Despite the increasing number of evidence-based research on relational spirituality (RS) and quality of life (QoL) in medical-health research, little is known about the links between RS and QoL outcomes and the mechanisms by which RS aspects are functionally tied to QoL.
To determine how RS is perceived/positioned in relation to QoL, we (a) examined recent available data that identify and appraise the links between RS and QoL; (b) identified themes emerging from the association between RS and QoL, and (c) discussed the implications of the effects of RS on QoL outcomes.
We conducted an integrative research review of English-language peer-reviewed articles published between 2007 to March 2017 which examined an association between RS and QoL, as identified from a search of three databases: PubMed, PsycINFO, and ScienceDirect.
A total of 20 studies were analysed. Of these, twelve (60%) reported positive association between RS and QoL, three (15%) studies reported inverse associations, whereas five (25%) studies showed evidence of lack of association (with two out of the five studies showing an indirect association). Physical health and psychological functioning were the most researched domains of QoL, and some studies suggest an attachment-based model of RS in the last 10 years of RS and QoL research. Studies conducted with participants with serious illnesses ranging from dementia, cardiac arrest, and breast cancer reported no association between RS and physical health. Our review shows evidence of both the direct and/or indirect effects of RS on QoL as a possible spiritual coping model for complementary alternative health therapy, albeit occurring through several religious-related psychosocial conduits.
RS appears to be associated with health benefits as indicated across QoL domains. General medical practitioners and other healthcare agencies could benefit from the understanding that a spiritual coping model could aid their patients, and therefore their clinical practices, in the healing process.
There is a growing body of research that promotes spirituality as an internal locus of control in terms of regulating negative emotional states [1, 2]. These studies assert spiritual activities as helpful means of attaining self-transcendence and coping with life stressors. Chaney and Southwick  made such a claim in their book Resilience, describing how people overcome life's challenges by searching for connectedness and seeking comfort in spirituality based on what is transcendent. Spirituality differs in many ways from 'religiosity/religiousness'. The former emphasizes the personal character of spiritual transcendence in terms of the changing, developing constitutive trait and dynamic attribute one has from cradle to grave , whereas the latter is considered in terms of the institutionalised character of religious beliefs. In this paper, we refer to relational spirituality (RS) as the former—as an important platform for personal development that draws people to forge meaning in life through spiritual transcendence . Piedmont  ascribes a special role to RS with regards to spiritual transcendence, arguing that it should be considered as the sixth domain of personality since it represents a broad-based motivational domain and language term (e.g., universality, prayer fulfilment, and connectedness) that capture adaptively important psychological qualities that are comparable to The Big Five personality: Neuroticism, extraversion, openness to experience, conscientiousness, and agreeableness. Several other authors have weighed in on the concept of spirituality and provided different definitions. For example, as "the personal quest for understanding answers to ultimate questions about life" , "an organised system of beliefs and symbols designed to facilitate closeness to the sacred" , an aspect of quality of life [9, 10], "as subjective belief systems that incorporate self-awareness and reference to a transcendence dimension" (: 288), as a perceived relationship with a 'divine attachment figure' , and the "unique window into attachment processes in adulthood" (: 917).
In examining the above definitions, it seems that RS is mostly discussed within two categories: (1) as a cognitive appraisal of existential issues and (2) as the experiential knowledge of the divine . The former recognises RS in connection to the cognitive appraisal of stressors and interpersonal struggles when the individual is in a relationship with the sacred and often referred to as the 'head-knowledge of God' . The latter focuses more on the 'heart-knowledge of God'  in its application of attachment theory and developmental psychology. Both perspectives of RS draw largely from a relational perspective , and will be used for guiding this review in terms of the conceptualisation of RS as implicit relational and experiential representations of the sacred that are essential to faith development, spiritual transcendence, and appraising life stressors and QoL.
QoL is used in health-related research to study life satisfaction and the extent to which an individual evaluates their holistic life experience from a subjective point of view . It is a broad-ranging concept "affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment" (, p.1404), and covering several aspects of individual needs satisfaction that constitute aspects of life that contribute to overall experience.
QoL has much to do with individual satisfaction with key areas of life that enhance a general sense of physical and emotional well-being. Research shows that this concept is applicable for adolescents , women , migrants [19, 20], older adults , religious people , non-religious groups , among others. Studies have also shown that QoL has much broader implication for health care  and life satisfaction . As a context-specific construct , measures of QoL are used to assess the individual evaluation of their health-related outcomes, and in recent cases, modified for assessing disease-specific QoL outcomes. These include, HIV/AIDS-targeted QoL , geriatric quality of life-dementia (GQOL-D) , QoL—alzheimer disease scale (e.g., ), and heart-disease specific QoL scale (e.g., ).
Researchers recognise QoL as a multidimensional concept in terms of its subjective, objective, and culture/spirituality components, while at the same time identifying the relationship between these aspects (e.g., [9, 25, 31, 32]). Marshall  and Rule  mention income, education, and housing as examples of objective aspects of QoL. Collinge et al. , along with O'Connell and Skevington , spirituality' as/spirituality' as an important aspect of QoL.
The subjective satisfaction aspect is the most researched aspect in QoL literature, as it mostly assesses physical health, psychological health, social relationship health, and environmental health (e.g., [31, 35]). While QoL is likely to be related to individual contexts, as well as to the subjective satisfaction aspects, we argue that the spiritual aspect may be related to beneficial health outcomes and should be positioned as an additional conceptualisation of RS. A similar proposition can be seen in other studies (e.g., [9, 10]), concluding that one's spiritual well-being is an important aspect of QoL since it influences the subjective domain. The concept of QoL is continuum in nature since it considers overall life satisfaction that is connected with the individual's physical, mental, environmental, social, and spiritual functioning. Nonetheless, QoL is constantly changing, depending on the lived experience resulting from several factors that control one's life, especially ones related to self-transcendence and the connection to the sacred .
Based on this theoretical and empirical background, RS may be perceived as a relational dynamic and an implicit relational representation (e.g., ) that highlights a perspective which seeks to understand the human need for an object of devotion and spiritual functioning, guiding the quest for meaning and attachment to the sacred (e.g., [16, 38, 39]), in terms of its association with QoL. This relational perspective is largely drawn from the works of object relations theorists (e.g., [40–42]), and recently, RS has been theorized from an attachment theoretical perspective . Although the original thesis on attachment proposed by Bowlby  largely assumed an evolutionary perspective and its manifestation in parent-child relationships, he also noted that attachment processes may have a broad implication for psychological development throughout a person's life. Cicirelli  studied lifespan attachment developments among older adults, with empirical evidence supporting a strong sense of attachment to God among older adults. Other studies (e.g., [16, 37, 45]) have proposed an idea of a RS that can be interpreted in terms of an attachment-based model, one defined as a perceived relationship with the sacred. Granqvist and Kirkpatrick  refer to this as the maturational aspect of attachment development resulting from the increased ability in core specific cognitive tasks such as processing speed (e.g., ), voluntary response suppression (e.g., ), and working memory (e.g., ), which are usually immature in childhood .
Several studies (e.g., [13, 16, 50]) have integrated the principles of Bowlby's  attachment theory into the study of religious and spiritual development. Aspects of RS as an attachment-based model of spiritual development have been reported in studies (e.g., ) suggesting that attachment relational variables consistently emerge as predictors of various outcome variables that match spiritual and psychological well-being. For example, Augustyn et al.  report that RS (through spiritual practices such as prayer, awareness of God, spiritual meaning, and forgiveness) strengthens the link between spiritual well-being and psychological outcomes. Bradshaw and Kent  report that RS in terms of an attachment connection to the sacred strengthens the relationship between prayer and psychological outcomes. However, Sloan et al. [51, 52] have criticized empirical studies' claim of health benefits associated with religiosity, arguing that about 83% of the studies making such claims were methodologically flawed and misrepresented data; thus, there is no empirical basis for asserting that religious involvement is related to positive health outcomes. Miller and Thoresen  have argued that the consistency of empirical reports on the effects of spirituality on health-related outcomes point toward salutary effects. Other studies (e.g., [54, 55]) have linked adverse effects to beliefs in a punitive divine figure, extrinsic religiousness, and upholding a religious moral standard.
Recent literature reviews (e.g., [56, 57]) have shown evidence of positive links between spirituality/religiosity and QoL, albeit these studies were mostly limited to organizational religious affiliation among elderly adults in South America (e.g., ) and how religious participation correlates to mental disorders (e.g., ). These two reviews found empirical support for the association between several aspects of religiosity and health and mental health outcomes. For example, Bonelli and Koenig's  review provides evidence to show that religious involvement is associated with better mental health outcomes in 72.1% of the studies, while Abdala et al.  concluded, based on the positive association in 75% of the studies, that the religious affiliation of elderly South Americans is associated with better outcomes of quality of life. However, it seems that the conceptualisation used in these studies differ from that offered in our proposed study in terms of our definitions of RS and QoL. There appears to be no recent review study which appraises RS as (1) a domain of QoL that relates to spiritual functioning, and (2) a relational dynamic in terms of the relationship connection with a symbolic sacred object or figure, either through spiritual transcendence, prayer fulfilment, attachment to God, or other implicit relational conduits. In addition, while much has been done in promoting RS as an aspect of QoL, little is known about the broader perspective regarding the association between RS and QoL in disease-specific medical-health research. With debate around the salutary effects of RS on health outcomes, this paper contributes to the ongoing debate on how RS functioning is associated with perceptions of QoL. This study will thus: (1) review recent available data that identify and appraise the links between RS and QoL; (2) determine how RS is perceived/positioned in relation to QoL; (3) identify emerging themes emerging from the association between RS and QoL and (4) discuss the results and implications of the association between RS and QoL.
An integrative research review (IR) design is used to appraise the existing literature on RS and QoL. IR is a 'systematic' process "restricted to relevant studies that point to new data related to the study goals" (: 12). The choice of an IR allows for synthesizing knowledge from diverse disciplinary sources to better describe a subject . The use of this method to conduct a systematic literature review is especially appropriate for interpreting complex subjects. This is because it deconstructs theoretical and interdisciplinary domains related to such topics in order to formulate new reliable models, research agendas, or a meta index of meanings and definitions . An IR contrasts with meta-analysis in that its aim is to have a comprehensive collection of literature, especially when the subject is in one knowledge domain. An IR is comparative for review of subjects from diverse knowledge domains, as is the case in this review, and consistent with previous review on the subject (i.e., ). An IR also has a more flexible and inclusive review design (involving both quantitative and qualitative studies), compared to other types of review methods. It allows for a more purposeful selection and inclusion of diverse data sources and empirical contributions which show the association between RS and QoL in diverse and broad sampling frames. Hence, we have targeted and integrated representative sources of research which have the potential to identify and appraise the links between RS and QoL.
As shown in Fig. 1, a search was carried out between February and March 2017 using three online databases (i.e., PubMed, PsycINFO, and ScienceDirect) with DeCs1 and MeSH2 keywords such as 'religion' or 'spirituality' and 'quality of life' or 'health,' and later specified using the following keyword strings: 'spirituality and quality of life'; 'religion and quality of life'. We chose PubMed, PsycINFO, and ScienceDirect as reliable electronic databases for our literature search because they are leading sources for assessing scientific, technical, and medical research, which have not been used in previous literature reviews, except for Bonelli & Koenig  who used PubMed in their literature review search. Abdala et al. , on the other hand, used different sources for their literature search, including Virtual Health Library, Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Medical Literature Analysis and Retrieval System Online (Medline), and the U.S. National Library of Medicine.
Date of publication: 2007 to March 2017.
English-language peer-reviewed articles with published abstracts on PubMed, PsycINFO, and ScienceDirect.
Empirical, cross-sectional, longitudinal, quantitative, and qualitative studies.
Studies reporting on the association between RS and QoL.
Studies that explored either one or two or all aspects of QoL in terms of its subjective, objective, and spiritual/cultural factors.
Studies that conceptualised RS as a domain of QoL concerned with spiritual functioning and a relational dynamic that represents attachment to a sacred object or figure.
Reviews, theoretical articles, books, chapters, dissertations, conference proceedings, blog articles, and working papers.
Studies not indexed by either PubMed, PsycINFO, or ScienceDirect.
Studies published before 2007 and after March 2017.
organise the themes and critically analyse them in relation to the research problem.
First, the purpose of our review is to address the claims about RS and QoL outcomes so as to determine how RS is perceived/positioned in relation to QoL and the emerging themes that can help in interpreting the association between RS and QoL. We summarized results from previously conducted studies to appraise the conclusions from all studies relating to the claims of the effects of RS on QoL. As shown in Tables 13 and 2,4 we summarized and compared empirical data in our IR to allow for the achievement of general conclusions about the research problem , and analysed results as direct evidence, indirect, positive, and negative associations and lack of associations.
A prospective study. Interviews (n = 499) from 1982 to 1994 with terminally ill elderly persons in the last year of their lives.
Those who had a sense of religious attachment were more likely to see friends, and they had better QoL, fewer depressive feelings, and were observed by the interviewer to find life more exciting compared with the less religious respondents.
*** Saffari et al. .
Cross-sectional survey design (n-362) with Muslim patients undergoing haemodialysis.
Spiritual/religious factors were related to QoL and health status. Regression models revealed that demographics, clinical variables, and especially spiritual/religious factors explained about 40% of variance of QoL and nearly 25% of the variance in health status.
Quantitative interviews and cross-sectional design with 111 Individuals With Dementia (IWD) and their family caregivers from two service-based organizations in the San Francisco Bay Area and Cleveland, Ohio.
Mean Age: Caregiver (M = 61.20, SD = 14.00); IWD (M = 76.80, SD = 8.90).
After controlling for care-related stress, one's own religiosity is not significantly related to individuals' or caregivers' perceptions of the QoL of individuals with Dementia. However, when modelled for both the individuals and their caregivers, effects of religiosity on perceptions of QoL, caregivers' religiosity was positively related to the QoL of individuals with Dementia whereas the religiosity of individuals with Dementia was negatively associated with caregivers' perceptions of IWDs' QoL.
# Miller et al. .
Cross-sectional survey with 44 (dyads) couples between 49 and 73 years of age following a first-time cardiac event.
Gender: Patient Males (n = 35) and Females (n = 9).
Age range: Patients (49 to 73 years of age); Spouses (47 and 71 years of age).
Mean Age: Spouses (M = 59.1, SD = 12.6); Patients (M = 61.6, SD = 11.8).
The findings suggest that there is no association between dimensions of spirituality and QoL and perception of the patient's physical self-efficacy following a first-time cardiac event.
# Nguyen et al. .
A prospective study. Data was analysed from the 2002 National Health Interview Survey (n = 106,000) that covered responses regarding use of complementary therapies reported by older adults aged 55 to 85 and the association with health outcomes assessed in the 2003 US Medical Expenditure Panel Survey (n = 1683).
Age range: 55 to 85 years of age.
Even though there was no association between prayer and functional status or QoL, results show that the use of prayer for health was the most common complementary alternative medical therapy reported by those aged 55 to 85 (52.3%), which was more than twice as common as any other category of complementary therapy in term of users of biologically based therapies (20.4%) which predicted better functional status.
Quantitative interviews with 294 middle-aged and older patients following open-heart surgery.
Age range: aged 35 to 89 years of age.
Results show support for adaptive faith-based coping in patients, suggesting that prayer coping was positively associated with cognitive and behavioural changes, as well as perceived social support from family, friends, and significant others at the time of participant's surgery.
Quantitative interviews with 75 consecutive Amyotrophic Lateral Sclerosis (ALS) patients and their informal caregivers, using tests evaluating religiosity, QoL, satisfaction with life.
Results showed that the QoL of the caregivers of patients with ALS was associated with their private religiousness (i.e. subjective religiosity) whereas their satisfaction with life related to their overall religiosity.
A 1239 days daily diary study on 87 college students using lagged analysis to examine whether spirituality is causing greater well-being or vice versa.
There was a significant positive relationship between daily spirituality, self-esteem, meaning in life, and positive affect. Furthermore, present-day spirituality was associated with next day's meaning in life. There was no evidence shown that supports that meaning in life predicted next day spirituality. Lower positive affect and greater negative emotion on 1 day was associated with greater spirituality on the next day.
Quantitative interviews were conducted with stable outpatients with schizophrenia (n = 63), mostly African-Americans (nearly two-thirds of the sample size) living in south-eastern United States to examine the role of religion in coping with their disorder.
Results show that about 68% of the participants were involved in one form of religious activity that involved their religious others. 64% of the participants indicated that being connected to a faith community was important to them. 91% indicated that they were involved in private religious activities that involve praying at least once a day. These kinds of positive religious coping (i.e., religious forgiveness, seeking spiritual support, collaborative religious coping, spiritual connection, religious purification, and benevolent religious reappraisal) were associated with greater QoL (r = .28, p = .03) and psychological health (b = .72, p = .05) whereas negative religious coping (i.e., spiritual discontent, reappraisal of God as punishing, interpersonal religious discontent, reappraisal of demonic powers, and reappraisal of God's powers) in the form of feeling abandoned by God was associated with worse QoL (r = .30, p = .02).
Data collected from nationwide Religion, Aging, and Health Survey from 1024 older Americans.
Prayer is not directly associated with improvements in psychological well-being. However, when moderated by attachment to God there was a relationship between prayer and psychological well-being. This association was only seen in individuals with secure attachments and not with those who are insecurely attached to God.
# Sorensen et al. .
A cross-sectional survey from a sample of 2086 cancer patients and 6258 cancer-free controls from the Nord-Trøndelag Health Study in Norway that took place between 2006 and 2008.
Mean Age for cancer patients (Sample), 6.9 years; cancer cases (Sample 2a), 7.7 years; cases of breast, prostate, or colorectal cancer (Sample 2b), 6.3 years.
Spirituality in terms of 'seeking God's help' was associated with lower levels of sexual QoL in the unadjusted model, but when adjusted for other factors (e.g., gender, age, anxiety, neuroticism, extraversion, follow-up time, daily smoking, infrequent exercise, negative outlook, and positive outlook) it did not remain significant for life satisfaction or to QoL measures. There was a lack of association between 'Seeking God's Help' and Life Satisfaction among patients, nor was 'Seeking God's Help' associated with Disease-Specific QoL in patients with breast, prostate, or colorectal cancer.
A prospective cohort study of 481 terminally ill Korean cancer patients. 76% (n = 466) were interviewed till the time of death.
Mean age: Users of complementary alternative medicine (CAM) (58.2 years); Nonusers of CAM (59.0 years).
Those who used mind-body interventions (e.g. meditation, prayer therapy, music therapy, art therapy, yoga, horticultural therapy) experienced a significant decline in their QoL compared to non-users. Participants using prayer therapy showed a significantly worse survival of insomnia.
Data collected from a cross-sectional survey of a random national sample of Jewish participants (n = 1287) who are 50 years and older.
Frequency of prayer was inversely related to self-rated health, and positively associated with activity limitation, physical symptoms, and poor physical functioning.
A cross-sectional survey with older Koreans (n = 274) 65 and over, living alone in Chuncheon, South Korea.
Gender: Females = 82.1%, Males = 17.9%.
There were associations between dimensions of depression, QoL, and spirituality. Spirituality explained the variance on depression and QoL amongst Christians, but did not account for the difference in the Buddhist sample.
A cross-sectional survey with 208 Jewish men and women.
Gender: 74.5% (Females), 25.5 (Males).
There was a positive correlation between physical health and trust in God (r.14, p < .05), and inverse relationship with mistrust in God (−.16, p < .05) and negative religious coping (r.14, p < .05). When adjusted for gender and age, correlation with physical health remained significant, especially in trust in God and physical health.
A cross sectional study with 198 persons with HIV/AIDS in urban Philadelphia.
Results of the multiple hierarchical analyses reveal that negative religious coping was significantly related to low levels of QoL when adjusted for demographic and clinical variables. Positive religious coping was also significantly associated with positive affect and life satisfaction, but not with overall QoL.
A cross-sectional data on 678 military Veterans with posttraumatic stress disorder (PTSD).
When adjusted for demographic risk factors, combat exposure, and severe PTSD symptoms in the structural equation modelling, results revealed that spirituality was significantly associated with forgiveness and QoL. "Higher levels of spiritual functioning were associated with fewer forgiveness problems among these Veterans, and their propensity to forgive self and others was also concurrently linked with QOL" (p.175).
Mediation analyses was conducted on data collected from the American Cancer Society's Study of Cancer Survivors-II (n = 8405).
Results show evidence that faith was strongly associated with meaning and peace in uncontrolled analyses. The mediation analyses show that faith had a significant positive effect on mental functioning (when mediated with greater meaning) and physical functioning (when mediated by both meaning and peace).
Data were collected from a nationwide survey with adults (n = 1774) from 18 years above.
# Rohani et al. .
A cross-sectional survey with Iranian women with breast cancer (n = 162).
Spirituality and positive religious coping was not associated with increases in QoL in Iranian patients.
Based on Whittemore and Knafl's  second guideline, literature search of recent studies between 2007 to March 2017 was carried out using three online databases (e.g., PubMed, PsycINFO, and ScienceDirect) with the aim of identifying studies that have investigated the links between RS and QoL. Third, to appraise and evaluate the quality and results of selected studies, we presented a clear and synthetic description of study data using Tables 1 and 2. Summarizing the data in tables allowed for the identification of knowledge gaps and pointed out the state of the art of the scientific production that results from selected studies examining the effects of RS on QoL . For this reason, Tables 1 and 2 are drawn as concepts matrix  to help highlight study characteristics and summarise key themes from each study. The use of tables also aim to clarify the different contexts and themes that have been explored by the researchers, showing the procedures adopted to examine it, as well as their contributions on the subject.
Instrument: 20-item Center for Epidemiological Studies Depression Scale.
The idea of a connection to the sacred through religious rituals or experiences that serve as sources of strength and comfort in the last year of life.
QoL in the last year of life is positively related to subjective religiosity due to the social support that is gained in the process of associating with religious believers.
Instrument: EQ-5D-3 L (which includes the EQ-5D assessing mobility, self-care, usual activities, pain/discomfort, anxiety/depression; and the Visual Analogue Scale (EQ-VAS) that allows respondents to rate their current health status from 0 to 100.
Intrinsic religiosity and private religious activities that draw a sense of connection to the sacred.
Spiritual resources may contribute to better QoL and health status among haemodialysis patients.
Instrument: Designed variable for subjective ratings of religiosity (How religious or spiritual would you say you are?) answered on a Likert scale from 1 (not at all religious/spiritual) to 4 (very religious/ spiritual).
The religiosity of a caregiver for an individual with Dementia may affect the perception of QoL of the individual they are looking after. In contrast, one's own perception of spirituality does not guarantee QoL.
Prayer or meditation, consequential religiosity for coping with personal problems, theological belief system, experiential religiosity pertaining to feeling of religious comfort.
Instruments: The Spiritual and Religious Concerns (SRC) questionnaire; The Religiosity Measure (RM); Religious coping activities scale.
The distress following a cardiac event may require support from religious behaviour and spiritual beliefs. However, if there is no such support, as shown in the results, the authors argue that lower perceptions of QoL may trigger negative forms of religious coping and put the couples at risk of spiritual distress.
Prayer and having a sense of connection to the sacred may be a complementary health practice among older adults since it is used more than as any other alternative health therapy. However, this position may change over time since it is not necessarily associated to QoL.
Psychological functioning (behaviour coping, cognitive coping, levels of distress, anger coping, avoidant coping, depression), physical functioning (fatigue symptoms), social relationships (perceived social support).
"Psychosocial factors may explain the potential role of using prayer for coping on short-term postoperative QoL" (p. 471).
The religiosity of caregivers of patients with ALS can be a helpful coping resource for negotiating their own QoL. Hence, "Health care professionals caring for ALS patients should consider that the needs of the caregivers include religious/spiritual concerns" (p.168).
Psychological well-being, meaning in life, positive affect, self-esteem.
Daily spirituality, Personal relationship with a power greater than one's self, the spiritual part of one's life.
The study shows that spirituality is used as a coping strategy to deal with negative emotions. This is because the negative emotion experienced on 1 day is likely to predict increases in spirituality on the next day.
Physical health, psychological health, social relationships, environmental health.
Instrument: 14-item RCOPE consisting of the positive religious coping pattern (e.g., religious forgiveness, seeking spiritual support, collaborative religious coping, spiritual connection, religious purification, and benevolent religious reappraisal) and the negative religious coping pattern (e.g., spiritual discontent, reappraisal of God as punishing, interpersonal religious discontent, reappraisal of demonic powers, and reappraisal of God's powers).
Spirituality or religious coping in the form of community prayer services and devotion to God is an important factor that may have a major impact on the treatment of patients of African-American origin with Schizophrenia.
A relationship with God makes prayer effective: the impact of prayer on one's QoL depends on one's perceived relationship (attachment) with God.
Instrument: Psychological wellbeing in terms of life satisfaction was measured by the item: "Thinking about your life at the moment, would you say that you, by and large, are satisfied with life, or are you mostly dissatisfied?", with response option dichotomised into 'Dissatisfied with Life' and 'Satisfied with Life'. In addition, physical health was assessed using The EORTC breast cancer module (BR-23), prostate cancer module (PR-25), and colorectal cancer module (CR-29) which cover symptoms, self-image, sexuality, and specific complaints during the previous week.
Instrument: A sub-scale of the Instrument of Religious Coping (RCOPE) (e.g., "I seek God's help when I need strength and solace") was dichotomized into two response options: 'Seeking God's Help' and 'Not Seeking God's Help'.
Cancer patients in Norway are not likely to seek God's help to negotiate their QoL.
Instrument: Investigated participants' use of mind–body intervention (yoga, meditation, prayer therapy, music/dance therapy, art therapy, and horticultural therapy).
Using mind-body interventions (e.g. prayer) may not be helpful for Korean cancer patients.
Instrument: Activities of Daily Living Scales and variables on indicators of physical health such as self-rated health, long-term health problems, activity limitation, diagnosed chronic diseases, physical symptoms.
Religious involvement in the Synagogue is a much stronger predictor of better physical health than prayer, among Jewish people.
Physical health status, mental health status, social relationships, and the environment.
Lee, Nezu, & Nezu .
Physical health, psychological health, social and environmental QoL.
Spiritual functioning in terms of forgiveness of self, others, and God.
Forgiveness is an important factor to consider when modelling for spirituality and QoL.
Mental functioning, physical functioning, spiritual functioning.
Faith makes an important contribution to the QoL of cancer survivors.
Instrument: Physical health was measured using the Physical Component Summary score of the Short Form Health Survey (SF-12).
Depressive symptoms were also assessed as an aspect of psychological QoL functioning using a short form of the Center for Epidemiologic Studies Depression Scale (CES-D).
Instrument: 6-item Brief Trust/Mistrust in God Scale (e.g., "God cares about my deepest concerns"; "God hates me"); 16-item Jewish Religious Coping Scale (JCOPE) (e.g., "I try to see how God may be trying to teach me something," "I question my religious beliefs, faith and practices," and "I look for a stronger connection with God").
Intrinsic religiosity was measured using three items from the Duke Religion Index which are also present in the Religious Orientation Scale and the Hoge Intrinsic Religion Scale (e.g., "My religious beliefs are what really lie behind my whole approach to life," "In my life, I experience the presence of the Divine (i.e., God)," and "I try hard to carry my religion over in to all other dealings in life").
Spiritual/social support from fellow members of a church influences one's perception of God as benevolent and gratitude to God, which in turn leads to better health.
Spirituality is not associated with QoL for Iranian women with breast cancer.
The fourth element of the 5-step guideline for IR involved reviewing selected studies in order to identify emerging themes that may help in conceptualizing the association between RS and QoL, as shown in Table 2. Themes summarized here help to identify areas for future studies and disclose relevant potential questions central to RS and QoL. Finally, emerging themes from our review were organized and critically analysed in the discussion section in relation to addressing the research problem on claims about the association between RS and QoL. Analysing study themes generated from reviewing diverse research output is expected to account for the integrated framework in terms of understanding the complexity of RS and QoL research. In conducting an IR, the authors addressed questions which related to existent knowledge regarding about the links between RS and QoL, the quality and complexity associated with these links, and steps for future research into investigating the effects of RS on QoL .
All selected studies have been summarised in Table 1, showing evidence of positive (***), indirect (#*), negative association (**), and lack of association (#) between RS and QoL. A total of 132,053 participants were involved across the 20 selected studies. In particular, 70% of the studies were conducted with participants suffering from one form of mental or physical health-related challenge which included: 499 terminally ill elderly persons , 362 Muslim patients undergoing haemodialysis , 111 individuals with dementia , 44 couples (dyads) following a first-time cardiac event , 294 patients following an open-heart surgery , 63 outpatients with schizophrenia , 1024 older American adults , 8344 Norwegian cancer patients , 481 terminally ill cancer patients , 198 HIV/AIDS infected patients , 678 military veterans with PTSD , 8405 cancer survivors , 75 ALS patients and their caregivers (dyads) , and 162 Iranian women with breast cancer . The remaining 30% were conducted with other study populations, including 87 college students , 1287 older Jews in Europe , 208 Jewish men and women , 274 older Koreans living alone in Chuncheon , 107, 683 older adults in a national health survey , and 1774 American adults .
All the 20 studies selected for the review employed quantitative research designs, while one study adopted a mixed-methods design (i.e., ). With the exception of a few prospective cohort studies (e.g., [22, 62, 67, 75]), for the most part a cross-sectional design was used.
As shown in Table 1, of the 20 articles used for the predictive analyses outcomes, 12 (60%) of the studies with 12,917 participants reported positive associations between RS and QoL (e.g., [27, 28, 62–65, 68–70, 72, 74, 76]). Participants in these studies reported on the main effects of RS on their QoL, showing correlations between measures of RS and QoL. For example, Saffari et al.  found that spiritual resources accounted for substantial variance to better QoL and health; Idler et al.  reported that individuals with stronger religious attachment were more likely to have better QoL and fewer depressive feelings. In another report (e.g., ), RS, through adaptive faith-based coping mechanism such as prayer, was positively associated with psychological functioning among cardiac patients; this relationship was also strengthened by perceived social support from family, friends, and significant others at the time of participant's surgery. The study showed the indirect influence of using prayer for coping on short-term QoL and positions prayer to functions as "the mediation of cognitive coping and perceived social support". Calvo et al.  reported that QoL and life satisfaction of the caregivers of patients with ALS was associated with aspects of RS. Kashdan and Nezlek  reported a significant positive relationship between daily RS and psychological functioning (i.e., self-esteem, meaning in life, and positive affect).
Evidence shows that RS was associated with greater QoL and psychological health in a study  with mainly African American Christians in South-eastern United States (commonly identified as the Bible Belt region), where 98% of the respondents were involved in various aspects of RS that include religious activities such as prayer meetings, being connected to a religious community, praying once a day, meditation, and spiritual reading; as well as religious coping activities such as practising forgiveness, seeking spiritual support, collaborative religious coping, spiritual connection with God, religious purification, and benevolent religious reappraisals. Krumrei et al.  report a positive correlation between measures of physical health and RS in terms of 'trust in God' in both the adjusted and unadjusted models, and an inverse association between physical health and mistrust in God (i.e., didn't trust God). RS accounted for the variance in depression and QoL among older Christian Koreans, with results showing significant associations between measures of RS and QoL . However, this was not the case for Buddhist older Koreans who seem to attend religious meetings less regularly than the Christian respondents, based on the observations of the authors. Currier et al.  report on the salutary effects of spiritual functioning in terms of forgiveness of self and others on QoL outomes, noting that "Higher levels of spiritual functioning were associated with fewer forgiveness problems among Veterans, and their propensity to forgive self and others was also concurrently linked with QOL" (p.175). Other studies further show evidence of a positive association between a person's faith experience and mental and physical functioning (e.g., ), and between spiritual behaviours and views developed through prayer and increases in QoL (e.g., ).
All these 12 studies make a case for the effects of RS on QoL and provide evidence to show that RS accounted for the variation in QoL and health status, particularly among older adults [28, 62, 64], military Veterans , cancer patients , persons with HIV/AIDS , Jewish men and women , lonely elderly Koreans , outpatients with schizophrenia , college students , patients with Amyotrophic Lateral Sclerosis , patients recovering from heart surgery , patients undergoing haemodialysis , and patients with posttraumatic stress disorder .
The study with individuals with dementia (IWD) coded in the 'no association' (#) index in Table 1 (e.g., ) reported a lack of association between RS and QoL, but recorded an indirect relationship when a third party is involved (IWD caregivers). Nagpel and colleagues concluded that the spirituality of a caregiver of IWD may influence perceptions of QoL among IWD. Another study coded in the 'no association' category (e.g., ) reveals that prayer (as an activity of RS) is not directly associated with improvement in QoL, except when moderated by attachment to God (having a relationship with God). The study by Bradshaw and Kent suggests that without a relationship with God the frequency of prayer is ineffective in terms of improvements in psychological well-being. These indirect associations reflect the complexity of the positive relationship between RS and QoL, showing that the effects of RS on QoL may be dependent on other factors and activities of RS that translate into better health outcomes. Our findings support the salutary effects of RS on QoL, be it through direct or indirect associations, as shown in Table 1.
As shown in Table 1, three (15%) studies with 10,112 participants reported inverse associations between RS and QoL [66, 67, 73]. Sorensen et al.  report that the prevalence of RS in terms of 'seeking God's help' was negatively associated with sexual QoL, although this relationship was not retained when controlled for other factors such as gender, age, anxiety, neuroticism, extraversion, follow-up time, daily smoking, infrequent exercise, negative outlook, and positive outlook.
Yun et al.  report that the RS of terminally ill Korean cancer patients showed a significantly worse survival of insomnia and change in health-related QoL subscales. Yun and colleagues examined the health outcomes of Complementary and Alternative Medicine (CAM) among users and non-users. In comparing CAM users and non-CAM users, they found that CAM users did not have better survival ratio than nonusers. Prayer was identified as an aspect of CAM, but results showed worst insomnia survival and cognitive functioning for terminally ill cancer patients who use it as a religious coping behaviour, compared to that of nonusers. Yun et al. concluded that CAM use is associated to worst health outcomes, even though some patients often used CAM in the hope that it will cure their illness. Yun et al. also pointed to the limitations of the study as the possible reasons for the results. First, they note that it is difficult to draw firm conclusions from the results due to the nonrandomized design used for data collection. Secondly, they reasoned that due to the small sample size used for the analysis of CAM subcategories (e.g. meditation, prayer therapy, music therapy, art therapy, yoga, horticultural therapy), the statistical power might have been too weak to detect benefits of CAM use.
Levin  reports that RS in terms of prayer was negatively related to physical health QoL among Jewish respondents age 50 and above . In the unadjusted model, prayer was negatively correlated to self-rated health, but positively associated with physical symptoms, poor physical functioning, and activity limitation. Adjusting for covariates (e.g., age group, gender differences, education background, relationship status, and birth place) and mediators (e.g., drinking, smoking, and help received from outside the home), the frequency of prayer retained its negative association with self-rated health, and positively correlated with physical symptoms, poor physical functioning, and activity limitation. In contrast, Synagogue participation had a better physical health outcome for Jewish respondents who seem to have a strong attachment to the Synagogue. According to Levin, the dynamics of Jewish spirituality may explain the negative relationship between prayer and physical health since it comparatively has to do with integration into a synagogue community than it does with using prayer as a coping mechanism. As Levin suggests, both findings may in part result from the effects of preventing Synagogue participation and focusing on using prayer as a religious coping behaviour, since "certain expression of religiousness may decline with poor health (e.g., synagogue attendance) and others may increase as a coping response (e.g., prayer)" (: 598).
As shown in Table 1, the results reveal that five (25%) studies showed no direct association between aspects of RS and outcomes of QoL [22, 29, 30, 71, 75], even though two of these studies (i.e., [22, 29]) later reported an indirect association between RS and QoL via psychosocial factors such as secure attachment to God and perceived social support from caregivers who have a relationship with God. In addition, participants in three of these studies had serious illnesses, ranging from dementia , cardiac arrest , and breast cancer , while data from the two other studies [22, 75] were also retrieved from health-related contexts. This connotes that the lack of association in the illness context between RS and physical health-related QoL may be due to the salutary effects of RS, which provide comfort but do not change the physical status of the patients. In contrast, RS was strongly correlated with psychological functioning, as shown in other studies (e.g., [62, 64]).
It is possible that the different results in terms of the positive, negative, indirect or not detected associations between RS and QoL could be due to conceptualisation and operationalisation of key variables and different study designs (see Table 2). For example, most of the 'no association' studies used health-specific QoL measures to assess the physical health domain of participants. Nepgal et al.  examined QoL using the Quality of Life Alzheimer's Disease Scale (QoL-AD); Miller et al.  used a Heart-disease specific QoL questionnaire; the same approach was taken by Nguyen et al. . Studies that showed 'positive association' (e.g., [27, 28, 63, 68, 74]) mostly employed cross-sectional designs which make it impossible to make firm claims about causality in the IR. However, it is also possible that the estimated effects of aspects of RS on outcomes of QoL are conditional upon each other, e.g., that the effects of RS that are perceived as both positive (e.g., seeking spiritual support) and negative (e.g., spiritual discontent) religious coping emotions and behaviours could be especially consequential for QoL outcomes. These complex patterns warrant further investigation.
This section identifies themes used in conceptualising RS and QoL. First, we examine themes used in all the studies for examining RS as a domain of QoL that relate to spiritual functioning and a relational dynamic in terms of attachment with a symbolic sacred object or figure via implicit relational conduits. Second, we further identify themes used for the conceptualisation of QoL in all the studies as aspects of individual needs satisfaction with key areas of life that contribute to overall wellbeing.
Although the study data contain different definitions of RS as shown in Table 2, it still conveys similar relational ideas of attachment to the sacred (e.g., [22, 27, 76]). The meanings attached to these relational experiences serve as sources of strength and comfort in one's life , taking the form of private spiritual activities that draw one closer to the sacred , and a personal relationship with a power greater than one's self or the spiritual part of one's life [22, 72]. RS was also commonly interpreted as 'subjective religiosity' [28, 29, 70], 'intrinsic religiosity' , 'experiential and consequential religiosity' , 'spiritual connection' , 'attachment to God' , 'spiritual functioning' , 'God image representations' , spiritual behaviours and views , and as an aspect of spiritual functioning that has to do with forgiveness of self and others .
In addition, most of the studies referred to RS as a frequency of 'prayer' or as a form of spiritual transcendence that is achieved through private prayer (e.g., [29, 30, 64, 67, 71, 73, 75]). However, Bradshaw and Kent  interpreted RS differently as an attachment to God experience achieved through prayer. Nolan et al.  saw RS as a connection to the sacred that is facilitated through the context of a faith community. This is similar to the findings of Nagpal et al.  and Ai et al.  who also stressed the role played by psychosocial factors in terms of perceived social support and community prayer services in their conceptualisation of RS. One study  had a vague definition of RS as 'feelings of comfort and strength', even though this generally suggests an idea of spiritual functioning.
Levin  presents a different understanding of RS which considers the intersection of religion and place as a conceptualisation of Jewish RS, which is formed within the context of the Synagogue experience. Different RS themes and perspectives were identified in the selected studies. As shown in Table 2, the results from these studies are likely to be influenced by the different conceptualisation used by respective researchers. In addition, the results from the studies may also be linked to an operationalisation problem since RS was assessed based on a variety of designs. For example, some studies measured the RS construct using unstandardized subjective ratings of religiosity (e.g., [29, 62, 75]), while other studies (e.g., [22, 30, 63, 74]) measured RS using psychometric assessments such as The Spiritual and Religious Concerns questionnaire, The Religiosity Measure, Religious coping Activities Scale, Attachment to God Scale, Brief Trust/Mistrust in God Scale, Jewish Religious Coping Scale (JCOPE), Duke Religion Index.
Results on aspects of QoL reported in all the studies are presented in Table 2. Aspects of QoL assessed in some of the studies were not clearly defined, even though the concepts used to describe QoL corroborate our theoretical assumptions. All the reviewed studies assessed several QoL domains that include psychological, physical, social, and spiritual functioning, while few studies seem to integrate other health-related factors as aspects of QoL. For example, we observed that a number of studies conceptualised QoL in terms of a single indicator such as depressive symptoms (e.g., [62, 63, 70, 76]), fatigue symptoms (e.g., ), and levels of anxiety (e.g., ). As expected, these unconventional definitions led to using instruments that are not necessarily designed for measuring QoL, such as the Fatigue Scale, Center for Epidemiologic Studies Depression Scale, Medical Outcomes Study questionnaire. However, two QoL aspects (i.e., psychological functioning and physical health) are the most researched domain of QoL in medical-health research, as all the studies assessed either one or both aspects.
Interestingly, Calvo et al.  took a more holistic approach in their examination of QoL, as they investigated physical health, psychological functioning, and other aspects of QoL that are related to social well-being, spiritual functioning, and financial aspects among Amyotrophic Lateral Sclerosis patients. Canada et al.  integrated aspects of mental functioning, physical functioning, and spiritual functioning in their study of faith and QoL of cancer survivors. As shown in Table 2, most of the QoL scales used in selected studies were modified, based on specific cases of interest, such as the HIV/AIDS-Targeted QoL (e.g., ), Geriatric QoL-dementia (GQOL-D) , QoL – Alzheimer's Disease Scale (e.g., ), Heart-disease Specific QoL Scale (e.g., ), McGill QoL Questionnaire (e.g., ), Physical and Mental Health Summary Scales (e.g., ), World Health Organisation QoL Scale (WHOQoL-BREF) (e.g., Currier et al. , and the European Organization for Research and Treatment of Cancer QoL Questionnaire (e.g., ). Other assessment techniques were based on designing categorical variables (e.g., nominal, dichotomous, or ordinal) on subjective ratings of questions connected to aspects of health-related QoL that may have health implications for the participants (e.g., [66, 72, 73]).
There is good evidence that RS is associated with better outcomes of QoL in the areas of physical health, psychological wellbeing, social relationship quality, and spiritual functioning.
The effects of RS on QoL may take the form of direct and/or indirect associations, depending on the psychosocial factors (e.g., perceived social support by fellow members of the church, a religious caregiver, or group prayer services) and contexts (e.g., illness, secular, or religious) involved.
The effects of RS on QoL may depend on the right application of meaning in terms of how it is defined (conceptualisation) and measured (operationalisation).
RS coping activities and beliefs (e.g., trusting in God, prayer, positive spiritual connections, or forgiving self and others) activate coping strategies during times of distress, leading to better outcomes of QoL.
These findings highlight the significance of RS as an important component for negotiating day-to-day QoL. While most of the studies identify RS as a form of coping strategy with health benefits, in 75% of the reviewed studies (*** and #*), others showed the role of perceived social support in enhancing the effects of RS on QoL via caregivers who are religious , being part of a faith community , or seeking spiritual support and collaborative religious coping through community prayer services . Psychosocial activities that include practices of RS became a helpful coping recourse for achieving better QoL and played a major role in the way participants experienced spirituality and negotiated their QoL.
The role of prayer in moderating the effects of RS is also noteworthy in the IR (e.g. [22, 64, 75]). Prayer was often used by the participants as a spiritual conduit for assessing the sacred and an important aspect of RS, with studies referring to 'prayer' as a form of religious coping behaviour. Overall, prayer was the most commonly used aspect of religious coping behaviour among older adults, and was positively associated with cognitive, behavioural and psychological changes.
However, religious coping behaviour may not be used as a coping therapy in every context, as demonstrated in studies conducted within the illness context (e.g., Miller et al.; [29, 30, 71, 75]), secular context (e.g., ), and religious context (e.g., [28, 73]), which highlight this shift in perspective. First, we see this shift in health-specific studies (except for ) reporting on a variety of patients (e.g., dementia, cardiac arrest, and breast cancer patients), which found that RS was not related to physical health QoL. This suggests that even though RS may have provided comfort, it does not necessarily change the physical health status of the patients. Second, we also found that the same applies for participants in the secular Norwegian context (e.g., ) whose RS did not translate to better health outcomes.
Third, another study (e.g., ) also support that the effects of RS on QoL is context-driven, and may be different depending on individual religious background, or how RS is practiced as in the case of Jewish participants (i.e., ) whose integration into the Synagogue community was a significant predictor of better physical health than their prayer life. Moon and Kim reported that spirituality accounted for the variance in QoL among Korean Protestants and Catholics, but not for the Buddhist sample. One interpretation given for this result was that "Buddhists usually attend religious meetings less regularly than Protestant or Catholics" (: 298), and that Buddhists had lower RS outcomes than Protestants and Catholics. These different perspectives suggest varying accounts of the salutary effects of RS on QoL, which seem to vary based on the individual's social context. In other words, even though RS may have provided symbolic beneficial experiences (e.g., a sense of meaning, social support, and spiritual connection) that are good for negotiating QoL, these health benefits can also be because of other sources such as the social context that affect the spiritual role. To better understand the role of RS on health outcomes, we need to consider the "ways in which culture influences religion's expression of the spiritual" (: S54).
This IR has shown the discrepancies in themes used to describe RS and QoL over the last 10 years. Table 2 shows the different themes associated with all the studies, although the various conceptualisations still point to some sort of relational dynamics that involve attachment to the sacred and aspects of spiritual functioning. Of the 20 studies identified, none exclusively used the term "relational spirituality", even though the conceptualisations bear semblance with our definitions of RS. The specific terms used in describing RS in most of the studies are "religion", "religiosity", "faith", "spirituality", "complementary therapy", "private prayer", "religious coping", "attachment to God", "seeking God's help", "Jewish spirituality", and "images of God." In using these terms, most of the studies failed to clearly define RS as a relational dynamic that deals with attachment to the sacred. Instead, they used measures and categorical variables that assess aspects of RS that involve intrinsic aspects, such as meditation, prayer, and attachment to a higher power. Conceptually, RS continues to change while retaining the relational dynamic of its tradition.
At present, an attachment-based model of RS, though achieved through prayer and other religious-related activities with others and positive perceptions of the divine, seems to be the overriding theme in studies examining RS and QoL over the past 10 years. God image representations and trust/mistrust in God as seen in the works of Krause et al.  and Krumrai et al.  also re-emphasize similar relational perspectives, along with other studies which demonstrate a similar attachment-religion connection. These conceptualisations are likely because of the operation of Bowlby's  proposed internal working models of attachment which, even though developed during the early years of life, remain active in one's lifespan attachment development  and determine the extent to which a potential object of attachment is experienced, even in the RS context (e.g., [13, 16, 37]).
Long  found a significant correlation between measures of attachment to God RS, parental bonding, and religious coping. The ability to regulate emotional states in RS contexts due to the internal working model of the attachment system may be the very key to unfolding spiritual coping model for negotiating QoL when drawn to the sacred. The direct and/or indirect associations with QoL suggest the activation of a spiritual coping model that helps in relational processes and in dealing with stressful life situations, based on the connection to what is transcendent. The idea of the transcendent can take different directions, as shown in our IR as spiritual functioning, forgiving self, forging a meaningful relationship with others, and building a sense of attachment to God. This framework of a spiritual coping model is more active in the third aspect in terms of the association between RS and QoL.
The limitations across these 20 studies include the following: mostly focused on older adults with younger people unrepresented; mostly quantitative design which lacks in-depth perspectives capture; mostly cross-sectional studies with limited causality examination; lack of QoL specific measures; and the use of categorical rather than continuous operationalization of RS and QoL.
Although study findings show evidence of the links between RS and QoL in medical-health research for the last decade, we were unable to retrieve some studies related to RS and QoL during our initial literature search due to indexing problems and date of publication. After conducting a manual search of related articles reporting on the links between RS and QoL, we found some related studies (e.g., [16, 37, 79–83]), but were not able to report them because they were either not indexed in the selected databases (i.e., PubMed, ScienceDirect, and PsycINFO), using a different conceptualisation of QoL (e.g., levels of emotional distress), or were published after our deadline of literature search (i.e., March 2017). However, the results from these "missing" studies also support the salutary effects of an attachment-based model of RS on levels of psychological wellbeing. We are confident that the studies selected for this IR are good representatives of relevant studies published within the past 10 years demonstrating how RS has been perceived/positioned in relation to QoL.
The findings from this review have broad implications for the role of RS in relation to QoL in medical-health contexts. Existing models of RS coping are better understood by integrating spiritually-based perspectives that include identifying aspects of faith and individual life that may be understood as a contextual 'biopsychosocial spirituality' . Greater awareness of the importance of RS among healthcare professionals may improve cultural competence in healthcare services and community support in addressing patient's spirituality, and strengthen collaborative relationship between healthcare and faith-based organizations. Further research on the relation between RS and QoL should be conducted across different population and health contexts.
Table 1 explores and summarizes the general categories of the articles in terms of the study characteristics.
Table 2 contains themes and meanings that emerge from the studies for describing the link between RS and QoL.
This study was funded by the School of Social Sciences and Psychology, Western Sydney University, NSW, Australia.
References of all data generated or analysed during this study are included in the reference list of this article.
VC drafted the initial version of article and contributed in designing the study, acquisition of data, analysis and interpretation of the data, critical revision of the manuscript, and final approval of the article. PA contributed to the data interpretation, critical revision of the article, and final approval of the version to be published. TM contributed to the conception of the review, data analysis and interpretation, critical revision of the article, and final approval of the version to be published.


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Why the old crisis comms playbook should be thrown out
Home / Why the old crisis comms playbook should be...
Specializations: Crisis Planning & Prevention
For crisis communications, it's a data obsession that will deliver results in the future.
Though there has been a pressing need for PR pros to show tangible results for their work, such as adopting measurement best practices like the Barcelona Principles, the COVID-19 pandemic offers a clear turning point for crisis communicators.
"It's no longer acceptable or even preferable to just go on your experience alone," says Robert Gemmill, senior vice president at Argyle, an agency that focuses on trust and reputation management. "I think there's a number of tools out there now that practitioners should rely on that puts data at the foundation of their counsel."
Robert Gemmill, SVP Washington, D.C., Argyle
That doesn't mean that listening software and artificial intelligence can replace the human element. Brands still need experts to make sense of the data—but a gut feeling is a poor foundation for a modern crisis communications strategy.
Everyone owns reputation now
Gemmill also argues that brand reputation can no longer exist as a siloed communications problem.
"COVID made it abundantly clear that there are no silos anymore, and reputation needs to be addressed at every level of the organization," he says. That requires a communicator to develop deep relationships across departments in advance. Gemmill says it is crucial to loop in HR, IT, finance and general counsel, to name a few, and make sure all players are "on the same page."
Organizations must do constant work to make sure that the entire organization has the same readiness plan ready to be activated if a crisis strikes. "When something like (COVID-19) hits and it's just handed over to the communications department," Gemmill warns, your response is not going to be prepared to activate in time.
The new playbook
So what does the new crisis playbook need to look like? Perhaps it's instructive to first look at what isn't working from the old playbook.
"For years, crisis communications teams have been tasked with coming up with a very tactical playbook, and that playbook could be anywhere from 20 pages to 100 pages long," says Gemmill. "It lists all of the stakeholders and all of the messages. It's very detailed about who to contact if X happens at Y time … so you can flip to page 47 if something similar to a scenario happens." However, Gemmill warns that this exhaustively detailed approach can still leave organizations—particularly C-suite level leaders— unprepared to take action.
"Simulations and trainings are becoming more and more important," he says, "and making sure that you're constantly reevaluating your risk profile, and that the scenarios in your communications approach are in line with your organizational approach as a company."
Holistic crisis comms
Crisis communications is no longer the art of spinning CEO missteps to avoid public fallout, bury bad news or provide cover for disastrous errors. That work is still being done—but fewer and fewer PR pros want to take it on.
It's the kind of work that Evie Smith, founder of Rebellious PR, specifically set out to avoid when she started her own PR shop after years in Silicon Valley. "I was not interested in having to spin when brands messed up in some way," she says. "Whatever it was, it was usually the brand's fault."
Evie Smith, Founder, Rebellious PR
However, in 2020 amid COVID-19, social justice movements and more, every communicator is a crisis communicator, and Smith and her team had to pivot to help their clients tell the whole story about themselves and their values. "Everybody is in crisis," she says, "and anybody who is doing PR has to somehow kind of get their crisis bearings."
That's when her team developed flow charts—themed around the character David Rose from the TV show "Schitt's Creek"—to help organizations build in some basic workflows for the next inevitable crisis.
[FREE REPORT: The Future of the Role of the PR Pro]
(Image via Rebellious PR)
One key question Smith continues to ask clients as they prepare for crisis scenarios is: "How fast do you want to respond?" That choice would then dictate other decisions, such as the number of people who would be contacted to sign off on a holding statement or how many people would convene on a task force to take action.
Gemmill agrees with Smith that a crisis plan that fails to align with the actions of the whole organization is bound for failure.
"You can't just handle a crisis from the communications side as if you're trying to get out of or mitigate that particular issue, he says. "It's much broader now, and everything that happens on the crisis communication side needs to complement the wider organization's goals."
It's why so many organizations are turning to purpose-driven communications and leaning into CSR and ESG. A modern crisis communications plan requires actively pushing and defending your record on core values at all times—and as the data from Deloitte shows, the stakes are very high to get that messaging right.
See more: https://www.ragan.com/why-the-old-crisis-comms-playbook-should-be-thrown-out/

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Rohan Gavaskar, Eklak join KKR
11yCricinfo staff
8hGeorge Dobell
Kolkata Knight Riders have recruited Rohan Gavaskar and left-arm seamer Eklak Ahmid - both former ICL players - into their ranks
Cricinfo staff01-Dec-2009
Rohan Gavaskar played for Royal Bengal Tigers in the ICL ICL
Kolkata Knight Riders have recruited Rohan Gavaskar and left-arm seamer Eklak Ahmid - both former ICL players - into their ranks. The Bengal duo were part of a two-day training camp at the Eden Gardens in Kolkata under the supervision of Dav Whatmore, KKR's new coach.
Gavaskar, son of Sunil, has represented India in 11 ODIs. He's played 116 first-class games, scoring 6914 runs at 44.60, and also bowls occasional left-arm spin. He played for Royal Bengal Tigers in the ICL, so did Eklal, who just has two first-class appearances to his name.
"It's certainly great that I am now a part of KKR after joining the Bengal Ranji Trophy squad. Twenty20 suits my style as I have scored good amount of runs in the ICL as well," Gavaskar said at the end of the day's practice session. "The association with someone so successful like Dav Whatmore should benefit me. Dav has certainly had loads of success as a coach, especially during his stint with the Sri Lankan team".
The third edition of the IPL, in 2010, runs from March 12 to April 25.


Do I have to travel into the Houston Medical Center to find a good dentist?
Finding a quality dentist in Houston doesn't automatically mean going to the Medical Center. Although, Houston's Medical Center is one of the most advanced in the world, with facilities that attract people from all over the globe, Houston's medical and dental talent can be found all over the city. There are many talented dentists that have set up their practice outside of the inner loop to serve communities throughout Houston.
Anyone who commutes to the Medical Center regularly knows how difficult it can be to drive through, as well as park. Fortunately, this is not necessary. No matter where you are in Houston, there's likely a quality dentist within a few miles.
How can I tell a good dentist apart from the rest?
A strong recommendation – Ideally, you have someone you trust to give you a head start on the search. This could be a trusted family member or friend, but it can also be your current dentist, if you're moving to Houston from another city. It's always a good idea to consult with your current dentist if you'll be moving because even if they can't provide a specific recommendation, they can give you an idea of what to look for in a new dentist.
A willingness to earn your business – Dentists are used to being selected in a somewhat random way, so it will probably be a nice surprise if you ask to interview the dentist a bit before settling on them permanently. The word "interview" is used loosely here. Inquire about the dentist's specialties, who they are comfortable working with, the technology they champion and so on. If you or a family member have special dental needs, make these known as soon as possible. For example, if your children are nervous around dentists, inquire about the methods they use to keep children calm and relaxed. Every practice is different in this regard, so verify that their approach is the one you want for your family. Otherwise, you may be forced into an uncomfortable position during an appointment. You should never settle for a dentist that balks at answering honest questions. If they make you feel like you're inconveniencing them, look elsewhere.
Positive reviews that you can trust – Yes, there is a mountain of online reviews for dentists, but you can't trust all of them. The most believable reviews are those that relate a story or experience with the dentist in question, as these tend to be truthful. If a review lists a ton of general stuff that concerns the practice as a whole, it could be a fake. If a dentist has earned a lot of believable, positive reviews, then that's a good sign. It's especially promising if the dentist is getting positive reviews due to their patient handling methods. Dentists that address a patient's needs directly are dentists that are usually solid all around.
An easy office staff to work with – When selecting a dentist, you're not just picking a dentist. You're selecting their entire staff, so make sure it's a staff that you can work with easily. Although you'll never know for sure until you visit the practice and interact with the office staff directly, you can still tell a lot by how the appointment-making process goes. If setting up or rescheduling an appointment is difficult, factor this in. That same staff will be responsible for ensuring your prescriptions are sent to the right place and on time. An inefficient and careless staff could make your day a nightmare if they are liable to make mistakes on the important details.
Strong communication – Chances are, the only people in the examination room that understands dentistry are the dentist and their assistants. That means you'll have to rely on your dentist to provide you with any information regarding your dental health and treatment options. Medical professionals, including dentists, normally succeed on their experience, education and abilities, and not on their ability to communicate. That means you never know what you'll get from a dentist regarding their patient handling until you've sat in the examination chair. So, did the dentist explain everything fully? Did they explain exactly why they recommend certain treatments? Did they show you the X-rays and point out where your teeth need some work? Did they sit there and answer your questions without hurrying you out the door? The ability to communicate is clearly a valuable trait to have in a dentist, but it's one that so many dental professionals fail to develop. It's a trait to target, though, because a dentist that communicates poorly is one that you will struggle to build a strong dentist/patient relationship with.
That may seem like a long list of demands to detail for a dentist, but there are plenty of Houston dentists that can check all the boxes. Although there are many dentists in Houston, including The Woodlands, Humble, Kingwood, Spring, Cypress and Katy, the location of a dentist is not as important as the quality of the staff and the thoroughness of the care you receive.


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Board index » The Forum » Other airforces
Mig 21 - C340
Moderators: Kremlin, Dean
Martiens
Post subject: Mig 21 - C340
Posted: 19 Sep 2017, 20:44
Location: Hermanus
Saw this on Facebook, for me it's sad, saw it years ago at museum
Post subject: Re: Mig 21 - C340
Location: Centurion, Pretoria, SA
If true, I'm deeply saddened. The MiG and F1CZ together were a great (and historically relevant) display. It'll most probably end up in the open and get vandalized.
20 September 2017: defenceWeb
SA returns MiG fighter to Angola
By Dean Wingrin
Under a cloak of secrecy, the South African government has returned a MiG-21 fighter jet that it acquired during the Border War conflict in 1988.
A prized possession of the SAAF Museum and placed on display at Air Force Base Swartkop, the MiG-21bis Fishbed with serial C340 of the Força Aérea Popular de Angola (FAPA, the Angolan Air Force) was acquired in December 1988 when the jet landed in northern South West Africa (now Namibia) after becoming lost and running low on fuel.
General Francisco Afonso Hanga, Commander of the Angolan Air Force, announced on Angolan National Radio (RNA) that the MiG-21 was returned to Angola on Sunday September 17. This was, he is quoted as saying, a goodwill gesture by South African President Jacob Zuma to mark the official opening that day of the Cuito Cuanavale monument.
The fighter was quietly removed from the Museum's display hall where it was exhibited next to a Mirage F1CZ, its South African Air Force (SAAF) adversary during the Border War, on Friday September 15 before being transported to the nearby AFB Waterkloof. It was then flown to Angola inside a FAPA Ilyushin IL-76TD Candid (serial T-911) transport aircraft.
It is not known if Angola specially requested the return of the aircraft, but Angola has many old MiG-21 aircraft available locally for display purposes.
The news has not been met with enthusiasm by South African military historians and aviation enthusiasts. The aircraft had pride of place at the SAAF Museum and was an important exhibit, drawing many local and foreign visitors to view and take photos of the two old adversaries standing next to each other.
The fighter was acquired by South Africa during the Border War, when on December 14 1988 FAPA pilot Lt Vinez took-off from the airfield at Lubango for a routine ferry flight to Menongue airfield. However, he became lost after entering cloud and decided to divert to the airfield at Cuito Cuanavale.
Flying in a south-easterly direction, but west of the planned route, he became low on fuel and executed a near prefect landing in an open field outside Tsumeb in the then South West Africa (now Namibia). The aircraft sustained minor damage to the underside.
An ex-SAAF officer, who requested not to be identified and was present at the time, says that contrary to popular belief, Lt Vinez had no intention to defect. During discussions at the accident site with him, his greatest concern was that he was in UNITA occupied territory. "It took some time to convince him otherwise," the officer remarked.
As there was no formal request at the time for the return of the aircraft, it was repaired to display condition for the SAAF Museum by Atlas Aviation's Apprentice School and first put on display in 1991. It had subsequently been repainted by the SAAF Museum.
Numerous requests to the SAAF and SAAF Museum for comment over the past two days were not responded to.
How come every time my ship comes in, I'm at the airport?
If this was the right thing to do, they would not have done this in secret.
GLF4
T-911 IL76 flew to Menongue from Waterkloof.
vlamgat16
She will be a rust bucket in less than 3 years....sad.
Location: ILS RWY19, FACT (Cape Town)
Sad news !!! ai ai ai
I was however, under the impression the Mig crashed in 1988, not 1989?
EDIT: The crash was in December 1988. On the 31st March 1989, the Mig21 pilot, Lt Domingos Vinez, along with 11 Angolans and 3 Cuban soldiers, were exchanged for a South African soldier - Johan Papenfus.
Brent Best
Roger the Dodger
They've already broken it! The nosecone was straight when it was on display...
Kremlin wrote:
Corrected to 1988.
The info board in front of the MiG-21 when it was on display says 1989!
Well then why does Angola not return all the SA Army equipment that was left there as well.??
Again no one can stop politicians taking over final decisions,I feel the youth of the country needed that aircraft here to show the history of the border war..the display was made with the F1 that shot down a similar plane.
The nose cone was loose before taking it away.
I find this sad..
Yesterday is history.
Tomorrow is a mystery.
But today is a gift.
That's why it's called the present.
Adrian Munro
http://www.weddingduo.co.za
https://www.facebook.com/Airfirephotography/
unfortunately once an aircraft/article gets handed over to the SAAF Museum there is no guarantee that it will remain in the collection. It has happened a couple of times now that aircraft have been taken out of the museum, or are left outside to deteriorate until the point they have to be scrapped.
This present's a conflict of interest between preserving heritage for the South African public and conforming to political/ military influence. The problem stems from the fact that the Museum is a SAAF unit, to be truly effective the museum should be separated from the SAAF and setup as non-profit organisation.
Disgusting and pathetic.
Its just petty really.
Mistral wrote:
In the early day's of the museum, they displayed the Mig-21, F-1CZ, and IIICZ 204 together in the same hanger. 204 was in very good condition but was transferred to AFB Makhado, where I trust she is being looked after. The Mig is now gone as well, leaving just the F1 by herself.
The lesson being, take your photo's whilst you can.
Airfire wrote:
This is what makes this whole thing seem a so sinister. To secretly raid museums when no one is looking and remove important/ relevant articles is basically the same as rewriting the history books. Surely heritage is more important than goodwill.
Another point is that it compromises the the Museum as a tourist destination which has a impact on the local economy. (Not that the museum is concerned about that point at all). Better the Museum, greater the impact on the economy. Nobody wants to see empty hangars.
Now when we visit the museum we can tell people, "you see the empty space over there, that is where a Mig-21 once stood but it was given away for some daft reason"
Sorry, but I find the lack of foresight to be very disturbing.
Location: Whangarei, New Zealand
"Victors" attempting to rewrite history.
A plan is simply a basis for change.
H1017412 wrote:
Correct they cannot get over the past conflict or racism of the past.Again just a show of black power and politicians doing as they wish in this country with whatever they wish,no one has any say in any of there stupid acts to so called IMPRESS other nations of the past communistic regime.
Why did they not just paint a few of the scrap Mig-21's in Angola for the monument..makes no sense.waste of time money and resources,as the politicians waste the air forces time with VIP transport,mostly what the SAAF does,at least our pilots get there hours.
I guess next will be the Mil-24 that the museum has and anything else they send back to the old communists(Did not say who now)
Last edited by Airfire on 21 Sep 2017, 14:48, edited 1 time in total.


text:
Pew: Smartphone penetration ranges from 24% in India to 95% in South Korea
Kyle Wiggers@Kyle_L_Wiggers	 February 5, 2019 11:00 AM
Taking into account the estimated five billion people with mobile devices around the world, the percentage of adults who own smartphones is higher in South Korea than in any other advanced economy (95 percent), including Israel (88 percent) and the Netherlands (87 percent). (The U.S. ranks sixth on the list with 81 percent, tied with Australia and just ahead of Spain.) Only 49 percent of people in developing countries use social media. And 50 percent or more of people in more than a dozen emerging economies now regularly browse the web.
Those stats come courtesy the Pew Research Center, which today published the latest in a series of studies concerning internet, social media, and mobile phone trends. More than 30,133 people in 27 countries responded for the Spring 2018 Global Attitudes Survey, and while a few of the results don't tread new ground — such as the fact that social media usage is on the rise globally — others, like the strong correlation between education and social media usage, are more than a little surprising.
Smartphone usage
People in the U.S., Canada, U.K., and other developed economies are more likely to have phones than people in emerging countries, Pew found — a median of 76 percent compared with 45 percent. That said, across the nine developing nations surveyed, smartphone ownership increased in eight — a remarkable shift considering that in 2015, roughly 27 percent of people in those countries owned a smartphone. In South African alone, the portion of people who own smartphones grew from 37 percent to 60 percent, while in Brazil, it quadrupled to 60 percent.
Still, emerging economies trailed advanced economies overall when it came to smartphone ownership. In the former, rates ranged from a low of 24 percent in India to a high of 60 percent in Brazil and South Africa, compared with 86 percent in countries such as Sweden.
Phone ownership varied widely by geography — even in developed countries. While around 90 percent of South Koreans, Israelis, and Dutch people told Pew they had a smartphone, rates were closer to 60 percent in nations like Poland, Russia, and Greece. Meanwhile, in emerging economies, ownership rates ranged from highs of 60 percent in South Africa and Brazil to around 40 percent in Indonesia, Kenya, and Nigeria.
Perhaps unsurprisingly, young people — folks under the age of 35 — were much more likely to have smartphones, access the internet, and use social media than older populations in every country Pew surveyed. (In Russia, only a quarter of adults 50 and older own a smartphone.) But the age gap appears to be narrowing. Nine in 10 Americans ages 34 and under report owning a smartphone since 2015, while ownership among the 50-and-older crowd rose from 53 percent to 67 percent over the same period. And in Germany, ownership among those ages 50 and above rose from 40 percent in 2015 to 64 percent in 2018.
That wasn't necessarily true in emerging economies. In Mexico, 29 percent of 18- to 34-year-olds reported owning smartphones in 2013 compared with 7 percent of Mexicans ages 50 and older, and although smartphone ownership jumped to roughly two-thirds of young Mexicans by 2018, it remained at just 30 percent among those ages 50 and above.
Internet and social media usage
Internet usage is nearly universal in most of the advanced economies surveyed. According to Pew, 90 percent of respondents in the United States, Sweden, Australia, the Netherlands, Israel, and South Korea reported regularly accessing the web, while 50 percent or more people in all developing countries but India reported the same. Furthermore, usage grew rapidly in emerging economies — from 45 percent and 34 percent in Mexico and the Philippines, respectively, to 73 percent and 66 percent.
Social media usage is somewhat less widespread. A median of around half (49 percent) of survey takers reported using social networking sites, and the results varied across countries. In Mexico, the Philippines, Brazil, and South Africa, half or more reported using social media, while only around a quarter of Indians said they used social media.
Age dictated usage, to an extent. About 90 percent of respondents under the age of 35 in Argentina said they used social media, compared with roughly 38 percent of those ages 50 and older. And in all emerging economies surveyed but India, more than half of those ages 18 to 34 said they used social media, compared with the third of people 50 and older who said they do the same. The generational disparity is especially large in South Africa, where 70 percent of 18- to 34-year-olds use social media and just 19 percent of those 50 and older use it.
Gender predicted social media usage in some countries. In the U.S., Spain, and Australia, women were more likely than men to use social media, while in other advanced economies, such as Japan and France, men were slightly more likely to use them. In Kenya, Nigeria, and India, where smartphone ownership differed substantially by gender, women were less likely than men to use Facebook, Twitter, and other social media sites.
The role of education and gender
Better-educated and higher-income people are more likely to use the internet than people with lower levels of education or income, Pew found.
A majority of Nigerians with a secondary education or more said they used social media (58 percent), compared with just 10 percent of Nigerians with less education. And in Indonesia, nearly three in four adults with the same education level reported using sites like Facebook compared with about a quarter of adults with lower levels of education (23 percent). Those same gaps were present in advanced economies — in the U.K., 75 percent of those with a high school degree or better reported using social media, compared with 63 percent of those with a secondary education or less.
Divisions in education cut across internet usage: For example, 65 percent of more-educated Nigerians use the internet compared with just 12 percent of those with less schooling.
In most countries, gender wasn't a strong predictor of technology adoption. But the opposite was true in India, where men (34 percent) were much more likely than women (15 percent) to own smartphones. India's gender gap appears to be growing, moreover — it's 10 points wider than it was just five years ago, when 16 percent and 7 percent of men and women reported owning smartphones, respectively.


Elly-May Barnes is the youngest daughter of Jimmy Barnes, front man for Cold Chisel, and his wife Jane Mahoney.
She was a member of children's pop group the Tin Lids, along with her sisters Mahalia, Eliza-Jane and Jackie, releasing three albums in the early 1990s. Elly now has a son with long-term partner, Liam Conboy.


Benevolent Jupiter remains in Libra, 11th to your natal Moon, till October 11, 2018 and then in Scorpio, 12th to your sign for the remaining part of the year.
Karmic grandmaster Lord Saturn stays in Sagittarius, your ascendant, conjunct to your natal Moon for the entire year.
Rahu, North Node of Moon stays in the sign of Cancer, 8th to your natal Moon throughout the year.
Ketu, the South Node of the Moon stays in Capricorn, 2nd to your natal Moon throughout the year.
Mars, the mighty Warrior has an exceptionally long stay in Capricorn from May 2, 2018 - November 6, 2018, i.e. 2nd to your natal Moon.
The Sagittarius born individuals are likely to face mixed results during the year 2018. While Jupiter's auspicious transit through the 11th house for most part of the ensures that you are relatively comfortable, it is the Saturn transit overhead - in your ascendant, known as the difficult Janma Shani part of the sade sati period, that may create several challenges.
Sagittarius, the Jupiter ruled archer that moves with agility of a horse can get tremendously frustrated with obstacles and repeated efforts in the same direction! With this transit, the mind and willpower often get affected and facing challenges with a straight face becomes difficult.
You will do well to get most of the important work accomplished during the first three quarters. You will also need to keep a firm handle on your communication - both verbal and written. There may be opportunities to do well but you could end up creating not just misunderstandings but even enemies because of the sharp edges in your communication.
The last quarter maybe tough so get all your ducks in a row, well before that time.
The first three quarters of 2018 are definitely much better than the last part. It would be the wisest to make use of this sunny patch brought in by Jupiter's 11th transit - straighten out any complex situations in your professional or financial life. Saturn overhead definitely does not make things easy, however Jupiter's position may make things relatively better till mid October 2018. Since Saturn rules the 2nd house of wealth and income and 3rd house of courage and initiative for this sign, monetary matters and financial issues are certainly areas for concern.
Some Sagittarius individuals looking for a new job may find a suitable one but the responsibilities at work or the pressure you must face now, increases in a significant way. Some individuals may get a promotion or may be put in a leadership role - this however, may get really demanding as the days go by!
Some of the Sagittarius individuals may be pushed into borrowing, despite resistance. There may be similar and possibly more challenging situations for those engaged in business activity. However, if you do not shirk from disciplined hard work and also do not allow your ego to mess up your relationships with partners, vendors and employees as well, you are likely to fare much better!
Persistence with little flexibility could go a long way. The period from the month of May through November is tricky. Mars conjunct Ketu may bring opportunity to create good wealth but it may be equally perilous for your fortunes if you are associated with unethical people or work with only short-term goals in sight.
You will need to weigh your decisions really well before taking any action on it. Impulsive actions and randomly trusting people are perfect recipe for disaster. Overheated temperament, unnecessary arguments and scraps unlikely so keep wary, as this may lead to situations with serious consequences. Those in partnership may suddenly decide to part way.
Some of the Sagittarius individuals may get to work on large, prestigious projects bringing in big profits. Make sure that you deliver well within the timelines. Some of you may even begin a business on the side - a hobby turned serious! Opening up another avenue of income definitely helps but it may cause lots of physical fatigue unless you are really careful about maintaining a healthy lifestyle.
The year 2018 also brings focus on inheritance related matters and also on legal battles related to getting your fair share in land or property. If it stretches beyond September, it may take a lot more time to settle down. Be careful of false allegations and do not put your signature on any documents before thoroughly studying it. You may not have any mentor/ father figure to fall back on for advice, when you really need it.
The year 2018 brings wedding bells for the eligible and willing Sagittarius individuals. There may also be a chance of reconciliation among partners who have been facing a hard time. It is a pleasant opportunity brought about by Jupiter's 11th transit. You may surpass challenges posed due to interference from extended family members and may start a new life together in a different city altogether.
Some Sagittarius individuals may be blessed with a child during this time too. Saturn's direct aspect on the 7th house of marriage and interpersonal relationships will create occasional hiccups. There may be health issues of an elderly within the family that cause anxiety as well as impact on your health and monetary resources as well.
Watch your communication closely and make concerted effort to be kind in speech from May to November. Harsh speech may actually cause damage to some close equations. Anger issues should be defined and then root cause must be addressed effectively. A new home or vehicle could be bought this year bringing excitement.
The Sagittarius individuals need to be careful about health - especially, mental health issues streaming from overwork, stress and anxiety. Chronic health conditions may become worse towards year end.
Bone health, metabolic issues and stomach ailments may cause problems. Avoiding pungent, spicy food will be of much help.
Issues related to reproductive health system and genitalia may affect you mid-year.
The Sagittarius individuals could consider wearing a good natural ruby to get the best out of this time, if Sun/ Surya happens to be a natural yoga karaka for you. Wearing a good yellow sapphire will bring significant health benefits. Get your suitable detailed personalized gemstone recommendation or a brief personalised gemstone recommendation before you get your powerful talisman!


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