Can spirituality lead to better health outcomes? In this interview, we speak to Dr. Tracy Balboni from Harvard Medical School to find out more!
Please can you introduce yourself and tell us what inspired your latest research into spirituality?
My name is Tracy Balboni, and I'm a radiation oncologist specializing in palliative care at the Dana-Farber/Brigham and Women's Cancer Center, two of Harvard's teaching hospitals. I also co-lead with Dr. Tyler VanderWeele and Dr. Howard Koh from the Harvard T.H. Chan School of Public Health, the Initiative on Health, Spirituality, and Religion at Harvard.
My primary research interests have been improving the well-being of patients facing serious illnesses, like cancer, including attention to their spirituality. Spirituality – the ways in which persons find ultimate meaning, purpose, connection, and value – is mostly neglected in the medical profession. Medicine largely focuses on the material body and related technologies.
While this focus has brought about wonderful advancements in medical care, it has been at the expense of other key aspects of what it means to be human. In particular, overlooking spirituality in medicine can miss important resources for well-being in health and illness. Furthermore, such neglect within medical care, particularly in serious illnesses, can be depersonalizing and even dehumanizing. Such challenges inspired our latest research published in the Journal of the American Medical Association. There has been much research on spirituality in serious illness and health, but that evidence has not yet had a major impact on the practice of medicine or health promotion.
An expert overview of the research, with implications of those studies for health care, was needed to focus on these findings and their implications. Hence, this study systematically reviewed the literature on spirituality within serious illness and health and, with the help of an expert panel, summarized that research into key evidence statements and implications for how that evidence should shape health care.
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Spirituality is a concept that means different things to different people. How would you describe spirituality, and how can it help an individual to become more in tune with their body?
Based on the definition from the International Consensus Conference on Spiritual Care in Health Care: "Spirituality is the way individuals seek ultimate meaning, purpose, connection, value, or transcendence." Hence there are myriad ways individuals can experience spirituality.
For some, it is through family connections or nature. For others, it is through specific religious communities, beliefs, and practices. Based on the literature we reviewed, acknowledging and nurturing our spiritual health is good for many aspects of our physical and mental health. For example, the person that finds deep connection and meaning through nature should cultivate that practice in their lives. Finding ways to retain that practice can be key if they become ill.
I remember one dying cancer patient whose spirituality was found in his connection to, and love for, nature. We discussed this value and prioritized his being in a setting where he could be in nature during his last weeks of life. His family set up his hospital bed in the living room next to a window looking out on their garden and the surrounding woods. For others, their spirituality is found in a religious tradition.
Cultivating those spiritual practices and particularly cultivating shared practices with others can be important to overall well-being. The research we summarized demonstrated the importance of communal forms of spirituality on many health outcomes.
You have recently conducted a study focused on spirituality and health outcomes. Please can you tell us more about this study and how it was conducted?
We performed systematic reviews of all evidence since January 2000 informing the role of spirituality in serious illness and the role of spirituality in health outcomes, including overall mortality and mental health outcomes such as depression. Using criteria to ensure a high standard of rigor for these studies, the literature was reviewed by two study staff who determined whether or not each study fit those criteria. Only those studies where both agreed that criteria were met were included.
The studies, both on serious illness and health outcomes, were then systematically summarized, and another two reviewers graded the presence of bias. Finally, these summaries were brought to our diverse, multi-disciplinary Delphi panel of 27 experts, who reviewed the evidence and provided summaries of the key evidence and implications of these findings for the practice of medicine in serious illness and health outcomes.
Our Delphi panelists graded the strength of the research supporting the evidence statements; only those evidence statements rated as supported by strong research were included. The Delphi panelists concluded by ranking their top 3 implications for serious illness and their top 3 for health outcomes, resulting in suggestions for how this evidence should impact the future practice of medicine in serious illness and public health.
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When looking through this evidence, what did you discover?
There were many discoveries. I'll first detail those in serious illness. Consistently across many cultural and health care settings, spirituality is important to most seriously ill patients. Additionally, most have spiritual needs, which are often associated with decrements in quality of life. Though many patients want their spirituality addressed within medical care, spiritual needs are largely unaddressed. Where present, attention to the spiritual health of seriously ill patients within health care is associated with better quality-of-life outcomes.
In healthy populations, communal forms of spirituality - as exemplified by regular religious service attendance - are associated with many improved health outcomes, including greater longevity, better mental health, less suicide, and reduced substance use. Among adolescents, being involved in spiritual communities is associated with better health outcomes, including less substance use and less risky health behaviors.
Your team consisted of a multi-disciplinary group of experts. How important was this collaboration for your research, and what are the benefits of having a research team of different specialties and backgrounds?
This research and its implications for health care touch on a number of critical areas in medicine and public health. Hence we chose a multi-disciplinary panel with expertise in a variety of disciplines. Specifically, panelists had expertise in palliative care practice and research, mental health care and research, public health research and policy, health care systems, medical ethics, chaplaincy, and theology.
We also ensured a diversity of health care practitioners, including nurses, physicians (of various specialty areas), social workers, and chaplains. Finally, we ensured a diversity of spiritual backgrounds, including spiritual-not-religious to traditions such as Catholicism, Hinduism, Islam, and Judaism.
If spirituality was incorporated into care for patients, what would this look like? What benefits would this have for patients?
A health professional (such as a physician, nurse, or social worker) caring for a well or ill patient can incorporate simple questions such as 'Do you consider yourself a spiritual person?' or 'Is faith important to you in your life/illness?' Such questions signal respect for a patient's values and beliefs, help the clinician understand the patient better, and lead to meaningful dialogue about what is important to their health both during that visit and in future visits.
Clinicians may refer the patient to a spiritual care specialist (e.g., chaplain) after initial intake, depending on the patient's needs and preferences and the care setting. Spiritual care should always be patient-centered (i.e., acknowledges and focuses on the values and beliefs of the patient) and hence can be done even when patients and clinicians don't share similar views, which may often be the case.
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Despite its recognized benefits, many people do not practice spirituality. What more should governments, policymakers, and organizations be doing to help promote spirituality, not just in healthcare but in everyday life?
As mentioned previously, spirituality has been broadly defined as what brings ultimate meaning, purpose, connection, and value. With such a broad definition, one can argue that every person has a spirituality. The term 'spirituality' can sometimes be narrowly construed as religious forms of spirituality only when, in fact, it can take many non-religious forms. For example, a person may find their ultimate source of meaning, purpose, and value in work, nature, or family.
As far as promoting spirituality, an important step is the acknowledgment that it is not only an essential part of health but also of flourishing as a human individual and community. Our government, policymakers, and other organizations can seek ways of honoring and supporting the diverse manifestations of spirituality. This can be through policies that protect religious practice and expression for this country's myriad of religious traditions.
Furthermore, the role of nature in promoting spiritual connection and meaning for many persons can be supported through city policies that promote green spaces and state and federal policies that protect our environment and natural spaces. Another avenue might be through support for the arts and music, such as through policies that promote greater access to artistic expressions for a diversity of persons. These are just a few examples of ways to cultivate diverse forms and expressions of spirituality that flow from the recognition that human flourishing requires the cultivation of spirituality in its diversity of shared and individual forms, whether religious traditions, nature, music, the arts or other avenues.
What is next for you and your research?
One next step will be facilitating the engagement of diverse thought leaders' regarding these research findings. For example, we plan to start by holding events that engage thought leaders in a variety of disciplines at Harvard to reflect on these findings, including theology, medicine, public health, and policy.
We would also like to facilitate engagement among faith community leaders. Input from many perspectives is required to shape the way forward to the engagement of spirituality as a key component of health and well-being both in serious illnesses and in healthy populations.
Where can readers find more information?
About Dr. Tracy Balboni
Tracy Balboni, MD, MPH, FAAHPM, holds degrees from Stanford University, Harvard Medical School, and the Harvard TH Chan School of Public Health and is board certified in both radiation oncology and palliative medicine.
Dr. Balboni currently serves as Professor of Radiation Oncology at Harvard Medical School and as Program Director of the Harvard Radiation Oncology Program. She also co-leads the Initiative on Health, Spirituality, and Religion at Harvard. Dr. Balboni's primary research interests are located at the intersection of oncology, palliative care, and the role of spirituality in life-threatening illnesses.
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