Content uploaded by Parameshwaran Ramakrishnan
Author content
All content in this area was uploaded by Parameshwaran Ramakrishnan on Jul 04, 2014
Content may be subject to copyright.
1 23
Journal of Religion and Health
ISSN 0022-4197
J Relig Health
DOI 10.1007/s10943-013-9721-2
Perspectives of Indian Traditional and
Allopathic Professionals on Religion/
Spirituality and its Role in Medicine: Basis
for Developing an Integrative Medicine
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, et al.
1 23
Your article is protected by copyright and all
rights are held exclusively by Springer Science
+Business Media New York. This e-offprint is
for personal use only and shall not be self-
archived in electronic repositories. If you wish
to self-archive your article, please use the
accepted manuscript version for posting on
your own website. You may further deposit
the accepted manuscript version in any
repository, provided it is only made publicly
available 12 months after official publication
or later and provided acknowledgement is
given to the original source of publication
and a link is inserted to the published article
on Springer's website. The link must be
accompanied by the following text: "The final
publication is available at link.springer.com”.
ORIGINAL PAPER
Perspectives of Indian Traditional and Allopathic
Professionals on Religion/Spirituality and its Role
in Medicine: Basis for Developing an Integrative
Medicine 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. Ramakrishnan
AdiBhat Foundation, R-90, Greater Kailash-I, New Delhi 110048, India
P. Ramakrishnan (&)
21332 38th Avenue SE, Bothell, WA 98021, USA
e-mail: dr.eshwaran@gmail.com; dr.kris@theadibhat.org
A. Dias
Department of Preventive and Social Medicine, Goa Medical College, Goa University, Goa, India
A. Rane
Institute of Psychiatry and Human Behavior, Goa Medical College, Goa University, Goa, India
A. Shukla N. SatyaPrasad
B.R.K.R. Government Ayurvedic Medical College, Hyderabad, India
S. Lakshmi
Gandhi Institute of Yoga and Naturopathy, Hyderabad, India
B. K. M. Ansari A. Mushtaq
Central Research Institute of Unani Medicine, Hyderabad, India
R. S. Ramaswamy
National Institute of Siddha Medical Sciences, Chennai, India
123
J Relig Health
DOI 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 for
Indian 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;Wuetal2009) 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. Reddy
J.S.P.S Government Homeopathic Medical College, Hyderabad, India
A. Tribulato A. K. Agarwal
Clinical Faculty, Help Foundation of Omaha, Omaha, NE, USA
J. Bhat
Department of Pediatrics, Goa Medical College, Goa University, Goa, India
P. H. Rao
Sweekaar-Upkaar Rehabilitation Institute for Handicapped, Osmania University, Secunderabad, India
P. Murthy
National Institute of Mental Health and NeuroSciences, Bangalore, India
H. G. Koenig
Duke University Medical Center, Durham, NC, USA
H. G. Koenig
King Abdulaziz University, Jiddah, Saudi Arabia
J Relig Health
123
Author's personal copy
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 patient’s 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: Physician’s Perspective (RSMPP) (Curlin et al 2005,2006,
2007) was used as the principal survey questionnaire, and it has questions on the partic-
ipant’s 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
J Relig Health
123
Author's personal copy
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 Foundation’s 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 physician’s agreement with the following statement:
‘Spirituality as a healthcare tool is worthy to be introduced as an academic subject into the
medical school curriculum’—Answer choices were ‘strongly agree, agree, disagree, or
strongly disagree’. Predictor variables were clustered into participant’s (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 participant’s 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, Yoga–Naturopathy, 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 participant’s religious characteristics and then for their
agreement with each criterion measure. We utilized the Student’s ttest, Pearson’s v
2
test,
and multivariate binomial logistic regression. Two institutes, one from the TCAM group
J Relig Health
123
Author's personal copy
Table 1 Demographic, religious/spiritual characteristics of health care professionals in the study
Demographic variables TCAM Allopathic Analysis
Mean SD Mean SD p(ttest)
Age (years) N=185, mean =29.19 10.02 N=171, mean =34.49 11.79 0.0000
N=192 % N=201 % v
2
,df,pvalue
Age groups
20–29 years 139 72.40 83 41.29
30–39 years 15 7.81 34 16.92 27.279
40–49 years 13 6.77 21 10.45 3
50–59 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
J Relig Health
123
Author's personal copy
(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-responder’s 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-responder’s 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 TCAM
group (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 diverse
specialties 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 % v
2
,df,pvalue
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
J Relig Health
123
Author's personal copy
Table 2 Physician’s clinical observations and interpretations of the influence of R/S on health
Questionnaire item (Q no. in
brackets) on clinical observations
and their interpretation
Response (Codes) TCAM Allopathic Analysis
v
2
,df,
pvalue
N=192 % N=201 %
How often would you say the
experience of illness increase
patients’ awareness of and
focus 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 of
R/S Considering your
experience how often do you
think..….R/S helps to prevent
‘hard’ medical outcomes like
heart attacks, infections, or
even 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 cope
with and endure illness and
suffering
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 of
R/S: Considering your
experience how often do you
think..…R/S leads patients to
refuse, delay, or stop medically
indicated 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 often
have your patients used R/S as
a reason to avoid taking
responsibility for their own
health?
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 interpretation
Overall, how much influence do
you think religion/spirituality
has 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 generally
positive or negative?
Generally Positive 119 61.98 128 63.68 0.713
Generally Negative 9 4.69 10 4.98 3
Equally positive
and negative
51 26.56 45 22.39 0.8701
It has no influence 8 4.17 8 3.98
J Relig Health
123
Author's personal copy
Religious/Spiritual Characteristics (Table 1)
Religious affiliations were collapsed into four groups—Christianity, 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 and
allopathic 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). Asignificantly
greater 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 patient’s 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. in
brackets) on clinical observations
and their interpretation
Response (Codes) TCAM Allopathic Analysis
v
2
,df,
pvalue
N=192 % N=201 %
Clinical experience and
inference:
How often have your patients
received emotional or practical
support from their religious
community?
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 prior
experience
86 44.79 101 50.25 0.0020
Spiritual healing has some
benefits, and it could be a
complement to modern medical
treatment
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
J Relig Health
123
Author's personal copy
Table 3 Comforts, barriers, and unmet needs of healthcare providers regarding R/S in clinical medicine
Questionnaire item Response
category
TCAM Allopathic Analysis v
2
,
df,pvalue
N=192 % N=201 %
Comfort:
To what extent do you agree or
disagree with the following
statements
I would feel comfortable
discussing a patient’s religious/
spiritual concerns if the patient
brought them up
Strongly
agree
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
Strongly
agree
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 not
apply
32 16.67 28 13.93
How often have patients seemed
uncomfortable when you inquire
about their religious/spiritual
issues?
N=192 % N=201 % v
2
,df,pvalue
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 discussing
religion/spirituality with
patients?
* You can check more than one
choice
You can
check on
more than
one choice*
N=192 % N=201 % v
2
,df,pvalue
General
discomfort
67 34.90 55 27.36 2.603, 1,
0.1067
Insufficient
knowledge/
training
51 26.56 50 24.88 0.1463, 1,
0.7021
Insufficient
time
53 27.60 63 31.34 0.6599, 1,
0.4166
Concern
about
offending
patients
31 16.15 39 19.40 0.7116, 1,
0.3989
Concern that
colleagues
will
disapprove
9 4.69 9 4.48 0.0098, 1,
0.9207
Formal Training Regarding R/S in
medicine
Have you ever had any formal
training regarding religion/
spirituality in medicine?
N=192 % N=201 % v
2
,df,pvalue
No 112 58.33 179 89.05 48.226
Yes 80 41.67 22 10.95 1
0.0000
J Relig Health
123
Author's personal copy
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 Response
category
TCAM Allopathic Analysis v
2
,
df,pvalue
N=192 % N=201 %
If yes, You can
check on
more than
one choice*
N=80 % N=22 % v
2
,df,pvalue
Where did you get such training?
* You can check more than one
choice
Medical
school
course
(A20 a1)
32 40 0 0 12.82, 1,
0.0003
Book, CME
literature
(a2)
17 21.25 7 31.82 1.07, 1,
0.3007
Grand
rounds/
conference
(A20 a3)
6 7.5 0 0 1.75, 1,
0.1855
Training
from
religious
tradition
(A20 a4)
30 37.5 14 63.64 4.81, 1,
0.0284
To what extent do you agree with
the following statements?
Responses N=192 % N=201 % v
2
,df,pvalue
Spirituality is a scientific subject
following some biophysical laws
unknown to the current scientific
community
Strongly
agree
66 34.38 29 14.43
Agree 93 48.44 91 45.27 19.390
Disagree 17 8.85 34 16.92 3
Strongly
disagree
4 2.08 6 2.99 0.0002
Spirituality as a health care tool is
a subject worthy to be
introduced as an academic
subject into the medical school
curriculum
Strongly
agree
59 30.73 26 12.94
Agree 98 51.04 102 50.75 18.640
Disagree 18 9.38 31 15.42 3
Strongly
disagree
4 2.08 10 4.98 0.0003
J Relig Health
123
Author's personal copy
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 family’s religious tradition. Significantly (p=0.0002), larger numbers
among 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) more
supportive 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 b–coefficient of 0.206 and z-score of
2.180 (p=0.0279, odds ratio of 0.814 with 95 % CI of 0.677–0.979). The predictability of
the categorical variables, TCAM Vs. allopathy, improved consistently through all the
models with statistical significance of p=0.0215 in the full model, McFadden’s Pseudo
R-Square increased to 6.35 %, and the percentage correctly predicted value for this full
model 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
J Relig Health
123
Author's personal copy
Table 4 Multiple logistic regression outcome measure was agreement to a question ‘Spirituality as a health
care tool is a subject worthy to be introduced as an academic subject into the medical school curriculum’
Variables (*…to what extent do you agree
with this statement?)
Model 1: Model 2: Full model:
Includes Step-1
variables
Includes Step-1
and Step-2
variables
Includes Step-1,
Step-2, and Step-
3 variables
bzbzbz
Step–1: Participants’ religious/spiritual characteristics, beliefs, and practices as numeric variables)
Numerical variables (Items from the Likert scale)
To what extent do you consider yourself as
a religious person?
0.213 1.04 0.271 1.28 0.281 1.320
To what extent do you consider yourself to
be 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 supernatural
being ever intervenes in patient’s
health?
0.108 0.592 0.084 -0.45 0.060 0.317
Categorical variable: TCAM Vs allopathic
healthcare professionals
0.664* 0.317*
a
––––
Step–2: Clinical observations and interactions with patients on R/S issues
Numerical variables (Items from the Likert scale)
How often would you say that the
experience of illness increases patients’
awareness of and focus on religion/
spirituality?
– – 0.031 0.214 0.047 0.33
Considering your experience, how often do
you think religion/spirituality…helps to
prevent ‘hard’ medical outcomes like
heart attacks, infections, or even death?
– – 0.206* 2.199*
b
0.206* 2.180*
d
In your experience with religious/faith
healers, have you been satisfied and to
what extent?
– – 0.190 1.82 0.185 1.74
Spiritual healing has some benefits, and it
can complement modern medical
treatment.
– – 0.024 0.100 0.035 0.14
Categorical variable: TCAM Vs allopathic
healthcare professionals
– – 0.713* 2.220*
c
Step–3: Knowledge/training and personal comforts. Beliefs in R/S role in medicine:
Numerical variables (Items from the Likert scale)
‘‘I enjoy discussing R/S issues with
patients’’*
– – – – 0.107 0.81
Have you had any formal training
regarding religion/spirituality in
medicine?
– – – – 0.265 0.33
Received spirituality training through
medical school course
– – – – 0.645 0.71
Received spirituality training from
religious tradition
– – – – 0.682 0.76
J Relig Health
123
Author's personal copy
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 agree
with this statement?)
Model 1: Model 2: Full model:
Includes Step-1
variables
Includes Step-1
and Step-2
variables
Includes Step-1,
Step-2, and Step-
3 variables
bzbzbz
Categorical variable: TCAM Vs allopathic
healthcare professionals
– – 0.822* 2.299*
e
McFadden’s Pseudo R-Square, DR
2
, percent correctly predicted: Model-1 3.00 %, –, 83.28 %, Model-2
5.73 %, 2.73, 83.28 %, Model-3 6.35 %, 0.62, 83.28 %
*p\0.05
Odds ratio (95 % CI):
a
0.515 (0.281–0.944),
b
1.229 (1.023–1.478),
c
2.040 (1.087–3.828),
d
0.814
(0.677–0.979),
e
0.440 (0.218–0.886)
J Relig Health
123
Author's personal copy
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 financial
support of HELP and AdiBhat Foundations in USA and India, respectively. HELP Foundation is a non-profit
organization in Omaha, NE, USA, serving the underprivileged population with its community urgent care
clinics. AdiBhat is a non-profit organization founded in New Delhi to develop spirituality as a medical
subject. Sincere thanks to Dr. Curlin F. A. (University of Illinois, Chicago, Illinois, USA) for providing his
RSMPP 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 AYUSH
institutes. Many thanks for dean Dr. V. N. Jindal for his permission and guidance to initiate the study at Goa
Medical College, Goa. Thanks goes to Dr. M. S. Kulkarni at Goa Medical College and Dr. Sharavi Gandham
at Univ. of Washington for their invaluable statistical inputs. We also like to appreciate all the staff at HELP
Foundation for participating in the focus group discussions and other research processes leading to the
development of our supplementary survey questionnaire. Finally, we would like to thank all our research
respondents for donating their invaluable time and providing their opinions and perspectives toward a
successful completion of this study.
References
Anandarajah, G. (2008). The 3 H and BMSEST models for spirituality in multicultural whole-person
medicine. Annuals of Family Medicine, 6(5), 448–458.
Chattopadhyay, S. (2007). Religion, spirituality, health and medicine: Why should Indian physicians care?
Journal of Postgraduate Medicine, 53(4), 262–266.
Clarke, J. (2006). Religion and spirituality: a discussion paper about negativity, reductionism and differ-
entiation in nursing texts. International Journal of Nursing Studies, 43(6), 775–785.
Crammer, C., Kaw, C., Gansler, T., & Stein, K. D. (2011). Cancer survivors’ spiritual well-being and use of
complementary methods: a report from the American Cancer Society’s Studies of Cancer Survivors.
Journal of Religion and Health, 50(1), 92–107.
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., 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., 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.
Department of AYUSH. (2011). Mainstreaming of AYUSH under National Rural Health Mission. Department
of AYUSH, Ministry of Health & Family Welfare, Government of India. http://indianmedicine.nic.in/
writereaddata/mainlinkFile/File614.pdf. Accessed 02 Mar 2013.
Dhar, N., Chaturvedi, S. K., & Nandan, D. (2011). Spiritual health scale 2011: Defining and measuring 4th
dimension of health. Indian Journal of Community Medicine, 36(4), 275–282.
Dwyer, J. M. (2004). Good medicine and bad medicine: science to promote the convergence of ‘‘alternative’’
and orthodox medicine. Medical Journal of Australia, 180(12), 647–648.
Fabian, T. K., Vertes, G., & Fejerdy, P. (2005). Pastoral psychology, spiritual counseling in dentistry.
[Article in Hungarian] (Abstract). Fogorvosi szemle, 98(1) 37–42.
Fortin, A. H. V. I., & Barnett, K. G. (2004). Medical school curricula in spirituality and medicine. JAMA,
291, 2883.
Grabovac, A. D., & Ganesan, S. (2003). Spirituality and religion in Canadian psychiatric residency training.
Canadian Journal of Psychiatry, 48(3), 171–175.
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. Medical Teaching, 28(8), 702–707.
J Relig Health
123
Author's personal copy
Hayward, R. (2004). Demonology, neurology, and medicine in Edwardian Britain. Bulletin of the History of
Medicine, 78(1), 37–58.
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.
Hughes, B. M. (2008). How should clinical psychologists approach complementary and alternative medi-
cine? Empirical, epistemological, and ethical considerations. Clinical psychology review, 28(4),
657–675.
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.
Kattimani, S. (2012). Spirituality and medical education in India: Are we ready? Journal of Research in
Medical Sciences, 17(7), 500–501.
King, M. B., & Koenig, H. G. (2009). Conceptualizing spirituality for medical research and health service
provision. BMC Health Services Research, 13(9), 116.
Lawrence, R. M., & Duggal, A. (2001). Spirituality in psychiatric education and training. Journal of the
Royal Society of Medicine, 94(6), 303–305.
Lukoff, D., Lu, F., & Turner, R. (1992). Toward a more culturally sensitive DSM-IV. Psychoreligious and
psychospiritual problems. Journal of Nervous & Mental Disease, 180(11), 673–682.
Menniti-Ippolito, F., & De Mei, B. (1999). The characteristics of the use and the levels of diffusion of
nonconventional medicine. [Article in Italian] (Abstract). Annali dell Istituto Superiore di Sanita,
35(4), 489–497.
Ministry of Health and Family Welfare. (2005). Task force on medical education for the national rural
health mission.http://mohfw.nic.in/NRHM/Documents/Task_Group_Medical_Education.pdf. Acces-
sed 02 Mar 2013.
Murray-Swank, A. B., Lucksted, A., Medoff, D. R., Yang, Y., Wohlheiter, K., & Dixon, L. B. (2006).
Religiosity, psychosocial adjustment, and subjective burden of persons who care for those with mental
illness. Psychiatric Services, 57(3), 361–365.
Neely, D., & Minford, E. J. (2008). Current status of teaching on spirituality in UK medical schools. Medical
Education, 42(2), 176–182.
Puchalski, C. M. (2006). Spirituality and medicine: curricula in medical education. Journal of Cancer
Education, 21(1), 14–18.
Puchalski, C. M., & Larson, D. B. (1998). Developing curricula in spirituality and medicine. Academic
Medicine, 73(9), 970–974.
Rao, R. B. R. (2009). Spirituality and mental health: Reflections of past, applications in present, projections
for future. Indian Journal of Psychiatry, 51(3), 233–234.
Sikand, A., & Laken, M. (1998). Pediatricians’ experience with and attitudes toward complementary/
alternative medicine. Archives of Pediatrics and Adolescent Medicine, 152(11), 1059–1064.
Silenzio, V. M. (2002). What is the role of complementary and alternative medicine in public health?
American Journal of Public Health, 92(10), 1562–1564.
Spurlock, W. R. (2005). Spiritual well-being and caregiver burden in Alzheimer’s caregivers. Geriatric
Nursing, 26(3), 154–161.
Warrier, M. (2009). Seekership, spirituality and self-discovery: Ayurveda trainees in Britain. Asian Med
(Lieden), 4(2), 423–451.
Willis, G. B., Lessler, J. T. (1999). Question appraisal system: QAS 99. National Cancer Institute.
http://appliedresearch.cancer.gov/areas/cognitive/qas99.pdf. Accessed 02 Mar 2013.
Wu, C., Weber, W., Kozak, L., Standish, L. J., Ojemann, J. G., Ellenbogen, R. G., et al. (2009). A survey of
complementary and alternative medicine (CAM) awareness among neurosurgeons in Washington
State. Journal of Alternative and Complementary Medicine, 15(5), 551–555.
Ziegler, J. (1998). Spirituality returns to the fold in medical practice. Journal of the National Cancer
Institute, 90(17), 1255–1257.
J Relig Health
123
Author's personal copy
