Abstract

In recent years there has been growing awareness regarding the role of religion and spirituality   (R/S) in the practice of clinical medicine. Despite hundreds of articles in professional journals on the subject, little is known about physician beliefs regarding the influence of religion on health. We aim to assess the beliefs and observations of physicians regarding the role of R/S and patient’s health and whether they address such issues in their clinical practice. Concomitantly, we aim to assess the beliefs of our patients and whether they like to address such issues. Questionnaire was based on a cross sectional survey among hospitalized patients and their treating physicians. Nearly all patients and physicians reported a high prevalence of religiosity. Patients also acknowledged that their R/S was respected by the staff, and that physicians inquired R/S about half of the time. R/S was described as beneficial as it enabled patients to cope better with their illness and gave them a positive state of mind. Religion is important to many patients and physicians, but half of the physicians ignore it in their clinical practice. Physicians need to be attentive to patients R/S issues and address them in specific clinical situations.

Ibrahim Med. Coll. J. 2010; 4(1): 4-8

Key words: Religion, spirituality, medicine, health, beliefs

Address for Correspondence: Dr. R M Yousuf, Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia

Introduction

The role of religion and spirituality (R/S) in clinical medicine has begun to be appreciated in recent years, largely from arguments that such activities improve health and well-being.1-4 R/S may mean different things to different people, but there is general agreement that both are related to the search for the sacred or transcendent, which includes concept of God, a higher power, the divine, and/or ultimate reality and their aims coincide with each other.5 Religion is an organized system of beliefs, practices, and rituals designed to facilitate closeness to the sacred or transcendent, while religiosity refers to the extent and degree of adherence of an individual towards the core values and beliefs of a religion. Spirituality refers to a person’s quest for understanding answers to ultimate questions about purpose of life, its meaning, and relationship with the sacred or transcendent.6 Cohen et al.7 suggest that the religious dimension may be one component of spirituality. The majority of researches today that talk about spirituality and its effects on health, in reality examine only religion. Surveys among general public and patients have consistently revealed that more than 90% of people believe in a higher being and that 96% of patients believe spiritual well being is a cardinal factor in health.4-9 Many patients have strong R/S beliefs that often influence them in making medical decisions.10-11 Until recently, assessing patients’ R/S beliefs was viewed as unnecessary and inappropriate, but many recent surveys suggest that the ‘religiosity gap’ between therapist and patient is narrowing.12 Many organizations in USA have stressed the need for addressing R/S issues in patient care as well as in training of healthcare professionals.13,14 This emphasises the need for a holistic understanding of the illness experience from the patient’s point of view. Koenig et al. have suggested that even in the absence of supporting evidence, it would still be permissible for physicians to recommend R/S activities to their patients, because such activities provide comfort.15 In Malaysia, R/S beliefs among physicians and patients are not known and the requests from patients for R/S input are similarly diverse. Virtually all of the research in this field has been with Western, largely Christian, populations. There is a need for more cross-cultural and cross-national studies on the subject in different countries. Assessment and support of R/S practices vary widely among physicians and to the best of our knowledge our study is the first to address such issues in Malaysia. The present study has some promise since it samples a population of patients and physicians who are multi-racial and multi-faith. We want to ascertain the prevalent R/S beliefs among patients and physicians and whether physicians like to address such issues in clinical practice.

Subjects and Methods

This was a questionnaire based cross sectional study among 280 hospitalized patients from Hospital Tengku Ampuan Afzan (HTAA) and their treating doctors (92) to inquire about their religious affiliation, beliefs and experiences regarding the role of R/S in specific clinical situations. Malaysia is a multi-racial, multi-religious, fast developing country where a western oriented information delivery policy is adopted in the medical curriculum. HTAA is an 800-bed, tertiary level state hospital in Pahang- the biggest state in Peninsular Malaysia with a population of about 1.6 million people. It is also the main teaching hospital for the medical faculty of the International Islamic University Malaysia (IIUM).

Patients were selected from different wards and disciplines conveniently. They were approached in person, provided with a brief description and aim of the study. Their consent was obtained before they were administered a simple, self reported questionnaire. The questionnaire consisted of two parts, the first being questions regarding patients’ demographic parameters and the second part regarding patients’ R/S beliefs. Two hundred eighty patients responded by filling the questionnaire out of 300 approached.

A similar self-reported questionnaire based study of physicians from the same hospital was conducted and questions were framed on similar issues. They were approached individually, provided with a brief description and aim of the study and requested to fill up the questionnaire form at their leisure. The forms were collected again after contacting the respondents. Ninety two physicians responded by filling the questionnaire out of 110 approached.

Physicians and patients’ responses were compared on individual items and composite scores were derived from subset of items relevant to R/S. Statistical analysis was done using the Statistical Package for Social Sciences (SPSS), Version 12 available at the faculty of medicine IIUM. Chi-square test was used to compare the proportions between the doctors and patients and a p-value of less than 0.05 was taken as being statistically significant.

Results

Of the 92 participant physicians (men 61, women 31), the majority were Muslim (53), followed by Hindu (17) and Buddhist (12). Table 1 summarises the beliefs of the physicians towards R/S. Table 2 depicts the physicians clinical practices/observations. Most physicians reported a high prevalence of religiosity and were inquisitive but respectful of patients’ R/S issues. About two thirds (65%) did encourage R/S practices and 54% would do so irrespective of R/S beliefs of their patients. Of the 280 participating patients (men 176, women 104), 75% were Muslims and 11% were Buddhists, and the rest were from Christian and Hindu religion. Regarding education, 80% were from primary and secondary and 5.7% were from tertiary level and 13.3% were illiterate. Patients reported high religiosity, acknowledged that their R/S was respected by the staff, and that physicians inquired about half of the time about R/S (Table 3). About half of the patients could not recall any inquiry by physicians about religious issues. About 79% patients noticed increase in faith due to illness and wanted religious counselor to help them rather than a psychiatrist. Table 4 compares the religiosity of HIV/AIDS patients relative to rest of the patients. It was found that patients in HIV/AIDS category, 22.1% had never performed meditation or Salat as against 24.7% who had daily performance of meditation or Salat.

Table-1: Belief of physicians

Table-2: Physician’s clinical practices/experiences

Table-3: Belief of patients

Table-4: Religiosity among HIV/AIDS patients compared to all other patients

Discussion

In general, research has shown R/S positively affects physical and mental health and the findings apply across boundaries and religions.1,4,16-18 Physicians in our sample were in agreement that religion has a positive impact on health. 85% of our patients who used prayer for their health concerns reported high levels of perceived helpfulness as has been reported by earlier studies.19 R/S beliefs and practices are associated with not only lower anxiety, lesser degree and frequency of depression, lower suicide rates, less substance abuse, but also help patients to cope better with greater wellbeing, hope and optimism, more purpose and meaning in life, greater marital satisfaction and higher social support.1,20 R/S practices are also statistically significant in coping with a terminal illness.21 Many prospective studies have also shown that R/S involvement lead to reduced death rates from cancer, lower rates of heart disease, emphysema and cirrhosis; lower blood pressure and lower levels of cholesterol, reduced rates of myocardial infarction and increased longevity.11,22-24 Religion serves an important preventive role, as most religions discourage or as in the case of Islam altogether ban alcohol and drug abuse. Many studies have found inverse relationship between religiosity and substance abuse.21,25,26 According to a report by the Center for Harm Reduction in Australia’s Burnet Institute based on illicit drug and injection safety study of 20 Asian countries, drug use has become one of the major causes of the HIV epidemic in Asia. Most (81.5%) of the HIV infected persons were young males (age 20-40 years) - people in their prime of life.27 Among our patients 27.5 % had HIV/AIDS, 88.3% of whom were young IVDUs with mean age of 34 ±7 years. They were least religious as depicted by their religious activities (p<0 .001). When asked whether they were told their diagnosis and how they felt about it, many of them responded by saying “Don’t bother.” Drug abuse renders a person a diseased member of society and may result in the destruction of the family, and commit various types of crime, homicide and suicide.

Out of 92 physicians, two thirds reported that they do encourage R/S practices. However majority of patients could not recall any inquiry by doctors about such issues. Why do physicians resist discussing R/S issues? Many possible explanations have been given. Lack of time to discuss, lack of training in obtaining a R/S history and difficulty in identifying patients who want to discuss R/S issues, are some of the reasons put forth.14,28 To reduce the impact of such taboos, a number of commentators have argued that medical training should include R/S issues, including knowledge of major religions.15,29 Students should include the R/S dimension in history-taking. The American Counseling Association (ACA) Code of Ethics (2005) provides ethical guidelines for the integration of spirituality into the counseling process in a variety of aspects. More than 80 US medical schools now offer courses on R/S as part of their curriculum.30 A recent initiative from the Scottish executive health department makes spiritual care a central element of the way their National Health Service cares for people.31 Because the concept of spirituality is becoming more widely accepted as an integral component of counseling and multicultural and diversity training, guidance in the use of spirituality assessment will become not only useful but imperative to the clients’ lives with whom the counselors work.32

Conclusion

Physician is not just a dispenser of medicine but a value maker, having ethicist, social force and political influence in the life of his patients. Religion and spirituality deserve attention in professional practice, as it appears to have a positive influence on patients’ health. It may also go a long way in making the practice of medicine more holistic, ethical and compassionate. It will also strengthen medical students in their commitment as caring doctors.

Acknowledgment

This research was conducted under a short term research grant from the Research Centre of IIUM. We thank the director of HTAA in Kuantan for allowing us to interview the patients.

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