Prayers and beliefs among relatives of children admitted in pediatrics wards.

CONTEXT: Spirituality/Religion is important to many parents and they may call upon God to make the child healthier and normal. AIMS: We surveyed parents/relatives of children admitted to in-patient services for their praying practices and beliefs thereof. SETTINGS AND
DESIGN: Cross-sectional survey in 150 parents/relatives of patients admitted to pediatric ward, pediatric intensive care (PICU) unit, and neonatal intensive care unit (NICU) (50 each).
MATERIALS AND METHODS: We collected demographic, praying practices' information and asked them to fill a Prayer Questionnaire Score Chart which classified the individual's religiosity. STATISTICAL ANALYSIS USED: Descriptive statistics, Chi-square test, independent t-test, and one-way ANOVA were used for analysis.
RESULTS: Hindus constituted 126 (84%) participants. In 118 (78.67%) cases, mothers responded to survey. Average time of prayer in PICU (159 min) was more than NICU (109 min) and pediatric ward (114 min). Average frequency of prayer before admission (10.49) was less significant than frequency of prayer after admission (13.64) (P value < 0.001). Most of the people, 91 (60.67%), prayed by standing near statues of God or praying silently while recalling God's images. Almost all people, 149 (99.33%), believed that both medical care and prayer were required for recovery of patient. According to patient's relatives, average 52% recovery of patient was due to medicine.
CONCLUSIONS: Prayer was an integral component of parents/relatives' daily spiritual/religious ritual that was directed toward the admitted child's recovery. Statistically significant increase in frequency of praying after admission indicates the importance of prayers and spirituality in their minds as a part of treatment.

Introduction

Prayer conventionally brings to mind an image of a person joining both his hands and standing in front of a statue of God, speaking, or singing some words. However, it is not always so, as, prayer varies from religion to religion, region to region, and in fact from person to person. Praying is a discourse by which a person feels connected to supernatural power. It may be in any form, silent praying at any place or praying in temple in front of an idol for Hindus, Gurudwara for Sikhs, Mosque for Muslims, Church for Christians, and so on.

In essence, the word prayer or prarthna (in Sanskrit) is derived from two words ‘pra’ and ‘artha’ meaning pleading fervently. Prayer includes respect, love, pleading, and faith. Through a prayer, a devotee expresses his helplessness and endows the doership of the task to God. Giving the doership to God means that we acknowledge that God is helping us and getting the task done.[1]

What is the importance of prayers amongst relatives and why is there a need to assess them? Prayer may not only help parents cope with their grief and bereaved mothers maintain their mental health but also in experiencing personal growth. Many studies suggest that spirituality and prayer is a meaningful factor in children's ability to cope with stressors such as sickness, hospitalization, disability, cancer, terminal illness, and death.[2] The spiritual foundation can be significantly altered by the diagnosis of a chronic illness. An illness can lead to increased risk of psychiatric conditions and behavior problems.[3]

In a country like India, spirituality and religion are a part of life. Our research indicates that spirituality/religion is important to many patients and that they want it to be an integrated component of their care. The parents of admitted children are distressed and so they pray to God for the well-being of their child. It is thus necessary to focus on their belief in a higher being/a greater force to improve the situation of such children.

Religious practices like prayers represent the most prevalent complementary and alternative therapies all over the world. Especially in a secular country like India, the impact of religion and local beliefs amongst people cannot be over looked.

Most people dedicate any illness to be the will of God and recovery as help from God. So ignoring this notion of people and not considering what they truly feel/believe from inside is equal to neglecting what patient's relatives actual feelings are.

Doctors also respect spirituality and religious beliefs of relatives and show empathy and respect regarding beliefs of relatives of patient.[4] This may be due to similar cultural and religious background of doctors and perhaps an empathetic understanding of what patient's relatives feel when their child is suffering. Yet, there is a gap between the spiritual perception and religious thoughts of the patient's relatives and the doctor's perceptions and sentiments. This gap can only be filled up by a formal spiritual assessment. Spiritual assessment allows physicians to support patients by stressing on empathetic listening, documenting spiritual preferences for future visits, incorporating the precepts of a patient's faith and traditions into treatment plans, and encouraging patients to use the resources of their spiritual traditions and communities for overall wellness. Conducting a spiritual assessment may also help strengthen the physician–patient relationship and offer physicians opportunities for personal renewal, resiliency, and growth.

In our study, we mainly focused on prayers in medical illnesses. We tried to assess how the patient's relatives are involved in praying for their near and dear ones and what benefits they perceive they are getting.

Materials and Methods

This is a cross-sectional study. We interviewed 150 patient's relatives individually for data collection, of which 50 patient's relatives from each pediatric ward, neonatal intensive care unit (NICU), and pediatric intensive care (PICU) were administered a questionnaire adapted from a freely available instrument [Appendix 1].

Appendix 1

Prayer Score Questionnaire

	Question	5=Strongly agree 1=Completely disagree
1	When people pray, it is because they have no other way of making a bad situation better	5 4 3 2 1
2	God listens to all our prayers but does not give us everything we want. God is too wise to do that	5 4 3 2 1
3	Prayer is just as much about getting people to tune in to God as it is about getting God to do what people ask	5 4 3 2 1
4	I am not sure what to believe about prayer, but I do pray sometimes, and I do not think it is pointless	5 4 3 2 1
5	The main benefit of prayer is that it calms your mind	5 4 3 2 1
6	If you pray or meditate, you do not have to be in a temple or a church: You can touch the spiritual real many where	5 4 3 2 1
7	Prayer or meditation should not just be wishing for stuff for yourself - that would be selfish prayer	5 4 3 2 1
8	If you pray and really believe it, for others (not selfishly), God uses that prayer to help spread love into the world	5 4 3 2 1
9	It is important to pray every day - it keeps you in touch with the Almighty and can stop you getting too selfish	5 4 3 2 1
10	Prayer might make you feel better, but it is not heard by anyone - there is no God to listen to it	5 4 3 2 1
11	Sometimes prayer is answered how you want, sometimes it is answered differently, sometimes you cannot see any answer at all. But God is good	5 4 3 2 1
12	In my life, prayer and meditation are valuable to me	5 4 3 2 1

The investigator identified the relatives of the admitted patient. The selection of the relatives was on the priority basis with first degree followed by second degree (first-degree relatives would include mother, father, brother {major}, sister {major}; second-degree relatives would be maternal and paternal grandparents and uncles and aunts). These relatives were then taken to a pre-allotted room. He or she was given the information and orientation about the project and after taking the informed consent was administered the questionnaire. Throughout the procedure, the investigator was accompanied by a coinvestigator who is well experienced in handling the emotional instability that may have been caused during the questionnaire.

Descriptive statistics were used to describe data, frequencies, and percentages for categorical variables and mean values with standard deviations for continuous variable. Chi-square test was applied for analysis of categorical data. Independent t-test and one-way ANOVA was used for analysis of continuous variables. Human research ethics committee of HM Patel Centre for Medical Care and Education approved the study.

Results

We approached 180 relatives of patients, of which 150 consented to participate in the study, in which 50 were from each pediatric ward, NICU, and PICU. Details are given in Table 1 of the evaluation of the questionnaire [Appendix 1]. Mean (SD) age of patient's relatives was 29.1 (7.6). Most of them 110 (73.3%) were educated up to 12 standards, 125 (83.3%) were female relatives, and 126 (84%) were Hindus. Out of female relatives 118 (93.6%) were mothers of admitted children and the primary caretaker. Average time of prayer in PICU (159 min) was more than that in NICU (109 min) and pediatric ward (114 min). Mean frequency of prayers before admission was (10.49) less than mean frequency of prayer after admission (13.64) and it was a statistically significant difference (P value <0.001). Most of the people, 91 (60.67%), prayed by standing near statues of God or praying silently while recalling God's image. Almost all people, 149 (99.33%), believed that both medical care and prayer were required for recovery of patient. According to patient's relatives, 52% recovery of patient was due to medicine.

Table 1

Comparison of prayers score in different wards

n=150	Ward	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
PQ1	Pediatric	2 (4%)	15 (30%)	5 (10%)	24 (48%)	4 (8%)
	PICU	4 (8%)	10 (20%)	7 (14%)	25 (50%)	4 (8%)
	NICU	2 (4%)	10 (20%)	1 (2%)	34 (68%)	3 (6%)
	Overall	8 (4.33%)	35 (23.33%)	13 (8.67%)	83 (55.33%)	11 (7.33)
PQ2	Pediatric	0	0	2 (4%)	27 (54%)	21 (42%)
	PICU	0	0	10 (20%)	33 (66%)	7 (14%)
	NICU	0	0	7 (14%)	38 (76%)	5 (10%)
	Overall	0	0	19 (12.67%)	98 (65.33%)	33 (22%)
PQ4	Pediatric	0	0	4 (8%)	32 (64%)	14 (28%)
	PICU	0	1 (2%)	6 (12%)	23 (46%)	20 (40%)
	NICU	0	2 (4%)	4 (8%)	26 (52%)	18 (36%)
	Overall	0	3 (2%)	14 (9.33%)	81 (54%)	52 (34.67%)
PQ5	Pediatric	0	0	1 (2%)	20 (40%)	29 (58%)
	PICU	0	0	1 (2%)	21 (42%)	28 (56%)
	NICU	0	0	0	23 (46%)	27 (54%)
	Overall	0	0	2 (1.33%)	64 (42.67)	84 (56%)
PQ6	Pediatric	0	0	1 (2%)	18 (36%)	31 (62%)
	PICU	0	2 (4%)	0	19 (38%)	29 (58%)
	NICU	0	0	0	21 (42%)	29 (58%)
	Overall	0	2 (1.33%)	1 (0.67%)	58 (38.67%)	89 (59.33%)
PQ7	Pediatric	0	0	6 (12%)	35 (70%)	9 (18%)
	PICU	0	0	17 (34%)	24 (48%)	9 (18%)
	NICU	1 (2%)	1 (2%)	20 (40%)	25 (50%)	3 (6%)
	Overall	1 (0.67%)	1 (0.67%)	43 (28.67%)	84 (56%)	21 (14%)
PQ9	Pediatric	0	2 (4%)	14 (28%)	26 (52%)	8 (16%)
	PICU	0	2 (4%)	17 (34%)	22 (44%)	9 (18%)
	NICU	0	0	25 (50%)	24 (48%)	1 (2%)
	Overall	0	4 (2.67%)	56 (37.33%)	72 (48%)	18 (12%)
PQ10	Pediatric	33 (66%)	11 (22%)	3 (6%)	3 (6%)	0
	PICU	28 (56%)	11 (22%)	6 (12%)	2 (4%)	3 (6%)
	NICU	28 (56%)	17 (34%)	4 (8%)	1 (2%)	0
	Overall	89 (59.33%)	39 (26%)	13 (8.67%)	6 (4%)	3 (2%)
PQ11	Pediatric	0	0	2 (4%)	25 (50%)	23 (46%)
	PICU	0	0	1 (2%)	20 (40%)	29 (58%)
	NICU	0	2 (4%)	0	26 (52%)	22 (44%)
	Overall	0	2 (1.33%)	3 (2%)	71 (47.33%)	74 (49.33%)
PQ12	Pediatric	0	1 (2%)	0	18 (36%)	31 (62%)
	PICU	0	0	0	21 (42%)	29 (58%)
	NICU	0	0	1 (2%)	21 (42%)	28 (56%)
	Overall	0	1 (0.67%)	1 (0.67%)	60 (40%)	88 (58.67%)

Discussion

Our study helps to reflect on the psychology of the relatives of patients and the need of a physician to understand their religious and spiritual views, which may play an important part while counseling the relatives. Our study also clearly indicates that relatives of patients consider prayer and medicine equally important for the well-being and recovery of the patient.

Majority of relatives were Hindus, which can be attributed to local population being predominantly Hindus. This also implies that majority of our study findings apply to Hindu religion more, which may be considered a limitation of the study.

Also in our study, majority of responders were mothers of patients. This may be attributed to fathers being away at work, while mothers as the primary caretakers spend most of the time with the child during their hospital stay.

The average time of prayers was maximal in PICU, explained by the more critical condition of patients in PICU as compared to those in pediatric ward. Comparatively, lesser amount of prayer time for NICU patients could be due to lesser memories and attachment to a newly born child.

Statistically significant increase in frequency of praying after admission indicates the importance of prayers and spirituality in their minds as a part of treatment. It also indicates the relatives’ fear and concern on admission of the child to hospital. The perception of prayer is not only helpful to patients and their relatives but is also helpful to pediatricians in approaching the patients by their spiritual and religious beliefs. In this study, patient's relatives demonstrate the belief that both medical care and prayers have equal value in patient's care. Thus by integrating the practice of prayer in clinical care, we can significantly reduce the burden of worries of patient's relatives.

Praying to God's statue or by imagining God's image simply reflects majority of patients being Hindus as there is a custom of statue worship in Hinduism. However, 98% relatives in our study believed that we need not be in temple or church to pray, it can be done anywhere.

Similar studies have been conducted in the past outside India. While some studies have focused on the benefits of prayers on the patient's medical condition, others attempted to determine the benefits to the patient's relatives (psychological or emotional benefits).

A study conducted in California on the effects of prayer found that patients with advanced AIDS, who were prayed for, survived in greater numbers, got sick less often, and recovered faster than those who did not receive prayer.[5] On the other hand, some studies showed that there was no effect of prayers on the condition of the patients. A triple blind study by Mathai et al. on children with psychiatric illness showed no benefit of prayers on the condition of their children.[6] A study conducted by Mayo clinic on 799 patients also failed to prove any benefits on health of patients.[7]

Similar studies in adults have been conducted outside India and have shown mixed results. Interestingly in a study, prayers were shown to improve pregnancy rates in in-vitro fertilization.[8] Another study showed lesser complications in patients who were prayed for while admitted in cardiac care unit.[9] However, contradicting this study, another study on patients undergoing coronary artery bypass grafting showed comparable outcomes amongst those who were prayed for to those who were not.[10] Thus, it is still inconclusive whether prayers actually help in faster recovery of the patient or not. Some studies[5911] support faster recovery and lesser complications in patients, whereas others show no medical benefit to the patients.[6710] But many studies showed benefits to relatives in terms of hope, positivity, and emotional supported.[111213] Our study focuses on the beliefs and patterns among the parents about the prayers and not on effect of prayers on patient's health.

In our study, all relatives felt that prayers help calm them. Only 6% relatives believed that prayers are not heard by anyone and are just to calm oneself. Almost all relatives believed that prayers may not be answered or may be answered differently, but they believed it is the way of God, he is still good. All relatives considered meditation and prayers as valuable to them personally. In a similar study, families reported that spirituality increases their sense of self-transcendence, a sense of meaningful construction, and by this a spiritual connection among mother, father, and infant; prayers restore a sense of control, meaning, and the ability to cope. Hence, spirituality helps the families of patients in shift from a state of hopelessness to wholeness, especially in coping up with chronic illness of patients.[11] Most people view spirituality as a vital aspect of the illness experience.[12] In another study, many parents were shown to rely on their religion and prayer to guide them in the end-of-life decision-making, to make meaning of the loss and to sustain them emotionally.[13]

Spirituality should also be discussed with a family because it may affect their normal psychology and attitude toward the condition of their ward. Research studies demonstrate that up to 94% of hospitalized patients believe that spiritual health is as important as physical health,[14] that 40% of patients use faith to cope with illness,[15] and that 25% of patients use prayer for healing each year.[16] Guidelines from the National Consensus Project for Quality Palliative Care state that spirituality is a core component of palliative care.[17]

Majority of relatives in our study believed that prayer should not be selfish, but for all, representing the selfless nature of prayers. They believed that prayers should be part of daily routine, to keep in touch with the almighty. Praying daily selflessly helps God spread love in the world and this in turn makes you selfless.

In our study, most relatives gave equal credit to medicine and prayers in curing the patient, reflecting upon the strong belief of patient's relatives in spirituality as part of childcare and the need for the doctor to understand the same. Our study results are similar to the study by Hexem et al., which stated that families may use faith healing alongside conventional medicine or as an alternative. Parents feel that both God and medicines, which were being given to their child, are important for their child.[18]

Issues of belief can affect the health-care encounter, and patients may wish to discuss spirituality with their physician. Many physicians report barriers to broaching the subject of spirituality, including lack of time and experience, difficulty in identifying patients who want to discuss spirituality, and the belief that addressing spiritual concerns is not a physician's responsibility.

Additionally, there is literature indicating which patients – including those who are hospitalized or terminally ill – are more likely to welcome a spiritual assessment.[19]

Study also suggest that the people who are involved in religious or spiritual activities have less high-risk sexual behaviors which is helpful in prevention of HIV/AIDS transmission.[20] Study done in cancer patients in Iran reveals that return to spiritual care in cancer patients is a main coping mechanism.[21] Patients diagnosed with chronic illness were benefited by spiritual and religiousness in the form of hope, piece, and meaning of life.[22]

Understanding the spiritual or religious beliefs of parents of seriously ill-child is helpful in decision-making process.[23] Religion or spirituality has significant role in decreasing the risk of coronary heart diseases.[24] Integration of spirituality in nursing care of cancer patients is very helpful to both patients as well as nurses to cope up with the distress.[25]

Medical care is not always sufficient to cure or relieve patient symptoms or illness. Holistic approach in patient care must take into account this important aspect of beliefs, culture, feelings, and prayers amongst relatives of patients.

This study is the first study of its kind in India, and although we need more of such studies to determine the impact of spirituality, prayers, and beliefs on relatives and patients, one thing is certain that spiritual assessment and assessment of beliefs amongst relatives of admitted children must be considered an integral part of patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

‘Prayer Questionnaire Score Chart’

Section 1: Add up the scores to numbers 1, 4, 5, 6, 10, and 12	19-30: Subject is a spiritual person, but not a religious one. While meditation and prayer have some value to the individual, he/she is working out his/her own path, not following one made up centuries ago
	15-18: Subject is kept in about praying - does not really know if it is for them or not. Does not dismiss others points of view, preferring to listen to different ideas
	6-14: Subject has quite clear and definite ideas about prayer and meditation, whether as a believer in God or not. Is confident in his/her own view points and may be very good at arguing about religious topics because of this
Section 2: Add up the scores for numbers 2, 3, 7,8, 9, and 11	18-30: Subject sees prayer as something to stop human self-centeredness and is a strong believer in the power of spiritual practice to make a difference to the life of the person praying
	11-17: Subject thinks that prayer makes a difference to the hearts and minds of those who take it seriously. May not be a person who prays much himself/herself, but respects those who do
	6-10: Subject is quite cynical about the practice of spiritual life, and does not think it makes much difference to people