Patient Spirituality in Clinical Care: Clinical Assessment and Research Findings — Part II
Patient Spirituality in Clinical Care: Clinical Assessment and Research Findings—Part II
Authors: David B. Larson, MD, MSPH, President, National Institute for Healthcare Research, Adjunct Professor, Departments of Psychiatry and the Behavioral Sciences, Duke University Medical Center and Northwestern University Medical School; Susan S. Larson, MAT, Editor, Research Reports, National Institute for Healthcare Research; Christina M. Puchalski, MD, MS, Director of Education, National Institute for Healthcare Research, Assistant Professor, Division of Aging, Department of Medicine, George Washington University Medical School; and Harold G. Koenig, MD, MHSc, Associate Professor, Departments of Psychiatry and Medicine, Duke University Medical Center, GRECC, Durham, N.C., Veterans Administration Medical Center.
Peer Reviewers: Mark R. Ellis, MD, MSPH, Faculty Physician, Cox Family Practice Residency Program, Springfield, Mo., and Kenneth E. Olive, MD, FACP, Interim Chair, Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, Tenn. Editor’s Note—Recognition of the role of life factors and their influence on patients’ health and well-being continues to grow in medicine. Many patients, when confronted with serious illness or disability, turn to their spiritual/religious framework to cope. A majority of medical schools currently teach medical students how to take a spiritual history as part of the social history to become more sensitive to patients’ personal beliefs and life context. Suggestions for taking this clinical assessment follow, along with a discussion of the importance of collaboration with chaplains and recognition of potential ethical concerns.
Furthermore, published research is finding significant, primarily beneficial links between spiritual/religious commitment and health, indicating the potential relevance of spirituality to clinical care. However, at times religious/spiritual beliefs can be harmful to health, such as when patients refuse medical treatment for treatable diseases. Part I of this article provided a brief overview of some of the research findings on the links between spiritual/religious commitment and longevity. Part II will provide an overview of research findings on blood pressure, coping with severe illness, recovering from surgery, prevention, treatment outcomes, and patient quality of life when facing terminal illness.
Immune System Functioning
In exploring links between immune system functioning and religious participation, an innovative study of more than 1700 older adults found that persons who attended church to any degree were only half as likely as nonattenders to have elevated levels of a blood protein that can reveal problems in immune system functioning.1 Interleukin-6 (IL-6) is a proinflammatory cytokine. Elevated levels are associated with an increased incidence of a variety of diseases.
High levels of stress are associated with the release of hormones, such as cortisol and IL-6. Koenig and colleagues hypothesized that if religious commitment improved stress control whether by better coping, richer social supports, or more coherent world view, as indicated in other study findings, then religious commitment might also reduce the production of IL-6 and the release of cortisol. The study found a relationship between low religious attendance and higher levels of IL-6 that could not be explained by other controlled-for variables, including depression or negative life events, which might also increase levels.2 This link between more stable immune system functioning and religious commitment may provide one partial explanation of why studies are discovering a strong link between attending religious services and lowered risk of earlier death.
Medical Compliance
Medical compliance can play a key role in enhancing health outcomes. A study of heart transplant patients at the University of Pittsburgh in Pittsburgh, Pa., found that patients who participated in religious activities and had strong beliefs complied better with their follow-up treatment. They showed more improved physical functioning at the 12-month follow-up, had higher self-esteem, and experienced diminished anxiety and fewer health worries.3 Another study following hemodialysis patients for three years found that those patients who attended religious services weekly had the highest level of compliance with their medical treatment regimen.4
Recently, in the first detailed examination of religious coping methods used by hospitalized patients, a study of nearly 600 patients at Duke University Medical Center in Durham, NC, found that 12 measures of positive religious coping all were related to greater cooperativeness. Several were also linked to higher quality of life and less depression, even after controlling for severity of illness, age, sex, race, and education.5
Use of Health Services
Patients with a religious link reduced hospital stays by more than half in a study of a consecutive sample of elderly medical patients admitted to Duke University Medical Center. Those with no religious affiliation spent an average of 25 days in the hospital compared to 11 days for patients who had a religious affiliation.6 Controlling for other clinical predictors that could prolong one’s hospital stay, patients who attended religious services weekly or more were also 43% less likely to have been hospitalized in the previous year. Similarly, those attenders who were admitted had shorter stays than patients who attended religious worship services less often, when controlling for factors like age, physical functioning, and severity of illness. Koenig and Larson suggested religion/spirituality may help people cope more effectively and, thus, hasten recovery from medical illness.
Recovery
In addition to prevention of disease, religious commitment in some studies appears to help enhance recovery, especially from surgery and from depression.
Recovery from Surgery. Religious commitment can play a significant role among patients undergoing surgery. A study at Dartmouth Medical School in Hanover, NH, found that elderly heart patients were 14 times less likely to die following surgery if they found strength and comfort in their religious faith and also were socially involved. In this study of 232 patients, those who said they derived no strength or comfort from their religious faith had almost three times the risk of death at the six-month follow-up as patients who found at least some strength. None of those who saw themselves as deeply religious prior to surgery had died six months later, compared to 12% of those who rarely or never went to religious services.7
Another study of elderly women recovering from hip fractures also found patients’ religious commitment enhanced recovery. Women with the best surgical outcomes were those to whom God was a strong source of strength and comfort and who frequently attended religious services. Testing showed they were less depressed and could walk farther at discharge than patients who lacked a strong religious commitment. In essence, the significance of their faith lowered their risk of depressive symptoms and aided them in better handling this stressful medical event.8
Recovery from Depression Among the Medically Seriously Ill. Depression often strikes older patients hospitalized for medical illness. While major depression afflicts only 1% of older adults living in the community, the figure rises to a much larger 10% among medically ill hospitalized elderly, and 35% or more suffer with less severe types of depression. Often, these depressions persist long after treatment of the medical illness. Most of these depressions probably result from the suffering, physical disability, and loss of control the hospitalized elderly encounter with their physical illness. Besides impairing quality of life, depression appears to delay recovery from physical illness, lengthen hospital stays, and potentially increase further clinical problems and even increase risk of death.9 (See Table.)
| Table. Depression Findings |
| • Visits to physicians for depression nearly doubled within 10 years—from 11 million in 1985 to 20.4 million by 1994, according to the Journal of the American Medical Association.1 • Antidepressant medication more than doubled from 5.3 million to 12.4 million in the same time.1 • Between 10-25% of women and 5-12% of men will meet the medical criteria for major depressive disorder within their lifetime.2 • Persons who have no connection with a religious/spiritual group are at an increased risk of depression.3 • People with major depression have a substantially increased risk for early death and suicide attempts.4 • Some 45% of older, hospitalized, seriously ill patients experience some form of depression, compared to only 1% of the elderly in the community.4 • Depression among the seriously, physically ill can lengthen hospital stays and increase use of medical services.4 • People who often attend religious services and highly value their religious faith are at a substantially reduced risk for depression.3 • Persons whose religious faith is a central motivating factor may recover faster from depression when it strikes.5 |
| 1. Pincus HA, et al. Prescribing trends in psychotropic medications: Primary care, psychiatry, and other medical specialties. JAMA 1998;7:526-531. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. 3. McCullough ME, Larson DB. Religion and depression: A review of the literature. Twin Research 1999;2:126-136. 4. Koenig HG, George LK. Depression and physical health outcomes in depressed medically ill hospitalized older adults.Am J Geriatr Psychiatry 1998;6:230-247. 5. Koenig HG, et al. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry 1998; 155(4):536-542. |
Researchers at Duke University investigated whether religious coping resources might help patients recover faster from their depression. The research team used multidimensional measures including questions about frequency of religious attendance and private religious activities like prayer or Bible study. They also used Hoge’s 10-item validated scale to measure intrinsic religious commitment, which examines to what extent a person takes their religious beliefs to heart as a major motivating factor in their decisions and behavior. The study sample included 87 depressed older adults hospitalized with medical illness. The course of their depression was tracked for almost a year. For every 10-point increase in intrinsic religion score, there was a 70% increase in their speed of remission from depression. This effect remained after controlling for multiple demographic, psychosocial, physical health, and treatment factors.10
In another study of 850 elderly men acutely admitted to the hospital, researchers found that patients who used their religious faith to cope were significantly less depressed.11 In a subgroup of 201 patients, the extent of their religious coping predicted lower depression scores on follow-up six months later. Furthermore, the clinical effects of religious commitment were strongest among those with severe disability.
Coping with Serious Illness
Coping with Cancer. To discover how to better meet needs of cancer patients, University of Michigan researchers in Ann Arbor, Mich., surveyed 108 women undergoing treatment for various stages of gynecological cancer. What helped these women cope and what did they expect from their doctors? Some 93% of these cancer patients said their religious lives helped them sustain their hopes. Some 75% said religion had a significant place in their lives, and 41% noted their religious lives supported their sense of worth. Almost half (49%) felt they had become more religious after their cancer diagnosis. Somewhat surprisingly, not one patient noted becoming less religious since being diagnosed with cancer.
Regarding their relationship with doctors, 96% of the patients wanted "straight talk" about their illness. Fear of pain seized most, so they wanted information on potential pain management as soon as receiving the diagnosis. As for their need for physician caring, some 64% evaluated their doctors by the compassion they showed. Based on these findings, the researchers concluded that responsive care for cancer patients would include providing frank information about the illness with compassion, educating the patients on pain relief, maximizing comfort and dignity, and supporting the patients in their religious coping.12
Coping with AIDS. A study at Yale University School of Medicine in New Haven, Conn., surveyed 90 HIV-positive patients about their fear of death, end-of-life decisions, religious status, and guilt about HIV infection. They found that those who were religiously active had less fear of death and less guilt about their disease than those less spiritually active. Fear of death was more likely among the 26% of patients who felt their disease was some form of punishment—17% felt it was punishment from God. Fear of death diminished among patients who read the Bible frequently, attended church regularly, or stated that God was a central part of their purpose in life. Those patients who believed in God’s forgiveness were more likely to engage in discussions about resuscitation status, indicating that their religious beliefs played at least some role in helping them make end-of-life discussions.
The researchers suggested that belief in a God who forgives and comforts may signify an ability to accept HIV infection or premature death.13
These coping studies point to the relevance of incorporating chaplains on the health care team to address these religious issues, particularly when patients are dealing with potential terminal illness.
Coping with Medical Concerns—Prayer as an Indicator. If prayer is believed by patients to have potential beneficial effects particularly when facing stress, it could increase in times of need. This indicates again the clinical importance of taking a spiritual history to learn how patients cope and to what extent they are using these religious/spiritual coping mechanisms currently. A rise in how often patients pray may indicate a heightened concern relevant to medical care.
A study of more than 250 African-American and Hispanic mothers in Galveston, Tex., found that although 48% of the mothers prayed daily for their developing babies, the mothers who prayed the most for their babies experienced poorer health during their pregnancy. Healthier mothers prayed less often for their babies. These findings persisted after controlling for self-rated religious commitment, age, marital status, and years of education.14
Consequently, inquiring not only about frequency of religious practices in general, but whether these practices have increased or declined in recent months or during a particular time of treatment may serve as another clinical indicator of potential medical concerns that could be further addressed by physicians.
Unfortunately, some clinicians, especially in mental health fields in the past, may have misinterpreted frequent prayer by suggesting that since the patient has a problem and he or she is praying often, the prayer must be the problem. Rather, the more frequent prayer more likely indicates a culturally relevant attempt to draw upon spiritual resources to better handle a physical or emotional health problem that concerns the patient.
Coping with Pain. A recent study in Family Medicine discovered a link between a patient’s strong spirituality and better overall health, but not necessarily less pain.15
In a random survey of more than 460 patients at a suburban family medicine clinic, the study found that persons with either a high or moderately high internally motivated relationship with God were much more likely to experience better health.
The patients each filled out a questionnaire developed at Dartmouth to examine a patient’s health and level of physical pain. They also responded to a questionnaire to assess their level of "intrinsic" spirituality—a personal connection with God or a Higher Power that gives life meaning and guides life choices. This contrasts with an "extrinsic" measure like simply a belief in God or membership in a church or synagogue, which may or may not affect one’s internal motivations, the researchers explained. Differences in health were greatest between patients having a low level of spirituality and those with either moderately or high levels, confirming other research that found spiritual commitment may enhance prevention and coping.
An unexpected finding centered on physical pain. Moderately spiritual patients experienced the least pain, highly spiritual persons more pain, and the low spirituality group the most pain. Spirituality may exert some influence over health, but health is also likely to influence patients’ spiritual experiences, making relationships more difficult to untangle. For instance, at times, more pain may increase spiritual practices, as more health concerns lead to more frequent prayer.
Coping at End-of-Life. A long-term study of more than 1000 seriously ill hospitalized men found that those who most strongly relied on their religious faith to cope had lower rates of depression and a wider network of supportive friends, yet they lived no longer than less religious patients. Dependence on a strong personal religious faith, while not adding years to life, appeared to add life to years in terms of quality of life.16
In this study, which followed seriously ill men for nine years after admission to a Veterans Administration hospital in Durham, NC, about 68% of the patients died during the nine years whether they drew on their religious faith for strength or comfort to a great degree, somewhat, or not at all. About one-fifth of these hospitalized patients at the start of the study indicated that religion was the most important coping factor that kept them going. The finding that strong religious coping did not result in longer lives differed from some earlier research showing higher survival rates among heart surgery patients who drew strength from their religious faith.17
The fact that many of these hospitalized men were already near death at the start of the study may partly explain why no differences were found in survival rates among the strong religious copers and others. Age and physical illness may simply have overwhelmed the effects of religious coping and other psychosocial predictors of mortality. Neither marital status, education, income level, social support, nor depression had any effect on survival, despite the fact they are well-known psychosocial predictors of mortality in community-dwelling populations. Many of these patients may have sought comfort in religion/spirituality as they became sicker and required acute hospitalization. Thus, a link between nearness to death and religious coping arose, possibly indicating that as patients became more ill, they turned more to their religious faith, canceling out any protective effect that long-term or life-long religious commitment may have afforded.
Although religious coping did not prolong these hospitalized men’s lives, the lower rates of depression and higher social support among these men and in studies of other patients have shown that dependence on religious faith during physical illness and hospitalization may enhance quality of life during the time that remains.
Negative Religious Coping
Coping with Medical Crises—When Does Religion Help or Hinder? One recent study of 550 older hospitalized patients found whether one sees crisis events like a hospital stay in light of a caring God or a condemning one makes a difference in levels of emotional distress.18 Patients showed less psychological distress with positive patterns of religious coping, such as seeking control through a partnership with God in problem solving, searching for comfort and reassurance through God’s love and care, asking God’s forgiveness and trying to forgive others, as well as trying to see how God might be providing strength through the crisis. Positive religious coping was also related to positive personal growth as a result of the stress, as well as positive spiritual changes, such as growing closer to God and one’s religious congregation.
In contrast, more depression, poorer quality of life, and callousness toward others was linked with negative religious coping, such as seeing the crisis as punishment from God or questioning God’s power or love. Negative religious coping may serve as a "red flag," indicating appropriateness of referral to chaplains to help in instances of spiritual distress that may arise if a person’s religious commitment appears to be hindering rather than helping treatment and recovery.
Refusal of Medical Treatment for Treatable Disease. A comprehensive and more intentional scientific examination of the instances in which religion may have deleterious effects on physical and mental health remains warranted. How might abusive, manipulative, punitive, and condemning religion adversely affect health? The tragic death stories of the followers of Branch Davidian cult leader David Koresh in Waco, Tex., and the mass suicide of more than 900 followers of cult leader Jim Jones in Jonestown, Guyana, stand out as prime examples of certain religious sects becoming not only deleterious to health, but also fatal. What characterizes these groups and how can people avoid their death-giving rather than life-giving messages?
Also, tough, ethical decisions may come into play regarding some religious denominations’ teachings. For instance, Jehovah’s Witnesses doctrine instructs patients to refuse blood transfusions. Do physicians allow Jehovah’s Witnesses to refuse blood transfusions for their children—who are minors and, therefore, not making decisions for themselves—or do physicians seek a court order when they feel a child’s life is at stake? Research shows beliefs of certain religious groups who reject medical interventions for "faith healing" can lead to earlier death from often treatable diseases.19
Even within mainstream religious traditions, what aspects of religious commitment tend to be more health producing than others? Some studies on anxiety and fear of death show persons who are extrinsically, but not intrinsically, religious have higher rates of anxiety than persons who have either internalized their faith or completely rejected religion.20 This contrasts with persons with a strong religious commitment who have lowered death anxiety. Yet, as noted above, many patients turn more to religion/spirituality as they become more gravely ill, and a sense of rejection or disappointment with God or guilt that healing is not taking place may indicate appropriateness of referral to a hospital chaplain.
Prevention
Besides serving as a strong factor in coping and recovery, studies also show religious commitment plays a role in disease prevention. It may help improve immune functioning, reduce risk of high blood pressure, and overall enhance chances of living longer. Furthermore, religious/spiritual commitment can protect against emotional disorders involving self-destructive behaviors like suicide and substance abuse.21 Part of the reason for disease reduction and potentially longer life may be the healthier lifestyle choices persons with a strong religious commitment might make, such as avoiding smoking or alcohol. Choosing healthier behaviors in itself stands an important contribution religious/spiritual commitment might make in enhancing health. But healthy choices alone fail to fully account for religious/spiritual commitment’s links with health. In a number of studies, even when these healthy behaviors are controlled for, the health links with a strong religious commitment remain.
High Blood Pressure. A recent community survey of nearly 4000 people aged 65 years and older found that people who both attended religious services at least once a week and prayed or studied the Bible at least daily had consistently lower blood pressure than those who did so less frequently. Regular participants in these religious activities were 40% less likely to have diastolic hypertension, reducing risk of heart attacks and strokes. These findings remained after taking into account age, gender, race, education, and other variables that could affect outcomes. The study also found that the associations between religious involvement and measures of blood pressure were stronger in blacks than in whites and in the "younger older" people—those aged 65-75—than in those older than 75.22
These findings provide support for previous studies investigating the relationship between religious commitment and blood pressure, even when taking into account specific lifestyle factors. For instance, a study of white men who smoked found that smokers who both attended religious services weekly and rated their religion as important to them were seven times less likely to have abnormal pressures than the smokers who had no interest in religion. This difference could not be explained by simply avoiding risky lifestyles such as the unhealthy behavior of smoking. Furthermore, those smokers who attended religious services weekly or more but did not rank their faith as highly important were still four times less likely to have abnormal diastolic pressure levels. These results indicated that the two factors of attendance and personal importance of one’s religion showed the greatest protection against abnormal blood pressure, also underscoring the need for multidimensional measures to identify what aspects of religious commitment might contribute the most to healthier lives.23
Previously, a survey of epidemiological research found nearly 20 studies published in 30 years examining religious factors and blood pressure. In all but one, measures of frequency of attendance or religious attitudes found an association with lower blood pressure or lower rates of hypertension indicating hypertension may be mitigated by religion/spirituality.24
Depression. A review of more than 80 studies published over the last 100 years found religious/spiritual factors generally linked with lower rates of depression.25 Persons who participated in a religious group and highly valued their religious faith were at a substantially reduced risk of depressive disorder while people with no religious link may raise their relative risk of major depression by as much as 60%. (See Table.)
Lack of organizational religious involvement was linked with a 20-60% increase in the odds of experiencing a major depressive episode. McCullough and Larson suggested that valuing one’s religious faith as centrally important and actively belonging to a religious group may give spiritual roots that provide meaning as well as support from others, creating anchors of hope and caring, which might help protect against depression.
Suicide. In the United States, one in seven deaths among those 15-19 years of age results from suicide. Suicide rates in this age group have soared 400% from 1950 to 1990, according to the National Center for Health Statistics in Hyattsville, Md. One study of 525 adolescents found religious commitment significantly reduced risk of suicide.26 Adolescent suicide has also been linked to depression. Another study of adolescents found that frequent church attenders with high spiritual support had the lowest scores on the Beck Depression inventory. Those high school students of either gender who infrequently attended church and had low spiritual support had the highest rates of depression, often at clinically significant levels.27
How significantly might religious commitment prevent suicide? One large-scale study found that persons who did not attend religious services were four times more likely to kill themselves than were frequent worship attenders.28 The rate of church attendance predicted suicide rates more effectively than any other evaluated factor, including unemployment.29 The study proposed several ways in which religion might help prevent suicide including: 1) enhanced self-esteem; 2) improving personal accountability; or 3) a sense of responsibility to God. Religious commitment can provide a unique source of self-esteem through a belief that one is loved and created by God. Given that low self-esteem can contribute to suicide potential, the self-esteem derived from one’s religious commitment could play an important role in deterring suicide. In addition, many religions believe in a holy force or a God who responds caringly to human needs. The beliefs in justice, an afterlife, and the possibility of accountability for taking one’s own life may play an important role in reducing the appeal of potentially self-destructive behavior.
Drug Abuse Prevention. Lack of religious commitment arises in research findings as a risk factor for drug abuse. A review of nearly 40 studies found that people with higher levels of religious commitment were less likely to become involved in substance abuse.30 These findings supported an earlier review, which also found that lack of religious commitment stood out as a predictor of those who abuse drugs.31
Another survey of almost 14,000 youths found that analysis of six measures of religious commitment and eight measures of substance abuse showed religious commitment was linked with less drug abuse. In this study, the measure of "importance of religion" to the person was the best predictor in indicating lack of substance abuse, implying that the controls operating here were internalized values and norms rather than fear or peer pressure."32
Drug Abuse Treatment. Drawing upon spiritual resources can also make a significant difference in outcomes in effective drug treatment.33 For instance, 45% of participants in a religious treatment program for opium addiction were still drug-free one year later compared to only 5% of participants in a nonreligious public health service hospital treatment program—a nine-times difference.34
Treatment of Alcohol Abuse. As well as reducing use of illicit drugs, religious involvement similarly predicts fewer problems with alcohol.35 Studies reveal that persons lacking a strong religious commitment are more at risk to abuse alcohol. Religious involvement tends to be low among people diagnosed for treatment for alcohol abuse.36 A study of the religious lives of alcoholics found that 89% of alcoholics had lost interest in religion during their teenage years.37 Alcoholics often report having had negative experiences with religion and hold concepts of God that are punitive, rather than loving and forgiving.38
Furthermore, a relationship between religious commitment and the nonuse or moderate use of alcohol has been documented. One study found that whether a religious tradition specifically teaches against alcohol use, those who are active in a religious group consumed substantially less alcohol than those who were not active.39
Once alcohol addiction has taken hold, spirituality is often a powerful force in achieving abstinence. Alcoholics Anonymous (AA) invokes a Higher Power to help alcoholics recover from addiction. Those who participate in AA are more likely to remain abstinent after inpatient or outpatient treatment.40,41
Smoking Prevention. Currently, more than one-quarter of all Americans smoke regularly. Most begin as teenagers or young adults, and about one-third of smokers quit by the time they reach 65.
An initial study of smoking and religious activity in older Americans found that the life-long, strongly religious are much more likely never to have smoked at all. Also, the elderly who actively participated in their religious faith were 90% less likely to smoke. Among those older adults who did smoke, the number of cigarettes smoked per day decreased significantly among the more religiously active.
Frequently attending religious services stood out as the most important religious factor linked with less smoking in this study. Private study of scripture and prayer didn’t show nearly as strong a link. Watching religious TV or listening to religious radio had no connection to smoking reduction.42 Not only potentially effective in prevention, religious involvement is associated with higher success rates in smoking cessation treatment.43
Adolescent Health Risks. Unlike in the past when infectious diseases were the leading causes of early sickness and death in the United States, now social and lifestyle factors are what often precipitate premature death. Thus, researchers are now looking at psychosocial and other factors like religious commitment that might protect teen health. Also, many lifestyle patterns that take a health toll in adult years, like drinking, smoking, and poor eating habits, begin in teenage years, marking adolescence as an important time in forming healthy behaviors.
A recent study of a national survey of 5000 high school seniors by University of Michigan researchers found that seniors who attended church weekly and reported that religion was important were less likely than other youth to engage in high-risk behaviors and more likely to engage in behaviors that promote long-term physical well-being.44 Levels of current cigarette use, binge drinking during the past two weeks, and annual marijuana use ranked lowest among youth for whom religion is important and attend church once a week or more, even after taking into account other sociodemographic factors. Teens who never went to religious services and who felt religion was not important showed the most substance abuse, with rates shrinking as religious attendance and importance increased.
Accidents account for 60% of all deaths among U.S. teenagers, with most (78%) of these fatalities the results of car crashes. Driving a car while under the influence of alcohol or other drugs—or riding in a car with a driver under the influence—greatly increases the risk of injury or death. By reducing drinking and drug rates—as shown among teens who rank religion as important and often attend religious services—religious commitment arises as a protective health factor. Religious teens are also more likely to wear seat belts, the study found, further curtailing potential auto injuries. Also, youth violence (e.g., murder and suicide) stand as the second and third leading causes of death among adolescents, with firearms accounting for most. More religious teens are less likely to carry weapons or get into fights, the study found. Also, youth for whom religion is important and who attend church weekly are significantly more likely than their less religious peers to eat in a healthy fashion, to exercise regularly, and to get adequate sleep, the study found. Other studies have found religious teens are less likely to engage in precocious adolescent sex with multiple partners, protecting them from risks of pregnancy and sexually transmitted diseases, including HIV and cancer of the cervix and uterus.
Relative to their peers, religious youth are less likely to engage in behaviors that compromise their health, suggesting that religious resources are a potentially important, often overlooked, ally in the effort to promote health. Physicians can be more intentional in recognizing and supporting this factor when it’s important to the teen.
Summary
As shown in Patient Spirituality in Clinical Care: Clinical Assessment and Research Findings—Part I (Larson DB, et al. Primary Care Reports 2000;6:165-172), by becoming sensitive to a patient’s life context and taking a spiritual history, physicians help identify coping resources or possible treatment conflicts. Part II provided research findings indicating that religion/spirituality is a potential component of patient health and well-being, potentially contributing to prevention, coping, recovery from surgery and depression, and quality of life. By assessing the potential role religion/spirituality might play in patients’ lives as they deal with illness, physicians compassionately care for patients in the context of their values and beliefs, acknowledging what may play a central role in patients’ coping with their illness and disability.
References
1. Matthews DA, et al. Religious commitment and health status: A review of the research and implications for family medicine. Arch Fam Med 1998;7:118-124.
2. Koenig HG, et al. Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. Int J Psychiatry Med 1997;27(3):233-250.
3. Harris RC, et al. The role of religion in heart transplant recipients’ long-term health and well-being. J Religion Health 1995; 34(1):17-32.
4. O’Brien ME. Religious faith and adjustment to long-term hemodialysis. J Religion Health 1982;21(1):68-80.
5. Koenig HG, et al. Religious coping and health status in medically ill hospitalized older adults. J Nerv Ment Dis 1998;185(9): 513-521.
6. Koenig HG, Larson DB. Use of hospital services, religious attendance, and religious affiliation. South Med J 1998; 91(10):925-932.
7. Oxman TE, et al. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995;57(1):5-15.
8. Pressman P, et al. Religious belief, depression, and ambulation status in elderly women with broken hips. Am J Psychiatry 1990;147(6):758-760.
9. Koenig HG, et al. Survival and healthcare utilization in elderly medical inpatients with major depression. J Am Geriatr Soc 1989;37:599-606.
10. Koenig HG, et al. Religiosity and remission from depression in medically ill older patients. Am J Psychiatry 1998;155:536-542.
11. Koenig HG, et al. Religious coping and depression in the elderly hospitalized medically ill men. Am J Psychiatry 1992;149(12): 1693-1700.
12. Roberts JA, et al. Factors influencing views of patients with gynecological cancer about end-of-life decisions. Am J Obstet Gynecol 1997;176(1):166-172.
13. Kaldijian LC, et al. End-of-life decisions in HIV-positive patients: The role of spiritual beliefs. AIDS 1998;12(1):103-107.
14. Levin JS, et al. Prayer and health during pregnancy: Findings from the Galveston low birthweight survey. South Med J 1993; 86(9):1022-1027.
15. McBride JL, et al. The relationship between a patient’s spirituality and health experiences. Fam Med 1998;30(2):122-126.
16. Koenig HG, et al. Religion and the survival of 1010 hospitalized veterans. J Religion Health 1998;37(1):15-29.
17. Oxman TE, et al. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995;57(1):5-15.
18. Pargament KI, et al. Patterns of positive and negative religious doping with major life stressors. J Scientific Study Religion 1998;37(4):710-724.
19. Asser SM, Swan R. Child fatalities from religion-motivated medical neglect. Pediatrics 1998;101(4):625-629.
20. Baker M, Gorsuch R. Trait anxiety and intrinsic-extrinsic religiousness. J Scientific Study Religion 1982;21(2):119-122.
21. Larson DB, Larson SS. The Forgotten Factor in Physical and Mental Health: What Does the Research Show? Rockville, Md: National Institute for Healthcare Research; 1994.
22. Koenig HG, et al. The relationship between religious activities and blood pressure in older adults. Int J Psychiatry Med 1998; 28(2):189-213.
23. Larson DB, et al. The impact of religion on men’s blood pressure. J Religion Health 1989;28(4):265-278.
24. Levin JS, Vanderpool HY. Is religion therapeutically significant for hypertension? Soc Sci Med 1989;29(1):69-78.
25. McCullough ME, Larson DB. Religion and depression: A review of the literature. Twin Research 1999;2:126-136.
26. Stein D, et al. The association between adolescents’ attitudes toward suicide and their psychosocial background and suicidal tendencies. Adolescence 1992;27(108):949-959.
27. Wright LS, et al. Church attendance, meaningfulness of religion, and depression symptomatology among adolescents. J Youth Adolescence 1993;22(5):559-568.
28. Comstock GW, Partridge KB. Church attendance and health. J Chronic Disease 1972;25:665-672.
29. Stack S. The effect of religious commitment on suicide: A cross- national analysis. J Health Soc Behav 1983;24:362-374.
30. Benson P. Religion and substance use. In: Schumaker JF, ed. Religion and Mental Health. New York, NY: Oxford University Press; 1992:211-220.
31. Gorsuch RL, Butler MC. Initial drug abuse: A view of predisposing social psychological factors. Psychol Bull 1976;3:120-137.
32. Loch BR, Hughes RH. Religion and youth substance use. J Religion Health 1985;24(3):197-208.
33. Miller WR. Researching the spiritual dimensions of alcohol and other drug problems. Addiction 1998;93(7):979-990.
34. Desmond DP, Maddox JF. Religious programs and careers of chronic heroin users. Am J Drug Alcohol Abuse 1981;8(1):71-83.
35. Hardesty PH, Kirby KM. Relation between family religiousness and drug use within adolescent peer groups. J Social Behavior Personality 1995;10(2):137-142.
36. Brizer DA. Religiosity and drug abuse among psychiatric inpatients. Am J Drug Alcohol Abuse 1993;19(3):337-345.
37. Larson DB, Wilson WP. Religious life of alcoholics. South Med J 1980;73(6):723-727.
38. Gorsuch, RL. Assessing spiritual values in Alcoholics Anonymous. In: McCrady BS, Miller WR, eds. Research on Alcoholics Anonymous: Opportunities and Alternatives. New Brunswick, NJ: Rutgers Center for Alcoholic Studies; 1993:301-318.
39. Amoateng AY, Bahr SJ. Religion, family, and adolescent drug use. Psychol Perspectives 1986;29:53-73.
40. Lo B, et al. Discussing palliative care with patients. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians—American Society of Internal Medicine. Ann Intern Med 1999;130:744-749.
41. Montgomery HA, et al. Does Alcoholics Anonymous involvement predict treatment outcome? J Subst Abuse Treat 1995; 12(4):241-246.
42. Koenig HG, et al. The relationship between religious activities and cigarette smoking in older adults. J Gerontol Med Sci 1998; 53A(6):M1-M9.
43. Voorhees CC, et al. Heart, body, and soul: Impact of church-based smoking cessation interventions on readiness to quit. Prev Med 1996;25(3):277-285.
44. Wallace J, Forman T. Religion’s role in promoting health and reducing risk among American youth. Health Educ Behav 1998; 25(6):721-741.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.