Religion and spirituality in three major general medical journals from 1998 to 2000.

Objectives: Religion and spirituality provide the means by which many individuals and their families cope with illness. Moreover, there is evidence to suggest that health outcomes may be influenced by patients' religious beliefs, attitudes, and behavior.

Methods: We examined three representative nonspecialty journals (Journal of the American Medical Association, Lancet, and the New England Journal of Medicine) between 1998 and 2000 for references to the role of religion/spirituality. Of the 2,385 studies found, only 20 (0.8%) examined some aspect of spirituality (n = 5), religion (n = 13), or both (n = 2). Spirituality was treated as a dependent variable in all seven articles in which it was studied.

Results: The effect of religion was analyzed in 11 of the 15 articles in which it was measured, and its effect was statistically significant in 8 of the 11 studies in which it was analyzed.

Conclusions: Although religious variables were a key element of most of the studies in which they were measured, overall, little attention appears to be paid to these concepts in general medical journals, even though they may be useful for refining outcomes research.

Key Words: effects of religion, medical journals, research, spiritual care

**********

Gallup polls conducted since the 1960s have found high rates of religious involvement and commitment among Americans, (1) and religious beliefs and practices are commonly used to cope with stress and illness. (2-4) Recently, an article in the New England Journal of Medicine reported that 90% of Americans turned to religion as a coping response after the terrorist attacks on September 11, 2001. (5) Research also indicates that religious faith can influence the progress of and recovery from illness. (6) A 1999 nationwide survey of physicians found that 81% of them thought that "better clinical outcomes can result directly from a patient's spirituality." (7) A full 91% agreed that "it is important for doctors to understand the religious beliefs and spiritual practices of their patients." In a similar study, a survey of British physicians found that 72% of them saw religion as a resource for their patients. (8) Given the importance of religion and spirituality from both patients' and physicians' perspectives, one might expect to find medical studies including some assessment of the effects of religion/spirituality, especially in areas such as end-of-life care, (9,10) physician assisted suicide (PAS), (11) cancer treatment and survival, (12) and acute or terminal illnesses. (6) This study was undertaken to develop an understanding of how often studies in general medical journals sought to take into account the role of religion or spirituality. The Journal of the American Medical Association, Lancet, and the New England Journal of Medicine were selected for study because they were recently ranked as the three most influential medical journals in print (based on the frequency of their citations in the scientific literature), with a cumulative circulation of 591,042. (13)

Materials and Methods

The sample for the study consisted of all original research studies using quantitative methods that were published in the Journal of the American Medical Association, Lancet, and the New England Journal of Medicine from January 1998 through December 2000. Each article was read by two judges to see if it contained a measure of spirituality or religion, (12,14-17) including religious affiliation, religious beliefs (ie, belief in God), and religious practices (eg, prayer, church attendance). Studies containing a measure of religion or spirituality were categorized in 4 ways: (1) the type of topic addressed by the study; (2) the type of religious or spiritual variable measured; (3) whether these variables were statistically analyzed; and (4) whether citations about religion/spirituality were included in the reference list. Occasional disagreements between the judges were resolved by mutual consent. The analysis was restricted to quantitative research studies to allow the comparisons of findings to other systematic reviews of the literature that examined research on the same variables in other healthcare fields. (12,14-20)

Results

Over a period of 3 years, the three selected journals published a total of 2,385 quantitative studies that included at least a single descriptive statistic used in the methods and results section. Of the 2,356 studies we examined, 20 (0.8%) measured some aspect of spirituality (n = 5), religion (n = 13), or both (n = 2).

Topics covered

The studies fell into four topical areas: end-of-life issues (n = 8); alternative medicine (n = 4); specific medical diseases (n = 7); and other (n = 1), that is, the psychologic sequelae of torture among refugees. The eight studies that dealt with end-of-life issues included five that documented patient and/or physician attitudes about euthanasia/PAS. One of the other three studies on end-of-life issues examined the extent to which such issues are covered in medical education, another documented the types of nonphysician medical care that are given to terminally ill patients, and the last asked patients, families, and physicians what were their greatest concerns. Among the four that examined alternative medicine were two that looked at factors that contribute to its use, one that looked at trends in its use in the United States, and one that surveyed US medical schools about courses they offered that covered alternative medicine. Six of the seven articles examined religion in relation to specific diseases studied in populations outside the United States. (21-26)

Variables measured

Religious denomination was the only religious variable used in 8 of the 15 studies in which religion was measured. In the seven remaining studies, religious denomination was measured along with one or two other measures of religion. (27-33) Spirituality was measured as a dependent variable in all seven studies that examined it. Five of the seven studies that measured spirituality dealt with alternative medicine, (9,35-37) including three that examined the use of spiritual therapy (34-36) and two that examined spirituality in medical courses (37) or textbooks. (9)

Only 1 (33) of the 20 studies in the sample used a multiple item scale of religion/spirituality, and only 1 of the 20 studies contained a citation in its reference list that mentioned religion in its title. (21) No inferential statistics were provided for any of the measures of spirituality.

Effects of religion

Of the 15 studies that measured religion, 11 included 1 or more religious variables in their statistical analyses, treating them as independent variables or covariates. These 11 studies are listed in Table 1. All five studies of PAS analyzed the effects of religion, and in each case, one or more significant religious effects were found. (28,29,31,32,38) In the four studies that focused on physicians, higher levels of religiousness were associated with lower levels of participation in assisted suicide. (28,29,32,38) In a similar vein, patients who were more religious were less likely to consider assisted suicide. (31) In related work, Steinhauser et al (33) found that people who were more religious were less likely to desire to have control over their time and place of death. Two other findings of the Steinhauser et al (33) study also are of interest. When asked to rate the importance of different attributes at the end of life, 85% of patients rated prayer and 89% rated being at peace with God as being very important to them. By contrast, 55% of physicians rated prayer and 65% rated being at peace with God as very important. The other studies in Table 1 present a potpourri of findings. (39)

Table 2 compares the current study with similar reviews published in clinical specialties journals. (40,41) The use of religious/spiritual variables in the current study is less than that found in psychiatry, (14,17) gerontology, (15) family medicine, (41) and psychology (18) and much lower than in adolescence journals, (20) marriage and family therapy, (19) oncology, (12) and mental health nursing. (42)

Discussion

Our review of three major general medical journals found relatively few studies published between 1998 and 2000 that measured some aspect of religion or spirituality. The percentage of quantitative studies that contained a religious or spiritual variable (0.8%) was lower than that found in similar systematic reviews of journals in other clinical disciplines (12,18-20,42) and medical specialty journals. (14,15,17) The medical studies we reviewed were not only less likely to use multiple measures of religion/spirituality, (12,42,16,19) they were less likely to cite published research on religious/spiritual factors than studies in medical specialty journals (14,15,17) or other healthcare fields. (12,19,20,42)

Of the 15 studies in our survey that measured religion, only 11 of them statistically analyzed its effects. Religious affiliation, which has been the most common measure of religion in medical research (14,15,43) and nursing research, (12,16) was analyzed in 10 of the 11 studies.

The most common area of study involving religion in the articles we examined was assisted suicide. We found five studies in this area, including four studies of physicians and one study of patients. Three of the four studies of physicians found that those who reported being more religious according to the measures used were less likely to perform PAS (28,29,32) or other activities that could shorten life, and the other study (38) found that physicians who did not belong to any religion were more likely to engage in activities that could shorten life. From the patient perspective, Ganzini (31) found that patients who were more religious and/or were church members were less likely to consider assisted suicide.

Although our review was intensive, in that we examined every published article, the results are limited to a rather narrow time frame. Since editorial policies and research interests change over time, a wider time frame may have yielded different results. An examination of a wider range of journals may also affect the results, especially if the results reflect editorial policy. Although we compare the percentage of articles on religion/spirituality in the present sample to that found in specialty medical journals and other disciplines, it would be informative to directly compare different types of journals over the same time period.

Conclusion

With the rising interest in spirituality and health, (44) one wonders why so few studies in these three journals examined spirituality or religion. Since there is no evidence that it is due to editorial policies, it may be due to research interest or the lack thereof. Researchers may not think religion/spirituality will have an effect on the dependent variable or variables of interest, so they do not measure them to look at their possible influence. At the same time, researchers studying end-of-life issues certainly appear to recognize the importance of religion and they analyze its effects. (28,29,31-33,38) However, most use rather simple measures, such as religious affiliation, suggesting that they are unaware of the more sophisticated measures that are available. (45) The relatively small number of citations of articles concerning religion also suggests a lack of knowledge. Lack of knowledge about suitable measures of spirituality could also help account for the lack of research on it, but this does not explain why it is studied more often in other fields. To the degree that religion and spirituality influence health, and they clearly do to some extent, (6) researchers should consider their influence. But, to do so, they must first familiarize themselves with the relevant literature and the tools that are available for measuring these concepts.

CME Evaluation Form

CME Credit--December 2004

Featured CME Topic: Spirituality

To receive a CME certificate for 1 category 1 credit toward the AMA Physician's Recognition Award, complete all sections of this form and mail it with a check (payable to SMA) for $15 ($30 for nonmembers) to: Publications Department, SMA, PO Box 190088, Birmingham, AL 35219-0088. The completed form and your check must be received by December 1, 2005. If you wish to preserve your Journal, it is permissible to submit a photocopy of this page. You may also submit your form online at www.sma.org.

[GRAPHIC OMITTED]

Three o'clock is always too late or too early for anything you want to
do.
--Jean-Paul Sartre

Table 1. Studies that measured religion and statistically tested its
effects (a)

                                                    Religious
Study                          Sample               measure

Cuttini et al (2000) (28)      Physicians           Denomination
                                                    Importance of
                                                      religion
Deliens et al (2000) (38)      Physicians           Denomination
Emanuel et al (1998) (29)      Physicians           Denomination
                                                    Religiousness
Meier et al (1998) (32)        Physicians           Denomination
                                                    Prayer
Ganzini et al (1998) (31)      Patients             Importance of
                                                      religion
                                                    Religion practices
                                                    Church membership
Steinhauser et al (1999) (33)  Family, Patients     Denomination
                                 and Physicians     Religiosity
Shrestha et al (1998) (39)     Refugees (tortured)  Denomination
Hawkes et al (1999) (40)       Patients             Denomination
Emanuel et al (1999) (30)      Patients             Denomination
                                                    Religiousness
Dandona et al (1998) (22)      General public       Denomination
Cramer et al (1995) (27)       Patients             Denomination

                               Statistically
Study                          significant    Effects

Cuttini et al (2000) (28)         No          No significant effect on
                                                PAS and related actions
                                  Yes         PAS is lower for those
                                                rating religious
                                                importance higher
Deliens et al (2000) (38)         Yes         Nonreligious more likely
                                                to take action that can
                                                shorten life
Emanuel et al (1998) (29)         No          No significant effect on
                                                performance of PAS
                                  Yes         More religious less likely
                                                to perform PAS
Meier et al (1998) (32)           Yes         Denominational difference
                                                in performing PAS
                                  Yes         Those who pray less
                                                performed more PAS
Ganzini et al (1998) (31)         Yes         Higher ratings of
                                  Yes           importance and practices
                                                associated with lower
                                                likelihood of
                                                considering assisted
                                                suicide
                                  Yes         Members less likely to
                                                consider assisted
                                                suicide
Steinhauser et al (1999) (33)     Yes         Denominational differences
                                                in desire to die at home
                                  Yes         Religious less likely to
                                                want control over place
                                                of death
Shrestha et al (1998) (39)        Yes         Being Buddhist was
                                                predictor of less PTSD,
                                                depression, and anxiety
                                                because fewer Buddhists
                                                in tortured sample
Hawkes et al (1999) (40)          Marginal    Denominational differences
                                                in endogenous infections
Emanuel et al (1999) (30)         No (b)      Members of a religious
                                  No (b)        community and those who
                                                are religious are not
                                                more likely to have
                                                volunteer assistance
Dandona et al (1998) (22)         No           No effect on rate of
                                                blindness in India
Cramer et al (1995) (27)          Yes (b)     Being Catholic influenced
                                                use of analgesics

(a) PAS, physician-assisted suicide; PTSD, post-traumatic stress
disorder.
(b) No data presented.

Table 2. Studies containing religious variables by clinical specialties,
as found by several systematic literature reviews of various health care
fields

                                 Percentage
                                 containing a         Years
Clinical specialty               religious variable   examined

Family medicine (41)                   3.5            1976-1986
Psychiatry (14)                        2.5            1978-1982
Gerontologic nursing (16)              6.8            1991-1997
Gerontology (15)                       3.6            1985-1991
Oncology nursing (12)                 14.1            1990-1999
Psychology (18)                        2.7            1991-1994
Psychiatry (17)                        1.2            1991-1995
Mental health nursing (42)            10.0            1991-1995
Adolescence (20)                      11.8            1992-1996
Marriage and family (19)              13.2            1995-1999
General medical (current study)        0.8            1998-2000

Accepted September 30, 2003.

Please see Dana E. King's and Kennerth E. Olive's editorials on pages 1150 and 1152 of this isue.

Selected Resources

Boykin K, May GG. Zen for Christians: A Beginner's Guide. John Wiley & Sons Inc., 2003.

Center for Spirituality, Theology, and Health: www.dukespiritualityandhealth.org

Ciarrocchi JW. The Doubting Disease: Help for Scrupulosity and Religious Compulsions. Paulist Press, 1996.

Fitchett G. Assessing Spiritual Needs: A Guide for Caregivers. Academic Renewal Press, 2002.

Friedman DA. Jewish Pastoral Care: A Practical Handbook from Traditional and Contemporary Sources. Jewish Lights Publishing, 2000.

Hill PC, Hood RW (eds): Measures of Religiosity. Religious Education Press, Inc, 1999.

Koenig HG. Is Religion Good for Your Health: The Effects of Religion on Physical and Mental Health. Haworth Press, Inc, 1997.

Koenig HG, Weaver AJ. Counseling Troubled Older Adults: A Handbook for Pastors and Religious Caregivers. Abingdon Press, 1997.

Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health: A Century of Research Reviewed. Oxford University Press, 2000.

Koenig HG, Cohen HJ. Link between Religion and Health: Psychoneuroimmunology and the Faith Factor. Oxford University Press, 2001.

Koenig HG. Spirituality in Patient Care: Why, How, When, and What. Templeton Foundation Press, 2002.

McMinn M, Phillips TR (eds): Care for the Soul: Exploring the Intersection of Psychology and Theology. Inter-Varsity Press, 2001.

Miller WR (ed): Integrating Spirituality into Treatment: Resources for Practitioners. American Psychological Association, 1999.

Pargament KI. The Psychology of Religion and Coping: Theory, Research, Practice. Guilford Publications, Inc, 2001.

Richards PS, Bergin AE. Handbook of Psychotherapy and Religious Diversity. American Psychological Association, 1999.

Shafranske E, Jacobson JW (eds): Religion and the Clinical Practice of Psychology. American Psychological Association, 1996.

Spilka B, Hunsberger B, Gorsuch R, Hood RW. Psychology of Religion: An Empirical Approach. Guilford Publications, Inc, 2003.

Stone HW. Caring Church: Guide for Lay Pastoral Care. Augsburg Fortress, 1999.

Sullender RS. Losses in Later Life: A New Way of Walking with God. Haworth Press, Inc, 1999.

Switzer DK. Pastoral Care of Gays, Lesbians, and Their Families. Augsburg Fortress, 2000.

Weaver AJ, Preston JD, Jerome LW. Counseling Troubled Teens and Their Families: A Handbook for Pastors and Youthworkers. Abingdon Press, 1999.

Weaver AJ, Furlong M (eds): Reflections on Forgiveness and Spiritual Growth. Abingdon Press, 2000.

Weaver AJ, Revilla LA, Koenig HG. Counseling Families across the Stages of Life: A Handbook for Pastors and Other Helping Professionals. Abingdon Press, 2002.

Weaver AJ, Flannelly LT, Flannelly JD. Counseling Survivors of Traumatic Events: A Handbook for Pastors and Other Helping Professionals. Abingdon Press, 2003.

References

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2. Guillory JA, Sowell R, Moneyham L, et al. An exploration of the meaning and use of spirituality among women with HIV/AIDS. Altern Ther Health Med 1997;3:55-60.

3. Kaplan MS, Marks G, Mertens SB. Distress and coping among women with HIV infection. Am J Orthopsychiatry 1997;67:80-91.

4. Koenig HG, Pargament KI, Neilson J. Religious coping and health status in medically ill hospitalized older adults. J Nerv Ment Dis 1998;186:513-521.

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11. Cavalieri TA, Pomerantz SC, Ciesielski J, et al. Attitudes of osteopathic physicians toward physician-assisted suicide. J Am Osteopath Assoc 2002;102:27-34.

12. Flannelly LT, Flannelly KJ, Weaver AJ. Religious and spiritual variables in three major Oncology nursing journals: 1990-1999. Oncology Nursing Forum 2002;29:679-685.

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15. Sherrill KA, Larson DB, Greenwold M. Is religion taboo in gerontology? Am J Geriatr Psychiatry 1993;1:109-117.

16. Weaver AJ, Flannelly LT, Flannelly KJ. A review of research on religious and spiritual variables in two primary Gerontological nursing journals: 1991-1997. J Gerontol Nursing 2001;27:335-340.

17. Weaver AJ, Samford J, Larson DB, et al. A systematic analysis of research on religious variables in four major psychiatric journals: 1991-1994. J Nerv Ment Dis 1998;186:187-190.

18. Weaver AJ, Kline AE, Samford J, et al. Is religion taboo in psychology? A systematic analysis of research on religion in seven major American Psychological Association journals: 1991-1994. J Psychol Christianity 1998;17:222-234.

19. Weaver AJ, Samford JA, Morgan VJ, et al. A systematic review of research on religion in six primary marriage and family journals: 1995-1999. Am J Fam Ther 2002;30:293-309.

20. Weaver AJ, Samford JA, Morgan VJ, et al. Research on religious variables in five major adolescent research journals: 1992-1996. J Nerv Ment Dis 2000;188:36-44.

21. Anand SS, Salim Y, Vuksan V, et al. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: the Study of Health Assessment and Risk in Ethnic Groups (SHARE). Lancet 2000;356:279-284.

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27. Cramer DW, Harlow BL, Titus-Ernstoff L, et al. Over-the-counter analgesies and risk of ovarian cancer. Lancet 1998;351:104-107.

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44. Weaver AJ, Flannelly L, Oppenheimer JE. Religion, spirituality, and chaplains in the biomedical literature: 1965-2000. Int J Psychiatry Med 2003;33:155-161.

45. Hill PC, Hood RW Jr (eds): Measures of Religiosity. Birmingham, AL, Religious Education Press, 1999.

RELATED ARTICLE: Key Points

* Evidence suggests that health outcomes may be influenced by patients' religious beliefs, attitudes, and behavior.

* Three medical journals (Journal of the American Medical Association, Lancet, and the New England Journal of Medicine) were examined between 1998 and 2000 for reference to the role of religion/spirituality.

* Of the 2,385 studies found, only 20 examined some aspect of spirituality or religion.

* Little attention was paid to the concepts of religion and spirituality in these journals, even though these factors may be useful for refining outcomes research.

Andrew J. Weaver, MTH, PHD, Kevin J. Flannelly, PHD, David B. Case, MD, MACP, and Karen G. Costa, BA

From the HealthCare Chaplaincy, and Weill Medical College of Cornell University, New York, NY.

Reprint requests to Dr. Andrew J. Weaver, 260 18th Street, #2, Brooklyn, NY 11215. Email: [e-mail]