Influence of Religious and Spiritual Elements on Adherence to Pharmacological Treatment

Depósito de investigación de la Universidad de Sevilla https://idus.us.es/ Esta es la versión aceptada del artículo publicado en: This is a accepted manuscript of a paper published in: Journal of Religion and Health (2018): 26 March DOI: https://doi.org/10.1007/s10943-018-0606-2 Copyright: © Springer Science+Business Media, LLC, part of Springer Nature 2018 El acceso a la versión publicada del artículo puede requerir la suscripción de la revista. Access to the published version may require subscription. “This version of the article has been accepted for publication, after peer review (when applicable) and is subject to Springer Nature’s AM terms of use, but is not the Version of Record and does not reflect post-acceptance improvements, or any corrections. The Version of Record is available online at: http://dx.doi.org/10.1007/s10943-018-0606-2”. Title: Influence of Religious and Spiritual Elements on Adherence to Pharmacological 1 Treatment 2 Abstract 3 The objective of this study is to know the influence of religious/spiritual elements 4 on the adherence to pharmacological therapy. The descriptors used for this literature 5 review were ‘‘medicine, medication, drug, or treatment,’’ ‘‘adherence to treatment,’’ and 6 ‘‘religion or spirituality or faith or prayer’’ in different databases (CINAHL, PsycINFO, 7 PubMed). Finally, 23 articles were selected. Articles available in full text, published 8 between 2010 and 2017, in English or Spanish were included. The results showed that 9 some studies relate positively the R/S and therapeutic adherence, but others determine an 10 opposite or even mixed effect, mainly addressing pathologies such as HIV and other 11 chronic diseases. The influence of religiosity/spirituality on therapeutic adherence requires 12 that health professionals acquire sensitivity and competence to address these issues with 13 their patients. 14 Keywords Religion; Spirituality; Treatment adherence; Pharmacological therapy 15 Background 16 Since the mid-twentieth century, studies show the relationship between religiosity/spirituality 17 (R/S) and health (de Diego and Badanta 2017; de Diego 2016; Lucchetti and 18 Lucchetti 2014). This connection is highlighted in areas related to the health promotion and 19 the prevention of disease (Byrne and Price 1979; Levin 1994; Levin and Vanderpool 1987; 20 Quiceno and Vinaccia 2009; Vaux 1976), such is the case of the influence on adherence to 21 clinical treatments (Barría et al. 2016; Stewart et al. 2013; Abarzúa et al. 2011; Laos 22 Manrique 2010). 23 However, health professionals continue to focus on pragmatic aspects of their work, 24 which in many cases do not take into account the type of beliefs of patients. This obviates 25 the reality that people use their religion to confront problems related to their health or 26 illness and that this trend does not disappear with the discovery and evolution of 27 increasingly effective and precise medical treatments (Moreira-Almeida 2013). 28 Patients are often those who demand comprehensive care including spiritual or religious 29 factors as a way to improve the coping with diseases (Cardoso et al. 2014). It is also 30 important to improve health professionals knowledge about the beliefs of the population 31 they serve aiming to provide holistic care, considering that in the specific case of adherence 32 to treatment, it is a conditioning factor (Carrasco 2015). 33 Objective 34 The objective of the study is to know the influence of religious and spiritual elements on 35 pharmacological therapy’s adherence. 36 Methods 37 Relevant databases have been used for this literature review: CINAHL, PubMed, PsycINFO. 38 The search strategy was performed using these descriptors: ‘‘medicine, medication, 39 drug, or treatment,’’ ‘‘adherence to treatment,’’ and ‘‘religion or spirituality or faith or 40 prayer,’’ combining them with the Boolean ‘‘AND’’ (Table 1). 41 INSERT TABLE 1 HERE 42 Inclusion criteria were articles with full text available, published between 2010 and 43 2017, and whose theme was appropriate to the objectives. Exclusion criteria were articles 44 referring to relationships between beliefs and adherence to non-pharmacological therapeutic 45 treatments. The selection resulted among reading the title, abstract, and full text if it 46 was appropriate. Finally, 23 scientific articles were selected. 47 Results 48 The content analysis of the literature review shows the impact of religious and spiritual 49 factors on the pharmacotherapy adherence (Table 2). 50 INSERT TABLE 2 HERE 51 Most studies address chronic pathologies: firstly HIV/AIDS (9 articles), secondly 52 psychiatric disorders (4 articles), and finally cystic fibrosis (3 articles). The remaining 53 studies address other chronic diseases such as diabetes mellitus, cardiovascular problems, 54 intestinal disease, asthma or cancer. Of all the selected studies, 9 show negative relationships 55 between R/S and pharmacological adherence, and 7 detect positive relationships. 56 On the other hand, there are also 6 articles that show mixed results, both positive and 57 negative, and 1 article where the existence of a relationship is not determined. Although in 58 some studies the religious and spiritual elements are approached simultaneously, in the 59 majority the cultural elements associated with religion predominate. In general, religion is 60 not specified, but among those identified, Islam stands out, followed by Catholicism and 61 Protestantism. For the spiritual elements, the attribution of healing powers to healers or 62 agents of nature such as water is frequent. 63 Discussion 64 There is a disparity of results in the studies analyzed. While some show a positive relationship 65 between R/S and therapeutic adherence, in others an opposite effect is observed. 66 One of the best-known examples of the negative correlation is between contraceptive 67 therapy and religiosity (Carvajal and Gavilanez 2014). Other times the influence is mixed 68 (Peeters et al. 2015; Zagozdzon and Wrotkowska 2017). In these studies with diabetic 69 patients and with mental pathology, respectively, there are cases where the R/S improves 70 the adherence and others in which the opposite occurs. While depression and religiosity did 71 not correlate with adherence, for spirituality the correlation was positive according to the 72 results of Álvarez et al. (2016) in patients with heart failure. 73 In the case of HIV/AIDS (one of the diseases most addressed in the selected studies), 74 therapeutic adherence is related to the suppression of viral load, which decreases the risk of 75 morbidity, mortality, and subsequent transmission of the virus. According to Tymejczyk 76 et al. (2016), both this pathology and CF are associated with a shortening of life. This 77 magnifies the importance of adherence to treatment and raises spiritual or religious 78 problems (Grossoehme et al. 2013). In this respect, findings of Lyon et al. (2011) also 79 coincide. They identify that young people with HIV/AIDS are more likely to ask themselves 80 ‘‘Has God abandoned me?’’ In this case, adolescent spirituality was associated with 81 less anxiety and depression and better adaptation to chronic illness. Park and Nachman 82 (2010) also detected a higher religious score in the best adherence to treatment in adolescents 83 with HIV. However, Vyas et al. (2014) got opposite results. The people least 84 adherent to antiretroviral treatment were those who believed that God would not turn away 85 from them, regularly attended religious services, and prayed and meditated. 86 The use of spirituality as a method of coping with chronic diseases can be positively or 87 negatively related to the adherence to pharmacological treatment depending on the type of 88 coping. Adherence is greater with positive coping styles, referring to trusting an attachment 89 to God, finding meaning in life, and being spiritually connected with others (Grossoehme 90 et al. 2016). The negative coping style—associated with worse adherence—refers to the 91 lack of attachment to God, the difficulties in finding the meaning in life, and spiritual 92 struggles. These struggles include questioning the existence of God, doubts about love or 93 acts of God, or redefining the stressor as a punishment from God or the act of an evil power 94 (Freitas et al. 2015). Conventional beliefs in God as a source of comfort, support, and help 95 to cope with stressors seem to be associated with better adherence, while fundamentalist 96 beliefs in God’s powers to heal prevent some patients from continuing pharmacological 97 treatment (Tumwine et al. 2012). On the other hand, Hobbs (2010) determined that 98 adherence to medication was not related to spiritual well-being, social support, or trust in 99 the doctor. However, a significant positive correlation was found between spiritual wellbeing 100 and trust in the doctor, which could be a factor favoring this adherence. 101 In relation to elements of R/S that favor adherence to treatment, some works should be 102 highlighted. A study that addressed the adherence to oral hormonal therapy in women with 103 cancer showed that 94% was adherent during Ramadan. Although this percentage was 104 lower than that reported in months of non-fasting (96%), no statistically significant differences 105 were observed. Maintaining this adherence during Ramadan was facilitated by the 106 non-complex schedules of these medications and the relative lack of their side effects. In 107 this way women instead of taking drugs during the day did so at night, at which time eating 108 and drinking are allowed by Islam (Zeeneldin et al. 2012). These factors could also explain 109 the differences obtained in the study by Hanif et al. (2013), where during the Ramadan fast, 110 treatment with vildagliptin resulted in better adherence to treatment compared to 111 sulfonylureas in Muslim patients with diabetes mellitus. Although Dávila Soto et al. (2014) 112 emphasized factors favoring adherence to oral antidiabetics such as marital status, educational 113 level, and the presence of other chronic pathologies, cultural or belief aspects are 114 not taken into account once again. 115 In another study of Muslim people, the desire to fulfill the obligations of fasting affected 116 the adherence to antiretrovirals, but also these people wanted to avoid the questions of 117 relatives and friends who did not know their HIV status (Ume Tocco 2017). 118 Dalmida et al. (2017) showed that the satisfaction of social support as well as praying at 119 least once a day was significantly associated with 90% adherence to antiretroviral treatment. 120 Also in patients with HIV/AIDS and high religiosity, Tumwine et al. (2012) 121 determined the main reasons for adherence or not to pharmacological treatment. Among 122 the supporters were the perception of the ineffectiveness of prayers to cure HIV, the 123 continuous counseling from multiple sources, and beliefs such as that God heals in different 124 ways. However, the main reasons associated with non-adherence in patients with 125 high religiosity were related to the support of biblical scriptures, teachings and prophecies 126 of religious leaders and testimonies of ‘‘comrades already healed’’ who had stopped ART 127 to explain their decisions. Other beliefs based on the locus of divine control reflect lower 128 scores of therapeutic adherence in Africans who reported that God played an influential 129 role in their asthma in relation to white patients (Ahmedani et al. 2013). These results 130 coincide with Finocchario-Kessler et al.’s (2011) who obtain that those people who 131 believed that God controlled their HIV strongly were less prone to an adherence of 90% or 132 more. The active coping style, a lower perception of God as a controller of health, and a 133 lower perceived stress were the best predictors of greater adherence. 134 In relation to spiritual beliefs, in Ethiopia, the healing potential of holy water was 135 associated with non-adherence to ART (Tymejczyk et al. 2016). In another study performed 136 in Tanzania (Thielman et al. 2014), most participants who took antiretrovirals 137 sought an herbal cure for HIV by going to a spiritual leader. The visit to the healer was 138 associated with a significant, but not permanent decrease in adherence to treatment, 139 highlighting fatigue as an influential factor in making the decision to go to the healer. On 140 another occasion, the presence of religion displaced the belief in Mapuche healers as the 141 main actors in the process of health recovery. Nevertheless, they continued using medicinal 142 herbs, to complement the pharmacological treatment of their chronic pathology, to 143 diminish the side effects or to enhance the therapeutic effect (Barría et al. 2016). 144 In the case of other diseases such as cystic fibrosis in children, the parents’ R/S has 145 influenced both treatment adherence and decision making; lower levels of R/S were 146 associated with worse adherence, perhaps due to greater parental anxiety due to the lack of 147 divine support to cope with their children’s illness (Grossoehme et al. 2015). The influence 148 of the R/S was contrary in the HTA. In an intervention performed by Kretchy et al. (2013), 149 it is evident that the spiritual beliefs of the patients increased their confidence in the 150 expectation of divine healing, thus decreasing the adherence to the treatment with 151 antihypertensive 152 drugs. However, in the study by Silva et al. (2016), weekly religious attendance 153 was associated with a lower prevalence of hypertension compared to participants 154 who did not attend religious services. The social support of these practices could favor 155 normalized blood pressure figures. 156 For psychiatric disorders, although in recent decades research on religion and 157 schizophrenia has increased, these have mainly focused on hallucinations and delusions 158 (Gearing et al. 2011). Some of the limiting factors of drug adherence have been the belief 159 in the supernatural causes of mental illness related to the support of religious and spiritual 160 sources (Abdel Aziz et al. 2016). In patients with mental illness, Touchet et al. (2012) 161 observed the influence of the R/S both in the medication treatment adherence (delays in 162 searching for treatment and non-adherence to it) and in the participation in psychotherapy. 163 This was due to experimentation in 14.4% of conflicts between their spiritual and religious 164 views and psychiatric treatments. 165 Definitely, to address the R/S of patients and make it a mechanism that favors therapeutic 166 adherence, it would be necessary to create specialized departments to manage the 167 integration of spirituality with conventional treatment in hospitals, such as those identified 168 by Lucchetti et al. (2012); spiritual therapies were performed by volunteers and offered 169 free of charge to patients and staff. In another study (Huguelet et al. 2011), patients showed 170 willingness to discuss religious issues with their psychiatrist. Also Stolovy et al. (2013) 171 showed how patients were more engaged, involved, and better connected with their doctor 172 when the doctor had a greater knowledge of the particular religion. Therefore, it is 173 important to promote cultural sensitivity and offer assistance from the health system. 174 Conclusions 175 The positive or negative influences of religious and spiritual elements on adherence to 176 pharmacological therapy are evidenced. Therefore, it is necessary to design interventions 177 aimed at encouraging the use of positive coping strategies and addressing the adverse 178 implications of religious fatalism. 179 There are numerous pathological processes or pharmacological treatments linked to the 180 R/S. Those who address HIV/AIDS stand out, in which the social support provided by 181 belonging to a certain religion or practices such as prayer has positive effects for adherence 182 to ART. 183 Health professionals should be aware of the role that R/S plays in the life of patients. 184 They must respect beliefs and include them in care planning. This will promote a holistic 185 patient-centered approach and will support them in making self-care decisions. 186 References 187 Abarzua Ibáñez, F., Jara Royer, K., López Sandoval, E., & Pardo Zúñiga, D. (2011). Relación entre 188 la adherencia a la terapia farmacológica y factores del usuario, su enfermedad y tratamiento en 189 adultos mayores autovalentes polimedicados del CESFAM Federico Puga, Chillán Viejo 190 (Doctoral Thesis). Faculty of Health Sciences and food. Nursing school. University of BI´O-BI´O, 191 Chile. 192 Abdel Aziz, K., Elamin, M. H., El-Saadouni, N. M., El-Gabry, D. A., Barakat, M., Alhayyas, F., et al. 193 (2016). Schizophrenia: Impact of psychopathology, faith healers and psycho-education on 194 adherence to medications. International Journal of Social Psychiatry, 62(8), 719–725. 195 Ahmedani, B. K., Peterson, E. L., Wells, K. E., Rand, C. S., & Williams, L. K. (2013). Asthma 196 medication adherence: The role of God and other health locus of control factors. Annals of 197 Allergy, Asthma & Immunology, 110(2), 75–79. 198 Álvarez, J. S., Goldraich, L. A., Nunes, A. H., Zandavalli, M. C., Zandavalli, R. B., Belli, K. C., et al. 199 (2016). Associação entre Espiritualidade e Adesão ao Tratamento em Pacientes Ambulatoriais 200 com Insuficiência Cardíaca. Arquivos Brasileiros de Cardiologia, 106(6), 491–501. 201 Barría, D., Beroíza, R., & Gutiérrez, F. (2016). Percepción de pacientes mapuche que se atienden 202 en control de crónicos del Cesfam niebla, en relación a la adherencia del tratamiento 203 farmacológico y no farmacológico (Doctoral Thesis). Universidad Austral de Chile. Faculty of 204 Medicine. Nursing School. 205 Byrne, J. T., & Price, J. H. (1979). In sickness and in health: The effects of religion. Health 206 Education, 10(1), 6–10. 207 Cardoso, Y. E., Castro, I. C., Burbano, D. C., & Vernaza, P. (2014). Espiritualidad de las 208 personas/pacientes atendidos en una unidad renal de mediana complejidad en el 209 departamento del Cauca-Colombia. Revista Facultad Ciencias de la Salud. Universidad del 210 Cauca, 16(1), 9–16. 211 Carrasco, Y. (2015). La religio´n y su influencia en las conductas de salud (Doctoral Thesis). 212 Disponible en: 213 http://rabida.uhu.es/dspace/bitstream/handle/10272/11985/La_religion_y_su_influencia.pdf? 214 sequence=2. Accessed 20 Sept 2017. 215 Carvajal E. L. M., & Gavilanez A. A. M. (2014). Conocimientos y uso de la pı´ldora anticonceptiva 216 de emergencia en la prevención del embarazo, en los/las adolescentes que acuden a la 217 consulta externa del Centro de Salud Latacunga, en el periodo de abril 2013 a marzo 2014 218 (Doctoral Thesis). University of Bolívar. 219 Dalmida, S. G., McCoy, K., Koenig, H. G., Miller, A., Holstad, M. M., Thomas, T., et al. (2017). 220 Examination of the role of religious and psychosocial factors in HIV medication adherence 221 rates. Journal of Religion & Health, 56(6), 2144–2161. 222 Dávila Soto, R. A., García Bustamante, N. A., & Saavedra Huanuiri, K. J. (2014). Adherencia al 223 tratamiento de diabetes mellitus tipo 2 en adultos mayores: Variables asociadas. In Iquitos- 224 2013. Universidad Nacional de la Amazonia Peruana. 225 de Diego Cordero, R. (2016). Nuevos movimientos religiosos: la Iglesia de Jesucristo de los 226 Santos de los últimos días en Sevilla (Doctoral Thesis). Universidad de Sevilla. España. 227 de Diego Cordero, R., & Badanta Romero, B. (2017). Health impacts of religious practices and 228 beliefs associated with the church of Jesus Christ of latter-day saints. Journal of Religion and 229 Health, 56,1371. https://doi.org/10.1007/s10943-016-0348-y. 230 Finocchario-Kessler, S., Catley, D., Berkley-Patton, J., Gerkovich, M., Williams, K., Banderas, J., et 231 al. (2011). Baseline predictors of ninety percent or higher antiretroviral therapy adherence in a 232 diverse urban sample: The role of patient autonomy and fatalistic religious beliefs. AIDS Patient 233 Care and STDS, 25(2), 103–111. 234 Freitas, T. H., Hyphantis, T. N., Andreoulakis, E., Quevedo, J., Miranda, H. L., Alves, G. S., et al. 235 (2015). 236 Religious coping and its influence on psychological distress, medication adherence, and quality 237 of life in inflammatory bowel disease. Revista Brasileira de Psiquiatria, 37(3), 219–227. 238 Gearing, R. E., Alonzo, D., Smolak, A., McHugh, K., Harmon, S., & Baldwin, S. (2011). Association 239 of religion with delusions and hallucinations in the context of schizophrenia: Implications for 240 engagement and adherence. Schizophrenia Research, 126(1–3), 150–163. 241 Grossoehme, D. H., Cotton, S., Ragsdale, J., Quittner, A. L., McPhail, G., & Seid, M. (2013). I 242 honestly believe God keeps me healthy so I can take care of my child: Parental use of faith 243 related to treatment adherence. Journal of Health Care Chaplaincy, 19(2), 66–78. 244 Grossoehme, D. H., Szczesniak, R. D., Britton, L. L., Siracusa, C. M., Quittner, A. L., Chini, B. A., et 245 al. (2015). Adherence determinants in cystic fibrosis: Cluster analysis of parental psychosocial, 246 religious, and/or spiritual factors. Annals of the American Thoracic Society, 12(6), 838–846. 247 Grossoehme, D. H., Szczesniak, R. D., Mrug, S., Dimitriou, S. M., Marshall, A., & McPhail, G. L. 248 (2016). Adolescents’ spirituality and cystic fibrosis airway clearance treatment adherence: 249 examining mediators. Journal of Pediatric Psychology, 41(9), 1022–1032. 250 Hanif, W., Malik, W., Hassanein, M., Kamal, A., Geransar, P., Andrews, C., et al. (2013). 251 Treatment adherence with vildagliptin compared to sulphonylurea as add-on to metformin in 252 Muslim patients with type 2 diabetes mellitus fasting during Ramadan. Current Medical 253 Research and Opinion, 29(7), 807–811. 254 Hobbs, M. A. (2010). The characteristics of adherent, Black, HIV? women: The influence of 255 spirituality, social support and trust in physician on medication adherence and CD4 cell count. 256 Disertaciones de acceso abierto, 398. Disponible en: 257 http://scholarlyrepository.miami.edu/oa_dissertations/398. Accessed 20 Sept 2017. 258 Huguelet, P., Mohr, S., Betrisey, C., Borras, L., Gillieron, C., Marie, A. M., et al. (2011). A 259 randomized trial of spiritual assessment of outpatients with schizophrenia: Patients’ and 260 clinicians’ experience. Psychiatric Services, 62(1), 79–86. 261 Kretchy, I., Owusu-Daaku, F., & Danquah, S. (2013). Spiritual and religious beliefs: Do they 262 matter in the medication adherence behaviour of hypertensive patients? BioPsychoSocial 263 Medicine, 7(1), 15. 264 Laos Manrique, S. V. (2010). Calidad de vida y religiosidad en pacientes con cáncer de mama. 265 Facultad de Letras y Ciencias Humanas (Doctoral Thesis). Pontificia Universidad Católica del 266 Perú´. 267