2. Literature Review, Theory, and Hypotheses
The relationship between religious beliefs and perceptions of mental illness are quite complex. There is a sizable scholarly literature illustrating a rather negative influence of religious beliefs on perceptions of strategies for addressing mental illnesses. When living with a mental illness, many religious people struggle to make sense of their condition (
Milner et al. 2019). There is a well-documented tension between those with conservative religious outlooks and mental illnesses, and while many religious people hope to obtain support and guidance from their religious community during times of distress, not all do (
Stanford and McAlister 2008). In a study by
Stanford (
2007), approximately one-third of Christians who sought religious counsel for their mental illness indicated their interaction was negative, and in a subsequent investigation by
Stanford and McAlister (
2008), 41.2% of respondents indicated that their church suggested they did not have a mental illness, even though they had been professionally diagnosed with one. Of these respondents who reported this denial of mental illness from their church, many expressed that their church was conservative with doctrine and scriptural interpretations (
Stanford and McAlister 2008). In another study by
Lloyd and Waller (
2020), 34% of a sample of self-identified evangelical Christians expressed that their church framed mental disorders as the result of demons or spirits, and 31% of these Christians said their church proposed that recovery from a mental illness depended on prayer and deliverance alone. When mental illnesses are discussed as the work of Satan, the product of demons, or the result of personal sin (
Stanford 2007), it becomes easy to attach a stigma to the individual and attribute all blame to their own wrongdoings or their lack of spiritual fortitude (
Webb et al. 2008;
Wesselmann and Graziano 2010).
Furthermore, prior research has indicated that those who are theologically conservative do not endorse professional psychological treatments for mental illnesses and tend to hold more stigma towards mental illnesses. Conservative Protestants
1 place immense value on religious teachings, and research has shown that those who score higher on levels of religious fundamentalism show a greater preference for religious help-seeking than psychological help-seeking (
Wamser et al. 2011). In addition, when comparing denominational affiliations, Protestant and non-denominational Christians endorse spiritually oriented causes and treatments of mental illnesses more than Catholics (
Wesselmann and Graziano 2010). This preference for religious sources of help may emerge out of tension between those who believe in the Bible as divinely inspired and those who do not (
Nakash et al. 2019). Alternatively, this preference may result from concerns that secular service providers may dismiss spiritual experiences and explanations of mental illnesses (
Milner et al. 2019). A third possibility for this preference may be the religious clients’ perceived discrepancy between their own belief system and that of a secular therapist (
Crosby and Bossley 2012).
Generally, stigma acts as a deterrent to seeking mental healthcare (
Brenner et al. 2018;
Crosby and Bossley 2012) and research has illustrated that stigma of mental illness may vary among religious denominations. It is documented that self-stigma of seeking help is related to negative attitudes towards professional psychological help for mental illnesses (
Brenner et al. 2018). In evaluating self-stigma among religious groups, it has been shown that Christians hold a greater self-stigma of depression than non-Christians (
McGuire and Pace 2018), while Evangelicals hold a greater self-stigma toward depression than both non-evangelical Christians and non-Christians (
McGuire and Pace 2018). Since stigma is associated with less favorable attitudes toward seeking professional help, and theologically conservative groups hold greater self-stigma, this study will account for the stigma of mental illness.
Prior research has highlighted the substantial role of religious leaders as providers of mental health assistance among those who are religious. Clergy are often seen as valuable sources of advice and guidance and are commonly regarded as having formidable interpersonal communication skills (
Ellison et al. 2006;
Wang et al. 2003). Furthermore, clergy are frequently viewed as a familiar, trusting, easily accessible, and “free” (economical) source of mental health guidance (
Payne and Hays 2016;
Pickard and Guo 2008). In one study, it was indicated that clergy were contacted at a higher rate than psychiatrists and general medical doctors, and almost one-quarter of all people who sought mental health treatment of any kind also sought help from clergy (
Wang et al. 2003). Additionally, in 1996, approximately one-third of U.S. adults viewed clergy as the first or second choice of assistance for a variety of mental health issues (
Ellison et al. 2006), and, in evaluating trends from 1996 to 2006, there was a noteworthy increase (from 22% in 1996 to 42% in 2006) in the endorsement of spiritual healers as being an appropriate source of help for those with depression (
Blumner and Marcus 2009).
Furthermore, while research has indicated that religious affiliation, attendance at religious services, and global religiosity influence one’s preference for mental health assistance from religious leaders, none of these studies have provided a comprehensive evaluation of religious beliefs on preferred types of assistance. Among religious denominations, Conservative Protestants were shown to be more favorable disposed to selecting clergy as a primary or secondary source of mental health assistance, followed by moderate Protestants, then liberal Protestants, and then Catholics (
Ellison et al. 2006). In addition, frequent attendance at religious services is positively associated with a preference for clergy as a mental health support (
Pickard and Guo 2008), with one study indicating that a majority (56%) of regular church attenders regard religious leaders as a first or second choice for assistance (
Ellison et al. 2006). Moreover, some have indicated that global religiosity is a robust predictor of seeking help from religious sources, perhaps even being more important than attendance at religious services (
Crosby and Bossley 2012). Those with high intrinsic religiosity are more willing to seek assistance from clergy (
Pickard and Guo 2008) and having a greater preference for religious help-seeking for mental health issues was associated with a decreased preference for seeking secular assistance (
Crosby and Bossley 2012).
Additionally, biblical literalism has been evaluated as a predictor of one’s preference for mental health assistance from religious leaders; however, this single measure alone does not provide a complete evaluation of a multidimensional religious worldview on preferred assistance. Biblical literalism is the belief that the Bible is the literal word of God (
Ellison et al. 2006;
Hempel and Bartkowski 2008). Biblical literalists are more likely to endorse religious leaders as an appropriate source of help than non-biblical literalists (
Stanfield 2002), and in some studies, biblical literalists are more inclined to select clergy as a first or second source of help than non-biblical literalists (
Ellison et al. 2006). Interestingly, though, a study by
Stanfield (
2002) revealed that biblical literalists were just as likely as non-biblical literalists to suggest that psychiatrists, psychologists, and other secular professionals were appropriate sources of mental health assistance. While these investigations are insightful, they neglect to address the reductionist nature of this singular item.
It becomes evident in reviewing the scholarly literature that religious beliefs have been largely overlooked as a predictor of one’s preference for mental health assistance. Indeed, biblical literalism alone has been studied; however, only evaluating one’s interpretation of the Bible is an overly simplistic approach to analyzing an entire religious worldview (
Hempel and Bartkowski 2008). This study rectifies the lack of attention given the relationship between theological conservatism and preferences for mental health assistance.
The present study evaluates the concepts of schemas and theological conservatism in relation to preferences for various sources of assistance with mental illnesses. A schema is a cognitive framework that allows an individual to perceive and comprehend the world and determine appropriate action for different circumstances (
Bartkowski et al. 2012;
McIntosh 1995). Schemas give people a mental structure to perceive, process, and conceptually understand a situation (
McIntosh 1995). They help us to accomplish the sense-making tasks we are faced with daily. Schemas are built through interactions with one’s environment, and while they have a potential to undergo modification, they are often quite stable (
McIntosh 1995). In other words, we often adjust the external stimuli to fit our established schema rather than revise the schema itself. Additionally, these mental frameworks are generalizable to the extent that a well-developed schema can be applied to new situations as they occur (
Sewell 1992). Religious schemas emerge as an interconnected system of theological principles that allow an individual to reach morally justified conclusions (
Bartkowski et al. 2012). Schemas are then a constellation of beliefs that are activated on a routine basis. In addition, research has indicated that some religiously conservative groups (in particular, those who are members of Conservative Protestant denominations) generally hold negative attitudes towards science (
Ellison and Musick 1995). Therefore, those with a mature religious schema of this sort would arguably be skeptical of secular interventions for mental illnesses, thus preferring religious options (e.g., clergy) as a source of assistance for mental illnesses (
Taylor 2001).
Theological conservatism can be understood as a religious schema because it is a cognitive framework through which people interact with the world.
Hempel and Bartkowski (
2008) contend that theological conservatism provides a more thorough understanding of the complexities associated with a Conservative Protestant faith tradition and the norms that prevail in this tradition. They argue that specific beliefs about scripture, sin, and salvation are the central tenets of a theologically conservative worldview. Rooted in ethnographic research, the construct of theological conservatism encompasses a set of collectively shared understandings through which people practice, and live, their theological beliefs. Thus, it is not concerned with academic debates about theology, but rather focuses on how adherents apply doctrinal principles in their everyday lives. With scripture, theological conservatives believe that the Bible is the “literal word of God.” Thus, the epistemology of theological conservatism privileges religious sources of truth (especially the Bible) over secular ways of knowing (e.g., science) (
Bartkowski 2001). Concerning sin, theological conservatives believe that humans are innately sinful and that God has created a world in which justice demands people being punished for their transgressions. The ontology of theological conservatism, then, is centrally focused on sin and punishment (
Bartkowski 2001). Somewhat tautologically, this perspective on the inherent corruption of human nature (ontology) is grounded in a particular reading of scripture (epistemology) that elevates passages which emphasize people’s penchant for disobedience to God’s laws. Finally, salvation beliefs are the domain of soteriology, that is, what must one do to be “saved” (
Bartkowski 2001). Among theologically Conservative Protestants, it is believed that salvation entails the imperative for an individual to accept Jesus Christ as his or her “personal savior.” Altogether, the combination of these three distinct positions on scripture, sin, and salvation constitute theological conservatism as a shared hermeneutic posture that creates an interpretive community among those who hold these views. With a reliance on three axes, rather than a single component alone (e.g., biblical literalism only), this more holistic approach to theological conservatism can shed additional light on a multifaceted set of beliefs that make conservative faith traditions unique.
How, then, would theological conservatism as a schema be expected to influence preferences for different sources of mental health assistance? As noted, theological conservatives believe that scripture is the literal word of God (
Hempel and Bartkowski 2008). Those who hold this commitment to scripture would be expected to use the Bible as a key resource throughout a mental illness recovery process as it and God are seen as providing authoritative guidance. For instance, within Biblical Counseling, a form of counseling common among Conservative Protestants, emphasis is often placed on scripture for the duration of this therapy (
Kinghorn 2016;
Peteet 2019). With this scriptural focus, frequent Bible-reading as well as continual recall of God’s authority and will are understood as an appropriate response to mental illness.
In addition, through this theologically conservative worldview, mental illnesses may be viewed as the result of personal sin. Mental illnesses could be seen as punishment for one’s transgressions (sinful behaviors) or a product of spiritual weakness such as a lack of faith or trust in God (
Webb 2012). In some cases, mental illnesses are thought to be the product of being a failed or “bad” Christian (
Webb et al. 2008). If this perception is held, then the appropriate response to address a mental illness would involve taking personal responsibility for and confessing one’s sins, engaging in religious practices such as prayer, and trusting in God or Jesus Christ to save the wayward person from this condition (
Webb et al. 2008).
Moreover, theological conservatism indicates that the salvation of one’s soul is only accomplished by accepting Jesus Christ as his or her savior (
Hempel and Bartkowski 2008). Consequently, if one views mental illness as a burden on the soul, salvation may be the key to releasing the burden and becoming renewed (
Sontag 1984). Similarly, if the illness is viewed as being the result of demonic works or influences, an appropriate response to address the ailment may be to turn to Christ for restoration (
Webb et al. 2008).
Understanding these key components of theological conservatism, and how they might influence one’s evaluation of mental health, it becomes possible to speculate how someone might evaluate various avenues of mental health assistance in accord with this worldview. Religious approaches such as reading the Bible, confession of personal sin, prayer, and trust in God are encouraged among Conservative Protestants. It could be inferred that if these individuals were willing to seek assistance for mental issues, they would most likely encourage seeking assistance from others who share their similar faith and understanding, including clergy and other religious leaders. Furthermore, those with this theology might value assistance from religious leaders as more beneficial than assistance from external, secular sources that do not share their theology such as psychiatrists and other secular mental health professionals.
When treated as a schema, the tenets of theological conservatism are perceived as operating in combination with one another; scripture, sin, and salvation would be expected to function together. While this constellation approach has been useful in evaluating more general social ideas such as support of gender traditionalism (
Bartkowski and Hempel 2009) or one’s inclination to exhibit generalized trust in others (
Hempel et al. 2012), it is possible that when presented with personal issues of mental health, a single dimension of theological conservatism would exhibit greater influence than the others.
In particular, the salvation dimension of theological conservatism may be elevated in influence over scripture and sin given the perceived need for “inner change” for which salvation could be perceived as the quintessential solution. Moreover, our study uses a methodology that prioritizes the personalized nature of mental illness, and salvation is a understood an acceptance of Jesus Christ as one’s personal savior. In this investigation, vignettes depicting an individual with a mental health disorder are presented to respondents for assessment. Vignettes are often used in research to simulate and evaluate participants’ decision-making process with various phenomena (
Evans et al. 2015), and the mental health vignettes in this study provide an opportunity to see how respondents interact with and interpret highly personalized mental health scenarios. Furthermore, research investigating secular social services and faith-based initiatives have highlighted the role of personal transformation as a key facet of many faith-based approaches to social problems (
Bartkowski and Grettenberger 2018). This personal transformation requires an individual to initiate change from within (
Bartkowski and Grettenberger 2018). In essence, the inner change only begins once one accepts God or Jesus Christ as their savior. Therefore, this individualized approach to salvation may be emphasized among those who are theologically conservative when presented with personalized mental health vignettes. Understanding this possibility, this study is taking a slightly different approach to utilizing theological conservatism. Rather than analyzing the three components of theological conservatism in tandem, this study individually evaluates each dimension to assess its independent influence.
Overall, making use of how theological conservatism can be analyzed from the perspective of epistemology (scripture), ontology (sin), and soteriology (salvation), this research comprehensively assesses how those holding this set of beliefs make interpretations about sources of help for mental illnesses. If religious approaches to coping with mental illness such as reading the Bible, confessing sin, and accepting Christ are encouraged among people of faith, these individuals would perhaps be more willing to seek assistance for mental health issues from others who share their faith, including clergy and other religious leaders. Therefore, this research study proposes the following hypothesis.
Hypotheses 1 (H1). Theological conservatism will be positively associated with a preference for mental health assistance from a minister, priest, rabbi, or other religious leader for a mental disorder, net of confounding factors.
Furthermore, those who embrace conservative theology might perceive assistance from religious leaders as more beneficial than assistance from external, secular sources, given that many secular professionals may not share their religious worldview. For that reason, our investigation proposes the following hypothesis.
Hypotheses 2 (H2). Theological conservatism will be negatively associated with a preference for mental health assistance from secular sources of help for a mental disorder, net of confounding factors.
Finally, given that the salvation dimension of theological conservatism is closely aligned with personalized issues of mental health and individual transformation, we propose the following hypothesis.
Hypotheses 3 (H3). Among the theological conservatism predictors, the associations between salvation beliefs and preferences for mental health assistance from various sources of help will be more consistently predictive than scripture and sin beliefs.
These hypotheses are explored in what follows with attention to all three elements of theological conservatism, namely, scripture, sin, and salvation, where possible (General Social Survey [GSS] 2006); however, in some circumstances, data limitations lead us to drop one element of this tripartite construct, such that only the associations with scripture and salvation are explored (GSS 2018). In this latter series of analyses, the sin component needed to be dropped due to its status as a missing variable without an adequate proxy in the 2018 wave of GSS data. In addition, this move is justified by the GSS 2006 evidence of limited influence for the sin component of theological conservatism.
5. Discussion
Previous research has evaluated how various religious dimensions are associated with preferences for different sources of mental health assistance. This study has expanded on these prior investigations by using theological conservatism (
Hempel and Bartkowski 2008) to evaluate this complex phenomenon. Theological conservatism is complex due to its multidimensional character (scripture, sin, and salvation), and because of its inherently interpretive elements (questions about valid knowledge, the nature of human beings and the world they inhabit, and what is required for people to achieve salvation). Accounting for the three core beliefs about biblical scripture, human sin, and salvation, and thus assessing how these beliefs are internalized at the individual level, our study has investigated how this constellation of views influences attitudes towards mental health services. Additionally, we have tested how theological conservatism does not always operate as a coherent or singular schema. The three dimensions of theological conservatism are not routinely activated in tandem as the schema approach proposes, but rather act as individual facets of a multifaceted theologically conservative worldview. Hence, the results of this study do not provide strong support for the influence of theological conservatism as a schema on vignette-prompted preferences for various sources of mental health assistance.
Overall, our study hypotheses received mixed support. Theological conservatism was only modestly associated with a preference for mental health assistance from a minister, priest, rabbi, or other religious leader for a mental disorder, net of confounding factors. In several models, those who have been “born again” were more likely to support seeking mental health assistance from a religious leader. Thus, there was weak support for Hypothesis 1. Furthermore, theological conservatism was not negatively associated with a preference for mental health assistance from secular sources of help for a mental disorder, net of confounding factors. Specifically, when assessed as individual indicators, those who have been “born again” were less likely to support seeking mental health assistance from a psychiatrist or medical doctor, and biblical literalists were less likely to accept prescription medication as a form of assistance. With regard to seeking assistance from another mental health professional, those who were biblical literalists were less accepting of these professionals’ help. Interestingly, in some cases, the individual indicators displayed results that were in direct opposition with Hypothesis 2. There was only a direct (and counterintuitive) association between one of the salvation indicators of theological conservatism and approving of a mental hospital as a source of mental health assistance. Taking these observations into consideration, there was only modest support for Hypothesis 2.
Nevertheless, this study has investigated how the salvation dimension of theological conservatism is closely aligned with personalized issues of mental health, and the results did provide strong support for Hypothesis 3. Among the theological conservatism predictors, the associations between salvation beliefs and preferences for mental health assistance from various sources were more consistently significant than the associations between scripture and sin beliefs and preferences for assistance. Indeed, the “born again” and “encourage someone to believe in/accept Jesus Christ as his or her savior” (i.e., “save soul”) indicators were significant net of other indicators in numerous models. Arguably, these results emerged given the personal nature of the mental health vignettes and individualized approach to salvation. When presented with a personalized mental health problem and possible solutions to help alleviate the problem, those who are theologically conservative are perhaps more inclined to rely on their understanding of personal, inner transformation that begins with salvation through Jesus Christ. Moreover, the results of this study illustrate that this dimension of theological conservatism was not applied universally among the two salvation indicators. While the “save soul” indicator was associated with a greater preference for mental health hospitals and more support for religious leaders, the “born again” indicator demonstrated less support for psychiatrists and medical doctors and more support for religious leaders. These indicators for salvation did not operate in the same manner, and arguably, the reborn measure performs as its own component within this context. When respondents are presented with a personalized mental health problem, this measure of salvation overshadows the other indicators of theological conservatism. Perhaps this pattern is observed because this conception of salvation taps into the idea that mental health adversities are personal issues, and thus solutions to help alleviate these psychological states are achieved through personal change in whatever form it may be available (religious or secular).
Given that many indicators of theological conservatism were not significantly associated with preference for mental health assistance from secular sources, one might speculate that perhaps some aspects of mental health have become accepted by those with conservative religious beliefs. There is a well-documented convergence of secular and faith-based services to help address numerous mental health ailments (
Bartkowski and Grettenberger 2018). Perhaps the acceptance of the medicalization of mental health has reached religious communities, thus blurring the boundaries of spirituality and science. Furthermore, greater acceptance of secular interventions may indicate some destigmatization of seeking professional help for mental illnesses.
Key insights from this research investigation rest on the complexity and specificity of both theological conservatism and research on mental health and mental health assistance. There is complexity with theological conservatism in that the tenets of this perspective are not activated and expressed in a uniform way, not just between each dimension, but within each as well (i.e., the variations between the two salvation components). Moreover, there is complexity with the indicators for various sources of mental health assistance. As the results showed, none of the secular sources of assistance were evaluated in the same way. Thus, specificity is needed with both theological conservatism and mental health research. While the schema approach to theological conservatism has been suitable for prior research using this concept (
Bartkowski and Hempel 2009;
Hempel and Bartkowski 2008;
Hempel et al. 2012), the personalized nature of mental health considered here necessitates a more precise, distinct indicator approach. Further, the vignette method utilized in this study targets specificity in a novel way. Rather than asking general questions about mental health or mental health disorders in this country, the vignettes provided respondents with a detailed account of an individual’s personal issue. Prior studies have used a similar vignette method to better understand the relationship between religious beliefs and assistance (e.g.,
Noort et al. 2012). To our knowledge, however, ours is the first study to use vignettes in this way to examine preferences for sources of assistance among those with a theologically conservative worldview.
Altogether, this examination produces a few implications for future research. First, while there is value in understanding theological conservatism as a schema and evaluating it in quantitative research as such (i.e., using structural equation modeling), there is also room for this concept to be addressed as having three dimensions that operate independently, rather than in tandem, depending on the context in which they are used.
Hempel and Bartkowski (
2008) contended that this schema approach would allow for a more thorough understanding of the Conservative Protestant faith tradition. While this blended method has been useful with more general social issues (see
Bartkowski and Hempel 2009;
Hempel et al. 2012), future research should consider the capacity for the dimensions to operate in an independent fashion and consider separating the indicators used. Additionally, in some cases, certain dimensions of theological conservatism may be elevated in their influence over others, again depending on the context. Therefore, although beliefs about scripture, sin, and salvation could be viewed as interrelated ideas, attention should be paid to the uniqueness of each component. Next, given the noteworthy observations seen with the reborn (“born again”) measure of salvation, it is recommended that future research investigating the influence of Christian religious beliefs on other social topics should consider incorporating this measure into its study design. Furthermore, while this research has only evaluated the influence of a literalist interpretation of the Bible (as proposed by
Hempel and Bartkowski 2008), future research can be conducted to consider how different theologically conservative gradations (e.g., the influence of inspired, rather than literal, views of the Bible) might present similar or different evaluations of sources of mental health assistance. We explored this prospect but found absolutely no evidence that inspired views of the Bible affect appraisals of religious versus secular sources of mental health assistance (results available by request). (By far, an inspired view of the Bible is the largest response category in the GSS for this item.) It is possible, however, that other aspects of mental health may be associated with inspired views of the Bible. We leave it to other researchers to consider this possibility. Finally, the use of vignettes in this investigation allowed this study to assess how respondents interact with highly personalized scenarios depicting cases of mental illness and their possible sources of assistance. These vignettes are then a unique way to access respondent’s attitudes on social issues that tend to be quite personal. Thus, future research should consider expanding the use of vignettes within attitudinal research.
As with all research, this study has some limitations. Given that the GSS has a cross-sectional design and only two waves of the GSS were used in this investigation, this study is limited in its ability to draw causal inferences. While the two waves of the GSS provided the most comprehensive analysis of relevant indicators, partial reusing of this dataset (i.e., using the 2006 GSS dataset twice) does prove to be a limitation. Moreover, this study’s theoretical casual ordering could pose some limitations. While this study has interpreted that one’s conservative theological beliefs occur prior to one’s interpretation of these mental illness vignettes, the possibility remains that prior exposure to mental illnesses could influence one’s conservative theological worldview. Furthermore, while this study has attempted to evaluate internal heterogeneity (e.g., literalist vs. inspired views of scripture), there are a series of external linkages that our investigation does not take into consideration. For instance, changing societal views of mental health, subcultural distinctions between theological conservatives and mainstream culture, and larger political and religious dynamics (demonization of public spaces, religious deprivatization, etc.) may influence theological conservatives’ views of mental health assistance (cf.
Taylor et al. 2012;
Casanova 1994). Moreover, while the mental health assistance response options in this study provide a vast assortment of secular mental health options, these items did not account for psychologists or mental health professionals who are potentially religiously based (e.g., Christian counselors) or religious themselves. In addition, the ballot design of the GSS left us lacking predictor variables across some models. This limitation was quite evident with the lack of a sin indicator (e.g., PUNSIN) for the 2018 wave. As such, our ability to operationalize theological conservatism consistently was limited. Perhaps future waves of the GSS could incorporate additional items that better feature the three components of theological conservatism, as well as include more sources of assistance into this module that tap into this secular/religious overlap. Additionally, while our focus is on theological conservatives, our study did not account for various subgroups of theological conservatives. As such, future researchers are encouraged to evaluate preference for sources of mental health assistance among fundamentalists versus other conservative religious groups such as evangelicals and Pentecostals (
Unsworth and Ecklund 2021). For instance, as a subgroup of theological conservatives, fundamentalists are distinguished by their opposition to modernity, which can include the use of psychological science to treat mental health conditions. While not the sum total of all theological conservatives, analysis of these subgroups would be beneficial to further understand the complexity of a theologically conservative worldview when evaluating mental health sources of assistance. Finally, we acknowledge the possibility that empirical observations can be spurious. We were unable to consider some important measures that could influences one’s interpretation of mental illnesses, such as having a family member or close friend with a mental illness. Despite these limitations, however, our study has advanced prior research into preferences for different sources for mental health assistance among those who are conservative in their religious beliefs.