Despite the relatively recent introduction of professional spiritual care in Israel, the percentage of patients interested in the service (41%) or valuing its inclusion in the hospital's services (60%) indicate a significant positive disposition towards hospital-based spiritual care. Previous studies in hospitals where spiritual care was better established found a range of patient interest in spiritual care: 54% (rehabilitation) , 41% (internal medicine) , and 35% (medical/surgical) . Despite the newness of the Israeli spiritual care service, levels of patient interest were within the range found in those more established settings. As can be seen in Table 4, the value given to addressing spiritual needs correlates with a desire for spiritual care, suggesting that patients already look positively at this service as a means of helping them with their spiritual needs. Patients' sense of understanding what spiritual care is was a predictor of their interest in the service that persisted in the multivariate analysis. This suggests the importance of education and awareness in determining public interest in the service – the more patients understood what the service has to offer, the greater their interest in receiving the service. That result parallels the finding that lack of knowledge and understanding are key factors in institutions not including spiritual care . The results for patient interest may be expected to change as levels of awareness grow.
Even among those who expressed indifference to a spiritual care visit, between half and two-thirds of such patients found the kinds of support spiritual caregivers provide to be important to them for most items. Increased patient education might shift that indifference into openness, although it also could be the case that those patients’ needs are being met elsewhere.
The significance of previous experience in receiving spiritual care as a positive predictor of patient interest in the service supports previous findings [31, 32]. The persistence of this factor even in the multivariate model suggests that it is not just that those who were previously likely to be interested in spiritual care continue to be interested. Rather, this finding supports the positive impact of care and suggests that it is being well received.
To what extent does the significance of demographic, medical, and social/experiential factors vary between Israel and other cultural settings, in predicting patient interest or satisfaction? As described in the Background, we are aware of four studies, all American, that measured this question. In the present study, as in those previous studies, gender, marital status, religion, and ethnicity were not predictive factors [29–32] (with the exception of "Other" ethnicity in ).
Older age was a significant predictor in 3 of 4 studies, but not in the present study. Perhaps its significance was confounded in our results by the fact that younger Israelis show increased spirituality , or it may provide evidence for a cross-cultural difference. Educational level, significant in every prior study though not always in the same direction, was not significant here, perhaps suggesting that it, too, can reflect cultural difference.
Our study was the only one to examine country of origin. Israel is a nation of immigrants from countries with widely differing cultural approaches in caring for illness and spirituality . This item is of particular interest regarding the question of whether we should expect to find cross-cultural difference in patient interest around the world, and the fact that it was an insignificant factor in our study strengthens the above conclusion that variance between countries will not be significant.
As in most other studies, self-defined spirituality [30, 32], or religiosity [29, 30] were significant predictors of positive perceptions of spiritual care. It seems likely that these are fairly universal factors. Our study did not find significance in public religious practices, such as attendance at worship services; other studies also differed regarding the significance of that item [29–31]. It should be noted that our results showed co-linearity between spirituality and religiosity even though the questionnaire cover letter, viewable in the Additional file 1, distinguishes clearly between the two.
In examining the impact of the seriousness of the medical condition on patient interest in spiritual care, the results have not been uniform. Ledbetter's approach to spiritual screening assumes that the likely impact of the medical condition on the patient’s life is a major factor . Some studies found significance in average disease length of stay  or severity of pain , but other medical factors including cancer diagnosis and comorbidity were found in those studies and elsewhere  not to be statistically significant. Our study did not find any of the medical factors, including recurrence, metastasis, and treatment stage, to be significant. However, the fact that respondents had to be physically able to answer the questions, even if at times with the help of family or staff member, excluded those who were in worse condition, perhaps masking the predictive significance of medical condition. In addition, because all respondents were diagnosed with cancer, we could not measure the differential impact of a cancer diagnosis to that of other illnesses.
Lucas' approach to pastoral care emphasizes community, with the expectation that lesser community support increases the need for spiritual care , and community is one of the key areas covered by Puchalski’s FICA tool for spiritual history taking . Ledbetter's screening approach considers lack of social support to be a major factor determining low coping resources . One study did not find a significant relationship between social support and patient requests for spiritual care , and some of the social support items we included were insignificant as well. However, Lucas' and Ledbetter's predictions of the significance of community were supported by our persistent finding that lower frequency of visits by friends and family was a predictor of patient interest in spiritual care. Identifying "lonely" patients as more likely candidates for spiritual care helps provide direction to departmental staff members and spiritual caregivers in determining whom to visit in the limit number of available staff hours.
What do these results suggest for the viability of cross-cultural screening protocols? The current data suggest that most demographic factors are consistently irrelevant, though age and education may be significant in certain cultures. The stage or severity of disease is of ambiguous utility for screening regardless of cultural setting. It should be noted that the persistent factors in the present study, including spirituality/religiousness and support from family/friends, largely match the factors identified in the FICA tool, which may prove to be a valuable cross-cultural measure.
In looking at spiritual needs and the kinds of spiritual care support patients most valued, there was a significant cultural difference, as predicted, regarding explicitly religious/spiritual items. There were four such items, and they were the four lowest-rated. Prayer ranked last in our study among kinds of spiritual support desired, at 30% of those interested in spiritual care, whereas in America prayer was the most common intervention expected of spiritual caregivers , desired by 74% of those interested in spiritual care in one study . Other low-ranked items were addressing spiritual/religious questions (35% overall) and bringing a sense of spirituality to the room (46% of those interested in the service), versus 61% of Irish hospice patients  and 78% of religious Japanese bereaved family members , respectively. Only 43% of patients overall were interested in relaxation, meditation, music, or guided imagery, which could be generally characterized as spiritual techniques. Although interest in these religious/spiritual items predicted interest in spiritual care, there were many similarly predictive items, not explicitly religious/spiritual, endorsed by a much larger percentage of the population. The spiritual care desired by Israeli patients is not limited or primarily directed to the explicitly religious/spiritual realm.
The main methodological limitation of the study was the population response bias. The questionnaires were offered to all patients currently hospitalized or in the treatment clinic at that moment. However, we did not gather demographic data on those who chose not to complete the survey to compare with those who did, and did not analyze the bias in who chose to participate. We also did not record what percent of patients approached chose not to complete a questionnaire, for physical or other reasons.
The question regarding "Frequency of Visitors (if Hospitalized)" had the final answer option "not hospitalized". However, many respondents did not see that option and left this question blank, although many outpatients did answer this question. Thus, those data should best be looked at as a composite of all patients, rather than distinguishing between in- and outpatients. As a result, we do not have precise data on the breakdown among respondents between outpatient and inpatient, though we can provide a general estimation that at least 80% were outpatient. Finally, the question about types of support was not pilot tested with patients.