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Religious Coping, Ethnicity, and Ambulatory Blood Pressure

From the Department of Psychiatry and Behavioral Sciences (P.R.S., J.A.B., A.S.), Duke University Medical Center, Durham; and the Department of Medicine (A.L.H.), University of North Carolina, Chapel Hill, North Carolina.

Address reprint requests to: Andrew Sherwood, PhD, Box 3119, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC 27710.

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
OBJECTIVE: To investigate the relationship between religious coping, ethnicity, and ambulatory blood pressure (ABP) measured during daily life.

METHODS: A 24-hour ABP was obtained from 155 men and women (78 African American and 77 white) on a typical workday. ABP was averaged over awake and sleep periods, and clinic BP was also assessed. Psychosocial measures of coping style, negative affect, social support, stress, and health behaviors were completed before ABP measurement.

RESULTS: Multiple regression analyses, controlling for demographic variables, revealed a significant religious coping by ethnicity interaction for ABP (p < .01) and clinic BP (p < .05). Religious coping was not related to BP among whites. Among African Americans, however, higher levels of religious coping were associated with lower awake (p < .05) and sleep (p < .01) ABP. Social support satisfaction also was related to lower awake ABP among African Americans, but it did not mediate the relationship between religious coping and ABP.

CONCLUSIONS: The results of this study extend previous findings by showing that, among African Americans, religious coping and BP are related during daily activities as well as in the clinic. Lower 24-hour BP load may be a pathway through which religiosity and cardiovascular health are related.

Key Words: religious coping • ethnicity • blood pressure • ambulatory blood pressure

Abbreviations: BP = blood pressure; ABP = ambulatory blood pressure; SBP = systolic blood pressure; DBP = diastolic blood pressure; SES = socioeconomic status.

	INTRODUCTION

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The relationship between religiosity and health has received increased attention during recent years (1–3). In general, religious factors such as church attendance, religious beliefs, and religious activities are associated with psychosocial functioning, health behaviors, and a variety of health outcomes (4–12). People who score higher on measures of religiosity usually have less depression and anxiety, and have better coping abilities and resources and increased social support, compared with people with low religiosity. Religious individuals also tend to engage in fewer negative health behaviors (eg, smoking, alcohol consumption, poor diet), perceive themselves as being healthier than the average person, and have decreased mortality and morbidity, compared with those who are less religious. Controlling for relevant psychosocial and health behavior variables explains, in part, the relationship between religion and physical health outcomes (12). Critiques of this line of research have noted that not all research studies have found positive results, that many studies have methodological problems including the failure to control for potential confounds, and that appropriate statistical adjustments have not always been made when performing multiple statistical tests (3, 13).

BP is one potential mechanism by which religion may be related to health (14). Approximately 25% of the adult population in the US (about 50 million) suffer from hypertension (15). Hypertension significantly increases the risk for heart disease, kidney failure, and stroke (16). A number of research studies have found that higher levels of religiosity are related to lower levels of BP (17–24). The religious variables that have been found to be particularly important in BP are personal religious coping activities, such as prayer, scripture study, and seeking religious help and comfort (23, 24). Individuals with higher levels of religious coping have been shown to have lower levels of clinic BP, even after controlling for age and BMI, which are significant factors in hypertension (16).

Ethnicity has been shown to be related to both BP and religious coping. African Americans, compared with whites, have a greater prevalence of hypertension, develop high BP at an earlier age, and have more frequent occurrences of hypertension-related diseases (15, 25–27). This higher prevalence has been attributed to several factors, including obesity, diet, and lower socioeconomic status (28, 29). African Americans also typically score higher on measures of intrinsic religiosity and report using higher levels of religious coping (30–36). Perhaps surprisingly, the relationship between religious coping and BP has been found to be stronger among African Americans than among whites, with African Americans high in religious coping having lower BPs, compared with those low in religious coping (24). These research findings suggest an interaction between ethnicity and religious coping in predicting BP and highlight the need to examine that interaction when conducting research.

To date, published studies on the relationship between religious coping and BP have measured BP only in the clinic setting. To our knowledge, no studies have measured BP during daily life using ABP monitoring. Recent research indicates that ABP measurement, especially sleep ABP levels, are stronger predictors of cardiovascular mortality and morbidity than standard clinic BP assessment (37–40). The purpose of this study was to investigate religious coping in relation to both clinic BP and BP measured over the course of a typical day by use of ABP monitoring in African American men and women as compared with white men and women. Higher levels of religious coping were hypothesized to be related to lower levels of BP in the clinic, during a typical day, and during sleep. Factors that have been postulated to mediate the relationship between religiosity and health, including depression, anxiety, social support, stress, and negative health behaviors, also were examined in the context of religious coping and BP.

	METHODS

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Subjects
The study sample was composed of 155 employed men and women, aged 25 to 45 years, who participated in the Duke Biobehavioral Investigation of Hypertension study. Subjects were self-selected in response to advertisements in local newspapers and magazines. Subjects taking any cardiovascular medications or using tobacco products were excluded from the study. Subjects with SBP >180 mm Hg or DBP >100 mm Hg were excluded from the study. The final sample consisted of 99 subjects (64%) in the normotensive range, 30 (19%) in the high normal range, and 26 (17%) in the mild hypertension range.

Procedure
Clinic BP assessment. To determine subject eligibility, BP was taken by a trained staff member on three separate visits, each approximately 1 week apart. Three seated BP readings were taken, each 2 minutes apart, by use of an appropriately sized occlusion cuff, mercury column sphygmomanometer, and stethoscope. SBP was recorded coincident with the first occurrence of Korotkoff sounds (phase I) and DBP with the disappearance (phase V) of Korotkoff sounds.

ABP assessment. A typical workday period was chosen for the ABP studies. Subjects were fitted with the AccuTracker II (Suntech, Raleigh, NC) ABP monitor (41). A calibration procedure ensured that stethoscopic blood pressure measurements were within ±5 mm Hg of the AccuTracker SBP and DBP determinations. The AccuTracker was programmed to take blood pressure measurements four times per hour, at variable intervals, throughout the workday. Subjects were instructed to follow their normal schedule and to complete a one-page set of diary items indicating time, posture, location, activity, alcohol and caffeine consumption, and stress level at the time of each reading. The same procedure was extended into the evening hours. From 11:00 PM until 7:00 AM (or commensurate with the individual’s sleep pattern, if different), readings were programmed to be reduced in frequency to two per hour. Subjects removed the monitor after rising the following morning and returned it to the laboratory, where the data were downloaded into computer files. All BP readings were reviewed by an experienced staff member, and artifactual readings were deleted following criteria described previously (42).

Body mass index (BMI). BMI scores were obtained for each subject. On the morning of the ambulatory assessment, subjects’ height and weight were measured before they were fitted with the ABM monitor. BMI was calculated as weight in kilograms divided by height in meters squared (kg/m²).

COPE. All coping subscales used in this study were derived from the COPE scale developed by Carver et al. (43). Religious coping was assessed with the use of the religion subscale, which consists of four questions: I put my trust in God, I seek God’s help, I try to find comfort in religion, and I pray more than usual. Each question is rated on a four-point scale, where 1 indicates "not at all" and 4 indicates "all the time." A total score is obtained by summing the answers to the four questions together. In addition to the religious coping subscale, three other coping subscales were examined: active coping, avoidant coping, and acceptance coping (43). The active coping subscale is a combination of subscales that focus on active, effortful activities on the part of the individual to cope with problems. These included active coping, planning, restraint, suppression of competing activities, positive reinterpretation and growth, and use of instrumental support. Avoidant coping, on the other hand, is a combination of subscales that focus on denial of and disengagement from problems. These included denial, behavioral disengagement, behavioral disengagement, and focus on venting of emotions. Acceptance coping, which focuses on accepting things as they are, includes the acceptance and humor subscales.

Beck Depression Inventory (BDI). The BDI (44) is a widely used measure of depression, consisting of 21 items, each corresponding to a specific category of depressive symptoms and attitudes. It has been shown both a reliable and valid measure of depression severity (45).

State-Trait Anxiety Inventory (STAI). The STAI (46) is a 40-item questionnaire that measures levels of anxiety in general (trait) and anxiety over the prior 7 days (state). High scores are associated with higher levels of anxiety.

Social Support Questionnaire—short form (SSQ6). The SSQ6 (47) is a six-item self-report inventory designed to measure two features of global support: the perceived availability of others to whom one can turn for support and satisfaction with this perceived available support.

Health behaviors. Health behaviors were obtained by questionnaire. Alcohol intake was obtained by summing the number of beer, wine, and liquor drinks consumed during the previous week. An overall exercise score was derived by use of aerobic activity points, on the basis of a system developed by Cooper (48). Subjects reported the number of minutes they engaged in various aerobic activities, such as jogging, biking, tennis, aerobics class, etc., during the prior 7 days. Aerobic activity points were then calculated for each activity on each day of the week, and a total score was obtained by summing all the points together. The number of hours slept was defined by the diary cards filled out during ambulatory assessment and represents the amount of sleep received while wearing the ambulatory blood pressure monitor.

Data Analyses
Ethnic differences among demographic and psychosocial variables were examined by use of t tests or chi-square tests, depending on the metric of the variable being studied. In addition to mean clinic BP, awake and sleep BP variables were created by calculating the mean ambulatory BP over awake and sleep periods, respectively. The main goal of this article was to examine the effects of religious coping and ethnicity on BP, controlling for relevant demographic and psychosocial variables. Therefore, regression was selected as the main analytic tool (49). Regression was also used to measure the relative contribution of religious coping in predicting BP. Because sex did not interact with religiosity or ethnicity in predicting BP, it was only included as a covariate in these analyses.

The first set of regression analyses examined religious coping and ethnicity in predicting BP, controlling for age, sex, BMI, education, and income. A hierarchical approach was used with demographic variables entered first, religious coping and ethnicity entered next, and the interaction between religious coping and ethnicity entered last. The second set of regression analyses looked at potential mediators of the relationship between religious coping and BP. Pearson’s correlation coefficients were first used to identify potential mediators of the relationship between BP and religious coping. In addition to controlling for age, sex, BMI, education, and income, perceived social support satisfaction, number of support individuals, and alcohol consumption were also included in the model. Regression was then used to measure the relative contribution of religious coping in predicting BP, by use of the same covariates as those described previously. All analyses were conducted with the use of the SAS system (SAS Institute, Cary, NC), with alpha set at 0.05.

	RESULTS

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Sample Characteristics
Sample characteristics are presented by ethnic group in Table 1. Among the demographic variables, the African American sample had a greater proportion of women, were less educated, and reported less income. Age and number of children were not significantly different between African Americans and whites. Measures of body size indicated that the African Americans had higher BMI scores. BP measurements were not different between groups during clinic and awake ABP assessments. Sleep ABP, however, was significantly higher among African Americans.

Religious Coping, Ethnicity, and Blood Pressure
Hierarchical multiple regression analyses, which included the demographic variables age, BMI, sex, and income as covariates, revealed no overall effect for religious coping on clinic, awake, or sleep ABP. However, it was found that the interaction between religious coping and ethnicity was significant for clinic BP (SBP: t[139] = 1.95, p = .05; DBP: t[139] = 2.21, p < .05), awake ABP (SBP: t[147] = 2.42, p < .05; DBP: t[147] = 2.64, p < .01), and sleep ABP (SBP: t[147] = 2.81, p < .01; DBP: t[147] = 2.66, p < .01). The interaction consisted of religious coping being related to lower BP among African Americans across BP measurements and religious coping not being related to BP among whites. Figures 1 and 2 illustrate graphically the relationships between religious coping and SBP and DBP by ethnicity (means were adjusted for the demographic covariates).

View larger version (23K): [in this window] [in a new window]   Fig. 1. SBP (mean ± SE) in the clinic and during waking and sleeping in African Americans and whites. For purposes of illustration, religious coping was dichotomized into low and high groups by use of a median split. Means were adjusted for the demographic covariates.

View larger version (24K): [in this window] [in a new window]   Fig. 2. DBP (mean ± SE) in the clinic and during waking and sleeping in African Americans and whites. For purposes of illustration, religious coping was dichotomized into low and high groups by use of a median split. Means were adjusted for the demographic covariates.

	DISCUSSION

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African Americans scored significantly higher on religious coping, compared with whites. This finding is consistent with previous studies (30–36). Several studies have noted that religious coping plays a central role in the psychosocial functioning of African Americans (30, 31, 33–35, 50). Bourjolly (35), Connell and Gibson (34), and Conway (30) each found that African Americans frequently use religious behaviors as coping mechanisms. Nelson (31) found that African Americans are more oriented intrinsically to religion than are whites and that higher levels of intrinsic religiosity were related to lower levels of depression. Maton et al. (33), in a study of social support among youth, found that spiritual support was higher among African American youth and that this support was positively related to self-esteem. Religiosity has been related to an increased ability to handle stress, leading to enhanced feelings of self-esteem and personal control (50). The central nature of religious coping in the lives of African Americans may explain why religious coping and BP were more strongly related in this group (24).

In the present study, we found that African Americans classified as high in religious coping had 6 to 7 mm Hg lower awake and sleep SBP, compared with those low in religious coping. This was true even after controlling for demographic and anthropometric variables such as age and BMI, which are known risk factors for hypertension (16). Given the higher prevalence of hypertension and hypertension-related diseases among African Americans (15, 25–27), our observations suggest that religious coping may help buffer cardiovascular disease in African Americans. Of interest, at least two hypertension prevention projects conducted in African American communities have focused their efforts on churches and local congregations as a means of disseminating information and encouraging healthy behaviors (51, 52). Both of these studies reported having success in lowering BP and concluded that social support and interpersonal networks were key to that success.

Social support has been hypothesized as an important pathway through which BP and religiosity are related (22). A number of studies have found social support to be related to BP and cardiovascular disease, with higher levels of social support related to lower BP and less disease (53–56). Social support has also been found to be positively related to religious coping, especially in African Americans (22). In the present study, perceived social support satisfaction was positively related to religious coping in African Americans. However, religious coping was found to be a more consistent predictor of BP than perceived social support satisfaction (see Table 4). Religious coping was related to both awake and sleep ABP, whereas support satisfaction was only related to awake ABP. This observation may be important, because recent studies indicate that overall 24-hour BP load and sleep ABP are stronger predictors of cardiovascular morbidity and mortality than clinic or daytime only BP assessments (38–40). Furthermore, religious coping remained a significant determinant of clinic BP and ABP after accounting for the effects of perceived support satisfaction.

Measures such as education and income also have been found to have a negative relationship with BP and to have a positive relationship with social support (16, 28, 29). Lower levels of education in particular have been found to be a significant predictor of high BP (29). Of interest, although higher religious coping is related to higher social support and lower BP, it has also been related to lower SES (32). In the present study, higher religious coping was related to lower education only among whites and was unrelated to income. Religious coping may buffer some of the negative effects associated with low SES by facilitating access to additional support systems and resources. It is important to note that, in the present study sample, African Americans had significantly lower levels of education and income, compared with whites (see Table 1). It is possible that these SES differences were indicative of differences in the availability of support and resources. For African Americans with limited resources, religious coping might represent the most effective coping tool available. For whites, on the other hand, higher education and income might indicate the greater availability of other resources that may help buffer stress.

There are several study limitations that require consideration when interpreting the results of this study. First, because the study was cross-sectional in design, no statements can be made about causality or about how religious coping is related to BP over time. Second, the social support measure used in this study was a brief six-item questionnaire that assessed number of support persons and perceived satisfaction with that support. A more comprehensive measure of social support and available community resources may have helped to delineate more clearly the role of religious coping in BP. Third, the religious coping measure used in this study focused on individuals looking to God for strength and comfort. There are other religious coping scales that are broader in nature, which might have lead to different results.

It is also of note that the age range of the present sample was 25 to 44 years, whereas the majority of research conducted on religion and BP has focused on older populations. Our findings therefore extend previous observations of religious coping and BP in African Americans to a younger population. Several studies, however, also have found that religious coping was related to BP among whites. The absence of a relationship between religious coping and BP among whites in the present study may partly be a reflection of age differences between the present and previous studies.

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
Among African Americans, higher levels of religious coping were related to lower levels of BP during normal daily activities and during sleep as assessed by ABP monitoring, as well as during clinic assessment. Religious coping remained a significant determinant of BP, after accounting for the effects of significant demographic and psychosocial variables. This study extends previous research findings by showing that religious coping and blood pressure are related during real-life activities as well as in the clinic. Additional research studies might build on these findings by studying the longitudinal relationship between religiosity and ABP, as well as by further examining potential mediating variables, including ethnicity, SES, health behaviors, and psychosocial factors.

	ACKNOWLEDGMENTS

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This work was supported by National Institutes of Health Grants HL49427, MH19109, and M01-RR-30; National Center for Research Resources, General Clinical Research Centers Program, National Institutes of Health.

Received for publication May 9, 2000.

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TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 

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