Review and Characterization of Portuguese Theses , Dissertations , and Papers about Spirituality in Health

Research about spirituality has grown widely in the past decades and the interest in health care is also evident in Portugal. This literature review aims to identify and to characterize Portuguese theses, dissertations, and papers about spirituality in health, and to provide a systematic overview of the knowledge concerning this subject. The search was conducted in February 2017 and updated in January 2018. Four independent reviewers screened and analyzed all citations, and a total of 76 results were included. Publications started in 2002 and include master degree dissertations (n = 37), scientific papers (n = 31), and PhD theses (n = 8). Papers were published in 24 national and international journals. Most papers were psychologyand nursing-related and had a quantitative design (n = 55). Samples were mostly composed of patients living with a chronic disease (n = 20) or elderly (n = 11). The Spiritual Well-Being Questionnaire (SWBQ) was the most used tool. A multidisciplinary approach is regarded as foundational in implementing spirituality in the provision of health care and the results underline the interest on this topic from other disciplines rather than nursing. Further studies must provide a deeper understanding of spirituality in children, adolescents or families’ perspective bringing new insights to advanced health practice.


Introduction
Spirituality is an individual dimension and a complex and universal phenomenon (Barber 2012).Several attempts to define the concept have been made based on the subjective nature of spirituality, and different conceptual approaches can be found in the literature throughout the years.Recently, spirituality has been defined as "a way of being in the world in which a person feels a sense of connectedness to self, others, and/or a higher power or nature; a sense of meaning in life; and transcendence beyond self, everyday living, and suffering" (Weathers et al. 2016, p. 93).The same authors identified connectedness, transcendence, and meaning in life as the main attributes of the concept (Weathers et al. 2016).Spirituality plays a critical role in human existence, on perceptions of health and well-being, and relates to patients' quality of life (Koenig 2012;Papathanasiou et al. 2014) from the beginning to the end of life (Crowther and Hall 2017;Romeiro et al. 2017aRomeiro et al. , 2017b)).Closely related to challenging and unpredictable life events, spirituality was proven to be supportive and therapeutic during adverse health conditions (Koenig 2012;Timmins and Caldeira 2017).For example, chronic, terminal, and/or unexpected illness seems to trigger patients' and families' suffering and evoke spiritual coping mechanisms regardless religious affiliation (Weathers et al. 2016).
Since ancient times, spirituality has evolved side by side with health-related practices.For example, religious leaders were pioneers in hospitals' organization and were basilar in setting the foundations for current professional standards of health care (Koenig 2012;Theofanidis and Sapountzi-Krepia 2015).Nevertheless, over the years a fragmentation of care is often stated, based on the scientific advances, which led to a transformation in the way patients were treated, mostly reduced to the physical and biological aspects of treatments (Papathanasiou et al. 2014).This reductionist approach, and the implications on the assessment and the intervention towards patient's health, set in action a holistic and patient-centered care movement (Papathanasiou et al. 2014).Despite this new paradigm, health concept is currently and internationally defined as a state of well-being (physical, social, or mental) and not simply the absence of disease (WHO 2014).The spiritual dimension of health care seems to be kept absent, as critically pointed out by some authors, and is still a missing dimension of the health concept (Dhar et al. 2013).
One of the barriers of the absence of spirituality in health care is the subjectivity of the concept, and several measurement tools have been developed to measure its complex nature (Austin et al. 2018).These revealed the positive influence of religion and spirituality on the physical (e.g.,: immune system functioning, longevity, dementia, heart diseases, hypertension, among others), mental (like anxiety, depression, and suicidal ideation), lifestyle (e.g., physical activity, smoking, sexuality, and others) and social aspects (such as marital relationships, social interactions, and social support) of a person's life (Koenig 2012;Lucchetti and Lucchetti 2014).A recent review uncovered the existence of 75 tools from which 25 were found to be used in clinical environments (Austin et al. 2018).A synthesis of Brazilian literature found only two instruments translated into European Portuguese (Lucchetti et al. 2013).In addition, a review of 15 years of worldwide spiritual research in health has revealed a wide and growing interest regarding this phenomenon with major developments in mental health (Koenig 2012).The United States and England were the countries with the highest numbers of published papers (Koenig 2012).Moreover, in Portugal the only study aiming to map the scientific evidence related to spirituality in health comprised only nursing literature (Caldeira et al. 2011a).Therefore, this study aims a broader perspective as the goal is to characterize the Portuguese theses, dissertations, and papers about spirituality in health disciplines.The paper will provide a new insight of research about this phenomenon and highlight the development and knowledge gaps that may provide guidance to future research.

Materials and Methods
A literature review based on a systematic search was independently conducted by all four authors in February 2017 and updated in January 2018.The search was conducted on seven international databases (PubMed; CINAHL with full text; MEDLINE with full text; MedicLatina; Academic Search Complete; SciELO and Web of Science) and on Portuguese databases including RCAAP (Open Access Portuguese Scientific Repository) and repositories of three nursing schools: Lisbon (Escola Superior de Enfermagem de Lisboa-ESEL), Coimbra (Escola Superior de Enfermagem de Coimbra-ESEnfC) and Porto (Escola Superior de Enfermagem do Porto-ESEP).Search terms with truncation were searched with no time limit and included "spirituality", "religion" and "health".Additionally, some other related words such as "forgiveness", "hope" and "well-being" in English and/or Portuguese were used in accordance with each database (Table 1).Papers considered eligible were primary studies, articles, PhD theses and masters dissertations, available in a full-text format, conducted by Portuguese researchers (as first authors) in national samples and in a health context, regardless of the health discipline.Editorials, opinion articles, reports, and literature reviews were excluded.The search and protocol strategy followed the PRISMA guidelines (Figure 1).Initial search retrieved a total of 5308 results.Then, 48 duplicates were removed and 5260 studies remained.Reviewers screened those results and from the 138 obtained documents, 62 were excluded with reasons after reading the full text.Discrepancies in results were solved through joint discussion.Finally, a total of 76 results were included in this review.Data was gathered and extracted to a pre-defined Excel sheet comprising author(s), title, theme of study, type of publication, discipline, university or journal of publication, design, sample, aim, spiritual instruments used, results, limitations, and suggestions.

Results
A total of 76 Portuguese studies about spirituality have been included (Table 2).The first paper was published in 2002 (Caldeira 2002).Moreover, a growing interest in this theme led to the increasing publication of papers through time, and most studies were published in 2015 (n = 14), 2014 (n = 11), and 2016 (n = 10).Data was gathered and extracted to a pre-defined Excel sheet comprising author(s), title, theme of study, type of publication, discipline, university or journal of publication, design, sample, aim, spiritual instruments used, results, limitations, and suggestions.

Results
A total of 76 Portuguese studies about spirituality have been included (Table 2).The first paper was published in 2002 (Caldeira 2002).Moreover, a growing interest in this theme led to the increasing publication of papers through time, and most studies were published in 2015 (n = 14), 2014 (n = 11), and 2016 (n = 10).Although 76 documents were identified, a total of 111 different authors were listed (Table 3).Academic documents (PhD theses and master's dissertations) (n = 45), and scientific papers (n = 31) were identified in this study.In addition, a wide range of health disciplines was dedicated to the study of spirituality (Table 4) with the highest number of published papers on this topic presented by psychology (n = 38) and nursing (n = 23).Most studies used a quantitative (n = 55), qualitative (n = 7), or mixed design (n = 6).Although there was a tendency to use a quantitative approach, the number of qualitative studies increased between 2010 and 2012 (Figure 2).31) were identified in this study.In addition, a wide range of health disciplines was dedicated to the study of spirituality (Table 4) with the highest number of published papers on this topic presented by psychology (n = 38) and nursing (n = 23).Most studies used a quantitative (n = 55), qualitative (n = 7), or mixed design (n = 6).Although there was a tendency to use a quantitative approach, the number of qualitative studies increased between 2010 and 2012 (Figure 2).Samples ranged from eight (Garrett 2010;Martinho 2016) to 1876 participants (Gouveia 2011).Participants shared similar characteristics, but some studies included both adolescents and their parents (Simões and Simões 2015), physicians and nurses (Alves 2011), people with chronic or acute illness (Branco 2015), health professionals, clients and caregivers (Catré et al. 2014), health professionals (Albuquerque 2009; D. M. d. S. Pereira 2014), individuals with different religious backgrounds (Freire et al. 2016;Garrett 2010), palliative care professionals and volunteers (Martins 2011), and working and retired individuals (Verbisck 2010).Patients with chronic disease (n = 20), elderly (n = 11), and adults (n = 9) (Table 5) were the most frequent participants.Samples ranged from eight (Garrett 2010;Martinho 2016) to 1876 participants (Gouveia 2011).Participants shared similar characteristics, but some studies included both adolescents and their parents (Simões and Simões 2015), physicians and nurses (Alves 2011), people with chronic or acute illness (Branco 2015), health professionals, clients and caregivers (Catré et al. 2014), health professionals (Albuquerque 2009;Pereira 2014), individuals with different religious backgrounds (Freire et al. 2016;Garrett 2010), palliative care professionals and volunteers (Martins 2011), and working and retired individuals (Verbisck 2010).Patients with chronic disease (n = 20), elderly (n = 11), and adults (n = 9) (Table 5) were the most frequent participants.
According to the aim of each study, it was possible to list 76 different themes (Table 6).Links between spirituality and oncology (n = 14), mental health (n = 9), and instruments' validation (n = 7) were found to be more frequent in the selected studies.Quantitative or mixed-method research used a wide range of instruments to measure spirituality (Table 7), in a total of 78 tools.The Portuguese version of the Spiritual Well-Being Questionnaire (SWBQ) was the most used to measure spirituality (n = 25).Regarding the time frame, only one study was found to be longitudinal (Marques et al. 2013), and aimed to determine the relationship between hope, spirituality, religious practice, and life satisfaction in Portuguese students.All remaining studies were cross-sectional.Specific characteristics of the articles and theses/dissertations included in this review are presented as follows.

Articles
Thirty-one primary studies were published in 24 different journals (11 national and 13 international journals) (Table 8).Although studies included Portuguese participants, papers were published in journals from the United States (n = 8), followed by Brazil (n = 3), Japan (n = 1), the Netherlands (n = 1), England (n = 1), and Switzerland (n = 1).The highest number of papers were published in Portuguese-written journals (n = 16) when compared to English-written journals (n = 15) (Table 8).Indexed journals were most chosen (n = 21).The quantitative design was the most used (n = 28) in masters' dissertations and in PhD theses, followed by qualitative design (n = 6) and mixed-methods (n = 4).People with chronic health conditions were the most frequent participants (n = 10).A general analysis of the findings (Table 10) highlighted oncology (n = 6), mental health (n = 5), geriatrics (n = 3), palliative care (n = 3), and spiritual distress (n = 3) as the main themes addressed in the academic studies.Diagnostic validation, hospital care, and hospitalized patients were singular aspects found to be studied in PhD studies and not on masters' dissertations.Still, diabetes, end of life, meditative practices, spiritual care, and spiritual distress were studied in both academic degrees.

Discussion
This review focused on characterizing Portuguese theses, dissertations, and papers about spirituality in health.It brings a new insight towards the academic literature as it identified 76 Portuguese scientific documents related to spirituality research in health disciplines.The findings revealed that Portuguese publication about spirituality in health started in 2002.Interestingly, Portuguese and Brazilian studies about spirituality and religion were most published in 2003-2004(Damiano et al. 2016)).
Overall, these results have contributed to the acknowledgement that Portuguese studies are expanding and are not only limited to nursing (Caldeira et al. 2011a).In fact, this study points to a primary evidence that clearly extrapolates the four studies reported in one nursing review conducted between the years of 1990 and 2010 (Caldeira et al. 2011a), and reinforces the multidisciplinary interest also previously addressed in an international review conducted between 1999 and 2013 (Lucchetti and Lucchetti 2014).
While psychology was the discipline that gathered the highest number of results in this Portuguese review, psychiatry was in a Brazilian review (Damiano et al. 2016).Nevertheless, nursing was found important in this type of research (Damiano et al. 2016).
Samples, such as elderly and adult patients suffering from chronic illness, such as cancer, have predominated, confirming previous statements of the lack of research on a national level related to the study of spirituality in people with nononcologic health issues (Ferreira et al. 2016), and in different phases of lifespan (Romeiro et al. 2017a(Romeiro et al. , 2017b)).On the other hand, mental health and spirituality revealed a significant relationship, which has been underlined in literature (Koenig 2012).
Although three types of methodological approaches were used, the quantitative approach was the most frequent.This may be due to the primary need to firstly quantify, measure, and generalize a phenomenon before understanding the subjective nature and the deep meaning (Ferreira et al. 2016), which is critical in spirituality.In this regard, 78 instruments were identified in Portuguese research with predominance of the Spiritual Well-Being Questionnaire (SWBQ) (Gommez and Fisher 2003), translated and validated to the Portuguese population (Gouveia et al. 2009).From the 76 Portuguese studies that were conducted, seven were used to validate spiritual tools to a national context, which reflects the lack of instruments available to authors and transculturally adapted to the Portuguese population, not only to the specificities of this sample but to particular settings.
When analyzing the time frame, a scarce number of studies adopted a longitudinal design.Longitudinal studies have been considered necessary in the study of spirituality to decrease the gap of knowledge related to patients' spirituality across time (Martins et al. 2017).
Regarding the nature of the scientific papers, it was possible to determine the recurrence of PhD theses and masters' dissertations (n = 45) when comparing with published articles (n = 31).Most of the international selected journals derive from the USA which goes in line with previous findings of a review of 15 years of publications on spirituality and religion (Lucchetti and Lucchetti 2014).Portuguese authors seemed to prefer Portuguese-written and English-written journals, although the majority chose national or Brazilian to other journals.This might be explained by the closeness between both languages when compared to other foreign idioms.The journals had a specific scope, related to the theme, such as religion, psychology, and nursing.
Since this is an original review, there is no comparison with other Portuguese reviews related to master dissertations and doctoral theses addressing spirituality and religion.Yet, a palliative care and bibliometric nursing study conducted in 2016 discloses the existence of a higher number of academic masters degrees when compared to doctoral degrees (Damiano et al. 2016).This might also justify the higher number of masters' dissertations (n = 37) when compared with PhD theses (n = 8) in this review.
Furthermore, it is of no surprise that ISPA, traditionally dedicated to psychological research and education, was the university that presented the highest numbers of masters' dissertations related to spirituality.However, most nursing doctoral theses were conducted at the UCP.Doctoral research included essentially samples of adults, and this interest of nurses has been reported before (Basto 2012).In addition, the number of theses exceeds the number of published articles which may indicate that Portuguese PhD findings are still not being properly disclosed (Basto 2012).
These findings should be analyzed considering some limitations, such as the possibility of some theses/dissertations being available only in print and the delay between the viva and the publication in online repositories, which might have compromised the analysis and extraction of significant information.Moreover, it was also acknowledged the possibility of some documents, mainly theses, not being listed in the universities repositories and being only available in a hand or physical search in libraries.

Conclusions
This study provides the characterization of Portuguese theses, dissertations, and papers about spirituality in health, mapping the scientific knowledge development that has occurred in the country.It is evident the growth of interest related to this phenomenon in health disciplines, although with a still slow progression when compared to worldwide research on the topic.A multidisciplinary approach is foundational in implementing spirituality in health care and the results underline the interest in this topic from other disciplines, rather than only nursing.Most studies are quantitative, cross-sectional, and descriptive or focused on theoretical concerns.Further studies must provide a deeper and closer understanding of spirituality in patients' or families' perspective that could bring new insights to practice.Also, including children and adolescents as participants in the research about spirituality

Figure 1 .
Figure 1.PRISMA flow diagram of this systematic review.

Figure 1 .
Figure 1.PRISMA flow diagram of this systematic review.

Figure 2 .
Figure 2. Evolution in time of the studies' design included in this review.

Figure 2 .
Figure 2. Evolution in time of the studies' design included in this review.

Table 1 .
Terms used in search per data base.

Table 2 .
References included in this review.

Table 3 .
First authors and authorship of studies included in this review.

Table 4 .
Health disciplines of studies included in this review.

Table 4 .
Health disciplines of studies included in this review.

Table 5 .
Characteristics of participants included in the studies.

Table 6 .
Main themes of the studies included in this review.

Table 7 .
List of instruments used in the studies included in this review.

Table 9 .
Year of publication, health-related disciplines and design of the studies.

Table 10 .
Characteristics of academic studies and comparison between master dissertations and PhD theses.