Religiosity/spirituality and health. A critical review of the evidence for biological pathways

Role of the social milieu in health and wellness

Can "we" be modified? The impact of the social milieu on health and wellness is not a new concept. Before the invention of an effective pharmacopoeia, manipulation of the social environment was one of the few tools available to physicians. Modern medicine continues to focus on individual rather than community efforts at risk reduction. To understand health and wellness, we must look not only at bodies and illnesses but also at communities and social structure. This article discusses the impact of spirituality and religion, education, economics, and politics on health and wellness. The impact of these issues on health will drive system-level change in global health.

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.

Looking Inside the Black Box of "Attendance at Services": New Measures for Exploring an Old Dimension in Religion and Health Research

Research in religion and health has spurred new interest in measuring religiousness. Measurement efforts have focused on subjective facets of religiousness such as spirituality and beliefs, and less attention has been paid to congregate aspects, beyond the single item measuring attendance at services. We evaluate some new measures for religious experiences occurring during congregational worship services. Respondents (N=576) were religiously-diverse community-dwelling adults interviewed prior to cardiac surgery. Exploratory factor analysis of the new items with a pool of standard items yielded a readily interpretable solution, involving seven correlated but distinct factors and one index variable, with high levels of internal consistency. We describe religious affiliation and demographic differences in these measures. Attendance at religious services provides multifaceted physical, emotional, social, and spiritual experiences that may promote physical health through multiple pathways.

An examination of the relationship between multiple dimensions of religiosity, blood pressure, and hypertension

Researchers have established the role of heredity and lifestyle in the occurrence of hypertension, but the potential role of psychosocial factors, especially religiosity, is less understood. This paper analyzes the relationship between multiple dimensions of religiosity and systolic blood pressure, diastolic blood pressure, and hypertension using data taken from the Chicago Community Adult Health Study, a probability sample of adults (N=3105) aged 18 and over living in the city of Chicago, USA. Of the primary religiosity variables examined here, attendance and public participation were not significantly related to the outcomes. Prayer was associated with an increased likelihood of hypertension, and spirituality was associated with increased diastolic blood pressure. The addition of several other religiosity variables to the models did not appear to affect these findings. However, variables for meaning and forgiveness were associated with lower diastolic blood pressure and a decreased likelihood of hypertension outcomes. These findings emphasize the importance of analyzing religiosity as a multidimensional phenomenon. This study should be regarded as a first step toward systematically analyzing a complex relationship.

Usefulness of routine periodic fasting to lower risk of coronary artery disease in patients undergoing coronary angiography

Coronary artery disease (CAD) is common and multifactorial. Members of the Church of Jesus Christ of Latter-day Saints (LDS, or Mormons) in Utah may have lower cardiac mortality than other Utahns and the US population. Although the LDS proscription of smoking likely contributes to lower cardiac risk, it is unknown whether other shared behaviors also contribute. This study evaluated potential CAD-associated effects of fasting. Patients (n(1) = 4,629) enrolled in the Intermountain Heart Collaborative Study registry (1994 to 2002) were evaluated for the association of religious preference with CAD diagnosis (> or = 70% coronary stenosis using angiography) or no CAD (normal coronaries, <10% stenosis). Consequently, another set of patients (n(2) = 448) were surveyed (2004 to 2006) for the association of behavioral factors with CAD, with routine fasting (i.e., abstinence from food and drink) as the primary variable. Secondary survey measures included proscription of alcohol, tea, and coffee; social support; and religious worship patterns. In population 1 (initial), 61% of LDS and 66% of all others had CAD (adjusted [including for smoking] odds ratio [OR] 0.81, p = 0.009). In population 2 (survey), fasting was associated with lower risk of CAD (64% vs 76% CAD; OR 0.55, 95% confidence interval 0.35 to 0.87, p = 0.010), and this remained after adjustment for traditional risk factors (OR 0.46, 95% confidence interval 0.27 to 0.81, p = 0.007). Fasting was also associated with lower diabetes prevalence (p = 0.048). In regression models entering other secondary behavioral measures, fasting remained significant with a similar effect size. In conclusion, not only proscription of tobacco, but also routine periodic fasting was associated with lower risk of CAD.

The 3 H and BMSEST models for spirituality in multicultural whole-person medicine

PURPOSE

The explosion of evidence in the last decade supporting the role of spirituality in whole-person patient care has prompted proposals for a move to a biopsychosocial-spiritual model for health. Making this paradigm shift in today's multicultural societies poses many challenges, however. This article presents 2 theoretical models that provide common ground for further exploration of the role of spirituality in medicine.

METHODS

The 3 H model (head, heart, hands) and the BMSEST models (body, mind, spirit, environment, social, transcendent) evolved from the author's 12-year experience with curricula development regarding spirituality and medicine, 16-year experience as an attending family physician and educator, lived experience with both Hinduism and Christianity since childhood, and a lifetime study of the world's great spiritual traditions. The models were developed, tested with learners, and refined.

RESULTS

The 3 H model offers a multidimensional definition of spirituality, applicable across cultures and belief systems, that provides opportunities for a common vocabulary for spirituality. Therapeutic options, from general spiritual care (compassion, presence, and the healing relationship), to specialized spiritual care (eg, by clinical chaplains), to spiritual self-care are discussed. The BMSEST model provides a conceptual framework for the role of spirituality in the larger health care context, useful for patient care, education, and research. Interactions among the 6 BMSEST components, with references to ongoing research, are proposed.

CONCLUSIONS

Including spirituality in whole-person care is a way of furthering our understanding of the complexities of human health and well-being. The 3 H and BMSEST models suggest a multidimensional and multidisciplinary approach based on universal concepts and a foundation in both the art and science of medicine.

Family history: value-added information in assessing cardiac health

The purpose of this study was to describe family health history profiles and objective indices of cardiac health among ethnically diverse working adults. Family history of disease is an important predictor of individual health, yet is underused by clinicians. Participants were staff in an elder-care facility and completed a web-enabled program capturing family history, objective cardiovascular measures (blood lipids, blood pressure, height, weight, and waist-to-hip ratio), and subjective measures (anxiety, spirituality, and health status appraisal). Of the 44 participants, 89% were unable to provide complete information about their family health and mortality for the three-generation genogram; 25% had one or more first-degree relatives with cardiac disease; and more than two thirds had first-degree relatives with diabetes. More than 80% of the sample exhibited objective indices of risk including body mass indexes in the overweight or obese categories. Family history information was incorporated into health screening and enabled more appropriate health counseling for these employees.

Challenges inherent to t'ai chi research: part I--t'ai chi as a complex multicomponent intervention

In this, the first of 2 companion papers, we present a framework for viewing t'ai chi as a complex, multicomponent intervention that integrates numerous physical, cognitive, and ritualistic components. We discuss how the richness and complexity of t'ai chi poses challenges related to the traditional distinction between specific versus nonspecific effects, the development and interpretation of valid sham controls, and more generally, to the reductionist causal approach of attributing observed outcomes to single, independent component factors. We also discuss parallels between t'ai chi research and the emerging field of whole systems research, and how t'ai chi research may benefit from the use of an ecologic framework. In a second, companion paper, we discuss additional challenges inherent in defining the t'ai chi intervention itself, and more comprehensively outline the benefits and limitations of commonly used clinical research designs to evaluate the efficacy and safety of t'ai chi.

Spirituality and autonomic cardiac control

BACKGROUND

Spirituality has been suggested to be associated with positive health, but potential biological mediators have not been well characterized.

PURPOSE AND METHODS

The present study examined, in a population-based sample of middle-aged and older adults, the potential relationship between spirituality and patterns of cardiac autonomic control, which may have health significance. Measures of parasympathetic (high-frequency heart rate variability) and sympathetic (pre-ejection period) cardiac control were obtained from a representative sample of 229 participants. Participants completed questionnaires to assess spirituality (closeness to and satisfactory relationship with God). Personality, demographic, anthropometric, health behavior, and health status information was also obtained. A series of hierarchical regression models was used to examine the relations between spirituality, the autonomic measures, and two derived indexes--cardiac autonomic balance (CAB, reflecting parasympathetic to sympathetic balance) and cardiac autonomic regulation (CAR, reflecting total autonomic control).

RESULTS

Spirituality, net of demographics, or other variables were found to be associated with enhanced parasympathetic as well as sympathetic cardiac control (yielding a higher CAR) but was not associated with CAB. Although the number of cases was small (N = 11), both spirituality and CAR were significant negative predictors of the prior occurrence of a myocardial infarction.

CONCLUSIONS

In a population-based sample, spirituality appears to be associated with a specific pattern of CAR, characterized by a high level of cardiac autonomic control, irrespective of the relative contribution of the two autonomic branches. This pattern of autonomic control may have health significance.

Meditation lowers stress and supports forgiveness among college students: a randomized controlled trial

OBJECTIVE AND PARTICIPANTS

The authors evaluated the effects on stress, rumination, forgiveness, and hope of two 8-week, 90-min/wk training programs for college undergraduates in meditation-based stress-management tools.

METHODS

After a pretest, the authors randomly allocated college undergraduates to training in mindfulness-based stress reduction (MBSR; n = 15), Easwaran's Eight-Point Program (EPP; n = 14), or wait-list control (n = 15). The authors gathered pretest, posttest, and 8-week follow-up data on self-report outcome measures.

RESULTS

The authors observed no post-treatment differences between MBSR and EPP or between posttest and 8-week follow-up (p > .10). Compared with controls, treated participants (n = 29) demonstrated significant benefits for stress (p < .05, Cohen's d = -.45) and forgiveness (p < .05, d = .34) and marginal benefits for rumination (p < .10, d = -.34).

CONCLUSIONS

Evidence suggests that meditation-based stress-management practices reduce stress and enhance forgiveness among college undergraduates. Such programs merit further study as potential health-promotion tools for college populations.

Deconstructing spiritual well-being: existential well-being and HRQOL in cancer survivors

We demonstrate the utility of partitioning the spiritual well-being (SpWB) construct into spiritual and religious components using results from a study of the relationship of existential well-being to health-related quality of life (HRQOL) in a sample of 237 cancer survivors. Existential and religious well-being were measured using the FACIT-Sp-12 and HRQOL was measured using the mental and physical component scores of the SF-12. In hierarchical linear regression analyses, existential well-being fully mediated religious well-being's effect on HRQOL and explained unique variance in both the mental and physical HRQOL domains, controlling for demographic, disease, and psychosocial variables previously shown to impact HRQOL. Religious well-being was not predictive of HRQOL.

Spiritual well-being, anxiety, and depression in antepartal women on bedrest

This descriptive correlational study examined relationships among anxiety, depression, and spiritual well-being (SWB) in three groups of women (non-pregnant, normal pregnancy, high-risk pregnancy on bedrest). Women in each group completed a demographic survey, a Spiritual Well-Being Scale, and depression and anxiety subscales from the Abbreviated Scale for the Assessment of Psychosocial Status in Pregnancy. All groups (N = 180) demonstrated significant, inverse relationships among SWB, anxiety, and depression. Findings emphasize the importance of obstetrical nurses screening pregnant women to evaluate emotional health, especially in high risk pregnancies. Collaboration with mental health nurses may be useful in developing interventions to improve a woman's SWB, reduce anxiety and depression, and improve pregnancy outcomes.

Religion and disability: clinical, research and training considerations for rehabilitation professionals

PURPOSE

This article (i) reviews existing research on the relationships that exist among spirituality, religion, and health for persons with disabilities; and (ii) compares different theoretical coping models (i.e., spiritual vs. psychoneuroimmunological).

BACKGROUND

Over the past decade interest has increased in relationships among spirituality, religion, and health in both the mainstream media (e.g., Newsweek) and scientific literature (e.g., Koenig). In general, research has concluded that religion and spirituality are linked to positive physical and mental health outcomes. Most religion and health research has focused on populations with life-threatening diseases (e.g., cancer, cardiovascular disorders, AIDS) with minimal attention to persons with chronic, life-long disabling conditions such as brain injury, spinal cord injury, and stroke. However, religion is used by many individuals with disabilities to help them adjust to their impairments and to give new meaning to their lives.

CONCLUSIONS

Religion and spirituality are important coping strategies for persons with disabilities. Practical suggestions for rehabilitation professionals are provided regarding: (a) strategies to enhance religious coping; (b) methods to train rehabilitation professionals about religious issues; and (c) issues to consider regarding future research on rehabilitation and religion.

Influences on children's oral health: a conceptual model

OBJECTIVES

Despite marked improvements over the past century, oral health in America is a significant problem: caries is the most common chronic disease of childhood. Much oral health research examines influences primarily in the oral cavity or focuses on a limited number of individual-level factors. The purpose of this article was to present a more encompassing conceptual model of the influences on children's oral health.

METHODS

The conceptual model presented here was derived from the population health and social epidemiology fields, which have moved toward multilevel, holistic approaches to analyze the complex and interactive causes of children's health problems. It is based on a comprehensive review of major population and oral health literatures.

RESULTS

A multilevel conceptual model is described, with the individual, family, and community levels of influence on oral health outcomes. This model incorporates the 5 key domains of determinants of health as identified in the population health literature: genetic and biological factors, the social environment, the physical environment, health behaviors, and dental and medical care. The model recognizes the presence of a complex interplay of causal factors. Last, the model incorporates the aspect of time, recognizing the evolution of oral health diseases (eg, caries) and influences on the child-host over time.

CONCLUSIONS

This conceptual model represents a starting point for thinking about children's oral health. The model incorporates many of the important breakthroughs by social epidemiologists over the past 25 years by including a broad range of genetic, social, and environmental risk factors; multiple pathways by which they operate; a time dimension; the notion of differential susceptibility and resilience; and a multilevel approach. The study of children's oral health from a global perspective remains largely in its infancy and is poised for additional development. This work can help inform how best to approach and improve children's oral health.

Spirituality, religion and health: evidence and research directions

Levels of spirituality and religious beliefs and behaviour are relatively high in Australia, although lower than those in the United States. There is mounting scientific evidence of a positive association between religious involvement and multiple indicators of health. The strongest evidence exists for the association between religious attendance and mortality, with higher levels of attendance predictive of a strong, consistent and often graded reduction in mortality risk. Negative effects of religion on health have also been documented for some aspects of religious beliefs and behaviour and under certain conditions. Health practices and social ties are important pathways by which religion can affect health. Other potential pathways include the provision of systems of meaning and feelings of strength to cope with stress and adversity.

Spiritual well-being and health

Data on empirical associations between religious variables and health outcomes are needed to clarify the complex interplay between religion and mental health. The aim of this study was to determine whether associations with health variables are primarily attributable to explicitly religious aspects of spiritual well-being (SWB) or to "existential" aspects that primarily reflect a sense of satisfaction or purpose in life. Three hundred forty-five pairs of twins from the Vietnam Era Twin Registry completed a diagnostic interview and questionnaires containing the 2-factor SWB Scale and general health items. Observed associations between SWB and health outcomes were uniquely explained by the SWB subscale of existential well-being, with much less of a unique explanatory contribution from religious well-being or "spiritual involvement." We concluded that studies of SWB and health should continue to distinguish between explicitly religious variables and others that more closely approximate the psychological construct of personal well-being.

Physiological mechanisms involved in religiosity/spirituality and health

During the last two decades of the 20th century, psychological science rediscovered religiosity/spirituality (R/S) as a legitimate subject matter in understanding the human experience. In large measure, this renewed interest was motivated by the positive association between this variable and health (physical and mental) reported in much of the literature. If the described relationship between R/S and health is accurate, the question of how such an influence might be realized becomes important and subject to empirical investigation. The present paper develops a rationale for why such an outcome might be expected and describes various physiological mechanisms that could mediate the effect of R/S on health.

Religious service attendance and allostatic load among high-functioning elderly

OBJECTIVE

To examine the association between frequency of religious service attendance and an index of cumulative physiological dysregulation as measured by allostatic load (AL) (systolic and diastolic blood pressure, waist/hip ratio, high-density lipoprotein and total cholesterol, glycosylated hemoglobin, cortisol, serum dihydroepiandrosterone sulfate, norepinephrine, and epinephrine). There is growing empirical evidence of a positive relationship between religious engagement and better clinical health outcomes. However, studies exploring the subclinical levels of physiological dysregulation are rare; hence, the physiological processes underpinning the religion-health relationship are not well understood.

METHODS

In 1988, 853 participants from the MacArthur Successful Aging Study provided information on the frequency of religious service attendance as well as blood and urine samples needed to obtain measures for a ten-item cumulative AL index. Gender-stratified multivariate linear regression models were used to estimate the direction and magnitude of the association between weekly religious service attendance and AL.

RESULTS

At least weekly religious service attendance was associated with lower AL levels among women (b = -0.47; p < .01), but not among men (b = 0.02; p = .88) in models that statistically controlled for age, income, education, marital status, and level of physical functioning. This relationship could not be attributed to the association between religious attendance and any one or two of the components of the AL index. It also was not explained by either higher physical functioning or social integration.

CONCLUSION

Cumulative physiological dysregulation may be one mechanism through which religious engagement may influence a diverse range of clinically relevant health outcomes.

Prayer as medicine: how much have we learned?

Many people use prayer, and some studies have shown a positive association between prayer and improved health outcomes. This article explores four possible mechanisms by which prayer may lead to improved health. While acknowledging the efficacy of prayer and recognising the needs of patients, prayer, being a personal spiritual practice, cannot be prescribed, nor should it be used in place of medical care.

Chaplaincy and resuscitation

This paper summarises the results of 327 Australian health care chaplains with regard to their involvement in issues concerning Not For Resuscitation (NFR)/Do Not Attempt Resuscitate (DNAR) decisions within the health care context. The findings indicate that 24% of the chaplains surveyed had provided some form of pastoral intervention directly to patients and/or their families dealing with issues concerning NFR/DNAR and that approximately 18% of chaplains had assisted clinical staff with issues concerning NFR/DNAR decisions. Differences of involvement between volunteer and staff chaplains are noted, as are the perspectives of chaplaincy informants regarding their role in relation to NFR/DNAR decisions. Some implications of this study with respect to chaplaincy training and practice are noted.

Do religious or spiritual beliefs influence bereavement? A systematic review

BACKGROUND

Responses to bereavement may be influenced by characteristics such as age or gender, but also by factors like culture and religion.

AIM

A systematic review was undertaken to assess whether spiritual or religious beliefs alter the process of grief and/or bereavement.

METHODS

Fifteen computerized databases were searched. Thirty-two studies met the inclusion criteria. Evidence was graded according to the standard grading system of the Clinical Outcomes Group and by the SIGNAL score.

RESULTS

In total, 5715 persons were examined: 69% women, 87% white, 83% protestant. Ninety-four percent of studies show some positive effects of religious/spiritual beliefs on bereavement, but there was a great heterogeneity regarding included populations and outcome measurements.

CONCLUSION

Available data do not allow for a definite answer on whether religious/spiritual beliefs effectively influence bereavement as most studies suffer from weaknesses in design and methodological flaws. Further research is needed. Recommendations for further research are given.

Religious service attendance and decline in pulmonary function in a high-functioning elderly cohort

BACKGROUND

Pulmonary function is an important indicator of respiratory and overall health, yet little is known about the psychosocial factors that predict pulmonary function itself. At the same time, religious activity is emerging as a potential health promoting factor, especially among the elderly. Whether there is a connection between religious activity and pulmonary function is unknown.

PURPOSE

In this study, we sought to examine the association between religious attendance and rate of decline in pulmonary function.

METHODS

The sample consisted of 1,174 healthy elderly persons enrolled in the MacArthur Study of Successful Aging who were followed for an average of 4.6 years. Information on frequency of religious service attendance and peak expiratory flow rate (PEFR) was collected over 3 waves. A linear mixed model with repeated measures was used to compare rate of decline in PEFR between those who attended religious services regularly and those who did not.

RESULTS

Regular religious service attendance was associated with a slower pulmonary function decline among men (by 3.71 L/min per year, p = .02) and women (by 3.27 L/min per year, p = .02), compared to those who never attend services. The findings could not be explained by differences in smoking or physical activity.

CONCLUSIONS

Overall findings support the hypothesis that religious activity may play a protective role in maintaining pulmonary health among the elderly.

Measuring Spirituality and Spiritual Emptiness: Toward Ecumenicity and Transcultural Applicability

The authors review Eastern and Western conceptions of spirituality, explicate the spirituality construct and differentiate it from religiosity, propose strategies for achieving ecumenicity and transcultural applicability, and suggest innovative techniques for measuring spirituality and spiritual emptiness. The essential attributes of ecumenical spirituality are that it (a) is concerned with existential or transcendent questions; (b) belongs to the domain of cardinal values underlying all aspects of life; and (c) is self-reflective, and hence metacognitive, in nature. The paths to spirituality are many and are grounded in different values and beliefs across philosophical-religious traditions. However, commonalities may be extracted at a high level of abstraction and with maximal inclusiveness. Thus, the goal of ecumenicity, and hence transcultural applicability, is attainable.

PSYCHOLOGICAL DISTRESS, EXPERIENCES OF EGO LOSS AND SPIRITUALITY: EXPLORING THE EFFECTS OF SPIRITUAL PRACTICE

The literature supports a positive relationship between spirituality and health. The relationship between spirituality and distress is an underresearched topic. We investigated the relationship between spiritual experiences (SE) and mental distress within two sociodemographically balanced samples (n = 100) of a spiritually practicing (SP) and a nonpracticing sample (NSP) for two points of measurement (t1; t2). Applying linear regression analysis we compared the influence from SEs, as measured with the Exceptional Experiences Questionnaire (EEQ; Kohls & Walach, 2006), towards mental distress measured by the Brief Symptom Inventory (BSI; Klaiberg, 2002). A strong association between the EEQ (t1) and the BSI (t1, t2) for the NSP (NSP: R2t1 = .36; R2t2 = .27) was found, but only a weak, relatively moderate one for the SP sample (SP: R2t1 = .07; R2t2 = .16). Path analysis revealed that SP seems to buffer deconstructive spiritual experiences (SP: ßt1 = .06 (ns); ßt2 = .18 (ns); NSP: ßt1 = .52 (p < .01); ßt2 = .39 (p < .01)) but not psychopathological experiences (SP: ßt1 = .20 (p = ns); ßt2 = .33 (p < .01); NSP: ßt1 = .18 (p = ns); ßt2 = .31 (p < .01), although no significant relationship was found for positive spiritual experiences and visionary dream experiences for either sample. Our findings suggest that spiritual practice seems to be a potential buffer for distress derived from experiences of ego loss. Correspondingly, the differentiation between experiences of ego loss and psychopathological experiences seems to be pivotal for understanding the intrapersonal effects of SP.

Pain control and chaplaincy in Australia

This paper summarizes the experiences of 327 Australian health care chaplains with regard to their involvement in issues concerning pain control within the health care context. The findings indicate that approximately 60% of surveyed chaplains had provided some form of pastoral intervention directly to patients and/or their families dealing with issues concerning pain, and that approximately 36% of chaplains had assisted clinical staff with issues concerning patient pain. Differences of involvement between volunteer and staff chaplains are noted, as are the perspectives of chaplaincy informants regarding their role in relation to pain control. Some implications of this study with respect to chaplaincy utility and training are noted.

Medical student beliefs: spirituality's relationship to health and place in the medical school curriculum

The relationship between spirituality and health is receiving increased attention; consequently medical schools have begun asking how and in what manner these issues should be addressed in medical education. Unfortunately, student beliefs concerning spirituality and health have not been adequately assessed. This study examined medical student beliefs regarding the relationship between spirituality and health and the level of instruction spirituality should receive in the curriculum. Questionnaire results from 254 medical students indicated that religiousness and spirituality are important, with spirituality more important than religiousness. Spiritual practices were seen as more helpful for acute and mental health conditions than for chronic or terminal conditions and believed to be more helpful for coping with a health condition than healing tissue. Students believed that patients could benefit from spiritual practices more than they could for their own health conditions. Most students endorsed a lecture or one- to two-week seminar with instruction in the first or second year of medical school. Student spirituality was the only predictor of required level of instruction in the medical school curriculum.

Hypo-Egoic Self-Regulation: Exercising Self-Control by Diminishing the Influence of the Self

Theory and research dealing with self-regulation have focused primarily on instances of self-regulation that involve high levels of self-reflection and effortful self-control. However, intentionally trying to control one's behavior sometimes reduces the likelihood of achieving one's goals. This article examines the process of hypo-egoic self-regulation in which people relinquish deliberate, conscious control over their own behavior so that they will respond more naturally, spontaneously, or automatically. An examination of spontaneously occurring hypo-egoic states (such as flow, deindividuation, and transcendence) suggests that hypo-egoic states are characterized by lowered self-awareness and/or an increase in concrete and present-focused self-thoughts. In light of this, people may intentionally foster hypo-egoism via two pathways-(a) taking steps to reduce the proportion of time that they are self-aware (such as repeating a behavior until it is automatic or practicing meditation) or (b) increasing the concreteness of their self-thoughts (such as inducing a concrete mindset or practicing mindfulness). In this way, people may deliberately choose to regulate hypo-egoically when effortful control might be detrimental to their performance.

Relationship of frequent mantram repetition to emotional and spiritual well-being in healthcare workers

BACKGROUND

Healthcare workers report high levels of stress in the workplace. To determine how to reduce stress, the authors examined the effectiveness of frequently repeating a mantram (a word with spiritual meaning) on emotional and spiritual well-being.

METHODS

A pretest-posttest design was used to measure stress, state/trait anxiety and anger, quality of life, and spiritual well-being in a convenience sample (N=42) of hospital workers completing a mantram intervention program.

RESULTS

Significant improvements were found in stress (p < .001), trait-anxiety (p = .002), trait-anger (p = .02), quality of life (p = .001), and spiritual well-being (p = .003). When examining the effects of mantram practice, trait-anxiety and religious and spiritual well-being were significant (p < .05).

CONCLUSION

Improvements in emotional and spiritual well-being may be mediated by frequent mantram repetition.

Effects of a holistic health program on women's physical activity and mental and spiritual health

Intervention studies aimed at promoting increased physical activity have been trialled in many different settings including primary care, worksites and the community. Churches are also potential settings for physical activity promotion. However, little is known about the effectiveness of this setting for promoting physical activity, particularly in Australia. The purpose of this study was to evaluate the effectiveness of a mind, body and spiritually based health promotion program in increasing physical activity and promoting mental and spiritual health. Nineteen women completed the 8-week intervention, and 30 women in a non-health related 8-week program at the same church comprised a comparison group. Pre- and post-program surveys assessed outcome measures. Between-group differences over time were examined using one-way MANOVA's. Physical activity was higher in the intervention group than the comparison group. In contrast to the comparison group, both mental health (depression symptoms) and spiritual health improved significantly more among intervention participants. The data highlight the potential for a church-based setting and holistic approach to health promotion as a successful means of increasing physical activity and promoting mental and spiritual health among Australian women.

Passage meditation reduces perceived stress in health professionals: a randomized, controlled trial

The authors evaluated an 8-week, 2-hr per week training for physicians, nurses, chaplains, and other health professionals using nonsectarian, spiritually based self-management tools based on passage meditation (E. Easwaran, 1978/1991). Participants were randomized to intervention (n = 27) or waiting list (n = 31). Pretest, posttest, and 8- and 19-week follow-up data were gathered on 8 measures, including perceived stress, burnout, mental health, and psychological well-being. Aggregated across examinations, beneficial treatment effects were observed on stress (p = .0013) and mental health (p = .03). Treatment effects on stress were mediated by adherence to practices (p = .05). Stress reductions remained large at 19 weeks (84% of the pretest standard deviation, p = .006). Evidence suggests this program reduces stress and may enhance mental health.

Religion, spirituality and the well-being of informal caregivers: a review, critique, and research prospectus

The purpose of this article is to review and critique the published literature examining the relationships between religion/spirituality and caregiver well-being and to provide directions for future research. A systematic search was conducted using bibliographic databases, reference sections of articles, and by contacting experts in the field. Articles were reviewed for measurement, theoretical, and design limitations. Eighty-three studies were retrieved. Research on religion/spirituality and caregiver well-being is a burgeoning area of investigation; 37% of the articles were published in the last five years. Evidence for the effects of religion/spirituality were unclear; the preponderance (n = 71, 86%) of studies found no or a mixed association (i.e., a combination of positive, negative, or non-significant results) between religion/spirituality and well-being. These ambiguous results are a reflection of the multidimensionality of religion/spirituality and the diversity of well-being outcomes examined. They also partially reflect the frequent use of unrefined measures of religion/spirituality and of atheoretical approaches to studying this topic. Investigators have a fairly large number of studies on religion/spirituality and caregiver well-being on which to build. Future studies should be theory driven and utilize psychometrically sound measures of religion/spirituality. Suggestions are provided to help guide future work.

Health psychology: psychological adjustment to chronic disease

Chronic diseases carry important psychological and social consequences that demand significant psychological adjustment. The literature is providing increasingly nuanced conceptualizations of adjustment, demonstrating that the experience of chronic disease necessitates adaptation in multiple life domains. Heterogeneity in adjustment is apparent between individuals and across the course of the disease trajectory. Focusing on cancer, cardiovascular disease, and rheumatic diseases, we review longitudinal investigations of distal (socioeconomic variables, culture/ethnicity, and gender-related processes) and proximal (interpersonal relationships, personality attributes, cognitive appraisals, and coping processes) risk and protective factors for adjustment across time. We observe that the past decade has seen a surge in research that is longitudinal in design, involves adequately characterized samples of sufficient size, and includes statistical control for initial values on dependent variables. A progressively convincing characterization of risk and protective factors for favorable adjustment to chronic illness has emerged. We identify critical issues for future research.

Mantram repetition for stress management in veterans and employees: a critical incident study

AIM

This paper reports a study assessing the usefulness of a mantram repetition programme.

BACKGROUND

Complementary/alternative therapies are becoming commonplace, but more research is needed to assess their benefits. A 5-week programme teaching a 'mind-body-spiritual' technique of silently repeating a mantram - a word or phrase with spiritual meaning - to manage stress was developed. A mantram was chosen by individuals, who were taught to repeat it silently throughout the day or night to interrupt unwanted thoughts and elicit the relaxation response.

METHODS

Participants who attended a 5-week course were invited to participate in the study. Of those who consented, a randomly selected subset (n = 66) was contacted approximately 3 months after the course for a telephone interview using the critical incident interviewing technique. Participants were asked whether the intervention was helpful or not, and if helpful, to identify situations where it was applied. Interviews were transcribed and incidents were identified and categorized to create a taxonomy of uses. The data were collected in 2001-2002.

RESULTS

Participants included 30 veterans, mostly males (97%), and 36 hospital employees, mostly females (86%). Mean age was 56 years (sd = 12.94). Fifty-five participants (83.3%) practiced the technique and reported 147 incidents where the programme was helpful. Outcomes were organized into a taxonomy of incidents using four major categories that included managing: (a) emotions other than stress (51%); (b) stress (23.8%); (c) insomnia (12.9%); and (d) unwanted thoughts (12.3%). A group of raters reviewed the categories for inter-rater reliability.

CONCLUSIONS

The majority of participants from two distinct samples reported that the mantram programme was helpful in a variety of situations. The critical incident interviewing method was found to be practical, efficient, and thorough in collecting and analyzing data. Such qualitative methods contribute to understanding the benefits of mind-body complementary therapies.

Effects of spiritual mantram repetition on HIV outcomes: a randomized controlled trial

We examined the efficacy of a psycho-spiritual intervention of mantram repetition--a word or phrase with spiritual associations repeated silently throughout the day--on psychological distress (intrusive thoughts, stress, anxiety, anger, depression), quality of life enjoyment and satisfaction, and existential spiritual well-being in HIV-infected adults. Using a 2-group by 4-time repeated measures design, 93 participants were randomly assigned to mantram (n = 46) or attention control group (n = 47). Over time, the mantram group improved significantly more than the control group in reducing trait-anger and increasing spiritual faith and spiritual connectedness. Actual mantram practice measured by wrist counters was inversely associated with non-HIV related intrusive thoughts and positively associated with quality of life, total existential spiritual well-being, meaning/peace, and spiritual faith. Intent-to-treat findings suggest that a mantram group intervention and actual mantram practice each make unique contributions for managing psychological distress and enhancing existential spiritual well-being in adults living with HIV/AIDS.

Developing an Agenda for Translational Studies of Resilience and Vulnerability Following Trauma Exposure

Here we outline a translational research agenda for studies of resilience, defined as the process of adapting well in the face of adversity or trauma. We argue that an individual differences approach to the study of resilience, in which the full range of behavioral and biological responses to stress exposure is examined can be applied across human samples (e.g., people who have developed psychopathology versus those who have not; people who have been exposed to trauma versus those who have not) and even, in some cases, across species. We delineate important psychological resilience-related factors including positive affectivity and optimism, cognitive flexibility, coping, social support, emotion regulation, and mastery. Key brain regions associated with stress-related psychopathology have been identified with animal models of fear (e.g., extinction and fear conditioning; memory reconsolidation) and we describe how these regions can be studied in humans using neuroimaging technology. Finally, we cite recent research identifying neuroendocrine markers of resilience and recovery in humans (e.g., neuropeptide Y [NPY], dehydroepiandrosterone [DHEA]) that can also be measured, in some cases, in other species. That exposure to adversity or trauma does not necessarily lead to impairment and the development of psychopathology in all people is an important observation. Understanding why this is so will provide clues for the development of therapeutic interventions for those people who do develop stress-related psychopathology, or even for the prevention of adverse outcomes.

Religious involvement and health outcomes among older persons in Taiwan

We use data from a nationally representative, longitudinal survey of older Taiwanese to examine the relationship between religious involvement-including religious affiliation, religious attendance, beliefs, and religious practices-and self-reported measures of overall health status, mobility limitations, depressive symptoms, and cognitive function; clinical measures of systolic and diastolic blood pressure, serum interleukin-6, and 12-h urinary cortisol; and 4-year mortality. Frequency of religious attendance shows the strongest, most consistent association with health outcomes. But, with only one exception, this relationship disappears in the presence of controls for health behaviors, social networks, and prior health status. Religious attendance remains significantly associated with lower mortality even after controlling for prior self-assessed health status, but the coefficient is substantially reduced. Other aspects of religiosity are only sporadically associated with health and, in all cases, private religious practices and stronger beliefs are associated with worse health; again, this relationship disappears after controlling for prior health status. These results suggest that reverse causality may partly account for both the positive and negative correlations between religiosity and health. We find no significant associations between religious involvement and biological markers. Notably, even after controlling for prior health, participation in social activities has a more robust effect on health than religious attendance. Consequently, we question whether the purported health benefits are attributable to religion or to social activity in general.

Quality of life with vitiligo: Comparison of male and female muslim patients in Iran

BACKGROUND

Vitiligo is a chronic pigmentary disorder of the skin that, although not life threatening, may considerably influence the psychological well-being of patients. It has been suggested that vitiligo patients suffer from low self-esteem, poor body image, and poor quality of life (QOL).

OBJECTIVE

The aim of this study was to explore and compare QOL in male and female patients with vitiligo in Iran.

METHODS

To obtain the patients' self-assessment of QOL, we used a 17-item multiple-choice questionnaire based on the Dermatology Life Quality Index (DLQI). All statistics used 2-way analysis of variance comparisons with an (alpha-risk of 5%. DLQI scores were assessed using nonparametric comparisons, and qualitative variables were compared with xi(2) testing. Categorical regression analyses were also used as an exploratory aim.

RESULTS

A total of 77 Muslim patients with vitiligo (53 females, 24 males; mean age, 29.3 years) were included in this survey. The mean (SD) DLQI score of 42.9 (11.4) for females was lower than that of 51.6 (8.8) for males (P = 0.002). Female patients experienced significantly more impairment of general and psychological health (P < 0.003), social relationships (P < 0.02), and sexual activity (P < 0.001) than did male patients.

CONCLUSIONS

This study indicates the specific areas of patients' lives that are most affected by vitiligo. Gender and location of disease independently affect QOL in Muslim patients in Iran. Women with vitiligo experience greater QOL impairment than their male counterparts.

Frequency of attendance at religious services, hypertension, and blood pressure: the Third National Health and Nutrition Examination Survey

OBJECTIVE

To test the hypothesis that frequency of attendance at religious services is inversely related to prevalence of hypertension and blood pressure level.

METHODS

In the Third National Health and Nutrition Examination Survey (NHANES III), 14,475 American women and men aged 20 years and over reported frequency of attendance at religious services, history of hypertension treatment, and had blood pressure (BP) measured.

RESULTS

The percentage reporting attending religious services weekly (52 times/yr) was 29 and more than weekly (>52 times/yr) was 10. Prevalence of hypertension (systolic BP > or = 140 or diastolic BP > or = 90 mm Hg or current use of blood pressure medication) was 21% in never at attenders, 19% in those attending less than weekly (1-51 times/yr), 26% in those attending weekly, and 26% in those attending more than weekly (p < .01). After controlling for sociodemographic and health variables, religious attendance was associated with reduced prevalence compared with nonattendance, significantly so for weekly (beta = -0.24; 95% confidence interval [CL], -0.37 to -0.11; p < .01) and more than weekly (beta = -0.33; 95% CL, -0.60 to -0.07; p < .05). No significant effect modification by gender or age was observed. Compared with never attenders, persons attending weekly had a systolic BP 1.46 mm Hg (95% CL 2.33, 0.58 mm Hg, p < .01) lower and persons attending >52 times/yr had systolic BP 3.03 mm Hg (95% CL 4.34, 1.72 mm Hg, p < .01) lower. No significant effect modification by gender was observed; these estimates are adjusted for a significant interaction between age and less than weekly attendance (1-51 times) (p < .05).

CONCLUSIONS

Compared with never attending, attendance at religious services weekly or more than weekly was associated with somewhat lower adjusted hypertension prevalence and blood pressure in a large national survey.

Reducing the risk of burnout in end-of-life care settings: the role of daily spiritual experiences and training

OBJECTIVE

Individuals in the helping professions are subject to unique stressors that may lead to burnout, and research has shown that those who work with dying or bereaved individuals might be particularly at-risk. This study explores how factors such as spirituality and level of training might buffer the stress of working with terminally ill clients and their families.

METHOD

A total of 80 medical and mental health practitioners attending palliative care seminars were surveyed, with each completing validated measures of daily spiritual experiences and caregiver burnout, as well as assessments of demographic factors, their general education and training experiences specific to working in end-of-life care and bereavement settings.

RESULTS

Findings indicate that daily spiritual experiences might mitigate physical, cognitive, and emotional forms of burnout in the workplace. In addition, a negative correlation was found between the amount of end-of-life training received and burnout in the physical and cognitive domains. However, training was not related to professionals' level of emotional exhaustion.

SIGNIFICANCE OF THE RESEARCH

Results reinforce a growing literature on the salutary effects of spirituality, and underscore its relevance as one possible form of constructive coping for professionals attending to the needs of the dying and bereaved. The study carries further implications for how the stresses of such work might be ameliorated by enhanced training efforts, as well as creative facilitation of diverse spiritual expressions (e.g., inclusive forms of ritual recognition of loss) in the workplace.

A systematic review of associations among religiosity/spirituality and adolescent health attitudes and behaviors

PURPOSE

To systematically review and synthesize literature concerning the relationships among religiosity, spirituality, health attitudes, and health behaviors in adolescents.

METHODS

Forty-three studies between 1998 and 2003 were systematically reviewed to (a) determine if the studies were based on conceptual or theoretical frameworks, (b) identify the types of religiosity and spirituality measures used as well as their effects on health attitudes and behaviors, (c) evaluate the quality of these measures, (d) determine categories and frequency of measures of health attitudes and behaviors, (e) evaluate the quality of the research designs, and (f) determine the effects of religiosity or spirituality on adolescent health attitudes and behaviors.

RESULTS

Over half (n = 26) the studies were atheoretical or had an unclear framework and the other half were based on a wide variety of conceptual and theoretical models. A total of 37 distinct religiosity/spirituality variables were identified and varied in specificity. Less than half (n = 21) reported reliability of the measures and only seven contained information about validity of the measures. All 43 studies included measures of health-risk behaviors and/or attitudes but only seven addressed health-promoting behaviors. Most studies (84%) showed that measures of religiosity/spirituality had positive effects on health attitudes and behaviors.

CONCLUSIONS

The variety of studies and measures indicate that religiosity and spirituality may be important correlates of adolescent health attitudes and behaviors. Although the majority of the studies reviewed were well designed, there was no consistency in the theoretical bases and operational definitions of religiosity/spirituality phenomena.

Do people turn to religion in times of stress?: an examination of change in religiousness among elderly, medically ill patients

This study examined the effect of health-related stress on changes in religiousness in a sample of elderly, medically ill patients. Patients admitted to Duke University Medical Center (N = 745) were interviewed at baseline and 3-month follow-up. Increases in illness severity (from baseline to follow-up) were associated with decreases in both organizational and private religiousness at follow-up. Effect of illness severity on organizational religiousness was statistically mediated by changes in physical activity, while its effect on private religiousness remained significant after controlling for physical activity. These findings encourage further research investigating causal relationships between stress and religion, as well as identifying measures of religiousness that may capture this construct in the medically ill population.

A systematic review of recent research on adolescent religiosity/spirituality and mental health

There is accumulating evidence that religiosity/spirituality (R/S) are important correlates of mental health in adult populations. However, the associations between R/S and mental heath in adolescent populations have not been systematically studied. The purpose of this article is to report on a systematic review of recent research on the relationships between adolescent R/S and mental health. Twenty articles between 1998 and 2004 were reviewed. Most studies (90%) showed that higher levels of R/S were associated with better mental health in adolescents. Institutional and existential dimensions of R/S had the most robust relationships with mental health. The relationships between R/S and mental health were generally stronger or more unique for males and older adolescents than for females and younger adolescents. Recommendations for future research and implications for mental health nursing are discussed.

Spiritual experiences of parents and caregivers who have children with disabilities or special needs

Despite the fact that faith has been described as a universal concern, and despite the realization that the presence of social supports is an essential element in successful coping, there has been no systematic examination of the quality of spiritual networks important to families impacted by childhood disability. There is also little understanding of how spirituality in children influences the lived experience of faith in the adults who care for them. Findings reported here come out of a larger existential phenomenology study that examined the lived experience of parents or caregivers who sought to obtain formal religious education for their children with special needs. Participants included 26 parents/caregivers representing 44 children with special needs and 15 different faith traditions. Narratives indicated that many clergy and members of faith communities either devalue or fail to recognize the spiritual lives of disabled children. This lack of recognition was associated with participant disillusionment or crises of faith and a sense of alienation from potential sources of emotional support. In contrast, those participants whose children were welcomed reported feeling sustaining support and strengthened faith. No parent or caregiver perceived nurses as having an awareness of or interest in spirituality within families of children who have special needs.

Spirituality, mental health, physical health, and health-related quality of life among women with HIV/AIDS: integrating spirituality into mental health care

HIV-positive women have used spirituality as a resource to enhance their psychological well-being and health-related quality of life (HRQOL). The purpose of this article is to review the literature about depression among HIV-positive women and to describe the positive associations reported among spirituality, mental health, and HRQOL. This article also advocates the development and use of interventions integrated with spirituality. The incorporation of spirituality into traditional mental health practices can optimize healthcare for HIV-positive women who are diagnosed with depression. A case example is presented and spiritual implications are discussed.

Exploring heart and soul: effects of religiosity/spirituality and gender on blood pressure and cortisol stress responses

The current study investigated gender effects on the influence of self-reported religiosity and spirituality on cardiovascular and cortisol responses to a laboratory stressor among young adults. Participants with higher composite religiosity/spirituality scores, religiosity, levels of forgiveness and frequency of prayer showed lower cortisol responses. Greater composite religiosity/spirituality, religiosity, frequency of prayer and attendance at services were associated with lower blood pressure in males and elevated blood pressure in females. Findings suggest that spiritual and/or religious individuals may experience a protective effect against the neuroendocrine consequences of stress, though cardiovascular benefits may vary by gender. This work represents an important step in the convergence of multiple realms of research by linking physiological measures with indicators of individual belief systems.

Spirituality predicts outcome independently of expectancy following flower essence self-treatment

OBJECTIVE

The aim of this study was to determine whether absorption and spirituality predict the placebo response independently of expectancy.

METHOD

This was an open study of self-treatment with self-selected Bach flower essences. Participants' expectancy of the effect of flower essences, attitudes to complementary medicine, holistic health beliefs, absorption, and spirituality were measured prior to treatment. One month after the start of treatment, participants responded to an e-mail enquiry about symptom change using a single seven-point change scale.

RESULTS

One hundred sixteen participants (97 university undergraduates and 19 staff) completed all assessments. Spirituality and absorption together predicted additional variance compared with a cluster of expectancy measures comprising expectancy, attitude to complementary medicine, and holistic beliefs (increment in R(2)=.042, P=.032), and spirituality alone (but not absorption alone) predicted more additional variance than did the expectancy cluster (increment in R(2)=.043, P=.014).

CONCLUSION

Our data are inconsistent with conventional explanations for the placebo effect. The mechanism underlying the placebo response is not fully understood.