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The Relationship Between a Patient’s Spirituality and Health Experiences
J. LeBron McBride, PhD, MPH; Gary Arthur, EdD; Robin Brooks, MA; Lloyd Pilkington, MEd
Background and Objectives: The relationship between spirituality and health is a new frontier in medicine. This study is a preliminary investigation into the relationship between a patient’s experience of overall health, physical pain, and intrinsic spirituality. Methods: We used a stratified, random sample of 462 patients at a family practice residency clinic. The Index of Core Spiritual Experiences (INSPIRIT) measured intrinsic spirituality, and Dartmouth Primary Care Cooperative Charts measured overall health and pain. Pearson correlations tested the association between health, pain, and spirituality. Patient scores on the INSPIRIT were then placed into three groups (high, medium, and low levels of intrinsic spirituality). ANOVA tested for significant differences in health and pain. Results: We collected information from 442 of the patients surveyed (95%). We found significant correlation between patient health and spirituality. Significant differences were also found in both overall health and physical pain, based on the three levels of spirituality. Gender differences were only significant for overall health, not for patient pain. Conclusions: Our results suggest an association between intrinsic spirituality and a patient’s experience of health and pain. Assessment of spirituality may be important for family physicians to consider as a supplement to patient interviews. (Fam Med 1998;30(2):122-6.) The relationship between spirituality and health is a new frontier in medicine.1-3 Health care services in family medicine take into consideration influences from the patient’s family, community, and culture. Yet, spirituality has been a relatively neglected area of training and research in health care.4,5 This is true despite the fact that belief systems have been found to influence clinical outcomes, illness prevention, coping, recovery, and how patients define their illness experience.1,6 Additionally, patients have indicated their desire for physicians to address spirituality in their overall assessment of patients.7-9 While it is beyond the scope of this article to review the studies of the relationship between spirituality and health, there have been attempts to synthesize these data.6,10 The results of the research have been mixed. After reviewing the literature, Hill and Butler suggest that findings in this area will be more consistent if intrinsic factors of spirituality are distinguished from extrinsic ones.6 Therefore, this article defines spirituality as an intrinsic experience that goes beyond simply a belief in God or a higher power. Intrinsic spirituality is an internally focused perceptual or belief orientation about God or a higher power that influences life’s meaning and serves as a guide for living. The most practical means of identifying intrinsic spirituality may be by assessing what some call “core spiritual experiences.”11 These involve an event or multiple events that result in a personal conviction that God (or a higher power) exists, as well as the person’s relationship with God being internalized so that he or she feels personally connected with God.11 For example, communication with God through prayer and a belief that prayer influences life would be considered intrinsic spirituality. An intrinsic spiritual orientation has been correlated with having a higher life purpose and satisfaction and decreases in the frequency of stress-related medical symptoms.12 Extrinsic spirituality, on the other hand, addresses external religious behavior, which may or may not be an expression of the patient’s internal orientation. For example, church or synagogue membership, an extrinsic factor, may not be as important as subjective intrinsic beliefs and practices that motivate an individual.
From Georgia Baptist Family Practice Residency Program, Morrow, Ga (Dr McBride) and Georgia State University, Atlanta (Dr Arthur, Mr Pilkington, and Ms Brooks).
two did not indicate their gender.61) with the Intrinsic Religious Motivation Scale. we used the COOP chart for measuring overall health. The instruments. and for measuring pain. reliable. 1% Asian. The clinic serves a suburban and rural population outside a major southeastern metropolitan area. and spirituality. Children under age 18 were excluded.16 For this research. Therefore. random sample of patients at a suburban family practice residency clinic. There were more females than males simply because there was no differentiation made between males and females in the random sampling. brief instruments that obtain clinical data from patients.18 indicating concurrent validity. Although the diagnosis of each patient was not ascertained. The present research. which shows the level of physical pain a patient may be experiencing. We need studies from several arenas of health care to assess this possibility more fully. Findings in this area may offer evidence that expanding family physicians’ attention to patients’ spiritual experiences is a useful adjunct to the assessment and treatment processes. as is true of most family practice offices. there is some indication that intrinsic spirituality might be associated with better health outcomes. They were also told that their participation was entirely voluntary. A close examination of the INSPIRIT data revealed that the upper quartile of subjects scored at or above the score described by the test’s authors as indicating . except as reported in group data. No. based on a patient’s level of spirituality and gender.15. Females (n=279) made up 63% of the sample. The majority of patients identified with the Christian or Jewish faiths (86%). and there is a higher percentage of females who come to the center. the research hypotheses for the present study are: 1) There is a significant relationship between spirituality and a patient’s overall health and pain. 2 123 A total of 462 patients were given the survey. 3) There are significant differences in the effects spirituality has on health and pain for male and female patients.17 In addition to measuring the patient’s internal beliefs. They were asked to participate in a survey on wellness and were informed that the information would be kept confidential.11.15 The Dartmouth COOP charts are a set of simple. INSPIRIT focuses on experiences that the patient interprets as spiritual. Another important factor in understanding spirituality and health is the significant difference that research has found in the way men and women experience spirituality. The participants were instructed to complete the survey instruments while waiting for their physician and return them to a box marked “research” at the front counter or at the check-out desk as they left. Every third patient entering the family practice clinic waiting room was given the survey instruments. These questions offer a useful format for physicians and other health care workers to help them learn about patients’ spirituality. The median age group was 41–50. including how close a person feels to God or a higher power and how strongly religious or spiritually oriented a person considers himself or herself. research needs to clarify the role that intrinsic spirituality has on the way patients experience their health and physical pain and how that might be different across genders. Total scores on the INSPIRIT were used to calculate correlations with the other variables.14 At this point. Vol. and 37% were male (n=161). and 1% other. physical pain. however.15 They have also been found to be acceptable. the spectrum of patient diagnoses at the family practice clinic is extensive. have been well received by patients and physicians. 30. 442 returned them. aimed to assess the association between intrinsic spirituality and reported health outcomes of patients at a family practice center. and valid in primary care settings. for a 95% return rate. which shows the level of the patient’s overall well-being. which have illustrations for assistance in understanding each question. each measures a different aspect of patient functional status. Data Analysis Pearson correlations tested the association between health. it also provides an avenue for physicians to learn more about the patient’s subjective world. 18% African-American. Sixty-eight percent of the sampled patients were married. As mentioned. Methods Subjects Our report is based on a stratified. 2) There are significant differences in overall health and pain.Clinical Research and Methods Many years ago. While most spiritual assessment instruments focus on cognitive beliefs or conscious values. More than 50% of the sample had 1 or more years of post-secondary education. INSPIRIT. Allport described a similar kind of spirituality distinction with the terms institutionalized and internalized religion and saw these as having different effects on the person. We used the Dartmouth Primary Care Cooperative Information Project (COOP) charts to measure the health of subjects.13 Kass and others used intrinsically oriented variables to measure spirituality and developed a simple instrument called the Index of Core Spiritual Experiences (INSPIRIT) for this purpose. 1% Hispanic. The ethnic composition was 79% Caucasian.11 INSPIRIT questions provide examples of intrinsic spirituality.17 The scores on the instrument have been found to reflect intrinsic religiosity and to correlate (r=. Measures COOP Overall Health Chart. There are nine instruments.
To determine differences in patients’ health and pain. In other words. and low spirituality groups and for males and females.017). indicating that gender differences do not interact with differences in health based on level of spirituality for this group. Both the high and moderate spirituality groups had an almost identical mean level of health. Significant differences were found in pain across the three levels of spirituality (F [2. moderate.05 alpha level. and low spirituality groups were the same for male and female patients.08).61 3. This was consistent with the original distribution of scores reported on by the test authors. It is moderation. P<. the high spirituality group reported more pain. The differences in health across high. moderate.67* 2. Based on the present results.05 1.25.83** 2. patients’ physical pain was not significantly associated with spirituality (r=-.61. not extremes in spirituality.27 1. However. P=. For patient pain.04. which were significantly higher than that for the low spirituality group. multiple comparisons revealed that men (M=2. there were no significant differences between males and females on pain (F [1. Discussion Findings from this research confirmed the hypothesis that overall health varied significantly for patients having different levels of spirituality. Post hoc analyses using multiple comparisons revealed that significant differences existed between the high and low spirituality groups (P=. but the only statistically significant differences were between the low and moderate spirituality groups. two-way ANOVA testing was used. P=. P=. based on the level of patient spirituality. the lowest average level of pain was reported Table 1 Means and Standard Deviations for Health and Pain. changes in spirituality would be expected to correspond with lower levels of pain only when moving from high or low spirituality to moderate spirituality.06 SD 1. The finding of higher levels of pain for both the high and low spirituality groups was contrary to expectations. All statistical tests were evaluated at the . using Tukey’s HSD tests to identify where the specific differences occurred.006) and between the moderate and low groups (P=.18. For gender. The second ANOVA examined differences in mean scores for the perceived pain of those in the high. further suggesting the actual relationship between physical pain and intrinsic spirituality is curvilinear. the differences in health were greatest between patients having a low level of spirituality and those with either moderate or high levels. There were also significant health differences between genders.016) overall health than women (M=2. When group differences were statistically significant.09.89 1. P=. The first ANOVA examined differences in mean scores for the perceived health of those in the high. high spirituality.84) and no significant interaction between spirituality and gender. . and low spirituality groups and for males and females. 396] =5. moderate. Table 1 gives the means and standard deviations for health and pain. men reported overall better levels of health. 396] =5.07 3. 391]=.19 . These results are consistent with the findings of a nonsignificant linear relationship between these same variables. Significant differences were found in overall health across the three levels of spirituality (F [2.70.12 SD—standard deviation * Lower mean scores indicate better reported health. both the high and low spirituality groups had higher levels of pain than the moderate spirituality group. there was no significant interaction between spirituality and gender. 391]=4. so the association between spirituality and health was the same for both genders. It is important to note that these differences did not occur between the high and moderate spirituality groups but only between those two groups and the low spirituality group.124 February 1998 Family Medicine by those in the moderate spirituality group.008).66 2. P=. However. the ANOVAs were followed up with multiple comparisons.004) and across genders (F [1.015) (Table 1). Based on Level of Spirituality Spiritual Level High spirituality Moderate spirituality Low spirituality Measure Overall health Pain Overall health Pain Overall health Pain # 142 140 139 136 121 121 Mean 2.65) reported significantly better (P=. we decided to also designate the lower quartile of the distributions scores as the low spirituality group and the middle range of scores as the moderate spirituality group. Post-hoc analyses revealed significant differences between only the low and moderate spirituality groups (P=. and the low spirituality group reported significantly more pain.06 1. that appear to be key to predicting lower levels of patient pain. The negative correlations were due to the INSPIRIT using a response scale that was directly inverse to the other measures. However. Results Overall health was significantly related to spirituality (r=-.008). In this case.11 Based on this. These designations provided a way to more clearly examine group differences and is consistent with procedures suggested by the test’s authors. ** Lower mean scores indicate less reported pain.001).85).
A limitation to this study is the measurement of overall health and pain using the self-report COOP charts. Even when patients don’t include information on spirituality.Clinical Research and Methods Vol. enhances. At this time. such that health may be associated more closely with some other aspect of patient behavior. or disease. It may also be that both intrinsic spirituality and patient health have reciprocal relationships. those differences do not follow a clearly linear pattern and do not account for much of the difference in patient health.19 Given this knowledge. some from the INSPIRIT instrument. and research surrounding this topic continues. spirituality may exert some influence over health. No. patient health is influenced by a wide variety of demographic. Table 2 shows questions. As research in this area continues. making relationships more difficult to untangle. at Lesley College. carefully listening to the patient’s language and assessing how spirituality can be used to enhance treatment.9 The present research gives preliminary support to the belief that there are differences in health found across various levels of internalized spirituality. . family physicians may find that considering the spirituality of their patients informs. a copyrighted instrument. Recently. Further research is necessary to clarify the type of relationship that exists between health and intrinsic spirituality and to better judge the role that intrinsic spirituality should play in the physician-patient dialogue. Despite the fact that differences in health occur with patients having different levels of spirituality. injury. lifestyle. It may be the interplay between these. Finally. Cambridge. that ultimately determine how a patient perceives his or her health status.) Another finding was the small. However. This preliminary study is important because it reveals the existence of significant differences in patients’ health and pain for those with high. enhancing the physician-patient relationship. This may be considered in light of the findings on pain and spirituality. moderate. Even at this stage of refinement in our understanding. physicians may listen for issues of spirituality and faith when a patient discusses symptoms and related experiences. which in turn has a relationship with spirituality. correlation between spirituality and health. and improving patient satisfaction and compliance. how does your faith impact on your decisions?* • How close do you feel to God or a higher power?** • Have you ever had an experience that convinced you that God or a higher power exists?** • How strongly religious (or spiritually oriented) do you consider yourself to be?** • How has your religious or spiritual history been helpful in coping with your illness? • How has your belief system been affected by your illness? * From the SPIRITual History20 ** From INSPIRIT11 (INSPIRIT. a physician may explore it with them at appropriate points. Another possible reason for the low correlation is that intrinsic spirituality and health and pain may be related only indirectly. family physicians may want to be aware of and listen for mention of patients’ intrinsic spiritual experiences.9. These charts provide global measures of health and pain. In light of the desire that patients have for physicians to inquire about spirituality. and environmental factors. although statistically significant. that may appropriately be used or adapted by physicians to explore intrinsic spirituality with patients. and low levels of internalized spirituality. they do have the advantage of revealing a patient’s health experience and subjective world. Self-reports also have limitations when assessing physical health and pain.20 One scientific poll found that 79% of the respondents believe that spiritual faith can help people recover from illness. which demonstrate that the relationships under investigation are complex. spirituality is an emerging area of interest. genetic. PhD. It has been well documented that objective clinical findings alone do not always give the information necessary for adequate treatment. which may have obscured some of the relationships between intrinsic spirituality and separate components of health and pain. and adds a new dimension to clinical practice. and the present research results. In other words. and other yet-to-be identified factors. some family physicians have reported making a spiritual inquiry a part of the social history. consideration should also be given to whether sensitivity to patient spirituality assists with prioritizing and presenting treatment options. 30. 2 125 Table 2 Questions Physicians Could Use to Facilitate Discussions On Spirituality • What does your spirituality/religion mean to you?* • What aspects of your religion/spirituality would you like to me to keep in mind as I care for you?* • Would you like to discuss the religious or spiritual implications of health care?* • As we plan for your care near the end of life. was used with permission for this research and is available from Jared Kass. Mass. but health is also likely to influence patients’ spiritual experiences. such as coping styles.
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