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Influence of spiritual interventions on the most lethal chronic non-communicable diseases: a scoping review

DUARTE, Rilvane de Carvalho
Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), rilvaneduarte@gmail.com, ORCID https://orcid.org/0000-0003-0546-8705
PEIXOTO, Ariani Cavalcante
Centro de Reabilitação Avançada Camila Gurian
ariani_cp@hotmail.com, ORCID https://orcid.org/0009-0003-0308-1993
FERREIRA, Ana Carolina Rocha Gomes
Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL),
carolina.rocha@uncisal.edu.br, https://orcid.org/0000-0003-1877-0487

BANDINI, Carmen Silvia Motta
Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL),
carmen.bandini@uncisal.edu.br, https://orcid.org/0000-0002-4731-5785

ABSTRACT
Goal: to identify and map studies on spiritual interventions in individuals with, or undergoing prevention of, more lethal chronic non-communicable diseases.
Methods: a scoping review following the recommendations of the Joanna Briggs Institute and the PRISMA extension for scoping reviews was conducted in search of studies published from 2000 onwards on the influence of spiritual interventions on chronic cardiovascular and respiratory diseases, diabetes mellitus and cancer.
Findings: of the 1564 studies identified, 26 experimental or quasi-experimental studies published between 2000 and 2022 were eligible, covering eight modalities of spiritual intervention and a total population of 3,103 participants. The influence of spirituality on cardiovascular diseases was addressed in 16.0% of those studies; on diabetes mellitus, in 11.5%; and on cancer, in 73.0%. No results were found relating to respiratory diseases.
Conclusions: spiritual care was found to have positive effects on the physical, mental, and spiritual health of individuals with chronic illnesses. It is suggested that specific modalities of intervention be studied for associations with participants’ spirituality; this important object of investigation may afford the possibility of enhancing gains by these interventions.
Keywords: chronic disease; spirituality; religion; prevention; health.
 
Introduction
In science, spirituality has been presented as an active aspect intrinsic to individuals, that can enable them to seek meaning and purpose in life by looking inward in search of something that transcends matter. It is thus important as an instrument for giving direction and balance (1,2).
For research purposes, it is important to distinguish between religiosity and spirituality: the literature acknowledges that, although related and largely overlapping, the terms are not synonymous (3,4). Religiosity comprises a system of beliefs and practices, that is, the manner in which the individual believes in and follows a religion and worships, communicates with and approaches the holy, the divine, God, by organised participation in religious prayer, readings and programmes at a religious temple or even individually (5). Spirituality, meanwhile, is presented as a set of inner experiences and feelings, where each individual seeks meaning and purpose and which is reflected in how they relate to themselves, their family and general surroundings (friends, society, nature) and is also bound up with what is transcendent or sacred (6).
In sickness, spirituality plays an important part in coping and strengthening: it can affect perceptions of wellbeing and quality of life on the part of patients and their families, especially when faced by severe and terminal illnesses, by helping them deal with pain and suffering while trying to make sense of the moment they are living through (7,8).
The most lethal chronic noncommunicable diseases – represented here by the acronym MLCNCDs, which although not standard usage in the current scientific literature is intended to make this article more readable – are considered the leading cause of death, incapacity and lost quality of life. They fall into four main groups – cardiovascular disease (CD), cancer (CA), chronic respiratory disease (CRD) and diabetes mellitus (DM) – and, because of their severity, are responsible for important impacts on global public health (9–11).
It is estimated that, of total deaths worldwide, 41 million (71%) are caused by chronic noncommunicable diseases (CNCDs). Of these, 15 million premature deaths (of individuals from 30 to 69 years of age) occur especially in low- and middle-income countries (Africa, East Mediterranean, Southeast Asia, Europe, West Pacific and the Americas) (11–13).
Given that scenario, studies connecting spirituality with MLCNCDs have emerged to address the issue by reporting on strategies that can contribute to preventing and managing MLCNCDs and treating patients suffering from them(14). These include spiritual interventions, which use religious and/or spiritual instruments in care for patients or their families so as to bring the spiritual dimension to health care and thus contribute to comprehensive individual care (15,16). Accordingly, the aim of this study was to identify and map existing studies on spiritual interventions in individuals with MLCNCDs or undergoing prevention of related risk factors.

MATERIALS AND METHODS
A scoping review was conducted following the recommendations of the Joanna Briggs Institute (17) and the PRISMA extension for scoping reviews (PRISMA-ScR) (18), with a view to answering the following research question: What studies are there on spiritual interventions in individuals with, or undergoing prevention of, MLCNCDs? Formulation of the inclusion and exclusion criteria was framed by that question and the PCC (population, concept and context) mnemonic strategy. “Population” was specified to be individuals of either sex and any age with, or undergoing prevention of, MLCNCDs; “concept”, to be spiritual interventions in health care; and “context”, MLCNCDs.
The studies included were all original, with experimental and quasi-experimental designs, addressing the use of spiritual interventions in prevention of risk factors for MLCNCDs or in treatment for individuals with such diseases, published since 2000 in indexed journals in the health field and available in full and free of charge in Portuguese, English, Spanish, French or Italian. The information search of primary sources excluded review articles and grey literature.
The research strategy comprised two stages: 1) initial search of selected electronic data bases (PubMed, Scielo and the VHL Regional Portal) to identify keywords given in the articles that could be used in combination with the index terms of those bases; and 2) development of a strategy for searching the three above databases with a broader range of keywords and official descriptors so as to assure a more thorough search. Medical Subject Headings (MeSH) and entry terms were used in the PubMed database, while DeCs and synonyms were used in the other bases.
The searches obeyed the inclusion and exclusion criteria specified above and were performed in May 2023. The research terms, with some variations from base to base, included: “spirituality” OR “religiosity” OR “religion” AND “non_communicable chronic diseases” OR “neoplasms” OR “diabetes mellitus” OR “respiratory tract diseases” OR “cardiovascular diseases”, as shown in Table 1.
After the searches, the data were compiled and organised in Microsoft Excel spreadsheets. The articles were examined independently and blind by two reviewers (RCD and ACP) in 4 stages: 1. Eliminate duplicates; 2. Read titles and abstracts; 3. Read the studies in full; and 4. Search the studies’ references for complementary studies. Any incongruities or doubts were resolved by consensus among the authors.
After completing the fourth stage, an instrument was prepared for analysis and synthesis of the studies reviewed, which were grouped by similarities in the studies’ characteristics (authors, year of publication, country, objectives, study type, population, collection instruments), populations and spiritual interventions. The extracted data were then analysed using tables and figures reflecting both the attributes of the study selection and screening stages and the interventions performed and their repercussions on individual health. Before making definitive use of this instrument, a pilot test was conducted to verify that its items were appropriate. The search strategies and initial findings are available in the Scielo Data collection at:
https://demo.dataverse.org/dataset.xhtml?persistentId=doi%3A10.70122%2FFK2%2FCOHZJQ&version=DRAFT.

RESULTS
A total of 1564 studies were identified, 138 of them eligible for reading in full, after which 112 studies were excluded as at variance with the concept (42), context (2) or design (68) addressed by this review. Accordingly, the synthesis was produced from 26 studies, as shown in Figure1.
The publications, which spanned the period from 2001 to 2022, were concentrated mostly (69.2%) between 2013 and 2021. By geographical distribution, most of the studies were concentrated in four countries: the USA (13; 50%), Iran (7; 26.9%); Brazil (4; 15.3%) and Japan (2; 7.6%).
All 26 studies included were of the experimental or quasi-experimental type, demonstrating the researchers’ concern to find scientific evidence of the effects of spiritual interventions on individual health. Of these, 4 (16.0%) addressed the influence of spirituality on individuals with, or undergoing prevention against, cardiovascular diseases; 3 (11.5%), diabetes mellitus; and 19 (73.0%), cancer, with one of these latter directed to caregivers of children with cancer. After applying the exclusion criteria, no studies were found on the influence of spirituality on chronic respiratory diseases.
In all, the 26 studies, with numbers of participants ranging from 10 to 443, involved a total population of 3,103 participants with, or undergoing prevention of, MLCNCDs. Of the total population, 172 (5.4%) participants had a cardiovascular disease; 619 (19.9%) were undergoing prevention for cardiovascular disease risk factors; 90 (2.9%) were diabetics; 604 (19.46%) were undergoing prevention for diabetes risk factors; 658 (21.2%) had cancer; and 960 (30.9%) were undergoing prevention for cancer risk factors.
The spiritual interventions used in the studies are shown in Table 2. One study (3.8%) used the Spiritist laying on of hands (19); eight (30.7%) used intercessory, centring, group or recitation prayer (20–27); four (15.3%), used readings of holy scriptures and religious texts (20,27–29); one (3.8%) used writing on religious topics associated with deep-seated feelings (30); one (3.8%) used musicalisation (gospel, dance of praise and worship) (27); two (7.6%) used booklets on spiritual care (Healthy Heart model of spiritual care, religious topics and Bible scriptures) (31,32); thirteen (46.15%) used spiritual reflection (on elements of faith and spirituality, counselling, informed decision making, integration with educational materials) (24,29,33–42); three (11.5%) used transcendental or concentration method meditation (20,24,26); and two studies (7.6%) used spiritual assessment itself, as a method of intervention (26,30,43).
From the main findings described in Table 2, it can be seen that spiritual interventions had influence on physical and physiological factors: reducing physical, disease-related symptoms (19,21,23,30,33,38), such as levels of fatigue, pain and muscular tension (19,33); improving the efficiency of myocardial mechanisms and cardiovascular health (21,27); lowering body weight; reducing fasting plasma glucose (38); improving systemic arterial pressure and respiratory rate (23); and increasing natural killer cell activity (41). Spirituality also had an influence on illness-related awareness, that is, on patients’ commitment to their own treatment, as regards self-care and coping (25,29,32,39,42).
Table 2 also shows the main findings with regard to the influence of spirituality on aspects of participants’ mental and spiritual health. Ten studies mentioned participants’ improved quality of life, hopefulness or wellbeing after the spiritual intervention (19,20,24,26,30,33,34,37,40,41); while four found reductions in depression (19,30,36,40); five, in anxiety (19,23,30,36,40); and eight, in pain and spiritual anguish (19,22,26,31,33,35,41,43).

DISCUSSION
After application of the search strategy and eligibility criteria, this study of the influence of spiritual interventions on the most lethal chronic noncommunicable diseases identified 26 studies, mostly of them experimental.
The eight modalities of spiritual intervention found were offered in primary, secondary and tertiary health care. Most of the studies in this review pointed to a need to offer spiritual care as an important tool for raising awareness on illness, which has repercussions on disease prevention, treatment adherence, motivation to self-care and improved quality of life, wellbeing and physical, mental and spiritual health, corroborating the findings of studies by Moreira, Santana Junior & Posso (44).
Although the benefits of the spiritual dimension have been indicated in a large number of Brazilian and international studies, drawing practitioners’ and researchers’ interest to the topic (45), studies of advances in such care for MLCNCDs are still scarce, as shown by this review, which also found that the literature searched lacks evidence of the influence of spirituality on chronic noncommunicable diseases of the respiratory tract.
Management of pain and spiritual suffering – pace the studies by Conceição et al. (46) – was not limited to spiritual assessment. This review found that, in addition to the various modalities of interventions addressed, the spiritual diagnosis itself is one possible means of alleviating this kind of distress in that it provides a moment for listening to and expressing thoughts and feelings relating to the spiritual dimension.
As shown in the findings of this study, spiritual health is a complement towards total domination of individual health, and its influence can affect both spiritual and physical and mental health. Accordingly, as argued by Saad & Medeiros (47), models of health care should contemplate spiritual health, especially because it favours improvements in multivariate aspects of health, harmonises religious and spiritual misunderstandings that can interfere in treatment progress and meets the implicit demand already identified by science, with a view to reducing the costs of conventional treatment.
Spiritual suffering is a clinical symptom and thus deserves to be alleviated, diagnosed and treated, because the quality of life of individuals who experience severe spiritual anguish tends to worsen, while they progress to depression and anxiety (48). The results of this review both attest to psychological symptoms, such as depression and anxiety, and broaden the range of benefits of spiritual care beyond the symptoms of this kind.
Nonetheless, as indicated by Santos et al. (49), there are blockages that need to be cleared in implementing this modality of care in health services: added to the need for health care personnel specifically trained for the purpose, staffs have limited time to reconcile their routines with this modality of care; the knowledge and training needed for an appropriate approach is lacking and, thus staffs need to train and assimilate the tools involved; and, lastly, there is a lack of awareness building and service structuring for spiritual care.
The main limitation of this review was the difficulty in generalising from the studies, especially in view of their heterogeneity in measurement instruments, modalities of intervention and length of time the care was provided.

CONCLUSION
This scoping review indicated possible manners in which different forms of spiritual care can have beneficial effects on the physical, mental and spiritual health of individuals with more lethal chronic noncommunicable diseases.
The spiritual interventions identified were the Spiritist laying on of hands, prayers, reading of holy scriptures or religious texts, writing on religious topics associated with deep feelings, musicalisation (gospel, dance of praise and worship), a booklet on spiritual care, spiritual reflection, meditation and spiritual assessment itself.
The findings of this review corroborate the existing scientific findings on the health benefits of spiritual care and, at the same time, indicate a scarcity of studies on the subject. This highlighted opportunities for future research: (1) to explore modalities of spiritual care separately, so as to identify the efficacy of each of them and associate them with investigation into the spirituality of the individuals targeted. That spirituality may itself be an important object of investigation in that it can affect the gains produced by the interventions; and (2) to explore their repercussions on specific sets of symptoms.

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