J Relig Health DOI 10.1007/s10943-014-9906-3 ORIGINAL PAPER
Religious/Spiritual Characteristics of Indian and Indonesian Physicians and Their Acceptance of Spirituality in Health care: A Cross-Cultural Comparison P. Ramakrishnan • A. Karimah • K. Kuntaman • A. Shukla B. K. M. Ansari • P. H. Rao • M. Ahmed • A. Tribulato • A. K. Agarwal • H. G. Koenig • P. Murthy
•
Springer Science+Business Media New York 2014
Abstract Religious/spiritual (r/s) characteristics of physicians influence their attitude toward integrative medicine and spiritual care. Indonesia physicians collaborate with traditional, complementary, and alternative medicine (TCAM) professionals within modern healthcare system, while Indian physicians are not reported to do so. The aim of the study was to understand the r/s characteristics and their influence on Indian and Indonesian physicians’ acceptance of TCAM/spirituality in modern healthcare system. An exploratory, pilot, crosscultural, cross-sectional study, using Religion and Spirituality in Medicine, and Physician Perspectives (RSMPP) survey questionnaire, compared r/s characteristics and perspectives on integrative medicine of 169 physicians from two allopathic, Sweekar-Osmania University
P. Ramakrishnan Center for Development of Spirituality as Medical Subject, AdhiBhat Foundation India, R-80 Greater, Kailaish, New Delhi, India P. Ramakrishnan (&) Center for Study of World Religions, Harvard Divinity School, Harvard University, 42 St. Francis Avenue, Cambridge, MA 02138, USA e-mail: [email protected] A. Karimah Department of Psychiatry, Faculty of Medicine, Dr. Soetomo General Hospital, University of Airlangga, Jl. Mayjen Prof. dr. Moestopo 6-8, Surabaya, Indonesia K. Kuntaman Department of Clinical Microbiology, School of Medicine, Dr. Soetomo Hospital Surabaya, Airlangga University, Surabaya, Indonesia A. Shukla Institute of Post Graduate Teaching and Research in Ayurveda, Jamnagar, Gujarat, India B. K. M. Ansari M. Ahmed Central Research Institute of Unani Medicine, Hyderabad, Andhra Pradesh, India P. H. Rao Sweekaar-Upkaar Rehabilitation Institute for Handicapped, Osmania University, Secunderabad, India
123
J Relig Health
(Sweekar-OU), India, University of Airlanga (UNAIR), Indonesia, and a TCAM/Central Research Institute of Unani Medicine (CRIUM) institute from India. More physicians from UNAIR and CRIUM (89.1 %) described themselves as ‘‘very’’/‘‘moderately’’ religious, compared to 63.5 % Sweekar-OU (p = 0.0000). Greater number of (84.6 %) UNAIR physicians described themselves as ‘‘very’’ spiritual and also significantly high (p \ 0.05) in intrinsic religiosity as compared to Sweekar-OU and TCAM physicians; 38.6 % of UNAIR and 32.6 % of CRIUM participants reported life-changing spiritual experiences in clinical settings as against 19.7 % of Sweekar-OU; 92.3 % of UNAIR, compared to CRIUM (78.3 %) and Sweekar-OU (62 %), felt comfortable attending to patients’ spiritual needs, (p = 0.0001). Clinical comfort and not r/s characteristics of participants was the significant (p = 0.05) variable in full regression models, predictive of primary outcome criteria; ‘‘TCAM or r/s healing as complementary to allopathic treatment.’’ In conclusion, mainstreaming TCAM into healthcare system may be an initial step toward both integrative medicine and also improving r/s care interventions by allopathic physicians. Keywords Allopathy Spirituality Religion Integrative medicine TCAM Transcultural Curriculum
Introduction Physicians and patients in advanced/developed nations seek to provide and receive, respectively, religious/spiritual (r/s) interventions for medical and mental illnesses. Physicians are known to ascribe more responsibility to r/s healers when modern medicine seems to fail (Sheppe et al. 2013); their personal r/s commitments are reported to influence their support to integrative medicine programs (Lee and Baumann 2013; Curlin et al. 2005, 2009). Similarly, patients in these developed nations seek traditional, complementary, and alternative (TCAM) treatment for chronic ailments such as arthritis and serious illnesses such as cancer (Lee Ventola 2010); increased religiosity/spirituality is known to be the reason for patient’s preference for TCAM use (Hsiao et al. 2008; Mao et al. 2008). Increased usage of TCAM therapies by patients is reportedly due to beneficial effects outweighing the costs, increased patient autonomy, availability of information on TCAM or contact with its users, and/or perception that TCAM is safer and less expensive (Lee Ventola 2010; Frass et al. 2012). Though medical professionals regard the clinical efficacy of TCAM methods to be controversial, the health administrative bodies in these developed nations have encouraged and/or provided TCAM training to their physicians and medical students (Lee Ventola 2010; Frass et al. 2012). Thus, attempts to integrate pluralistic medical systems in these developed nations include integration of healthcare services, educational, and research programs (Bodeker and Kronenberg 2002).
A. Tribulato A. K. Agarwal HELP Foundation of Omaha, Omaha, NE, USA H. G. Koenig Department of Psychiatry, Duke University Medical Center, Durham, NC, USA P. Murthy De-addiction Center, Department of Psychiatry, National Institute of Mental Health and NeuroSciences, Bangalore, Karnataka, India
123
J Relig Health
In developing countries, 60–90 % of population in the rural and remote parts of the society is known to be dependent on TCAM medications for their primary healthcare needs—the main reason for such an extensive use is because of their perception of safety, availability, and affordability of TCAM medications and services (World Health Organization Regional Office of South East Asia 2009). TCAM methods are also considered to be holistic care, which becomes more important specially while treating mental illnesses; speaking of India and Indonesia, the two countries of interest in this study, TCAM and r/s care are preferred over modern medicine because of the belief in the supernatural causation of mental disorders (Avasthi et al. 2013; Kurihara et al. 2006) as well as because of stigma toward modern mental health facilities (Kurihara et al. 2006; Mishra et al. 2011; Lahariya et al. 2010; Chandrashekar et al. 2009; Pols 2006). In accordance with World Health Organization policies on TCAM [(Bodeker and Burford 2008; Bodeker et al. 2014), India and Indonesia had started integrating TCAM into modern healthcare systems. India and Indonesia have robust TCAM systems functioning alongside modern healthcare system but in Indonesia, there is extensive collaboration between the two while modern medical professionals in India are opposed to the integration of their services (Bodeker et al. 2014). Indonesian healthcare system allows its allopathic professionals to provide TCAM therapy such as acupuncture and pharmacists are allowed to dispense TCAM medications. In this country, TCAM schools are located within the allopathic medical education system and their education/training is regulated by university programs that govern allopathic medical education. TCAM providers are legally recognized and function within healthcare services (Bodeker and Burford 2008; Bodeker et al. 2014). Thus, there seems to be functional fluidity between allopathic and TCAM medical systems in Indonesia. India, on the other hand, has a separate federal department of AYUSH (acronym for Ayurveda, Yoga-Naturopathy, Unani, Siddha, and Homeopathy) that supervises TCAM education and training, independent of allopathic medical system (Sharma et al. 2008). TCAM physicians have minimal training in allopathic methods during their schooling while allopathic students have none of TCAM training. Yet, in reallife practice, we find allopathic physicians prescribing Ayurvedic/herbal medications and vice versa—such a practice is legally contested by individuals from both the systems citing inadequate training of professionals in ‘‘integrative medicine’’ (Verma et al. 2007). While Indian National Rural Health Mission attempts to develop an integrative healthcare system by recruiting AYUSH professionals into mainstream allopathic practice (Sharma et al. 2008), one may be informed of the significant resistance of Indian allopathic physicians against such integration (Bodeker et al. 2014). This study was carried out to understand Indian and Indonesian professionals’ differential support to integrative medicine in their respective countries. Based on the existing literature on clinical practices, we hypothesized that Indonesian physicians will be more religious or spiritual as compared to Indian counterparts and that would be the reason for their acceptance of integrated healthcare system.
Methodology This is an exploratory, pilot, cross-cultural study that included three tertiary care medical institutes, two from India and one from Indonesia. Sweekar, a mental health institute under Osmania University (Sweekar-OU), Hyderabad, India, and the psychiatric medical faculty of University of Airlanga (UNAIR) in Surabaya, Indonesia, are two allopathic medical institutions that were preselected into this study. However, we realized that the religious
123
J Relig Health
affiliation of participants in these two institutes was strikingly different; the Indonesian group consisted of predominantly Muslim physicians while Indian group had predominantly Hindu participants. To offset such sampling error and to compare groups with identical r/s characteristics, we also included Central Research Institute of Unani Medicine (CRIUM) in Hyderabad, India, into our study. Unani is a TCAM with its origin in Islamic tradition, and hence, participants from CRIUM shared identical religious affiliation as that from UNAIR. Including these three institutes gave us a unique opportunity to compare not only professionals across nationalities but also across medical systems. All officially registered clinicians undergoing rotatory training, during the 2010–2011 academic year, in these settings were enrolled consecutively, and they formed the three comparative groups of our study. Participants were provided with Religion and Spirituality in Medicine: Physician Perspective (RSMPP) (Curlin et al. 2005; Curlin et al. 2006, 2007); a self-administered, semistructured survey questionnaire to understand their r/s beliefs, practices, and perspectives on r/s in clinical medicine was used along with a specially developed supplementary questionnaire that explores participant’s views on r/s in mental healthcare services. Detailed methodology of the study and questionnaire development was described elsewhere (Ramakrishnan et al. 2013, (2014). The primary criterion variable was physician’s agreement with the statement: ‘‘Spiritual healing has some benefits, and it could be a complement to modern medical treatment’’— answer choices were ‘‘strongly agree, agree, disagree, or strongly disagree.’’ Predictor variables were clustered into participant’s (a) personal r/s characteristics except their religious affiliation (Table 1), (b) clinical observations and interpretations of patients’ spiritual care needs as well as participants’ attempts to address them (Table 2), and (c) participants’ and patients’ referral/self-referral practices related to mental health, stigma, and spiritual healing (Table 3). The control variables (Table 1) include participant’s age, gender, and religious affiliation. Sigma XL statistical software was used to compare the data between study groups; one-way ANOVA, Pearson’s v2 test, and multivariate logistic regression models were used. We first generated overall population estimates for participant’s religious characteristics and then measured them against their agreement with the primary criterion variable.
Results All enrolled participants in each of the study centers Sweekar-OU (N = 71), UNAIR (N = 52), and CRIUM (N = 46) returned their completed survey; this response rate of 100 % was achieved through three or more personal meetings, encouraging the participants to return their completed survey questionnaires. The Sociodemographic Characteristics (not in Tables) Participants at UNAIR were significantly younger (mean age 29.6, SD 4.1) than those at CRIUM and Sweekar-OU (35.3, SD 12.4) (p = 0.0146, F = 4.352). Though more number of females participated at CRIUM (59.1 %) as compared to other groups (45.6 % at Sweekar-OU and 42 % at UNAIR), there was no statistically significant difference (p = 0.2181, v2 = 3.046, df 2) between groups’ gender distribution.
123
J Relig Health Table 1 Personal religion/spiritual characteristics of participants Religious/spiritual variables
CRIUM
Religious affiliation
N = 46 (%)
SweekarOU N = 71 (%)
Christianity
1 (2.2)
10 (14.1)
7 (13.5)
Hinduism
2 (4.3)
53 (74.6)
1 (2.0)
41 (89.1)
5 (7.0)
44 (84.6)
Islam
UNAIR
Analysis
N = 52 (%)
v2, df, p value 117.62 4 0.0000
To what extent do you consider yourself a religious person? Would you say you are Very religious
22 (47.8)
6 (8.5)
8 (15.4)
Moderately religious
19 (41.3)
39 (55.0)
39 (75.0)
Slightly religious
2 (4.3)
20 (28.2)
4 (7.7)
Not religious at all
1 (2.2)
4 (5.6)
1 (1.9)
41.507 6 0.0000
To what extent do you consider yourself a spiritual person? Would you say you are Very spiritual
16 (34.8)
6 (8.5)
8 (15.4)
Moderately spiritual
18 (39.1)
39 (55.0)
36 (69.2)
Slightly spiritual
8 (18.4)
21 (29.6)
6 (11.5)
Not spiritual at all
2 (4.3)
2 (2.8)
2 (3.8)
20.451 6 0.0023
Religious practices How often do you attend religious services (A29) Never to about once or twice a month
7 (15.2)
17 (24.0)
0 (0.0)
Several times a year to two or three times a month
11 (24.0)
16 (22.5)
5 (9.6)
Nearly every week to several times a week.
26 (56.5)
33 (46.5)
46 (88.5)
24.138 4 0.0001
Intrinsic religiosity: ‘‘My whole approach to life is based on my religion’’ (A32 h) Strongly agree/agree Disagree/strongly disagree
36 (78.3)
28 (39.4)
47 (90.4)
7 (15.2)
37 (52.1)
4 (7.7)
‘‘I try hard to carry on my religious beliefs over into all my other dealings in life’’ (A32 g) Strongly agree/agree
17 (37.0)
41 (57.7)
41 (78.8)
Disagree/strongly disagree
25 (54.3)
23 (32.4)
10 (19.2)
‘‘My religious beliefs influence my practice of medicine’’ (A32 d) Strongly agree/agree Disagree/strongly disagree
38 (82.6)
30 (42.3)
43 (82.7)
3 (6.5)
29 (40.8)
7 (13.5)
‘‘I find it challenging to remain faithful to my religion in my work as a healthcare provider’’ (A32 e) Strongly agree/agree
23 (50.0)
24 (33.8)
42 (80.8)
Disagree/strongly disagree
15 (32.6)
33 (46.5)
9 (17.3)
‘‘My experiences as a healthcare provider have caused me to question my religious beliefs’’ (A32 f) Strongly agree/agree
10 (21.7)
12 (17.0)
24 (46.2)
Disagree/strongly disagree
30 (65.2)
46 (64.8)
27 (52.0)
38.074 2 0.0000 15.800 2 0.0004 27.618 2 0.0000 18.325 2 0.0001 9.725 2 0.0077
Counts do not equal ‘‘N’’ due to partial non-responses
123
J Relig Health Table 2 Physician’s clinical observations and interpretations on patient’s behavior related to their physical, mental, and spiritual health needs Questionnaire item (Q no. in brackets) on clinical observations and their interpretation
Response (Codes)
In your experience, how often have your patients received emotional or practical support from their religious community? (A10 b)
Never/rarely
In your experience, how often have your patients mentioned r/s issues like God, prayer, scriptures etc.?
Often/always
How often would you say experience of illness increases patients’ awareness of and focus on r/s?
Never/rarely
24 (52.2)
Often/always
10 (21.7)
32 (45.1)
16 (30.8)
Overall, how much influence do you think religion/spirituality has on patients’ health
Very much ? Much
34 (74.0)
41 (57.7)
44 (84.6)
Is the influence of religion/spirituality on health generally positive or negative?
In the following clinical situations, how often do you inquire about religious/ spiritual issues? (a) …faces a frightening diagnosis or crisis (b) …faces the end of life
N = 46 (%)
SweekarOU N = 71 (%)
UNAIR N = 52 (%)
7 (15.2)
22 (31.0)
13 (25.0)
Sometimes
13 (28.3)
12 (17.0)
12 (23.1)
Often/always
12 (26.1)
29 (41.0)
25 (48.1)
Never/rarely
11 (24.0)
19 (26.8)
9 (17.3)
Sometimes
10 (21.7)
9 (12.7)
12 (23.1)
9 (19.6)
30 (42.3)
26 (50.0)
7 (15.2)
12 (17.0)
5 (9.6)
25 (35.2)
27 (52.0)
Sometimes
Some
3 (6.5)
10 (14.1)
1 (2.0)
A little/very little to none
9 (19.6)
19 (26.8)
7 (13.5)
Generally positive
39 (84.8)
39 (55.0)
39 (75.0)
Generally negative
2 (4.3)
8 (11.3)
1 (2.0)
Equally positive and negative
4 (8.7)
18 (25.4)
12 (23.1)
It has no influence
1 (2.2)
4 (5.6)
0 (0.0)
Never/rarely
12 (26.0)
26 (36.6)
3 (5.8)
Sometimes
14 (30.4)
11 (15.5)
36 (68.2)
9 (19.6)
16 (22.5)
10 (19.2)
Often/always Never/rarely Sometimes
(c) …suffers from anxiety or depression
CRIUM
5 (10.9)
24 (33.8)
3 (5.8)
26 (56.5)
18 (25.4)
43 (82.7)
Often/always
4 (8.7)
8 (11.3)
3 (5.8)
Never/rarely
6 (13.0)
20 (28.2)
2 (3.8)
Sometimes
25 (54.3)
20 (28.2)
32 (61.5)
Often/always
10 (21.7)
18 (25.4)
14 (26.9)
To what extent do you agree/disagree with following statement? I would feel comfortable discussing patient’s r/s concerns if patient brought them up: (Re-A8)
Strongly agree/ agree
36 (78.3)
44 (62.0)
48 (92.3)
6 (13.0)
27 (38.0)
4 (7.7)
Have you had any formal training regarding r/s in medicine?
Yes
24 (52.2)
6 (8.5)
No
16 (34.8)
62 (87.3)
42 (8)
Did you ever have a r/s experience that changed your life?
Yes
24 (52.2)
37 (52.1)
36 (69.2)
No
19 (41.3)
26 (36.6)
15 (28.8)
123
Disagree/ strongly disagree
10 (19.2)
Analysis v2, df, p value
6.096 4 0.1921 8.121 4 0.0873 8.248 4 0.829 11.393 4 0.0225
15.948 6 0.0140
33.041 4 0.0000
33.009 4 0.0000 19.630 4 0.0000 18.024 2 0.0001
36.547 2 0.0000 2.572, 2 0.2763
J Relig Health Table 2 continued Questionnaire item (Q no. in brackets) on clinical observations and their interpretation
Response (Codes)
CRIUM
If Yes: did the experience occur in the context of practicing medicine?
Yes
15 (32.6)
14 (19.7)
20 (38.5)
No
8 (17.4)
22 (30.9)
16 (30.8)
N = 46 (%)
SweekarOU N = 71 (%)
UNAIR
Analysis v2, df, p value
N = 52 (%)
4.262, 2 0.1187
Counts do not equal ‘‘N’’ due to partial non-responses
R/S Characteristics (Table 1) The religious affiliations were collapsed into four major groups: Christian, Hindu, Islam, and Others. ‘‘Others’’ included non-respondents as well as those who described themselves as Atheists or Agnostics. Groups differed significantly (p = 0.0000) due to participants religious affiliation; it was predominantly Islam among CRIUM (89.1 %) and UNAIR (84.6 %) while being Hinduism at Sweekar-OU (74.6 %). Significantly (p = 0.0001) greater numbers (88.5 %) of UNAIR physicians reportedly attended religious services, ‘‘nearly every week to several times a week,’’ as compared to CRIUM (56.5 %) and Sweekar-OU (46.5 %) professionals. While 90.4 % of UNAIR and 89.1 % of CRIUM called themselves (moderate/very) ‘‘religious’’ (p = 0.0001), and similarly greater numbers among these two groups (84.6 % of UNAIR and 73.9 % of CRIUM) considered themselves to be (moderate/very) ‘‘spiritual’’ (p = 0.0023), though fewer in numbers, Sweekar-OU allopaths considered themselves to be equally (63.5 %) ‘‘religious’’ and ‘‘spiritual’’ (moderate/very). Intrinsic religiosity (Lee Ventola 2010; Allport 1967) (measured as agreement with statements such as ‘‘My whole approach to life is based on my religion,’’ ‘‘I try hard to carry on my religious beliefs over into all my other dealings in life,’’ and ‘‘My religious beliefs influence my practice of medicine’’) was significantly (p \ 0.0005) high among UNAIR followed by CRIUM and least in Sweekar-OU group. Ironically, almost equally greater numbers (80.8 %) of UNAIR participants, also, reportedly ‘‘find it challenging to remain faithful to their religion’’ while providing health care, about half (46.2 %) of them also agree that their clinical experiences ‘‘cause them to question their religious beliefs’’; greater percentage of both the Indian study groups disagreed to both these statements (p \ 0.05). Participants’ Clinical Observations and Interpretations on Patient’s Behavior Related to their Physical, Mental, and Spiritual Health Needs (Table 2) University of Airlanga had greatest percentage (71.2) of participants who believed their ‘‘patients to be receiving (sometimes/often/always) emotional and practical support from their religious community,’’ followed by Sweekar-OU (58 %) and CRIUM (54.4 %). Majority (73.1 %) among UNAIR report their patients referring to ‘‘r/s issues such as God or scriptures’’ during clinical visit as compared to only 55 % of Sweekar-OU and 41.3 % of CRIUM participants. On the other hand, fewer UNAIR (52.8 %) participants as compared to Indian (80.3 % of Sweekar-OU and 73.9 % of CRIUM) believed that illness experience increased patients’ awareness and focus on r/s issues.
123
J Relig Health Table 3 Professionals’ and patients’ referral/self-referral practices with regard to mental health care Questionnaire item (Q no. in brackets) on clinical observations and their interpretation
Response (Codes)
A patient presents to you with continued deep grieving two months after the death of his wife; If you were to refer the patient, to which of the following would you prefer to refer first? (A16)
A religious place for healing
Please answer to the best of your knowledge about the behavior among the public …If a patient is severely mentally ill to which of the following would they prefer to visit first? (B5)
CRIUM N = 46 (%) 4 (8.7)
SweekarOU N = 71 (%) 2 (2.8)
UNAIR N = 52 (%) 1 (1.9)
TCAM
14 (30.4)
13 (18.3)
10 (19.2)
A psychiatrist or psychologist
19 (41.3)
51 (71.8)
40 (76.9)
Others (Specify)
4 (8.7)
0 (0.0)
0 (0.0)
A religious place for healing
9 (19.6)
10 (14.1)
8 (15.4)
TCAM A psychiatrist or psychologist
6 (13.0)
11 (15.5)
14 (26.9)
23 (50.0)
40 (56.3)
28 (53.8)
Others (Specify)
5 (10.9)
1 (1.4)
2 (3.8)
Almost always— usually true
27 (58.7)
51 (71.8)
48 (92.3)
Sometimes true
14 (30.4)
10 (14.1)
4 (7.7)
Usually-almost never true
4 (8.7)
3 (4.2)
0 (0.0)
Very satisfied/ Satisfied
21 (45.7)
26 (36.6)
21 (40.4)
Dissatisfied/very dissatisfied
4 (8.7)
7 (9.9)
11 (21.2)
Stigma associated with mental illness can be reduced (if not eliminated) by integrating spirituality into psychiatry; To what extent do you agree with this statement? (B8)
Strongly agreeagree
44 (95.6)
46 (64.8)
50 (96.2)
0 (0.0)
12 (16.9)
1 (1.9)
Spiritual healing has some benefits and it could be a complement to modern medical treatment. (B14 c)
Strongly agree/agree
38 (82.6)
47 (66.2)
49 (94.2)
4 (8.7)
7 (9.9)
3 (5.7)
Spirituality as a healthcare tool is a subject worthy to be introduced into medical school curriculum
Strongly agree/agree
34 (73.9)
49 (69.0)
35 (67.3)
8 (17.4)
7 (9.9)
17 (32.7)
Public in general tries to consciously avoid seeing a psychiatrist for any mental illness: How true is this statement? (B7) In your experience with religious/ faith healers, have you been (A17)
Disagree-strongly disagree
Disagree/strongly disagree Disagree/strongly disagree
Analysis v2, df, p value
22.070 6 0.0012
8.698 6 0.1913
15.455 4 0.0038
2.861 2 0.2392 17.979 2 0.0001
1.601 2 0.4491 6.732 2 0.0345
Counts do not equal ‘‘N’’ due to partial non-responses
Significantly (p \ 0.05) greater numbers of participants from UNAIR and CRIUM report r/s to have greater (very much/much) influence on patients health (84.6 and 74 %, respectively) and believed that influence to be ‘‘generally positive’’ (75 and 84.8 %, respectively); \58 % of Indian allopaths reportedly believed in such an influence. UNAIR physicians reportedly attended to spiritual needs of their patients in clinical situations such as (a) ‘‘facing dangerous diagnosis or crisis,’’ (b) ‘‘end of life,’’ and (c) ‘‘suffering from anxiety and depression,’’ in significantly (p = 0.0000) greater numbers (86.4, 88.5, 88.4 %, respectively); even CRIUM participants report to provide such a service at higher numbers (50, 65.2, 76 %, respectively) as compared to allopaths at Sweekar-OU (38, 36.7, and 53.7 %, respectively).
123
J Relig Health
Almost all UNAIR participants (92.3 %) reportedly felt comfortable discussing r/s concerns of their patients (compared to only 78.3 % of CRIUM and even less, 62 % of Sweekar-OU), p = 0.0001; In spite of this fact, significantly (p = 0.0000) fewer Indonesian/UNAIR (19.2 %) and Indian/Sweekar-OU (8.5 %) allopaths reportedly received formal training regarding ‘‘r/s in medicine’’ as compared to 52.2 % of Indian TCAM/ CRIUM physicians. Greater number of UNAIR physicians (69.2 %) reported r/s experiences that changed their lives, about half of those experiences (38.5 %) were in clinical settings. Professionals’ and Patients’ Referral/Self-Referral Practices with Regard to Mental and Spiritual Health Needs Majority of Sweekar-OU (71.8 %) and UNAIR (76.9 %) allopaths preferred to refer a 2-month grieving patient to a psychiatrist/psychologist while only 41.3 % of TCAM/ CRIUM group reported to do the same (p = 0.0012). A significant (p = 0.0038) number of UNAIR allopaths (92.3 %) reportedly believe that ‘‘general public consciously avoids (almost always/usually) seeing psychiatrists for mental illnesses’’ as compared to only 71.8 % of Indian allopaths and even lesser (58.7 %) of CRIUM. Significantly (p = 0.0001) greater numbers of CRIUM (95.6 %) and UNAIR (96.2 %) as compared to Sweekar-OU (64.8 %) agreed that ‘‘stigma associated with mental illness can be minimized by integrating spirituality into psychiatric services.’’ A majority within each study group, highest being UNAIR at 94.2 %, agreed/strongly agreed that ‘‘spiritual healing has some benefits and it can complement modern medical treatment.’’ Also, significant majority of them (73.9 % of CRIUM, 69 % of Sweekar-OU, and 67.3 % of UNAIR) agreed to having spirituality as an academic subject in medical curriculum (p = 0.0345). Multivariate Binomial Logistic Regression (Full Models Given in Table 4) The binary response variable was agreement to the statement that ‘‘spiritual healing has some benefits and it could be complement to modern medical treatment.’’ Three sets of independent regression analysis was performed comparing (1) Indian TCAM/CRIUM versus Sweekar-OU and UNAIR allopaths clubbed together; (2) Hindu predominant Sweekar-OU versus Muslim predominant groups of CRIUM and UNAIR clubbed together; and (3) Indonesian/UNAIR versus Indian groups/Sweekar-OU and CRIUM combined. All significant variables within each of the study groups were included as numerical predictors into regression model in stepwise manner: step-1 included only demographic variables of age, gender, occupation, and religious affiliation (Model-1). In second step, we entered demographic variables and religious spiritual characteristics of Table 1, (Model-2). In step3, variables related to participants clinical observations and inferences (Table 2) were added to previous models to create Model-3. In fourth/final step, we added variables related to participants’ clinical spiritual care training and interventions (Tables 2, 3) to arrive at our full models. The full models of regression analysis from each of our three sets of regression analysis are shown in Table 4 for comparison, and other three models from step-1, step-2, and step-3 are not shown in tables. Sociodemographic variables (Model-1) were not significant predictors in any of our three comparisons. R/S variables were significant predictors in Models 2 and 3 of all the three comparative sets (p \ 0.05). ‘‘Physicians’ comfort’’ in attending to patient’s spiritual needs became the significant predictor (p = 0.05) in full model of two (CRIUM vs. Others
123
J Relig Health
and Sweekar-OU vs. Others) comparative sets of regression, while it only showed a trend toward significance (p = 0.054) in the full model of regression set ‘‘UNAIR versus Others.’’ Goodness-of-fit test remained significant (p = 0.000). and Kendall’s Tau-a improved to 0.35 through to the final model in all regression sets.
Discussion As hypothesized, more number of Indonesian physicians describes themselves as highly religious and spiritual. They also rated themselves high in intrinsic religiosity as compared to both Indian allopathic as well as TCAM physicians. While such highly r/s orientation could explain Indonesian physician’s acceptance for integrating TCAM and modern medical healthcare services, as literature suggests, in-depth analysis, notwithstanding the low power, revealed that, in actuality, physician’s comfort in providing r/s interventions including interacting with patients on r/s matters and/or referring and interacting with TCAM or r/s healers, etc., to be more predictive of their acceptance of spiritual care as a complement to allopathic treatment. If we consider ‘‘spiritual care’’ as a proxy for TCAM (Hsiao et al. 2008; Mao et al. 2008), then our findings can be extended to suggest that physician’s comfort in attending to patient’s r/s needs to be predictive of their acceptance for ‘‘Integrated health care.’’ Implications of this study findings can be manifold: (1) since physician’s clinical experience of working with r/s or TCAM healers is more important in influencing their acceptance of an ‘‘integrative medicine,’’ we need to encourage or provide opportunities for more collaborative work between the two professionals. (2) In the absence of randomized control studies on TCAM methods, personal experiences of TCAM efficacy may have helped UNAIR physicians grow in comfort while working within an integrated system. Hence, placing TCAM and allopathic physicians ‘‘under one roof’’ as initiated through Indian National Rural Health Mission program (Bodeker et al. 2014; Sharma et al. 2008) may be beneficial to start-with. However, physicians in both counties prefer to work only with evidence-based methods of TCAM (Bodeker et al. 2014). Acceptance of integration may not be an approval of all TCAM methods of care—hence, for more deeper collaboration, RCT studies in TCAM methods may be intensified; (3) integration with TCAM being ancillary to satisfying patient’s ‘‘spiritual care’’ needs the scientific focus should be toward improving spiritual care methods; as of now, there is growing concern of TCAM systems adapting biomedical methods rather than the traditional spiritual components of care (Warrier 2009). Traditional, complementary, and alternative medicine (TCAM) healers are known to develop unique and complex combinations of healing values and traditions by imbibing all effective healing methods that they come across (Popper-Giveon and Weiner-Levy 2013); hence, they may be quick to accept integration with the proven and effective allopathic systems of care but this should only follow an intensive training in it. Modern/evidencebased medicine does not allow easy adaptation of TCAM; hence, we have couple of ways toward an integration process. Since healthcare consumers’ attraction toward TCAM is in its inbuilt element of ‘‘spirituality’’ (Hsiao et al. 2008; Mao et al. 2008), the focus has to be on developing the subject of spirituality in academic medicine. Developing spiritual care curriculum as being provided in several of US medical schools (Anandarajah 2008; Guck and Kavan 2006; Graves et al. 2002; Hull et al. 2001; Lawrence and Duggal 2001; Puchalski 2006) and introduction of spiritual care programs may serve as the best conduit
123
J Relig Health Table 4 Binary logistic regression: comparing the full models of various group combinations listed in columns Outcome measure was agreement with the statement: ‘‘Spiritual healing has some benefits, and it could be a complement to modern medical treatment’’
Full model for CRIUM vs. others (SweekarOU ? UNAIR)
Full model for Sweekar-OU vs. others (CRIUM ? UNAIR)
Full model for UNAIR vs. others (CRIUM ? SweekarOU)
Predicting variables as shown below: *to what extent do you agree with this statement?
B
b
z
B
Z
0.81
z
Step-1: Sociodemographic variables of participants (Model-1): 1. Age
0.103
0.92
0.094
0.93
0.087
2. Gender
0.536
0.41
0.528
0.43
0.389
0.31
3. Religious affiliation
17.451
0.01
17.493
0.01
17.384
0.01
4. Occupational code
10.049
0.01
10.033
0.01
10.028
0.01
Step- 2: Participants’ r/s characteristics and intrinsic religiosity variables (Step-1 ± Step-2 = Model-2) 1. To what extent do you consider yourself as a religious person?
2.680
1.03
2.282
0.97
2.573
1.00
2. To what extent do you consider yourself to be a spiritual person?
0.012
0.00
0.206
0.10
0.046
0.02
3. How often do you attend religious services?
1.634
0.84
1.280
0.79
1.315
0.67
4. *My religious beliefs influence my practice of medicine.
80.407
0.01
96.508
0.01
78.939
0.01
5. *I find it challenging to remain faithful to my religion in my work as physician.
2.412
1.07
2.671
1.18
2.564
1.09
6. *My experiences as a physician have caused me to question my religious beliefs
1.235
0.72
1.292
0.75
1.264
0.73
7. *I try hard to carry my religious beliefs over into all other dealings in life.
0.252
0.14
0.064
0.04
0.240
0.13
8. *My whole life approach is based on my religion
6.279
0.00
5.291
0.00
5.976
0.00
Step-3: Variables related to participants clinical observations and inferences (Step-1 ± Step-2 ? Step3 = Model-3) 1. Overall, how much influence do you think r/s has on patients’ health?
2.325
1.38
2.394
1.40
2.375
1.38
2. Is the influence of r/s on health generally positive or negative?
0.529
0.48
0.449
0.41
0.543
0.49
3. If a patient is severely mentally ill to which of the following they prefer to visit first?
1.705
1.16
1.716
1.19
1.630
1.13
4. *Public in general tries to consciously avoid seeing a psychiatrist for any mental illness.
1.337
0.48
1.615
0.60
1.406
0.50
5. *Stigma associated with mental illness can be reduced by integrating spirituality with psychiatry.
27.966
0.00
37.200
0.00
27.527
0.00
123
J Relig Health Table 4 continued Outcome measure was agreement with the statement: ‘‘Spiritual healing has some benefits, and it could be a complement to modern medical treatment’’
Full model for CRIUM vs. others (SweekarOU ? UNAIR)
Full model for Sweekar-OU vs. others (CRIUM ? UNAIR)
Full model for UNAIR vs. others (CRIUM ? SweekarOU)
Predicting variables as shown below: *to what extent do you agree with this statement?
B
b
B
z
z
Z
Step-4: Variables related to professional training and spiritual care activities (Step-1 ? Step-2 ? Step3 ? Step-4 = Full model) 1. Have you had any formal training regarding r/s in medicine?
6.931
1.46
6.803
1.42
6.699
1.40
2. How often do you inquire about r/s issues when a patient faces a frightening diagnosis or crisis?
1.287
0.60
1.252
0.61
1.164
0.55
3. How often do you inquire about r/s issues when a patient faces the end of life?
1.924
0.48
2.152
0.88
1.971
0.79
4. How often do you inquire about r/s issues when a patient suffers from anxiety and depression?
1.994
0.00
1.901
1.15
1.950
1.17
5. If you were to refer a patient with continued grieving 2 months after death of his wife, to whom would you refer first?
3.097
1.48
3.125
1.50
2.994
1.45
6. *I would feel comfortable discussing r/s concerns if patient brought them up.
7.480§
1.96§
7..535§
1.96§
7.331§
1.92§
Categorical variables (as listed in the columns):
0.935
0.04
8.402
0.00
0.096
0.11
Odds ratio (95 % C.I.), p value [only trend toward significance§]
§
Goodness-of-fit test: Pearson’s Chisquare, df, p value Measures of association between response variables and predicted probabilities: Percentage concordance and Kendall’s Tau-a McFadden’s
*0.00 (0.00–1.00), 0.050
§
98.204, 48, 0.000
119.155, 48, 0.0000
125.648,47, 0.000
96.3 %, 0.35
96.4 % 0.35
96.1 % 0.35
0.00 (0.00–0.99), 0.050
0.00, (0.00–1.14), 0.054
toward a systematic integration of TCAM and modern healthcare systems (Ramakrishnan et al. 2014). Least number of Indian allopaths reportedly received formal training in spirituality— lack of emphasis, during clinical training, on the importance of r/s aspects of health care is reported to be the reason for physician’s indifference or negative attitude toward r/s role in medicine (Hafizi et al. 2013). Research supports that improved communication between allopathic and TCAM practitioners and exposure of allopaths to healthcare benefits of spiritual/TCAM healing to help the integration process but most important issue may be dual-training for clinicians in allopathic and TCAM systems of care (Keshet and PopperGiveon 2013; Popper-Giveon et al. 2013).
123
J Relig Health
Our study findings also reveal that the relationship between r/s beliefs and integrative clinical services may be bidirectional; UNAIR physicians did not shy away from reporting that their clinical experiences were influencing their r/s beliefs as well. Such an openminded approach to inclusion of r/s methods of care (TCAM being used as proxy variable) in an evidence-based/scientific discipline may be beneficial for both, i.e., scientific discipline of medicine as well as for developing our understandings on r/s issues in clinical care. Further studies should include healthcare recipients, i.e., patients and their caregivers, as well as spiritual care providers, such as religious healers, chaplains, and temple priests, so as to understand the perspectives of all the participants in an integrative healthcare system.
Limitations The findings from this study cannot be generalized, and we need further studies to understand underlying subtle religious and cultural factors that influence professionals’ support for integrative medicine or spirituality in healthcare system. Cross-cultural surveys or studies inherently difficult; the challenging part of this exploratory cross-cultural study with three different institutes, Sweekar-OU, UNAIR, and CRIUM, was like comparing oranges to apples to mangoes; these groups differed from one another either in their r/s composition and/or medical system of training. The survey measures are largely selfreports and may not accurately represent physicians’ actual practice. The methods may also not capture the subtle nuances of the ways in which a particular religious theme is represented or understood. R/S affiliation and characteristics are vital parts of sociocultural makeup that influence professional care; hence, we did not control them in our statistical analysis but subtle forms of response bias are possible due to physician’s intrinsic religiosity. Hence, there may be some unmeasured characteristics influencing participant’s responses. The participating institutions were selected based on convenience and in an exploratory way and not randomly; being a pilot study in a newly emerging discipline, institutions that were more willing to participate were chosen. It must be acknowledged that funding is another important barrier for such new initiatives, particularly in a crosscultural context; we were able to overcome this constraint by selecting interested and likeminded partners committed to this area of research. Nevertheless, such studies as this, throwing light on the experiences of professionals across cultural divides will help in quicker knowledge transfer and Lamarckian type of growth/evolution of our medical systems.
Conclusion Physicians’ clinical experiences in meeting patients’ spiritual care needs play more important role than their personal r/s characters in influencing perspectives on the role of spirituality in medicine or integrative medicine. This study supports a circular logic that comfort in attending to patient’s spiritual care needs allows clinicians to accept integrative services and only through clinical association/experience an allopath grows in such comfort. This paper also highlights the importance of conducting cross-cultural studies that can compare sets of populations with similar and dissimilar religious, social, cultural, and educational (such as TCAM vs. allopathy) variables. Each of these factors/variables may be important in influencing physicians’ interest and comfort in providing spiritual care for their patients and by extension to integrative healthcare services.
123
J Relig Health
References Allport, G. W., & Ross, J. M. (1967). Personal religious orientation and prejudice. Journal of Personality and Social Psychology, 5(4), 432–443. Anandarajah, G. (2008). The 3 H and BMSEST models for spirituality in multicultural whole-person medicine. Annuals of Family Medicine, 6(5), 448–458. Avasthi, A., Kate, N., & Grover, S. (2013). Indianization of psychiatry utilizing Indian mental concepts. Indian Journal of Psychiatry, 55(Suppl 2), S136–S144. doi:10.4103/0019-5545.105508. Bodeker, G., & Burford, G. (2008). Traditional, complementary and alternative medicine-policy and public health perspectives. Jounal of Alternativeand Complementary Medicine, 14(1), 103–104. Bodeker, G., Ong, C. K., Grundy, C., Burford, G., & Shein, K. (2014). WHO Global Atlas of Traditional, Complementary and Alternative Medicine. World Health Organization. The WHO Center for Health Development, Kobe 2005. (http://books.google.com/books?id=VO8K9h9GvaoC&printsec= frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false. Accessed January 30, 2014. Bodeker, G., & Kronenberg, F. (2002). A public health agenda for traditional, complementary, and alternative medicine. American Journal of Public Health, 92(10), 1582–1591. Chandrashekar, H., Prashanth, N. R., Naveenkumar, C., & Kasthuri, P. (2009). Innovations in psychiatry: Ambulatory services for the mentally ill. Indian Journal of Psychiatry, 51, 169–170. Curlin, F. A., Chin, M. H., Sellergren, S. A., Roach, C. J., & Lantos, J. D. (2006). The association of physicians’ religious characteristics with their attitudes and self-reported behaviors regarding religion and spirituality in the clinical encounter. Medical Care, 44(5), 446–453. Curlin, F. A., Lantos, J. D., Roach, C. J., Sellergren, S. A., & Chin, M. H. (2005). Religious characteristics of U.S. physicians: A national survey. Journal of General Internal Medicine, 20(7), 629–634. Curlin, F. A., Lawrence, R. E., Odell, S., Chin, M. H., Lantos, J. D., Koenig, H. G., et al. (2007). Religion, spirituality, and medicine: Psychiatrists’ and other physicians’ differing observations, interpretations, and clinical approaches. American Journal of Psychiatry, 164(12), 1825–1831. Curlin, F. A., Rasinski, K. A., Kaptchuk, T. J., Emanuel, E. J., Miller, F. G., & Tilburt, J. C. (2009). Religion, clinicians, and the integration of complementary and alternative medicines. Journal of Alternative and Complementary Medicine, 15(9), 987–994. Frass, M., Strassl, R. P., Friehs, H., Mu¨llner, M., Kundi, M., & Kaye, A. D. (2012). Use and acceptance of complementary and alternative medicine among the general population and medical personnel: A systematic review. The Ochsner Jounal, 12(1), 45–56. Graves, D. L., Shue, C. K., & Arnold, L. (2002). The role of spirituality in patient care: Incorporating spirituality training into medical school curriculum. Academic Medicine, 77(11), 1167. Guck, T. P., Kavan, M. G. (2006). Medical student beliefs: Spirituality’s relationship to health and place in the medical school curriculum. Creighton University School of Medicine, Omaha, NE 68102, USA. Medical Teaching, 28(8), 702–707. Hafizi, S., Koenig, H. G., Arbabi, M., Pakrah, M., & Saghazadeh, A. (2013). Attitudes of Muslim physicians and nurses toward religious issues. Journal of Religion and Health. Hsiao, A. F., Wong, M. D., Miller, M. F., Ambs, A. H., Goldstein, M. S., Smith, A., et al. (2008). Role of religiosity and spirituality in complementary and alternative medicine use among cancer survivors in California. Integrative Cancer Therapies, 7(3), 139–146. Hull, S. K., DiLalla, L. F., & Dorsey, J. K. (2001). Student attitudes toward wellness, empathy, and spirituality in the curriculum. Academic Medicine, 76(5), 520. Keshet, Y., & Popper-Giveon, A. (2013). Integrative health care in Israel and traditional arab herbal medicine: When health care interfaces with culture and politics. Medical Anthropology Quarterly, 27(3), 368–384. doi:10.1111/maq.12049. Epub 2013 Oct 8. Kurihara, T., Kato, M., Reverger, R., & Tirta, I. G. (2006). Pathway to psychiatric care in Bali. Psychiatry and Clinical Neurosciences, 60(2), 204–210. Lahariya, C., Singhal, S., Gupta, S., & Mishra, A. (2010). Pathway of care among psychiatric patients attending a mental health institution in central India. Indian Journal of Psychiatry, 52, 333–338. Lawrence, R. M., & Duggal, A. (2001). Spirituality in psychiatric education and training. Journal of the Royal Society of Medicine, 94(6), 303–305. Lee, E., & Baumann, K. (2013) German psychiatrists’ observation and interpretation of religiosity/spirituality. Evidence-Based Complementary and Alternative. 2013:280168. doi:10.1155/2013/280168. Epub 2013 Nov 14. Lee Ventola, C. (2010). Current issues regarding Complementary and Alternative Medicine (CAM) IN United States Current Issues Regarding Complementary and Alternative Medicine (CAM) in the United States. Part 1: The Widespread use of CAM and the need for better-informed health care professionals to provide patient counseling. P T. 2010 August; 35(8): 461–468.
123
J Relig Health Mao, J. J., Palmer, S. C., Straton, J. B., Cronholm, P. F., Keddem, S., Knott, K., et al. (2008). Cancer survivors with unmet needs were more likely to use complementary and alternative medicine. Journal of Cancer Survivorship, 2(2), 116–124. Mishra, N., Nagpal, S. S., Chadda, R. K., & Sood, M. (2011). Help-seeking behavior of patients with mental health problems visiting a tertiary care center in north India. Indian Journal of Psychiatry, 53(3), 234–238. Pols, H. (2006). The development of psychiatry in Indonesia: from colonial to modern times. International of Review of Psychiatry, 18(4), 363–370. Popper-Giveon, A., Schiff, E., & Ben-Arye, E. (2013). We and they in the house of healing: Debate among Arab complementary medicine practitioners on an integrative versus alternative approach to supportive cancer care. Integrative Cancer Therapies, 12(6), 488–495. doi:10.1177/1534735413485818. Epub 2013 Apr 26. Popper-Giveon, A., Weiner-Levy, N. (2013). Returning to ourselves: Palestinian complementary healers in Israel. Qualitative Health Research. 2013 Nov 8. [Epub ahead of print]. Puchalski, C. M. (2006). Spirituality and medicine: Curricula in medical education. Journal of Cancer Education, 21(1), 14–18. Ramakrishnan, P., Dias, A., Rane, A., Shukla, A., Lakshmi, S., Ansari, B. K., Ramaswamy, R. S., Reddy, A.R., Tribulato, A., Agarwal, A. K., Bhat, J., Satyaprasad, N., Mushtaq, A., Rao, P. H., Murthy, P., Koenig, H. G. (2013) Perspectives of indian traditional and allopathic professionals on religion/ spirituality and its role in medicine: Basis for developing an integrative medicine program. Journal of Religion and Health. 2013 Apr 27. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/ 23625126. Ramakrishnan, P., Rane, A., Dias, A., Bhat, J., Shukla, A., Lakshmi, S., Ansari, B. K., Ramaswamy, R. S., Reddy, R. A., Tribulato, A., Agarwal, A. K., Satyaprasad, N., Mushtaq, A., Rao, P. H., Murthy, P., & Koenig, H. G. (2014) Indian health care professionals’ attitude towards spiritual healing and its role in alleviating stigma of psychiatric services. Journal of Religion and Health. 2014 Jan 16. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/?term=24430129. Sharma, S. K., Chadha, S. K., Negi, M., Katoch, D. C., Raghu, A., & Sharma, V. (2008). A manual for doctors on mainstreaming of AYUSH under NRMH. New Delhi: Department of AYUSH, Ministry of Health and Family Welfare. Sheppe, A. H., Nicholson, R. F, 3rd, Rasinski, K. A., Yoon, J. D., & Curlin, F. A. (2013). Providing guidance to patients: Physicians’ views about the relative responsibilities of doctors and religious communities. Southern Medical Journal, 106(7), 399–406. Verma, U., Sharma, R., Gupta, P., Gupta, S., & Kapoor, B. (2007) Allopathic vs. ayurvedic practices in tertiary care institutes of urban North India. Indian Journal of Pharmacology. 2007. 39, 1, Jan–Feb, 52–54 (http://www.bioline.org.br/request?ph07012. Accessed January 30, 2014. Warrier, M. (2009). Seekership, spirituality and self-discovery: Ayurveda trainees in Britain. Asian Med (Lieden), 4(2), 423–451. World Health Organization Regional Office of South East Asia (2009) The use of herbal medicines in primary health care. report of regional meeting, Yongon, Myanmar, March 10–12, 2009. (http://www. searo.who.int/entity/primary_health_care/documents/pch_sea_hsd_322.pdf. Accessed January 1, 2014.
123
Religious/Spiritual Characteristics of Indian and Indonesian Physicians and Their Acceptance of Spirituality in Health care: A Cross-Cultural Comparison P. Ramakrishnan • A. Karimah • K. Kuntaman • A. Shukla B. K. M. Ansari • P. H. Rao • M. Ahmed • A. Tribulato • A. K. Agarwal • H. G. Koenig • P. Murthy
•
Springer Science+Business Media New York 2014
Abstract Religious/spiritual (r/s) characteristics of physicians influence their attitude toward integrative medicine and spiritual care. Indonesia physicians collaborate with traditional, complementary, and alternative medicine (TCAM) professionals within modern healthcare system, while Indian physicians are not reported to do so. The aim of the study was to understand the r/s characteristics and their influence on Indian and Indonesian physicians’ acceptance of TCAM/spirituality in modern healthcare system. An exploratory, pilot, crosscultural, cross-sectional study, using Religion and Spirituality in Medicine, and Physician Perspectives (RSMPP) survey questionnaire, compared r/s characteristics and perspectives on integrative medicine of 169 physicians from two allopathic, Sweekar-Osmania University
P. Ramakrishnan Center for Development of Spirituality as Medical Subject, AdhiBhat Foundation India, R-80 Greater, Kailaish, New Delhi, India P. Ramakrishnan (&) Center for Study of World Religions, Harvard Divinity School, Harvard University, 42 St. Francis Avenue, Cambridge, MA 02138, USA e-mail: [email protected] A. Karimah Department of Psychiatry, Faculty of Medicine, Dr. Soetomo General Hospital, University of Airlangga, Jl. Mayjen Prof. dr. Moestopo 6-8, Surabaya, Indonesia K. Kuntaman Department of Clinical Microbiology, School of Medicine, Dr. Soetomo Hospital Surabaya, Airlangga University, Surabaya, Indonesia A. Shukla Institute of Post Graduate Teaching and Research in Ayurveda, Jamnagar, Gujarat, India B. K. M. Ansari M. Ahmed Central Research Institute of Unani Medicine, Hyderabad, Andhra Pradesh, India P. H. Rao Sweekaar-Upkaar Rehabilitation Institute for Handicapped, Osmania University, Secunderabad, India
123
J Relig Health
(Sweekar-OU), India, University of Airlanga (UNAIR), Indonesia, and a TCAM/Central Research Institute of Unani Medicine (CRIUM) institute from India. More physicians from UNAIR and CRIUM (89.1 %) described themselves as ‘‘very’’/‘‘moderately’’ religious, compared to 63.5 % Sweekar-OU (p = 0.0000). Greater number of (84.6 %) UNAIR physicians described themselves as ‘‘very’’ spiritual and also significantly high (p \ 0.05) in intrinsic religiosity as compared to Sweekar-OU and TCAM physicians; 38.6 % of UNAIR and 32.6 % of CRIUM participants reported life-changing spiritual experiences in clinical settings as against 19.7 % of Sweekar-OU; 92.3 % of UNAIR, compared to CRIUM (78.3 %) and Sweekar-OU (62 %), felt comfortable attending to patients’ spiritual needs, (p = 0.0001). Clinical comfort and not r/s characteristics of participants was the significant (p = 0.05) variable in full regression models, predictive of primary outcome criteria; ‘‘TCAM or r/s healing as complementary to allopathic treatment.’’ In conclusion, mainstreaming TCAM into healthcare system may be an initial step toward both integrative medicine and also improving r/s care interventions by allopathic physicians. Keywords Allopathy Spirituality Religion Integrative medicine TCAM Transcultural Curriculum
Introduction Physicians and patients in advanced/developed nations seek to provide and receive, respectively, religious/spiritual (r/s) interventions for medical and mental illnesses. Physicians are known to ascribe more responsibility to r/s healers when modern medicine seems to fail (Sheppe et al. 2013); their personal r/s commitments are reported to influence their support to integrative medicine programs (Lee and Baumann 2013; Curlin et al. 2005, 2009). Similarly, patients in these developed nations seek traditional, complementary, and alternative (TCAM) treatment for chronic ailments such as arthritis and serious illnesses such as cancer (Lee Ventola 2010); increased religiosity/spirituality is known to be the reason for patient’s preference for TCAM use (Hsiao et al. 2008; Mao et al. 2008). Increased usage of TCAM therapies by patients is reportedly due to beneficial effects outweighing the costs, increased patient autonomy, availability of information on TCAM or contact with its users, and/or perception that TCAM is safer and less expensive (Lee Ventola 2010; Frass et al. 2012). Though medical professionals regard the clinical efficacy of TCAM methods to be controversial, the health administrative bodies in these developed nations have encouraged and/or provided TCAM training to their physicians and medical students (Lee Ventola 2010; Frass et al. 2012). Thus, attempts to integrate pluralistic medical systems in these developed nations include integration of healthcare services, educational, and research programs (Bodeker and Kronenberg 2002).
A. Tribulato A. K. Agarwal HELP Foundation of Omaha, Omaha, NE, USA H. G. Koenig Department of Psychiatry, Duke University Medical Center, Durham, NC, USA P. Murthy De-addiction Center, Department of Psychiatry, National Institute of Mental Health and NeuroSciences, Bangalore, Karnataka, India
123
J Relig Health
In developing countries, 60–90 % of population in the rural and remote parts of the society is known to be dependent on TCAM medications for their primary healthcare needs—the main reason for such an extensive use is because of their perception of safety, availability, and affordability of TCAM medications and services (World Health Organization Regional Office of South East Asia 2009). TCAM methods are also considered to be holistic care, which becomes more important specially while treating mental illnesses; speaking of India and Indonesia, the two countries of interest in this study, TCAM and r/s care are preferred over modern medicine because of the belief in the supernatural causation of mental disorders (Avasthi et al. 2013; Kurihara et al. 2006) as well as because of stigma toward modern mental health facilities (Kurihara et al. 2006; Mishra et al. 2011; Lahariya et al. 2010; Chandrashekar et al. 2009; Pols 2006). In accordance with World Health Organization policies on TCAM [(Bodeker and Burford 2008; Bodeker et al. 2014), India and Indonesia had started integrating TCAM into modern healthcare systems. India and Indonesia have robust TCAM systems functioning alongside modern healthcare system but in Indonesia, there is extensive collaboration between the two while modern medical professionals in India are opposed to the integration of their services (Bodeker et al. 2014). Indonesian healthcare system allows its allopathic professionals to provide TCAM therapy such as acupuncture and pharmacists are allowed to dispense TCAM medications. In this country, TCAM schools are located within the allopathic medical education system and their education/training is regulated by university programs that govern allopathic medical education. TCAM providers are legally recognized and function within healthcare services (Bodeker and Burford 2008; Bodeker et al. 2014). Thus, there seems to be functional fluidity between allopathic and TCAM medical systems in Indonesia. India, on the other hand, has a separate federal department of AYUSH (acronym for Ayurveda, Yoga-Naturopathy, Unani, Siddha, and Homeopathy) that supervises TCAM education and training, independent of allopathic medical system (Sharma et al. 2008). TCAM physicians have minimal training in allopathic methods during their schooling while allopathic students have none of TCAM training. Yet, in reallife practice, we find allopathic physicians prescribing Ayurvedic/herbal medications and vice versa—such a practice is legally contested by individuals from both the systems citing inadequate training of professionals in ‘‘integrative medicine’’ (Verma et al. 2007). While Indian National Rural Health Mission attempts to develop an integrative healthcare system by recruiting AYUSH professionals into mainstream allopathic practice (Sharma et al. 2008), one may be informed of the significant resistance of Indian allopathic physicians against such integration (Bodeker et al. 2014). This study was carried out to understand Indian and Indonesian professionals’ differential support to integrative medicine in their respective countries. Based on the existing literature on clinical practices, we hypothesized that Indonesian physicians will be more religious or spiritual as compared to Indian counterparts and that would be the reason for their acceptance of integrated healthcare system.
Methodology This is an exploratory, pilot, cross-cultural study that included three tertiary care medical institutes, two from India and one from Indonesia. Sweekar, a mental health institute under Osmania University (Sweekar-OU), Hyderabad, India, and the psychiatric medical faculty of University of Airlanga (UNAIR) in Surabaya, Indonesia, are two allopathic medical institutions that were preselected into this study. However, we realized that the religious
123
J Relig Health
affiliation of participants in these two institutes was strikingly different; the Indonesian group consisted of predominantly Muslim physicians while Indian group had predominantly Hindu participants. To offset such sampling error and to compare groups with identical r/s characteristics, we also included Central Research Institute of Unani Medicine (CRIUM) in Hyderabad, India, into our study. Unani is a TCAM with its origin in Islamic tradition, and hence, participants from CRIUM shared identical religious affiliation as that from UNAIR. Including these three institutes gave us a unique opportunity to compare not only professionals across nationalities but also across medical systems. All officially registered clinicians undergoing rotatory training, during the 2010–2011 academic year, in these settings were enrolled consecutively, and they formed the three comparative groups of our study. Participants were provided with Religion and Spirituality in Medicine: Physician Perspective (RSMPP) (Curlin et al. 2005; Curlin et al. 2006, 2007); a self-administered, semistructured survey questionnaire to understand their r/s beliefs, practices, and perspectives on r/s in clinical medicine was used along with a specially developed supplementary questionnaire that explores participant’s views on r/s in mental healthcare services. Detailed methodology of the study and questionnaire development was described elsewhere (Ramakrishnan et al. 2013, (2014). The primary criterion variable was physician’s agreement with the statement: ‘‘Spiritual healing has some benefits, and it could be a complement to modern medical treatment’’— answer choices were ‘‘strongly agree, agree, disagree, or strongly disagree.’’ Predictor variables were clustered into participant’s (a) personal r/s characteristics except their religious affiliation (Table 1), (b) clinical observations and interpretations of patients’ spiritual care needs as well as participants’ attempts to address them (Table 2), and (c) participants’ and patients’ referral/self-referral practices related to mental health, stigma, and spiritual healing (Table 3). The control variables (Table 1) include participant’s age, gender, and religious affiliation. Sigma XL statistical software was used to compare the data between study groups; one-way ANOVA, Pearson’s v2 test, and multivariate logistic regression models were used. We first generated overall population estimates for participant’s religious characteristics and then measured them against their agreement with the primary criterion variable.
Results All enrolled participants in each of the study centers Sweekar-OU (N = 71), UNAIR (N = 52), and CRIUM (N = 46) returned their completed survey; this response rate of 100 % was achieved through three or more personal meetings, encouraging the participants to return their completed survey questionnaires. The Sociodemographic Characteristics (not in Tables) Participants at UNAIR were significantly younger (mean age 29.6, SD 4.1) than those at CRIUM and Sweekar-OU (35.3, SD 12.4) (p = 0.0146, F = 4.352). Though more number of females participated at CRIUM (59.1 %) as compared to other groups (45.6 % at Sweekar-OU and 42 % at UNAIR), there was no statistically significant difference (p = 0.2181, v2 = 3.046, df 2) between groups’ gender distribution.
123
J Relig Health Table 1 Personal religion/spiritual characteristics of participants Religious/spiritual variables
CRIUM
Religious affiliation
N = 46 (%)
SweekarOU N = 71 (%)
Christianity
1 (2.2)
10 (14.1)
7 (13.5)
Hinduism
2 (4.3)
53 (74.6)
1 (2.0)
41 (89.1)
5 (7.0)
44 (84.6)
Islam
UNAIR
Analysis
N = 52 (%)
v2, df, p value 117.62 4 0.0000
To what extent do you consider yourself a religious person? Would you say you are Very religious
22 (47.8)
6 (8.5)
8 (15.4)
Moderately religious
19 (41.3)
39 (55.0)
39 (75.0)
Slightly religious
2 (4.3)
20 (28.2)
4 (7.7)
Not religious at all
1 (2.2)
4 (5.6)
1 (1.9)
41.507 6 0.0000
To what extent do you consider yourself a spiritual person? Would you say you are Very spiritual
16 (34.8)
6 (8.5)
8 (15.4)
Moderately spiritual
18 (39.1)
39 (55.0)
36 (69.2)
Slightly spiritual
8 (18.4)
21 (29.6)
6 (11.5)
Not spiritual at all
2 (4.3)
2 (2.8)
2 (3.8)
20.451 6 0.0023
Religious practices How often do you attend religious services (A29) Never to about once or twice a month
7 (15.2)
17 (24.0)
0 (0.0)
Several times a year to two or three times a month
11 (24.0)
16 (22.5)
5 (9.6)
Nearly every week to several times a week.
26 (56.5)
33 (46.5)
46 (88.5)
24.138 4 0.0001
Intrinsic religiosity: ‘‘My whole approach to life is based on my religion’’ (A32 h) Strongly agree/agree Disagree/strongly disagree
36 (78.3)
28 (39.4)
47 (90.4)
7 (15.2)
37 (52.1)
4 (7.7)
‘‘I try hard to carry on my religious beliefs over into all my other dealings in life’’ (A32 g) Strongly agree/agree
17 (37.0)
41 (57.7)
41 (78.8)
Disagree/strongly disagree
25 (54.3)
23 (32.4)
10 (19.2)
‘‘My religious beliefs influence my practice of medicine’’ (A32 d) Strongly agree/agree Disagree/strongly disagree
38 (82.6)
30 (42.3)
43 (82.7)
3 (6.5)
29 (40.8)
7 (13.5)
‘‘I find it challenging to remain faithful to my religion in my work as a healthcare provider’’ (A32 e) Strongly agree/agree
23 (50.0)
24 (33.8)
42 (80.8)
Disagree/strongly disagree
15 (32.6)
33 (46.5)
9 (17.3)
‘‘My experiences as a healthcare provider have caused me to question my religious beliefs’’ (A32 f) Strongly agree/agree
10 (21.7)
12 (17.0)
24 (46.2)
Disagree/strongly disagree
30 (65.2)
46 (64.8)
27 (52.0)
38.074 2 0.0000 15.800 2 0.0004 27.618 2 0.0000 18.325 2 0.0001 9.725 2 0.0077
Counts do not equal ‘‘N’’ due to partial non-responses
123
J Relig Health Table 2 Physician’s clinical observations and interpretations on patient’s behavior related to their physical, mental, and spiritual health needs Questionnaire item (Q no. in brackets) on clinical observations and their interpretation
Response (Codes)
In your experience, how often have your patients received emotional or practical support from their religious community? (A10 b)
Never/rarely
In your experience, how often have your patients mentioned r/s issues like God, prayer, scriptures etc.?
Often/always
How often would you say experience of illness increases patients’ awareness of and focus on r/s?
Never/rarely
24 (52.2)
Often/always
10 (21.7)
32 (45.1)
16 (30.8)
Overall, how much influence do you think religion/spirituality has on patients’ health
Very much ? Much
34 (74.0)
41 (57.7)
44 (84.6)
Is the influence of religion/spirituality on health generally positive or negative?
In the following clinical situations, how often do you inquire about religious/ spiritual issues? (a) …faces a frightening diagnosis or crisis (b) …faces the end of life
N = 46 (%)
SweekarOU N = 71 (%)
UNAIR N = 52 (%)
7 (15.2)
22 (31.0)
13 (25.0)
Sometimes
13 (28.3)
12 (17.0)
12 (23.1)
Often/always
12 (26.1)
29 (41.0)
25 (48.1)
Never/rarely
11 (24.0)
19 (26.8)
9 (17.3)
Sometimes
10 (21.7)
9 (12.7)
12 (23.1)
9 (19.6)
30 (42.3)
26 (50.0)
7 (15.2)
12 (17.0)
5 (9.6)
25 (35.2)
27 (52.0)
Sometimes
Some
3 (6.5)
10 (14.1)
1 (2.0)
A little/very little to none
9 (19.6)
19 (26.8)
7 (13.5)
Generally positive
39 (84.8)
39 (55.0)
39 (75.0)
Generally negative
2 (4.3)
8 (11.3)
1 (2.0)
Equally positive and negative
4 (8.7)
18 (25.4)
12 (23.1)
It has no influence
1 (2.2)
4 (5.6)
0 (0.0)
Never/rarely
12 (26.0)
26 (36.6)
3 (5.8)
Sometimes
14 (30.4)
11 (15.5)
36 (68.2)
9 (19.6)
16 (22.5)
10 (19.2)
Often/always Never/rarely Sometimes
(c) …suffers from anxiety or depression
CRIUM
5 (10.9)
24 (33.8)
3 (5.8)
26 (56.5)
18 (25.4)
43 (82.7)
Often/always
4 (8.7)
8 (11.3)
3 (5.8)
Never/rarely
6 (13.0)
20 (28.2)
2 (3.8)
Sometimes
25 (54.3)
20 (28.2)
32 (61.5)
Often/always
10 (21.7)
18 (25.4)
14 (26.9)
To what extent do you agree/disagree with following statement? I would feel comfortable discussing patient’s r/s concerns if patient brought them up: (Re-A8)
Strongly agree/ agree
36 (78.3)
44 (62.0)
48 (92.3)
6 (13.0)
27 (38.0)
4 (7.7)
Have you had any formal training regarding r/s in medicine?
Yes
24 (52.2)
6 (8.5)
No
16 (34.8)
62 (87.3)
42 (8)
Did you ever have a r/s experience that changed your life?
Yes
24 (52.2)
37 (52.1)
36 (69.2)
No
19 (41.3)
26 (36.6)
15 (28.8)
123
Disagree/ strongly disagree
10 (19.2)
Analysis v2, df, p value
6.096 4 0.1921 8.121 4 0.0873 8.248 4 0.829 11.393 4 0.0225
15.948 6 0.0140
33.041 4 0.0000
33.009 4 0.0000 19.630 4 0.0000 18.024 2 0.0001
36.547 2 0.0000 2.572, 2 0.2763
J Relig Health Table 2 continued Questionnaire item (Q no. in brackets) on clinical observations and their interpretation
Response (Codes)
CRIUM
If Yes: did the experience occur in the context of practicing medicine?
Yes
15 (32.6)
14 (19.7)
20 (38.5)
No
8 (17.4)
22 (30.9)
16 (30.8)
N = 46 (%)
SweekarOU N = 71 (%)
UNAIR
Analysis v2, df, p value
N = 52 (%)
4.262, 2 0.1187
Counts do not equal ‘‘N’’ due to partial non-responses
R/S Characteristics (Table 1) The religious affiliations were collapsed into four major groups: Christian, Hindu, Islam, and Others. ‘‘Others’’ included non-respondents as well as those who described themselves as Atheists or Agnostics. Groups differed significantly (p = 0.0000) due to participants religious affiliation; it was predominantly Islam among CRIUM (89.1 %) and UNAIR (84.6 %) while being Hinduism at Sweekar-OU (74.6 %). Significantly (p = 0.0001) greater numbers (88.5 %) of UNAIR physicians reportedly attended religious services, ‘‘nearly every week to several times a week,’’ as compared to CRIUM (56.5 %) and Sweekar-OU (46.5 %) professionals. While 90.4 % of UNAIR and 89.1 % of CRIUM called themselves (moderate/very) ‘‘religious’’ (p = 0.0001), and similarly greater numbers among these two groups (84.6 % of UNAIR and 73.9 % of CRIUM) considered themselves to be (moderate/very) ‘‘spiritual’’ (p = 0.0023), though fewer in numbers, Sweekar-OU allopaths considered themselves to be equally (63.5 %) ‘‘religious’’ and ‘‘spiritual’’ (moderate/very). Intrinsic religiosity (Lee Ventola 2010; Allport 1967) (measured as agreement with statements such as ‘‘My whole approach to life is based on my religion,’’ ‘‘I try hard to carry on my religious beliefs over into all my other dealings in life,’’ and ‘‘My religious beliefs influence my practice of medicine’’) was significantly (p \ 0.0005) high among UNAIR followed by CRIUM and least in Sweekar-OU group. Ironically, almost equally greater numbers (80.8 %) of UNAIR participants, also, reportedly ‘‘find it challenging to remain faithful to their religion’’ while providing health care, about half (46.2 %) of them also agree that their clinical experiences ‘‘cause them to question their religious beliefs’’; greater percentage of both the Indian study groups disagreed to both these statements (p \ 0.05). Participants’ Clinical Observations and Interpretations on Patient’s Behavior Related to their Physical, Mental, and Spiritual Health Needs (Table 2) University of Airlanga had greatest percentage (71.2) of participants who believed their ‘‘patients to be receiving (sometimes/often/always) emotional and practical support from their religious community,’’ followed by Sweekar-OU (58 %) and CRIUM (54.4 %). Majority (73.1 %) among UNAIR report their patients referring to ‘‘r/s issues such as God or scriptures’’ during clinical visit as compared to only 55 % of Sweekar-OU and 41.3 % of CRIUM participants. On the other hand, fewer UNAIR (52.8 %) participants as compared to Indian (80.3 % of Sweekar-OU and 73.9 % of CRIUM) believed that illness experience increased patients’ awareness and focus on r/s issues.
123
J Relig Health Table 3 Professionals’ and patients’ referral/self-referral practices with regard to mental health care Questionnaire item (Q no. in brackets) on clinical observations and their interpretation
Response (Codes)
A patient presents to you with continued deep grieving two months after the death of his wife; If you were to refer the patient, to which of the following would you prefer to refer first? (A16)
A religious place for healing
Please answer to the best of your knowledge about the behavior among the public …If a patient is severely mentally ill to which of the following would they prefer to visit first? (B5)
CRIUM N = 46 (%) 4 (8.7)
SweekarOU N = 71 (%) 2 (2.8)
UNAIR N = 52 (%) 1 (1.9)
TCAM
14 (30.4)
13 (18.3)
10 (19.2)
A psychiatrist or psychologist
19 (41.3)
51 (71.8)
40 (76.9)
Others (Specify)
4 (8.7)
0 (0.0)
0 (0.0)
A religious place for healing
9 (19.6)
10 (14.1)
8 (15.4)
TCAM A psychiatrist or psychologist
6 (13.0)
11 (15.5)
14 (26.9)
23 (50.0)
40 (56.3)
28 (53.8)
Others (Specify)
5 (10.9)
1 (1.4)
2 (3.8)
Almost always— usually true
27 (58.7)
51 (71.8)
48 (92.3)
Sometimes true
14 (30.4)
10 (14.1)
4 (7.7)
Usually-almost never true
4 (8.7)
3 (4.2)
0 (0.0)
Very satisfied/ Satisfied
21 (45.7)
26 (36.6)
21 (40.4)
Dissatisfied/very dissatisfied
4 (8.7)
7 (9.9)
11 (21.2)
Stigma associated with mental illness can be reduced (if not eliminated) by integrating spirituality into psychiatry; To what extent do you agree with this statement? (B8)
Strongly agreeagree
44 (95.6)
46 (64.8)
50 (96.2)
0 (0.0)
12 (16.9)
1 (1.9)
Spiritual healing has some benefits and it could be a complement to modern medical treatment. (B14 c)
Strongly agree/agree
38 (82.6)
47 (66.2)
49 (94.2)
4 (8.7)
7 (9.9)
3 (5.7)
Spirituality as a healthcare tool is a subject worthy to be introduced into medical school curriculum
Strongly agree/agree
34 (73.9)
49 (69.0)
35 (67.3)
8 (17.4)
7 (9.9)
17 (32.7)
Public in general tries to consciously avoid seeing a psychiatrist for any mental illness: How true is this statement? (B7) In your experience with religious/ faith healers, have you been (A17)
Disagree-strongly disagree
Disagree/strongly disagree Disagree/strongly disagree
Analysis v2, df, p value
22.070 6 0.0012
8.698 6 0.1913
15.455 4 0.0038
2.861 2 0.2392 17.979 2 0.0001
1.601 2 0.4491 6.732 2 0.0345
Counts do not equal ‘‘N’’ due to partial non-responses
Significantly (p \ 0.05) greater numbers of participants from UNAIR and CRIUM report r/s to have greater (very much/much) influence on patients health (84.6 and 74 %, respectively) and believed that influence to be ‘‘generally positive’’ (75 and 84.8 %, respectively); \58 % of Indian allopaths reportedly believed in such an influence. UNAIR physicians reportedly attended to spiritual needs of their patients in clinical situations such as (a) ‘‘facing dangerous diagnosis or crisis,’’ (b) ‘‘end of life,’’ and (c) ‘‘suffering from anxiety and depression,’’ in significantly (p = 0.0000) greater numbers (86.4, 88.5, 88.4 %, respectively); even CRIUM participants report to provide such a service at higher numbers (50, 65.2, 76 %, respectively) as compared to allopaths at Sweekar-OU (38, 36.7, and 53.7 %, respectively).
123
J Relig Health
Almost all UNAIR participants (92.3 %) reportedly felt comfortable discussing r/s concerns of their patients (compared to only 78.3 % of CRIUM and even less, 62 % of Sweekar-OU), p = 0.0001; In spite of this fact, significantly (p = 0.0000) fewer Indonesian/UNAIR (19.2 %) and Indian/Sweekar-OU (8.5 %) allopaths reportedly received formal training regarding ‘‘r/s in medicine’’ as compared to 52.2 % of Indian TCAM/ CRIUM physicians. Greater number of UNAIR physicians (69.2 %) reported r/s experiences that changed their lives, about half of those experiences (38.5 %) were in clinical settings. Professionals’ and Patients’ Referral/Self-Referral Practices with Regard to Mental and Spiritual Health Needs Majority of Sweekar-OU (71.8 %) and UNAIR (76.9 %) allopaths preferred to refer a 2-month grieving patient to a psychiatrist/psychologist while only 41.3 % of TCAM/ CRIUM group reported to do the same (p = 0.0012). A significant (p = 0.0038) number of UNAIR allopaths (92.3 %) reportedly believe that ‘‘general public consciously avoids (almost always/usually) seeing psychiatrists for mental illnesses’’ as compared to only 71.8 % of Indian allopaths and even lesser (58.7 %) of CRIUM. Significantly (p = 0.0001) greater numbers of CRIUM (95.6 %) and UNAIR (96.2 %) as compared to Sweekar-OU (64.8 %) agreed that ‘‘stigma associated with mental illness can be minimized by integrating spirituality into psychiatric services.’’ A majority within each study group, highest being UNAIR at 94.2 %, agreed/strongly agreed that ‘‘spiritual healing has some benefits and it can complement modern medical treatment.’’ Also, significant majority of them (73.9 % of CRIUM, 69 % of Sweekar-OU, and 67.3 % of UNAIR) agreed to having spirituality as an academic subject in medical curriculum (p = 0.0345). Multivariate Binomial Logistic Regression (Full Models Given in Table 4) The binary response variable was agreement to the statement that ‘‘spiritual healing has some benefits and it could be complement to modern medical treatment.’’ Three sets of independent regression analysis was performed comparing (1) Indian TCAM/CRIUM versus Sweekar-OU and UNAIR allopaths clubbed together; (2) Hindu predominant Sweekar-OU versus Muslim predominant groups of CRIUM and UNAIR clubbed together; and (3) Indonesian/UNAIR versus Indian groups/Sweekar-OU and CRIUM combined. All significant variables within each of the study groups were included as numerical predictors into regression model in stepwise manner: step-1 included only demographic variables of age, gender, occupation, and religious affiliation (Model-1). In second step, we entered demographic variables and religious spiritual characteristics of Table 1, (Model-2). In step3, variables related to participants clinical observations and inferences (Table 2) were added to previous models to create Model-3. In fourth/final step, we added variables related to participants’ clinical spiritual care training and interventions (Tables 2, 3) to arrive at our full models. The full models of regression analysis from each of our three sets of regression analysis are shown in Table 4 for comparison, and other three models from step-1, step-2, and step-3 are not shown in tables. Sociodemographic variables (Model-1) were not significant predictors in any of our three comparisons. R/S variables were significant predictors in Models 2 and 3 of all the three comparative sets (p \ 0.05). ‘‘Physicians’ comfort’’ in attending to patient’s spiritual needs became the significant predictor (p = 0.05) in full model of two (CRIUM vs. Others
123
J Relig Health
and Sweekar-OU vs. Others) comparative sets of regression, while it only showed a trend toward significance (p = 0.054) in the full model of regression set ‘‘UNAIR versus Others.’’ Goodness-of-fit test remained significant (p = 0.000). and Kendall’s Tau-a improved to 0.35 through to the final model in all regression sets.
Discussion As hypothesized, more number of Indonesian physicians describes themselves as highly religious and spiritual. They also rated themselves high in intrinsic religiosity as compared to both Indian allopathic as well as TCAM physicians. While such highly r/s orientation could explain Indonesian physician’s acceptance for integrating TCAM and modern medical healthcare services, as literature suggests, in-depth analysis, notwithstanding the low power, revealed that, in actuality, physician’s comfort in providing r/s interventions including interacting with patients on r/s matters and/or referring and interacting with TCAM or r/s healers, etc., to be more predictive of their acceptance of spiritual care as a complement to allopathic treatment. If we consider ‘‘spiritual care’’ as a proxy for TCAM (Hsiao et al. 2008; Mao et al. 2008), then our findings can be extended to suggest that physician’s comfort in attending to patient’s r/s needs to be predictive of their acceptance for ‘‘Integrated health care.’’ Implications of this study findings can be manifold: (1) since physician’s clinical experience of working with r/s or TCAM healers is more important in influencing their acceptance of an ‘‘integrative medicine,’’ we need to encourage or provide opportunities for more collaborative work between the two professionals. (2) In the absence of randomized control studies on TCAM methods, personal experiences of TCAM efficacy may have helped UNAIR physicians grow in comfort while working within an integrated system. Hence, placing TCAM and allopathic physicians ‘‘under one roof’’ as initiated through Indian National Rural Health Mission program (Bodeker et al. 2014; Sharma et al. 2008) may be beneficial to start-with. However, physicians in both counties prefer to work only with evidence-based methods of TCAM (Bodeker et al. 2014). Acceptance of integration may not be an approval of all TCAM methods of care—hence, for more deeper collaboration, RCT studies in TCAM methods may be intensified; (3) integration with TCAM being ancillary to satisfying patient’s ‘‘spiritual care’’ needs the scientific focus should be toward improving spiritual care methods; as of now, there is growing concern of TCAM systems adapting biomedical methods rather than the traditional spiritual components of care (Warrier 2009). Traditional, complementary, and alternative medicine (TCAM) healers are known to develop unique and complex combinations of healing values and traditions by imbibing all effective healing methods that they come across (Popper-Giveon and Weiner-Levy 2013); hence, they may be quick to accept integration with the proven and effective allopathic systems of care but this should only follow an intensive training in it. Modern/evidencebased medicine does not allow easy adaptation of TCAM; hence, we have couple of ways toward an integration process. Since healthcare consumers’ attraction toward TCAM is in its inbuilt element of ‘‘spirituality’’ (Hsiao et al. 2008; Mao et al. 2008), the focus has to be on developing the subject of spirituality in academic medicine. Developing spiritual care curriculum as being provided in several of US medical schools (Anandarajah 2008; Guck and Kavan 2006; Graves et al. 2002; Hull et al. 2001; Lawrence and Duggal 2001; Puchalski 2006) and introduction of spiritual care programs may serve as the best conduit
123
J Relig Health Table 4 Binary logistic regression: comparing the full models of various group combinations listed in columns Outcome measure was agreement with the statement: ‘‘Spiritual healing has some benefits, and it could be a complement to modern medical treatment’’
Full model for CRIUM vs. others (SweekarOU ? UNAIR)
Full model for Sweekar-OU vs. others (CRIUM ? UNAIR)
Full model for UNAIR vs. others (CRIUM ? SweekarOU)
Predicting variables as shown below: *to what extent do you agree with this statement?
B
b
z
B
Z
0.81
z
Step-1: Sociodemographic variables of participants (Model-1): 1. Age
0.103
0.92
0.094
0.93
0.087
2. Gender
0.536
0.41
0.528
0.43
0.389
0.31
3. Religious affiliation
17.451
0.01
17.493
0.01
17.384
0.01
4. Occupational code
10.049
0.01
10.033
0.01
10.028
0.01
Step- 2: Participants’ r/s characteristics and intrinsic religiosity variables (Step-1 ± Step-2 = Model-2) 1. To what extent do you consider yourself as a religious person?
2.680
1.03
2.282
0.97
2.573
1.00
2. To what extent do you consider yourself to be a spiritual person?
0.012
0.00
0.206
0.10
0.046
0.02
3. How often do you attend religious services?
1.634
0.84
1.280
0.79
1.315
0.67
4. *My religious beliefs influence my practice of medicine.
80.407
0.01
96.508
0.01
78.939
0.01
5. *I find it challenging to remain faithful to my religion in my work as physician.
2.412
1.07
2.671
1.18
2.564
1.09
6. *My experiences as a physician have caused me to question my religious beliefs
1.235
0.72
1.292
0.75
1.264
0.73
7. *I try hard to carry my religious beliefs over into all other dealings in life.
0.252
0.14
0.064
0.04
0.240
0.13
8. *My whole life approach is based on my religion
6.279
0.00
5.291
0.00
5.976
0.00
Step-3: Variables related to participants clinical observations and inferences (Step-1 ± Step-2 ? Step3 = Model-3) 1. Overall, how much influence do you think r/s has on patients’ health?
2.325
1.38
2.394
1.40
2.375
1.38
2. Is the influence of r/s on health generally positive or negative?
0.529
0.48
0.449
0.41
0.543
0.49
3. If a patient is severely mentally ill to which of the following they prefer to visit first?
1.705
1.16
1.716
1.19
1.630
1.13
4. *Public in general tries to consciously avoid seeing a psychiatrist for any mental illness.
1.337
0.48
1.615
0.60
1.406
0.50
5. *Stigma associated with mental illness can be reduced by integrating spirituality with psychiatry.
27.966
0.00
37.200
0.00
27.527
0.00
123
J Relig Health Table 4 continued Outcome measure was agreement with the statement: ‘‘Spiritual healing has some benefits, and it could be a complement to modern medical treatment’’
Full model for CRIUM vs. others (SweekarOU ? UNAIR)
Full model for Sweekar-OU vs. others (CRIUM ? UNAIR)
Full model for UNAIR vs. others (CRIUM ? SweekarOU)
Predicting variables as shown below: *to what extent do you agree with this statement?
B
b
B
z
z
Z
Step-4: Variables related to professional training and spiritual care activities (Step-1 ? Step-2 ? Step3 ? Step-4 = Full model) 1. Have you had any formal training regarding r/s in medicine?
6.931
1.46
6.803
1.42
6.699
1.40
2. How often do you inquire about r/s issues when a patient faces a frightening diagnosis or crisis?
1.287
0.60
1.252
0.61
1.164
0.55
3. How often do you inquire about r/s issues when a patient faces the end of life?
1.924
0.48
2.152
0.88
1.971
0.79
4. How often do you inquire about r/s issues when a patient suffers from anxiety and depression?
1.994
0.00
1.901
1.15
1.950
1.17
5. If you were to refer a patient with continued grieving 2 months after death of his wife, to whom would you refer first?
3.097
1.48
3.125
1.50
2.994
1.45
6. *I would feel comfortable discussing r/s concerns if patient brought them up.
7.480§
1.96§
7..535§
1.96§
7.331§
1.92§
Categorical variables (as listed in the columns):
0.935
0.04
8.402
0.00
0.096
0.11
Odds ratio (95 % C.I.), p value [only trend toward significance§]
§
Goodness-of-fit test: Pearson’s Chisquare, df, p value Measures of association between response variables and predicted probabilities: Percentage concordance and Kendall’s Tau-a McFadden’s
*0.00 (0.00–1.00), 0.050
§
98.204, 48, 0.000
119.155, 48, 0.0000
125.648,47, 0.000
96.3 %, 0.35
96.4 % 0.35
96.1 % 0.35
0.00 (0.00–0.99), 0.050
0.00, (0.00–1.14), 0.054
toward a systematic integration of TCAM and modern healthcare systems (Ramakrishnan et al. 2014). Least number of Indian allopaths reportedly received formal training in spirituality— lack of emphasis, during clinical training, on the importance of r/s aspects of health care is reported to be the reason for physician’s indifference or negative attitude toward r/s role in medicine (Hafizi et al. 2013). Research supports that improved communication between allopathic and TCAM practitioners and exposure of allopaths to healthcare benefits of spiritual/TCAM healing to help the integration process but most important issue may be dual-training for clinicians in allopathic and TCAM systems of care (Keshet and PopperGiveon 2013; Popper-Giveon et al. 2013).
123
J Relig Health
Our study findings also reveal that the relationship between r/s beliefs and integrative clinical services may be bidirectional; UNAIR physicians did not shy away from reporting that their clinical experiences were influencing their r/s beliefs as well. Such an openminded approach to inclusion of r/s methods of care (TCAM being used as proxy variable) in an evidence-based/scientific discipline may be beneficial for both, i.e., scientific discipline of medicine as well as for developing our understandings on r/s issues in clinical care. Further studies should include healthcare recipients, i.e., patients and their caregivers, as well as spiritual care providers, such as religious healers, chaplains, and temple priests, so as to understand the perspectives of all the participants in an integrative healthcare system.
Limitations The findings from this study cannot be generalized, and we need further studies to understand underlying subtle religious and cultural factors that influence professionals’ support for integrative medicine or spirituality in healthcare system. Cross-cultural surveys or studies inherently difficult; the challenging part of this exploratory cross-cultural study with three different institutes, Sweekar-OU, UNAIR, and CRIUM, was like comparing oranges to apples to mangoes; these groups differed from one another either in their r/s composition and/or medical system of training. The survey measures are largely selfreports and may not accurately represent physicians’ actual practice. The methods may also not capture the subtle nuances of the ways in which a particular religious theme is represented or understood. R/S affiliation and characteristics are vital parts of sociocultural makeup that influence professional care; hence, we did not control them in our statistical analysis but subtle forms of response bias are possible due to physician’s intrinsic religiosity. Hence, there may be some unmeasured characteristics influencing participant’s responses. The participating institutions were selected based on convenience and in an exploratory way and not randomly; being a pilot study in a newly emerging discipline, institutions that were more willing to participate were chosen. It must be acknowledged that funding is another important barrier for such new initiatives, particularly in a crosscultural context; we were able to overcome this constraint by selecting interested and likeminded partners committed to this area of research. Nevertheless, such studies as this, throwing light on the experiences of professionals across cultural divides will help in quicker knowledge transfer and Lamarckian type of growth/evolution of our medical systems.
Conclusion Physicians’ clinical experiences in meeting patients’ spiritual care needs play more important role than their personal r/s characters in influencing perspectives on the role of spirituality in medicine or integrative medicine. This study supports a circular logic that comfort in attending to patient’s spiritual care needs allows clinicians to accept integrative services and only through clinical association/experience an allopath grows in such comfort. This paper also highlights the importance of conducting cross-cultural studies that can compare sets of populations with similar and dissimilar religious, social, cultural, and educational (such as TCAM vs. allopathy) variables. Each of these factors/variables may be important in influencing physicians’ interest and comfort in providing spiritual care for their patients and by extension to integrative healthcare services.
123
J Relig Health
References Allport, G. W., & Ross, J. M. (1967). Personal religious orientation and prejudice. Journal of Personality and Social Psychology, 5(4), 432–443. Anandarajah, G. (2008). The 3 H and BMSEST models for spirituality in multicultural whole-person medicine. Annuals of Family Medicine, 6(5), 448–458. Avasthi, A., Kate, N., & Grover, S. (2013). Indianization of psychiatry utilizing Indian mental concepts. Indian Journal of Psychiatry, 55(Suppl 2), S136–S144. doi:10.4103/0019-5545.105508. Bodeker, G., & Burford, G. (2008). Traditional, complementary and alternative medicine-policy and public health perspectives. Jounal of Alternativeand Complementary Medicine, 14(1), 103–104. Bodeker, G., Ong, C. K., Grundy, C., Burford, G., & Shein, K. (2014). WHO Global Atlas of Traditional, Complementary and Alternative Medicine. World Health Organization. The WHO Center for Health Development, Kobe 2005. (http://books.google.com/books?id=VO8K9h9GvaoC&printsec= frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false. Accessed January 30, 2014. Bodeker, G., & Kronenberg, F. (2002). A public health agenda for traditional, complementary, and alternative medicine. American Journal of Public Health, 92(10), 1582–1591. Chandrashekar, H., Prashanth, N. R., Naveenkumar, C., & Kasthuri, P. (2009). Innovations in psychiatry: Ambulatory services for the mentally ill. Indian Journal of Psychiatry, 51, 169–170. Curlin, F. A., Chin, M. H., Sellergren, S. A., Roach, C. J., & Lantos, J. D. (2006). The association of physicians’ religious characteristics with their attitudes and self-reported behaviors regarding religion and spirituality in the clinical encounter. Medical Care, 44(5), 446–453. Curlin, F. A., Lantos, J. D., Roach, C. J., Sellergren, S. A., & Chin, M. H. (2005). Religious characteristics of U.S. physicians: A national survey. Journal of General Internal Medicine, 20(7), 629–634. Curlin, F. A., Lawrence, R. E., Odell, S., Chin, M. H., Lantos, J. D., Koenig, H. G., et al. (2007). Religion, spirituality, and medicine: Psychiatrists’ and other physicians’ differing observations, interpretations, and clinical approaches. American Journal of Psychiatry, 164(12), 1825–1831. Curlin, F. A., Rasinski, K. A., Kaptchuk, T. J., Emanuel, E. J., Miller, F. G., & Tilburt, J. C. (2009). Religion, clinicians, and the integration of complementary and alternative medicines. Journal of Alternative and Complementary Medicine, 15(9), 987–994. Frass, M., Strassl, R. P., Friehs, H., Mu¨llner, M., Kundi, M., & Kaye, A. D. (2012). Use and acceptance of complementary and alternative medicine among the general population and medical personnel: A systematic review. The Ochsner Jounal, 12(1), 45–56. Graves, D. L., Shue, C. K., & Arnold, L. (2002). The role of spirituality in patient care: Incorporating spirituality training into medical school curriculum. Academic Medicine, 77(11), 1167. Guck, T. P., Kavan, M. G. (2006). Medical student beliefs: Spirituality’s relationship to health and place in the medical school curriculum. Creighton University School of Medicine, Omaha, NE 68102, USA. Medical Teaching, 28(8), 702–707. Hafizi, S., Koenig, H. G., Arbabi, M., Pakrah, M., & Saghazadeh, A. (2013). Attitudes of Muslim physicians and nurses toward religious issues. Journal of Religion and Health. Hsiao, A. F., Wong, M. D., Miller, M. F., Ambs, A. H., Goldstein, M. S., Smith, A., et al. (2008). Role of religiosity and spirituality in complementary and alternative medicine use among cancer survivors in California. Integrative Cancer Therapies, 7(3), 139–146. Hull, S. K., DiLalla, L. F., & Dorsey, J. K. (2001). Student attitudes toward wellness, empathy, and spirituality in the curriculum. Academic Medicine, 76(5), 520. Keshet, Y., & Popper-Giveon, A. (2013). Integrative health care in Israel and traditional arab herbal medicine: When health care interfaces with culture and politics. Medical Anthropology Quarterly, 27(3), 368–384. doi:10.1111/maq.12049. Epub 2013 Oct 8. Kurihara, T., Kato, M., Reverger, R., & Tirta, I. G. (2006). Pathway to psychiatric care in Bali. Psychiatry and Clinical Neurosciences, 60(2), 204–210. Lahariya, C., Singhal, S., Gupta, S., & Mishra, A. (2010). Pathway of care among psychiatric patients attending a mental health institution in central India. Indian Journal of Psychiatry, 52, 333–338. Lawrence, R. M., & Duggal, A. (2001). Spirituality in psychiatric education and training. Journal of the Royal Society of Medicine, 94(6), 303–305. Lee, E., & Baumann, K. (2013) German psychiatrists’ observation and interpretation of religiosity/spirituality. Evidence-Based Complementary and Alternative. 2013:280168. doi:10.1155/2013/280168. Epub 2013 Nov 14. Lee Ventola, C. (2010). Current issues regarding Complementary and Alternative Medicine (CAM) IN United States Current Issues Regarding Complementary and Alternative Medicine (CAM) in the United States. Part 1: The Widespread use of CAM and the need for better-informed health care professionals to provide patient counseling. P T. 2010 August; 35(8): 461–468.
123
J Relig Health Mao, J. J., Palmer, S. C., Straton, J. B., Cronholm, P. F., Keddem, S., Knott, K., et al. (2008). Cancer survivors with unmet needs were more likely to use complementary and alternative medicine. Journal of Cancer Survivorship, 2(2), 116–124. Mishra, N., Nagpal, S. S., Chadda, R. K., & Sood, M. (2011). Help-seeking behavior of patients with mental health problems visiting a tertiary care center in north India. Indian Journal of Psychiatry, 53(3), 234–238. Pols, H. (2006). The development of psychiatry in Indonesia: from colonial to modern times. International of Review of Psychiatry, 18(4), 363–370. Popper-Giveon, A., Schiff, E., & Ben-Arye, E. (2013). We and they in the house of healing: Debate among Arab complementary medicine practitioners on an integrative versus alternative approach to supportive cancer care. Integrative Cancer Therapies, 12(6), 488–495. doi:10.1177/1534735413485818. Epub 2013 Apr 26. Popper-Giveon, A., Weiner-Levy, N. (2013). Returning to ourselves: Palestinian complementary healers in Israel. Qualitative Health Research. 2013 Nov 8. [Epub ahead of print]. Puchalski, C. M. (2006). Spirituality and medicine: Curricula in medical education. Journal of Cancer Education, 21(1), 14–18. Ramakrishnan, P., Dias, A., Rane, A., Shukla, A., Lakshmi, S., Ansari, B. K., Ramaswamy, R. S., Reddy, A.R., Tribulato, A., Agarwal, A. K., Bhat, J., Satyaprasad, N., Mushtaq, A., Rao, P. H., Murthy, P., Koenig, H. G. (2013) Perspectives of indian traditional and allopathic professionals on religion/ spirituality and its role in medicine: Basis for developing an integrative medicine program. Journal of Religion and Health. 2013 Apr 27. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/ 23625126. Ramakrishnan, P., Rane, A., Dias, A., Bhat, J., Shukla, A., Lakshmi, S., Ansari, B. K., Ramaswamy, R. S., Reddy, R. A., Tribulato, A., Agarwal, A. K., Satyaprasad, N., Mushtaq, A., Rao, P. H., Murthy, P., & Koenig, H. G. (2014) Indian health care professionals’ attitude towards spiritual healing and its role in alleviating stigma of psychiatric services. Journal of Religion and Health. 2014 Jan 16. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/?term=24430129. Sharma, S. K., Chadha, S. K., Negi, M., Katoch, D. C., Raghu, A., & Sharma, V. (2008). A manual for doctors on mainstreaming of AYUSH under NRMH. New Delhi: Department of AYUSH, Ministry of Health and Family Welfare. Sheppe, A. H., Nicholson, R. F, 3rd, Rasinski, K. A., Yoon, J. D., & Curlin, F. A. (2013). Providing guidance to patients: Physicians’ views about the relative responsibilities of doctors and religious communities. Southern Medical Journal, 106(7), 399–406. Verma, U., Sharma, R., Gupta, P., Gupta, S., & Kapoor, B. (2007) Allopathic vs. ayurvedic practices in tertiary care institutes of urban North India. Indian Journal of Pharmacology. 2007. 39, 1, Jan–Feb, 52–54 (http://www.bioline.org.br/request?ph07012. Accessed January 30, 2014. Warrier, M. (2009). Seekership, spirituality and self-discovery: Ayurveda trainees in Britain. Asian Med (Lieden), 4(2), 423–451. World Health Organization Regional Office of South East Asia (2009) The use of herbal medicines in primary health care. report of regional meeting, Yongon, Myanmar, March 10–12, 2009. (http://www. searo.who.int/entity/primary_health_care/documents/pch_sea_hsd_322.pdf. Accessed January 1, 2014.
123
