The Effects of Spirituality and Religiosity on Better Symptom Control in Patients With Covid-19

The new coronavirus (SARS-CoV-2), whose disease is COVID-19, in March 2020, spread around the world. To minimize the deleterious effects of emotional vulnerability, many strategies are in use worldwide, such as support groups, online courses, use of social networks, web meetings, yoga practice, meditation, and other contemplative religious and spiritual activities. Religious and spiritual beliefs have been used to deal with tough situations and, through scientific literature is still not so clear about the role of spirituality and religiosity (S/R) in physical and mental health during the pandemic. Therefore, this article proposes a discussion about the physiopathological mechanisms of COVID-19 and how S/R could be useful in this context. In this sense, religious faith can be a powerful resource for good health and well-being with a positive impact verified in mental health outcomes it is plausible to suggest that S/R should be an important tool in minimizing the population suffering at this moment. Spiritual care has long been recognized as one of the domains of quality palliative care, but every health care professional is ultimately responsible for ensuring spiritual care to deal with spiritual distress and improve quality of life in the scenarios inherent to COVID-19.

The world is currently facing the SARS-Cov-2 (disease known as COVID-19) pandemic, with still unknown proportions and consequences. The lack of a specific treatment or an effective vaccine, associated with a drastic change in social behaviors due to lockdowns and quarantines, has brought the world population to a situation of extreme economic, physical and emotional vulnerability [1,2].
To minimize the deleterious effects of this situation, many strategies are in use worldwide, such as support groups, online courses, use of social networks, web meetings, yoga practice, meditation, and other contemplative religious and spiritual activities [3]. Religious and spiritual beliefs have been used, long since, to deal with tough situations [4] and, through scientific literature is still not so clear about the role of spirituality and religiosity (S/R) in physical and mental health during the pandemic, previous studies seem to support its role in favorable health outcomes [5]. This article proposes a discussion about the physiopathological mechanisms of COVID-19 and how S/R could be useful in this context.
It is well known that spiritual distress and other emotional disorders increase susceptibility to infections [6,7]. The opposite way can also be true, once positive emotions seem to produce beneficial effects in the immune system [8,9]. In this sense, religious faith can be a powerful resource for good health and well-being [10], as shown in several studies, with positive impact verified in mental health outcomes [5,11,12], such as reduced prevalence of depression, anxiety, sleep disorders, use and abuse of toxic substances, and suicides [12]. Yet beyond, as several articles have associated social isolation and other pandemics with psychiatric disorders in the short and long term [1,[14][15][16], it is plausible to suggest that S/R should be an important tool in minimizing the population suffering at this moment.

LETTER
Regarding physical health, it is understood that better immunity added to control and suppression of inflammatory conditions play important role in the cure of serious diseases. Many studies demonstrate the positive influence of S/R in reducing serum levels of pro-inflammatory cytokines and an increase in immune functions [17][18][19]. Similarly, in a systematic review, Doolittle et al showed that religious involvement and spirituality were associated with increased CD4 cell count, reduced viral load, and mortality reduction [20].
Another important aspect to be considered is that cardiovascular diseases, hypertension, diabetes, obesity, advanced age, respiratory diseases, sedentary lifestyle, and cancer diseases are among the main factors associated with increased death risk in COVID-19 [21][22][23], Scientific literature already consistently demonstrates that S/R can influence cardiovascular and pro-inflammatory markers, hypertension, obesity and diabetes [24,25], being thus possible mediators of better prognostic in these patients. Now about respiratory diseases, it has been shown that S/R may positively influence COPD, pulmonary fibrosis, and patients waiting for lung transplantation. Though still in the early stages, science in this subject has demonstrated better results in 6-min walking test [26], in COPD Assessment Test [26], and quality of life of patients with several respiratory conditions [27,28]. But it is still not known if those beliefs could act in pulmonary rehabilitation of COVID-19 patients.
In a broader scope, S/R also seems to influence hospital and public health outcomes. Previous studies show that religious activities, spiritual attitudes, and experiences are more frequently present in hospitalized patients and are associated with improved social support, psychological and physical health, reducing even the number of hospitalizations and the length of each hospitalization [29,30]. Regarding survival in several diseases, previous metaanalyses have shown a reduction of 18-25% in mortality rates of individuals with higher S/R [31].
Beyond the already cited relations, S/R frequently plays an important and complex role at the end of life matters, including ethical issues and medical decisions. Daalaman & Dobbs, 2010 [32], evidenced that the positive approach to death-related behaviors is linked to a positive belief of an after-death life continuity and has been consistently associated with beliefs and religious practices. On the other hand, a recent Korean article suggests negative effects of religious belief in coping with COVID-19 [33]. Beliefs in the immortality of the soul have pushed away many faithful people from preventive measures guided by health authorities. The holding of religious services without protective measures, such as social distancing, sharing dishes, and the delay in searching for medical assistance after the onset of symptoms may have caused a delay in diagnoses and a relatively high number of positive cases among those religious people [34]. Thus, understanding this relationship, meeting the spiritual needs of the patient and his family, as well as the health professional beliefs, may be useful in the approach of ethical matters related to the COVID-19 pandemic [35], promoting more comprehensive care [36].
If, as discussed above, S/R is associated with favorable health outcomes most of the times, on the other hand, it is important to know that about 15% of the patients will face negative feelings in this subject, related to religious suffering and punitive perception of God [37]. These feelings have been related to negative outcomes, such as increased mortality and worse mental health, and may, possibly, influence negatively all outcomes above discussed related to COVID-19 [38]. Therefore, health professionals must be watchful, when dealing with this subject, to those negative feelings and, in those situations, refer the patient to a chaplain or any other religious authority.
Ultimately, it is not yet known whether S/R interventions could lead to better outcomes in people that have gone through the pandemic. Meanwhile, recent systematic reviews showed that those interventions are capable of improving outcomes in physical and mental health [39,40]. Several strategies, such as hotlines, community calls, telechaplaincy are in use at this moment and we will soon know if they were able to influence health outcomes [41,42].
There is an urgent need of discovering, evaluating and improving mechanically targeted interventions to address the social, psychological, and neuroscientific aspects of this pandemic, including psychological interventions custom-made for improving well-being and minimize mental health risks within society. We must quickly learn, with all successful strategies already known, to maintain and construct social resources and resilience, and to promote good mental health in specific populations.
It is also very important to address spiritual suffering due to patient and family isolation, loneliness, and vulnerability caused by this pandemic. Spiritual care has long been recognized as one of the domains of quality palliative care, but every health care professional are ultimately responsible for ensuring spiritual care to to deal with spiritual distress and improve quality of life and the experience of patients and families facing spiritual emergencies amid the complex life-and-death scenarios inherent to COVID-19 [7].

Conclusion
Therefore spirituality and religiosity can act on several fronts in the COVID-19 pandemic, influencing mental and physical health, ethical issues, and outcomes in public health, as well as assist in drafting preventive and therapeutic measures. Health professionals and managers must be able to approach those beliefs, seeking to understand them in each one of their patients, in a culturally sensitive manner, offering integral care.