Quantitative and Qualitative Research in the Field of 'Spirituality and Health': An Introductory How-to-Guide from a Brazilian Perspective.

The present article aims to describe the different steps on how to design, develop and conduct quantitative and qualitative Spirituality and Health (S/H) studies from a Brazilian perspective, discussing definitions and instruments, and proposing a "how-to guide" for those interested in this field of research. A narrative review of the literature has been conducted by experts in the field of S/H aiming to develop a "how-to-guide". Spirituality is a very complex concept that has several challenges in the current scientific literature, including the lack of consensus in the definitions, the numerous dimensions assessed, the diverse instruments for measurement, the criticisms from other scholars, the great diversity of religious and cultural traditions and the growing number of "spiritual but not religious" individuals. This review supports that S/H studies may follow the high scientific standards, using consolidated research procedures and solid methods for both qualitative and quantitative research. Some peculiarities of the research methods for this field are discussed. S/H research is still under development, and there are several future directions for S/H studies, aiming to minimize previous criticisms and generating stronger evidence.

The current status of "spirituality and health" teaching in Brazilian medical schools: a nationwide survey.

BACKGROUND: Recent data on the teaching of "spirituality and health" (S/H) in medical schools are needed. In this study, we aimed to investigate the current status of S/H teaching in Brazilian medical schools, the opinions of medical directors/deans on this topic and the factors associated with its incorporation into the curriculum. METHODS: A nationwide cross-sectional survey was carried out in 2021. Information concerning the S/H content in the curricula of medical schools was obtained through medical school representatives and other sources. Medical school representatives were asked about their opinions of and barriers to S/H teaching. Regression models were used to evaluate the factors associated with the incorporation of such content into the curriculum. RESULTS: Information on the incorporation of S/H content in medical curricula was retrieved from different sources for all 342 (100%) Brazilian medical schools. Among the representatives, 150 (43.9%) completed the online form. An increase in the S/H content in Brazilian medical schools was observed (from 40% to 2011 to 65.5% in 2021). Most medical school representatives agreed that this issue is important in medical training and that more space in the curriculum is needed. However, they also observed several barriers, such as a lack of knowledge of medical teachers/faculty, a lack of time, and the topic not being included in teaching plans. The most important factors that influenced the incorporation of S/H teaching in medical schools and representatives' opinions were a lack of time and knowledge, professor preparedness and standardized national competency requirements. CONCLUSION: These results could help medical educators rethink the incorporation of S/H content into their curricula.

Altruism, Volunteering and Cognitive Performance Among Older Adults: A 2-Year Longitudinal Study.

This study aims to investigate whether altruism and volunteering are associated differently with cognitive functioning in community-dwelling older adults. A 2-year longitudinal study of 291 Brazilian older adults was conducted. In the baseline analysis, altruism, but not volunteering, was associated with higher scores for the composite cognitive score, the Mini-Mental State Examination, the verbal fluency and the CERAD Recall. Concerning the longitudinal analyses, volunteering at baseline, but not altruism, was associated with verbal fluency and CERAD Word List Recall after 2 years of follow up. Same results were obtained while investigating changes in score. Altruism and volunteering were associated with cognitive tests, albeit in different ways. Volunteering, but not altruism, was associated with lower cognitive decline. However, altruism, but not volunteering, was associated with higher absolute score on these tests. These findings can further understanding of this new field of health research.

Relationship Between Mental Health, Resilience, and Physical Activity in Older Adults: A 2-Year Longitudinal Study.

The aim of this study was to longitudinally investigate the association between resilience and mental health in older adults and to determine the influence of physical activity on this relationship. A total of 291 older adults were included in a 2-year follow-up study. Adjusted linear regression models evaluated the association between resilience at baseline and mental health after 2 years in sufficiently and insufficiently physically active older adults. A negative correlation was found between resilience at baseline and depression, anxiety, and stress after 2 years for the overall sample. This association changed after stratifying the group. Sufficiently physically active individuals made greater use of the resilience components "Self-Sufficiency" and "Perseverance," whereas insufficiently physically active individuals made greater use of "Meaning of Life" and "Existential Singularity." Physical activity can influence the relationship between resilience and mental health. These results can help guide the devising of more effective interventions for this age group.

Smartphone Use, Digital Addiction and Physical and Mental Health in Community-dwelling Older Adults: a Population-based Survey.

This study aims to assess mobile technology use (cell phones and smartphones), level of digital addiction, and the association of these factors with physical, mental and social health and quality of life (QOL) in community-dwelling older adults. A population-based study of a city with a low-income population in Brazil was carried out. Sociodemographics, cognition(MMSE), mental health(DASS-21), QOL(WHOQOL-bref), sleep quality(Pittsburgh Index), instrumental activities of daily living(Lawton), loneliness(UCLA), digital addiction(Internet Addiction Test) and cell phone/smartphone use were investigated. A total of 668 older adults (93.6% of total) were included; 175(26.2%) owned cell phones, 172(25.7%) smartphones and 321(48.1%) no mobile device. Smartphones owners were predominantly younger, white, had higher income, MMSE scores and social support, and were less dependent. However, no group differences were observed for depression, anxiety or stress symptoms, QOL, sleep disturbances or loneliness. Among 172 smartphone users, Structural Equation Models revealed that the degree of digital addiction was correlated with better physical and environmental conditions, in detriment of a poorer sleep quality. Hours of use were not correlated with health outcomes, whereas greater importance of the smartphone in life correlated with less depressive symptoms and lower loneliness. Different from previous studies in adults or adolescents, older adults who were smartphones users had similar health outcomes than those without Internet access. These findings serve to further our understanding on technology use in this age group.

Comparison of the Role of Different Levels of Religiousness and Spirituality in Controversial Ethical Issues and Clinical Practice among Brazilian Resident Physicians: Results from the Multicenter SBRAMER Study.

This study compares clinical practice and objections to controversial ethical issues among 836 Brazilian resident physicians according to levels of religiousness/spirituality. Residents with low religiousness/spirituality (s/r) believed less in the influence of spirituality on clinical practice, were less comfortable addressing this issue, tended to listen less carefully and try to change the subject more than other groups. Residents with high spirituality and low religiousness (S/r) inquired more about religious/spiritual issues, while those with high religiousness/spirituality (S/R) were more supportive and reported fewer barriers to addressing these issues. Concerning ethical issues (e.g., physician-assisted suicide, withdrawal of life support, abortion), S/R had more objections than others.

Empathy, well-being, and mental health: do gender differences diminish by the end of medical school?

This study aims to investigate if medical students demonstrate differences related to gender in terms of empathy, burnout, tolerance, openness to spirituality, well-being, and mental health, and to examine whether these differences vary across levels of medical training. A cross-sectional study was conducted in the first semester of 2015 in a Brazilian medical school. The following were evaluated: quality of life (WHOQOL-Bref), burnout (Oldenburg), mental health (DASS-21), empathy (Empathy Inventory and ESWIM), and tolerance, well-being, and openness to spirituality (ESWIM). We investigated how these outcomes varied in terms of gender, stage of medical training, and its interaction using a two-way MANOVA. A total of 776 students were included and important differences were observed. As medical training advanced, the differences between genders that were present during students' initial years (greater empathy, worse quality of life, and worse mental health among women) tended to become nonsignificant during the clerkship years. In addition, a significant interaction between stage and gender was found for ESWIM Wellness; WHOQOL; DASS Anxiety and DASS Stress. These results may denote a shortcoming in the way medical schools approach gender differences. Educators should consider these findings when restructuring curricula to respect gender differences, thus fostering their respective potentials.

Factors associated with successful aging in Brazilian community-dwelling older adults: When physical health is not enough.

OBJECTIVES: To determine the main factors (physical, psychological, social and spiritual) associated with successful aging in community-dwelling older adults. METHODS: A cross-sectional study of older adults was conducted evaluating successful aging (Successful Aging Scale-SAS) and its associated factors (sociodemographics, resilience, religiosity/spirituality, meaning in life, quality of life, social support, self-reported diseases, mental health, medications used, among others) using regression models. RESULTS: A total of 534 older adults were assessed. Linear regression models showed an association of higher SAS score with greater resilience (Beta = 0.371, p < 0.001), spiritual well-being - meaning (Beta = 0.174, p < 0.001) and quality of life - physical (Beta=0.203, p < 0.001), fewer diseases (Beta=-0.128, p < 0.001), greater meaning in life (Beta=0.116, p = 0.001), less loneliness (Beta=-0.133, p = 0.001), lower tobacco use (Beta=0.080, p = 0.013), greater quality of life - environment (Beta=-0.092, p = 0.013) and more frequent religious attendance (Beta=0.068, p = 0.035). CONCLUSION: The study results suggested that physical factors, although relevant, were not the main factors associated with successful aging.

Religiosity/Spirituality and Mental Health and Quality of Life of Early Pregnant Women.

The present study aims to investigate how religious/spiritual (R/S) beliefs are associated with depressive, anxious and stress symptoms and quality of life (QOL) of 160 Brazilian women in early pregnancy. In this cross-sectional study, religiosity/spirituality (DUREL, Daily Spiritual Experiences, Brief-RCOPE), mental health (DASS-21) and quality of life (WHOQOL-Bref) were assessed. Negative R/S coping was associated with higher levels of depressive, anxious and stress symptoms and worse physical and psychological QOL. On the other hand, positive R/S coping, intrinsic religiosity, and spirituality were associated with better psychological QOL, while only spirituality was associated with better social QOL.

Effects of a Required Large-Group Mindfulness Meditation Course on First-Year Medical Students' Mental Health and Quality of Life: a Randomized Controlled Trial.

BACKGROUND: Teaching mindfulness techniques has been used in the attempt to prevent mental health problems in medical students. Although it has already shown promising results when offered to volunteers, the use as a required strategy is still controversial. OBJECTIVES: To verify the efficacy of teaching mindfulness techniques to large groups when made part of a required discipline at the beginning of medical training. DESIGN: Randomized controlled trial PARTICIPANTS: First-year medical students at the Federal University of Juiz de Fora, Brazil METHOD: Students were randomized into two groups: an intervention group (receiving a 6-week mindfulness protocol) and a control group (given a 6-week course containing organizational aspects of the medical school). MAIN MEASURES: Intervention and control groups were compared on the levels of quality of life (WHOQOL-Bref), stress, anxiety and depression (DASS 21) and the facets of mindfulness (FFMQ) at baseline and at the end of the intervention. RESULTS: A total of 141 students were included in the study, 70 in the intervention group and 71 in the control group. No significant differences were found between the intervention and control groups in all mental health, quality of life, and FFMQ scores (Cohen's d = 0.01 to 0.14). Likewise, no significant gains in mental health measures, quality of life, and FFMQ were identified in the intervention group when compared with the control group (Cohen's d = 0.02 to 0.33). CONCLUSIONS: The incorporation of a required mindfulness course for large groups in the curriculum during the first semester of medical training was not associated with an improvement on medical students' mental health and quality of life. CLINICAL TRIALS REGISTRATION: NCT03132597.

Religiosity and Spirituality of Resident Physicians and Implications for Clinical Practice-the SBRAMER Multicenter Study.

OBJECTIVES: To assess the attitudes, knowledge, and experiences of Brazilian resident physicians regarding religiosity/spirituality (R/S), factors associated with addressing this issue, and its influence on clinical practice. METHODS: We report results of the multicenter "Spirituality in Brazilian Medical Residents" (SBRAMER) study involving 7 Brazilian university centers. The Network for Research Spirituality and Health (NERSH) scale (collecting sociodemographic data, opinions about the R/S-health interface, and respondents' R/S characteristics) and the Duke Religion Index were self-administered. Logistic regression models were constructed to determine those factors associated with residents' opinions on spirituality in clinical practice. RESULTS: The sample comprised 879 resident physicians (53.5% of total) from all years of residency with 71.6% from clinical specialties. In general, the residents considered themselves spiritual and religious, despite not regularly attending religious services. Most participants believed R/S had an important influence on patient health (75.2%) and that it was appropriate to discuss these beliefs in clinical encounters with patients (77.1%), although this was not done in routine clinical practice (14.4%). The main barriers to discussing R/S were maintaining professional neutrality (31.4%), concern about offending patients (29.1%), and insufficient time (26.2%). Factors including female gender, clinical specialty (e.g., internal medicine, family medicine, psychiatry) as opposed to surgical specialty (e.g., surgery, obstetrics/gynecology, orthopedics), having had formal training on R/S, and higher levels of R/S were associated with greater discussion of and more positive opinions about R/S. CONCLUSION: Brazilian resident physicians held that religious and spiritual beliefs can influence health, and deemed it appropriate for physicians to discuss this issue. However, lack of training was one of the main obstacles to addressing R/S issues in clinical practice. Educators should draw on these data to conduct interventions and produce content on the subject in residency programs.

Mental Health and Quality of Life Among Adults With Single, Multiple, and No Religious Affiliations.

Few studies have investigated the "multiple religious affiliations" phenomenon. This study aims to understand those with "multiple religious affiliations," describing its prevalence and investigating if there are differences in mental health and quality of life between this group and those with a single religious affiliation and those with no religious affiliation. A total of 1169 adults were included, and 58% had a single religious affiliation, 27.7% had multiple religious affiliations, and 12.3% had no religious affiliation. Participants with a single religious affiliation presented better mental health and quality of life than those with multiple or no religious affiliations. Although most outcomes were similar between multiple and no religious affiliations, happiness and optimism were higher in the multiple religious group, and anxiety was lower in the no religious group. Health care professionals should be aware of the secondary religious affiliations of their patients to identify possible conflicts and to treat them comprehensively.

Validation of the Brazilian version of the Shame and Stigma Scale (SSS-Br) for patients with head and neck cancers.

OBJECTIVE: To evaluate the psychometric properties of the Brazilian version of the Shame and Stigma Scale (SSS) in a sample of patients with head and neck cancers (HNC). METHODS: This is a validation study carried out in a Brazilian cancer hospital. Patients over 18 years old who knew about their HNC diagnosis were consecutively recruited, answering the SSS, the Functional Assessment of Cancer Therapy (General and Head and Neck supplement) questionnaire, and the University of Washington Quality of Life Questionnaire. Internal consistency, test-retest procedure, convergent validity, and responsiveness analysis were the psychometric properties evaluated. RESULTS: A total of 122 HNC patients were included. The SSS showed appropriate internal consistency (alphas ranging from 0.71 to 0.86), test-retest reliability (higher than 0.92 with exception of the "Regret domain"), and convergent validity. The responsiveness analysis with 38 patients was able to discriminate the scores before and after prosthetic procedures. SIGNIFICANCE OF THE RESULTS: The Brazilian Portuguese version of the SSS may be considered a valid and reliable instrument for the evaluation of Brazilian patients with HNC. Future SSS validation studies are welcome in other developing countries in order to make cancer health providers aware of these negative feelings in their HNC patients.

Implementation of a Longitudinal Mentorship Program for Quality of Life, Mental Health, and Motivation of Brazilian Medical Students.

OBJECTIVES: Mentoring has been used as a strategy for mental health prevention and the promotion of quality of life in medical students, with mixed results. The aim of this study was to compare the levels of mental health, quality of life, and academic motivation of medical students after implementation of a longitudinal curricular mentoring program relative to those students without mentoring in their curricula. METHOD: The results of the mentoring program were assessed by comparing two classes of 2nd-year students of a school of medicine (one that had received mentoring since admission and another which had no exposure to the method during the course). Self-report questionnaires were used to collect data on sociodemographics, quality of life (WHOQOL-BREF), mental health (DASS-21), and academic motivation (Academic Motivation Scale-AMS). RESULTS: A total of 95 medical students were included: 55 received the mentoring program and 40 did not receive the program. The Multivariate GLM regression model revealed no significant main effect of mentoring on domains of the WHOQOL-BREF (Wilks's Lambda = 0.938, F = 1.427, p < 0.232); the DASS-21 (Wilks's Lambda = 0.051, p < 0.985); or the AMS (Wilks's Lambda = 0.957, F = 0.628, p < 0.708). Likewise, the Univariate GLM regression showed no significant main effect of mentoring on medical students' perceived health (F = 0.585; d.f. = 1; p = 0.446). CONCLUSION: Mentoring promoted no significant changes in the students of this Brazilian institution. These results highlight the challenges faced in structuring, maintaining, and assessing an effective mentoring program for students on medicine courses.

The Impact of Spirituality and Religiosity on Mental Health and Quality of Life of Patients with Active Crohn's Disease.

We aim to investigate the association among religious/spiritual coping (RSC), quality of life (QOL), and mental health in patients with active Crohn's disease (CD). This cross-sectional study included 102 patients with active CD. Religious and spiritual beliefs were common among patients, being positive RSC higher than negative RSC. Negative coping was associated with mood disorders (depressive or anxiety symptoms) through the Hospital Anxiety and Depression Scale (ß = 0.260, p < 0.01) but not with QOL (Inflammatory Bowel Disease Questionnaire) (ß = - 0.105, p = NS) after adjustments. Positive coping and other religious/spiritual beliefs and behaviors were not associated with either QOL or mental health. This study suggests that a negative RSC is associated with worse mental health outcomes. This may detrimentally impact adaptations to deal with CD in the active phase, although patients generally tend to use more common positive strategies. These findings may increase the awareness of health professionals while dealing with spiritual beliefs in patients with CD.

Opinions and attitudes on the relationship between spirituality, religiosity and health: A comparison between nursing students from Brazil and Portugal.

AIMS AND OBJECTIVES: To compare the opinions and attitudes of Portuguese-speaking nursing students from Brazil and Portugal on the relationship between religiosity/spirituality and the ability to approach these issues with patients, in their undergraduate training and practice. BACKGROUND: Although there are studies investigating nursing students' opinions concerning religiosity and spirituality in clinical practice, few have investigated if there are cross-cultural differences between countries. DESIGN: Observational, cross-sectional and multicenter study carried out in 2010 and 2011 in Brazil and in 2016 in Portugal. METHODS: A total of 260 third and fourth year nursing students (139 from Portugal and 121 from Brazil) from four nursing schools were included. Religious beliefs (Duke Religion Index), attitudes and opinions about spirituality and health (Curlin's questionnaire) were assessed. A comparison between students from both countries was carried out. RESULTS/FINDINGS: Significant differences were found between nursing students from Brazil and Portugal, which are countries with the same language, but with different nursing training programs and population characteristics. Brazilian students were more religious and have stronger opinions on the influence and appropriateness of spirituality in clinical practice than Portuguese students. However, both groups of students indicated they should be prepared to address religiosity and spirituality with patients, that these subjects should be included in the curriculum and that they were not properly prepared to address spiritual issues. CONCLUSION: Although different opinions and attitudes were found between Brazilian and Portuguese nursing students, more training in these issues should be implemented in the undergraduate education. Cross-cultural studies could help fostering a broad discussion in the field. RELEVANCE TO CLINICAL PRACTICE: These findings could contribute to raise awareness on the importance of improving the training of relational competencies that prepare students to address the dimension of spirituality and religiosity with their patients.

The Role of Physical Activity in the Association Between Resilience and Mental Health in Older Adults.

The aim of this study is to evaluate the relationship between resilience and mental health in older adults and how physical activity influences that relationship. A cross-sectional study was carried out with 312 older adults (179 active and 133 sedentary classified by IPAQ). Considering the whole sample, an inverse relationship was found for resilience (Wagnild-Young's Resilience Scale) with depression and stress (DASS-21). Among the sedentary, in spite of there not being an association between total resilience and mental health, there was an inverse relationship for the "meaning of life" component of the resilience and depression scale. For the active group, there was a relationship between total resilience and its components with depression and stress, but not for the "meaning of life" component of the resilience scale. Physical activity played an important role in the relationship between resilience and depression, showing that active and sedentary people use different components of resilience.

The Use of Smartphones in Different Phases of Medical School and its Relationship to Internet Addiction and Learning Approaches.

The use of smartphones is revolutionizing the way information is acquired, leading to profound modifications in teaching medicine. Nevertheless, inadvertent use can negatively affect student learning. The present study aims to evaluate smartphone use in the educational context as well as Internet addiction and its repercussions on surface and deep learning and to compare them during the different phases of medical students' education. This is a cross-sectional study involving medical students in all phases of education. Sociodemographic data, type and frequency of smartphone use, degree of digital addiction (Internet Addiction Test - IAT), and surface and deep approaches to learning (Biggs) were analyzed. A total of 710 students were included. Almost all students had a smartphone and a total of 96.8% used it during lectures, classes, and meetings. Less than half of the students (47.3%) reported using a smartphone for more than 10 min for educational purposes, a usage that is higher among clerkship students. At least 95% reported using a smartphone in the classroom for activities not related to medicine (social media and searching for general information) and 68.2% were considered problematic Internet users according to the IAT. The most common reasons for noneducational use were that the class was uninteresting, students needed to receive or make an important call, and the educational strategy was not stimulating. The "frequency of smartphone use" and higher "internet addiction" were correlated to both higher levels of surface learning and lower levels of deep learning. Educators should advise and educate their students about conscientious use of this tool to avoid detrimental impact on the learning process.

Cross-cultural Differences in Mental Health, Quality of Life, Empathy, and Burnout between US and Brazilian Medical Students.

OBJECTIVE: This study aimed to compare mental health, quality of life, empathy, and burnout in medical students from a medical institution in the USA and another one in Brazil. METHODS: This cross-cultural study included students enrolled in the first and second years of their undergraduate medical training. We evaluated depression, anxiety, and stress (DASS 21), empathy, openness to spirituality, and wellness (ESWIM), burnout (Oldenburg), and quality of life (WHOQOL-Bref) and compared them between schools. RESULTS: A total of 138 Brazilian and 73 US medical students were included. The comparison between all US medical students and all Brazilian medical students revealed that Brazilians reported more depression and stress and US students reported greater wellness, less exhaustion, and greater environmental quality of life. In order to address a possible response bias favoring respondents with better mental health, we also compared all US medical students with the 50% of Brazilian medical students who reported better mental health. In this comparison, we found Brazilian medical students had higher physical quality of life and US students again reported greater environmental quality of life. Cultural, social, infrastructural, and curricular differences were compared between institutions. Some noted differences were that students at the US institution were older and were exposed to smaller class sizes, earlier patient encounters, problem-based learning, and psychological support. CONCLUSION: We found important differences between Brazilian and US medical students, particularly in mental health and wellness. These findings could be explained by a complex interaction between several factors, highlighting the importance of considering cultural and school-level influences on well-being.

Spirituality, Religiosity, Quality of Life and Mental Health Among Pantaneiros: A Study Involving a Vulnerable Population in Pantanal Wetlands, Brazil.

This study aims to investigate the relationship between spirituality, religiosity (S/R), mental health and quality of life in a vulnerable population in the Pantanal wetlands of Brazil. A total of 129 individuals were interviewed. We examined mental health (Hospital Anxiety and Depression Scale), quality of life (SF-12), spirituality (self-spirituality rating scale), religiosity (DUREL) and R/S opinions. Individuals had high levels of spirituality, non-organizational and intrinsic religiosity, but low levels of religious attendance. Most participants said they would like to have their faith addressed by a health professional and that this approach would strengthen their trust on the doctors. Higher levels of spirituality were associated with less anxiety (ß = - 0.236, p < 0.01) and depressive symptoms (ß = - 0.398, p < 0.001); higher levels of non-organizational religiosity were associated with less anxiety (ß = - 0.250, p < 0.01) and depressive symptoms (ß = - 0.351, p < 0.001); and higher levels of intrinsic religiosity were associated with less depressive symptoms (ß = - 0.315, p < 0.001). Quality of life was not associated with any religious/spiritual measures.