Which question is most effective in assessing a patient’s personal beliefs about health and illness?

Authors: David B. Larson, MD, MSPH, President, National Institute for Healthcare Research, Adjunct Professor, Departments of Psychiatry and the Behavioral Sciences, Duke University Medical Center and Northwestern University Medical School; Susan S. Larson, MAT, Editor, Research Reports, National Institute for Healthcare Research; Christina M. Puchalski, MD, MS, Director of Education, National Institute for Healthcare Research, Assistant Professor, Division of Aging, Department of Medicine, George Washington University Medical School; and Harold G. Koenig, MD, MHSc, Associate Professor, Departments of Psychiatry and Medicine, Duke University Medical Center, GRECC, Durham, N.C., Veterans Administration Medical Center.

Peer Reviewers: Mark R. Ellis, MD, MSPH, Faculty Physician, Cox Family Practice Residency Program, Springfield, Mo., and Kenneth E. Olive, MD, FACP, Interim Chair, Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, Tenn.

Editor’s Note—Recognition of the role of life factors and their influence on patients’ health and well-being continues to grow in medicine. Many patients, when confronted with serious illness or disability, turn to their spiritual/religious framework to cope. A majority of medical schools currently teach medical students how to take a spiritual history as part of the social history to become more sensitive to patients’ personal beliefs and life context. Suggestions for taking this clinical assessment follow, along with a discussion of the importance of collaboration with chaplains and recognition of potential ethical concerns.

Furthermore, published research is finding significant, primarily beneficial links between spiritual/religious commitment and health, indicating the potential relevance of spirituality to clinical care. However, at times religious/spiritual beliefs can be harmful to health, such as when patients refuse medical treatment for treatable diseases. Part I of this article provides a brief overview of some of the research findings on the links between spiritual/religious commitment and longevity. Part II will provide an overview of research findings on blood pressure, coping with severe illness, recovering from surgery, prevention, treatment outcomes, and patient quality of life when facing terminal illness.

Clinical Assessment

Current medical education accentuates patient-centered care, encouraging doctors to respond compassionately to patients while providing highly skilled treatment of their disease. A physician cares for a person, who is far more than a "case" of pneumonia or diabetes.

In this regard, the Association of American Medical Colleges Medical School Objectives Project recently stated that physicians must seek to understand the meaning of patients’ stories in the context of their patients’ beliefs, family, and cultural values.1 These goals for training caring doctors emphasize developing sensitivity to patients’ worldviews and cultural milieu, attending to what gives patients’ lives vitality as well as monitoring their vital signs and diagnosing and treating their symptoms. Similarly, an American College of Physicians—American Society of Internal Medicine End-of-Life Consensus Panel report counsels physicians to extend their care for those with serious medical illness by attentiveness to psychosocial, existential, or spiritual suffering.2

To promote a fuller understanding of a patient’s life context, nearly 70 U.S. medical schools incorporate curriculum on spirituality. In courses sometimes co-taught by physicians and chaplains, medical students learn how to take a spiritual history as part of the social history along with the physical exam and how to identify when patients’ spiritual beliefs may be helpful or harmful in their coping with and understanding their illness. Students learn how to collaborate with and refer to chaplains as part of the health care team for those patients who desire it.3 Published research on religion/spirituality and health outcomes is also reviewed.4 More detailed components of these curricula appear in Academic Medicine.5

Spirituality can be defined as a belief system that focuses on intangible elements that impart meaning and vitality to life’s events.6 Taking a spiritual history also opens up the potential to discuss advance directives long before a disease might progress to a terminal point.7

By asking patients if they have religious/spiritual beliefs that would affect their medical decisions if they became gravely ill, physicians often deepen the trust level in the doctor-patient relationship. For instance, a study of pulmonary outpatients at the University of Pennsylvania found that 66% of study respondents agreed that a physician’s inquiry about religious or spiritual beliefs would strengthen their trust in their physician.8 Some 94% of those who indicated that they did have religious or spiritual beliefs that would make a difference felt physicians should ask, indicating their desire for doctors to be sensitive to their values framework. Also, as much as half of those without such beliefs thought doctors should at least inquire when facing serious illness.

In contrast, only 15% of the study patients recalled having been asked whether their religious or spiritual beliefs would influence their medical decisions—a large gap between the number of those who would like to and the number of physicians who had invited them to discuss it.

Understanding a Patient’s Life-Context

The proportion of Americans who believe in God has remained remarkably constant according to Gallup polls: 96% in both 1944 and 1995. Also, 85% of Americans consider their religion to be "very important" or "fairly important" in their lives. About 42% weekly attend one of the 500,000 places of worship in the United States, including churches, synagogues, and mosques. Another 20% attend monthly for a total of 62% attending monthly or more.9

These trends are likely to continue in the next generation, based on a 1992 national Gallup survey of teenagers. Large numbers of U.S. teens believe in God (95%), pray alone frequently (42%), read scriptures weekly (36%), belong to a religion-sponsored youth group, and attend services weekly (45%). These figures remain relevant to the medical arena as a backdrop for patients’ potential religious/spiritual outlook when handling the stress of illness, disability, and potential death.

Relevance in Diverse Cultures

The relevance of religion and spirituality to patients’ life-context also goes beyond the United States, an important consideration in developing sensitivity to increasingly diverse patient populations with different religious backgrounds.

A position paper from the World Health Organization (WHO) on how to assess quality of life across cultures noted the importance of including patient’s religion/spirituality and personal beliefs.10 The centers in various countries consistently identified religion and spirituality as an important dimension, prompting the WHO to recognize spirituality as one of the six broad domains of quality of life significant across cultures. These included the physical domain, psychological domain, level of independence, social relationships, environment, and spirituality/religion/personal beliefs.

The WHO report commented that spirituality/religion/personal beliefs might affect quality of life by helping the person cope with difficulties in their life, by giving structure to their experience, ascribing meaning to spiritual and personal questions, and more generally by providing the person with a sense of well-being. For many people, religion, personal beliefs, and spirituality are a source of comfort, well-being, security, meaning, sense of belonging, purpose, and strength. However, the report noted some people feel that religion can have a negative influence on their life. Inquiring about religion/spirituality allows this facet to also emerge.

Patient Desire for Inclusion in Care

According to survey data, religion plays a central role in many Americans’ lives, but how pervasively do patients want spiritual issues addressed by their physicians? A study published in The Journal of Family Practice surveying more than 200 inpatients found that 77% said physicians should consider patients’ spiritual needs. Furthermore, 37% wanted their physicians to discuss religious beliefs with them more frequently, and nearly one in two, or 48%, wanted their physicians to pray with them.11 However, only 32% stated their physician had ever discussed religious beliefs with them. Similarly, a national poll conducted by USA Weekend found that 63% surveyed felt that physicians should talk to patients about their spiritual faith, but only 10% of their doctors had done so.12

Illness and Spiritual Crisis

Why might patients so strongly perceive the potential relevance of spirituality to their medical care? A decline in physical health often precipitates a spiritual crisis. When serious illness strikes, patients often start to question their purpose in life, the meaning of their work, their relationships, and their personal identity, as well as their ultimate destiny. Furthermore, patients hospitalized with severe medical illness often face high levels of stress as well, including anxiety about their diagnosis, pain and discomfort from their illness and therapeutic procedures, a sense of isolation, and a loss of control over personal activities like eating and sleeping.13

One study of hospitalized seriously ill patients found that 90% of patients indicated they used religion to cope at least to a moderate extent or more, and 75% indicated they used religion to cope at least to a large extent or more.14 How might religious coping help those patients who draw on their spiritual/religious framework? Spiritual/religious coping can provide 1) hope—for a cure, hope they will be able to cope, hope for their families and loved ones, hope for recovery, for a peaceful death, or for life after death; 2) a sense of control—by praying to God or a Higher Power who they believe is ultimately in control; 3) strength—to cope with their condition; 4) meaning—to help make sense of suffering; and 5) purpose, usefulness, and a sense of mission—which helps preserve self-esteem in the midst of a stressful, painful, or debilitating illness.13

Medical crises and life-threatening events can provoke angst, panic, and despair. The caring and support stemming from a primary care physician’s attentiveness to their patients’ life-contexts can make a difference in elevating their patients’ trust. Taking a spiritual history along with the social history indicates doctors maintain interest in what might mean a great deal to a patient in the midst of their suffering. It also alerts doctors to when referral to chaplains or clergy may be appropriate. For instance, when people become sick or disabled they often become angry and blame God. Anger and questioning directed toward God may be a normal and expected reaction to sudden loss or calamity. Usually this resolves, and the patient draws on religious resources for comfort. However, sometimes anger and bitterness persist, indicating an appropriate referral to a chaplain if the patient so desires.

Barriers to Inclusion

In the past, many physicians remained unaware of the importance of spiritual issues for numerous patients as they struggled with chronic or serious illness. One study at Duke University Medical Center found that 44% of patients indicated that religious beliefs were the most important factor in coping with their illness, compared to only 9% of physicians recognizing this potential central role.15 However, a more recent survey of Missouri family physicians found 96% considered spiritual well-being an important health component and 58% believed physicians should address patients’ spiritual concerns.16

Some physicians may believe that a discussion of patients’ religious and spiritual beliefs is inappropriate based on a perceived lack of clinical relevance, resulting from a lack of familiarity with the magnitude of patient desire to have spirituality addressed in their care as well as the growing clinical research on the effect of religious commitment on health reviewed below. In addition, physicians may feel personally uncomfortable with the subject matter, or have an understandable reluctance or fear of projecting their own beliefs on patients, or feel they might offend or perplex some patients by inquiring.15 Also, doctors may feel inquiring about spiritual beliefs may intrude into a patient’s privacy. Yet many questions physicians ask are highly personal, and when asked with respect allows the patient to respond with what is comfortable for the patient.

To address some of these issues, a study of family medicine patients found that by taking a spiritual history as part of the social and physical history, a physician could identify patients most interested to discuss spiritual concerns with their doctors—patients who frequently attended religious services. Some 90% of patients who attended religious services monthly or more felt doctors should refer to chaplains or clergy and 68% felt a religious evaluation or history should be part of the medical record.17

Criticism of Relevance

Some clinical professionals object to incorporating inquiry about a patient’s spiritual/religious framework into medical care, even when patients desire it, stating that patients often ask for things that are unrealistic or that may not be in their best interest.18 Yet ignoring spiritual/religious issues may be turning a deaf ear to many patients’ core values when coping and dealing with chronic and serious illness. As stated above, for many in the U.S. population religion/spirituality plays a central role in their lives. According to Gallup polls, 72% agree or strongly agree that "religion is the most important influence in my life."19

Critics have also implied that inquiring about such beliefs can be equivalent to imposing a religion on patients, suggesting that inquiring is the same as prescribing.20 Yet by asking a question like, "Do you have spiritual beliefs that help you cope with the stress of your illness?" a doctor shows openness regarding the patient’s medically relevant religious or spiritual beliefs, but also allows a patient to respond "no" if that is the patient’s choice.

Doctors who ignore a patient’s religious/spiritual framework may imply that it’s irrelevant at best, even if patients hope for acknowledgement or support. In addition, religious/spiritual variables may be operating whether a physician chooses to recognize this.21

Taking a Spiritual History

Taking a spiritual history can occur in a time-efficient manner and can save time in the long run by discovering potential treatment resources like religious social support on the one hand, or potential roadblocks, such as a patient’s reluctance to take a certain medication or a concern about procedures like blood transfusions.

In taking a spiritual history, finding what the clinician feels comfortable with and most helpful to their patients may involve picking and choosing from various suggested formats. The acronym FICA can serve as a potential tool to structure questions (see Table 1).22 Another approach uses the mnemonic SPIRIT for suggested questions, presented as a "SPIRITual History" (see Table 2).6 Drawing from both the SPIRITual History and another instrument called INSPIRIT,23 other clinicians and researchers used a condensed list (see Table 3).24

It is important to keep the discussion centered on the patient and work within the patient’s frame of reference or spiritual belief system. It is crucial that physicians not impose their own beliefs or lack of them on their patients.

Ethical Concerns in Addressing Patients’ Spirituality

Rather than treating patients’ religion/spirituality as a "don’t ask-don’t tell" aspect of medical care, an article in the Annals of Internal Medicine encourages clinical respect for patient spirituality as an important resource for coping and also addresses clinical and ethical boundaries in the doctor-patient relationship as well.3

Assessment and Referral. Although a few health care professionals have argued that religious/spiritual issues have little place in medical care, calling spirituality a "non-medical agenda"25 for those patients for whom spirituality and religion are significant, the ethical responsibility suggests the importance of attention to spirituality.22 Consequently, the physician who is committed to the patient’s best interests should consider how to support patient spirituality, if and when the patient deems it relevant. Because patients often draw on their religious/spiritual beliefs in the context of their serious illness, physicians who have no such belief systems can still consider how best to respect and, when appropriate, support patients’ beliefs that may assist them in coping with illness. The physician might refer patients to chaplains or clergy to discuss further and in greater depth their spiritual concerns, if the patient would like to do this.

The Role of Chaplains on the Healthcare Team. Hospital chaplains and pastoral care counselors undertake specialized training to meet needs of patients and, consequently, can serve as a valuable resource on the health care team. A patient may seek spiritual support or possible aid with spiritual questions sparked by suffering or by impending death. Patient desires for a relationship with a pastor and for prayer along with requests for sacraments and rituals such as communion and anointing. Chaplains have identified spiritual needs they encounter to include explicitly religious concerns (sinfulness, grace, revelation, reconciliation) and spiritual-psychosocial needs (alienation, loneliness, depression, hostility).26

Referrals to chaplains can be critical to providing good health care for many patients and can be as appropriate as referrals to other specialists.27 A national survey of U.S. family physicians found 80% referred patients to pastoral care.28 In the past, many clinicians did not routinely inquire about spirituality and lacked appreciation for its frequent patient relevance. Consequently, referrals and collaboration with chaplains occurred less frequently.29

Handling Requests for Prayer. Beyond taking initial spiritual histories and making chaplain referrals, deciding how best to respond to a patient’s spiritual issues or interests can raise professional ethical issues for physicians.3 For instance, should doctors pray with patients? One study earlier cited in the Journal of Family Practice found 48% of the patients surveyed wanted their doctors to pray with them.30 But what are the ethical and professional boundaries?

In secular medical settings, a physician who initiates prayer without first being asked presents an ethical concern in that patients might easily feel coerced. A physician might respond to a patient’s explicit request if he or she feels it appropriate. An identified religious leader like a hospital chaplain or visiting clergy should lead the prayer whenever possible so as to avoid even an appearance of religious coercion.

Professional boundaries may appear somewhat artificial to the patient who believes that God is working through the physician. Yet, this does not mean that these boundaries become unimportant. Since chaplains are specially trained to address patients’ spiritual concerns, they should be referred to whenever possible, ensuring competency and appropriate boundaries by keeping the chaplain’s and physician’s roles distinct. Responding to patients’ requests for their doctor to pray with them might be appropriate if 1) pastoral care is not available; 2) the patient is intent on prayer with the physician; or 3) the physician can pray without having to feign faith or without manipulating the patient.

For the doctor who personally is nonreligious or feels uncomfortable with spiritual matters but recognizes the importance of prayer for a patient, the doctor can respectfully allow the patient to pray and remain silent but present.3

A Brief Introduction to the Research on Spirituality and Health

Religious/spiritual vitality and its potential salutary links with physical and emotional health emerges in research findings as a relevant clinical factor. A consensus report culminated the collaboration of more than 70 researchers, clinicians, and ethicists in the fields of physical and mental health, addictions, and neuroscience to review current research findings and to map out future research directions as well as barriers to overcome.31 The 1998 report concluded that the data from many of the studies conducted to date are both sufficiently robust and tantalizing to warrant continued and expanded clinical investigations.

Mortality Studies

In the past five years, a number of well-designed, longitudinal studies of large community samples have found a link between active religious involvement and living longer (see Table 4). The fact that many studies used a somewhat superficial single-item measure of how frequently persons attend religious services and still found a significant link with living longer points to a consistent, robust association, which underscores the relevance of considering religious commitment in medical care. By controlling for numerous factors that could reduce mortality, these studies addressed the concern that the link between religious/spiritual commitment and health is "nothing but" social support, better initial health status, or healthier lifestyles.

When summing studies, the review excluded those that looked only at religious affiliation (e.g., Christian, Judaism, or Moslem) and instead focused on studies that included some measure of religious involvement. For instance, the measures included how often one attends religious services, how personally important one ranks one’s religious faith, or the degree to which one finds strength or comfort from one’s relationship to God. The review found a stronger link with living longer among those with participation in religious organizations like attending religious services rather than from private religious attitudes and beliefs alone. However, a recent study published after this meta-analysis found that elderly who engaged in private religious practices such as prayer and scripture reading before the onset of impairment of activities of daily living appeared to have a survival advantage over those who do not.33

Since other variables might predict longer lives—like healthier life styles and better overall initial health—the review also took a close look at studies that controlled for 15 variables that also might play some role in contributing to living longer to see if they might explain the lower odds of early death among the more religious. Although these factors accounted for part of the link, the association between religious involvement and lowering the chance of earlier death remained substantial. These 15 controlled-for variables included race, income, education, employment status, functional health, global health appraisals, clinical or biomedical measures of physical health, social support, social activities, marital status, smoking, alcohol use, obesity/body mass index, mental health or effective distress, and exercise. Of all these factors, the only one that appeared to approach the protective effect of religious involvement was lack of obesity. Surprisingly, studies that did control for smoking and alcohol use found an even stronger link between religious involvement and living longer than studies that did not control for alcohol and smoking, an unexpected finding.

Attending religious services more than once a week stretched lives an average of seven years for Caucasians and added a potential 14 more years for African Americans in a study in Demography, which tracked a nationally representative sample of more than 21,000 U.S. adults for nine years.34 The study examined numerous social, economic, and health and lifestyle factors, as well as religious attendance, to see who was most likely to avoid death by any cause. Religious attendance surfaced as a strong predictor for living longer, even when other relevant factors were statistically controlled for. The study found little evidence that religious attendance is associated with mortality due to the lack of controlling for patient socioeconomic factors. Stronger social ties and better health behaviors did explain some of the link with living longer among the highly religious, but a strong religious attendance effect remained.

Persons who never attended religious services exhibited 50% higher risks of mortality over the follow-up period than those who attended most frequently. Those who attended weekly or less than once a week displayed about a 20% higher risk of mortality than those who attended more than once a week. Although the strength of the association between religious attendance and mortality varied by cause of death, the direction of the association remained consistent across causes of death. For instance, those who never attended were about four times as likely to die from respiratory disease, diabetes, or infectious diseases. However, stronger social ties also helped reduce death rates from diabetes. Healthier lifestyle choices, such as not smoking, lowered risk of death from respiratory and circulatory diseases. But these factors did not fully account for the gap between very high and nonattenders in risk of death from these diseases.

Persons who attended religious services weekly or more were much less likely to die than infrequent attenders, during a 28-year follow-up of 5286 people in Alameda County, California, in the American Journal of Public Health.35 When controlling for confounding factors such as age, gender, ethnicity, education, and health conditions, frequent attenders were 33% less likely to die during the nearly 30-year follow-up than infrequent attenders. When also controlling for mediating or explanatory factors—which also might reflect some of the benefits of religious commitment, such as healthier lifestyle practices and increased social connections—frequent attenders remained 23% less likely to die. Among women, the protective effect of attending services was stronger than even choosing not to smoke, and stronger for men than exercise. To consider whether these findings might be explained by a selection factor in that persons in better health are more likely to attend religious services than those who are sick or disabled and thus unable to attend, the study found persons with significant impairment in mobility were more likely to be frequent attenders. Improved health practices, increased social contacts, and more stable marriages occurred in conjunction with greater frequency of worship attendance and helped contribute to the lower mortality rates.

In another California mortality study published in the American Journal of Public Health, 2025 residents of Marin County aged 55 years or older were followed for nearly five years. Some 454 of the sample died. The most significant factor predicting who still lived was attendance at religious services.36 For each gender, weekly attenders had the lowest mortality and nonattenders had the highest mortality. But would different activities or nonreligious social support have the same effects? Although substituting other clubs for church, synagogue, or mosque failed to help people live longer, a "complementary" effect appeared. Persons who engaged in volunteer work along with attending religious services were even more likely to live longer.

The researchers analyzed an extensive range of factors that could affect health, which might explain why those attending religious services might live longer. These included 1) demographic factors such as age, sex, race, ethnic group, income, education, and employment; 2) chronic diseases like stroke, heart disease, cancer, diabetes, and other illness; 3) physical functioning and driving status; 4) health habits such as exercise, drinking, smoking, body fat, and seeking medical care; 5) social participation, activities, marital status, health of spouse, and having confidants; and 6) emotional conditions such as depression and fearfulness. Even after controlling for these six classes of potential confounding and mediating variables, religious attendance still protected against mortality. Oman and Reed noted these findings supported previous research that showed attending religious services was linked with lower blood pressure, lower deaths from cardiovascular disease, less depression, and less earlier death from all causes.36

Similarly, a recent study in the Journal of Gerontology found chances to live longer expanded by 28% for older Americans when they attended religious meetings each week, even after controlling for key health and social factors that could also lengthen lives.37 This random sample of nearly 4000 seniors aged 64 and older living in North Carolina were interviewed every 18 months to six years to track death rates and potential links with health, religious, and social factors. Age, race, gender, education, marital status, ability to perform daily living tasks, chronic health conditions, depression, negative life events, social support, and attendance at religious meetings, as well as health practices such as cigarette smoking and alcohol use, were assessed. After adjusting for these health and social factors that could help foster longer lives, frequent attenders were still 28% less likely to have died during the six years. The link was strongest for women, who after controlling for other factors, had a 35% lower risk of death, compared to a 17% lower risk for men in this study.

The researchers posited that religious attendance could be related to lower rates of depression, anxiety, and stress. A strong religious faith reinforced by active religious participation may help persons to also better cope with life stressors, particularly physical health problems later in life. Lower rates of depression, like higher social support, may translate into stronger immune systems and better defenses against disease.

Peer-reviewed published studies in the areas of immune functioning, reducing hospital stays, increasing medical compliance, recovering from surgery, coping with severe medical illness and major depression, lowering blood pressure, preventing suicide, preventing and treating substance abuse, and lowering teen health risks are summarized in the next issue of Primary Care Reports, Patient Spirituality in Clinical Care: Clinical Assessment and Research Findings, Part II.

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