including me in the HUNT-family, for his everlasting patience, and thorough responses. To co-supervisor prof. Lars Lien, MD, PhD (University of Oslo, Center for dual diagnoses, and Innlandet Hospital Trust), for his obligingness and for his quick and pronounced replies. It has also been a pleasure to extend the team with other excellent scholars as co-authors on different papers. Thanks to prof. Harold G. Koenig, MD, PhD (Duke University Medical Center, NC, USA), for sharing his accumulated knowledge from the religion and health field 5

the last 25 years, and for never being more than five minutes away on mail. I am in debt to prof. Sophie D. Fosså, MD, PhD and prof. Alv A. Dahl, MD, PhD (both at National Resource Centre for Late Effects after Cancer Treatment, Oslo University Hospital, Radiumhospitalet), for their contribution to the cancer-paper. And statistician Tore Wenzel-Larsen made important efforts on two of the papers giving hands-on supervision. Several people have been supporters all the way. Thanks to dean Per Halstein Nielsen and vicar/dean Nils Åge Aune, my good colleagues in Verdal back in 2004, for the idea and mutual encouragement working towards inclusion of the religiousness items in HUNT 3. Prof. Hans Stifoss-Hanssen (Diakonhjemmet University College) and prof. Leif Gunnar Engedal (MF Norwegian School of Theology) have participated at the national seminar for psychologists of religion and given valuable feedback on presentations together with PhD Tor Torbjørnsen and the other PhD-candidates. Thank you very much to everyone else, colleagues, relatives, and friends, who gave their encouragements. At the cabin, just now, our oldest daughter Ingrid is fetching milk on the nearby farm for the waffles we are having in the afternoon, Ola is doing some carpentry next to me on the veranda, Johanne is running around just smiling, while my wife Ingvild, a bit unyielding, is taking the last skiing trip for the season. I am truly grateful for them being around me. There are some advantages from having a wife who knows how to merge files and who knows what it takes to get a paper published. But first and foremost she is my best friend. An imaginary spring at Sisselvollkoia in Vera, somewhere in Nord-Trøndelag Torgeir Sørensen 6

List of papers Paper I: Sørensen, T., Lien, L., Holmen, J., Danbolt, L.J. (2012). Distribution and understanding of items of religiousness in the Nord-Trøndelag Health Study, Norway. Mental Health, Religion and Culture, 15 (6), 571-585 Paper II: Sørensen, T., Danbolt, L.J., Lien, L., Koenig, H.G., Holmen, J. (2011). The relationship between religious attendance and blood pressure: the HUNT Study, Norway. The International Journal of Psychiatry in Medicine, 42 (1), 13-28 Paper III: Sørensen, T., Dahl, A.A, Fosså, S.D., Holmen, J., Lien, L., Danbolt, L.J. (2012). Is Seeking God s help Associated with Life Satisfaction and Disease-Specific Quality of Life in Cancer Patients? The HUNT Study, Norway. Archive for the Psychology of Religion, 34 (2), 191-213 Paper IV: Sørensen, T., Danbolt, L.J., Holmen, J., Koenig, H.G., Lien, L. (2012). Does Death of a Family Member Moderate the Relationship between Religious Attendance and Depressive Symptoms? The HUNT Study, Norway. Depression Research and Treatment, Special Issue: Religious and Spiritual Factors in Depression, doi:10.1155/2012/396347, available from URL: http://www.hindawi.com/journals/drt/2012/396347/abs/ 7

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Summary The main objective for this thesis was to investigate, in a Norwegian context, relationships between attendance at a church/prayer house and seeking God s help for strength and solace on the one side, and different health factors on the other. Possible relationships between religion and health have not been investigated with population-based large data sets in Norway before, and hardly ever in a North-European context. Therefore, the approach was explorative and attempted to cover the largest disease groups: cardiovascular diseases and lifestyle, cancer, and mental health. Initially, an introduction regarding religiousness and worldview in the third wave of the Nord-Trøndelag Health Study (the HUNT 3 Study) was made, together with an assessment of their applicability for this kind of research (Paper I). In Paper II, the aim was to investigate the relationship between religious attendance and diastolic and systolic blood pressure in a large Norwegian sample. In Paper III, the variable I seek God s help when I need strength and solace and its relation to the time since a cancer diagnosis among patients was investigated, in addition to its association with life satisfaction for all cancer types, and disease-specific quality of life for patients with breast, prostate and colorectal cancer. Finally, the relationship between attending a church/prayer house and depressive symptoms was investigated, with an analysis of whether or not this relationship was moderated by the death of a close family member (Paper IV). One central finding in the thesis was that attendance at a church/prayer house was associated with lower systolic as well as lower diastolic blood pressure, the latter displayed with gradients in both genders (Paper II). In the cancer study (Paper III), there was an increased prevalence of seeking God s help, which decreased after follow-up of more than five years in men, but not in women. However, there were no significant associations either between seeking God s help for strength and solace and life satisfaction among all cancer patients, or between seeking God s help and disease-specific quality of life among breast, prostate or colorectal cancer patients. In the last study (Paper IV), attending a church/prayer house was significantly and inversely related to symptoms of depression. Death of an immediate family member interacted with attendance at religious services. Consequently, the inverse relationship between religious attendance and depressive symptoms was strongest among those who had lost an immediate family member in the previous 12 months, especially among men. 9

In public health and epidemiology research, investigators search for risk factors that contribute to poor health outcomes. At the same time, protecting and promoting health are also emphasised. Among several other themes, researchers have also looked into religion and religious activity, and have investigated whether religious factors are associated with health, either negatively or positively. Thus, religion and health research has been an emerging research field internationally, especially in the last three decades. Because the Nord-Trøndelag Health Study (The HUNT Study) included items of religiousness and worldview in its third wave (HUNT 3, 2006-2008), it was possible to investigate relationships between religion and health in a Norwegian context. The HUNT Study provides for large-scale public health research with numerous health and health-related variables, mapping both mental and physical health status, quality of life and risk factors, as well as health-promoting factors for the whole population in the county of Nord-Trøndelag, in Central Norway. Through its three waves (HUNT 1, 1984-1986; HUNT 2, 1995-1997; HUNT 3, 2006-2008), data from 120,000 persons have been obtained. In HUNT 3, 50,405 people 20 years old and older participated. Of these, 37,981 participants (21,247 women and 16,734 men) responded to the question about attendance at a church/prayer house, which constituted the samples in Paper II and Paper IV. Between 36,280 and 40,031 participants rated items regarding religiousness and worldview affiliation presented in Paper I. The basis for the sampling in Paper III was the 2,777 participants in HUNT 3 with a record in the Cancer Registry of Norway (CRN, 2012). Most previous religion and health research has been conducted in the USA. Norwegian research in the field should be welcome, since religious and cultural environments appear to be quite different from continent to continent. Typical for the Norwegian context, and especially for Nord-Trøndelag County, is its folk-church environment, with high membership, but low rates of weekly attendance compared to other countries. Compared to Americans, less Norwegians believe in God, and even less Norwegians have faith in a personal God. This makes Norway an interesting environment for investigations regarding religion and health, and for comparisons with earlier findings. 10

In the current population, religiousness was measured only once, which allowed for a crosssectional research design. Frequency distribution was considered to derive the characteristics of the sample, and cross-tabulations, one-way ANOVAs, t-tests and Pearson correlations were performed to describe bivariate relationships among variables. When associations between religiousness and the selected aspects of health were investigated, regression analyses were applied, with adjustments for socio-demographic factors together with other relevant control variables. This thesis represents a first step in a systematic composition of knowledge regarding the relationship between religion and health in a Norwegian context using an epidemiologic approach to population-based data. The cross-sectional design of this current work represents pure research and shows significant relationships between religiousness and both physical and mental health. However, an obvious limitation concerning the research design is the missing possibility to demonstrate any causal direction between the variables included in the analyses. The thesis includes suggestions for further research strategies, and possible implications are also discussed. 11

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1. Background A personal approach For eight years, from 2000-2007, I served as a vicar in several parishes in Verdal, Nord- Trøndelag County, Norway. I held services every Sunday. Some days the church was full; other days only a handful of people participated. I followed the church members, who were inhabitants in the area, through joy and sorrow, in life and death. The high level of attendance related to baptism, confirmation, funerals, and also to some extent weddings was striking. The inhabitants in the parishes seemed to be strongly connected with their local church, and this was brought to light especially when it came to rites of passage and other occasions when they were especially invited. At the same time, it seemed difficult for these people to articulate the significance of church. Even among those attending services, it was not common for them to put their beliefs into words. So, in fact, as a vicar I did not know very much about the religious life of church members except that they came to church. I did not know what function their religion had, what it meant to them, or whether religious life was a help in their everyday lives. In 2004, the HUNT Research Centre (HUNT Research Centre, 2012), situated in Verdal at that time, was planning the third wave (HUNT 3) of its population-based health survey. My colleagues and I started discussions with the HUNT Research Centre, arguing that the HUNT Study should include questions about religion and worldviews because a holistic view is among several factors, including religious practices that could be important for health. As a result of these discussions, a group including science scholars covering the psychology of religion and medicine, in addition to a colleague and I, was established to work with relevant religious and worldview perspectives to be included in the HUNT 3 Study. Finally, five items were accepted by the HUNT Research Centre and were included in the HUNT 3 survey. The question was how the religious variables would work, whether data from the HUNT 3 Study could generate new knowledge, would include some of my questions regarding the religious life of church members, and would give some perspectives on the function of religious life for the inhabitants of Nord-Trøndelag County, Norway. 13

Religion and health as a theme of interest throughout the centuries As long as there has been human life, there has also been interest in health and religion. From ancient times religious leaders like priests, shamans, and wizards had, in addition to the keeping of faith and contact with the gods, responsibilities as mediums for healing (Koenig et al., 2012). Despite quite varied religious origins, it was thought that health depended on the gods, spirits, ancestors, or evil powers. The practice of laying on of hands, the use of herbs and amulets in the service of healing is known in notes from the old cultures of, for instance, Egypt and Mesopotamia, as well as from India and China in pre-christian times (Prioreschi, 1995). It is clear that both religious rituals and natural methods were used to address health issues. In the Western world, from the first centuries AD, a paradigm shift occurred in the development of Christianity. Among Christians, caring for the sick, rather than curing their illnesses, became the most important issue. This was based on the Christian teachings and sayings in the Bible, where care for those in need was one of the most profound requests. Subsequently, in the middle of the fourth century, a hospital funded by Orthodox Christians was established in Asia Minor. Two hundred years later, Benedict of Nursia wrote his rule on prayer and labour. In the prolongation monks and nuns dedicated their lives to their God and to serve the sick. Later on, in the eleventh century, monks learned about Greek medicine and established the first medical school in Italy. Thus, medicine became part of the university, run by clerics and church (Koenig et al., 2012:19-23). A typical example of the link between religion and health in a Norwegian setting arose in the Middle Ages, when special interest emerged in Norway, and later on throughout Europe, regarding the sacred places linked to St. Olav. Stiklestad in Nord-Trøndelag County, where St. Olav died in 1030 AD, and Trondheim, where his body was kept in a shrine in the cathedral, became important. Due to the tradition of wonders related to St. Olav s death and the time after, people made pilgrimages to these sacred places for healing the body as well as the soul (Sturluson, 1979:445). Even though medicine became a profession of its own during the Middle Ages, and the clergy concentrated more on their theological duties than on medicine later on, Christians and the Church were still strongly involved in diaconal care for the sick and the indigent. In Norway 14

in the second half of the nineteenth century, for example, the education of nurses was established by deaconess Cathinka Guldberg, in close cooperation with the Christiania home mission (Munkeby, 2008). Throughout the centuries, people have maintained an interest in religion and health together, and these important aspects of people s lives have been interwoven on several levels. In the Western tradition, this relationship has been motivated through Christian care for the sick and respect for their faith. However, wider religious references have emerged in later years through the ritualisation of healing, for instance from a New Age perspective (Danbolt & Stifoss-Hanssen, 2007:56). Additionally, in relation to demanding events and catastrophes in Norway, new practices have arisen regarding seeking God, sacred places, rituals, etc. Such practices, and the psychological and healing function of rituals, have been observed and discussed (Danbolt & Stifoss-Hanssen, 2007; Stifoss-Hanssen, 2001). The development of natural science placed research on subjectivity and religious experience in the shadow during large parts of the twentieth century. But, as described below, a new era may have emerged, at least with respect to research, concerning the relationship between religion and health. What remains to be seen is what impact the generated knowledge will have on further epidemiological research and on a longer perspective on different practices, for instance in clinical settings and in practical theology. Religion and health research In the beginning Throughout the last hundred years some milestones have been important for the development of religion and health research, some of which will be presented below. As a theme for research its history goes back to between the 19 th and the 20 th century (Wulff, 1997:23-30). At that time, the field of psychology arose as a separate discipline, growing out of philosophy. Interestingly, the pioneers were already interested in religious experience and the function of religion as it relates to psychology. The psychologist Edwin Starbuck established the quantitative paradigm, tracing conversion and religious development through questionnaires (Wulff 1997:26). In the first scientific paper written in the field of the psychology of religion, psychologist James Henry Leuba (1896) characterised religious experience as naive and illusory because, according to him, it lacks a transcendent object. He also argued that mystical 15

experiences could be explained by psychosocial processes. The Harvard psychologist and philosopher William James had a more positive approach towards religion s state within psychology, which was presented in the classic The Varieties of Religious Experience (James, 1902). Through a qualitative design, he established a descriptive approach to religious phenomena. Fundamental for James was that mental states are dependent on bodily states (Wulff, 1997:27). Further, he made a distinction between healthy ( once-born spirit) and unhealthy ( twice-born spirit) religiousness (Wulff, 1997:491). This distinction between positive and negative types of religiousness and their impact on mental health was to be followed by other researchers in the field. The psychoanalytic tradition of Sigmund Freud also made important contributions to issues of religion and health, but it is left out here due to space limitations and because its methods, interwoven with clinical practice, deviate from religion and health research in general. The Allport tradition In the 1950s, there was renewed interest in the objectifying paradigm (Engedal, 2011:214) and the religion and mental health research field. Gordon Allport (1950) developed sophisticated standardised questionnaires describing religiousness and its relationship with mental health. As such, Allport emphasised the cognitive aspects of religion. Through his instruments he was able to measure what he called extrinsic and intrinsic religiousness. Extrinsic religiosity was characterised as instrumental, self-oriented, dependent on authorities, prejudiced and immature. On the other hand, intrinsic religiosity was described as integrated, personal, authentic and mature. Extending the Allport tradition, a third construct of religiousness, the quest, was introduced by Batson and colleagues (Batson et al., 1993:169), and emphasised the individual s religion and its involvement in an open-ended responsive dialogue with existential questions raised by the contradictions and tragedies of life. These three different approaches to religiousness represent quite different relationships to mental health. Integrated intrinsic religiousness may have a protective function towards mental health problems, and can be of help for persons with serious problems, for instance related to anxiety (Shreve-Neiger et al., 2004). A firm conviction and a clear worldview may provide a determined direction for life when other factors are demanding. Those living within the borders of normal variations, the non-pathological variations of mental health, would benefit from the quest approach to life. People who adopt this approach towards religion and 16

life tend to experience better than average mental health (Stifoss-Hanssen, 1992). In general, the extrinsic approach towards religiousness contributes to worse than average mental health (Stifoss-Hanssen & Kallenberg, 1996:48). This is seen related to hospitalisation and diagnoses, as well as when rigid religiousness is seen in relation to the positive features of mental health, such as flexibility, or realizing one s potentials. On these grounds, it could be said that an ideal religious approach would be a combination of an integrated intrinsic religiousness, with its determined orientation, and the religiousness of the quest, with its willing view outwards in order to gain self-realization and flexibility (Stifoss-Hanssen & Kallenberg, 1998:70). Religious coping The strict categorisation of religiousness in the Allport tradition can be criticised for being just that, too categorical. Religion as a construct is too complicated to be defined in only three different groups, particularly when considering its relation to health. With that in mind, religious coping as an alternative approach was developed by Kenneth Pargament (1997). He emphasised that religion, together with coping, is seen as a multidimensional process. Religion is not merely static, traditional and ritual. According to Pargament, religion must also be seen in a physical, mental, social and spiritual context, because people constantly search for significance within these dimensions. Positive helpful religious coping reflects a confident relationship with a transcendent God or deity, a conviction that life has a meaning beyond the limits of the senses, and relationships with others in a social setting tied together by a common belief. With a negative harmful religious coping approach, people see the world as threatening and they struggle with religion in order to find and conserve significance in life (Pargament et al., 1998). Several studies have found positive religious coping to be significantly associated with desirable mental health indicators, such as optimism, and less severe stress symptoms, like numbness and avoidance (Pargament & Raiya, 2007). A meta-analysis of 49 studies also concluded that positive religious coping was related to positive psychological adjustment to stress (Ano & Vasconcelles, 2005). Negative religious coping, on the other hand, is related to negative health outcomes. In a longitudinal study, negative religious coping was associated with a higher risk of dying 17

(Pargament et al., 2001). This was especially true for people who felt that God had abandoned them and were uncertain about whether they were loved and cared for by God. Among cancer patients, negative religious coping (struggling with faith) was significantly related to poorer functioning in the areas of depression, distress, mental health, and pain and fatigue, after controlling for relevant variables (Sherman et al., 2005). In another cancer study, negative religious coping was associated with higher levels of depression, anxiety, pain severity and frequency, and poorer overall physical well-being (Cole, 2005). Pargament argued in favour of a direct connection between religion and health outcomes (Pargament & Raiya, 2007). This is due to numerous investigations of the relationship between religion and health that adjusted for all available relevant control-variables, and still found a significant association in multivariate analyses. In meta-analysis, this association is found with regard to religious involvement and lower mortality (McCullough et al., 2000). Another example is where religious coping predicts the degree of life satisfaction (Tix & Frazier, 1998). According to Pargament, a brief explanation of these relationships is that religion is a distinct dimension playing an independent role in life. Religious coping can also function as a mediating factor in relationships between religion and physical health, as religious coping may foster adaptive health behaviours that can lead to stress-related personal growth, as well as improved physical health (Oman & Thoresen, 2005). Since physical and mental health issues may be connected (see below), religious coping can serve as a complement to non-religious coping, offering resources beyond personal powers through connection with the transcendent (Pargament, 1997:310). Those who collaborate with God when facing demanding events in life may experience better outcomes than those who are passive towards problems, or those who approach stressful events through self-directive coping styles (Pargament, 1997:294). Even though the instrument for religious coping, RCOPE (Fetzer Institute, 2003), is utilised in Scandinavia (Ahmadi, 2006), adaption of this instrument to a Scandinavian context can be challenging. Religion and religion and health research depend on cultural context, as mentioned in the Discussion section of this thesis (DeMarinis, 2011). For instance, the wording of the items in RCOPE may not find echoes among the majority of the Scandinavian population to the same extent as in the USA. Especially in the homogenous folk-church 18

environments, such as in Nord-Trøndelag County in Central Norway, most people seem to find it difficult to identify with expressions like finding comfort in reading the Bible, or being punished by God. Still, more than half of this population prays to God and attends church at least once every six months. At the same time, RCOPE could be relevant for the most religious, but not necessarily for a whole population. Pargament is one of the most important contributors to the new era of the psychology of religion that emerged in the 1980s (Wulff, 1997:249). Although his theory has been considered suitable for qualitative research (Ekedal, 2002; Torbjørnsen, 2011), Pargament finds a natural place within what has been characterised as the measurement paradigm (Wulff, 2003) utilising quantitative methods. The emerging era from 1980 From the 1980s onwards, research in the field of religion and health developed extensively utilising empirical quantifiable measurements (Engedal, 2011; Koenig et al., 2001; Koenig et al., 2012; Paloutzian & Emmons, 2010). Illustrative of the expansion of religion and health research from this time on is the conceptualisation and operationalisation of religion, as well as the development of a wide range of instruments suitable for research on associations between religion and health (Fetzer Institute, 2003; Hill & Hood, 1999). At the same time, the field appeared as interdisciplinary, engaging social sciences like psychology, sociology, and anthropology; humanities like theology; and natural sciences like medicine. A quantitative approach to the objectifying paradigm has dominated the field (Engedal, 2011). Even though qualitative research, as well as mixed methods, is used in this research (Belzen & Hood, 2010), the body of research is derived from quantitative studies. For this thesis, the quantitative research approach was chosen in order to compare the thesis findings with other studies in the field. The typical approach in quantitative religion and health research has been to study the relationship between aspects of religion and selected health factors, controlling for sociodemographic variables and other relevant factors. Consequently, associations between most religious phenomena, like belief, affiliation, activity, etc., and a wide range of the most common physical and mental health factors are listed in the research-body of religion and health. 19

A vast majority of the research in the field of religion and health is performed in the USA. Several handbooks present and review the literature extensively. Handbook of Religion and Health (Koenig et al., 2001; Koenig et al., 2012) presents the majority of the quantitative measurement research up to 2011, and evaluates its strengths and weaknesses. All together its two volumes contain reviews of approximately 3,700 studies. Typical for Koenig and collaborators in their handbooks is an assessment of the quality of the studies and a summary of how many studies found positive, negative or no relationship between religious phenomena and health factors. They conclude that in the large picture, as well as within the special chapters of their handbooks, the majority of studies show positive relationships between religion and health, demonstrating that religion is positively related to health. Another collection of particular interest is the Handbook of the Psychology of Religion and Spirituality (Paloutzian & Park, 2005), which presents a thematic approach to several issues regarding religion and health. Work in the German tradition, for instance Murken s (1998) dissertation regarding the connection between mental health and a relationship with God, is absent in the reviews mentioned above, possibly because the German language is not widely accessible for an English-speaking audience. However, investigations published in English may be found, for example, regarding religion and health research among cancer patients (Büssing, 2008). Only few, typical representatives for and relevant contributors to religion and health research are found in a Scandinavian context. Especially relevant for this thesis is a 20-year follow-up study of 734 Danes (la Cour et al., 2006). La Cour and collaborators found that the hazard ratios for dying were lower among church attendees compared to non-attendees, with women attendees living 2.2 years longer and men, 1.4 years. Their findings were not very far from findings in corresponding research in California, USA (Strawbridge et al., 2001). Another study by la Cour (la Cour et al., 2008) investigated existential, religious and spiritual/religious practice variables and their relationship with dimensions of health among 480 Danish hospital patients. Among men it was found that levels of existential, religious, or spiritual/religious practice issues were low when illness was not severe, but the levels increased when illness became worse. The opposite was found among women. 20