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Religious Preference, Church Activity, and Physical Exercise
Preventive Medicine 33, 38–45 (2001) doi:10.1006/pmed.2001.0851, available online at http://www.idealibrary.com on
Religious Preference, Church Activity, and Physical Exercise Ray M. Merrill, Ph.D., M.P.H.,*,†,1 and Alton L. Thygerson, Ed.D.* *Department of Health Science, College of Health and Human Performance, Brigham Young University, Provo, Utah 84602; and †Division of Epidemiology, Department of Family and Preventive Medicine, University of Utah College of Medicine, Salt Lake City, Utah 84132 Published online June 6, 2001
lower levels of exercise among LDS versus non-LDS could not be explained and require further study.
Background. Utah has the highest percentage of physically active adults in the United States. It also has a high percentage of religiously active people. About 90% of the adult population has a religious preference and 62% of those individuals attend church weekly. This study evaluates the relationship between religious preference, church attendance, and physical activity. Methods. Analysis is based on 6,188 adult respondents ages 18 years and older to a cross-sectional random telephone survey involving 12 health districts in the state of Utah from June 1 to August 31, 1996. Results. Within religious groups, those attending church weekly were more likely to exercise than individuals attending church less than weekly. About 70% of Utah consists of members of the Church of Jesus Christ of Latter-day Saints (LDS). LDS attending church less than weekly were least physically active in Utah. The percentages of those exercising vigorously at least 20 min three times per week were 52.3% (LDS who attend church weekly), 44.5% (LDS who attend church less than weekly), 57.6% (non-LDS who attend church weekly), 54.3% (non-LDS who attend church less than weekly), and 53.1% (no religious preference) (P ⴝ 0.0070). When adjustment was made for age, smoking status, education, marital status, and general health, differences in exercise between church activity levels within religious groups became insignificant. Smoking and general health have the greatest influences on the relationship between religious preference, church attendance, and exercise. LDS were significantly less physically active than non-LDS in the adjusted model. Conclusions. Although differential smoking levels and general health status explained differences between church activity levels within religious groups,
䉷 2001 American Health Foundation and Academic Press
INTRODUCTION
Physical exercise relates directly to decreasing disease and premature death and preserving a high quality of life. Specifically, physical activity can help prevent and manage non-insulin-dependent diabetes mellitus [1–5] and decrease the risk of developing heart disease [6,7], high blood pressure [8–13], colon cancer [14–25], depression and anxiety [26–32], obesity [33–38], osteoarthritis [39–42], chronic obstructive pulmonary disease [43], and low-back pain [44,45]. However, despite the proven benefits of exercise, many Americans continue an inactive lifestyle. Little is known about the relationship between religious preference, church attendance, and physical exercise. Understanding such relationships may help us better identify whether religious preference has a protective effect against physical inactivity and whether this effect is similar between religiously active and less active members. This study considers three religious categories in Utah: (1) members of the Church of Jesus Christ of Latter-day Saints (LDS), commonly called Mormons; (2) members of non-LDS religions; and (3) individuals with no religious preference. The influence of church activity on exercise within groups (1) and (2) is also considered. These groups provide a diverse mix of health and lifestyle behaviors for analysis. MATERIALS AND METHODS
The study is based on the 1996 Utah Health Status Survey. The survey is a cross-sectional random survey sponsored by the Utah Department of Health. The Gallup Organization collected the data by incorporating a
1 To whom reprint requests should be addressed. Fax: (801) 3784388. E-mail: Ray [email protected].
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0091-7435/01 $35.00 Copyright 䉷 2001 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
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RELIGION AND PHYSICAL ACTIVITY
telephone survey instrument into a computer-assisted random digit dialing software program called SURVENT. Supervised interviews were conducted across 12 local health districts in Utah by trained interviewers. The survey questionnaire consisted of several core module questions. Questions covering demographic (age, marital status, education) and lifestyle (religious preference, church activity, smoking, alcohol consumption, general health, and physical exercise) characteristics were included and will be utilized in the study. The interview process occurred from June 1 to August 31, 1996. The survey interview was conducted with one randomly selected adult age 18 or older in each household. If required, as many as nine telephone attempts were made to contact a selected household. After a randomly selected survey respondent was identified, up to nine additional attempts were made to conduct the interview with that person. The response rate was 66.3%. A complex survey sample design was used in order to provide a representative sample of the Utah population. It may be described as a weighted probability sample of households disproportionately stratified by 12 local health districts that cover the state. Respondents from 500 households were interviewed in each health district, except for the Salt Lake City Health District, where respondents from 800 households were interviewed in order to increase precision in the statewide estimates. A single-state, nonclustered, equal probability of selection telephone calling design was used to generate telephone numbers [46]. In order to more accurately generalize the survey results to the Utah population, postsurvey weighting adjustments were made. Adjustments weighted the sample to be proportionally consistent with age, sex, geographic, and Hispanic status distribution of the 1996 Utah population. Variables used in the analysis include religious preference, religious activity, gender, age, marital status, alcohol consumption, smoking status, education, general health, mental health, and exercise. If a religious preference was identified, participants were then asked: “Do you attend services about once a week, or more, or less often than once a week?” Alcohol and tobacco use was based on questions of whether they were non-, former, or current drinkers of alcohol or smokers, respectively. General health was based on the question: “In general, would you say your health is excellent, very good, good, fair, or poor?” Mental health was based on the question: “During the past 12 months, did you seek help from a therapist, counselor, or other mental health professional for any personal or emotional problems?” Finally, exercise was based on the question: “Do you vigorously exercise for 20 minutes at least three times a week?” Test statistics involved standard errors of the survey estimates derived using a Taylor-series expansion that
accounts for the complex survey design. SAS (version 8.0)-callable SUDAAN was used for data analysis [47]. Weighted frequency and percentage distributions for two-way tabulations and logistic regression analysis were computed. Tests of independence and significance were performed, based on the 0.05 level. RESULTS
Of the 6,188 survey respondents ages 18 years and older, 49.1% were LDS attending church weekly, 20.2% were LDS attending church less than weekly, 6.8% were non-LDS attending church weekly, 13.7% were nonLDS attending church less than weekly, and 10.2% had no religious preference. Non-LDS religious preferences included 35% Protestant, 36% Catholic, 2% Jewish, and 28% other religions. The percentage of adults involved in vigorous exercise at least 20 min three times per week is presented according to religious preference in Fig. 1. Because of small numbers in some of the nonLDS groups, religious preference is hereafter classified as LDS, non-LDS, and no religious preference. In Table 1, the distribution of respondents is presented by religious preference, church activity, and select demographic, lifestyle, and health characteristic variables. Response rates for each of the variables are above 99%, except for age, which is at about 96%. The distribution of respondents across the levels of each variable differed significantly among the categories of religious preference and church activity. For example, consider the contrast between LDS attending church weekly and those with no religious preference. LDS attending church weekly were more likely to be women, have an older age distribution, be married, be nonconsumers of alcohol or cigarettes, have an advanced degree, report having excellent health, and not be seeking professional help for personal or emotional problems. Table 2 shows the percentage of respondents ages 18 years and older in Utah who exercised vigorously for at least 20 min three times a week by the select variables. The percentage of those exercising at this level differs significantly across the levels of age, marital status, smoking status, education, and self-assessment of general health. In particular, an inverse relationship exists between age and exercise; women who are widowed are least likely and women never married most likely to exercise; current cigarette smokers are less likely than former or never smokers to exercise; a positive relationship exists between education and exercise; a negative association exists between general health status and exercise. Overall, 51.4% of the adult population in Utah exercised vigorously for at least 20 min three times a week. This percentage varies significantly across the categories of religious preference and church activity. Percentages of exercisers at this level were 52.3% for LDS
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MERRILL AND THYGERSON
FIG. 1. Percentage participating in vigorous exercise at least 20 min three times a week according to religious preference among adults ages 18 years and older in Utah.
attending church weekly, 44.5% for LDS attending church less than weekly, 57.6% for non-LDS attending church weekly, 54.3% for non-LDS attending church less than weekly, and 53.1% for those with no religious preference (P ⫽ 0.0070). The percentage maintaining for 5 or more years that level of exercise did not differ significantly among the categories of religious preference and church activity (P ⫽ 0.3765). Measures of the association between exercise and combinations of religious preference and church activity are reported in Table 3. The table also shows the measures of association adjusted separately for age, marital status, smoking status, education, and general health. The measures of association were influenced by the adjustment for each variable. Gender, alcohol consumption, and seeking professional help for personal or emotional problems are not considered because they were not associated with the exercise variable. The relatively low level of physical exercise in LDS
attending church less than weekly is maintained until adjustment for smoking status or general health. In Table 4, measures of the association between exercise and combinations of religious preference and church activity, based on a model adjusting simultaneously for the select variables, are presented. Physical exercise in LDS attending church weekly versus less than weekly is no longer significantly different in the model. On the other hand, non-LDS were significantly more likely than LDS to exercise vigorously at least 20 min three times a week. The previously observed differences in exercise between church activity levels were no longer present. Estimates of the association between exercise and each of the variables included in the model are also reported. DISCUSSION
Little is known about the processes by which religious preference and church activity affect participation in
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TABLE 1 Summary of Respondents to the 1996 Utah Health Status Survey Ages 18 Years and Older by Religious Preference, Church Activity,a and Select Demographic, Lifestyle, and Health Characteristics Religious preference/church activity LDS Characteristic Gender Men Women Age 18–24 25–34 35–44 45–54 55–64 65⫹ Marital status Married Divorced/separated Widowed Never married Alcohol consumption per month Nondrinker Up to 60 drinks 60⫹ drinks Smoking status Never smoked Former smoker Current smoker Education Less than HS HS graduate More than HS Self-assessment of health Excellent Very Good Good Fair Poor Seeking professional help for personal or emotional problems Yes No
Non-LDS
Active
Less active
Active
Less active
None
P valueb
45.2% 54.8%
52.3% 47.7%
42.0% 58.0%
51.4% 48.6%
58.3% 41.7%
0.0002
18.8% 22.0% 20.0% 14.4% 11.2% 13.6%
16.9% 20.9% 19.2% 15.2% 12.6% 15.2%
10.0% 20.6% 21.9% 17.8% 12.0% 17.8%
13.3% 20.9% 30.0% 17.9% 8.5% 9.5%
29.9% 31.2% 22.6% 11.0% 4.1% 2.3%
0.0000
76.2% 3.1% 4.1% 16.6%
62.7% 13.7% 5.5% 18.2%
73.6% 10.3% 5.6% 10.6%
59.4% 17.3% 3.5% 19.9%
50.2% 16.9% 0.3% 32.7%
0.0000
98.5% 1.5% 0.0%
55.9% 40.6% 3.5%
55.0% 44.0% 1.0%
39.2% 55.4% 5.5%
37.7% 54.6% 7.7%
0.0000
92.6% 7.0% 0.4%
54.9% 23.7% 21.4%
64.8% 26.9% 8.3%
47.3% 24.6% 28.1%
51.8% 20.1% 28.1%
0.0000
1.9% 60.6% 37.5%
11.4% 68.7% 19.8%
12.5% 50.9% 36.5%
10.0% 57.5% 32.5%
10.1% 61.3% 28.7%
0.0000
32.9% 37.1% 22.2% 6.2% 1.6%
22.7% 31.7% 29.9% 11.2% 4.4%
30.3% 29.4% 27.6% 10.7% 2.1%
31.1% 29.4% 25.6% 8.8% 5.2%
21.2% 39.0% 27.8% 10.0% 2.0%
0.0000
6.5% 93.5%
12.3% 87.7%
8.9% 91.1%
10.4% 89.7%
14.1% 85.9%
0.0001
Note. Percentages by columns may not sum to 100 because of rounding. Race is not reported separately because of the high proportion of Caucasians in Utah (i.e., about 95%). a Active, attends church weekly. Less active, attends church less than weekly. b Based on the chi-square statistic.
physical exercise. A health behavior hypothesis may argue that religious persons engage in a broad range of health-enhancing behaviors. A recent national study of high school seniors documented that religious youth are more likely to exercise [48]. The current study systematically examines the processes by which religious preference and church attendance may affect levels of physical exercise among adults in Utah. This state represents a population with high levels of religious orientation, church activity, and physical exercise. Approximately 89.8% of the adult population in Utah has a religious preference and 62.2% of those people
attend church weekly. Along with high levels of church activity, Utah had the highest percentage of adults ages 18 years and older in the United States involved in any physical exercise during the previous month (82.9%), based on the 1998 Behavior Risk Factor Status Survey [49]. The Survey also found that Utah had the third lowest percentage of adults at risk for health problems related to lack of regular and sustained physical activity (72.9%) [50]. The indicator of physical activity used in this paper was vigorous exercise at least 20 min three times a week. Percentages of such physical activity reported in Utah are much higher than nationally. In the
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MERRILL AND THYGERSON
TABLE 2 Percentage of Adults Ages 18 Years and Older in Utah Who Exercise Vigorously at Least 20 min Three Times a Week (Exercise) by Select Demographic, Lifestyle, and Health Characteristics Characteristic Gender Men Women Age 18–24 25–34 35–44 45–54 55–64 65⫹ Marital status Married Divorced/separated Widowed Never married Alcohol consumption per month Nondrinker Up to 60 drinks 60⫹ drinks Smoking status Never smoked Former smoker Current smoker Education Less than HS HS graduate More than HS Self-assessment of health Excellent Very Good Good Fair Poor Seeking professional help for personal or emotional problems Yes No
Exercise
P valuea
52.8% 50.1%
0.1663
59.1% 50.1% 53.5% 51.5% 43.4% 45.6%
0.0004
50.0% 48.3% 44.5% 59.9%
0.0007
50.4% 54.6% 48.5%
0.1842
53.6% 54.4% 33.8%
0.0000
38.7% 50.6% 55.6%
LDS who consume alcohol or smoke cigarettes are unlikely to be active in the church. For example, only 0.4% of religiously active LDS are current smokers compared with 21.4% of less religiously active LDS. A noticeable difference in smoking and alcohol use was also observed between non-LDS who attended church weekly versus less than weekly, although less pronounced than among LDS. Consistent with other studies [53], age is inversely related with physical exercise. Independent of this relationship it is also associated with categories of religious preference and church activity. Adjusting for age in the model had its primary effect on the odds of exercise among those with no religious preference compared with LDS who attend church weekly (Table 3). This was expected, given the significantly younger age distribution among people in Utah with no religious preference. Other variables considered may have a mediating TABLE 3
0.0004
64.1% 52.2% 42.9% 37.6% 24.9%
0.0000
47.8% 51.7%
0.2471
Note. Data source: 1996 Utah Health Status Survey. Percentages by columns may not sum to 100 because of rounding. Race is not reported separately because of the high proportion of Caucasians in Utah (i.e., about 95%). a Based on the chi-square statistic.
United States in 1997, 23% of adults ages 18 years and older engaged in vigorous physical activity 3 or more days a week for 20 or more min each time [51]. The results support the hypothesis that people attending church weekly are more likely than those who do not to exercise vigorously at least 20 min three times a week. This may be explained, at least in part, by lower levels of cigarette smoking and better general health in religiously active people. Higher levels of physical exercise in those attending church weekly versus less than weekly were more pronounced in LDS than nonLDS. Since 1833, the LDS Church has proscribed use of tobacco or consumption of alcohol, coffee, or tea [52].
Measurement of the Association between Vigorous Exercise at Least 20 min Three Times a Week and Combinations of Religious Preference and Church Activity among Adults Ages 18 Years and Older in Utah Religious preference/ church activity
Odds ratio
LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference
— 0.73 1.25 1.09 1.04 — 0.74 1.28 1.09 0.98 — 0.88 1.34 1.41 1.34 — 0.79 1.33 1.15 1.10 — 0.73 1.29 1.08 0.97 — 0.84 1.34 1.18 1.16
95% Confidence interval
Adjusted variable
0.60–0.90 0.91–1.71 0.86–1.38 0.79–1.36 None 0.60–0.90 0.93–1.76 0.86–1.39 0.74–1.29 Age 0.71–1.09 0.97–1.86 1.10–1.81 Smoking status 1.00–1.80 0.64–0.98 0.96–1.82 0.90–1.45 0.83–1.45 Education 0.59–0.91 0.94–1.76 0.85–1.38 0.73–1.28 Marriage 0.68–1.04 0.97–1.87 0.93–1.51 0.88–1.52 Health status
Note. Data source: 1996 Utah Health Status Survey. Race is not reported separately because of the high proportion of Caucasians in Utah (i.e., about 95%).
RELIGION AND PHYSICAL ACTIVITY
TABLE 4 Measurement of the Association between Vigorous Exercise at Least 20 min Three Times a Week and Select Characteristics among Adults Ages 18 Years and Older in Utah Characteristic Religious preference/church activity LDS active LDS less active Non-LDS active Non-LDS less active No religious preference Age 18–24 25–34 35–44 45–54 55–64 65⫹ Marital status Married Divorced/separated Widowed Never married Smoking status Never smoked Former smoker Current smoker Education Less than HS HS graduate More than HS Self-assessment of health Excellent Very Good Good Fair Poor
Adjusted odds ratioa
95% Confidence interval
— 0.97 1.48 1.45 1.33
0.78–1.21 1.05–2.07 1.12–1.88 0.98–1.80
— 0.90 0.95 0.70 1.05 0.86
0.72–1.13 0.74–1.22 0.52–0.96 0.77–1.43 0.61–1.22
— 1.05 1.03 1.40
0.80–1.39 0.72–1.49 1.09–1.79
— 1.10 0.46
0.87–1.38 0.35–0.61
— 1.32 1.48
0.93–1.88 1.02–2.15
— 0.64 0.47 0.39 0.22
0.52–0.78 0.37–0.58 0.28–0.54 0.14–0.36
Note. 1996 Utah Health Status Survey. Race is not reported separately because of the high proportion of Caucasians in Utah (i.e., about 95%). a The odds ratios were simultaneously computed in a logistic model containing the characteristic variables religious preference/church activity, age, marital status, smoking status, education, and selfassessment of health.
influence in the association between religious preference, church activity, and exercise. For example, religious preference and church activity lead to lower levels of cigarette smoking, which in turn influences higher levels of physical exercise. In the model that adjusted for age, smoking status, education, marital status, and general health simultaneously, non-LDS became significantly more likely to exercise than LDS who attended church weekly. Differences in exercise between religiously active and less active church members disappeared. Reasons why LDS were less likely than non-LDS to be physically active in the adjusted model may seem contradictory given the LDS emphasis on a healthy lifestyle [52]. It may be that LDS were less physically active than non-LDS
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or those with no religious preference in Utah because of less free time. Lack of time is the most common reason reported for physical inactivity [54]. Marriage and having a family is a common lifestyle that occurs among LDS adults. Marriage may constrain physical activity by increasing the time required for tasks related to home, family, social, and religious or civic organizations [55]. It may also be that while the LDS Church emphasizes the importance of abstaining from alcohol and tobacco, it does not adequately emphasize the importance of regular physical activity. Perhaps members of the Church abstaining from tobacco and alcohol believe that such behaviors offset the need for rigorous physical exercise. Nevertheless, further research is needed before conclusions can be made on why lower levels of physical exercise exist in LDS when compared to other religions within Utah. As consistent with other studies, age, marital status, education, smoking status, and general health was associated with exercise [55,56]. Young people, singles, those with higher education, nonsmokers, and those with better general health are all more likely to be regularly involved in physical exercise. These factors have different forces on the association between religious preference, church activity, and physical exercise. For example, people with no religious preference are more likely to be younger and single, which characteristics are associated with higher levels of physical exercise, but people with no religious preference are more likely to be current smokers, which is associated with lower levels of exercise. High levels of education and low levels of cigarette smoking in Utah may be the primary reasons for the relatively high levels of physical activity observed in the state. In the United States, Utah has the highest percentage of adults with a high school education (e.g., 93% have a high school degree) [57] and the lowest percentage of people smoking cigarettes (14.2% of adults in 1998) [58]. A factor lowering the level of physical exercise in Utah is the high percentage of married adults [55]. Approximately 67.7% of adults in Utah are married. This reflects the highest percentage of married adults in the nation [59]. The study provides information that may be useful for directing physical activity intervention programs. Church members who attend church less than weekly are at greatest risk for a sedentary lifestyle, and modifiable behaviors such as smoking are probable explanations for this observation. Reasons for the significantly lower levels of physical activity among LDS, after adjustment is made for the select variables, remain unclear. Further investigation of this differential is warranted and may be required before health officials are able to effectively increase the level of physical activity in this majority population in Utah.
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MERRILL AND THYGERSON CONCLUSION
At the outset we referred to several studies showing that physical exercise can help prevent and manage various chronic conditions. This study shows that religious preference and church activity influence exercise. Processes by which this is done were explored. Within religious groups, those attending church weekly were more likely to exercise than those attending church less than weekly. Higher levels of current smoking or poorer general health are primary explanations for this observation. LDS attending church less than weekly were the least physically active people in Utah. When we adjust for differences in age, smoking status, education, marital status, and general health, LDS were significantly less physically active than non-LDS in Utah. The differences in exercise between church activity levels within religious groups became very small in the adjusted model, indicating that these adjusted variables explain differences in exercise previously observed. The significantly lower levels of exercise in Utah LDS versus non-LDS require further attention.
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42. Bouchard C, Shepard RJ, Stephens T. Physical activity, fitness, and health consensus statement. Champaign (IL): Human Kinetics, 1993. 43. Hodgkin JE. Exercise testing and training. In: Hodgkin J, Petty T, editors. Chronic obstructive pulmonary disease: current concepts. Philadelphia: Saunders, 1987:120–7. 44. Faas A. Exercises: which ones are worth trying for which patients, and when? Spine 1997;21:2874–9.
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45. Johannsen F, Remvig L, Kryger P, Beck P, Warming S, Lybeck K, Dryeer V, Largen LH. Exercises for chronic low back pain: a clinical trial. J Orthop Sports Phys Ther 1995;22:52–9. 46. Casady RM, Lepowski JM. Stratified telephone survey designs. Survey Methodol 1993;19:103–23. 47. SUDDAN. Software for the statistical analysis of correlated data. SUDAAN Release 7.5.4 for PCs. Research Triangle Park (NC): Research Triangle, copyright March 2000. 48. Wallace JM Jr, Forman TA. Religion’s role in promoting health
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and reducing risk among American youth. Health Educ Behav 1998;25:721–41. Exercise—1998. Behavior Risk Factor Surveillance System, Centers for Disease Control and Prevention Web site. Accessed May 14, 2000. Available at http://www2.cdc.gov/nccdphp/brfss/list. asp?cat⫽EX&yr⫽1998&qkey⫽4347&stste⫽US. Risk factors and calculated variables—1998. Behavior Risk Factor Surveillance System, Centers for Disease Control and Prevention Web site. Accessed May 14, 2000. Available at http://www2.cdc.gov/nccdphp/brfss/display.asp?cat⫽RF&yr⫽ 1998&qkey⫽&stste4401⫽US. U.S. Department of Health and Human Services. Healthy People 2010 (conference edition 22-11, in two volumes). Washington: 2000 Jan. The Doctrine and Covenants of the Church of Jesus Christ of Latter-day Saints, Section 89. Salt Lake City: The Church of Jesus Christ of Latter-day Saints, 1986. Frankish CJ, Milligan CD, Reid C. A review of relationships between active living and determinants of health. Soc Sci Med 1998;47:287–301. Pinto BM, Marcus BH, Clark MM. Promoting physical activity in women: the new challenges. Am J Prev Med 1996;12:395–400. Schmitz K, French SA, Jeffrey RW. Correlates of changes in leisure time physical activity over two years: the Healthy Worker Project. Prev Med 1997;26:570–9. U.S. Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. Demographics—1998. Behavior Risk Factor Surveillance System, Centers for Disease Control and Prevention Web site. Accessed May 14, 2000. Available at http://www2.cdc.gov/nccdphp/ brfss/list.asp?cat⫽DE&yr⫽1998&qkey⫽1737&state⫽US. Tobacco use—1998. Behavior Risk Factor Surveillance System, Centers for Disease Control and Prevention Web site. Accessed May 14, 2000. Available at http://www2.cdc.gov/nccdphp/brfss/ list.asp?cat⫽TU&ye⫽1998&qkey⫽621&state⫽US. Demographics—1998. Behavior Risk Factor Surveillance System, Centers for Disease Control and Prevention Web site. Accessed May 14, 2000. Available at http://www2.cdc.gov/nccdphp/ brfss/list.asp?cat⫽DE&yr⫽1998&qkey⫽745&state⫽US. Utah Health Status Survey code book. 2nd ed. Salt Lake City: Bureau of Surveillance and Analysis, Office of Public Health Data, Utah Department of Health, 1996.
Religious Preference, Church Activity, and Physical Exercise Ray M. Merrill, Ph.D., M.P.H.,*,†,1 and Alton L. Thygerson, Ed.D.* *Department of Health Science, College of Health and Human Performance, Brigham Young University, Provo, Utah 84602; and †Division of Epidemiology, Department of Family and Preventive Medicine, University of Utah College of Medicine, Salt Lake City, Utah 84132 Published online June 6, 2001
lower levels of exercise among LDS versus non-LDS could not be explained and require further study.
Background. Utah has the highest percentage of physically active adults in the United States. It also has a high percentage of religiously active people. About 90% of the adult population has a religious preference and 62% of those individuals attend church weekly. This study evaluates the relationship between religious preference, church attendance, and physical activity. Methods. Analysis is based on 6,188 adult respondents ages 18 years and older to a cross-sectional random telephone survey involving 12 health districts in the state of Utah from June 1 to August 31, 1996. Results. Within religious groups, those attending church weekly were more likely to exercise than individuals attending church less than weekly. About 70% of Utah consists of members of the Church of Jesus Christ of Latter-day Saints (LDS). LDS attending church less than weekly were least physically active in Utah. The percentages of those exercising vigorously at least 20 min three times per week were 52.3% (LDS who attend church weekly), 44.5% (LDS who attend church less than weekly), 57.6% (non-LDS who attend church weekly), 54.3% (non-LDS who attend church less than weekly), and 53.1% (no religious preference) (P ⴝ 0.0070). When adjustment was made for age, smoking status, education, marital status, and general health, differences in exercise between church activity levels within religious groups became insignificant. Smoking and general health have the greatest influences on the relationship between religious preference, church attendance, and exercise. LDS were significantly less physically active than non-LDS in the adjusted model. Conclusions. Although differential smoking levels and general health status explained differences between church activity levels within religious groups,
䉷 2001 American Health Foundation and Academic Press
INTRODUCTION
Physical exercise relates directly to decreasing disease and premature death and preserving a high quality of life. Specifically, physical activity can help prevent and manage non-insulin-dependent diabetes mellitus [1–5] and decrease the risk of developing heart disease [6,7], high blood pressure [8–13], colon cancer [14–25], depression and anxiety [26–32], obesity [33–38], osteoarthritis [39–42], chronic obstructive pulmonary disease [43], and low-back pain [44,45]. However, despite the proven benefits of exercise, many Americans continue an inactive lifestyle. Little is known about the relationship between religious preference, church attendance, and physical exercise. Understanding such relationships may help us better identify whether religious preference has a protective effect against physical inactivity and whether this effect is similar between religiously active and less active members. This study considers three religious categories in Utah: (1) members of the Church of Jesus Christ of Latter-day Saints (LDS), commonly called Mormons; (2) members of non-LDS religions; and (3) individuals with no religious preference. The influence of church activity on exercise within groups (1) and (2) is also considered. These groups provide a diverse mix of health and lifestyle behaviors for analysis. MATERIALS AND METHODS
The study is based on the 1996 Utah Health Status Survey. The survey is a cross-sectional random survey sponsored by the Utah Department of Health. The Gallup Organization collected the data by incorporating a
1 To whom reprint requests should be addressed. Fax: (801) 3784388. E-mail: Ray [email protected].
38
0091-7435/01 $35.00 Copyright 䉷 2001 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
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RELIGION AND PHYSICAL ACTIVITY
telephone survey instrument into a computer-assisted random digit dialing software program called SURVENT. Supervised interviews were conducted across 12 local health districts in Utah by trained interviewers. The survey questionnaire consisted of several core module questions. Questions covering demographic (age, marital status, education) and lifestyle (religious preference, church activity, smoking, alcohol consumption, general health, and physical exercise) characteristics were included and will be utilized in the study. The interview process occurred from June 1 to August 31, 1996. The survey interview was conducted with one randomly selected adult age 18 or older in each household. If required, as many as nine telephone attempts were made to contact a selected household. After a randomly selected survey respondent was identified, up to nine additional attempts were made to conduct the interview with that person. The response rate was 66.3%. A complex survey sample design was used in order to provide a representative sample of the Utah population. It may be described as a weighted probability sample of households disproportionately stratified by 12 local health districts that cover the state. Respondents from 500 households were interviewed in each health district, except for the Salt Lake City Health District, where respondents from 800 households were interviewed in order to increase precision in the statewide estimates. A single-state, nonclustered, equal probability of selection telephone calling design was used to generate telephone numbers [46]. In order to more accurately generalize the survey results to the Utah population, postsurvey weighting adjustments were made. Adjustments weighted the sample to be proportionally consistent with age, sex, geographic, and Hispanic status distribution of the 1996 Utah population. Variables used in the analysis include religious preference, religious activity, gender, age, marital status, alcohol consumption, smoking status, education, general health, mental health, and exercise. If a religious preference was identified, participants were then asked: “Do you attend services about once a week, or more, or less often than once a week?” Alcohol and tobacco use was based on questions of whether they were non-, former, or current drinkers of alcohol or smokers, respectively. General health was based on the question: “In general, would you say your health is excellent, very good, good, fair, or poor?” Mental health was based on the question: “During the past 12 months, did you seek help from a therapist, counselor, or other mental health professional for any personal or emotional problems?” Finally, exercise was based on the question: “Do you vigorously exercise for 20 minutes at least three times a week?” Test statistics involved standard errors of the survey estimates derived using a Taylor-series expansion that
accounts for the complex survey design. SAS (version 8.0)-callable SUDAAN was used for data analysis [47]. Weighted frequency and percentage distributions for two-way tabulations and logistic regression analysis were computed. Tests of independence and significance were performed, based on the 0.05 level. RESULTS
Of the 6,188 survey respondents ages 18 years and older, 49.1% were LDS attending church weekly, 20.2% were LDS attending church less than weekly, 6.8% were non-LDS attending church weekly, 13.7% were nonLDS attending church less than weekly, and 10.2% had no religious preference. Non-LDS religious preferences included 35% Protestant, 36% Catholic, 2% Jewish, and 28% other religions. The percentage of adults involved in vigorous exercise at least 20 min three times per week is presented according to religious preference in Fig. 1. Because of small numbers in some of the nonLDS groups, religious preference is hereafter classified as LDS, non-LDS, and no religious preference. In Table 1, the distribution of respondents is presented by religious preference, church activity, and select demographic, lifestyle, and health characteristic variables. Response rates for each of the variables are above 99%, except for age, which is at about 96%. The distribution of respondents across the levels of each variable differed significantly among the categories of religious preference and church activity. For example, consider the contrast between LDS attending church weekly and those with no religious preference. LDS attending church weekly were more likely to be women, have an older age distribution, be married, be nonconsumers of alcohol or cigarettes, have an advanced degree, report having excellent health, and not be seeking professional help for personal or emotional problems. Table 2 shows the percentage of respondents ages 18 years and older in Utah who exercised vigorously for at least 20 min three times a week by the select variables. The percentage of those exercising at this level differs significantly across the levels of age, marital status, smoking status, education, and self-assessment of general health. In particular, an inverse relationship exists between age and exercise; women who are widowed are least likely and women never married most likely to exercise; current cigarette smokers are less likely than former or never smokers to exercise; a positive relationship exists between education and exercise; a negative association exists between general health status and exercise. Overall, 51.4% of the adult population in Utah exercised vigorously for at least 20 min three times a week. This percentage varies significantly across the categories of religious preference and church activity. Percentages of exercisers at this level were 52.3% for LDS
40
MERRILL AND THYGERSON
FIG. 1. Percentage participating in vigorous exercise at least 20 min three times a week according to religious preference among adults ages 18 years and older in Utah.
attending church weekly, 44.5% for LDS attending church less than weekly, 57.6% for non-LDS attending church weekly, 54.3% for non-LDS attending church less than weekly, and 53.1% for those with no religious preference (P ⫽ 0.0070). The percentage maintaining for 5 or more years that level of exercise did not differ significantly among the categories of religious preference and church activity (P ⫽ 0.3765). Measures of the association between exercise and combinations of religious preference and church activity are reported in Table 3. The table also shows the measures of association adjusted separately for age, marital status, smoking status, education, and general health. The measures of association were influenced by the adjustment for each variable. Gender, alcohol consumption, and seeking professional help for personal or emotional problems are not considered because they were not associated with the exercise variable. The relatively low level of physical exercise in LDS
attending church less than weekly is maintained until adjustment for smoking status or general health. In Table 4, measures of the association between exercise and combinations of religious preference and church activity, based on a model adjusting simultaneously for the select variables, are presented. Physical exercise in LDS attending church weekly versus less than weekly is no longer significantly different in the model. On the other hand, non-LDS were significantly more likely than LDS to exercise vigorously at least 20 min three times a week. The previously observed differences in exercise between church activity levels were no longer present. Estimates of the association between exercise and each of the variables included in the model are also reported. DISCUSSION
Little is known about the processes by which religious preference and church activity affect participation in
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RELIGION AND PHYSICAL ACTIVITY
TABLE 1 Summary of Respondents to the 1996 Utah Health Status Survey Ages 18 Years and Older by Religious Preference, Church Activity,a and Select Demographic, Lifestyle, and Health Characteristics Religious preference/church activity LDS Characteristic Gender Men Women Age 18–24 25–34 35–44 45–54 55–64 65⫹ Marital status Married Divorced/separated Widowed Never married Alcohol consumption per month Nondrinker Up to 60 drinks 60⫹ drinks Smoking status Never smoked Former smoker Current smoker Education Less than HS HS graduate More than HS Self-assessment of health Excellent Very Good Good Fair Poor Seeking professional help for personal or emotional problems Yes No
Non-LDS
Active
Less active
Active
Less active
None
P valueb
45.2% 54.8%
52.3% 47.7%
42.0% 58.0%
51.4% 48.6%
58.3% 41.7%
0.0002
18.8% 22.0% 20.0% 14.4% 11.2% 13.6%
16.9% 20.9% 19.2% 15.2% 12.6% 15.2%
10.0% 20.6% 21.9% 17.8% 12.0% 17.8%
13.3% 20.9% 30.0% 17.9% 8.5% 9.5%
29.9% 31.2% 22.6% 11.0% 4.1% 2.3%
0.0000
76.2% 3.1% 4.1% 16.6%
62.7% 13.7% 5.5% 18.2%
73.6% 10.3% 5.6% 10.6%
59.4% 17.3% 3.5% 19.9%
50.2% 16.9% 0.3% 32.7%
0.0000
98.5% 1.5% 0.0%
55.9% 40.6% 3.5%
55.0% 44.0% 1.0%
39.2% 55.4% 5.5%
37.7% 54.6% 7.7%
0.0000
92.6% 7.0% 0.4%
54.9% 23.7% 21.4%
64.8% 26.9% 8.3%
47.3% 24.6% 28.1%
51.8% 20.1% 28.1%
0.0000
1.9% 60.6% 37.5%
11.4% 68.7% 19.8%
12.5% 50.9% 36.5%
10.0% 57.5% 32.5%
10.1% 61.3% 28.7%
0.0000
32.9% 37.1% 22.2% 6.2% 1.6%
22.7% 31.7% 29.9% 11.2% 4.4%
30.3% 29.4% 27.6% 10.7% 2.1%
31.1% 29.4% 25.6% 8.8% 5.2%
21.2% 39.0% 27.8% 10.0% 2.0%
0.0000
6.5% 93.5%
12.3% 87.7%
8.9% 91.1%
10.4% 89.7%
14.1% 85.9%
0.0001
Note. Percentages by columns may not sum to 100 because of rounding. Race is not reported separately because of the high proportion of Caucasians in Utah (i.e., about 95%). a Active, attends church weekly. Less active, attends church less than weekly. b Based on the chi-square statistic.
physical exercise. A health behavior hypothesis may argue that religious persons engage in a broad range of health-enhancing behaviors. A recent national study of high school seniors documented that religious youth are more likely to exercise [48]. The current study systematically examines the processes by which religious preference and church attendance may affect levels of physical exercise among adults in Utah. This state represents a population with high levels of religious orientation, church activity, and physical exercise. Approximately 89.8% of the adult population in Utah has a religious preference and 62.2% of those people
attend church weekly. Along with high levels of church activity, Utah had the highest percentage of adults ages 18 years and older in the United States involved in any physical exercise during the previous month (82.9%), based on the 1998 Behavior Risk Factor Status Survey [49]. The Survey also found that Utah had the third lowest percentage of adults at risk for health problems related to lack of regular and sustained physical activity (72.9%) [50]. The indicator of physical activity used in this paper was vigorous exercise at least 20 min three times a week. Percentages of such physical activity reported in Utah are much higher than nationally. In the
42
MERRILL AND THYGERSON
TABLE 2 Percentage of Adults Ages 18 Years and Older in Utah Who Exercise Vigorously at Least 20 min Three Times a Week (Exercise) by Select Demographic, Lifestyle, and Health Characteristics Characteristic Gender Men Women Age 18–24 25–34 35–44 45–54 55–64 65⫹ Marital status Married Divorced/separated Widowed Never married Alcohol consumption per month Nondrinker Up to 60 drinks 60⫹ drinks Smoking status Never smoked Former smoker Current smoker Education Less than HS HS graduate More than HS Self-assessment of health Excellent Very Good Good Fair Poor Seeking professional help for personal or emotional problems Yes No
Exercise
P valuea
52.8% 50.1%
0.1663
59.1% 50.1% 53.5% 51.5% 43.4% 45.6%
0.0004
50.0% 48.3% 44.5% 59.9%
0.0007
50.4% 54.6% 48.5%
0.1842
53.6% 54.4% 33.8%
0.0000
38.7% 50.6% 55.6%
LDS who consume alcohol or smoke cigarettes are unlikely to be active in the church. For example, only 0.4% of religiously active LDS are current smokers compared with 21.4% of less religiously active LDS. A noticeable difference in smoking and alcohol use was also observed between non-LDS who attended church weekly versus less than weekly, although less pronounced than among LDS. Consistent with other studies [53], age is inversely related with physical exercise. Independent of this relationship it is also associated with categories of religious preference and church activity. Adjusting for age in the model had its primary effect on the odds of exercise among those with no religious preference compared with LDS who attend church weekly (Table 3). This was expected, given the significantly younger age distribution among people in Utah with no religious preference. Other variables considered may have a mediating TABLE 3
0.0004
64.1% 52.2% 42.9% 37.6% 24.9%
0.0000
47.8% 51.7%
0.2471
Note. Data source: 1996 Utah Health Status Survey. Percentages by columns may not sum to 100 because of rounding. Race is not reported separately because of the high proportion of Caucasians in Utah (i.e., about 95%). a Based on the chi-square statistic.
United States in 1997, 23% of adults ages 18 years and older engaged in vigorous physical activity 3 or more days a week for 20 or more min each time [51]. The results support the hypothesis that people attending church weekly are more likely than those who do not to exercise vigorously at least 20 min three times a week. This may be explained, at least in part, by lower levels of cigarette smoking and better general health in religiously active people. Higher levels of physical exercise in those attending church weekly versus less than weekly were more pronounced in LDS than nonLDS. Since 1833, the LDS Church has proscribed use of tobacco or consumption of alcohol, coffee, or tea [52].
Measurement of the Association between Vigorous Exercise at Least 20 min Three Times a Week and Combinations of Religious Preference and Church Activity among Adults Ages 18 Years and Older in Utah Religious preference/ church activity
Odds ratio
LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference LDS active LDS less active Non-LDS active Non-LDS less active No religious preference
— 0.73 1.25 1.09 1.04 — 0.74 1.28 1.09 0.98 — 0.88 1.34 1.41 1.34 — 0.79 1.33 1.15 1.10 — 0.73 1.29 1.08 0.97 — 0.84 1.34 1.18 1.16
95% Confidence interval
Adjusted variable
0.60–0.90 0.91–1.71 0.86–1.38 0.79–1.36 None 0.60–0.90 0.93–1.76 0.86–1.39 0.74–1.29 Age 0.71–1.09 0.97–1.86 1.10–1.81 Smoking status 1.00–1.80 0.64–0.98 0.96–1.82 0.90–1.45 0.83–1.45 Education 0.59–0.91 0.94–1.76 0.85–1.38 0.73–1.28 Marriage 0.68–1.04 0.97–1.87 0.93–1.51 0.88–1.52 Health status
Note. Data source: 1996 Utah Health Status Survey. Race is not reported separately because of the high proportion of Caucasians in Utah (i.e., about 95%).
RELIGION AND PHYSICAL ACTIVITY
TABLE 4 Measurement of the Association between Vigorous Exercise at Least 20 min Three Times a Week and Select Characteristics among Adults Ages 18 Years and Older in Utah Characteristic Religious preference/church activity LDS active LDS less active Non-LDS active Non-LDS less active No religious preference Age 18–24 25–34 35–44 45–54 55–64 65⫹ Marital status Married Divorced/separated Widowed Never married Smoking status Never smoked Former smoker Current smoker Education Less than HS HS graduate More than HS Self-assessment of health Excellent Very Good Good Fair Poor
Adjusted odds ratioa
95% Confidence interval
— 0.97 1.48 1.45 1.33
0.78–1.21 1.05–2.07 1.12–1.88 0.98–1.80
— 0.90 0.95 0.70 1.05 0.86
0.72–1.13 0.74–1.22 0.52–0.96 0.77–1.43 0.61–1.22
— 1.05 1.03 1.40
0.80–1.39 0.72–1.49 1.09–1.79
— 1.10 0.46
0.87–1.38 0.35–0.61
— 1.32 1.48
0.93–1.88 1.02–2.15
— 0.64 0.47 0.39 0.22
0.52–0.78 0.37–0.58 0.28–0.54 0.14–0.36
Note. 1996 Utah Health Status Survey. Race is not reported separately because of the high proportion of Caucasians in Utah (i.e., about 95%). a The odds ratios were simultaneously computed in a logistic model containing the characteristic variables religious preference/church activity, age, marital status, smoking status, education, and selfassessment of health.
influence in the association between religious preference, church activity, and exercise. For example, religious preference and church activity lead to lower levels of cigarette smoking, which in turn influences higher levels of physical exercise. In the model that adjusted for age, smoking status, education, marital status, and general health simultaneously, non-LDS became significantly more likely to exercise than LDS who attended church weekly. Differences in exercise between religiously active and less active church members disappeared. Reasons why LDS were less likely than non-LDS to be physically active in the adjusted model may seem contradictory given the LDS emphasis on a healthy lifestyle [52]. It may be that LDS were less physically active than non-LDS
43
or those with no religious preference in Utah because of less free time. Lack of time is the most common reason reported for physical inactivity [54]. Marriage and having a family is a common lifestyle that occurs among LDS adults. Marriage may constrain physical activity by increasing the time required for tasks related to home, family, social, and religious or civic organizations [55]. It may also be that while the LDS Church emphasizes the importance of abstaining from alcohol and tobacco, it does not adequately emphasize the importance of regular physical activity. Perhaps members of the Church abstaining from tobacco and alcohol believe that such behaviors offset the need for rigorous physical exercise. Nevertheless, further research is needed before conclusions can be made on why lower levels of physical exercise exist in LDS when compared to other religions within Utah. As consistent with other studies, age, marital status, education, smoking status, and general health was associated with exercise [55,56]. Young people, singles, those with higher education, nonsmokers, and those with better general health are all more likely to be regularly involved in physical exercise. These factors have different forces on the association between religious preference, church activity, and physical exercise. For example, people with no religious preference are more likely to be younger and single, which characteristics are associated with higher levels of physical exercise, but people with no religious preference are more likely to be current smokers, which is associated with lower levels of exercise. High levels of education and low levels of cigarette smoking in Utah may be the primary reasons for the relatively high levels of physical activity observed in the state. In the United States, Utah has the highest percentage of adults with a high school education (e.g., 93% have a high school degree) [57] and the lowest percentage of people smoking cigarettes (14.2% of adults in 1998) [58]. A factor lowering the level of physical exercise in Utah is the high percentage of married adults [55]. Approximately 67.7% of adults in Utah are married. This reflects the highest percentage of married adults in the nation [59]. The study provides information that may be useful for directing physical activity intervention programs. Church members who attend church less than weekly are at greatest risk for a sedentary lifestyle, and modifiable behaviors such as smoking are probable explanations for this observation. Reasons for the significantly lower levels of physical activity among LDS, after adjustment is made for the select variables, remain unclear. Further investigation of this differential is warranted and may be required before health officials are able to effectively increase the level of physical activity in this majority population in Utah.
44
MERRILL AND THYGERSON CONCLUSION
At the outset we referred to several studies showing that physical exercise can help prevent and manage various chronic conditions. This study shows that religious preference and church activity influence exercise. Processes by which this is done were explored. Within religious groups, those attending church weekly were more likely to exercise than those attending church less than weekly. Higher levels of current smoking or poorer general health are primary explanations for this observation. LDS attending church less than weekly were the least physically active people in Utah. When we adjust for differences in age, smoking status, education, marital status, and general health, LDS were significantly less physically active than non-LDS in Utah. The differences in exercise between church activity levels within religious groups became very small in the adjusted model, indicating that these adjusted variables explain differences in exercise previously observed. The significantly lower levels of exercise in Utah LDS versus non-LDS require further attention.
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