Impact of Religion/Spirituality on Health: What are the Evidences?

From advancement of mechanistic view of human body to shifting paradigm of evaluation in medicine, world has changed a lot in last two decades in terms of visualizing a person as One Whole Being. Recently many studies have evolved with a question of spirituality benefits on health. Articles largely concentrated on reduction of physical as well as mental symptoms through association with religious practices. On the other hand, some argue on its association considering error in research designs and bias in studies which have linked positive correlation between religion and health. This review article has considered both accounts of objections as well as neutral studies along with recent developments, which is basically integration of spirituality into medical curriculum. Why it is now gaining attention? Why in need of most of the distressed patients? How religion affects coping and perception of a person and help in crisis? Current approach is critically analyzed for further studies to establish ambiguity in many areas and discussed benefits as how health system can be improved through incorporation of spiritual aspect into health assessment. Health of mind and body Ancient Greek period focused body and mind using two approaches (1) the materialist; stating matter, or brain (2) the personalist; central in the person is the core called the soul, self, or ego states i.e., thought and emotion. In most cultures of the world, both in ancient and in modern times care for the soul and body were integrated aspect of any culture. Those who were assigned to the care of people in the culture attended to both their physical and spiritual needs; there were no dichotomy between the needs of the body and the needs of the spirit. In many ancient cultures, the shaman was a religious figure as well as healer also in Christianity; Jesus was a healer of body and spirit. In last few decades, this separation has developed that resulted in religiosity that is solely dedicated for spiritual concerns, while physicians and scientists, to the physical one [1,2]. Rene Descartes, a seventeenth-century philosopher who believed in mechanical laws and gave little or no concern to meaning. His ideologies are dealing with rupture of body and spirit, the healing picture which came to surface contained detached body and soul [3]. Due to rapid succession of discoveries in last couple of decades and progression of neuro-anatomy, neurophysiology and micro-biology, the brain and behavior discussions got a new vision; vision of machine, science and objectivity. By the time, old belief of spiritual highness and intellectual well-being were overshadowed by molecular sciences [Freud et al., 1895]. The authors of the Persuasion and healing holds that effort should be made to steer between doubt and the acceptance. Too much “skepticism” dependent upon standardized scientific methods can miss real phenomena, while too enthusiastic “willingness” to accept every subjective finding may lead to false results. Remen, who has developed Commonweal Retreats for people with cancer, described it well: “Helping, fixing, and serving represent three different ways of seeing life. When you help, you see life as weak. When you fix, you see life as broken. When you serve, you see life as whole. Fixing and helping may be the work of the ego, and service the work of the soul.” [4,5]. Every person has his/her own life stories, relationships, meanings and purpose of life, simply treating a medical diagnosis is not more than approaching a patient with materialist approach only [6] or in another word devaluing him/her from existential connection with others. Significance of religion/spirituality in life Religion deals with external functions and apparent code of conduct while spirituality concerns with esoteric dimensions of personality like finding serenity with nature or with surrounding and with God, also to explore out meaning and motives of life. The main features of spirituality as defined by Martsolf and Mickley [7] are meaning, connecting, transcendence and value. Similarly, William James [8] has also distinguished an experiential religion from an Institutional religion with intrinsic and extrinsic meaning respectively. Simpson and Weiner [9], in the Oxford English Dictionary, offers two related themes .First, spirituality refers to life’s most vital issues and concerns (e.g., the term spiritus in Latin means “the breath,” most vital to life). Second, spirituality is seen as subjective features of life including the senses, such as sight and hearing. The Association of American Medical Colleges defines spirituality as a broad one: “Spirituality is recognized as a factor that contributes to health in many persons. The concept of spirituality is found in all cultures and societies. It is expressed in an individual’s search for ultimate meaning”. Anandarajah [10,11] explained that important aspects of spirituality are love and peace that individuals derive from their relationships, nature and God. Spirituality can be described as latent constructs; as it cannot be observed directly but can be inferred from some of their elements [12]. Journal of Psychiatry Jawaid, J Psychiatry 2014, 17:6 http://dx.doi.org/10.4172/1994-8220.1000164 Review Article Open Access J Psychiatry Journal of Psychiatry, an open access Volume 17 • Issue 6 • Psychiatry-14-111 More than an objective definition, the concept of health has emerged ahead of biological functioning, influenced by cultural, social, and philosophical factors, including purpose in life and the quality of healthy personal relationships [13]. Although researches helped out a lot in sorting out spirituality role but it will take many more years to understand different aspects of spirituality to unfold some of medicine’s greatest mysteries Evidence based association between spirituality and health When a person gets ill, he/she experiences stress over the changes in life then eventually looks for evident reasons or solutions for cure, and when the medical system fails to do so, then patient begins to look towards spirituality for healing in other way. Those who were not religious previously may turn to religion for comfort and acquired it as a new method of coping. In 1974, Benson found that 10 to 20 minutes of meditation twice a day leads to decreased metabolism, decreased heart rate, decreased respiratory rate, and slower brain waves, the practice was beneficial for the treatment of chronic pain, insomnia, anxiety, hostility, depression, premenstrual syndrome, and infertility and was a useful adjunct to treatment for patients with cancer or HIV. The personal beliefs influence illness prevention, coping, recovery, and illness experience. Patients showed less psychological distress if they connect with God in hope for healing and relaxation, most of them report strength and comfort from their spiritual beliefs [14,15].

In most cultures of the world, both in ancient and in modern times care for the soul and body were integrated aspect of any culture. Those who were assigned to the care of people in the culture attended to both their physical and spiritual needs; there were no dichotomy between the needs of the body and the needs of the spirit. In many ancient cultures, the shaman was a religious figure as well as healer also in Christianity; Jesus was a healer of body and spirit. In last few decades, this separation has developed that resulted in religiosity that is solely dedicated for spiritual concerns, while physicians and scientists, to the physical one [1,2].
Rene Descartes, a seventeenth-century philosopher who believed in mechanical laws and gave little or no concern to meaning. His ideologies are dealing with rupture of body and spirit, the healing picture which came to surface contained detached body and soul [3].
Due to rapid succession of discoveries in last couple of decades and progression of neuro-anatomy, neurophysiology and micro-biology, the brain and behavior discussions got a new vision; vision of machine, science and objectivity. By the time, old belief of spiritual highness and intellectual well-being were overshadowed by molecular sciences [Freud et al., 1895].
The authors of the Persuasion and healing holds that effort should be made to steer between doubt and the acceptance. Too much "skepticism" dependent upon standardized scientific methods can miss real phenomena, while too enthusiastic "willingness" to accept every subjective finding may lead to false results. Remen, who has developed Commonweal Retreats for people with cancer, described it well: "Helping, fixing, and serving represent three different ways of seeing life. When you help, you see life as weak. When you fix, you see life as broken. When you serve, you see life as whole. Fixing and helping may be the work of the ego, and service the work of the soul." [4,5].
Every person has his/her own life stories, relationships, meanings and purpose of life, simply treating a medical diagnosis is not more than approaching a patient with materialist approach only [6] or in another word devaluing him/her from existential connection with others.

Significance of religion/spirituality in life
Religion deals with external functions and apparent code of conduct while spirituality concerns with esoteric dimensions of personality like finding serenity with nature or with surrounding and with God, also to explore out meaning and motives of life. The main features of spirituality as defined by Martsolf and Mickley [7] are meaning, connecting, transcendence and value. Similarly, William James [8] has also distinguished an experiential religion from an Institutional religion with intrinsic and extrinsic meaning respectively. Simpson and Weiner [9], in the Oxford English Dictionary, offers two related themes .First, spirituality refers to life's most vital issues and concerns (e.g., the term spiritus in Latin means "the breath," most vital to life). Second, spirituality is seen as subjective features of life including the senses, such as sight and hearing. The Association of American Medical Colleges defines spirituality as a broad one: "Spirituality is recognized as a factor that contributes to health in many persons. The concept of spirituality is found in all cultures and societies. It is expressed in an individual's search for ultimate meaning". Anandarajah [10,11] explained that important aspects of spirituality are love and peace that individuals derive from their relationships, nature and God. Spirituality can be described as latent constructs; as it cannot be observed directly but can be inferred from some of their elements [12].
More than an objective definition, the concept of health has emerged ahead of biological functioning, influenced by cultural, social, and philosophical factors, including purpose in life and the quality of healthy personal relationships [13]. Although researches helped out a lot in sorting out spirituality role but it will take many more years to understand different aspects of spirituality to unfold some of medicine's greatest mysteries

Evidence based association between spirituality and health
When a person gets ill, he/she experiences stress over the changes in life then eventually looks for evident reasons or solutions for cure, and when the medical system fails to do so, then patient begins to look towards spirituality for healing in other way. Those who were not religious previously may turn to religion for comfort and acquired it as a new method of coping.
In 1974, Benson found that 10 to 20 minutes of meditation twice a day leads to decreased metabolism, decreased heart rate, decreased respiratory rate, and slower brain waves, the practice was beneficial for the treatment of chronic pain, insomnia, anxiety, hostility, depression, premenstrual syndrome, and infertility and was a useful adjunct to treatment for patients with cancer or HIV. The personal beliefs influence illness prevention, coping, recovery, and illness experience. Patients showed less psychological distress if they connect with God in hope for healing and relaxation, most of them report strength and comfort from their spiritual beliefs [14,15].

Positive outcomes
A number of studies suggest reduced mortality for population who are frequently attending religious services compared to those who do not attend. The 12-step program Alcoholics Anonymous lists as one of the 12 steps as: "[we] came to believe that a power greater than ourselves could restore us to sanity" [16][17][18]. With further exploration it was found out that meditation is a good therapy for chronic conditions such as headaches, anxiety, depression, premenstrual syndrome, AIDS, and cancer. Benson's relaxation response elicited by a simple two-step procedure: (a) Repeating a word or muscular activity (b) Passively ignore any other obtrusive thoughts and returning to the repetition.
In 2008, Pargament investigated factors such as heart disease, dyslipidemia, hypertension, cancer and mortality have inverse relationship with religious behaviors. Across every health domain, every predominant religion and spirituality has its own measure of involvement, most notably, frequency of church attendance. Growing literature suggested strong coping in adolescent religious patients with medical conditions such as arthritis, diabetes, renal disease, cancer, cardiovascular disease, pulmonary disease, HIV/AIDS, cystic fibrosis, sickle cell anemia, amyotrophic lateral sclerosis, chronic pain, and terminal illnesses. In 1995, McCullough reviewed effect of religious behavior on neuro-immunologic, cardiovascular, and musculoskeletal changes. Other than these findings better immune function, lower death rates from cancer, better cardiac outcomes, lower blood pressure, lower cholesterol and less cigarette smoking, more exercise and better sleep was also marked in his book called "Handbook of religion and health" [19][20][21][22][23].

Local findings
The study by Qidwai et al. [24] was conducted in 2008 represented majority of the respondents (95.8%) believed -prayers can heal. Three fourth (75.3%) of them believe that prayers can curtail the duration of disease, 49% believed that illness does not prolong by prayers. It is equally important to realize that 160 (40%) participants believed that prayers can prolong life. Methods used for healing by study participants, include: reciting verses from Holy Quran, blowing them on water and then drinking it and wearing of taweez (amulet) which is thought to speed up healing process.

Psychological/mental health associations with spirituality
Emmons (1999) observed that through stressful hours, religious adherence can provide stability, support, and direction to find an ultimate purpose and meaning in life. Spirituality orientations can shape efficient methods for coping that linked to better mental health [25,26]. In a study by Baetz et al. [27], religious attitudes were attributed to greater life satisfaction. Increased satisfaction was predicted by Worship-attendance frequency. Increased Alcohol use was inversely proportional to Worship-attendance frequency. Spiritual well-being is positively associated with quality of life, decreased episodes of depression, anxiety and cognitive avoidance [28].

Negative outcomes
Whether religious beliefs and practices are actually effective in helping people to cope? It was a complete "No" by 20th century professionals. Religion regarded as irrelevant to health, even extended to become a cause of neurosis [29,30]. Rosenstiel and Keefe found that spirituality has been found to be related to higher pain levels. When patients are hospitalized they often ask the question, "why me?", as prayers for healing and relief go unanswered, they ask "Is God punishing me for my sins"? Patients usually get "stuck" in these spiritual struggles and without help are unable to resolve them on their own. In turn they avoid spiritual beliefs to rely on that might otherwise give them comfort and hope.

No association
In 1872, Galton published a retrospective study of the effects of prayer on the health of clergy. Galton concluded that there were no benefits also cited an earlier study which concluded that the many prayers offered for the good health of British monarchs afforded them no increased longevity. In other studies, spirituality was shown to be unrelated to pain severity, pain distress, and the disruption of activities by pain [38].

Why spirituality was ignored?
Psychologists and other social scientists have generally kept their distance from religion and spirituality. Few professional training programs in psychology address religious and spiritual issues [39,40]. In general, clinicians appear to have little to do with religious leaders and institutions [28]. The polarization of religion and spirituality into institutional and individual domains has jeopardized the understanding of personal affairs [41].
Possible reasons for the neglect are: (a) It is less central (Bergin, 1991; "Politics of the Professorate," Shafranske) (b) Outside the scope of scientific study [42] (c) Should necessarily move away during an age of rational enlightenment [43,44].
Health professionals often undervalue the role that religion has on patients' medical decisions. More recently, the Journal of Clinical Oncology published a survey of 100 patients with advanced lung cancer, their caregivers, and 257 medical oncologists attending the annual meeting of the American Society of Clinical Oncology. In this study, investigators asked participants to rank the importance of factors that might influence chemotherapy treatment decisions. Patients and family members have ranked faith in God as second most important factor but Oncologists ranked faith in God as least important [45][46][47][48].
Two basic assumptions have contributed to the neglect of research in this area: (a) Spirituality cannot be studied scientifically (b) Neither it Should be studied scientifically

Developing attention
At this time, spirituality is an emerging area of interest. Physicians may find that considering the spirituality may add a new dimension to clinical practice. Between the years 2000 and 2002, more than 1,100 additional articles, studies, and reviews involving religion, spirituality, and mental health appeared in psychology literature, compared with 101 articles between 1980 and 1982, suggesting a remarkable increase in attention paid to this area by scientific community. Recent initiatives to cover spirituality in medical education are discussed. Studies and surveys on the importance of incorporating spiritual discussions into medical care are reviewed [49,50].
The Association of American Medical Colleges (AAMC) has cosponsored with National Institute for Healthcare Research to conduct four conferences on curricular development in spirituality and medicine. These conferences have been held annually since 1997.
A 1996 Gallup Poll showed that religion and expression of spirituality, plays a central role in the lives of many Americans. When asked, 95% of persons surveyed espoused a belief in God, 57% reported praying daily and 42% reported attending a worship service in the prior week. The American College of Physicians concluded that physicians should extend their approach to psychosocial, existential, or spiritual suffering [51,52].

Physician related
For physicians, collecting spiritual information may be:

Time consuming
Something for which they are not trained They may have difficulty managing, may project their views onto patients or question Difficulty in identifying patients who want such a discussion

Patient related
An agnostic patient should not be told to engage in worship any more than a highly religious patient who should not be criticized for frequent church attendance. Proselytizing is never appropriate. In Lindgren & Coursey's [53] study, 38% of patients expressed discomfort with mentioning their spiritual or religious concerns to therapist.

Research scarcity and inadequacies
Systematic reviews of the empirical literature indicate that religion and spirituality are understudied. Weaver et al. [54,55] conducted a systematic review of research on religion and spirituality in articles published in several American Psychological Association journals between the years 1991-94. Weaver found 2.7% of the quantitative studies included a religion and spirituality variable. Published work lacks consistency, even among well-conducted studies. Idler and Kasl found effects of religious attendance on functional capacity in the elderly: 1) Measures of "religious involvement", an index of the "private, reflective" aspects of religion were not associated with any health outcome 2) Neither church attendance nor religious involvement was associated with lower mortality Sloan et al. [56]  • An understanding of their own spirituality and how it can be nurtured as part of their professional growth, promotion of their wellbeing, and the basis of their calling as a physician

Looking ahead; requirements for better research Why it is needed?
Healing, derived from German word for 'Whole', is more than a particular symptom. Culliford [57,58] relates it to structures of meaning, value and purpose that form the human experience.
A Survey by Ehman et al. [59] at the University of Pennsylvania showing 65 % of patients in a pulmonary outpatient clinic noted that therapeutic alliance increases if physician's inquiry about spiritual beliefs addressed properly.
The American Journal of Psychiatry editorial (Andreasen) wrote it like, 'We must practice and preach the fact that psychiatrists are physicians to the soul as well as the body.' [60].
World Health Organization (1998) quotes health as 'a state of complete physical, mental and social well-being, not merely the absence of disease'. Mechanical treatment of objective findings in patients is no longer satisfactory. To shape more holistic view of health, Faith, hope and compassion should be integrated into healing process. Larson and Matthews [61] are building hope that the "wall of separation" between medicine and religion will be broken, and emphasize that "future is going to be prayer and Prozac".

Conclusion
According to the evidence based findings, mixed results of negative and positive associations are present, although data has showed positive linkage to great extent but considering past account of deficiencies, better methodology in future researches regarding religious practices and health findings are needed. Cross-sectional survey can be done among spiritually trained students and those who are not, in order to evaluate the differences (it is expected to make) in patient management and counseling. Proper training can diminish physician's related concerns like time consumption and poor spiritual assessment skills. More researches are needed on this ground for enhanced understanding of relationship and improvement of health system.