Spirituality and Health
By Howell Sasser, PhD, Dr. Sasser is Director, Research Epidemiology, R. Stuart Dickson Institute for Health Studies, Carolinas HealthCare System, Charlotte, NC; he reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
Part 1 of a Series on Spirituality
A large body of observational research has been published on the role of religious belief and practice on physical and mental health.1,2 The consensus appears to be that there is some beneficial effect of religion on health, but this conclusion comes with numerous conditions and assumptions. The purpose of this article is to summarize some of this work and introduce the most salient issues. A second article will address attempts to expand on the positive observational findings with experimental studies.
Religiosity or Faith?
A foundational problem in all research on spirituality and health is the definition and measurement of spirituality. Like many other traits, it can be difficult to measure directly, and the use of surrogate measures is common. One way of beginning to come to grips with this issue is to divide measures into behavioral and subjective as described by Chatters.1
Behavioral measures may include a study participant's faith tradition and denomination, frequency of church attendance and/or other religious devotions, and the size and programmatic offerings of his/her religious community. Certain parts of the substantive content of faith that might motivate behavior, such as fear of the consequences of sin and adherence to the religious community's moral norms, might also be included under this heading.
The subjective dimension addresses the metaphysical aspects of faith. These may include a view of the nature of the divine (god as a distinct being or a universal life force), a sense of the degree of divine awareness of and intervention in the world, and the presence or absence of a sense of having a personal relationship with the object of worship.
These two categories influence and interpenetrate each other, but neither is sufficient to describe the complete religious experience. For instance, health status may influence one's ability to participate in public religious life, but may also intensify private, inner devotion. Potential confounding relationships of this kind mean that the results of studies of religiosity/spirituality and health should be approached with caution, especially when an attempt is made to generalize from one population to another. It should also be noted that, as will become apparent in the discussion of potential mechanisms, the operational definition of faith has great influence on the nature and explanation of study findings.
A second issue with research on spirituality and health is the measurement and nature of the outcomes under study. From the biomedical perspective, it might seem that the goal of studies of spirituality and health should be to show measurable improvements in objective dimensions of health. Numerous studies have taken this approach.3-6 However, because spirituality is at least in part a means to apply values and explanations to experience, the use of objective measures may not be the only appropriate strategy.
Other research has considered the relationship of spirituality and the subjective assessment of health.7,8 These studies showed evidence that spirituality had a positive effect on participants' assessment of their own health that was independent of other measures of health.
Mechanisms of Action
In considering the potential mechanisms by which spirituality might influence health, it is useful to consider a lesson learned in the study of dietary supplements. Once a potential health benefit is identified in a natural substance, considerable effort may be devoted to identifying the critical ingredient(s) so that they may be extracted and delivered more efficiently. However, when these are tested in isolation, their effects often fail to meet expectations. There is something lost when the total context is not considered. The same is true of spirituality. Many of the potential explanatory mechanisms involve psychological and/or social factors. These are often highly correlated with one another and difficult to tease out into distinct strands, with consequent difficulties in measurement. For ease of presentation, however, the most commonly proposed mechanisms can be divided into several broad categories.
Healthy Behaviors
Considerable research has been done with denominational groups (Mormons, Seventh Day Adventists, and Orthodox Jews) that are known to have specific dietary and health practices, and other behaviors that might be associated with positive health states.9-12 Some of these factors, such as the Adventist preference for a vegetarian diet, Mormons' abstention from tobacco and alcohol, or many faiths' discouragement of sexual promiscuity, may have direct benefits.
Other factors may be more subtle. If the culture of a religious community frowns on risk-taking, this may translate into avoidance of behaviors with potentially negative health consequences, such as injuries or sexually transmitted infections.2 This may even extend to non-health dimensions, such as business and personal ethics, with potential benefit in the form of avoidance of conflict and stress. However, it may also be the case that religious communities preferentially attract people who are already risk-averse. Regardless, there appears to be some value in religious sanction of behaviors that have the concurrent (or in some cases subsequent!) blessing of medical science.
Social Support
Religious groups are natural communities from which members can draw material and moral support.13-15 There is evidence that those belonging to religious communities report having more, and richer, resources and support to draw upon than those who do not belong.16 At a practical level, this may translate into transportation and/or childcare for doctors' visits and other appointments, a reliable supply of prepared food after childbirth or bereavement, periodic visits to the homebound, and a variety of kinds of help in times of crisis or household disruption. At a psychological level, the principal benefit likely is a ready source of familiar and sympathetic people with whom to share one's troubles. However, it is important not to overlook the psychological value of knowing that resources are available if needed.
There also is some benefit to being in the helping role. The perception that one is needed and valued can have a positive impact on mood and one's sense of self-worth. It may also encourage other desirable health behaviors (nutrition, rest, exercise) as ways of ensuring "fitness for duty."
Self-worth and Self-efficacy
The previous potential mechanisms deal mainly with concrete influences on health. However, there is also evidence that less tangible factors may be associated with health outcomes.17,18 Elements of both religiosity and spirituality can serve to boost self-image. As already mentioned, participation in a religious community can engender a sense of being needed. Long association brings with it the prestige of being a keeper of institutional memory. Spiritual practice, whether public or private, can create a sense of solidarity with the divine and a feeling of responsibility for enacting the divine will in one's life and in the world.
Any of these factors may increase consciousness of the need for self-care, including seeking medical attention as needed. They may also raise confidence in the faithful person that he or she can adhere to medical treatment and/or make and sustain needed lifestyle changes. The messages of strength through faith ("giving problems to God") and of the body as the temple of God, which are especially characteristic of the African-American church and appear to resonate with particular power among women, are good examples of how this mechanism might be seen to work.19
Coping and Emotional Support
A further twist in the potential relationship between faith and health is the possibility that faith does not so much improve health as alter the ways in which the faithful person views his or her health and the values that he or she assigns to specific health and life events.
Religion provides powerful resources for coping.20-22 Most religious traditions offer examples of faithful people who found strength in adversity through their religious devotion. The modern believer is offered the opportunity to identify with and emulate them. In this way, negative health or life events (such as bereavement) may be re-evaluated as opportunities to show stoicism. This, in turn, may raise the sufferer's standing in the eyes of others in the faith community, bringing emotional and material support.
Finally, to the extent that the believer understands his or her relationship with the divine to transcend specific actions (such as structured prayers, ritual acts, or corporate public worship), periods of disability may result in an intensification of spirituality and a deeper belief and trust to compensate for other religious expressions that are temporarily or permanently not available. In this situation, the roles are reversed, with health a promoter of certain aspects of spirituality.
Negative Effects
For balance, it is important to bear in mind that the avenues by which spirituality and religious practice might benefit health may each also involve potential harms.
The healthy behavior model presumes that the faith community will support the believer in seeking the medical care that he or she needs, or that his or her physician recommends. This may not always be the case. Some religious groups discourage or prohibit specific kinds of treatments, from blood transfusions, immunizations, and various types of intensive care interventions, to medical care of any kind.
The social support model is built on an implicit assumption of reciprocity—those in the community help one another. However, those who are the neediest may not be able to participate as fully in the giving role as in the taking, and may have consequent difficulty—either internally, from feelings of guilt, or externally, from compassion fatigue among their fellow believers.
The self-efficacy model depends on the assumption that the believer will use the empowerment gained from faith to engage in the kinds of behaviors and seek the kinds of medical care that are judged by mainstream medicine to be sound. This may or may not be the case.
Finally, the sort of adaptation described by the coping model may become overdeveloped, leading to fatalism and inaction.
Conclusion
The range of proposed mechanisms for the spirituality-health connection makes clear the lack of unanimity as to the "active ingredient" in religious faith. All models, and the research on which they are based, must contend with the complex and interconnected reasons why and how people express their faith. Inward faith (spirituality) and outward expression (religiosity) influence and motivate each other. Their individual and joint impact on the health of a person is both unique and changing over time. Also, like many other factors affecting health, religious faith can have both positive and negative impacts.
To return to the dietary supplement example, perhaps the best way to imagine faith is as a whole substance, with some identifiable and some unknown components, only the sum of which should be credited with any noticeable effect.
Recommendation
For many clinicians, discussion of faith with their patients is difficult at best. Indeed, direct interaction may be most comfortable if directed mainly toward the impact of religion in the patient's life (meaning, comfort, peace) rather than to specific religious beliefs. It also should be emphasized that there is no evidence to support physicians who might encourage patients to take up religion for their health. In any case, it is unclear whether entering into as complex an undertaking as religious faith for so instrumental a reason would have much chance of success.
With these cautions in mind, however, there are positive steps that the clinician can take. First, know the ethics and health-related religious beliefs of the cultures from which your patients come. Second, where appropriate, be ready to suggest that a patient seek needed resources and services from his or her faith community. Third, be open to patients' need to express health-related concerns in spiritual terms. In such situations, a clinician may even suggest that a patient seek to deepen or enrich his or her spiritual practice as part of a strategy to restore and maintain health. Finally, be aware of the religious ideas and values (either present or past) that you bring to patient encounters. These steps will not empower anyone to improperly prescribe or proscribe faith, but they will help to clarify the role it may play in the clinician-patient interaction.
References
1. Chatters LM. Religion and health: Public health research and practice. Annu Rev Public Health 2000;21:335-367.
2. Ellison CG, Levin JS. The religion-health connection: Evidence, theory, and future directions. Health Educ Behav 1998;25:700-720.
3. McBride JL, et al. The relationship between a patient's spirituality and health experiences. Fam Med 1998;30:122-126.
4. Masters KS, et al. Religious orientation, aging, and blood pressure reactivity to interpersonal and cognitive stressors. Ann Behav Med 2004;28:171-178.
5. Harrison MO, et al. Religiosity/spirituality and pain in patients with sickle cell disease. J Nerv Ment Dis 2005;193:250-257.
6. Tartaro J, et al. 2005. Exploring heart and soul: Effects of religiosity/spirituality and gender on blood pressure and cortisol stress responses. J Health Psychol 2005;10:753-766.
7. Daaleman TP, et al. Spirituality and well-being: An exploratory study of the patient perspective. Soc Sci Med 2001;53:1503-1511.
8. Daaleman TP, et al. Religion, spirituality, and health status in geriatric outpatients. Ann Fam Med 2004;2:49-53. Erratum in: Ann Fam Med 2004;2:179.
9. Cochran JK, et al. Religiosity and alcohol behavior: An exploration of reference group theory. Sociological Forum 1988;3:256-276.
10. Troyer H. Review of cancer among 4 religious sects: Evidence that life-styles are distinctive sets of risk factors. Soc Sci Med 1988;26:1007-1017.
11. Koenig HG, et al. Religious practices and alcoholism in a southern adult population. Hosp Community Psychiatry 1994;45:225-231.
12. Gardner JW, et al. Behavioral factors explaining the low risk for cervical carcinoma in Utah Mormon women. Epidemiology 1995;6:187-189.
13. Idler EL. Religious involvement and the health of the elderly: Some hypotheses and an initial test. Social Forces 1987;66:226-238.
14. Williams DR, et al. Religion and psychological distress in a community sample. Soc Sci Med 1991;32:1257-1262.
15. Strawbridge WJ, et al. Frequent attendance at religious services and mortality over 28 years. Am J Public Health 1997;87:957-961.
16. Ellison CG, George LK. Religious involvement, social ties, and social support in a southeastern community. J Scientific Study Religion 1994;33:46-61.
17. Lin N, Ensel WM. Life stress and health stressors and resources. Am Sociol Rev 1989;54:382-399.
18. Krause N. Religiosity and self-esteem among older adults. J Gerontol B Psychol Sci Sociol Sci 1995;50:P236-P246.
19. Holt CL, McClure SM. Perceptions of the religion-health connection among African American church members. Qualitative Health Res 2006;16:268-281.
20. Mattlin JA, et al. Situational determinants of coping and coping effectiveness. J Health Soc Behav 1990;31:103-122.
21. Idler EL. Religion, health, and nonphysical senses of self. Social Forces 1995;74:683-704.
22. Ellison CG, Taylor RJ. Turning to prayer: Social and situational antecedents of religious coping among African Americans. Rev Religious Res 1996;38:111-131.
Sasser H. Spirituality and health. Altern Med Alert 2006;9:101-104.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content