Religious Observance and Acute Coronary Syndrome in Predominantly Muslim Albania: A Population-based Case-Control Study in Tirana

Purpose

We aimed to assess the association of religious observance with acute coronary syndrome (ACS) in a predominantly Muslim population.

Methods

A case-control study conducted in Tirana, Albania in 2003–2006 included 467 nonfatal consecutive ACS patients (370 men, 97 women; 88% response) and a population-based control group (469 men, 268 women; 69% response). Religious observance was assessed as a composite score based on mosque/church attendance, frequency of prayer and ritual fasting. The association of religiosity with ACS was assessed by multivariable-adjusted logistic regression.

Results

Nonobservance was frequent in this population (67% among Muslim controls, 55% in Christian controls). Religious observance was inversely associated with ACS in both groups (multivariable-adjusted odds ratios for above median observance scores vs zero observance: 0.45 [95% confidence interval (CI) = 0.26–0.77] in Muslims, 0.58 [0.25–1.31] in Christians, and 0.48 [0.31–0.74] overall]. Associations with ACS were strongest for prayer and fasting.

Conclusions

In a country experiencing major socioeconomic transition from rigid communism, including extreme state-enforced secularism, we found an apparent protective effect associated with religious observance in both Muslims and Christians. This may be the first such study reported in a Muslim population.

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.