Culture, Spirituality, and Women’s Health

JOC;.\s C L I N I C A L

I S S U E S

Culture, Spirituality, and Women’sHealth Mary Ann Miller, RN,PhD

review of the literature on culture, health/women’s health, and spirituality/religion reveals that the purported relationships among these variables niay be tenuous. Nevertheless, there is a need for health care professionals to be aware of existing cultural/religious beliefs that niay affect women’s health behavior if provision of holistic health care is a goal. Implications for practice and research can be drawn froni the existing evidence in the literature. A

here is a burgeoning body of literature o n the sepamte topics of women’s health/health promotion, the concept of health in various cultures, a n d to a lesser degree, spirituality/religiosity.However, o n e is immediately struck that all three topics are never considered together. A recent publication o n women’s health and culture rarely mentions religion as a demographic characteristic (McElmurry, Norr, & Parker, 1993). Another o n health promotion has a limited treatment of the influence of religion/spirituality (Edelman & Mandle, 1994). O n e might question if these three topics are related. In fact, after reviewing the “evidence” for such a relationship, the reader is left with more questions than answers.

Spi~tuality/Reli~iorr Spirituality often is defined as a basic o r inherent quality in all humans that involves a belief in something greater than the self and a faith that positively affirms life (Cervantes & Ramirez, 1992; Haase, Britt, Coward, Leidy, & Penn, 1992; Stoll, 1989). Definitions also include values that generally exist in a broader sense outside of traditional religious practice: a search for meaning in life (Cervantes & Ramirez, 1992; Clemmons, 1991; Hiatt, 1986; Ochs, 1983; Reed, 1992; Shelly & Fish, 1988); a sense of mission (Clemmons, 1991); a sense of relatedness to dimensions that transcend the self in such a way that it increases self-esteem and empowers the individual (Cervantes & Ramirez, 1992; McFadden & Gerl, 1990; Murch/April I995

Reed, 1992; Spilka, Hood, CL Gorsuch, 1985); a sense of inner peace and harmony (Cervantes CL Ramirez, 1992; Hiatt, 1986;Vaughan, 1991); and a creative energy that is constant yet changing (Haase et al., 1992; Hiatt, 1986). Spirituality is not an exclusive internal activity but promotes participation in the fullness of life by giving meaning, value, and direction t o all human concerns (King, 1993). Thus, the values inherent in this sense of spirituality are manifested in an individual’s behavior (Haase et al., 1992; Hiatt, 1986; Ochs, 1983; Vaughan, 1991). The concept o f relatedness t o something greater than the self is the area most often associated with religion, which generally describes the nature o f the divine and prescribes ways o f relating t o it (McFadden CL Gerl, 1990;Ochs, 1983). All religions share common elements: a set of symbols that invoke feelings of awe, adoration, or reverence and a set of associated rituals (such as prayer, meditation, eating patterns) that are practiced by people w h o have certain beliefs (Schumaker, 1992). Each religious tradition also represents a respective clustering o f the following additional interdependent features: a world view (a comprehensive picture of nature and the purpose of human existence in the universe); a belief in s o m e super empirical, usually supernatural, beingts) o r power(s); distinctions between what is reverent and irreverent; moral codes; and social organizations (Levin CL Vanderpool, 1987). These commonly held beiiefs, rituals, and observances are onlya part of an individual’s spirituality. Thus, although some may use spirituality synonymously with religion, the two are not necessarily synonymous. Someone may b e spiritual without identifying with any particular religious group o r organization. In fact, s o m e perceive religion as a barrier to spiritual integration (McFadden CL Gerl, 1990). However, spirituality and religion, whether separately o r together, provide a framework that allows a person to make sense of the world and its vagaries and provide a ready resource for coping with life (Charnes & Moore, 1992; Fahlberg & Fahlberg, 1991; Koenig, Smiky, CL Gonzales, 1988; Stoll, 1989). T h e broad concept o f spirituality is central t o many

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religious or belief systems. I t is found ;it the core of t h e world’s great religions :ind in n o religion. I t may h e nionothcistic as in Judaism, Christianity, a n d Islam ( t h e youngest o f the worIcI’s great religions), nontheistic as in i3uclclhism, o r pol)-theistic ;ISin Hinduism. I t also can be h i ~ n ~ a n i s t i as c , expressed in t h e concepts o f peak e x periences o r strong ethical values. Creative endeavors :ind uplifting responses t o aesthetic anti sensuous e x p e riences are other ways that o n e ’ s spirituality may be manifested (Clenimons, 1991; Ley & Corliss, 1988; Stoll, 1980; Vaugh:in, 19911. Some describe spirituality in t h e context o f maturation (Iliatt, 1986; King, 1993). For women, t h e process of spiritiul m:itiir:ition usu:illy takes t h e form o f t h e self‘s coming into relationship with others (Ochs, 1983). Attention t o all aspects o f life with compassion and o p e n minclec1nes.s is thc natural result o f ;I psychologically mature spirituality, according t o Vaughan (1991). T h e spirit u d niatitrxion process follows a n uneven course throughout the life o f t h e person, and its order a n d timing is itidivic1u:ilizcd (IIiatt, 1986). T h e intellectual a n d psychologic growth that enables adults t o think abstractly, toler:tte :~mbiguitya n d p:tratlox, :ind commit themselves t o \.slues t h a t transcencl the conventional produce o p p o r tunities f o r tlcepeiiing and widening o f spirituality in t h e second half o f life (McFaclden & Gerl. 1990).

spirituality/Religion and Health Re Iig i o u s v;i r i ;I b I es ha ve bee t i i n c I u dccl i t i e pick m i o I o g ic research f o r alniost 200 years, :ilthough there has b e e n a recent tenrlency t o disregard tlie possible influence that religion may have on health. F o r example, f o r decades religion :IS ;I social vari:ible has not lieen routinely inclucled in largc~sc;tlesurveys clealing with health o r mortdity (Koetiig et al., 1988; Ixvin & Schillcr, 1987; Mullen, 190(J).Spirituality has received the 1e:ist attention in contempor:try Western heit It 11-related thinking, even though ;ISthe p a r t o f the person cx)nc~ernedwith meaning in life and thus ;I major cieterminant o f health-related attitudes, i t c u i c e i u b l y could be used ;ISa powerful resource f o r positive health behavior. I f one believes that spirituality pernie;ites :ill hum:in experiences rathcr than being :itlditional t o them, one must accept it as integral t o health o r ;I sense o f \vholc.ncss o r well-being (lliatt, 1986; King, 1993; Hcsetl, 1992). Optimal spiritual he:iltli may be considered ;IS t l i c aliility t o discover a n d articulate :I basic pitrposc* in life, t o learn h o w t o experience love, joy, ~ ~ i catid e , fultillnient. and t o achieve future potential ( C hap n u I 1 , I 986 ) . I ti cl ic;i tors o f spirit it a I w e I I-bei ng are :I sxisfying philosophy o f life, supportive relationships with other people, re:tlistic orient:itions t o w a r d loss a n d deprivation. wholesome self-concepts, and ethical conduct (hlolicrg, 197-1) . ‘l‘heinfluence ofspiritu;tlity o n oticb’s self-esteem and sense o f liclonging may p:trtially explain its role in sust:tining valued health Iiehavior. Spiritiul support also may influence he;ilth through enhancing positive :ud :tdapt i ~ cva!u:tLions c o f t h e incaning o f ;I traumatic event. As a coping st~itrg).,i t may :illow for greater well-tieing and

For many people, spirituality, as expressed through a religious atfiliation, influences the way in which they respond to signs and symptoms of illness.

emotional development, which could protect against stress-relateddiseases that have devastating effects (Koenig et al., 1988; Levin & Schiller, 1987; Levin & Vanderpoo1,1989; Maton, 1989). For many people, spirituality, as expressed through a religious affiliation, influences the way in which they respond t o signs and symptoms of illness. Many religions prescribe rituals associated with health protection and can affect t h e way p e o p l e choose t o prevent illness. For many individuals, their religion provides social, moral, and dietary directions designed to promote health. When illness occurs, many see it as a punishment for violating these religious codes (Idler, 1987; Koenig et al., 1988; Spector, 1991). For example, Judaism has a long legacy regarding what is permissible with respect to health-related interventions, such as diet a n d hygienic measures. Smoking, excessive alcohol consumption, and illicit drug use often are actively discouraged by other religious groups, including Mormons a n d Seventh-day Adventists. Christian Scientists a n d others (human potential groups such as Scientology and EST, Eastern meditation a n d yoga groups based o n Zen, Buddhism, o r Hinduism) focus energy o n developing alternative forms of healing, rather than patterns o f diet a n d hygiene ( Helman, 1990; Koenig et al., 1988; Levin Lk Vanderpool, 1987; McGuire, 1988). I n non-Western societies, self-help groups often have a religious basis. T h e r e are many folk healers, such as herb doctors, root doctors, a n d spiritualists. Such spiritual healers relieve t h e sick in mind and spirit by means o f laying o n o f hands o r by prayer a n d meditation, whether or not in t h e actual presence of the patient. In t h e United Kingdom, since 1965, m e m b e r s of t h e National Federation o f Spiritual Healers have b e e n able to attend patients in t h e hospital w h o request their presence (Helman, 1990). Unfortunately, t h e empirical relationship between spirituality/religiosity and health/health promotion has not b e e n firmly established. Most studies have examined relationships between religious affiliation a n d morbidity/mortality related t o heart disease a n d cancer a n d between religious affiliation and psychologic morbidity (Mullen, 1990). Although the relationships are tenuous at best, tlie literature illustrates their complexity a n d multifactorial nature. For example, o n e of t h e markers c o m monly used to measure the relationship between religion :rnd health has b e e n religious attendance, which Levin and Markicles (1986) point out may be a n indicator o f social support. Any type o f voluntary organizational involvement may be health promoting because being involvecl with other people, whether o n a religious o r sec-

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ular basis, can b e therapeutic. Religious attendance also may b e an indicator of functional ability a n d thus reflective of general health. The reader is urged to see Ellison (1983), Levin and Schiller (1987), Mullen (1990), and Schiller and Levin (1988) for a more detailed review of empirical work.

Spirituality/Religion and Culture Religion and health traditionally have been intertwined with people and their culture. I t often is difficult to distinguish between the aspects of a belief system that arise from a sense of spirituality/religious affiliation a n d those that stem from ethnic/cultural heritage. In s o m e cases, the religion is t h e culture. In other cases, s o m e people may share a c o m m o n ethnicity yet have different religions and vice versa. Thus, it is never safe to assume that all persons of a specific ethnicity/culture have the same religious beliefs. O n e person’s religion may be another’s heresy or superstition (Bourguignon, 1992; Spector, 1991). Each culture usually has a set of beliefs about the meaning of health and health maintenance and about correct behavior for preventing illness. Medicine, prayer, and rituals often provide cultural solutions to anxietyproducing problems, giving o n e a sense of mastery over threats, known o r unknown, and increasing a sense of well-being. For example, it is not uncommon in s o m e cultures for pregnant w o m e n to d e p e n d o n magic rituals and traditional healers w h o give assurance that all will g o well. They believe simultaneously in the efficacy of the gods and the indigenous medical system because they cannot afford to be without s o m e measure of mastery in times of stress (Scott, 1978). Amulets, charms, or other religious medallions also may be worn to attract good health and good luck and to ward off bad luck. Thus, responsibility for illness may fall outside the individual’s control; bad luck, not behavior, is the cause (Helman, 1990). Cultural/religious approaches to health often are based o n how human beings are viewed. For example, Eastern philosophies portray the person as a spiritual being with spiritual goals. If a sense of wellness o r good health influences the spiritual journey, the spiritual journey helps to clarify t h e emotions a n d intellect and provides a greater sense of vitality. Thus, health and spirituality can have a reciprocal effect o n each other, and wellbeing becomes a part of one’s spiritual growth (Martin, 1989). However, quiet acceptance of one’s fate, also pervasive in s o m e Eastern philosophies, is difficult to reconcile with a commitment to preventive methods. Symptoms may b e ignored because the fear of dying is lessened. Extraordinary efforts to preserve life may b e hard to accept when a deep-rooted belief in reincarnation exists (Bhayana, 1991). An in-depth presentation of the possible interaction between culture, spiritual/religious issues, and health/ women’s health is far beyond the scope of this article. A brief discussion of selected examples follows

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Eastern Religious Traditions In the closing decades of the 20th century, Islam has bec o m e second only to Christianity in number of active members. Believers hold as a religious obligation the preservation of health when o n e is not sick because the prophet Muhammad commanded this. Islam rivals Roman Catholicism in conservatism o n women’s rights and sexuality but permits abortion for a wide range of reasons during the first trimester (Ellwood, 1987; Kissling, 1993; Rahman, 1987). Hutchinson and Baqi-Aziz (1994) d e scribe issues particularly relevant to providing health care for the childbearing Muslim family. Buddhism has rich multireligious influences from Confucianism, Christianity, and Shintoism. Buddhists generally accept medical science. Some are vegetarians, a n d most practice moderation in all things and do not use alcohol, tobacco, and drugs. Buddhists generally do not accept personal responsibility for illness because they believe that it is caused by spirits (Kinzie (3r Leung, 1993; Krekeler, 1989). Hindus believe that praying for health is the lowest form of prayer; thus, they tend to dismiss o r be unconcerned about ill health, which is t h e result of misuse of the body or a consequence of sins committed in a previous life. They consider the benefits of medical treatment transitory but generally are accepting of medical science (Helman, 1990; Krekeler, 1989). Western Religious Traditions Beliefs of Christians generally d o not conflict with modern medical practice. Despite the position of the Catholic Church o n birth control, Catholic couples, including those w h o adhere to many formal church practices, deviate in increasing numbers from the Church’s birth control teachings. T h e Church also holds that abortion is never morally justified. Most Protestant denominations and most branches of Judaism consider abortion a serious moral matter but believe that the decision that must be made by the pregnant woman (Kissling, 1993; Spilka et al., 1985). There is a tremendous diversity of practice and beliefs among and within the main divisions of Judaism. American Jews commonly may b e unaffiliated with Judaism as a religion but b e attached to it as a culture and a history. There is n o contradiction between traditional Jewish beliefs and receiving health care o r promoting health; good health is highly valued (Charnes & Moore, 1992; Farber, Mindel, & Lazerwitz, 1988; Feldman, 1986). There is n o o n e rabbinic view o n reproductive technologies among the various Jewish denominations. Among methods used to treat infertility, husband insemination (AIH) provokes the fewest objections, although rabbis may disagree with each other o n whether masturbation is an acceptable method for obtaining sperm. Raising the most objections are donor insemination a n d surrogate motherhood. Concerns stem from a legal code that protects a patriarchal system of marriage, procreation, and inheritance. The father’s identity is crucial in this system, for it is the father w h o bestows legitimacy and property upon the children (Lasker & Parmet, 1990). Many religions are profamily, but Mormons prepch

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that the Kingdom o f G o d is composed of eternal family relationships. Their strongly held pronatalist views find d e e p roots in this belief system (Campbell 81 Campbell, 1988). The church opposes abortion, voluntary sterilization, and birth control, although high rates of fertility are more a reflection of a prochild philosophy than an antibirth control o n e . Devout Mormon w o m e n face a challenge. Their religious leaders urge them t o have large families, shun careers, and follow their husbands. However, as a group, Mormon w o m e n are having fewer children and increasing their participation in the work force. Both trends are likely to increase their relative power in marriage but also could be a source of increasing stress (Heaton, 1986; Jarvis 81 Northcott, 1987). As mentioned, Mormons are urged (as are Seventh-day Adventists) to avoid alcohol, tobacco, tea, coffee, a n d habit-forming drugs. They live conservative sex lives within a large family context and have well-organized support groups to cushion the effects of stressful life events. Mormon women are likely t o have had fewer s e x partners, more pregnancies, less use o f oral contraceptives, fewer miscarriages and hysterectomies, a n d m o r e self breast examinations and mammograms. Mormons have lower than average mortality associated with cancer and ischemic heart disease and have lower than average infant death rates Uarvis bi Northcott, 1987). Cultural Groups Mickley and Soeken (1993) state that by the e n d of the 20th century, Hispanics will represent the largest minority group in the IJnited States. T h e Hispanic population comprises diverse subgroups (60% o f Mexican origin; 14% Piierto Rican; smaller percentages of Central American and other), although they share c o m m o n sociocultural elements, o n e o f which is strong spiritual beliefs (Becerra, 1988; Corrine, Bailey, Valentin, Morantus, & Shirley, 1992; Herold, Westoff, Warren, & Seltzer, 1989; Sanchez-Ayendez, 1988). These beliefs provide Hispanics with a way to accept and cope with suffering and illness, often believed to be God's will. Health may be a day-to-day thing, always important, but considered in terms o f the present with little emphasis placed o n changing it. Such fatalism could be a deterrent in seeking preventive care o r in compliance with treatment (Boyle, 1991; Campana, 1989). Motherhood and childbearing o f ten are singled out a s special sources of fultilIment for Hispanic women. T h e assumption is that cultural and religious traditions promote attitudes that are favorable to continuous childbearing and opposed to contraception and abortion. In general, study samples have b e e n underrepresentative, and confounding variables have not b e e n investigated t o support these conclusions (Amaro, 1988). People o f black heritage constitute a diverse group from Africa, the Caribbean, Central and South America, and various parts o f the United States. Their health beliefs and practices have roots in African culture, early European folklore, and religion (Knox, 1986). Of all o f the cultures, spirituality may exert t h e greatest influence o n the thinking and living o f people in African societies (Edwards, 1987; Potts, 1991),and spiritualism (trusting in in-

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dividual moral strength a n d harmony with nature) is a cultural trait found among many African-Americans. Although s o m e blacks may practice witchcraft and voodoo, t h e organized church is the most profound instrument available to many of them w h e n it comes t o coping with the multiplicity of problems that confront them (Fountain, 1991; Knox, 1986). Living close to G o d is the key to the prevention of sickness caused by evil forces. Prayer, faith, pastors, and the Bible are important resources to h e l p persons strengthen their spiritual, mental, and physical health. I t has b e e n said that many blacks use prayer or traditional remedies to allow the body to heal itself or prefer to s e e k advice from the church leader or traditional healer a m o n g family members or friends before going to a clinic or physician (Bailey, 1987; Griffith bi Baker, 1993; Roberson, 1985; Wilson-Ford, 1992). T h e organized church has preserved many African customs that enhance respect for pregnant w o m e n and mothers of twins, w h o are thought to possess special powers. For s o m e AfricanAmerican women, religion/spirituality may be the only positive resource available to h e l p them c o p e with their daily problems (Corrine et al., 1992).

Women and Spirituality in a Feminist Culture T h e feminist literature provides a special perspective o n the spiritual nature of women's unique experiences. Feminists emphasize the spiritually empowering, transforming, and healing aspects of religion, an important source for shaping and enforcing the image and role of w o m e n in culture and society. Thus, o n e must always inquire carefully which images of women a particular religion has created a n d handed d o w n from generation to generation (King, 1993).

Feminists emphasize the spiritually empowering, transforming, and healing aspects of religion, an important source for shaping and enforcing the image and role of women in culture and society.

Childbearing and mothering, with their complex relationships t o another person, their ever-changing roles, and their d e e p concern may be ideal contexts within which to enrich the spiritual self. In this regard, Sered (1991) asked 55 Jewish women if they found childbirth to be a spiritually transformative experience. Although many of them answered negatively, others felt a sense of experiencing a miracle after the birth, w h e n they held or cared for the infant. T h e insights that occur naturally in t h e course of mothering-the n e e d to give oneself over completely for a time to the physical and spiritual care of the infant, the need t o know by empathic understanding,

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the necessity o f letting go--all reinforce t h e insights o f traditional spirituality ( O c h s , 1983). This spiritual force, if explored by health professionals, could be used t o promote positive health behaviors in w o m e n (Corrine et al., 1992). Peace, love, joy, and harmony are found in people of spiritual power a n d presence. They are not qualities unique t o w o m e n , I x i t w o m e n , by nature of their traditional work and experiences a n d by social pressures e x erted upon t h e m , often have developed these qiialities to an unusual d e g r e e (King, 1993). To tap into this part of their spiritual nature, many w o m e n regularly use meditation ;ISa liealth-l>roinotingtechnique. Some use Buddhist o r Hindu forms o f meditation, whereas others use forms that they have found in spiritual feminist literature. Some spiritual feminists believe that t h e deepest form of meclitation is that which makes ordinary work a spiritual exercise (King, 1993). In spiritual feminist thought, all w o m e n n e e d healing, if not from s p e c i f c illnesses then from t h e pains suffered as a result o f growing u p female in a patriarchal world. Spiritual feminists aspire to healing themselves and others through a variety o f techniques, including homeopathy, chakra balancing, massage, therapeutic touch, acupuncture. T h e overall holistic philosophy emphasizes positive well-being, rather than amelioration of symptoms o f disease. Spiritual feminist healing emphasizes w o m e n as possessors of natural healing knowledge. Healing often is placed in a broader, m o r e spiritual context, becoming a metaphor for any form o f self-transformation, whether physical, mental, or emotional. I t is the n a m e given t o t h e overall effort to k n o w oneself a n d develop personal power (Eller, 1993).

Implications for Nursing Practice/Research Practice Health care is influenced by t h e beliefs of providers a n d consumers. Health care beliefs, like religious beliefs, bec o m e value-laden and are held tenaciously. When these beliefs originate from a Familiar health culture, they are called science a n d b e c o m e truths. Beliefs that are foreign are called superstition a n d are labeled false (Stern, 1986). Health professionals n e e d to be aware of t h e religious a n d cultural values that they bring to their practice. Knowledge of spiritual themes that permeate different cultures will h e l p to provide them with t h e conceptual tools to link health behavior, culture, a n d spirituality (Cewantes & Ramirez, 1992; Corrine et al., 1992; Koenig et al., 1988). If the client’s cultural/spiritual systems a n d the professional health care culture are at odds, the nurse

may be the ideal “culture broker” t o resolve conflicts between them Uezewski, 1993). Increased interest in providing holistic care t o clients has resulted in greater ;ittention t o the conceptualization a n d understanding o f spiritual issues, :is indicated by t h e development o f holistic health care groups (Association for Holistic Health; American Ilolistic I Iealth Association; American Holistic Nurses Association) and professional journals Uoiirml of IIolistic ilealth, Hritish Journal of Holistic Health, Holistic Nirrsitig Practice). Providers of holistic health care explore their clients’ symbolic beliefs a n d methods o f spiritual support, provide t h e spiritual resources that clients request, and share beliefs without imposing values ( Krekeler, 1989). The emphasis on holistic care and personal responsibility for a healthy lifestyle a n d changes in t h e health care delivery system have facilitated t h e establishmcwt o f a n e w nursing role in t h e community, t h e parish nurse (McDermott & Burke, 1993). O n e o f the defined roles o f this nurse is interpreter o f the close relationship I m w e e n faith and health (Djupe, Olson, Si Ryan, 1991). Although clients would like t o discuss their spiritual concerns, they are not always given the opportunity. Health professionals have reported that doing so takes too m u c h time o r that they are uncomfortable exploring something o f such 3 personal nature (Krekeler, 1989; Sodestrom & Martinson, 1987). Some find it easier t o relegate spiritual care t o a religious member o f the health care team (Ley Si Corliss, 1988). Obstetric, gynecologic, a n d neonatal nurses, as they relate to w o m e n on the most personal of levels, are in an ideal position to provide for the spiritual care o f their clients. Although most women will be in n e e d of health promoting services, others will be facing t h e spiritual distress caused by situations such as t h e death o f a newborn, t h e death o f an infant o r a child from s u d d e n infant death synclronie, miscarriage, or infertility. In either case, obstetric, gynecologic, and neonatal nurses n e e d to make a formal assessment of the ways in which each woman brings her spirituality to bear o n health behavior issues. For example, do her spiritual beliefs have a strong impact o n how s h e defines health, t h e cause a n d effect of illness, o r her adherence to nursing/medical recommendations? Is a deity involved in her life? H o w is her faith meaningful t o her? What is the role o f significant religious persons during health and illness? What have b e e n her past sources o f strength and coping? With answers t o these basic questions, the nurse can e n courage t h e use of spiritual resources whenever appropriate. I f this is a n uncomfortable o r unfamiliar area of practice, t h e nurse has a n obligation t o attend continuing education offerings in t h e area (Cewantes 8r Kamirez, 1992; Corrine et al., 1992; Spector, 1991; Stoll, 1979).

Researcb Although soiritual/religious beliefs and attitudes mav . have a n important influence directly and indirectly o n health, this issue is unsettled, and many questions remain unanswered. T o what extent do relieious beliefs a n d atti<. tudes affect women’s health behavior, and for which religious/cultural groups may this be particularly true? I,

Health professionals need to be aware of the religious and cultural values that they bring to their practice.

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WhicI1 aspects of sl'irituality/religiosity are health promoting for w o m e n and which are not? Are there health I"actices/illnesses o f w o m e n m o r e influenced by religious beliefs, attitudes, a n d practices than others? What effect do spirituality, religious belief, and commitment have on health care u s e (Koenig et al., 1988; MickleY Soeken, 1993)? Almost all research has focused o n Christian or J e w ish religious traditions. What about similar questions for Muslims, Hindus, Buddhists, a n d others? Cross-cultural studies on the relationship between religion a n d health/ women's health are nonexistent. Finally, h o w do personal beliefs a n d activities o f health care professionals influence their opinions about a n d receptiveness to discussions o f religious issues with patients:' Do holistic models o f health care provide better care to individuals in a cost-effective manner (Koenig et al., 1988)? Multidimensional studies using adequate sample sizes, random sampling, validated measures for religious and health variables, control of confounding variables, and m o r e sophisticated m e t h o d s of analysis are n e e d e d (Gorsuch, 1984; Jarvis 8 Northcott, 1987; Koenig et al., 1988; Mullen, 1990). Because spirituality/religiosity is such a dynamic process, its importance a n d relevance t o the individual is constantly changing in response t o life experiences. Thus, its accurate assessment may remain difficult. Nursing research can h e l p t o provide s o m e of n g links in this vital aspect o f quality health care delivery.

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Culturul Concepts in Clinicul Curt

Americans. In A. Gaw ( E d . ) , Culture, ethnicity, a n d mental illness ( p p . 281-304). Washington: American Psychiatric Press. Kissling, F. (1993). Religion a n d abortion: Roman Catholicism lost in t h e pelvic z o n e . Women 3FIealth Issues, .?, 132-137. Knox, D. (1986).Spirituality: A t o o l in t h e assessment a n d treatment of black alcoholics a n d their families. Alcoholism Treatment Quarterly, 2,313-343. Koenig, H., Smiley, M., 81 Gonzales, J. (1988). Religion, health, a n d aging. N e w York: G r e e n w o o d Press. Krekeler, K. (1989). Spiritual health. In P. Potter 81 A. Perry (Eds.), Fundamentals of nursing: Co?icepts, process, 6 practice (pp.792-805). St. Louis: Mosby. Lasker, J., 81 Parmet, H. (1990). Rabbinic a n d feminist responses t o reproductive technology. Journal of Feminist Studies in Religion, 6(1), 117-130. Levin, J . , eG Markides, K. (1986). Religious attendance a n d s u b jective health. Journal for the Scientific Study of Religion, 25,31-40. Levin, J., 81 Schiller, P. (1987). Is there a religious factor in health?Journal of Religion a n d Health, 26.9-36. Levin, J . , 81 Vanderpool, H . (1987). Is frequent religious attend a n c e really conducive t o better health?: Toward a n epidemiology o f religion. Social Science a n d Medicine, 24, 589-600. Levin, J . , 81 Vanderpool, 11. (1989). Is religion therapeutically significant for hypertension? Social Science a n d Medicine, 29,69-78. Ley, D., 81 Corliss, I . (1988). Spiritualityand hospice care. Death Studies, 12, 101-110. Martin, J . (1989).Eastern spirituality a n d health care. In V. Cars o n ( E d . ) Spiritual dimemioris of nursing practice ( p p . 113-131 ) . Philadelphia: WD Saunders. Maton, K. (1989).T h e stress-buffering role o f spiritual support: Cross-sectional a n d prospective investigations. Journal for the Scientijic Study of Religion, 28, 310-323. McDermott, M.. CG Burke. J . ( 1 9 9 3 ) . W h e n t h e population is a congregation: T h e emerging role o f t h e parish nurse.Journalof Cornmunit)*Ilealth Nursing, 10, 179-190. McElmurry, R., Norr, K., LG Parker, K. ( 1993). Women S health a n d der~elopmerit:A global challeiige. Boston: J o n e s 81 Bartlett . McFadden, S., 81 Gerl, R . (1990). Approaches t o understanding spirituality in the s e c o n d half o f life. Generations, 1 4 ( 4 ) , 35-38. McGuire, M. (1988). Xitrcal healing in suhiirban America. New Brunswick, NJ: Rutgers Ilniversity Press. Mickley, J., 81 Soeken, K. (1993). Religiousness a n d h o p e in Hispanic- a n d Anglo-American w o m e n with breast cancer. Oiicolog)”ursirigForum, 20,1171-1 177. Moberg, D. (1974). Spiritual well-being in late life. In J . G u brium ( E d . ) , Lute life: Commrriiities and erir~iro?tmriital policy(pp. 256-279). Springfield, 11.: Charles C. Thomas. Mullen, K. (1990). Religion a n d health: A review o f t h e literature. I~iter~iatioiial~/oirriial of S o c i o l o ~arid ~ Social Policy,

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36. Addressfor correspondence: Mary Ann Miller, RN, PhD, G26,3131 Meetinghouse Road, Boolhwyn, PA 19061-2962.

lo( 1 ), 85-96.

Ochs, C. ( 1983). Women andspiritualiiy Totow:i, NJ: Rowman & Allanheld. Potts, R . f 1991). Spirits in t h e bottle: Spiritualityand alcoholism

Murch/April I995

Mary Ann Miller i s an assockte professor In the College of Nurstng of the Llnfoersity of Delauiare, Neujark, DE.