Religion and spirituality: important psychosocial variables frequently ignored in clinical research.

Religious and spiritual beliefs and practices are fundamental to the identity of many people. But, are such beliefs and practices relevant to health care? Previous work published in a variety of journals suggests that they are. Religious and spiritual variables have been associated with lower levels of mortality in prospective cohort studies, (1,2) improved recovery from surgery, (3,4) lower levels of substance abuse, (5,6) coping with serious illness, (7) immune function in HIV-infected patients, (8) blood pressure control, (9) and lower levels of health care utilization. (10) Patients recognize the importance of these issues in their own lives, and many want physicians to consider these factors in their health care. (11,12) Furthermore, physician values may affect their clinical decisions and their interactions with patients. (13,14) A limited number of studies have included a spiritual dimension in patient care, and examined health-related outcomes. (15,16)

There are plausible explanatory models for the potential salutary effect of religion and spirituality in health. (17,18) In addition, there is emerging data suggesting possible biological mechanisms for such effects. (19) Regardless of one's personal beliefs, the physician should appreciate the potentially beneficial role that religion and spirituality can play in the lives of individual patients.

In this issue of the Journal, Weaver et al (20) present their work demonstrating that studies published in three major general medical journals generally ignore religion and spirituality as a variable. Over a 3-year period of time, less than 1% of the quantitative studies published measured some aspect of religion, spirituality, or both.

Given the data indicating a generally positive relation between religion, spirituality, and health, why have so few articles in major journals examined this? One explanation is that researchers are not looking at these variables. While this is probably true to some degree, it is also clear that many researchers are examining these variables. Perhaps these variables are being examined in poorly conducted studies so that the quality of the research does not pass peer review. (21) Given that many current funding programs would not give high priority to such studies, studies examining these variables often are accomplished without significant resources, which may impact the quality of a study. Journal editors may have a bias against publishing such studies. Most medical journal editors--probably trained at a time when little attention was given to spiritual issues in clinical care--may deem such variables to be irrelevant. Finally, some editors might have an actively antagonistic perspective on studies examining religious and spiritual variables, and thus exclude their publication.

Over many years, the Southern Medical Journal has consistently published sound studies that have included religious and spiritual variables. Studies published have covered a broad range of topics, including recovery from trauma, (22) obstetrics, (23) rheumatologic disease, (24) and end-of-life issues. (25) Religion is a profoundly important thread in the fabric of life in the Southeast United States. The American Religious Identification Survey conducted in 2001 demonstrated that residents of Southern states have a higher level of religious identification than those in other regions of the United States. (26) Thus, it is appropriate for a regional general medical journal such as this to address health-related social issues important in the lives of patients in the region.

This area of study is ripe with future questions to address. Does lifestyle modification using spiritual intervention work better for spiritually oriented patients than traditional approaches? Does spiritual intervention have a role in the management of chronic pain? Could spiritual interventions enhance optimal use of health care resources among high utilizers? Can spiritual interventions or practices evoke specific beneficial physiologic responses? Innovative researchers should consider inclusion of spiritual and religious variables in their research. In many cases, such variables can be added to demographic information already collected with little additional effort. Researchers may be surprised at the relations they discover when they look.

It isn't that they can't see the solution. It is that they can't see the
problem.
--G.K. Chesterton

Accepted December 19, 2003.

Please see "Religion and Spirituality in Three Major Medical Journals from 1998 to 2000" on page 1245 of this issue.

References

1. Strawbridge WJ, Cohen RD, Shema SJ, et al. Frequent attendance at religious services and mortality over 28 years. Am J Public Health 1997;87:957-961.

2. Oman D, Reed D. Religion and mortality among the community-dwelling elderly. Am J Public Health 1998;88:1469-1475.

3. Oxman TE, Freeman DH, Manheimer ED. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995;57:5-15.

4. Pressman P. Lyons JS, Larson DB, et al. Religious belief, depression, and ambulation status in elderly women with broken hips. Am J Psychiatry 1990;147:758-760.

5. Whooley MA, Boyd AL, Gardin JM, Williams DR. Religious involvement and cigarette smoking in young adults: the CARDIA study. Arch Intern Med 2002;162:1604-1610.

6. Hadaway CK, Elifson KW, Peterson DM. Religious involvement and drug use among urban adolescents. J Sci Study Religion 1984;23:109-128.

7. Roberts JA, Brown D, Elkins T, Larson DB. Factors influencing views of patients with gynecologic cancer about end-of-life decisions. Am J Obstet Gynecol 1997;176:166-172.

8. Woods TE, Antoni MH, Ironson GH, Kling DW. Religiosity is associated with affective and immune status in symptomatic HIV-infected gay men. J Psychom Res 1999;46:165-176.

9. Larson DB, Koenig HG, Kaplan BH, et al. The impact of religion on men's blood pressure. J Religion Health 1989;28:265-278.

10. Koenig HG, Larson DB. Use of hospital services, religious attendance, and religious affiliation. South Med J 1998;91:925-932.

11. Maugans TA, Wadland WC. Religion and family medicine: a survey of physicians and patients. J Fam Pract 1991;32:210-213.

12. Ehman JW, Ott BB, Short TH, et al. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;159:1803-1806.

13. Neumann JK, Olive KE. Absolute versus relative values: effects on family practitioners and psychiatrists. South Med J 2003;96:452-457.

14. Olive KE. Physician religious beliefs and the physician-patient relationship: a study of devout physicians. South Med J 1995;88:1249-1255.

15. Burrell G. Group psychotherapy in Project New Life: treatment of coronary-prone behaviors for patients who have had coronary artery bypass surgery, in Allan R, Scheidt S (eds): Heart and Mind: The Practice of Cardiac Psychology. Washington, DC, American Psychological Association, pp 291-310.

16. Kumanyika SK, Charleston JB. Lose weight and win: a church-based weight loss program for blood pressure control among black women. Patient Educ Counsel 1992;19:19-32.

17. Sevensky RL. Religion and illness: an outline of their relationship. South Med J 1981;74:745-750.

18. Levin JS, Vanderpool HY. Religious factors in physical health and the prevention of illness. Prev Hum Serv 1991;9:41-64.

19. Koenig HG, Cohen HJ, George LK, et al. Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. Int J Psychiatry Med 1997;27:233-250.

20. Weaver AJ, Flannelly KJ, Case DB, Costa KG. Religion and spirituality in three major general medical journals from 1998 to 2000. South Med J 2004;97:1245-1249.

21. Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet 1999;353:664-667.

22. Sherrill KA, Larson DB. Adult burn patients: the role of religion in recovery. South Med J 1988;81:821-825.

23. Levin JS, Lyons JS, Larson DB. Prayer and health during pregnancy: finding from the Galveston Low Birthweight Survey. South Med J 1993;86:1022-1027.

24. Matthews DA, Marlowe SM, MacNutt FS. Effects of intercessory prayer on patients with rheumatoid arthritis. South Med J 2000;93:1177-1186.

25. King DE, Wells BJ. End of life issues and spiritual histories. South Med J 2003;96:391-393.

26. American Religious Identification Survey. Accessed at http://www.gc.cuny.edu/studies/aris_index.htm on October 14, 2003.

Kenneth E. Olive, MD

From the Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Reprint requests to Dr. Kenneth Olive, Department of Internal Medicine, James H. Quillen College of Medicine, PO Box 70622, East Tennessee State University, Johnson City, TN 37614.