REVIEW / REVISIÓN / REVISãO

Spirituality and low-risk consumption of alcohol in young adults

La espiritualidad y el consumo de bajo riesgo de alcohol en jóvenes

Luz Patricia Díaz Heredia¹; Alba Idaly Muñoz Sánchez²

¹RN, Ph.D. candidate. Professor, Universidad Nacional de Colombia, Colombia. email: lpdiazh@unal.edu.co .

²RN, Ph.D. Professor, Universidad Nacional de Colombia, Colombia. email: aisanchezs@unal.edu.co .

Receipt date: April 30, 2012. Approval date: February 4, 2013.

Article linked to research: Autotrascendencia, espiritualidad y bienestar en universitarios no consumidores y consumidores moderados de alcohol: aportes para promover la salud.

Subventions: División de Investigación de la Universidad Nacional de Colombia, sede Bogotá.

Conflicts of interest: none.

How to cite this article: Díaz-Heredia LP, Muñoz-Sánchez AI. Spirituality and low-risk consumption of alcohol in young adults. Invest Educ Enferm. 2013;31(2): 287-294.

ABSTRACT

The relationship between spirituality and health, as well as it effect on adopting healthy behaviors, is a topic of interest for nursing and, in general, for social and life sciences. Spirituality, as a human realm, is a relevant research theme that is often related to the promotion of health in individuals. Studies indicate that spirituality is related to mental and physical health, being a protective and promoting factor of healthy behaviors, among them low-risk consumption of alcohol in young adults.

Key words: spirituality; young adult; alcohol drinking.

RESUMEN

La relación entre la espiritualidad y la salud, así como su efecto en la adopción de conductas saludables, es un tema de interés para enfermería y, en general, para las ciencias sociales y de la vida. La espiritualidad, como ámbito del ser humano, es un tema de investigación relevante que frecuentemente se relaciona con la promoción de la salud de las personas. Los estudios indican que la espiritualidad está relacionada con la salud mental y física, siendo un factor protector y promotor de conductas saludables, entre ellas el consumo de bajo riesgo de alcohol en jóvenes.

Palabras clave: espiritualidad; adulto joven; consumo de bebidas alcohólicas.

INTRODUCTION

Spirituality is a universal human phenomenon that has been approached from diverse fields of knowledge, but which has always been regarded with certain skepticism from the scientific perspective. Among the motives for not accepting the findings of studies developed on the topic, the most important are the lack of consensus on the definition of spirituality and the cultural influence on the conceptualization of this construct.¹

To start, the Royal Academy of the Spanish Language defines the term spirituality as 'spiritual nature or condition', or as a 'set of ideas referring to spiritual life'.² In practice, spirituality is a subjective experience that occurs individually and which gathers philosophical ideas about life and its purpose, having the power to give shape and significance to being, knowing, and doing, motivating the individual in the selection of relationships and necessary searches to find wellbeing, happiness, and harmony.³

Spirituality as a construct is difficult to establish and it is not absolutely known how it is conformed by personality, culture, and cognition, which cannot be observed directly but which are present in measurements of phenomena related to the human being.⁴ Spirituality is established when the individual constructs a broad sense of personal significance within a specific context, which involves multiple domains, among which is highlighted the relationship with the transcendental and the sacred.⁵

In the history of the study of spirituality, one of the most important theoretical guides that founded the current vision was that introduced by Elkins,⁶ which indicates that the existence of a part of the human experience, which includes values, perspective attitudes, beliefs, and emotions, can be described as the expressions of spirituality.

It is, thereby, cleared that spirituality is not equal to religiosity. It is conceptualized as of the participation in a particular belief and is manifested through rituals and activities oriented by the religion professed. As indicated by Pargament,⁷ religiosity is founded on that which is sacred and involves representations of spirituality, traditional expressions of faith, participation in established churches, political and social actions, and personal actions of mercifulness and compassion. It is possible for an individual to be spiritual without being associated to a particular religion.

From the perspective of psychology, varied definitions of spirituality have been developed, stemming from the conceptual orientations by William James,⁸ who derived from the medical materialism the religious experience as part of the mental phenomena, and by Jung⁹ with his mental model, which postulated the collective conscience and the archetypes. These proposals were quite important in the suppositions presented by the founders of Alcoholics Anonymous.

Víctor Frankl¹⁰ defines the spiritual as that which can be confronted with the social, bodily, and even psychic. The spiritual is, by definition only that which is free in man, it is pure power; it does not possess a substantial reality, it is the mere possibility of manifestation. The spiritual offers unity and totality to individuals; it is the integrating dimension that only in its heuristic level can be separated from its psycho-physical organism. Additionally, it bestows consciousness to the aesthetic, the erotic, and the ethical. From the social sciences perspective, spirituality is a construct with attributes that can vary according to the discipline studying it. However, each person has his or her own spiritual dimension expressed through values and beliefs and which is manifested according to a culture and experience lived.¹¹

Transcendence has been acknowledged as a component strongly linked to spirituality. Two types of transcendence are distinguished: the first is the trans-personal, which describes the sense of connection the person has with God, the greater power, or the conscience; this is the most common form of transcendence referred to by people and it is related to belonging to a given community of faith;¹² and the intra-personal, which focuses on the potentiality of the being, and which is the inner capacity of self awareness.¹³ Self-transcendence, as part of the personality and of the temperament is described by Cloninger¹⁴ as part of the dimensions of the character; it is developed as the individual reaches maturity and inner and conceptual learning.

To conclude, spirituality lies within the human being and it is pure potentiality to accomplish freedom of action. Transcendence is conceived in a broader manner than spirituality and it is present in all people, but it is developed over time¹⁵; it might be identified as part of the personality and character of human beings.¹⁶

Spirituality from the nursing perspective

Spirituality as a phenomenon of interest in nursing has long been addressed; however, it was not until the 1980s when research was conducted involving this construct.¹⁷ Nurses in their continuous interaction with people during many stages of life, especially during difficult situations like disease, have been able to recognize the importance of this scope of human beings and the need to involve it in daily care.

Spirituality, as discussed, is a complex concept considered as the center of the human being, which must be conceived, in turn, as the biggest transcendence experience of oneself.¹⁸ The theoretical orientations that have permeated nursing have two origins: one from the vision influenced by religion and theological beliefs and the other with a secular, materialist, and existential vision. The current vision has been taken from the Judeo-Christian perspective that seeks to distance itself from the reductionist vision of the medical model, orienting itself toward the association of the existential philosophy and the purpose of life and satisfaction: there is recognition of transcendence and concern for something greater found beyond the individual.

One of the most relevant theorists of the discipline that has involved this construct within her postulates is Pamela Reed,¹⁹ who defined spirituality in terms of the human being's propensity to find significance in life, making it evident in behaviors related to the transcendent dimension and which may or may not include a particular religious participation. The tendency of individuals to find reason through the sense of relationships is developed in three dimensions: intra-personal (with oneself), inter-personal (with others), and trans-personal (with the superior force, which is not seen, God) in such a way that the persona is empowered and accomplishes identity.²⁰

One of the theoretical proposals, which from nursing include spirituality is that of Human Care by Watson,²¹ which involves aspects like Spirituality and low-risk consumption of alcohol in young adults metaphysics, the spirit, and transcendence, both in the conceptualization of the human being as in the results of caring. Likewise, Margaret Newman²² includes spirituality and, more specifically, transcendence in her theory of expansion of the conscience. She states that it permits individuals to accomplish development beyond themselves, permitting evolution toward a greater conscience.

Currently, it has become evident that the discipline is interested in clarifying the concept of spirituality. Thus, in a meta-synthetic study in 2011 in which it is introduced from the care science perspective, the central axis of spirituality is the connection with each person's inner space and which, in turn, is superimposed with the connection with a superior force, nature, others, and the community.²³

Also, an analysis of the concept was introduced in 2001 (the most complete until then) based on the proposal by Walker and Avant²⁴ and taking as reference 76 studies and 19 texts; arriving at the following definition: 'Spirituality is a personal search for significance and purpose of life, which may or may not be related to religion. It implies relationship with the beliefs of religious selfelection or of values and practices that give sense to life, which inspirers and motivates individuals to accomplish their wellbeing. This connection brings faith, hope, peace, and empowerment. The results are joy, forgiveness of one-self and others, awareness and acceptance of difficulties and mortality, a high sense of physical health and emotional wellbeing, and the capacity to transcend beyond the aches and pains of existence'.

As noted, spirituality is more than the search for the divine, the religious, lo metaphysical. On the contrary, it implies all the existence of human beings and their relationship with the environment in which they live. Hence, an important question emerges for the disciplines interested in the health of the populations: how could something so intangible influence upon health? The possible answer to this question is analyzed ahead.

Influence of spirituality upon health and on low consumption of alcohol

Spirituality has been related in health and nursing literature as an element that contributes to the mental and physical wellbeing of the people.^25-28 A proposal for a conceptual framework to explore the relationships of health and spirituality was developed by nursing. It was derived from literature findings and indicates that the relationships between health and spirituality can be centered on three areas.²⁹ The first focuses on transcendent aspects that permit the development of a mental attitude that promotes health through actions or behaviors, or of our way of being, an aspect that provides calm and balance. Also, if things do not go well, it offers support to confront adversity. The second, within the structural-behavioral approach, spirituality, through religion and its rituals and through social support, stimulates healthy behavior as an expression of hope and the meaning and purpose obtained from the connection with the divine. Finally, the third form in which spirituality can support health is through the value of the guide or orientation, given that it provides clarity regarding the significance and purpose of why we act in a certain manner. It is beneficial, especially, if the individuals are capable of understanding their experiences and taking creative control of them.

Many non-spiritual explanations of the influence of spirituality in health have been proposed. In this sense, many physical, emotional, and social factors may influence and cast light upon this complex relationship, among them life style, social networks, a vision of the world that promotes wellbeing and an optimistic explanatory style. From the transcendent perspective, studies carried out until now, where the central focus is spirituality, have permitted identifying that the perception of closeness with God is the biggest value for the spiritual mind. Also, it has been associated with better physical and health, especially in individuals under stress.³⁰ It may be that the explanation is related to feeling God as a shelter, as a being that provides protection and care - specifically during difficult moments.³¹

Additionally, the person does not feel alone and this is positive from the mental point of view, given that it permits him or her to seek ways to cope with the difficult situation experienced. This would be the transcendental perspective already mentioned.

Spirituality, from the proposal centered on religious practices, has permitted indicating that young adults who attend religious services have healthier behaviors and, further, have fewer confrontations with risk behaviors.^32,33 As indicated, if spirituality is expressed through religiosity, and the behaviors related to practices, beliefs and attitudes, or feelings associated to a community founded on faith, the impact is greater on behaviors like abstaining from drinking alcohol.

In practice religious affiliation, attending religious events and activities related to religiosity are considered important as factors associated to low rates of alcohol consumption in young adults. In a study carried out with 445 young adults attending Catholic and Mormon universities, it was found that spirituality reduced alcohol consumption, specifically in those attending the Mormon university. This may be due to the strong norms associated to this religious orientation,³⁴ but also, as discussed, because it provides structure to making decisions according to the principles and beliefs. Similarly, in a study at a university of religious affiliation that promoted non-consumption, it was found that young adults stated that their abstaining was associated to religious orientations and to the fact that they based themselves on values, symbols, and social behaviors.³⁵

A study conducted in Brazil³⁶ reported a direct relationship between the spiritual wellbeing and quality of life of the university students. Also, in this type of population a strong association has been found among the students' existential wellbeing and psychological and physical wellbeing, and their social relationships.³⁷ Additionally, it has been found that religious education during childhood is a protective factor to avoid abuse in alcohol consumption,³² inasmuch as principles and beliefs are promoted contributing to control its consumption.

Regarding the relationship of spirituality with physical and mental health, evidence reveals that the greatest impact in mental health.³⁸ It has been seen that religiosity and spirituality reduce symptoms of depression and anxiety in young adults,^39,40 besides diminishing the impact of stressful situations and it is associated to lower alcohol consumption in the adolescent population, in young adults,^41-44 and in university students.^45-47 It is necessary to state that a systematic review showed that many of the studies analyzed did not find this protective relationship or that the findings were mixed.⁴⁸

Regarding factors mediating between spirituality and alcohol consumption, the studies show that spiritual wellbeing,⁴⁹ spiritual practices,⁵⁰ and forgiveness⁴⁵ are important in the relation. Hence, spiritual wellbeing, supported in that life has sense, the experience of inner peace, and the connection with God and with others, aids in modeling the behaviors of young adults.⁵¹ Anyhow, spiritual practices are highlighted because they contribute to the construction of spiritual wellbeing and lead youth to other types of activities in which alcohol consumption is not present.

Beliefs on the harmful effects on health and on the negative social effects of abusive alcohol consumption are factors that intervene in the relationship between alcohol consumption and spirituality,⁵² given that they determine youth engaging in a social group according to their own beliefs.⁵³ It is now necessary to indicate from the disciplinary perspective how to include spirituality in interventions aimed at promoting and recovering health. A published article⁵⁴ evidenced that people's spiritual needs are important and can be addressed by different professionals and fields, among them nursing, which, from a holistic vision and through counseling and companionship activities may support individuals and communities when these are enduring pain, sadness, and distress at any point in their lives.

Knowing the spiritual needs of young adults can be indispensable in assessing the developmental needs of emerging adults.⁵⁵ The following are proposed as strategies for working through spirituality on preventing abusive alcohol consumption in this population group: a) inclusion of reflections on these topics in the classroom to learn how spirituality is perceived and interpreted and which are the experiences in which young adults have sought spirituality to adopt low-risk behaviors for health; b) development of programs that value participation in altruistic volunteer activities like caring for the environment and helping others in vulnerable conditions, among other activities; c) interventions that support individual inner strengths like meditation, yoga, development of artistic activities based on enjoying art and inner growth; and d) speaking of aspects that strengthen the inner growth of young adults.

Somehow, spirituality - in its transcendent perspective expressed by religion and the young person's beliefs, may be nourished and enhanced to cope with an environment that promotes behaviors that are not very healthy. Recognizing, appraising, and promoting the spiritual realm in young adults will promote trust, security, and hope in their inner development. Literature on the influence of spirituality in adopting healthy behaviors like, for example, low-risk alcohol consumption, presents results that permit pointing to the importance of including it in health promotion programs. Spirituality in humans is a potentiality and a motivating force with which young adults can confront the pressure and desire for social acceptance present in relationships within university communities for alcohol consumption.

Final reflection

Nursing, as a discipline and profession, has had as a predominating goal that of caring for the ill, given that it has concentrated on accomplishing the recovery of capacities and functions lost or impaired. However, from the holistic perspective, presented herein, the relationship between nurses and the people under their care becomes more complex, given that it involves recognizing and enhancing the inner strength of others independently of their physical, mental, social, or even spiritual condition. People's spiritual realm is currently a field in which nursing has much to learn and understand; for this case, the power of spirituality in promoting health and establishing behaviors that promote wellbeing. Applying this knowledge will serve as support for nurses when confronting complex situations during their daily routines and will become a central axis of their care giving interactions, a situation that opens new challenges, questions, and commitments in praxis.

Nurses can maintain the practice to support the young adult's spirituality through strategies that will allow these young adults to connect with other people; perhaps by receiving or providing aid or in projects in which their knowledge and formation will allow them to contribute to the wellbeing of the members of the community to which they belong; these actions support their inner strengths and their purpose in life.The literature review permits evidencing that certain aspects still need to be inquired regarding the spiritual realm of young adults in relation to healthy behaviors, given that it is necessary to consolidate knowledge on the topic through qualitative and quantitative studies. It is necessary to evaluate the validity of interventions supporting the spiritual realm and which promote this population group's health and wellbeing.

REFERENCES

1. Chiu L, Emblen JD, Van Hofwegen L, Sawatzky MH. An Integrative Review of the Concept of Spirituality in the Health Sciences. West J Nurs Res. 2004; 26(4):405-28.         [ Links ]

2. Real Academia Española [Internet]. Madrid: Real Academia Española; 2012 (Cited 2012 Feb 12). Available in: http://buscon.rae.es/draeI/SrvltConsulta?TIPOBUS=3LEMA=espiritualidad         [ Links ]

3. Sánchez B. Dimensión espiritual del cuidado en situaciones de cronicidad y muerte. Aquichan. 2004; 4(4):6-9.         [ Links ]

4. Galanter M. Spirituality and addiction: A research and clinical perspective. Am J Addict. 2006; 15(4):286-92.         [ Links ]

5. Piedmont R. Spiritual transcendence as a predictor of psychological outcome from an outpatient substance abuse program. Psychol Addict Behav. 2004; 18(3):213-22         [ Links ]

6. Perrin D. Studying Christian spirituality. New York; Routledge. 2007.         [ Links ]

7. Pargament KI. Spiritually integrated psychotherapy: Understanding and addressing the sacred. New York: Guilfort; 2007.         [ Links ]

8. Paolutzian R, Park C. Handbook of the psychology of religion and spirituality. USA: Guilford Press; 2005.         [ Links ]

9. Gutierrez R, Andrade P, Jiménez A, Juárez F. La espiritualidad y su relación con la recuperación del alcoholismo en integrantes de alcohólicos anónimos. Salud Ment (Mexico). 2007; 30(4):62-7.         [ Links ]

10. FRANKL VE. El hombre en busca de sentido último. Barcelona: Paidó         [ Links ]s; 1999.

11. Greenstree W. Integrating spirituality in health and social care. USA: Radcliffe Publishing; 2006.         [ Links ]

12. Coyle J. Spirituality and health: towards a framework for exploring the relationship between spirituality and health. J Adv Nurs. 2002; 37(6):589-70.         [ Links ]

13. Reed P. Demystifying self-transcendence for mental health Nursing practice and research. Arch Psychiatr Nurs. 2009; 23(5):397-400.         [ Links ]

14. Cloninger RC. Personality and the perception of health and happiness. J Affect Disord. 2011;128 (Supl): 24-32.         [ Links ]

15. Niklas R, Keltikangas-Jarvinen L. Cloninger's temperament and character dimensions in young adulthood and their relation to characteristics of parental alcohol use and smoking. J Stud Alcohol. 2001; 62(1):98-104.         [ Links ]

16. Quintana T y Muñoz G. Validación y adaptación del cuestionario de temperamento y carácter, JTCI de R. Cloninger, versión niños y padres, a escolares chilenos entre 8 y 13 años de edad. Ter. Psicol (Santiago). 2010; 18(1):37-43.         [ Links ]

17. Mcsherry W y Cash K. The language of spirituality: an emerging taxonomy. Int J Nurs Stud. 2004; 41(2): 151-61.         [ Links ]

18. Schmidt M y Nola A. Spiritual Care in Nursing Practice. Philadelphia: Lippincott Williams & Wilkins; 2003.         [ Links ]

19. Kim S et al. Spirituality and psychological wellbeing: testing a theory of family interdependence among family caregivers and their elders. Res Nurs Health. 2011; 34(2):103-15.         [ Links ]

20. Mcsherry W. Making sense of spirituality in nursing and health care practice. 2^nd ed. Londres: Jessica Kingsley Publishers; 2006.         [ Links ]

21. Watson J. Theory of human caring. En: Parker M. Nursing Theories and nursing practice. Philadelphia: Davis Company; 2001.         [ Links ]

22. Falkenstern SK, Gueldner SH, Newman MA. Health as expanding consciousness with families with a child with special healthcare needs. Nurs Sci Q. 2009; 22(3):267-79.         [ Links ]

23. Rykkje L, Eriksson K, Raholm M. A qualitative metasynthesis of spirituality from a caring science perspective. International Journal for human caring. 2011; 15(4):40-53.         [ Links ]

24. Ruth A. Tanyi. Towards clarification of the meaning of spirituality. J Adv Nurs. 2002; 39(5):500-9.         [ Links ]

25. Hodge D, Andereck K, Montoya H. The protective influence of spiritual -religious lifestyle profile on tobacco alcohol use, and gambling. Soc Work Res. 2007; 31(4):211-9.         [ Links ]

26. Jesse E y Reed PG. Effects of Spirituality and Psychosocial Well-Being on Health Risk Behaviors in Appalachian Pregnant Women. J Obstet Gynecol Neonatal Nurs. 2004; 33(6):739-47.         [ Links ]

27. Stewart C. The influence of spirituality on substance use of college students. Journal of drugs and education. 2001; 31(4):343-51.         [ Links ]

28. Sanchez B. Bienestar espiritual en personas con y sin discapacidad. Aquichan. 2009; 9(1):8-22.         [ Links ]

29. Coyle J. Spirituality and health: toward a framework to exploring the relationship between spirituality and health. J Adv Nurs. 2002; 37(6): 589-97.         [ Links ]

30. Hill PC, Pargament KI. Advances in the Conceptualization and Measurement of Religion and Spirituality: Implications for Physical and Mental Health Research. Psycholog Relig Spiritual. 2008; 58(1):64-74.         [ Links ]

31. Miles G. Science and religious experience. Portland: Sussex Academic Press; 2007.         [ Links ]

32. Sanchez Zila VM y Nappo SA. A religiosidade, a espiritualidade e o consumo de drogas. Rev Psiq Clín. 2007; 34(1):73-81.         [ Links ]

33. Miller W y Bogesnschutz M. Spirituality and addiction. South Med J. 2007; 100(4): 433-6.         [ Links ]

34. Barry Mcnamara C y Nelson JL. The role of religion in the transition to adulthood for Young emerging adults. Int J Behav Dev. 2005; 34(3):245-55.         [ Links ]

35. Abdala Gina, et al. A Religiosidade / Espiritualidade como Influência Positiva na Abstinência, Redução e/ou Abandono do Uso de Drogas. Revista de Estudos da Religião. 2010; 10(1):1-16.         [ Links ]

36. Da Costa CC, et al. Qualidade de vida e bem-estar espiritual em Universitários de psicología. Psicol Estud. (Maringa). 2008; 13(2):249-55.         [ Links ]

37. Ivtzan I, Chan C P L, Gardner H E, Prashar K. Linking Religion and Spirituality with Psychological Well-being: Examining Self-actualisation, Meaning in Life, and Personal Growth Initiative. J Relig Health. 2011 Oct 4. [Epub ahead of print]         [ Links ].

38. Guimarães H Penna, Avezum Á. O impacto da espiritualidade na saúde física. Rev Psiquiatr Clín. (São Paulo); 2007; 34(1):88-94.         [ Links ]

39. Galanter M. Spirituality and addiction: A research and clinical perspective. Am J Addict. 2006; 15(4): 286-92.         [ Links ]

40. Wong J, Rew L, Slaikeu K. A systematic review of recent research on adolescent religiosity spirituality and mental health. Issues Ment Health Nurs. 2006; 27(2):161-83.         [ Links ]

41. Newbury-Birch D,Walker J, Avery L, Beyer F, Brown N, Jackson K, et al. Impact of alcohol consumption on young people. A systematic review of published reviews. New Castle; University of New Castle. 2009. Research Report DCSF-RR067         [ Links ]

42. Brown T, Salsman J, Brechting E y Carlson C. Religiousness, spirituality and social support: how they related to underage drinking among College? Students. J Child Adolesc Subst Abuse. 2007; 17(2):15-39.         [ Links ]

43. Vondras DD, Schmitt R, Marx D. Association between aspects of spiritual well-being alcohol use, and related social- cognitions in female college students. J Relig Health. 2007; 46(4):500-15.         [ Links ]

44. Leigth J, Bowen S, Marlatt A. Spirituality, mindfulness and substance abuse. Addict Behav. 2005; 30(7): 1335-41.         [ Links ]

45. Wyatt L, Hutchings D, Pursley R. Spirituality and health of college students. J Relig Health. 2007; 46(2):249-65.         [ Links ]

46. Funai A. Uso do alcool e religiosidade em estudantes de enfermagem. [Master Dissertation]. Riberao Preto: Univesidade de São Paulo, Escola de enfermagem; 2010.         [ Links ]

47. Durant R. Adolescent's spirituality and alcohol use. South Med J. 2007; 100(4):341-42.         [ Links ]

48. Rew L, Wong J. A systematic review of associations among religiosity /spirituality and adolescent health attitudes and behaviors. J Adolesc Health. 2006; 38:433-42.         [ Links ]

49. Drerup M, Johnson T, Bindl S. Mediators of the relationship between religiousness/spirituality and alcohol problems in adult community sample. Addict Behav. 2011; 36(12):1317-20.         [ Links ]

50. Chamratrithirong A., Miller BA, Byrnes HF, Rhucharoenpornpanich O, Cupp PK, Rosati MJ et al. Spirituality within the family and the prevention of health risk behavior among adolescent in Bangkok, Thailand. Soc Sci Med. 2010; 71(10):1855-63.         [ Links ]

51. Knight, J et al. Alcohol Use and Religiousness/ Spirituality Among Adolescent. South Med J. 2007; 100(4):249-55.         [ Links ]

52. Johnson T, Sheets V, Kristeller J. Identifying Mediators of the Relationship between Religiousness/Spirituality and Alcohol Use. J Stud Alcohol Drugs 2008; 69(1):160-70.         [ Links ]

53. Haber JR, Grand JD, Jacob T, Coening LB, Heath A. Alcohol Milestones, Risk Factors, and Religion/ Spirituality in young Adult Women. J Stud Alcohol Drugs. 2012; 73(1):34-43.         [ Links ]

54. Rivera LA y López LM. Ejercicio Clínico y Espiritualidad. An Psicol (Murcia). 2007; 23(1):125-32.         [ Links ]

55. Cavendish R, et al. Opportunities for enhance Spirituality relevant to Well Adults. Nurs Diagn. 2000; 11(4):151-63.         [ Links ]