Religious Observance and Acute Coronary Syndrome in Predominantly Muslim Albania: A Population-based Case-Control Study in Tirana
Introduction
The health effects of religious observance and spirituality have been debated over the past decade 1, 2, 3, 4, 5, 6, 7, 8. Numerous studies have pointed to a protective effect on overall mortality 8, 9, 10, 11, 12, 13, 14, 15 and cardiovascular mortality and morbidity 8, 9, 11, 13, 16, 17, whereas others have questioned a beneficial health effect of religious observance 3, 5, or have argued for non-robust (18) and/or confounded relationships 18, 19. To date, most studies addressed Christian (e.g., references 1, 2, 4, 6, 7, 8, 15) or Jewish populations 9, 16, 20. Such research in Muslim societies is sparse and has focused mainly on associations with emotional well-being (e.g., references 21, 22). We are unaware of reports on cardiovascular disease or mortality outcomes, except for a small cross-sectional study of blood pressure (23).
Commencing in 1991, Albania has undergone a major social and political transition from xenophobic Stalinist communism to a free market economy with democratic institutions.
In 2001, the population of Albania officially numbered 3,087,159 (24), with 97% of the population being ethnic Albanians (25). In addition, it is estimated that at least 750,000 Albanians have emigrated in search of work because of rampant unemployment in the wake of transition 25, 26, although the economy has stabilized in recent years (27). The population of Tirana city was estimated as 343,078 (24). In 2004, the official Albanian gross domestic product per capita based on purchasing-power parity was $4,937 US (27). The Albanian healthcare system continues to operate within a state-owned framework.
God was officially “outlawed” in 1967 when the Albanian dictator Hoxha ordered all religious institutions demolished or converted into sport arenas and other secular facilities 25, 28. Ever since, the general perception has been that Albania is largely a secular state (25). Although religion has not been an overtly important identity element in Albanian society for half a century, with the return of religious freedom in 1991 numerous mosques and churches reopened. There have been no census data on religious affiliation in Albania since 1938. It is estimated that 70% of the population regard themselves as Muslim, 20% as Orthodox Christian, and 10% as Roman Catholic, irrespective of actual religious observance 25, 29.
In the context of this transitional and predominantly Muslim population and consequent to the communist experiment with state-enforced godlessness, we examined the association of religious observance, assessed in terms of attendance of religious institutions, frequency of prayer and ritual fasting, with coronary heart disease among residents of Tirana, the Albanian capital.
Section snippets
Study Population
A population-based case-control study of acute coronary syndrome (ACS) among 35- to 74-year-old residents of Tirana was conducted from 2003–2006. Details of the study population, sampling procedures, sample size, and case definition are described elsewhere (30). Briefly, we recruited 467 consecutive patients with non-fatal ACS (370 men aged 59.1 ± 8.7 years, 97 women aged 63.3 ± 7.1 years, all Tirana residents; 88% response; 301 first events, 166 repeat events) admitted to the University
Results
In the population-based control group, 67% of Muslims and 55% of Christians were completely non-observant, based on our scale. Regular attendance of religious institutions (at least once every 2 weeks) was low in both denominations (6% in Muslims and 9% in Christians), and weekly attendance was very low (2% and 1%, respectively). Frequent praying (at least 2 to 3 times per week) was higher in Christians (29%) than in Muslims (17%) (age-adjusted p < 0.01]. Praying several times daily (as
Discussion
The main finding of our study, in a population in transition from rigid Stalinism to a market economy, was the inverse association of ACS with higher scores of religious observance in both Muslims and Christians. This may be the first such evidence in a Muslim population. Religious observance was associated with age, religious affiliation (Christians were more observant than Muslims), lower educational status and income, more emigration of close family. and less smoking. The association of
Conclusions
Our study, which is one of the few studies undertaken outside a Judeo-Christian context, is consistent with a protective effect of higher levels of religious observance on coronary health in both Muslims and Christians in a largely nonobservant population. The findings, particularly among Muslims, withstood adjustment for potential confounding and mediating variables, suggesting that some quality associated with religious observance (e.g., stress amelioration) may be protective in a
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Contributors: G. Burazeri contributed to the study conceptualization and design, data acquisition, analysis and interpretation of the data, and writing of the article. A. Goda contributed to the acquisition of the data and commented on the manuscript. J. D. Kark contributed to the study conceptualization and design, analysis and interpretation of the data, writing of the article, and helped organize the funding. All authors have read and approved the submitted manuscript.