Religious involvement as a social determinant of sleep: an initial ...

SLEH-00276; No of Pages 6 Sleep Health xxx (2018) xxx–xxx

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Sleep Health Journal of the National Sleep Foundation journal homepage: sleephealthjournal.org

Religious involvement as a social determinant of sleep: an initial review and conceptual model Terrence D. Hill, PhD a,⁎, Reed Deangelis, MA b, Christopher G. Ellison, PhD b a b

The University of Arizona, School of Sociology, Social Sciences Bldg, Room 400, 1145 E S Campus Dr, Tucson, AZ 85721 Department of Sociology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249

a r t i c l e

i n f o

Article history: Received 4 February 2018 Received in revised form 26 March 2018 Accepted 2 April 2018 Available online xxxx Keywords: Religion Sleep Mental health Substance use Stress Allostatic load

a b s t r a c t Although numerous empirical studies show that religious involvement is associated with better health and longer life expectancies, researchers have virtually ignored possible links between religious involvement and sleep. To spark greater attention to this important and understudied area of sleep research, we review previous population-based studies, propose an initial conceptual model of the likely pathways for these associations, and offer several avenues for future research. Our review and critical examination suggest that religious involvement is indeed a social determinant of sleep in the United States. More religious adults in particular tend to exhibit healthier sleep outcomes than their less religious counterparts. This general pattern can be seen across large population-based studies using a narrow range of religion measurements and sleep outcomes. Our conceptual model, grounded in the broader religion and health literature, suggests that religious involvement may be associated with healthier sleep outcomes by limiting mental, chemical, and physiological arousal associated with psychological distress, substance use, stress exposure, and allostatic load. As we move forward, researchers should incorporate (1) more rigorous longitudinal research designs, (2) more sophisticated sleep measurements, (3) more complex conceptual models, (4) more comprehensive measurements of religion and related concepts, and (5) more measures of religious struggles to better assess the “dark side” of religion. Research along these lines would provide a more thorough understanding of the intersection of religious involvement and population sleep. © 2018 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Population-based studies of religious involvement and sleep . . . . . . . . . . . . . . Conceptual model linking religious involvement and sleep . . . . . . . . . . . . . . . . Psychological distress. . . . . . . . . . . . . . . . . . . . . . . . . . . . Substance use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stress exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Allostatic load . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion and directions for future research. . . . . . . . . . . . . . . . . . . . . . . Is religious involvement associated with healthier sleep outcomes? . . . . . . . Why might religious involvement be associated with healthier sleep outcomes? . Directions for future research . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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⁎ Corresponding author. E-mail address: [email protected]. (T.D. Hill). https://doi.org/10.1016/j.sleh.2018.04.001 2352-7218/© 2018 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Hill TD, et al, Religious involvement as a social determinant of sleep: an initial review and conceptual model, Sleep Health (2018), https://doi.org/10.1016/j.sleh.2018.04.001

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T.D. Hill et al. / Sleep Health xxx (2018) xxx–xxx

Introduction Is religious involvement a social determinant of sleep? Religious doctrine and popular culture suggest that it is. The Bible tells us that there is no rest for the wicked. 1 Other books describe sleep as “God's medicine.”2 Even the Irish rock band U2 suggests that “sleep comes like a drug in God's country.”3 Over the past 3 decades, numerous empirical studies have shown that religious involvement— indicated by observable feelings, beliefs, activities, and experiences in relation to the spiritual, divine, or supernatural—is associated with better health and longer life expectancies across a range of outcomes, including health behaviors (eg, drinking, smoking, substance use), mental health (eg, depression, anxiety, and nonspecific psychological distress), biological functioning (eg, blood pressure, overall allostatic load, and cellular aging), physical health (eg, self-rated health, disability, and stroke), and mortality risk (eg, all-cause and from circulatory and respiratory diseases). 4–11 In contrast to these bodies of work, researchers have virtually ignored possible links between religious involvement and sleep.11,12 This gap in the literature is surprising because religious involvement is consistently associated with several established risk and protective factors for sleep quantity and quality. In this article, we review previous US population-based studies a of religious involvement and sleep-related outcomes, propose an initial conceptual model of the likely pathways for these associations, and offer several avenues for future research. The general aim of this review is to spark greater attention to this important and understudied area of sleep research.

Population-based studies of religious involvement and sleep Is religious involvement associated with healthier sleep outcomes? In our review of the scientific literature, we could find only 7 population-based studies of religious involvement and sleep. In this section, we explore the key findings of this research. In 1998, Wallace and Foreman published the first examination of the association between religious involvement and sleep. 13 Their analyses of national cross-sectional data from the Monitoring the Future study (1995-1996) showed that high school seniors who attended religious services “about once a week or more” and rated religion as “very important” in their lives were more likely to “get at least 7 hours of sleep” than those who, respectively, “never” attended and rated their religion as “not important.” The authors also found that respondents with “moderate” (eg, Disciples of Christ, Lutheran, and Methodist) and “liberal” (eg, Episcopal, Presbyterian, United Church of Christ, Roman Catholic, and Jewish) religious affiliations were similarly advantaged relative to those with no affiliation. Interestingly, the sleep patterns of young adults with “conservative” religious affiliations (Baptist, Church of Christ, Muslim, and Latter Day Saints) were comparable to those with no affiliation. These patterns held with statistical controls for sex, race, parent's education, family structure, urbanicity, and region. In 2006, Hill and colleagues used cross-sectional data from the Survey of Texas Adults (2004), a statewide probability sample of Texans aged 18 and older, to model overall self-rated sleep quality as a function of religious attendance. 14 The results of this study showed that respondents who attended religious services more than once per week were more likely to report “sound sleep quality” (excellent, very good, or good) than respondents who never attended or attended less than once per month. These associations were a Although our review emphasizes the findings of quantitative population-based studies, there is certainly space for qualitative exploratory investigation from the perspectives of science and the humanities. Fundamental questions about how the experience of religion relates to the experience of sleep have yet to be explored. Research along these lines is vital to the development of this literature.

observed with statistical adjustments for age, sex, race, citizenship, interview language, marital status, number of children, education, employment status, family income, financial strain, and self-rated health. In 2007, Adam and colleagues published a unique study of timediary data from the second wave of the Child Development Supplement of the national Panel Survey of Income Dynamics (20022003). 15 “Religious activities,” “hours of sleep,” “bedtimes,” and “wake times” were assessed in children and adolescents from timediary reports on 2 randomly selected days (1 weekday and 1 weekend day). Their analyses showed that more time spent engaging in religious activities was associated with less total sleep time on weekdays and weekends, later bedtimes on weekdays (not weekends), and earlier wake times on weekdays and weekends. These results persisted with statistical adjustments for child demographics (age, sex, and race), family characteristics (family income, parental education, marital status, work hours, number of children), school start/ end times, time traveling to school, a range of weekday and weekend activities, family functioning (parental warmth, parental rules, economic strain, parenting stress, psychological distress, and family conflict), and child health (child health and internalizing/externalizing problems). In 2011, Ellison and colleagues published the first study linking measures of religious involvement (religious attendance, prayer, and secure attachment to God) and religious struggles (religious doubts and anxious attachment to God) with multiple self-reported sleep outcomes (overall sleep quality, restless sleep initiation, and use of sleep medications). 12 Using data collected from a national probability sample of active elders and other active members of the Presbyterian Church (USA) (2005-2007), these researchers showed that religious attendance and frequency of prayer were positively associated with overall sleep quality and unrelated to restless sleep initiation and the use of sleep medications. God attachment styles (secure and anxious) were consistently unrelated to all 3 sleep outcomes. Religious doubts were inversely associated with sleep quality and positively associated with restless sleep initiation and the use of sleep medications. These patterns held with statistical controls for age, sex, race, education, marital status, income, elder status, stressful life events, exercise habits, alcohol consumption, psychological distress, and self-rated physical health. In 2017, Krause and colleagues published 2 studies using national data from the Landmark Spirituality and Health Survey (2014). These studies used multiple measures of religious involvement and a global measure of sleep quality. The first study showed that a “sacred body view” (eg, “My body is a sacred gift from God.”) and “God-mediated control” beliefs (eg, “All things are possible when I work together with God.”) were positively associated with sleep quality. 16 Moderation analyses showed that the association between sacred body view and sleep quality was limited to respondents with strong Godmediated control beliefs (ie, “a strong religiously oriented sense of control”). These results were observed with statistical adjustments for age, sex, education, marital status, religious attendance, frequency of prayer, and religious affiliation. The second study tested an elaborate mediation model to explain the association between religious attendance and overall sleep quality.17 After statistically controlling for age, sex, education, marital status, and hope (a mediator) (eg, “I feel confident the rest of my life will turn out well.”), religious attendance, spiritual support (eg, church members “help you to lead a better religious life”), and God-mediated control (eg, “All things are possible when I work together with God.”) were unrelated to sleep quality. Most recently, White and colleagues 18 used national crosssectional data from the 2011 Health Related Behaviors Survey of Active Military Personnel to test whether religious involvement (religious attendance and religious salience) moderated or buffered the association between combat casualty exposure (eg, having “seen



human remains”) and sleep disturbance (“trouble falling asleep or staying asleep”) in US military veterans. The study showed that veterans who attended religious services more frequently and were more apt to agree that religious/spiritual beliefs influence their personal decisions were less likely to report sleep disturbance in the past 30 days. Religious salience (not religious attendance) also attenuated the strong positive association between combat casualty exposure and sleep disturbance. These patterns held with statistical controls for sex, marital status, branch of service, rank, combat deployment frequency, and traumatic brain injury. The authors explained that “individuals for whom religion is an especially important aspect of their personal lives may enjoy a coherent meaning system and interpretive framework via which to make sense of— and assign significance to—daily affairs and major life crises”.18 Conceptual model linking religious involvement and sleep Why might religious involvement be associated with healthier sleep outcomes? In this section, we explore these potential processes. The ensuing discussion is grounded in a general conceptual model that has emerged in the broader religion and health literature. 4–11 Our preliminary model is limited to 3 prominent classes of mechanisms, including psychological distress, substance use, stress exposure, and allostatic load (Fig. 1). We focus on these mechanisms because they exhibit consistent associations with sleep outcomes through mental, chemical, and physiological arousal.19–24 Psychological distress Religious involvement may be associated with healthier sleep outcomes by supporting mental health. Studies show that religious involvement is consistently associated with lower levels of psychological distress across a range of indicators, including, for example, anger, depression, anxiety, and nonspecific psychological distress.4,6,10,11 Researchers argue that religious involvement benefits mental health by reducing stress exposures and by promoting social resources (social engagement, social integration, and social support),

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psychological resources (hope, optimism, and a sense of meaning and purpose), and healthier lifestyles (especially lower levels of substance use).4–6,10,11 Only one of the studies described above directly tested the mediating influence of mental health. Ellison and colleagues assessed whether the association between religious attendance and sleep (overall sleep quality, restless sleep initiation, and use of sleep medications) was mediated by symptoms of psychological distress (depression and anxiety). 12 This study showed little to no attenuation of the effects of religious attendance across sleep outcomes among Presbyterians. The complex mediation model tested by Krause and Ironson offers some indirect evidence by establishing the indirect effects of religious attendance on overall sleep quality through spiritual support, God-mediated control, and hope.17 Religious attendance enhanced spiritual support from fellow church members. Greater spiritual support contributed to stronger God-mediated control beliefs. Finally, respondents who endorsed God-mediated control were more hopeful about the future. The authors concluded that “people who are hopeful about the future tend to rest easier because they are less likely to worry about how their lives will turn out.”17(p599)

Substance use Religious involvement may support healthier sleep outcomes by discouraging the use of substances that can undermine sleep. Numerous studies show that religious involvement is associated with lower rates of smoking, heavy alcohol consumption, and illicit substance use.4–11,25 Previous research has identified 4 general theoretical perspectives to explain these patterns. The socialization perspective suggests that involvement in religious institutions exposes adherents to specific moral directives (eg, against heavy drinking) and general religious doctrines (eg, “the body is the temple of the Holy Spirit”) that are supported by the authority of religious traditions and sacred texts. Ongoing exposure to these tenets may lead individuals to internalize specific religious messages that warn against substance use and abuse.

Fig. 1. Conceptual modeling linking religious involvement and sleep.


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The authority perspective suggests that religious involvement may deter substance use by encouraging a general deference to authority, conformity to societal norms, and adherence to laws. Those who are active within religious institutions may favor conformity through fear of divine retribution, internalized moral codes, guilt avoidance, and the social context of obedient peer networks. The social control perspective suggests that religious involvement may also discourage substance use through processes related to social control and social support. Religious involvement exposes individuals to reference groups that tend to espouse anti–substance use norms and exhibit low levels of substance use and high rates of abstinence. Religious involvement is also associated with direct and indirect exposure to social sanctions (eg, gossip, ostracism, and formal punishments) that function to elevate the costs (actual and perceived) associated with substance use, which presumably limit access and use. Finally, the self-regulation perspective suggests that religious involvement may be associated with lower levels of substance use by fostering self-control and generic self-regulatory capacities. 25–27 In a systematic review, McCullough and Willoughby show that religious individuals consistently score higher than their less religious counterparts on measures of self-control (eg, ability to control one's impulses, appetites, and emotions) and that self-control is a primary pathway to lower substance use. 26 Stress exposure Religious involvement may contribute to healthier sleep outcomes by limiting exposures to chronic strains (eg, chronic illness and incarceration) and stressful events (eg, divorce and victimization) throughout the life course. Religious involvement could limit exposures to stressful conditions across various life domains by supporting normative belief systems, deference to authority, social control, conventional lifestyles, and better health. It is argued that messages regarding moral behavior may be conveyed by formal means (eg, sermons, official church pronouncements, and printed materials) and reinforced by informal interaction and social sanctions (eg, expressions of disapproval, gossip, and formal penalties).6,28 Religious involvement may also affect exposures to stressful conditions by fostering self-control, selection and pursuit of conventional goals, self-monitoring, and self-regulatory strength and behavior.25–27 We have already noted that religious people tend to exhibit better mental and physical health outcomes than their less religious counterparts. Health problems are often stressful in themselves. They can also contribute to the proliferation of additional stressors (eg, financial hardship and relationship strains). The apparent health benefits of religious involvement are at least partly explained by less risky and less stressful lifestyles that are characterized by lower rates of substance use, precarious sexual practices, violence, and other forms of crime. 28–37 Allostatic load Finally, religious involvement may support healthier sleep outcomes by blunting chronic physiological arousal (ie, allostatic load). Research shows that various indicators of religious involvement are associated with healthier physiological functioning across the autonomic nervous, hypothalamic-pituitary-adrenal, cardiovascular, and immune systems. 8,11,38,39 More specifically, religious involvement is associated with lower levels of blood pressure, C-reactive protein, interleukin-6, white blood cells, Epstein-Barr virus, epinephrine, cortisol, and overall allostatic load. We currently know very little about how religious involvement gets “under the skin” to support healthier physiological functioning. However, previous studies have proposed several social (eg, social

integration and social support), psychological (eg, meaning and control beliefs), behavioral (eg, drinking and smoking), and biological (eg, stress) mechanisms. 8,11 According to this research, religious involvement (eg, religious meaning systems) may help to buffer appraisals of stressful life conditions and, by extension, their physiological consequences. Instrumental support, the sense of control, and moderate drinking practices could help adults to avoid stressful life conditions (events and appraisals) and chronic activation of the physiological stress response. In the event of stressful life conditions (and the activation of sympathetic systems), religious beliefs and practices, supportive relationships, strong psychological dispositions, and healthier lifestyles may also favor salubrious coping styles (and efficient activation of parasympathetic systems and various growth responses). Because stress, mental health, and unhealthy behaviors are reliably linked to religious involvement and the activation of allostatic systems, these factors (among others) may function as general mechanisms across markers of physiological functioning.40,41

Discussion and directions for future research Although numerous studies show that religious involvement is associated with better health and longer life expectancies, researchers have virtually ignored possible links between religious involvement and sleep. In this article, we reviewed previous population-based studies of religious involvement and sleep-related outcomes and proposed an initial conceptual model of the likely pathways for these associations. In this final section, we summarize our review and discuss several directions for future research.

Is religious involvement associated with healthier sleep outcomes? To answer this question, we reviewed seven large populationbased studies. In adult populations, religious involvement is often associated with healthier sleep outcomes. This general pattern has been observed across several measures of religious involvement (religious attendance, religious importance, frequency of prayer, sacred body view, and God-mediated control) and several sleep-related outcomes (sleep duration, overall sleep quality, sleep initiation, and sleep medications). In younger populations, among children and adolescents, more time spent engaging in religious activities was associated with less total sleep time on weekdays and weekends.

Why might religious involvement be associated with healthier sleep outcomes? To answer this question, we derived a preliminary conceptual model from prior work to specify the most likely pathways linking religious involvement and sleep. We focused on psychological distress, substance use, stress exposure, and allostatic load because these particular mechanisms tend to exhibit consistent associations with sleep outcomes. Our model suggested that religious involvement could promote healthier sleep outcomes by supporting better mental health, healthier lifestyles, stress reduction, and healthier physiological functioning. In a study of Presbyterian adults, symptoms of psychological distress failed to attenuate any of the effects of religious attendance across multiple sleep outcomes.12 Another study showed evidence for the mediating influences of spiritual support, Godmediated control, and hope (a symptom of depression). 17 Theories for the indirect effects of substance use, stress exposure, and allostatic load are compelling, but we were unable to find any formal mediation tests.



Directions for future research Although previous studies have made significant contributions to our understanding of the social patterning of sleep, this body of work is characterized by several theoretical and methodological limitations. All of the studies of religious involvement and sleep are based on cross-sectional designs. Because cross-sectional studies are unable to establish the causal order of any observed associations, it is often unclear why religious people appear to exhibit healthier sleep outcomes. We assume that religious involvement influences health, but health and functioning can also influence religious involvement. For example, poor health and sleep deprivation could undermine or limit public religious activities. In the absence of longitudinal designs and adequate statistical controls for baseline health status, certain indicators of religious involvement (especially indicators of public religious behaviors) can “select” healthier people into religious activities. Longitudinal studies are needed to test whether the patterns observed in previous research can be replicated with comprehensive statistical adjustments for baseline health and functioning. It is also important to consider more dynamic (growth models) and rigorous (fixed-effects) longitudinal designs. Sleep measurement is another important limitation. Although previous studies have examined a range of sleep outcomes, there is an overreliance on single-item self-reports. Under these conditions, the validity and reliability of sleep outcomes are major concerns. Clearly, additional research is needed to replicate previous findings using more sophisticated sleep inventories (eg, Pittsburgh Sleep Quality Index and Iowa Sleep Disturbances Inventory) and objective assessments (eg, polysomnography and actigraphy). Given that so few studies have focused on religious involvement and sleep, it should come as no surprise that this literature is also limited in terms of conceptual model development. Although 2 studies in our review proposed and tested mediation models, we were unable to find any studies of subgroup variations. These gaps leave open several fundamental questions. Under which social, psychological, and physiological conditions is religious involvement more or less protective? For example, do associations between religious involvement and sleep vary by race or ethnicity? Are the indirect processes linking religious involvement and sleep invariant across groups, or do certain causal processes fit certain groups more or less (ie, moderated mediation)? For example, is the apparent mediating influence of mental health more or less pronounced for women or men? Once we begin to consider subgroup variations in the effects of religious involvement, empirical explanations for these patterns should also be formally tested (ie, mediated moderation). For example, if we were to observe moderation by race or ethnicity, what factors might help to explain those variations? There is also the possibility of suppression effects. For example, if people who are more religious are more likely to be married and have children, the physical presence of more people in the household could conceivably suppress the association between religious involvement and healthy sleep. We should also move beyond the direct and indirect effects of religious involvement. Religious involvement could function to moderate the effects of established sleep patterns. For example, religious involvement might help some people to cope with a range of adverse conditions that might undermine sleep.18 Religious involvement could also condition age-graded changes in sleep architecture. We argue that model development would be aided by greater attention to the measurement of religion and related concepts. Although religion is conceptually complex,42 previous sleep research is generally limited to a narrow range of religion measures that are characterized by low validity and reliability. In particular, because studies typically rely on measures like religious attendance, we need better and more comprehensive assessments of global (eg, general religiosity and spirituality) and specific (eg, spirituality) constructs. The literature clearly

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shows that different religion measures can have different associations with sleep. Different religion measures can also serve unique analytical functions. Whereas some measures like religious attendance show direct and indirect effects on sleep outcomes, other measures like prayer and religious coping may serve more as moderators of other risk factors. The role of religious affiliation is also unclear. Are there consistent variations by religious group? If so, are there further internal variations within religious groups (eg, Orthodox vs Reform Judaism)? A final and related limitation is the tendency of previous research to focus on the potential benefits of religious involvement. Recent studies of the “dark side” of religious involvement suggest that religious struggles can also undermine health and longevity.43–55 For the purposes of this review, we define religious struggles as “tension and conflict about sacred matters within oneself, with others, and with the supernatural.”54(p1) There are 3 general dimensions of religious struggles: (1) interpersonal, (2) intrapersonal, and (3) divine/demonic.54 Interpersonal struggles refer to religious-based conflicts with family, friends, or less intimate relations within one's religious group or broader community. Intrapersonal struggles refer to intrapsychic battles with one's own religious beliefs and behavior, including struggles with internalized morality standards, religious doubts, and the search for meaning in life. Whereas divine struggles refer to negative beliefs about or strained relationships with God or another higher power, demonic struggles refer to ominous beliefs about the devil or other evil spirits. To date, only 1 study has considered any association between religious struggles and sleep. In their study of Presbyterian adults, Ellison and colleagues showed that religious doubts were inversely associated with sleep quality and positively associated with restless sleep initiation and the use of sleep medications. These patterns held with statistical controls for age, sex, race, education, marital status, income, elder status, stressful life events, exercise habits, alcohol consumption, psychological distress, and self-rated physical health. This study also directly tested the mediating influence of mental health, showing considerable attenuation of the effects of religious doubts across sleep outcomes after adjusting for psychological distress. The authors concluded that “part, but certainly not all, of the link between religious doubts and sleep quality may be due to heightened psychological distress.” 9(p131) Of course, more research is needed to replicate these patterns across populations and dimensions of religious struggles. Conclusion Our review and critical examination of published research suggest that religious involvement is indeed a social determinant of sleep in the United States. More religious adults in particular tend to exhibit healthier sleep outcomes than their less religious counterparts. This general pattern can be seen across large population-based studies using a narrow range of religion measurements and sleep outcomes. Our conceptual model, grounded in the broader religion and health literature, suggests that religious involvement may contribute to healthier sleep outcomes by limiting mental, chemical, and physiological arousal associated with psychological distress, substance use, stress exposure, and allostatic load. As we move forward, researchers should incorporate (1) more rigorous longitudinal research designs, (2) more sophisticated sleep measurements, (3) more complex conceptual models, (4) more comprehensive measurements of religion and related concepts, and (5) more measures of religious struggles to better assess the “dark side” of religion. Research along these lines would provide a more complete understanding of the intersection of religious involvement and population sleep. Disclosure Dr. Hill has nothing to disclose.


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