J Relig Health

DOI 10.1007/s10943-016-0272-1
ORIGINAL PAPER

Role of Spiritual Sentiments in Improving

the Compliance of Water Intake in Patients
with Urolithiasis
Liaqat Ali1 Saima Ali2 Syed Awlad Hussain3
Fayyaz Haider4 Shehla Ali5

Springer Science+Business Media New York 2016

Abstract The aim of this study was to compare the compliance for water intake and rate of
recurrence between spiritually motivated and non-motivated patients of renal tract stone
disease. It is a multi centric prospective cohort study, conducted in Department of Urology,
Institute of Kidney Diseases and Peshawar Medical College, from January 10, 2009 to
December 2012. A total of 180 patients with comparable demographic, IQ, EQ and BMI
after achieving complete stone clearance were divided into two equal groups. Both groups
were instructed to increase the water intake timetable according to AUA guidelines. Group
A comprising of 90 patients who were identified as spiritually motivated patients based
on questioner of FICA 12 is also instructed that increasing the water intake is mentioned in
contemporary Islamic medicine. No spiritual instruction was given to Group B. The
instructed guidelines and practice for amount and timing of water intake were recalled
from participants at the end of 6 and 12 months. The data were recorded on structured
proforma and was analyzed using SPSS version 17. The mean age of the patient in Group
A was 37.5 years (1870 years), while in Group B it was 34 years (1865 years).
Urolithiasis affected predominantly male gender in both groups. Sixty-five patients (72.2
%) in Group A have significant compliance (p \ 0.001) for water intake over Group B (46
%). The spiritually motivated Group A has significantly reduced rate of recurrence of
stones in 23 patients versus 37 in Group B. The spiritually motivated patients had significantly better compliance for water intake and reduced rate of recurrence versus nonmotivated individuals in urolithiasis.

& Liaqat Ali

liaqat_99@yahoo.com
1

Institute of Kidney Diseases, Hayatabad Medical Complex, Peshawar, Pakistan

Peshawar Medical College, Warsak Road, Peshawar 25160, Pakistan

SRSP, Peshawar, Pakistan

Quide Azam International Hospital, Islamabad, Pakistan

Florida, USA

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Keywords Urolithiasis
Recurrence
Spirituality
Compliance

Introduction
Urolithiasis is not a new phenomenon in the medical literature; the earliest description of
renal tract stones can be traced even in Hippocratic Oath. Urolithiasis is the most
common illness presenting to urology clinics in across the globe (Ali et al. 2014). It is
associated with significant morbidity, and it is the eighth common cause of renal failure
in three world countries (Vivekanand 2013). Despite all the medical and surgical
advancements, the recurrence rate of urolithiasis is very high, ranging from 25 to 50 %
after the first episode of urolithiasis (Porena et al. 2007). An important aspect of medical
and preventive therapy is maintaining a good fluid intake and subsequent high urinary
volume. The goal of good water intake is that the patient should able to produce 1.52 L
of urine in 24 h (Fink et al. 2009). The overall rate of compliance for dietary modification
and especially water intake ranges from 14 to 25 % by the end of first year of primary
treatment. The Markov model of estimating cost-effectiveness in urolithiasis suggests that
100 % compliance of increased water intake will result in cost savings of 49 million per
annum while only 25 % compliance will save 10 million per annum (Lotan et al. 2013;
Hausman 2001).
There has been tremendous research of increased association between spirituality,
religion and medicine during the last 15 years (Culliford 2002). The WHO reports say that
mechanistic view of patients is no longer satisfactory. Patients and physicians have begun
to realize the value of elements such as faith, hope and compassion in the healing process
and improving the compliance of the patients (Sulmasy 2009). Although few authors have
questioned the role of religion in compliance, majority had positive consensus of spirituality in improving the compliance (Sulmasy 2009; Lopez and Hoppe 2010).
The rationale of the of our study is based upon a research question that is there any
significant association between religion and spirituality in improving the compliance of
increasing water intake and in prevention of urolithiasis, keeping in view the fact that
Pakistan is a majority Muslim state and increasing the water intake is mentioned in contemporary Islamic medicine as Tib e Nabvi and Tib e Ayema Tahireen (Rahimi et al. 2013;
Azizai 1996).

Objective
The objective of this study is to compare the compliance and rate of recurrence between
spiritually motivated and non-motivated patients of renal tract stone disease.

Methods
Study design
Setting
Duration
Sample size

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It is a prospective cohort study.

Department of Urology, Institute of Kidney Diseases, Hayatabad
Medical Complex Peshawar and Abaseen Hospital Peshawar (Pakistan).
January 10, 2009, till December 2012.
A total of 180 patients.

J Relig Health

Sampling
technique
Inclusion
criteria

Non-probability consecutive sampling.

All the patients with comparable demographic, IQ, EQ and BMI and
who had completed the study duration were included in the study. We
included the patients after achieving complete stone clearance by
ESWL, PCNL and open stone surgery.

Data Collection Procedure

All the patients who fulfilled above-mentioned criteria were included in the study. A total
of 180 patients were equally divided into two equal groups. Both groups were instructed to
increase the water intake timetable according to AUA guidelines. Group A comprising of
90 patients who were identified as spiritually motivated patients based on questioner of
FICA (Puchalski 2001) was also instructed that increasing the water intake is mentioned in
contemporary Islamic medicine in the form of Sunnat, Tib e Nabvi and Tib e Ayema
Tahireen, while in Group B control (90 patients) no religious instruction is given.
Both groups were regularly followed up for 18 months. The instructed guidelines for
amount and timing of water intake were recalled from participants at the end of 12 months.
The data were recorded on structured proforma and were analyzed using SPSS version 17.

Results
Urolithiasis is the most common ailment presenting to our outpatient department of our
Institute of Kidney Diseases. The top ten disease chart in OPD in year 2014 is shown in
Fig. 1.
The mean age of the patient in Group A was 37.5 years (1870 years), while in Group B
it was 34 years (1865 years). Urolithiasis affected predominantly male gender in both
groups: 52 in Group A and 55 in Group B were male. A total of 108 (60 %) patients
suffered from renal stones, 51 (47.2 %) had Ureteric stones while 21 (19.4 %) patients had

Oncology
9%

Anomalies
4%

Miscell
2% AndrologyNeurg blad
2%
1%

UTI
13%

Urolithiasis
45%

Prostate
15%
Strict
9%

Fig. 1 Pie graph showing percentages of different diseases presenting to urology OPD of Institute of
Kidney Diseases, Peshawar, in 2014

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26

25

22

21

20
18
14

13
10
4

2
Open stone
surgery

ESWL

PCNL

Group A ( Spiritually motivated)

URS

Vesicolithotomy

Litholapaxy

Group B (Non motivated

Fig. 2 Figure showing different modalities of complete stone clearance n = 180 (Pearson Chisquare = 0.744)

bladder stones. The different modalities of the surgical management of stones are shown in
Fig. 2.
The details for compliance of water intake in both groups are shown in Table 1.
One of the important aspects in the management of urolithiasis is its recurrence. The
recurrence rate for both of groups is shown in Fig. 3. The need of secondary intervention
after recurrence of stone is shown in Table 2.

Discussion
Urolithiasis is a major health problem especially for Southeast Asia (Ali et al. 2014). There
are basically three major issues in the management of urolithiasis. First, it is the most
prevalent urological disease across the country specially affecting poor socioeconomic
community. Second, the rate of recurrence after primary treatment is very high. The
resources spent on the management of secondary stones result in bearish decline of already
exhausted health budget. Last but not the least, although increasing the water intake,

Table 1 Compliance of water intake in spiritually motivated and non-motivated groups (Pearson Chisquare test p \ 0.001)
Compliance

Group A
Spiritually motivated

Group B
Non-motivated

Total

Yes
% within study group

65
72.2 %

42
46.7 %

107
59.4 %

No
% within study group

25
27.8 %

48
53.3 %

73
40.6 %

Total
% within study group

90
100 %

90
100 %

180
100 %

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67

Fig. 3 Bar graph showing

recurrence rate in spiritually
motivated and non-motivated
patients (Pearson Chi-square test
p \ 0.001)

53
37 (41.7 %)
23 (25.2 %)

Recurrence
Group A ( Motivated

No Recurrence
Group B (Non Motivated )

Table 2 Rate of surgical intervention after recurrence of stones in motivated and non-motivated group
(Pearson Chi-square test p = 0.571)
Surgical intervention required

Group A
Spiritually motivated

Group B
Non-motivated

Total

Required

18 (78 %)

30 (81 %)

48

Not required

05 (21.7 %)

07 (19 %)

12

Total

23 (100 %)

37 (100 %)

60

leading to optimum diuresis, is an established phenomenon in prevention of stone disease,

unfortunately, the compliance of increasing the water intake is extremely low, jeopardizing
the paramount objective of reduction in recurrence in the overall management of
urolithiasis.
The strength of our study is that it is the first prospective cohort study on prevention of
urolithiasis by encouraging spiritual sentiments. We had followed up reasonable sample
size for 18 months. The weakness of the study is based upon a fact that the present study
has been conducted on spiritual component of Muslim patients, so it cannot be generalized
on believer of other religions.
Kidneys are the most commonly affected organ in urolithiasis. Our study has found the
frequency of renal stones in 60 % followed by ureteric and bladder calculi. Our observation is in accordance with the literature as Ahmad et al. (2015) had reported the
prevalence of renal stones as 73 % in different communities of Saudi Arabia which was
followed by ureteric and bladder stones. Hussain et al. (2009) had also reported the
frequency of renal stones as 61 % followed by ureteric and bladder stones. The
advancement in endourological equipments have made twenty-first century as an era of
minimal invasive surgery (Ali et al. 2014; Holman et al. 2002). This was found true in our
study as 135 (75 %) of the patients were managed with minimal invasive modalities; only
complex and giant stones (25 %) were managed with open stone surgery. This is in
accordance with the national and international literature (Ali et al. 2014; Holman et al.
2002; Esen et al. 1994).
The identification of spiritually motivated individual has been made easy by Puchalski
(2001) through simple and easy-to-fill questioner of FICA, so we also followed that model
for selecting spiritually motivated patients.

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Medical prevention of recurrence of urolithiasis is a best desired goal among all urologist, and all emphasis is placed on improving the compliance of water intake in different
series, but there is no plausible answer to question how to improve the compliance of water
intake in over all prevention of recurrence of urolithiasis (Agerwal et al. 2011). We
reported significant improvement in compliance with water intake as 72 % in spiritually
motivated patients which lead to significantly decreased rate of recurrence 25 % in Group
A versus 47 % in Group B. Our observation is in accordance with the literature (Hussain
et al. 2009; Colussi et al. 2000; Agerwal et al. 2011). Although we could not find any
specific reference for the role of spirituality in improving the compliance of water intake in
prevention of recurrence of stones, there are a number of series that have shown positive
influence of spirituality on compliance for medication. Ather (2001) and Kinnersley et al.
(1999) in their study had concluded that patient-centered approaches incorporating the
spiritual needs of patients have positive outcome in improving the compliance for medication and satisfaction. DSouza (2007) had also highlighted the role of spirituality in
improving the compliance for medications in practices of gynecology and obstetrics,
psychiatry and intensive care units.
Our study is implicated on urologists, nephrologists and primary care physicians who
are involved in the management of patients with urolithiasis.
Another limitation of the present study is that we have compared two groups, spiritually
motivated and non-motivated individuals, upon questioner of FICA, so we were not able to
randomize our sample. Further research in the form of randomized control trial is desired
in future by selecting only spiritually motivated individual. The assessment for compliance
for increasing the water intake will be then without the bias of placebo effect of spirituality.

Conclusion
Increasing the water intake is essential in preventing recurrence of urolithiasis. The spiritually motivated patients had significantly better compliance and reduced rate of recurrence versus non-motivated individuals in urolithiasis.

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