TITLE: Effect of Islam-based religious program on spiritual wellbeing in elderly with hypertension

  ABSTRACT.BACKGROUND:
Lack of spiritual health in patients with hypertension leads to many mental, social, and physical effects, On the other hand, considering the prevalence of hypertension among the elderly, interventions to enhance their spiritual wellbeing is essential. Therefore, the aim of this study was to examine the effect of religious programs based on Islam on spiritual wellbeing in elderly patients with hypertension who referred to the health centers of Isfahan in 2014.

ABSTRACT.MATERIALS AND METHODS:
This study was a randomized clinical trial. The participants (52 elderly patients with hypertension) were randomly divided in to experimental and control groups. Religious program was implemented for the experimental group in eight sessions in two Isfahan health centers. Spirituality wellbeing survey (SWB) questionnaire was completed in three steps, namely, pretest, posttest and follow-up (1 month) in two groups. In the study, Chi-square test, independent t-test, and repeated-measures analysis of variance were performed for analyzing the data.

ABSTRACT.RESULTS:
Before the intervention, there was no significant difference between the mean scores of spiritual wellbeing, the religious dimension, and the existential aspect of spiritual wellbeing of the two groups. However in the posttest step and follow-up stage, the mean scores of spiritual wellbeing, the religious dimension, and the existential aspect of spiritual wellbeing in the experimental group was significantly higher than in the control group (P < 0.001).

ABSTRACT.CONCLUSIONS:
The religious program based on Islam promoted the SWB of elderly patients with hypertension; further, nurses can use these programs to promote the SWB of elderly patients with hypertension.

BODY.I:
New developments in healthcare and preventive considerations as well as control of contagious diseases have increased the longevity of people; moreover, the population of the elderly is increasing world-wide.[1] Today, 8.5 percent of people worldwide (617 million) are aged 65 and over. According to a new report, "An Aging World: 2015," this percentage is projected to jump to nearly 17 percent of the world's population by 2050 (1.6 billion).[2] According to the Iranian Statistics Center's report (2011), The population of over 60 year old Iranians is more than 6 million of Iran's population (8/2 percent), and it is expected that it will reach more than 25 million by 2050.[3] It is obvious that a changing and aging demography will be followed with disability and mortality caused by chronic diseases among the elderly population.[4] Hypertension is a prevalent chronic disease in the old age, and is very common among 60–70% of over-60-year-old people. Hypertension is a serious cause of death and disability in the elderly.[5] Furthermore, its treatment and healthcare costs are very high.[6] It is known to play a role in provoking certain diseases such as myocardial infarction, heart failure, strokes, and renal diseases, and hence results in more deaths, which has attracted the attention of many health practitioners.[7] Stressful chronic events are an inseparable cause of hypertension.[8] Because old age is usually associated with a sense of failure and emptiness, stress is more serious and common in these years of life, and affects the elderly's strength and adaptability against diseases[9] and causes depression, fear, and lack of control over life.[10]  When adaptability mechanisms seem insufficient, they may induce a sense of loneliness. In brief, older people face a spiritual crisis;[11] spiritual wellbeing is a factor that shows how people can face problems and stresses caused by a disease, and as a dimension of well-being, it can integrate other dimensions of the disease.[12] Strengthening the spiritual well-being will provide the elderly the necessary strength to fight and adapt to the life's daily issues such as alterations, diseases, losses, and deaths.[13] Thus, it appears that supporting the spiritual or religious resources and offering such services can be useful for strengthening the spiritual health and the ability of the elderly people to face and fight against diseases. Because spiritual care is considered to be a duty of nurses, they are expected not only to consider and monitor the physical and mental health of the elderly people but also to respect their spiritual wellness dimensions and to better understand their needs.[14] Some studies have been conducted in this regard, for example, Pargament et al. (2004) found a relationship between positive religious adaptability technique and spiritual consequences, along with the physical and mental health of elderly people who were admitted to a hospital.[15] Delani and Barer showed that the spiritual care is effective in improving the spiritual wellness of patients with cardiovascular diseases.[16] Mo'tamedi et al. (2005) introduced successful aging to be a proper model in terms of having religious inclinations.[17] Likewise, some studies have indicated that patients with hypertension use religion and spirituality to control and adapt to their disease.[18] What is interesting here is that the relationship between religion and health in elderly people and patients with hypertension has not always been reported positive. Some studies implied that religious beliefs had no effects on patients' health, which is due to increased anger, feeling of guilt, lack of self-confidence and increased distress, and psychological and spiritual distress.[1920] The effect of various cultural factors including religious beliefs and spiritual activities in any nation on people's spiritual wellness has been studied. Likewise, the significance of spiritual health of elderly people with hypertension and their serious need for spiritual interventions, given the fact that approximately 98% Iranian people are Muslim and 90% of them are Shiite, and religious beliefs play a significant role in their life, especially under critical conditions.[21] It seems that using religious interventions based on Islam with deep roots in the Holy Quran and sayings of Hazrat Muhammad (PBUH) and other infallible Imams of Shia can be among the best spiritual interventions for the Muslim people in critical conditions. Islam cares about the spiritual wellness, which is called a pure heart.[22] The Islam-based religious interventions method is a mixture of cognitive, emotional, behavioral, and spiritual methods taken from Quranic verses and narratives of the Infallible Imams. What makes this method different is its comprehensive overview and its adaptability with human nature.[23] When people face with difficulties, prayer and recitation of the Quran and thanksgiving and forgiveness help them to cope with life difficulties and feel more health.[24] Therefore, because of the lack of research-based evidence regarding the effect of Islam-based religious interventions and because of lack of studies dealing with the direct effect of the religious interventions on the spiritual health of the elderly patients with hypertension, conducting this study seems relevant.

BODY.M:
This study was a randomized clinical trial, which has been registered with the code of IRCT2014090118997 in the Clinical Trial Registration Center of Iran, and was approved by the Research Deputy of Isfahan University of Medical Sciences on May 11, 2014 (393174); the study started on May 21, 2014 and finished on September 22, 2014. The participants of this study comprised older people with hypertension who visited the healthcare centers in Isfahan City. Two healthcare centers located in Isfahan City were sampled for 2 months (July–August 2014). For choosing the samples, initially, we selected two healthcare centers among all centers in Isfahan, which were very alike and similar in terms of cultural, economic, and social consideration. Thus, samples (either control or test) of this study were selected from two centers. Then, the sampling procedure started in these centers through simple sampling technique. The inclusion criteria of the study were: 60–75 year-old individuals, Muslim, blood pressure between 140.90 and 159.99 (based on the doctor's diagnosis recorded in the patient's case file), lack of acute physical or psychological disease (based on doctor's confirmation), and lack of other simultaneous supplementary medical procedures. Their conscious written consent was taken as another criterion for inclusion in the study. When the samples were determined in the final stage, members of both control and test groups of each center were randomized using a random figure table by the researcher. Samples were divided into two groups of test (26) and control (26). The questionnaires were filled by the members of both the groups before the intervention. After the pretest, an Islam-based religious plan was implemented collectively for the members of the test group. This plan was elicited from spiritual and religious interventions which were based on Quran verses and narratives of Infallible Imams on reliance on God, appreciation, patience, forgiveness, and participation in charities, Dhikrs and pilgrimage.[2526] The content of the program was confirmed by several experts of medicine, psychology, and theology. The program included eight sessions; one session per week, and each session lasted 60–90 minutes. Then, titles and overall scheme of the sessions were explained succinctly.  First session: Welcoming the participants, introducing, and discussing the concept of spiritual health. Second session: Explaining the concept of spirituality, studying about its role in improving the spiritual wellness, and mentioning some examples of the function of spirituality in human life. Third session: Reviewing the main agenda of the previous session, the role of reliance and trust in God in life for improving the spiritual health, proposing verses and narratives, and specifying examples in the participants' own life. Fourth session: Reviewing the main agenda of the previous session, discussing the role of thanking God, the definition of appreciation and thanking, and proposing several Hadiths and narratives in this regard. Fifth session: Reviewing the main agenda of the previous session, being familiar with the concept of forgiveness and discussing the key role of forgiveness in improving the spiritual health, proposing Ahadith and narratives about the importance of forgiveness, and pointing out the consequences of participating in charity affairs. Sixth session: Reviewing the main agenda of the previous session, the role of Dhikr, prayers, supplications, and pilgrimage in improving the spiritual health, its effect on personal life, and practicing it continuously. Seventh session: Reviewing the main agenda of the previous session, referring to the role of patience in life and improving the spiritual health, mental. Eighth session: Conclusion, answering questions, and receiving their feedbacks.  Speech, questions and answers, and group discussions were used to offer information; elderly people shared their experiences and viewpoints with other people present in the training course of Isfahan healthcare centers (Ghaedi and Rezaeian) regarding the subject of each session and the spiritual skill, determined as the target. At the end of each session, members of the test group were provided with a manual. Immediately after the trial and 1 month after completion of the intervention, all participants were invited to refill the spiritual health questionnaires. A question and answer session was conducted for the control group at the end of the study who were also provided with a manual containing information discussed during the sessions, and the participants were thanked for their participation in the study. It is interesting to note that nobody exited from the study and the follow-up stage was completed with 52 participants, 26 each in the test and control groups.  Data were collected using demographic characteristics survey and Palutzian and Ellison's spirituality wellbeing survey (SWB).[27] The mentioned spirituality wellbeing scale contains 20 questions, out of which 10 questions are about religious wellness and 10 questions appraise the spiritual wellness. The scores for religious and spiritual wellness vary from 10 to 60. The higher the achieved score is, the better the religious and spiritual wellness will be. The total sum of these scores constitutes the spiritual health score, which varies from 20 to 120. The answer to each question was classified into six parts based on a Likert Scale (completely disagree, disagree, slightly disagree, slightly agree, agree, and completely agree). In statements with positive verbs, completely disagree was marked with 1, whereas completely agree was scored with 6 and in questions with a negative verb, completely disagree was marked with 6, whereas completely agree was scored with 1. Finally, spiritual health was divided into three levels: High (99–120), medium (41–100), and low (20–41). In the study conducted by Seyed Fatemi et al., the spiritual health questionnaire's validity was specified through content validity and its reliability was determined by the Cronbach's alpha coefficient (0.82).[11] Data were analyzed using descriptive and analytical statistics, and certain tests such as independent t-test and analysis of variance (ANOVA) were performed Using the SPSS software (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 19. Armonk, NY: IBM Corp).

BODY.M.ETHICAL CONSIDERATIONS:
All possible ethical issues addressed as explained above and the participants signed a written informed consent. The research project has been approved by vice-chancellor of research of Isfahan University of Medical Sciences.

BODY.R:
Table 1 summarizes the demographic properties of both the control and test groups. As Table 1 shows, there was no significant difference between the groups in terms of demographic properties. ANOVA with repeated measures showed that time (P < 0.001) and Islam-based religious plan (P < 0.001) had a significant effect on the spiritual health score, including its religious and spiritual dimensions. In addition, the reciprocal effect of the Islam-based religious program and time was also significant (P < 0.001). In other words, the effect of time on the spiritual health score and its religious and spiritual dimensions was not equal in control and test groups, and as the table indicates, in the control group, the spiritual health score and its religious and spiritual dimensions were roughly similar before, during, and after intervention; however, in the test group, the spiritual health score and its religious and spiritual dimensions increased over time. Similarly, the effect of group (Islam-based religious program) was not equal at all time, and as this table shows, the average spiritual health score and its religious and spiritual dimensions were roughly equal for the test and control groups before intervention; however, immediately after the intervention, the average spiritual health score and its two dimensions were different in the control and test groups [Table 2].   Table 1 Demographic characteristics of the participants   Table 2 Determining and comparing the mean scores of spiritual wellbeing of elderly patients with hypertension in the pretest, posttest, and follow-up stages in the intervention group and the control group 

BODY.D:
This study aimed at analyzing the effect of an Islam-based religious program on the spiritual wellness and health of elderly people with hypertension. The results obtained after collecting and analyzing the information implies that this program was effective for the spiritual health of the elderly with hypertension. These findings confirmed the results of previous studies conducted in this area. Pargament et al. (2004) showed that a relationship exists between the positive religious adaptability method (seeking for spiritual resources and having a positive point of view about your condition) and the spiritual consequences, as well as the physical and mental health of the elders admitted to a hospital. However, the negative religious adaptability method (considering the disease a punishment by god and having an internal discontent) will deteriorate the physical, mental, and spiritual health of the patients.[15] Vahya et al. (2011) showed that spirituality is affected on health-related quality of life of elderly women.[28] Delani and Barer suggested that spiritual care has an effect on the spiritual health of cardiovascular patients.[16] The results of the present study made it clear that an Islam-based religious program affects the spiritual dimensions of the spiritual health of the elderly with hypertension and it confirmed the results reported by Momeni et al. who demonstrated that spiritual care including a supportive presence, supporting religious rites of the patient and using supportive systems was effective on the spiritual health of patients with cardiac Ischemia.[29] Similarly, the results were compatible with the results of Hedayati et al. who showed that the spiritual religious interventions based on needs were effective in the spiritual dimensions of the spiritual health of patients admitted to the intensive care unit (ICU) of a hospital. Our results also suggested that Islam-based religious program is effective in the spiritual dimension of the spiritual health of the elderly with hypertension; such findings are similar to what has been achieved in previous studies; the results of Hedayati et al. showed that the spiritual religious interventions based on needs were effective in the spiritual dimension of the spiritual health of patients admitted to the ICU of a hospital.[30] However, Momeni et al. showed that the average score of the religious dimension was not significantly different for the control and test groups, which was incompatible with the results of this study. For the author, the reason for this contradiction can be due to the different participants of studies (elderly patients with hypertension versus patients with cardiac ischemia); the critical nature of cardiac ischemia convinces people to show more inclination toward religion.[29] In general, all studies mentioned in this section confirmed our results. To explain the results of this study, we can point out the special effect of spirituality in improving people's vision and interpretation of life as one may find the ischemia events of their life as an opportunity rather than a threat which develops a stronger feeling of control in people.[31] In other words, spirituality may help the elderly, despite the disease and disappointment, to avoid focusing on their losses, but search for meaning in their life. Having meaning and target in life strengthens the mental and psychological health. Spirituality affects other aspects of health through its effect on mental health.[25]

BODY.C:
As the results of this study suggest, an Islamic religious program is a proper approach to improve the spiritual health of the elderly people with hypertension, and given the increased spiritual need of the elderly with hypertension, this substantial need can be met through a comprehensive and inexpensive program. Nurses can meet this substantial need of the elderly by providing them with such religious interventions. Thus, it is suggested that certain training courses with the aim of making nurses familiar with concepts and implementing religious interventions be conducted. Other studies can consider the effectiveness of an Islam-based religious program on other chronic diseases in people with different social, economic, and age groups.

BODY.C.FINANCIAL SUPPORT AND SPONSORSHIP:
Nil.

BODY.C.CONFLICTS OF INTEREST:
There are no conflicts of interest.

Question: Compared to Control  what was the result of Religious programs on Religious dimension improvement right after test ?
Evidence: However in the posttest step and follow-up stage, the mean scores of spiritual wellbeing, the religious dimension, and the existential aspect of spiritual wellbeing in the experimental group was significantly higher than in the control group (P < 0.001).
Answer: significantly increased