Effect of Spiritual Care Program on Quality of Life in Patients with Heart Failure

Introduction

Heart failure (HF) is a functional disorder of the ventricle during filling and emptying which reduces the ability of the heart to meet the metabolic needs, and causes dyspnea, fatigue, peripheral edema, and functional decline (1). HF is one of the most prevalent cardiovascular disorders. The prevalence of HF is increasing, despite recent advances in technical diagnostic tools and therapeutic methods, as it affects approximately 26 million individuals worldwide (2). According to a recent report, about 6.5 million individuals suffer from HF in the USA, and thousands of new cases are also diagnosed every year (3). In Iran, over one million individuals and about 1% of all adults over 40 years are affected by HF (4). HF is a main factor of mortality due to its complications around the world (5).

It should be noted that HF affects the quality of life (QoL) (6). The QoL is the perception of an individual from hope, physical, social, psychological, health status, and satisfaction (7). In other words, QoL is a culture-based logical process that summarizes values, beliefs, symbols, and experiences shaped by the culture, and provides a path to recognize conditions and experiences in human life (8). Finally, despite various descriptions presented for QoL, there is no consensus on this concept. In the present century, QoL is one of the major concerns of health experts and is recognized as an indicator for measuring health status in health-related research. In this regard, the present study aimed to investigate QoL and obtained results to empower individuals to live with more pleasure and meaning (9). Patients with HF failed to have a qualified QoL as HF impairs QoL more than any other chronic disease (10).

Spiritual care is the main factor in nursing that determines how individuals react to their disease and is the most important factor to achieve balance in preserving health and disease (7). Spiritual care can be effective in the QoL of patients with chronic diseases by decreasing anxiety and depression and promoting adaptation mechanisms in them (11, 12). In other words, religion and spirituality are considered important sources of physical and psychological adaptation for those with chronic diseases (13). Florence Nightingale has always emphasized that considering the spiritual and mental dimensions of the patients is necessary for nurses. In addition, nurses were asked to be committed to the concept of holistic care and understand the importance of considering physical, mental, emotional, social, spiritual dimensions, and the meaning of demands and cares (14). Although most nurses consider spiritual care an important part of holistic care, only about 28% of them practice regularly, and about half of them rarely perform spiritual care, and in most cases, it is neglected (15). In this regard, spiritual care has been considered by healthcare providers in recent years (16).

The study on the effect of religious intervention based on Tavasol prayer indicated that QoL and mental status of the patients with permanent pacemakers significantly improved by this intervention (17). Results of the aforementioned study revealed that spiritual care decreased death anxiety in patients with heart disease admitted to the Intensive Care Unit (ICU) (18). Results of another study indicated that spiritual care reduced pain in patients undergoing Coronary Artery Bypass Graft (CABG) (19). Another study conducted in 2018 showed that group spirituality therapy improved QoL and spiritual health of patients with Multiple Sclerosis (MS) in Ahvaz (20). Results of another study showed that spiritual therapy promoted QoL in women with breast cancer in Tehran, Iran (21).    

The QoL in HF patients is lower than those with other chronic diseases. Moreover, the COVID-19 pandemic negatively affects the QoL of patients (22, 23). COVID-19 causes numerous challenges including pain, fear, loneliness, and a near-death experience for everyone, especially patients (23, 24). In addition, patients are asked to consider their spiritual needs especially in critical conditions (25). Various studies have been conducted on the effect of spiritual care programs on QoL in coronary artery diseases, permanent pacemakers, or myocardial infarction which are a small part of the HF research community. Limited studies, to the best of our knowledge, are available on the effect of spiritual interventions on QoL in HF patients whose QoL is severely impaired, compared to other chronic diseases, such as cancer or MS, especially in critical conditions. Furthermore, most of the previous interventions are based on prayer therapy. However, in the present study, music therapy and listening to the sound of nature via CD have been used as well as prayer therapy. Therefore, the present study aimed to determine the effect of spiritual care program on QoL in HF patients.

Methods

Figure 1. Consort flow diagram of the participants

with self was through reinforcing the importance of self-esteem and patience, reading prayers related to the increase of patience. Communication with others was through forgiveness, charity, goodness to develop relationships with people. Finally,  communication with nature was through looking at the water and trees, listening to the song of birds, using bright and joyous colors, being kind to animals and growing plants, and using perfumes (30).

Prayer therapy was also used to strengthen self-esteem, forgiveness, and thanksgiving using the praying book. One of the CDs was Mozart’s symphonies which the patient listened to every night for 1 month (31). The other was the sound of nature which the patient listened to for 15 min in the morning or afternoon for 1 month (32). The first session was about the importance of the relationship with God and oneself and listening to a section of each CD at the end of the session. The second session was on the importance of connecting with others and nature and listening to a part of each CD at the end.

Ethical issues, such as plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, and redundancy have been completely observed by the authors.

After finishing the 1-month follow-up, the spiritual care program was performed in two educational sessions of 1.5 h. The intervention was followed up after 1 month with 1-h sessions three times per week to practice spiritual care for the control group via WhatsApp. The collected data were analyzed in SPSS software (version 22.0). The quantitative and qualitative data were expressed as “mean± standard deviation (SD)” and “frequency (percentage)”, respectively. An independent two-sample t-test was used to compare quantitative variables in two groups.

Additionally, the Chi-squared test and Fisher’s exact test were used to compare the frequency of qualitative variables. The QoL dimensions and total score of QoL were compared between the two groups before and after the intervention using the paired t-test. In addition, Multivariate Analysis of Covariance (MANCOVA) and a total score of Qol Analysis of Covariance (ANCOVA) was used to compare QoL dimensions after 1-month follow-up in two groups. Moreover, a p-value of less than 0.05 was considered statistically significant.

Results

The mean±SD of the age of the intervention and control groups were 46.27±11.24 and 51.11±10.49, respectively (P=0.060). No significant difference was observed between the two groups in terms of demographic and disease information as can be seen in Table 1.

Table 1. Demographic characteristics and disease information in patients with heart failure in intervention and control groups.

*Chi-squared test, ^**Fisher’s exact

The mean±SD of the ejection fraction of the intervention and control groups were 25.81±5.21 and 24.73±4.85, respectively. A two-sample independent t-test indicated that ejection fraction was not significantly different between the intervention and control groups (P=0.359). Findings also showed that the mean±SD of spirituality scores before intervention were 91.76±10.29 and 90.05±11.84 in the intervention and control group, respectively (P=0.511). Moreover, after the intervention, the mean±SD of spirituality scores were 94.08±10.18 and 89.35±11.40 in the intervention and control groups, respectively (P=0.060). Additionally, the mean±SD changes of spirituality scores in the intervention and control groups were 2.32±2.33 and -0.70±1.54, respectively (P<0.001). Accordingly, it was found that the spirituality score increased in the intervention group, while it decreased in the control group after the intervention.

The comparison of the mean±SD total QoL score and its dimensions in two groups before and after the intervention without adjusting the effect of confounding variables (Qol and spirituality score) before intervention is shown in Table 2. Presumptions of the tests were assessed through MANCOVA before analyzing the data. Results of the Shapiro-Wilk test showed that frequency distribution scores of QoL dimensions in intervention and control groups were normal before and after a 1-month follow-up (P>0.05).

In addition, Box’s M test indicated that the assumption of the equality of covariance matrices is confirmed in the studied groups (F=0.906, P=0.690). Besides, Levene’s test also represented that assumption of the equality of variances scores of QoL dimensions is approved in the studied groups (P>0.05). Moreover, the two-by-two correlation coefficient of different dimensions of QoL ranged from 0.250 to 0.580 after the intervention which indicates a positive and moderate correlation between dimensions of QoL.

Table 2. Comparison of the mean±SD total quality of life score and its dimensions in two groups before and after the intervention.

*paired t-test, QoL: quality of life

The results of Pillai’s trace test, Wilks’ Lambda test, Hoteling’s trace test, and Roy’s Largest Root on the difference of intervention and control groups were significant as P<0.001 in dimensions of QoL in patients with HF. The two groups were significantly and statistically different in at least one dimension of QoL (P<0.001). In addition, values of Partial Eta Squared showed that about 70% of difference (changes) scores of Qol dimensions in two groups after 1-month follow-up is caused by the intervention (spiritual care program).

After adjusting the effect of confounding variables before the intervention, the effects of the intervention on the dimensions of mental limitations and awareness on disease and self-care of QoL were statistically significant (P<0.05). In addition, Eta squared value in the dimension of mental limitations showed that about 80% of the difference of mental limitations in the intervention group after 1-month follow-up was caused by the intervention (spirituality care program) (Table 3).

Table 3. Results of Multivariate Analysis of Covariance on dimensions of quality of life score after the intervention

QoL: quality of life

The ANCOVA presumptions of the tests were assessed before data analysis through Analysis of Covariance. Results of the Shapiro-Wilk test showed that the frequency distribution of QoL scores in two groups was normal before and after the 1-month follow-up (P>0.05). In addition, Levene’s test showed that the assumption of the equality of variances of QoL scores was approved in the studied groups (P>0.05). Group effects in QoL were statistically significant after adjusting the effect of confounding variables (Qol and spirituality score) before intervention (P<0.05). In addition, eta square on QoL indicated that 67.5% of the difference (changes) of total QoL score in two groups was caused by the intervention after one-month follow-up (spiritual care program) as can be presented in Table 4.

Table 4. Results of Analysis of Covariance on total QoL score after intervention

Discussion

The results indicated two dimensions of mental limitations and awareness of QoL significantly increased in the intervention group after a 1-month follow-up of the spiritual care program. Moreover, the total score of QoL significantly increased after finishing a 1-month follow-up of the spiritual care program in the intervention group, compared to the control group. Results of a study performed on the effect of the spiritual intervention on QoL with cardiovascular diseases indicated that spiritual intervention promoted the total score of QoL in adult patients (32). The aforementioned study was performed only on one group and the spiritual intervention was done based on spirituality score for each patient. The present study was conducted on two groups and the spiritual care program was equally performed for the intervention group without estimating the spirituality score.

According to another study, spiritual intervention based on "Tavasol Pray" significantly improved QoL and mental status of patients with a permanent pacemaker (19). Although the results of the aforementioned study are consistent with those of the present study, the method of increasing QoL in the present study was presented as prayer therapy and music therapy as well as listening to the sound of nature via CD. Results of the study in 2020 indicated that spirituality therapy had promoted QoL in elders with acute coronary arteries (33). The difference is that the above-mentioned study assessed the effect of spirituality therapy on QoL in elders with acute coronary arteries; however, the present study evaluated the effect of spiritual care program on QoL in young and elder HF patients.

Theory of Ghalbe Salim stated that spiritual intervention increased the QoL of patients with acute myocardial infarction (34). Another study performed in 2018 revealed that group spirituality therapy had promoted QoL and spiritual health of patients with MS in Ahvaz, Iran (20). Results of the study indicated that spirituality therapy had promoted QoL in women with breast cancer in Tehran (21). The discrepancy is that these two studies have been conducted on MS and breast cancer and the Qol of HF patients which is severely damaged more than any other chronic disease is neglected.

Regarding the dimensions of QoL, according to the study of Delaney, psychological dimensions and physical health was statistically significant in patients with cardiovascular diseases after 1 month of spirituality therapy intervention. However, there was no statistical change in two aspects of social and family relationships (32). The spirituality-based intervention consisted of music/imagery sessions using CDs. Participants were instructed to listen to the CD at least three times per week for four weeks. The present study improved the mental aspect of QoL which is consistent with Delaney’s study and failed to change the physical dimension which is inconsistent with that of Delaney.

Heravi indicated that spiritual care promoted aspects of physical health, social relationships, and mental health of QoL in patients with acute myocardial infarction in the intervention group after the 1-month intervention. However, the difference between the two dimensions of mental health and social relations was statistically significant (33). The results of a study showed that spirituality therapy improved the physical and mental dimension of QoL in patients with MS in Ahvaz. The intervention included five 60-min face-to-face sessions (20).

Another study investigated the results of the effectiveness of spiritual therapy on QoL of women with breast cancer in which the aspects of mental and physical health and social relations were statistically significant, however, the aspect of living environment was not significant (21). The intervention included twelve 60-min face-to-face sessions. The above-mentioned results are consistent with those of the present study in terms of improving the mental aspect of QoL, however, differ from them in other aspects which may have different reasons, such as type of research community, duration of intervention, and cultural-religious beliefs. The limitation of this study was that educational sessions were not held face to face due to stress and high mortality of COVID-19, and the completion of questionnaires by phone calls after 1-month follow-up, and the lack of enough collaboration or organization to implement the sessions.

Implications for Practice

According to the results, spiritual care programs increased the total score of QoL in the intervention group. Therefore, a spiritual care program is suggested as a comprehensive care approach in improving the QoL of chronic diseases, especially HF patients.

Acknowledgments

The present article was derived from a thesis submitted in partial fulfillment of the requirement for the Master’s Degree and was approved by the Ethics Committee of Shahid Rajaie Cardiovascular and Medical Research Center under, Tehran, Iran (IR.RHC.REC.1399.042). It is also registered in the Iranian Clinical Trial Site (IRCT20201014049021N1). The authors would like to express their sincere gratitude to all hospital officials and staff as well as the patients participating in the research.

Conflict of Interest

The authors declare that there is no conflict of interest regarding the publication of the present study.