Perspectives of Indian Traditional and Allopathic Professionals on the Role of R-S in Medicine_Ramakrishnan Et Al JRH June 2013

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Journal of Religion and Health ISSN 0022-4197 J Relig HealthDOI 10.1007/s10943-013-9721-2

Perspectives of Indian Traditional andAllopathic Professionals on Religion/Spirituality and its Role in Medicine: Basisfor Developing an Integrative MedicineProgramP.Ramakrishnan, A.Dias, A.Rane,A.Shukla, S.Lakshmi, B.K.M.Ansari,R.S.Ramaswamy, A.R.Reddy,A.Tribulato, A.K.Agarwal, et al.

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ORI GIN AL PA PER

Perspectives of Indian Traditional and AllopathicProfessionals on Religion/Spirituality and its Rolein Medicine: Basis for Developing an IntegrativeMedicine Program

P. Ramakrishnan A. Dias A. Rane A. Shukla S. Lakshmi

B. K. M. Ansari R. S. Ramaswamy A. R. Reddy A. Tribulato

A. K. Agarwal J. Bhat N. SatyaPrasad A. Mushtaq

P. H. Rao P. Murthy H. G. Koenig

Springer Science+Business Media New York 2013

Abstract Allopathic medical professionals in developed nations have started to collab-orate with traditional, complementary, and alternative medicine (TCAM) to enquire on the

role of religion/spirituality (r/s) in patient care. There is scant evidence of such movement

in the Indian medical community. We aim to understand the perspectives of Indian TCAM

and allopathic professionals on the influence of r/s in health. Using RSMPP (Religion,

Spirituality and Medicine, Physician Perspectives) questionnaire, a cross-sectional survey

was conducted at seven (five TCAM and two allopathic) pre-selected tertiary care medical

institutes in India. Findings of TCAM and allopathic groups were compared. Majority in

both groups (75 % of TCAM and 84.6 % of allopathic practitioners) believed that patients

spiritual focus increases with illness. Up to 58 % of TCAM and allopathic respondents

P. RamakrishnanAdiBhat Foundation, R-90, Greater Kailash-I, New Delhi 110048, India

P. Ramakrishnan (&)21332 38th Avenue SE, Bothell, WA 98021, USAe-mail: [email protected]; [email protected]

A. DiasDepartment of Preventive and Social Medicine, Goa Medical College, Goa University, Goa, India

A. RaneInstitute of Psychiatry and Human Behavior, Goa Medical College, Goa University, Goa, India

A. Shukla N. SatyaPrasadB.R.K.R. Government Ayurvedic Medical College, Hyderabad, India

S. LakshmiGandhi Institute of Yoga and Naturopathy, Hyderabad, India

B. K. M. Ansari A. MushtaqCentral Research Institute of Unani Medicine, Hyderabad, India

R. S. RamaswamyNational Institute of Siddha Medical Sciences, Chennai, India

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J Relig HealthDOI 10.1007/s10943-013-9721-2

Author's personal copy

report patients receiving support from their religious communities; 87 % of TCAM and

73 % of allopaths believed spiritual healing to be beneficial and complementary to allo-

pathic medical care. Only 11 % of allopaths, as against 40 % of TCAM, had reportedly

received formal training in r/s. Both TCAM (81.8 %) and allopathic (63.7 %) profes-

sionals agree that spirituality as an academic subject merits inclusion in health education

programs (p = 0.0003). Inclusion of spirituality in the health care system is a need forIndian medical professionals as well as their patients, and it could form the basis for

integrating TCAM and allopathic medical systems in India.

Keywords Spirituality Religion Integrative Medicine Ayurveda TCAM India Education

Introduction

The discovery of various investigative techniques and identification of microorganisms as a

cause for pathogenesis led toward a more observable and evidence-based approach to

understanding disease pathophysiology and management (Ziegler 1998). As a result, ele-

ments such as spirit and vital energy, which are not as tangible as neurons and neuro-transmitters, were neglected or entirely eliminated from a largely bio-physically-oriented

approach to medicine. Such a perspective was also taken by some nineteenth century

neurologists and psychiatrists, who criticized all religious and supernatural phenomena as

pathological (Hayward 2004). This alienation continued through most of the twentieth

century. This phenomenon started to wane toward the late twentieth century (Clarke 2006;

Lukoff et al. 1992). Development of consumer-oriented healthcare services and a growing

consumer demand for Traditional and Complementary and Alternative Medicine (TCAM)

(Menniti-Ippolito and De Mei 1999; Crammer et al 2011; Wu et al 2009) has led

researchers to investigate and understand the unmet spiritual needs of patients (Fabian et al

2005); Spirituality was found to be the strongest predictor for TCAM use (Hsiao et al

2008). Mental health professionals in India and other countries have started to reflect on

A. R. ReddyJ.S.P.S Government Homeopathic Medical College, Hyderabad, India

A. Tribulato A. K. AgarwalClinical Faculty, Help Foundation of Omaha, Omaha, NE, USA

J. BhatDepartment of Pediatrics, Goa Medical College, Goa University, Goa, India

P. H. RaoSweekaar-Upkaar Rehabilitation Institute for Handicapped, Osmania University, Secunderabad, India

P. MurthyNational Institute of Mental Health and NeuroSciences, Bangalore, India

H. G. KoenigDuke University Medical Center, Durham, NC, USA

H. G. KoenigKing Abdulaziz University, Jiddah, Saudi Arabia

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the spiritual knowledge from the past and wondering about its application into the current

and future mental health services (Rao 2009). Such reflections and efforts are com-

mendable, but we believe that such knowledge and skill need to be developed through

modern evidence-based methods for better understanding and clinical application. Over the

last decade, there has been extensive research and publications on varied topics, ranging

from conceptualization (King and Koenig 2009) of spirituality to its application in health

care (Murray-Swank et al 2006; Spurlock 2005) and to its introduction in health education

curriculum (Anandarajah 2008; Neely and Minford 2008; Guck and Kavan 2006; Fortin

and Barnett 2004; Grabovac and Ganesan 2003; Graves et al 2002; Hull et al 2001;

Lawrence and Duggal 2001; Puchalski 2006; Puchalski and Larson 1998). Evidence-based

medical researchers have thus returned, completing a circle, to incorporate spirituality into

their bio-psycho-social model of patient management. Unfortunately, most of this research

has occurred in advanced/developed nations and conducted by allopathic/evidence-based

medical researchers. Only a small amount of scientific research has been conducted within

traditional systems of medicine to understand the pathophysiological mechanisms of dis-

ease causation or pharmacological mechanisms of herbal drugs or, more pertinent to our

current topic, spiritual methods in treatment. A PubMed search (on April 14, 2012) using

the keyword medicine yielded 3.0 million hits and the word religion had 46,690 hits,

while religion and medicine yielded 11,810 articles globally. However, the search terms

medicine and India yielded 20,380 publications, but medicine, India, religion yielded

only 350 articles. The search term Ayurveda (used as a proxy for all TCAM systems in

India) yielded only 2,377 articles, of which only 92 were related to religion and ayurveda.

Further, while there are scholarly publications and articles highlighting the need for

spirituality in health in India (Chattopadhyay 2007), researchers have just started to ponder

over the definitions and measuring scales for spiritual health (Dhar et al 2011) and to

question if we are ready for having the subject of spirituality in health education programs

in India (Kattimani 2012).

This paper examines the TCAM and allopathic professionals perspectives on spiritu-

ality in the context of healthcare practices in India. We compared TCAM and allopathic

physicians on their self-reported clinical observations and interpretations regarding the

influence of r/s on patients health. We also examined associations between physicians

personal beliefs and their acceptance of spirituality as an appropriate subject in health

education.

Materials and Methods

The study was conducted in India at seven pre-selected tertiary care medical institutes

between January 2010 and December 2011. The sites included two allopathic medical

institutes (Goa University Medical College, Bambolim, Goa and Sweekaar-Upkaar

Rehabilitation Institute for the Handicapped, Osmania University, Secunderabad, Andhra

Pradesh) and five TCAM institutes (BRKR Government Ayurvedic Medical College,

Gandhi Institute of Yoga and Naturopathy, Central Research Institute of Unani Medicine

and JSPS Government Homeopathic Medical College in Hyderabad, Andhra Pradesh and

the National Institute of Siddha Medical Sciences in Chennai, Tamil Nadu). The Religion

and Spirituality in Medicine: Physicians Perspective (RSMPP) (Curlin et al 2005, 2006,

2007) was used as the principal survey questionnaire, and it has questions on the partic-

ipants beliefs, practices, and perception of clinical role of r/s. The wordings of the items in

the RSMPP were modified and adapted for usage by non-physician healthcare

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professionals such as nurses and therapists. We also administered a specially developed

supplementary questionnaire that included questions to explore the association between

mental health and spirituality and the scientific merit of inclusion of spirituality as a subject

in academic health education programs. The adaptation of RSMPP and the supplementary

questionnaire were developed by the group of investigators at HELP Foundations clinics

and research lab in Omaha. This was made possible based on the feedback from a focus

group using a Question Appraisal System-1999 (QAS-99) (Willis and Lessler 1999);

QAS-99 has an 8-step systematic appraisal of question items to identify and fix mis-

communication, relevance, and clarity. The focus group comprised of eight members

drawn from medical (two physicians and two nurses) and non-medical professional (two

attorneys and two teachers) backgrounds. Our final sets of questions were subject to pretest

and piloting by administering it on the clinical staff at HELP Foundation clinic, comprising

of five physicians, three nurses, and two social workers. The members comprising the

focus and pretest groups were drawn from varied socio-cultural, religious, and national

backgrounds. The questions were further modified following feedback from this piloting

survey so as to arrive at a final set of questions for subsequent field studies.

Describing the Variables in Our Survey Questionnaires

The primary criterion variable was the physicians agreement with the following statement:

Spirituality as a healthcare tool is worthy to be introduced as an academic subject into the

medical school curriculumAnswer choices were strongly agree, agree, disagree, or

strongly disagree. Predictor variables were clustered into participants (a) personal r/s

characteristics (Table 1), (b) clinical observations and interpretations of patients behavior

related to r/s matters (Table 2), and (c) formal training in matters related to r/s, comforts,

and barriers thereof (Table 3). The control variables (Table 1) included participants age,

gender, and religious affiliation.

Methodology

The necessary permissions and ethical approvals were obtained from the respective heads

of participating institutions/institutional review boards as well as the commissioner of

AYUSH (acronym for Ayurveda, YogaNaturopathy, Unani, Siddha, and Homeopathy),

the state governing body for TCAM institutes. Since there are no previous studies of this

type to guide us, we assumed 50 % of the professional staff to favor the primary criterion

variable, and using the sample size calculator, we arrived at a sample size of 400 volunteer

participants in each of the study groups (TCAM and allopathy). For the sake of conve-

nience, this sampling was distributed among various participating institutes; individual

institutional breakup of data is not in the Table. Potential participants were invited to

small-group sessions at each of the institutions/departments to explain about the purpose of

this study before distributing the survey questionnaires. Key persons/regional investigators

designated at individual sites encouraged participants periodically, through personal

meetings or phone calls, to complete their surveys. Completed surveys were collected by

the key persons and submitted to the principal investigator in a secure manner. Obtained

data were double entered, with 100 % verification into an Excel spreadsheet and later

analyzed using, open source, SigmaXL statistical software. We first generated overall

population estimates for the participants religious characteristics and then for their

agreement with each criterion measure. We utilized the Students t test, Pearsons v2 test,and multivariate binomial logistic regression. Two institutes, one from the TCAM group

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Table 1 Demographic, religious/spiritual characteristics of health care professionals in the study

Demographic variables TCAM Allopathic Analysis

Mean SD Mean SD p (t test)

Age (years) N = 185, mean = 29.19 10.02 N = 171, mean = 34.49 11.79 0.0000

N = 192 % N = 201 % v2, df, p value

Age groups

2029 years 139 72.40 83 41.29

3039 years 15 7.81 34 16.92 27.279

4049 years 13 6.77 21 10.45 3

5059 years 18 9.38 33 16.42 0.0000

Gender

Male 68 35.41 80 39.80 1.815

Female 122 63.54 108 53.73 1, 0.1780

Religious affiliation

Christianity 11 5.73 43 21.39

Hinduism 124 64.58 133 66.17 51.587

Islam 49 25.52 7 3.48 3

Others 4 2.08 7 3.48 0.0000

Occupational groups

Physicians 79 41.15 54 26.86

Nurses 0 0 29 14.43

Residents in training 48 25 44 21.89 43.227

Medical students 36 18.75 33 16.42 4

Therapy staff 13 6.77 35 17.41 0.0000

To what extent do you consider yourself a Religious person? Would you say you are Very religious 45 23.44 16 7.96

Moderately religious 96 50.00 120 59.70 17.341

Slightly religious 40 20.83 48 23.88 3

Not religious at all 8 4.17 10 4.98 0.0006

To what extent do you consider yourself a Spiritual person? Would you say you are Very spiritual 44 22.92 22 10.95

Moderately spiritual 90 46.88 98 48.76 14.335

Slightly spiritual 53 27.60 60 29.85 3

Not spiritual at all 3 1.56 13 6.47 0.0025

Belief: do you believe in god?

Yes 181 94.27 182 90.55 1.646

No 4 2.08 2 0.99 2

Undecided 6 3.13 10 4.98 0.4391

Do you believe there is life after death?

Yes 109 56.77 71 35.32 16.862

No 45 23.44 55 27.36 2

Undecided 36 18.75 64 31.84 0.0002

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(i.e., BRKR Ayurvedic College) and another from allopathic group (Sweekar-Upkaar

Rehabilitation Institute), with the most number of non-responders were revisited to

understand the reason for non-response of their participants and to study if they differ in

their r/s characteristics from those who promptly returned a completed survey. About 10 %

of the non-responders were contacted randomly from each of these two institutes; elec-

tronic random number generator was used in this process of randomization. The findings of

this short non-responders survey was analyzed and factored into our discussion.

Results

A total of 192 completed surveys were returned by the TCAM participants; out of 400

(response rate 48 %) and of 400 allopathic participants, 201 returned their completed

surveys (response rate 50.55 %).

Non-responders Data (N = 14, Not in the Tables)

The reason for non-response was cited as lack of time by six (42.9 %) of them while the

rest, eight (57.1 %), stated that they forgot to submit (in spite of repeated reminders).

All of them answered either as strongly agree or agree to the primary criterion variable,

that is, Spirituality is a subject worthy to be introduced as an academic subject in medical

education program. There was no significant difference between the r/s characteristics of

the original responders and the non-responders.

Demographic Characteristics (Table 1)

The allopathic group was significantly (p = 0.0000) older (34.49 years) than the TCAMgroup (29.19 years) in their mean ages. TCAM respondents were mostly in the age group

between 20 and 29 years (72.4 %). Females predominated in both groups (63.54 % of

TCAM and 53.73 % of allopathic groups). There was no statistically significant difference

(p = 0.1780) in gender distribution. With respect to clinical professional characteristics,physician staff and residents in training together formed most of the respondents in TCAM

and allopathic groups, 66.15 % and 48.75 %, respectively. While there was no participa-

tion from the nursing staff at TCAM institutes, there was also fewer therapy staff (6.77 %)

among TCAM compared to the allopathic group (17.41 %). These differences were sta-

tistically different (p = 0.0000). Both the participant groups had representation of diversespecialties from within their institutes though in an uneven fashion; while a large number

of TCAM respondents were internists/general medicine (23.96 %), those in the allopathic

group were mental health professionals (20.89 %) (data not in the tables).

Table 1 continued

N = 192 % N = 201 % v2, df, p value

Do you think god or another supernatural being ever intervenes in patients health?

Yes 129 67.19 109 54.23 6.316

No 22 11.46 33 16.42 2

Undecided 37 19.27 52 25.87 0.0425

Counts do not equal N due to partial non-responses

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Table 2 Physicians clinical observations and interpretations of the influence of R/S on health

Questionnaire item (Q no. inbrackets) on clinical observationsand their interpretation

Response (Codes) TCAM Allopathic Analysisv2, df,p valueN = 192 % N = 201 %

How often would you say theexperience of illness increasepatients awareness of andfocus on R/S

Rarely 11 5.73 2 0.99

Never 21 10.94 20 9.95

Sometimes 56 29.17 75 37.31 13.012

Often 60 31.25 70 34.83 5

Always 28 14.58 25 12.44 0.0233

Not apply 11 5.73 4 1.99

Potential positive influences ofR/S Considering yourexperience how often do youthink...R/S helps to preventhard medical outcomes likeheart attacks, infections, oreven death

Rarely 30 15.63 36 17.91

Never 34 17.71 47 23.38

Sometimes 55 28.65 46 22.89

Often 25 13.02 22 10.95 13.611

Always 23 11.98 7 3.48 5

Not apply 18 9.375 26 12.93 0.0183

.R/S helps patients to copewith and endure illness andsuffering

Rarely 6 3.125 9 4.48

Never 18 9.375 19 9.45

Sometimes 65 33.85 61 30.35 2.391

Often 49 25.52 62 30.85 5

Always 32 16.67 31 15.42 0.7927

Not apply 16 8.33 13 6.47

Potential negative influences ofR/S: Considering yourexperience how often do youthink..R/S leads patients torefuse, delay, or stop medicallyindicated therapy

Rarely 41 21.35 40 19.90

Never 43 22.40 45 22.39

Sometimes 63 32.81 62 30.85 0.630

Often 18 9.375 21 10.45 5

Always 1 0.52 2 0.99 0.9866

Not apply 21 10.94 20 9.95

In your experience, how oftenhave your patients used R/S asa reason to avoid takingresponsibility for their ownhealth?

Rarely 29 15.10 47 23.38

Never 37 19.27 51 25.37

Sometimes 56 29.17 44 21.89 12.206

Often 22 11.46 18 8.96 5

Always 6 3.13 1 0.50 0.0321

Not apply 34 17.71 29 14.43

General interpretationOverall, how much influence do

you think religion/spiritualityhas on patients health?

Very much 33 17.19 45 22.39

Much 73 38.02 59 29.35 7.925

Some 68 35.42 63 31.34 4

A little 11 5.73 18 8.96 0.0944

Very little to none 2 1.042 7 3.48

Is the influence of religion/spirituality on health generallypositive or negative?

Generally Positive 119 61.98 128 63.68 0.713

Generally Negative 9 4.69 10 4.98 3

Equally positiveand negative

51 26.56 45 22.39 0.8701

It has no influence 8 4.17 8 3.98

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Religious/Spiritual Characteristics (Table 1)

Religious affiliations were collapsed into four groupsChristianity, Hinduism, Islam, and

Others. The Other group included Atheists and Agnostics. There was a significant dif-

ference (p = 0.0000) in the religious affiliation of respondents among the TCAM andallopathic groups. In the allopathic group, Hindu participants predominated (66.17 %) and

Christians were the 2nd largest religious denomination at 21.39 %. In the TCAM group as

a whole, Hindu participants were predominant (64.58 %) followed by Muslims (25.52 %);

among the individual TCAM institutes, Hindus predominated in Ayurvedic (73 %), Yoga

naturopathy (81 %), Siddha (91.7 %), and Homeopathy (87.9 %) institutes, while the

largest religious group in Unani was Islam (93.2 %) (data not in the tables). A significantlygreater proportion of TCAM respondents (23.44 %) considered themselves to be very

religious compared to the allopathy group (7.96 %) (p \ 0.005) as well as very spiritual(22.92 % and 10.95 %, respectively). More TCAM professionals (67.19 %) believed that

God or another supernatural being could intervene in patients health/illness than allo-

pathic professionals (54.23 %, p = 0.0425). Again, significantly greater number (56.77 %)of TCAM respondents compared to allopath (35.32 %) believed in the concept of life after

death (p = 0.0002).

Clinical Observations and Interpretations on Influence of R/S on Health (Table 2)

A majority of respondents in both groups (75 % of TCAM and 84.58 % of allopathic

professionals) acknowledge that patients awareness and focus on spirituality increases

(sometimes or often or always) following an illness experience. TCAMs more commonly

(53.5 % as compared to only 37.22 % of allopaths, p = 0.0183) believe that r/s has a

Table 2 continued

Questionnaire item (Q no. inbrackets) on clinical observationsand their interpretation

Response (Codes) TCAM Allopathic Analysisv2, df,p valueN = 192 % N = 201 %

Clinical experience andinference:

How often have your patientsreceived emotional or practicalsupport from their religiouscommunity?

Rarely 15 7.81 25 12.44

Never 29 15.10 27 13.43

Sometimes 65 33.85 74 36.82 5.376

Often 30 15.62 36 17.91 5

Always 11 5.73 7 3.48 0.3718

Not apply 33 17.19 25 12.44

In your experience with religious/faith healers, have you been

Very satisfied 13 6.77 8 3.98

Satisfied 80 41.67 54 26.87

Dissatisfied 5 2.60 19 9.45 16.928

Very dissatisfied 4 2.08 8 3.98 4

I have had no priorexperience

86 44.79 101 50.25 0.0020

Spiritual healing has somebenefits, and it could be acomplement to modern medicaltreatment

Strongly agree 65 33.85 30 14.93 16.644

Agree 102 53.13 118 58.71 3

Disagree 13 6.77 16 7.96 0.0008

Strongly disagree 1 0.52 5 2.49

Counts do not equal N due to partial non-responses

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Table 3 Comforts, barriers, and unmet needs of healthcare providers regarding R/S in clinical medicine

Questionnaire item Responsecategory

TCAM Allopathic Analysis v2,df, p value

N = 192 % N = 201 %

Comfort:To what extent do you agree or

disagree with the followingstatements

I would feel comfortablediscussing a patients religious/spiritual concerns if the patientbrought them up

Stronglyagree

28 14.58 33 16.42 4.614

Agree 118 61.46 109 54.23 3

Disagree 36 18.75 46 22.89 0.2024

Disagree/strongly

3 1.56 9 4.48

I enjoy discussing religious/spiritual issues with patients

Stronglyagree

19 9.90 12 5.97

Agree 78 40.62 62 30.84 12.064

Disagree 50 26.04 74 36.81 4

Disagree/strongly

10 5.208 21 10.44 0.0169

Does notapply

32 16.67 28 13.93

How often have patients seemeduncomfortable when you inquireabout their religious/spiritualissues?

N = 192 % N = 201 % v2, df, p value

Never 23 24.73 15 20.00

Rarely 38 40.86 31 41.33 2.142

Sometimes 24 25.81 20 26.66 4

Often 2 2.15 3 4.00 0.7096

Always 0 0 1 1.33

Barriers:Do any of the following

discourage you from discussingreligion/spirituality withpatients?

* You can check more than onechoice

You cancheck onmore thanone choice*

N = 192 % N = 201 % v2, df, p value

Generaldiscomfort

67 34.90 55 27.36 2.603, 1,0.1067

Insufficientknowledge/training

51 26.56 50 24.88 0.1463, 1,0.7021

Insufficienttime

53 27.60 63 31.34 0.6599, 1,0.4166

Concernaboutoffendingpatients

31 16.15 39 19.40 0.7116, 1,0.3989

Concern thatcolleagueswilldisapprove

9 4.69 9 4.48 0.0098, 1,0.9207

Formal Training Regarding R/S inmedicine

Have you ever had any formaltraining regarding religion/spirituality in medicine?

N = 192 % N = 201 % v2, df, p value

No 112 58.33 179 89.05 48.226

Yes 80 41.67 22 10.95 10.0000

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potentially positive influence on the outcome from illness/illness acceptance such as heart

attacks, infections, and even death. At the same time, more number of TCAM professionals

(43.76 %) than allopaths (31.35 %) believed that the patients used r/s to lower responsi-

bility for their own health (p = 0.0321). An equal number of TCAM and allopathic pro-fessionals (up to 58 %) experienced their patients receiving support from their religious

community. Only 54.26 % of TCAM and 46.84 % of allopathic professionals reportedly

had experience with religious/faith healers. However, of those TCAM professionals who

had such experience 90.57 % reported being satisfied, while only 62 % of allopathic

professionals, though high, reported satisfaction. Respondents from both groups, TCAM

(86.98 %) and allopaths (73.64 %), believed that spiritual healing has some benefits and

could complement allopathic medical treatment (p = 0.0008).

Table 3 Comforts, barriers, and unmet needs of healthcare providers regarding R/S in clinical medicine

Questionnaire item Responsecategory

TCAM Allopathic Analysis v2,df, p value

N = 192 % N = 201 %

If yes, You cancheck onmore thanone choice*

N = 80 % N = 22 % v2, df, p value

Where did you get such training?* You can check more than one

choice

Medicalschoolcourse(A20 a1)

32 40 0 0 12.82, 1,0.0003

Book, CMEliterature(a2)

17 21.25 7 31.82 1.07, 1,0.3007

Grandrounds/conference(A20 a3)

6 7.5 0 0 1.75, 1,0.1855

Trainingfromreligioustradition(A20 a4)

30 37.5 14 63.64 4.81, 1,0.0284

To what extent do you agree withthe following statements?

Responses N = 192 % N = 201 % v2, df, p value

Spirituality is a scientific subjectfollowing some biophysical lawsunknown to the current scientificcommunity

Stronglyagree

66 34.38 29 14.43

Agree 93 48.44 91 45.27 19.390

Disagree 17 8.85 34 16.92 3

Stronglydisagree

4 2.08 6 2.99 0.0002

Spirituality as a health care tool isa subject worthy to beintroduced as an academicsubject into the medical schoolcurriculum

Stronglyagree

59 30.73 26 12.94

Agree 98 51.04 102 50.75 18.640

Disagree 18 9.38 31 15.42 3

Stronglydisagree

4 2.08 10 4.98 0.0003

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Discomforts, Barriers, and Needs in Matters Related to Clinical Spirituality (Table 3)

A majority of TCAM (76.04 %) and allopathic professionals (70.65 %) in our study

reported feeling comfortable discussing r/s concerns if the patient brings them up. In fact,

50.5 % of TCAM professionals, as against 36.8 % of allopaths, also report that discussions

on r/s issues with their patients as enjoyable. Among the various barriers of providing

spiritual care were insufficient knowledge/training (26.6 % TCAMs and 24.9 % allo-

paths), insufficient time (27.6 % TCAMs and 31.3 % allopaths), general discomfort

(34.9 % TCAMs and 27.4 % allopaths), and a concern of offending the patients (16.2 %

TCAMs and 19.4 % allopaths). Regarding formal training on r/s in medicine, only

10.95 % of allopathic professionals reportedly received such training; however, further

questioning reveals that their formal training was from their own religious tradition

(63.64 %) and/or from self-study via medical literature (31.82 %). On the other hand,

40 % of TCAM professionals reported training through a medical school course. A large

percentage (37.5 %) of TCAM professionals also mentioned of having received that

training in their familys religious tradition. Significantly (p = 0.0002), larger numbersamong TCAM (82.8 %) group as compared to allopathic (59.7 %) professionals believed

that spiritual healing methods involved some biophysical mechanisms unknown to the

current scientific community. Though a majority of respondents in each of our groups

agreed to spirituality as an academic subject worthy to be included into medical education

programs, it was TCAM members (81.77 %) who were significantly (p = 0.0003) moresupportive than allopathic respondents (63.69 %).

Factors influencing the position that spirituality as an academic subject worthy to be

included into medical education curriculum were evaluated through a multivariate bino-

mial logistic regression (Table 4). Notwithstanding the power of significance, all factors

found significant in univariate analysis, as well as the group status (TCAM or allopathy),

were included into our regression model. Of the numerical variables, respondents belief

that spiritual healing could prevent adverse medical outcomes (heart attacks, infections

and even death) was a significant predictor with bcoefficient of 0.206 and z-score of2.180 (p = 0.0279, odds ratio of 0.814 with 95 % CI of 0.6770.979). The predictability ofthe categorical variables, TCAM Vs. allopathy, improved consistently through all the

models with statistical significance of p = 0.0215 in the full model, McFaddens PseudoR-Square increased to 6.35 %, and the percentage correctly predicted value for this fullmodel was 83.28 %.

Discussion

This was a multisite exploratory study ascertaining the views on religion and spirituality of

TCAM and allopathic professionals in India and its role in health care. Our hypothesis was

that TCAM professionals will be more supportive of a role for r/s in medicine as compared

to their counterparts in allopathic medical system in India. While TCAM practitioners were

significantly more comfortable with concepts of r/s compared to allopathic practitioners,

both equally perceived that patients tended to turn to r/s when ill. Contrary to expectation,

TCAM practitioners had received little formal training in r/s and much of their knowledge

stemmed from experiences and practices within their families. There are several limitations

of the study. The institutions were not randomly selected, respondents belong to diverse

health disciplines, with an overrepresentation of mental health professionals among the

allopathic respondents. It is also to be noted that medical specialties in TCAM and

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Table 4 Multiple logistic regression outcome measure was agreement to a question Spirituality as a healthcare tool is a subject worthy to be introduced as an academic subject into the medical school curriculum

Variables (*to what extent do you agreewith this statement?)

Model 1: Model 2: Full model:

Includes Step-1variables

Includes Step-1and Step-2variables

Includes Step-1,Step-2, and Step-3 variables

b z b z b z

Step1: Participants religious/spiritual characteristics, beliefs, and practices as numeric variables)

Numerical variables (Items from the Likert scale)

To what extent do you consider yourself asa religious person?

0.213 1.04 0.271 1.28 0.281 1.320

To what extent do you consider yourself tobe a spiritual person?

0.126 0.63 0.181 0.88 0.194 0.940

Do you believe there is life after death? 0.111 0.614 0.127 0.69 0.171 0.900

Do you think God or another supernaturalbeing ever intervenes in patientshealth?

0.108 0.592 0.084 -0.45 0.060 0.317

Categorical variable: TCAM Vs allopathichealthcare professionals

0.664* 0.317*a

Step2: Clinical observations and interactions with patients on R/S issues


How often would you say that theexperience of illness increases patientsawareness of and focus on religion/spirituality?

0.031 0.214 0.047 0.33

Considering your experience, how often doyou think religion/spiritualityhelps toprevent hard medical outcomes likeheart attacks, infections, or even death?

0.206* 2.199*b 0.206* 2.180*d

In your experience with religious/faithhealers, have you been satisfied and towhat extent?

0.190 1.82 0.185 1.74

Spiritual healing has some benefits, and itcan complement modern medicaltreatment.

0.024 0.100 0.035 0.14


0.713* 2.220*c

Step3: Knowledge/training and personal comforts. Beliefs in R/S role in medicine:


I enjoy discussing R/S issues withpatients*

0.107 0.81

Have you had any formal trainingregarding religion/spirituality inmedicine?

0.265 0.33

Received spirituality training throughmedical school course

0.645 0.71

Received spirituality training fromreligious tradition

0.682 0.76

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allopathy cannot be compared because of innate differences in their understanding of

pathophysiology and clinical management of illnesses. Participation was voluntary, with

approximately less than half the respondents completing the survey. Notwithstanding the

significant results, noticeable imbalance across co-variate groups was observed. Alternate

approaches were proposed that meant collapsing the lower sample categories into one or

other existing category to increase the overall power, so we can strongly conclude with

significant results. This will need additional resources as well as further improvement

in data collection, management, analysis, and/or computation.

Nevertheless, this first attempt to objectively determine health practitioners perceptions

highlights that although health practitioners are aware of the importance of r/s among their

patients, they do not have the necessary expertise or training to handle these issues.

There have been longstanding tensions between the practitioners of TCAM and

allopathy, with TCAM professionals criticizing the allopathic approach as being too

impersonal and reductionistic (Sikand and Laken 1998; Silenzio 2002) and allopathic

physicians undermining TCAM techniques as not being science-based (Hughes2008).In

fact, there is concern expressed as to whether TCAM institutes are moving away from their

traditional training to adopt a more bio-medicalized approach (Warrier 2009). As the

national healthcare system in India is trying to bring together allopathic and TCAM pro-

fessionals to work together under the same roof through its National Rural Health Mission

(NRHM) program (Department of AYUSH 2011), it is an opportune time to identify

common ground between the two disciplines. The recognition that spirituality may be one

such common area in which both the medical systems can interact may be an important

step for inter-disciplinary dialogue and for an integrative medicine program (Dwyer 2004).

This can also inform changes in pedagogic methodologies and address the disconnect

between medical education and morbidity patterns among health care service consumers

(Ministry of Health and Family Welfare 2005).

Conclusions

Both TCAM and allopathic professionals are open to spirituality as a scientific academic

subject. This is the best opportunity for TCAM systems to actively open the spiritual

Table 4 continued

Variables (*to what extent do you agreewith this statement?)

Model 1: Model 2: Full model:

Includes Step-1variables

Includes Step-1and Step-2variables

Includes Step-1,Step-2, and Step-3 variables

b z b z b z


0.822* 2.299*e

McFaddens Pseudo R-Square, DR2, percent correctly predicted: Model-1 3.00 %, , 83.28 %, Model-25.73 %, 2.73, 83.28 %, Model-3 6.35 %, 0.62, 83.28 %

* p \ 0.05Odds ratio (95 % CI): a 0.515 (0.2810.944), b 1.229 (1.0231.478), c 2.040 (1.0873.828), d 0.814(0.6770.979), e 0.440 (0.2180.886)

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knowledge scattered in their scriptural medical texts for scrutiny and development through

evidence-based methods. It is also an opportune moment for allopathic physicians to

understand the role of spirituality in improving health outcomes. The outcome of this

active collaboration may result in a truly integrative medicine.

Acknowledgments This study was made possible by the generosity in time, personal, and financialsupport of HELP and AdiBhat Foundations in USA and India, respectively. HELP Foundation is a non-profitorganization in Omaha, NE, USA, serving the underprivileged population with its community urgent careclinics. AdiBhat is a non-profit organization founded in New Delhi to develop spirituality as a medicalsubject. Sincere thanks to Dr. Curlin F. A. (University of Illinois, Chicago, Illinois, USA) for providing hisRSMPP survey questionnaire to conduct our study. We appreciate the support of Dr.Vijay Kumar, Com-missioner of the State department of AYUSH, for permitting us to conduct the study at the AYUSHinstitutes. Many thanks for dean Dr. V. N. Jindal for his permission and guidance to initiate the study at GoaMedical College, Goa. Thanks goes to Dr. M. S. Kulkarni at Goa Medical College and Dr. Sharavi Gandhamat Univ. of Washington for their invaluable statistical inputs. We also like to appreciate all the staff at HELPFoundation for participating in the focus group discussions and other research processes leading to thedevelopment of our supplementary survey questionnaire. Finally, we would like to thank all our researchrespondents for donating their invaluable time and providing their opinions and perspectives toward asuccessful completion of this study.

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Perspectives of Indian Traditional and Allopathic Professionals on Religion/Spirituality and its Role in Medicine: Basis for Developing an Integrative Medicine ProgramAbstractIntroductionMaterials and MethodsDescribing the Variables in Our Survey QuestionnairesMethodology

ResultsNon-responders Data (N = 14, Not in the Tables)Demographic Characteristics (Table 1)Religious/Spiritual Characteristics (Table 1)Clinical Observations and Interpretations on Influence of R/S on Health (Table 2)Discomforts, Barriers, and Needs in Matters Related to Clinical Spirituality (Table 3)

DiscussionConclusionsAcknowledgmentsReferences

Perspectives of Indian Traditional and Allopathic Professionals on the Role of R-S in Medicine_Ramakrishnan Et Al JRH June 2013

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