create the summary of the findings "MATERIALS AND METHODS
Patients and settings
This was a cross-sectional study carried out in Tehran, Iran. A sample of
patients with SCI attending the Brain and Spinal Cord Injury Repair Research
Center in Tehran, Iran, a referral center, were entered into the study. The
inclusion criteria were as follows: having SCI and at least 18-year old at the time
of study. Patients were excluded if they had chronic comorbidity including
diabetes mellitus, cardiovascular diseases, hypertension, rheumatic diseases and
kidney disease. Demographic and injury-related characteristics were obtained
from interviews, neurologic examination and hospital records and self-report.
The study was approved by the Institutional Review Board of the Brain and
Spinal Cord Injury Research Center in Neuroscience Institute, Tehran
University of Medical Sciences, Tehran, Iran.
Measures
1. A study-specific questionnaire in order to collect data on demographic and
injury-related characteristics.
2. International standards for neurological classification of SCI developed by
the American Spinal Injury Association (ASIA) in order to classify injury
severity into complete (ASIA grade A) and incomplete (ASIA grades B–E).20
3. The Brief Religious Coping Questionnaire (RCOPE) to collect data on
religious coping. It is a valuable, theoretically based comprehensive tool for
measuring religious coping. This is a 14-item questionnaire that consists of
two subscales: positive and negative religious coping. Positive religious
coping reflects a secure relationship with a transcendent force, and negative
religious coping reflects underlying struggles within oneself, with others and
with the divine. Each item is rated on a 4-point Likert scale ranging from 1
(strongly disagree) to 4 (strongly agree) giving a total score of 7–28 for each
subscale.21 The inventory has been validated in the Iranian population.22
4. The Spiritual Well-Being Scale (SWBS) to evaluate spiritual well-being. The
SWBS is a 20-item questionnaire that consists of two subscales: a religious
well-being and an existential well-being. Each item is rated on a 6-point
Likert scale (from 1 to 6), giving a total score ranging from 20 to 120 where
the higher scores indicate greater well-being. The Religious well-being
subscale provides a self-assessment of one's relationship with God, whereas
the existential well-being subscale gives a self-assessment of one's sense of life
purpose and life satisfaction.23 This questionnaire has been used in other
studies in Iran. The psychometric properties of the Iranian version of the
questionnaire are well documented.24
5. The Hospital Anxiety and Depression Scale (HADS) in order to measure
anxiety and depression. The HADS consists of 14 questions. Each item is
rated on a 4-point Likert scale ranging from 0 (absence of symptoms) to 3
(severe symptoms). Scores on both anxiety and depression subscales range
from 0 to 21. Scores of 11 or more on either subscale are considered to be a
significant ‘case’ of psychological morbidity, whereas scores of 8–10
represent ‘borderline’ and 0–7 ‘normal’. The psychometric properties of
the Iranian version of HADS are reported elsewhere.25
Statistical analysis
Descriptive statistics were used to explore the data. Logistic regression analysis
was performed to identify correlates of anxiety and depression with spirituality
and religious coping. Depression and anxiety status were treated as dependent
variables, whereas age, gender education, work status, neurological classification
of SCI (ASIA grade), time since injury, spiritual well-being and religious coping
were considered as independent variables. For the purpose of the logistic
regression analysis ‘borderline’ and ‘normal’ categories were merged. In order
to reduce experimental bias, the main investigator was blind to when the data
analysis had been completed.
RESULTS
In all, 213 patients with SCI were studied. The mean age of
participants was 33.7 (s.d.=9.5) years, and 64 patients (30%) reported
severe anxiety, whereas only 32 patients (15%) reported severe
depression. Overall, 20 patients (9%) reported both severe anxiety
and depression. The characteristics of the study sample are shown in
Table 1. The comparison of spiritual well-being and religious coping
by gender, education, marital status and employment is shown in
Table 2. There were significant differences between gender and
religious well-being and positive religious coping (P=0.023 and
P=0.005, respectively). In addition, there was a significant difference
in existential well-being between employed and unemployed patients
(Po0.001).
Table 1 The characteristics of study sample (n = 213)
No. (%)
Age (years)
Mean (s.d.) 33.71 (9.58)
Range (19–63)
Gender
Male 165 (77.5)
Female 48 (22.5)
Education
Primary 37 (17.4)
Secondary 131 (61.5)
Higher 45 (21.1)
Married status
Single 78 (36.6)
Married 113 (53.1)
Divorce 22 (10.3)
Employment status
Employed 30 (14.1)
Unemployed 183 (85.9)
Neurological classification of spinal cord injury (ASIA grade)
Incomplete 99 (46.5)
Complete 114 (53.5)
Time since injury
Mean (s.d.) 4.05 (5.02)
Range 0.08–33.0
Anxiety
Caseness 64 (30)
Borderline 53 (25)
Normal 96 (45)
Depression
Caseness 32 (15)
Borderline 62 (29)
Normal 119 (56)
Spiritual well-being
Religious well-being 50.9 (9.0)
Existential well-being 41.3(10.1)
Religious coping
Positive religious coping 24.22 (4.01)
Negative religious coping 15.02 (3.68)
Religion and spirituality in patients with SCI
P Rahnama et al
871
Spinal Cord
Risk factors for anxiety and depression
The relationship between depression and anxiety with independent
variables was examined by performing multiple logistic regressions.
The results indicated that gender (odds ratio (OR) for female=3.34,
95% confidence interval (CI)=1.31–8.51, P=0.011), employment
(OR for unemployed=5.71, 95% CI=1.17–27.78, P=0.031),
negative religious coping (OR=1.15, 95% CI=1.04–1.28, P=0.006)
and existential spiritual well-being (OR=0.93, 95% CI=0.89–0.97,
P=0.003) were significant contributing factors to anxiety
(Table 3), whereas negative religious coping (OR=1.21, 95%
CI=1.06–1.37, P=0.004) and existential spiritual well-being
(OR=0.90, 95% CI=0.84–0.96, P=0.001) were significant contributing factors to depression (Table 4). Indeed, the findings from the
present study indicated that female, unemployment, negative
religious coping and lower score in existential dimension of
spiritual well-being were significant predictors of anxiety. In addition,
negative religious coping and lower score in existential dimension
of spiritual well-being were significant contributing factors to
depression.
DISCUSSION
The findings from this study showed that the prevalence of severe
anxiety among patients with SCI in Iran was relatively high, whereas
the prevalence of severe depression was low, even lower compared
with the general population.26 Perhaps this low level of severe
depression might be attributed to the support they were receiving
from different organizations and family. A recent meta-analysis of
studies on depression in patients with SCI revealed that the prevalence
of depression in this population was 22.2%.27 However, our findings
on severe anxiety were consistent with previous studies where, for
instance, it was reported that out of the 443 patients with SCI 30%
experienced anxiety disorders.28
The findings of current study showed that, although higher
existential dimension of spiritual well-being contributed to decreased
anxiety, higher degree of negative religious coping increased the
risk of severe anxiety. Similar observation was evident for risk of
severe depression. In fact, the results obtained from this study
indicated that patients with lower negative religious coping and
higher levels of existential well-being had lower levels of severe
anxiety and depression. This might be true for any individual from
different religions; however, we think Iranian patients were under the
influence of Islamic believes and thus positive thinkers showed better
mental health. Islam emphasizes on the strategies to cope with
negative life events and reduces stress levels including having
positive thoughts, to stay hopeful, consider God’s mercy, the
remembrance of God and have patience in facing problems.29,30
Furthermore, as Muslims believe, Allah is able to do all things:
“And never give up hope of Allah's soothing mercy: truly no one
despairs of Allah's soothing mercy, except those who have no faith.”
(Quran, 12:87)31.
Table 2 Comparing spiritual well-being and religious coping by
gender, education, marital status and employment (n = 213)
Spiritual well-being Religious coping
Religious
well-being
Existential
well-being
Positive
religious coping
Negative
religious coping
Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.)
Gender
Female 50.2 (9.45) 40.43 (11.04) 25.64 (2.50) 15.64 (3.72)
Male 53.2 (7.25) 41.61 (9.89) 23.80 (4.27) 14.84 (3.66)
P 0.023a 0.482a 0.005a 0.188a
Education
Primary 51.18 (8.56) 40.89 (8.52) 24.24 (3.86) 15.32 (3.71)
Secondary 50.68 (8.70) 40.71 (10.90) 24.10 (3.79) 15.27 (3.65)
Higher 51.37 (10.60) 43.55 (8.91) 24.53 (4.79) 14.06( 3.66)
P 0.891b 0.259b 0.829b 0.143b
Marital status
Single 50.70 (10.03) 41.46 (10.08) 23.75 (4.75) 15.14 (3.59)
Married 50.55 (8.61) 42.04 (9.71) 24.45 (3.59) 14.79 (3.89)
Divorced 53.54 (7.65) 37.36 (12.03) 24.68 (3.12) 15.81 (3.00)
P 0.358b 0.140b 0.429b 0.467b
Employment status
Employed 53.36 (7.57) 47.20 (8.76) 24.56 (3.56) 14.33 (2.97)
Unemployed 50.52 (9.25) 40.38 (10.06) 24.16 (4.09) 15.14 (3.78)
P 0.111a o0.001a 0.612a 0.266
aDerived from t-test. bDerived from one-way analysis of variance.
Table 3 The results obtained from multiple logistic regression
analysis indicating risk factors for anxiety (n = 213)
ORa 95% CI P
Age (years) 1.00 0.96–1.05 0.734
Gender
Male 1.0 (ref.)
Female 3.34 1.31–8.51 0.011
Education
Primary 0.47 0.14–1.61 0.232
Secondary 1.02 0.396–2.67 0.953
Higher 1.0 (ref.)
Marital status
Single 1.0 (ref.)
Married 1.70 0.66–4.34 0.267
Divorced 1.60 0.39–6.516 0.505
Employment status
Employed 1.0 (ref.)
Unemployed 5.71 1.17–27.78 0.031
Neurological classification of spinal cord injury (ASIA grade)
Incomplete 1.01 0.48–2.06 0.993
Complete 1.0 (ref.)
Time since injury 0.94 0.86–1.02 0.177
Spiritual well-being
Religious well-being 1.03 0.98–1.08 0.196
Existential well-being 0.93 0.89–0.97 0.003
Religious coping
Positive religious coping 0.94 0.84–1.04 0.252
Negative religious coping 1.15 1.04–1.28 0.006
Abbreviations: ASIA, American Spinal Injury Association; CI, confidence interval; OR, odds ratio. aAdjusted for all independent variables using the enter model.
Religion and spirituality in patients with SCI
P Rahnama et al
872
Spinal Cord
Several studies from Iran in different samples of patients including
patients affected by mustard gas, multiple sclerosis, hemodialysis and
cancer confirm our findings.31–34 For instance, a qualitative study in
patients affected by mustard gas revealed that they were using
spirituality to handle stressful conditions they face because of their
disease complications.31
The findings from the present study indicated that gender
was a significant predictor of anxiety. Indeed, women experienced a
higher level of perceived anxiety compared with male. Similarly, a
study reported that the occurrence of anxiety among women
with traumatic SCI was more common than male patients.11 In
addition, a research has reported that 51% of women with SCI had
anxiety.35 This is an important finding, as this might lead to a gender
inequality. The findings suggest that there should be more attention to
this group of patients and ways should be found to reduce their
anxiety.
The findings from this study should be interpreted with caution, as
the study had several limitations. The study design was cross-sectional,
and we only focused on one coping strategy, whereas there are other
forms of coping strategies that do not involve religion and spirituality––such as, participation in a non-religious community, support
group, team sport/physical activity or craft.
Finally, as indicated, patients with SCI suffer from multiple
challenges that can affect their psychological and physical well-being.
Indeed, there is a need to recognize these challenges and help patients
in order to improve their quality of life."