Impact of spiritual beliefs and faith-based interventions on diabetes management

Charity Neejide Onyishi,Leonard Chidi Ilechukwu,Vera Victor-Aigbodion,Chiedu Eseadi

Charity Neejide Onyishi,Vera Victor-Aigbodion,Department of Educational Psychology,University of Johannesburg,Gauteng,2006,South Africa

Charity Neejide Onyishi,Vera Victor-Aigbodion,Chiedu Eseadi,Department of Educational Foundations,University of Nigeria,Nsukka,Enugu 410001,Nigeria

Leonard Chidi Ilechukwu,Department of Arts Education,University of Nigeria,Nsukka,Enugu 410001,Nigeria

Abstract Management of diabetes constitutes significant social and economic burdens worldwide.There is a shortage of empirical studies on the management of diabetes and the associated mental health issues through spiritual beliefs and faith-based interventions(FBIs).It is not also clear how spiritual beliefs and FBIs account for the effective management of diabetic conditions.This article discusses the impact of spiritual beliefs and FBIs in the management of diabetes,from relationship and efficacy studies that report outcomes from experimental procedures of related interventions.The majority of the relationship studies showed positive relationships,while efficacy studies showed a high efficacy of interventions in faith-based approaches.However,none of the studies clearly reported the mechanisms of change or modality of operation in a FBI that can serve as a model across culture and context.Possible mechanisms of change were discussed for further development of a standard faith-based model,and finally,suggestions for future research were also highlighted by the authors.

Key Words:Comorbid health conditions;Diabetes;Faith-based interventions;Diabetes management;Spirituality;Coping strategies

INTRODUCTION

Diabetes is among the chronic diseases that plague the victims throughout their lives.Diabetic conditions have been linked to comorbid health conditions such as blindness,kidney failure,and non-traumatic lower limb amputations[1,2].The worldwide prevalence of the lifelong disease has continuously increased from 422 million in 2014 to463 million people in 2019,and causes about 10% of United States annual expenditures on the adult population[1,2].About 1.6 million children and adolescents are also living with chronic illness[1].Diabetes is among the top 10 causes of global mortality[3,4].Diabetes accounts for increased mortality from comorbid diseases such as cardiovascular disease,stroke,chronic kidney disease,chronic liver disease,and cancer[3].The rising global prevalence of deaths and disability-adjusted life-years due todiabetes is estimated to be about 22.9 million.Hence,about 1 in 10 persons worldwide is suffering from one type of the three diabetes including type 1 diabetes,type 2 diabetes mellitus,and gestational diabetes mellitus[5].

Patients living with diabetes experience socio-economic challenges such as loss of a job,dependence on medical and nursing care,reduced social and family interactions and changes in lifestyle[4,6].This is because,unlike other disease conditions,where only medication is required to manage/cure,diabetes presents more complicated physiological,psychological and social conditions that make the management very difficult[7-9].Though,diabetes may be managed through medication and lifestyle modifications such as weight loss,diet,and exercise[10,11],there is also a high need for spiritual and psychological management[8,9].

This is because amputation and other disabilities and discomfort due to diabetes account for an array of disruptions in the patients' physical,mental,and spiritual lives[12].The spiritual health of diabetic patients can synchronize the physical,mental and social dimensions of their lives,and is necessary for coping with and management of the disease[7].Physical disabilities imposed by diabetes such as organ amputation tends to make the patients,mentally and spiritually disabled,exposing them to elevated stress[13].Thus,such patients seek different approaches to cope with and adapt to life.

There have been noteworthy arguments as to whether spirituality/religiosity directly affects diabetes outcomes and well-being globally.Spirituality can be a powerful coping strategy for persons with debilitating health conditions such as diabetes[14].Several studies indicate that increased religiosity is associated with better outcomes in clinical and general populations.Religion/spirituality generates a positive attitude towards life and life experiences,making the patient dominant against ill-fated life events including disease conditions(such as diabetes)and improving life with motivation and energy[6].This increases the tolerance and acceptance of unchangeable situations,especially when science is unable to help a patient[15].When disease condition becomes chronic and defiles medical interventions(as is typical of diabetes),patients and physicians tend to resort to praying and spiritual approaches.Furthermore,medical researchers have acknowledged the importance of medical procedures,as well as of traditional and complementary therapies such as prayer to treating the diseases[15].Studies also suggest that in caring for patients,medical personnel should not underscore the patients’ religious beliefs[16].This is because,people’s belief about the cause,prognosis and mortality of their disease conditions affect their responses to treatment and intervention[17].

Since diabetes is a chronic and terminal condition,which needs the mental and physical involvement of the patients for management,it is necessary to consider management approaches linked to spirituality and faith.Studies have shown that spirituality and faith-based interventions(FBIs)are viable management strategies for diabetes[18-20].Religion and spirituality are frequently engaged as coping mechanisms for diabetes and other psychologically threatening conditions and have been shown to effectively improve acceptance of diabetes and self-care behavior[18].Another study on coping and glycemic control in couples with type 2 diabetes showed that religion and faith could help in glycemic control[21].

The importance of spiritual beliefs in therapeutic practice has been demonstrated by various professional organizations in social work,psychology,and counseling,such as the Council for Social Work Education,which added it to their central aspect of human behavior interventions[22].However,very few articles have deeply addressed the issue of spirituality and FBIs in diabetes management.

This paper adds to the quality of information available in this area.This paper examines the impact of spiritual beliefs and FBIs in diabetes management.

SPIRITUAL BELIEFS AND DIABETES MANAGEMENT

Spiritual beliefs are invaluable in the management of diabetes and other chronic health conditions.Spirituality refers to the meaning or purpose in one’s life,a search for wholeness,and a relationship with a spiritual being or reality.Spirituality involves the search for meaning and purpose through which one establishes his/her relationship with time,oneself,others,and God[23].Individual’s spiritual beliefs may be expressed through religion or religious involvement,involving participation in an organized system of beliefs,rituals,and cumulative traditions[24].Spiritual beliefs and activities can impact the management of chronic conditions through two different pathways.First,it can assist in coping with chronic illnesses by providing support,confidence,and hope,and second,it can interfere with coping resources,especially when patients neglect self-care activities and rely on prayer and/or meditation to manage their illness[25].Empirical evidence demonstrates the relationship between spirituality and self-management of chronic diseases like hypertension[26]and diabetes[24].

Research has shown significant relationships between spiritual and religious beliefs and practices and general diet in patients with diabetes[20].This suggests that personal adaptations of diet and other health practices such as self-care practices are linked to spiritual beliefs.Given the importance of self-care practices such as healthy food adaptation,adequate physical activity,proper medication practices,and regular glucose monitoring[27,28],the significant link between spiritual beliefs and such selfcare practices suggests that spiritual beliefs impact the choice of management strategies and can make a difference in efficacy of management.

Additionally,spirituality is an imperative resource for emotional support[29,30].In this regard,God is perceived as central in providing strength to deal with daily challenges;God is often called upon for help in controlling diabetes;and a strong belief in God,prayer,meditation,and support from church members were all sources of support.Literature shows that humans develop an increased tendency towards spirituality and religion,especially when they experience stress or chronic illnesses[31,32].Spirituality assists in the management of patients’ health by yielding positive mental effects[32].Spirituality has also been identified as one of the important factors that affect the quality of life,quality of care,and satisfaction of patients with diabetes[33].

Hence,intervention using spiritual beliefs for the management of diabetes conditions involves utilizing any spiritual aspect in life,such as belief in a divine being,as a control to enhance self-management[34].Some spiritual belief-related interventions are prayer,meditation,fasting,and mindful attention.Thus in a study in Black women with type 2 diabetes,religion and spirituality were related to glycemic control[35].Furthermore,an exploratory study on the role of spirituality in diabetes management found minimal to profound impact;all participants appeared comfortable discussing spirituality within the context of strength and hope.A study conducted to explore the relationship of religiosity and/or spirituality to the self-care of diabetes[24]showed religion or spirituality as coping methods and social support.Studies have indicated that religious involvement is associated with better adaptation to chronic diabetes by improving attendance at scheduled medical appointments,and better compliance with medication[36].Table 1 shows the results of previous studies on spiritual beliefs and diabetes management[37-41].

Table 1 Empirical results on the impact of spiritual beliefs on diabetes management

FBI FOR DIABETES MANAGEMENT

Faith-based health promotion interventions and the relationship between dimensions of religion and numerous mental and physical health outcomes have been well researched[42].An intervention is faith-based if it arises from a church’s health ministry or a special interest group[43].Four levels or features are used to identify FBIs.The first level requires the church to be used as the recruitment site for the intervention;the second level requires that the intervention be delivered at a church;the third level includes members of local churches in intervention delivery;and the fourth level includes spiritual elements in the health message of the program[44].

FBIs have consistently reported significant health outcomes such as reductions in weight,blood pressure,glycemic,and lipid levels and increases in disease-related knowledge,physical activity,and intake of fruit and vegetables.The literature identified some spirituality issues that form the pathways for the impact of FBI on mental health on diabetic patients to include need for empowerment,courage,hope,finding meaning in suffering grieving or anxiety;patients’ uncertainty about their selfefficacy in enduring the chronic illness;difficulty expressing feelings about the situation;expressing guilt,concerns,grief and/or difficulty,as well as reflecting on joys,hopes and values;concerns regarding how caregivers are coping with illness,accepting the illness and associated mortality;and feeling of abandonment by God and others[45-48].FBIs often adopt approaches that are culturally-sensitive and behaviororiented and aim to foster positive health outcomes through the integration of social support[49].

Within the framework of FBI,patients with such spirituality issues can be gained from referrals to spiritual care professionals,active listening,emotional support and emotional expression;sharing of self in discussion,art,music and/or prayer;acknowledging the importance of family in the patient’s life;activity and exercise;humor;examination and encouragement of spiritual practices;observing sacred and divine spiritual rituals and practices such as prayer,communion,church attendance,guided visualization,relaxing,breathing[47].FBI for diabetes prevention and management is held in faith-based organizations such as churches,synagogues,mosques,meeting houses,and other worship places.They may be organized as congregations,national networks,or as free-standing organizations.

In faith-based organizations,diabetes management programs can be carried out using different strategies such as sharing messages with members through lectures,newsletters,and announcements;providing access to information and resources on diabetes prevention and management;partnering with community coalitions that address diabetes;arranging educational activities within the organization;offering emotional and social support;organizing workshops and programs to support healthy living through nutrition and physical activity;conducting community outreach,screening,and education;providing healthy food and activities during planned events;implementing policies that support healthy behaviors within the organization.

FBI PROCEDURE

FBIs have been criticized for the absence of methodological rigor in many efficacy/effectiveness trials[50-52].They generally utilize specific spiritual modalities such as prayers,meditation,voluntary fasting,sacred writing,focusing,journal writing and rituals[33,53-56].Prayer as an intervention can be a vehicle for creating cognitive change[56].The therapist can encourage clients to use prayer for coping,if appropriate,and praying in session might help to incorporate therapy into their worldview;practitioners can take advantage of clinical opportunities to use clients’prayer as a potential window into their spiritual and psychosocial functioning.Also,prayer might be used as a vehicle for creating cognitive-behavioral changes[57].

Meditation can be used as a method to attain a balanced lifestyle,and the topic of lifestyle balance can be introduced early in the clinical process.After discussion and questions about meditation are completed with the client in the session,the client should be given instructions for a practice session in the office[58].Sacred writings,also known as religious bibliotherapy[59,60]can be used when it is determined to be of value to the client,and the particular writings can be examined at least cursively in advance by the therapist.Milleret al[61]notes that such materials are useful for selfhelp,education,psychosocial support,and interaction.Focusing technique is defined as “the vague,bodily,holistic sense of the situation such as a problem,creative project,or spiritual experience” Milleret al[61].Through this intervention,the clients may learn to listen to themselves without judgment.Journal writing may be in the form of chronology,recollections and focused analysis.The intent is to help the client feel free and safe.Clients often learn to trust themselves and learn their inner thoughts and feelings and find inspiration.To effectively implement FBIs,Dodd[62]observed that it is very important to have the keenness and capability to incorporate spirituality into the psychotherapeutic process when appropriate.Lancasteret al[63]observed that the use of faith-based organizations can provide opportunity for the delivery of positive health messages and fostering of acceptance of healthy behavior due to the relevance of faith to many client populations.Another means of modality in FBIs is rituals.Rituals are religious or secular formalized behavior patterns that draw out certain feelings.They include creating a sacred space,the expectation of a change in insight,attitude,affect,or the receipt of guidance,and the expectation of awareness of the transcendent[64].

In a systematic review,Lancasteret al[63]notes that FBIs targeting changes at both the church and individual levels would have a greater impact on weight loss and related behaviors than interventions targeting a single level;interventions involving lay health advisors(LHAs)would be more successful in facilitating behavior change than investigator-led interventions.When LHAs facilitate the implementation of health programs faith-based organizations their relationships and familiarity with key church personnel,procedures and members can help facilitate outcomes[63].The research further showed that FBIs that include religious or spiritual components(e.g.,scripture,biblical concepts)would lead to greater improvements in outcomes than faith-placed interventions based on surface-level characteristics(e.g.,race,commonly eaten foods),including conducting programs in culturally appropriate settings[63].Hence the model of the process of FBIs is based on cultural background,spiritual perspective,and relationships,all of which are embedded in social-cognitive modalities.

IMPACT OF FBI ON DIABETES

Faith-based therapeutic interventions have been widely applied in managing diabetes and related variables across the world.An FBI on a multi-component curriculum including Scripture readings,prayer,goal-setting,a community resource guide,and walking competitions showed a decreased systolic blood pressure by 12.5 mmHg among intervention participants and only 1.5 mmHg among controls(P= 0.007)[47].In a preliminary study[64],presented the results of "faith on the move",a randomized pilot study of a faith-based weight loss program for black women.The study's goals were to estimate the effects of a 12-wk culturally tailored,faith-based weight loss intervention on weight loss,dietary fat consumption,and physical activity in overweight/obese black women.Although the results were not statistically significant,the effect size suggests that the addition of the faith component improved results.

Sattinet al[65]used a “fit body and soul(FBAS)”(an FBI program)for diabetes prevention to reduce weight and fasting plasma glucose(FPG)and increase physical activity from baseline to week-12 and to month-12 among overweight parishioners and recorded a significant decline in FPG in FBAS compared to the comparison group.In a methodological review,another study[47]found that faith-based organizations may be a promising avenue for delivering diabetes self-management education to Black Americans.

Another study on faith-based diabetes prevention program(fine,fit,and fabulous)for Black and Latino congregants at churches in low-income New York City neighborhoods,which included nutrition education and fitness activities while incorporating bible-based teachings that encourage healthy lifestyles,accounted for statistically significant change in participants’ dietary habits[66].Participants reported that they ate less fast food and were less likely to overeat at follow-up.The average weight loss across churches was 4.38 pounds or 2% of participants’ initial body weight.Churches and other faith-based organizations are increasingly popular settings to conduct health promotion programs[48].Table 2 shows the works conducted so far on the impact of FBIs on diabetes management.Table 2 suggests that all the studies found a positive impact of FBI in the management of diabetes across populations[67-70].

MECHANISMS OF CHANGEFOR FBIS FOR DIABETES MANAGEMENT

Considering that FBIs are efficacious in the management of diabetes,it is right to propose that such interventions work with multi-modal mechanisms,affecting different dimensions of the illness.FBI has positive effects on the prevention,selfmanagement and mental health of patients with diabetes[49].This suggests that FBI may take multiple pathways to affecting different dimensions of diabetes,however,little is known about the mechanisms of change in the area of FBIs for diabetes management.Mechanisms of change explain the key processes within a therapeutic intervention that are crucial to clinical change.Investigating mechanisms of change can help to identify and preserve the ingredients of an intervention which must not be diluted to achieve change and can enable the development of more effective treatments[71].

In the case of FBI for diabetes management,some of the paramount mechanisms are increasing general and religious social support,strengthening spiritual beliefs and cognition,providing relevant information,and integrating health-religion relationshipthrough improving emotion regulation and cognitive restructuring[71,72].For clarity,Figure 1 provides the pathways to changes in diabetes management due to FBI.Hence,we proposed that providing FBI for diabetes management culturally tailored and affect different dimensions that are sensitive to diabetes prevention,management and control.Within the Social Cognitive Theory Framework,FBI would improve diabetes knowledge,self-efficacy,diabetes symptoms management,and diabetes selfmanagement outcomes.To this end,FBI focuses on the three major dimensions,including the person(diabetes knowledge,self-efficacy,symptom management)and behavior(diabetes self-management)and the environment(the church setting).In the light of these expositions,we present a framework of FBI in the context of diabetes management as shown in Figure 1.

Table 2 Studies on the impact of faith-based interventions on diabetes management

CVD:Cardiovascular disease;DPP:Diabetes prevention program;FBAS:Fit body and soul;FFF:Fine,fit,and fabulous;PILI DPP:Pacific culturally adapted diabetes prevention program;WORD DPP:Faith-based diabetes prevention program.

IMPLICATIONS AND SUGGESTIONS FOR FURTHER RESEARCH

The present study has helped to illustrate the impact of FBIs and spiritual beliefs in the management of diabetes.The outcome of the study calls for emergent FBI modalities for diabetes management across the world.Further studies may attempt to develop and validate a standardized FBI program that would be useable in different religious samples.Such will provide handy,step-by-step approaches to FBI for diabetes.Researchers should attempt to increase access to diabetes management using a faithbased framework in different religious organizations.This is especially important given the place of effective management in diabetes prevention,treatment and control.

The spiritual beliefs of patients living with diabetes are of paramount impact for the purpose of maintaining good mental health of the patient[7,11-14].Linking spirituality with health has been found to be relevant in understanding the impact of FBI in the management of diabetes[15].Further studies are encouraged to trace the spiritual bases of diabetes management by finding out the mechanism through which spirituality affects diabetes outcomes.Given the link between spiritual variables such as prayers and beliefs and scriptures with diabetes management,and since the present study only relied on existing studies irrespective of their methodological flaws,correlation studies are encouraged,examining the impact of spiritual beliefs on diabetes outcomes.Studies should be intensified to determine the mechanisms of change in the FBI for diabetes management through experimental approaches.This will help determine the specific faith-based factors that account for positive change in diabetes management with FBIs.

CONCLUSION

There is a tendency of spiritual beliefs to be linked with the acceptance and management of diabetes conditions and FBIs can be useful in diabetes management.

Figure 1 Framework of faith-based intervention in diabetes management.The faith-based intervention acts on the three reciprocal sources of learning according to social-cognitive theory(the person,behavior and the environment).The three sources interact to produce improved skills,health behavior,mental health and social support.Finally,the improved outcomes lead to positive outcomes in diabetes management.