Spirituality and Health in Brazil: A Survey Snapshot of Research Groups

: Articles on “Spirituality and Health” have multiplied considerably in Brazil in the last decade. More recently, however, research groups created specifically to investigate this topic have emerged. This study aims to provide an overview of the field by means of a survey in the Directory of Research Groups in Brazil. Thirty-three groups were initially identified, of which 16 were selected for analysis and placed into two categories: “established” groups and lines of research, and “in-process” groups and lines of research. The survey made it possible to identify postgraduate programs that develop studies on this theme, the main researchers, and the potentials and challenges of this research field in Brazil. The results also indicate that “Spirituality and Health” is a fundamentally interdisciplinary field of research that is expanding and has gained greater legitimacy in the scientific community in the last four years. The main challenges to and potentials for advancement of knowledge are the need for theoretical and methodological development to support research, educational improvement in spiritual care, development of a critical and conscious reflection on the political implications of the field (especially due to the religious diversity in the Brazilian cultural context), and the role of spirituality/religiosity in public health promotion policies.


Introduction
"Religious influence is harmful to health and puts lives at risk" (Oliveira 2020). This statement is taken from an interview with Brazilian gynecologist Cristião Rosas by journalist Joana Oliveira for the newspaper El País on 30 August 2020. The interview was motivated by the reaction of Brazilian society to the issue of the right to legal abortion. A case, widely publicized in the media, told the story of a pregnant 10-year-old girl who had been sexually abused by her uncle since the age of six and was thus guaranteed the legal right to abortion. Nevertheless, the case caused a series of demonstrations by religious radicals.
The gynecologist's statement represents some Brazilian healthcare professionals' understanding of the relationship between spirituality, religion, and health. Such an understanding likely results from a lack of training on the adequate integration of spirituality in healthcare, as some Brazilian researchers have pointed out (Costa et al. 2010;Lucchetti et al. 2012Lucchetti et al. , 2013Cavalheiro and Falcke 2014;Esperandio and Machado 2018;Menegatti-Chequini et al. 2019).
Although the last Brazilian religious census (Instituto Brasileiro de Geografia e Estatística IBGE) pointed to significant growth in the number of atheists and agnostics (8% of a population of 191 million), 92% of the Brazilian population still declare themselves as belonging to a religion or as having "multiple religious belongings". Studies by Huber and Huber (2012) and Esperandio et al. (2019) also show that Brazilians are a "highly religious" population.
Despite this high level of religiosity, the discussion of how spiritual/religious beliefs and behavior can impact health outcomes is not yet fully included in the curricula of psychology courses (Costa et al. 2010;Esperandio and Marques 2015;Pereira and Holanda 2019) or in medical courses (Lucchetti et al. 2012Menegatti-Chequini et al. 2019) or in nursing courses (Oliveira 2017;Espinha et al. 2013). However, this scenario has been changing significantly, perhaps as a result of international research and the academic interest of Brazilian researchers, who seem to feel more freedom to develop research on the subject with the scientific rigor required in the academy. This increased interest can also be substantiated by the number of new research groups working on this topic.
In Brazil, the Ministry of Education organizes, monitors, and promotes the development of scientific knowledge via two government agencies-the Coordination for the Improvement of Higher Education Personnel (CAPES) and the National Council for Scientific and Technological Development (CNPq). CAPES' main objective "is to coordinate efforts to improve the quality of Brazil's faculty and staff in Brazil in higher education through grant programs" (Brazil, Ministério da Educação 2020b). CNPq acts as the agency responsible for "conceptualizing and conducting public policies on science, technology, and innovation. Its performance is essential for the national development and international recognition of Brazilian research institutions and researchers" (Ministério da Educação 2020a). By means of the Directory of Research Groups, CNPq monitors the development of science in higher education institutions and produces statistical data on the various areas of knowledge. Researchers working in stricto sensu graduate programs are encouraged to form research groups around the main topic of their research. Graduate students and undergraduate students (who are involved in scientific research projects) have to be registered in the research groups formally established in their faculties, and these groups are then registered in the Directory of Research Groups on the CNPq platform. So, when the intention is to map (a) the development of a specific research topic, (b) areas of knowledge where research on the topic is developed, (c) leading researchers, (d) geographical location, and (e) postgraduate programs where the topic has been developed, the search for Groups of Research registered in the Directory of Research Groups in Brazil is a useful strategy.
It is worth highlighting that if one wishes to verify gaps and needs for additional research or to identify conflicts in previous studies or unanswered questions about a particular topic, a literature review is a good strategy. However, a literature review alone cannot provide information about the researchers and the context from which the studies originate. A survey of research groups is useful to identify groups of researchers who are developing research around a common specific theme. It is also possible to identify the evolution of the interest in the topic in the academic scenario.
A search was conducted in the Directory of Research on the platform of the National Council for Scientific and Technological Development (CNPq) with the aim of answering the following question: which groups are working in the field of Spirituality and Health (S&H) in Brazil and what are the main themes of their research? Thus, this study provides a snapshot of the current field of S&H research in Brazil.

Methodological Procedures
According to the current census of research groups (based on the last quadrennium of national assessment from 2013 to 2016), there are 8091 research groups in the humanities and 5877 in health sciences in Brazil. The Directory of Research Groups User Manual (Conselho Nacional de Desenvolvimento Científico e Tecnológico CNPq) from the CNPq defines a research group as a group of individuals that are hierarchically organized around one or, eventually, two leaders; with the organizing foundation of this hierarchy being: experience, prominence and leadership in the scientific or technological field; professional and permanent involvement in the research activity; work organized around common lines of research that are subordinate to the group (and not the other way around); and, to some degree, shared facilities and equipment. The concept of group may be that composed of only one researcher and his or her students.

1.
Institutionally certified group: certified and updated group that participates in the directory census.

2.
Not updated group: certified group with no updates for more than 12 (twelve) months. The leader has 12 (twelve) months to update a group in this situation. After this period, the group's status will automatically change to "excluded" and can no longer be recovered in the database by the leader or the person representing the institution in which the research group is housed. The Research Officer can certify or withdraw certification from a not updated group, changing its status to "Certification Denied".
A not updated group does not participate in the directory's censuses but is available for examination in the public search of the DRG portal (in Search Groups, Current Base) for a maximum period of 12 months. If there are no updates during this period, that group is excluded from the database. 3.
Predominant area of the group: area of knowledge that most closely matches the group's research activities, among those existing in the classification of areas of knowledge used by CNPq. Even multidisciplinary and interdisciplinary groups must be related to an area that coordinates their activities. The research lines of a research group can be associated with up to three areas of knowledge and subareas or specialties.

4.
Research Lines: represent unified themes of scientific studies based on an investigative tradition, developing projects whose results are related to each other. Because research lines are subordinate to groups, groups can have one or more lines, and they do not necessarily need to be associated with all members of the group.
To verify which groups are leading the field on S&H (including their quantity of output, predominant disciplines from where they originate and in which universities they are anchored, and their main themes of research), a search in the Directory of Research Groups was carried out on two occasions in 2020 (September 23, and October 3) using the term "spirituality and health" with search application in the following fields: group's name, research line, and keyword of research line. The search contained no limitations on the duration of a group's registration in the directory.
The groups selected for analysis had to meet the following criteria: (1) To have a specific focus on S&H or at least one research line for S&H in conjunction with their main research focus; (2) To include both researchers and students; (3) To present scientific publications resulting from their research on the topic; (4) To be "certified by the institution". "Not updated" research groups (still within the deadline for regularization) and research groups "in completion" (as long as they had students linked to their lines of research and scientific publications by the researchers) were also selected. Groups that did not meet these established inclusion criteria were excluded.
The Directory of Research Groups does not list the researchers' scientific publications, but it does provide a link to the Lattes platform (Supplementary Materials). The Lattes platform is "the major scientific information system maintained by the National Council for Scientific and Technological Development (CNPq) [that] allows to manage the curricular information of researchers and institutions working in Brazil based on the so-called Lattes Curriculum" (Mena-Chalco and Junior 2009, p. 31). Thus, a search of all Lattes Curricula of research group leaders and researchers listed in the S&H line of research was carried out on the Lattes platform in order to extract their specific research foci and scientific publications related to the field. This analysis permitted us to categorize the groups and lines of research into two categories: "established" groups and lines of research, and "in-process" groups and lines of research.
"Established" groups and lines of research were those groups (a) with a primary focus on S&H; (b) researchers who regularly publish results of their studies, and (c) whose publications on the topic were prior to the creation of the research group. "In-process" were: (a) recently created groups (without publications) or groups that added S&H as a research line to an existing group, (b) groups whose scientific publications were not on S&H, or not regular (e.g., despite the registration of several researchers in a research group/line of research, only a single researcher has a single publication). The research topics, as well as the details of the scientific publications of all researchers involved in the groups and lines of research, can be verified in their Lattes Curricula, which are available on the Internet. The addresses to access such curricula are provided in the Supplementary Materials.

Results
Research groups in the humanities represent 21.5% of the total research groups registered in the Directory of Research Groups (DRG), while health sciences represent 15.6% of the total. Humanities and health sciences are the two major research categories to which S&H research groups are linked.
The two searches discovered a total of 33 unique groups, 16 of which met the selection criteria for analysis. Those 17 groups not included in the analysis were discarded for the following reasons: (1) the group had no focus on S&H or any line of research on the topic; (2) the words "spirituality" or "health" were mentioned but without any relation to S&H; (3) no students were registered in the group; (4) none of the researchers listed in the line of research had any publications on S&H. The last criterion for exclusion was based on the understanding that at least one researcher involved in a research group (or in a line of research) should have published accordingly.
The leading areas of knowledge for the groups with a main focus on S&H or with a line of research on the topic are shown in Table 1.

Geographical Location of Research Groups in Brazil
The 16 research groups which met the criteria were located in just eight states in Brazil ( Figure 1); the red spots mark their distribution on the map. Ten of the 16 groups are situated in Southeast Brazil (the yellow part of the map).

Categorization and Evolution of Groups and Lines of Research
The analysis of the 16 groups shows that nine of them fall into the category of "established" groups and lines of research (Table 2), and seven of them can be categorized as "in-process" groups and lines of research (Table 3). Tables 2 and 3 also provide information about when the groups were created and, if relevant, when a S&H line of research was added to an existing group. If a research line on S&H was added later, it follows the slash in the second column, e.g., 2013/2016 (Tables 2 and 3).
The first research group with a primary focus on S&H appeared in the directory in 2013 (Table 2), while the first S&H line of research was added to a research group (on Palliative Care and Health Quality of Life) in 2011. The evolution of the groups and lines of research is presented in Figure 2. "In-process" groups and lines began their activities in 2016.

Categorization and Evolution of Groups and Lines of Research
The analysis of the 16 groups shows that nine of them fall into the category of "established" groups and lines of research (Table 2), and seven of them can be categorized as "in-process" groups and lines of research (Table 3). Tables 2 and 3 also provide information about when the groups were created and, if relevant, when a S&H line of research was added to an existing group. If a research line on S&H was added later, it follows the slash in the second column, e.g., 2013/2016 (Tables 2 and 3).
The first research group with a primary focus on S&H appeared in the directory in 2013 (Table 2), while the first S&H line of research was added to a research group (on Palliative Care and Health Quality of Life) in 2011. The evolution of the groups and lines of research is presented in Figure 2. "In-process" groups and lines began their activities in 2016.
According to the survey, there are five established research groups with a primary focus on S&H in the following disciplines: nursing, medicine, religious studies, and theology. They are housed in the following programs: (1)

Main Topics Investigated in the Groups and Lines of Research
Based on the publications in the Lattes Curriculum, researchers in the selected groups investigated the following topics:

Main Topics Investigated in the Groups and Lines of Research
Based on the publications in the Lattes Curriculum, researchers in the selected groups investigated the following topics:  (Paiva et al. 2015;Paiva et al. 2014). (f) Spiritual/religious coping (Matos et al. 2017;Silva et al. 2019;Vitorino et al. 2018). (g) Meaning-making (Rocha et al. 2018a;Silva et al. 2020). (h) Creation and validation of instruments for assessing spirituality (Abdala et al. 2020;Esperandio et al. 2018;Oliveira da Silva et al. 2020a, 2020bCurcio et al. 2015;Silva et al. 2018).

Discussion
This mapping made it possible to identify both the postgraduate programs where this field of research is concentrated and the research groups whose leaders have contributed regularly to scientific publications. Research groups are housed in several areas of the humanities and health sciences, indicating that Spirituality and Health is an intrinsically interdisciplinary field. Within Brazil, this study shows that one-third of the research groups, 31.25%, are situated in São Paulo. This study also indicates that concentrated research on this topic is relatively recent; most groups and lines of inquiry have begun within the last decade.
It is noteworthy to highlight the number of current research lines added to research groups that previously did not address S&H (especially in the last four years). This indicates an increasing interest in the field and calls for more investigation on why this field of knowledge is now gaining attention (or legitimacy) within the academic community. This may be associated with a new understanding of the differentiation between spirituality and religiosity, as pointed out by Esperandio and Leget (2020, p. 38) in their literature review; this hypothesis should be investigated further.
The analysis of the Lattes Curriculum (for all researchers) indicates that, especially among the newest groups or research lines, there are few scientific publications. This recent "enthusiasm" for S&H could be understood as merely a "fad", but it could also indicate that scholars are beginning to pursue interests that they have hitherto left unexplored for any number of reasons. Therefore, it is possible to foresee an "explosion" of articles and journals on S&H by Brazilian scholars in the future, judging by the large number of researchers and students currently engaged in these research lines. The growing interest in this field was most evident recently, in 2020, as one new group with a primary focus on S&H formed, and unique S&H research lines were added to three existing groups. When one considers the main topics currently under investigation, one can also see that some themes have been insufficiently researched and should receive more attention in the future: models of spiritual care, the role of chaplains/spiritual caregivers, and training for healthcare professionals on how to adequately integrate spirituality into healthcare, among other themes.
While the first group was listed in the directory in 2013, studies on S&H have actually been carried out by a group of researchers from the Federal University of Juiz de Fora at the Center for Research on Spirituality and Health-NUPES-since 2006. More than a research group, NUPES is a reference center for studies on spirituality and health in Brazil. Its influence in both an academic context and Brazilian society regarding the discussion of this topic is widely recognized. This group (which falls outside the search parameters applied in this study) will be described in more detail in the following section.

Research Center on Spirituality and Health (NUPES)-Federal University of Juiz de Fora (UFJF)
Created in 2006, NUPES brings together researchers in the fields of medicine, psychology, neuroscience, nursing, physiotherapy, history, philosophy, and sociology and who supervise master's and doctoral students in the areas of medicine, public health, and psychology at the UFJF School of Medicine (Moreira-Almeida and Lucchetti 2016). As a research center, NUPES is not registered in the Directory of Research Groups; nevertheless, the center plays a prominent role in studies on S&H in Brazilian academia. According to the NUPES website, nine researchers are investigating three lines of research: Epidemiology of Religiosity and Health, Religious and Spiritual Experiences, and History and Philosophy of Research on Spirituality (NUPES-Núcleo de Pesquisa Em Espiritualidade e Saúde n.d.).
Among the topics being researched are spiritual/religious coping; integration of S&H into undergraduate courses in the area of health, the elderly, mediumship, and mental health; validation of scales; diagnoses that differentiate between mental disorder and religious experience, and the interrelationship between brain/mind and health outcomes. In the leadership of NUPES, Moreira-Almeida (lead researcher for the newly created Spirituality and Health Research Group, UFRJ-see Table 3) and Lucchetti (leader of the Research Group in Geriatrics and Gerontology-see Table 2) are both widely recognized in the field. NUPES has a channel on YouTube to disseminate the production of scientific knowledge to a broader, general public.

Challenges and Potentialities of Research Groups in the Field of S&H: Some Considerations
Given the growing interest in this topic, it is important to reflect on some of the challenges and potentialities for research groups interested in contributing to the advancement of knowledge in the field of S&H in Brazil.

A Starting Point that Should Be Considered by Beginners or "In-Process" Research Groups
Sufficient studies exist that address the relationship between spirituality/religiosity and health and the necessity of integrating this theme into healthcare (Moreira-Almeida and Lucchetti 2016; Rocha et al. 2018b; Esperandio and Rosa 2020). As has been already pointed out by Moreira-Almeida and Lucchetti (2016), to contribute new information to the field of research, studies need to investigate (a) how spirituality/religiosity impacts health outcomes; (b) what should be considered an adequate integration of spiritual/religious issues into healthcare; (c) if, and to what extent, the spirituality/religiosity of health professionals might impact their own performance in healthcare (Rocha et al. 2020). Brazilian researchers can contribute a great deal to international studies given the population's highly religious behaviors.

Searching for a Consistent Conceptualization of "Spirituality" and "Religiosity"
The term "spirituality" is used more frequently in Brazilian academic circles than "religion" and "religiosity". Oman (2013) observed that the preference for the term "spirituality" has been more noticeable in a North American context since the 1970s. However, the author also noted that between 1970 and 2005, the use of the word "religion" in published works had a "modest" increase. On the other hand, the term "spirituality" had a "dramatic increase", approximately 40 times more, in the period between 2005and 2009(Oman 2013, when compared to the period from 1970 to 2005. For Oman (2013, the word "spirituality" started to be used in English as something that can explicitly be sought, not only within formal religious traditions but also outside of them; this trend started to become more evident at the end of the 20th century. A similar phenomenon can also be seen in Brazil. One of the direct implications of this finding is the need for a national consensus on the meaning and differentiation between the terms "spirituality" and "religiosity", including the term "spiritual care". It is assumed that a national consensus could contribute both to the advancement of theoretical-practical knowledge in the field of care ethics and to guide the implementation of spiritual care as a specialized (and integrated) service in multidisciplinary healthcare teams (particularly in palliative care services) (Esperandio and Leget 2020).

Implications of the Conceptual Differentiation of Spirituality and Religiosity
The need to develop a consistent theoretical framework for the differentiation of the terms "spirituality" and "religiosity" may assist in the construction of scales for assessing spirituality, as well as religiosity, in both the research and clinical contexts. Based on data from the last IBGE census (2010), it is possible to infer a significant increase in the number of people who identify as "spiritual", but not "religious". In this case, scales developed for the Brazilian context to assess the notion of spirituality and not just religiosity would be useful for future research as this would include a broader array of participants, as well as a more accurate picture of the Brazilian populations.

A Promising Research Topic: The Relationship between Religious Cognition, Religious Behavior, and Health Outcomes
Considering the religious diversity across the country, Brazil is a living laboratory for studies on the relationship between religious cognition (religious identity, mental representation, and supernatural attribution) of specific religious groups and global health. Studies on S&H could greatly contribute to the advancement of knowledge on this topic and other related sciences: psychiatry, the various currents of psychology (cognitive psychology of religion, cultural psychology of religion, and evolutionary psychology), bioethics, and theology. Such studies would be advantageous in Brazil in order to find psychological and behavioral differences between what the researchers call Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies and non-WEIRD populations. For instance, attendance at religious service has been strongly predictive of longevity in the West, especially in the USA, as noted by Oman (2018). Still, does some other specific spiritual/religious dimension demonstrate exceptional predictiveness in Brazil? The investigation of the Attachment Theory and the Attachment to God (August and Esperandio 2019; August and Esperandio 2020), for example, in mental health and the grieving processes would contribute to the quality of spiritual and psychological care to both bereaved family members in the context of palliative care and to people affected by COVID-19.

Models of Spiritual Care
Several studies have pointed to the importance of meeting the spiritual needs of sick people and their families. However, models of interdisciplinary spiritual care in the various health contexts (nursing, psychiatry, psychotherapeutic clinic, mental health, and palliative care, hospice) are scarce in Brazil, as well as internationally (Peteet and Balboni 2013). This demonstrates the necessity worldwide for the development of practical proposals with a theoretical base, such as the study developed by Mendonça et al. (2018) which offers a theoretical model of spiritual interventions based on Jean Watson's Theory of Human Care that can be applied in the context of oncological nursing.

Specificities of Spiritual Assistance and Spiritual Care Education
Studies highlighting the need to train various healthcare professionals on how to meet the spiritual needs of sick people and their families (Veras et al. 2019) are still scarce. Thus, the investigation of the specificities of spiritual care in distinct medical specialties which still maintain an interdisciplinary perspective can significantly contribute on at least two fronts: (1) formation of spiritual care competence in multidisciplinary healthcare teams, and (2) evidence-based subsidies to compose curriculum content in different areas of professional training.

The Need for a Critical Perspective on the Field
National (Lucchese and Koenig 2013; Moreira-Almeida and Lucchetti 2016) and international (Koenig 2012) studies have shown that spirituality/religiosity has positive effects on health. However, the topic also demands a critical eye, i.e., spiritual/religious issues can trigger negative health outcomes, as noted by the gynecologist Cristião Rosas, who was mentioned in the beginning of this study. In this sense, it is essential to investigate the negative, as well as the positive, impact of spirituality/religiosity on health, e.g., spiritual/religious struggles and the extent to which they can cause harm to people's health.

Training of Professional Spiritual Caregivers to Work in Multidisciplinary Healthcare Teams
There is a lack of studies focusing on spiritual care that is offered by spiritual caregivers/chaplains who are part of multidisciplinary healthcare teams. However, this absence merely demonstrates the absence of these professionals in multidisciplinary teams. Spiritual assistance provided by spiritual caregivers is a topic neglected by the courses that should be the most concerned with it: theology and sciences of religion. This subject should matter in these disciplines, and studies need to be developed at the interface of bioethics, theology, and the sciences of religion in Brazil.

Political Implications Concerning Spirituality as a Public Health Issue
It is, finally, absolutely necessary that these research groups observe the political implications and social impact of their research. Given the religious diversity that characterizes the Brazilian cultural context, it is necessary to pay attention to spirituality/religiosity in public health promotion policies. Researchers in this field cannot be unaware of the political misuse of their findings. We cannot ignore the impact of religious beliefs in decision-making on health-related issues. As stated by Park (2014), global meaning (individuals' general orienting system) "has many effects on general aspects of health; further, its effects may be even more potent in the context of illness" (p. 21). We also have to be aware that those who are systematically excluded from more equitable and qualified care are the most vulnerable. In Brazil, not rarely, some religious and political leaders make use (or misuse) of people's faith, as became particularly evident in the pandemic context of COVID-19 (Bandeira and Carranza 2020). Our studies should take this population into account in the reflections on public health, S&H, and vulnerable populations.

Conclusions
The analysis of the research groups on S&H in Brazil showed the extent of possibilities in this field, given the undeniable interest of many Brazilian researchers in the subject. In this sense, the formation of research networks and greater dialogue between the groups seems essential to further enhance what is already presented as a "fruitful field". The list of nine items above is not intended to exhaust the data's discussion but to be the starting point for further discussions and possible other ways of promoting research in this field.
The investigation of this theme is still relatively young in Brazil. Opening the field up to the interdisciplinary dialogue that already characterizes the research while planning future research in this field with clear intentionality can result in major academic and social contributions. After all, we are talking about the investigation of the "spirit", the "breath of life", the "vital power" that is the condition for the continuity of life and its processes. The health of the vital potency is all that life needs in order to expand and assert itself in all its strength.