Relationship between Religious Attitudes and Coping Strategies for Stressful Conditions in Mothers with Epileptic Children

Introduction pilepsy is one of the non-communicable and disabling diseases. Epilepsy is the most common chronic disorder of the nervous system, which occurs due to abnormal electrical discharge in a group of brain neurons, and causes frequent seizures (1, 2). The annual incidence of epilepsy is estimated to be 2-4 per 100,000 population in adults and 17-23 per 100,000 population in children (3). Epilepsy may occur at any age, but about 75% of cases occur before the age of 20 years (4). Typically, the onset of a disease, especially chronic disease, in children, causes a family crisis, because in this situation, the child's parents are often responsible for his/her illness and feel anxious, guilty, helpless, and ineffective, and as a result, their function and ultimately the function of the whole family is affected (5). In this regard, mothers are more and more deeply affected by the crisis, but fathers are comparatively more stable and gradually recover (6). Psychological disorders, especially stress and anxiety, are some of the problems that parents of children with epilepsy deal with. Therefore, the family members, as with the patient, may need to adapt to stressors in order to maintain their internal balance (7). The concept of coping refers to the application of various types of approaches including adaptive or maladaptive (ineffective) strategies to adapt to a threat to create a psychological balance (8). According to Lazarus and Falkman, two main strategies of coping include problem-focused coping and emotion-focused E Abstract


Introduction
pilepsy is one of the non-communicable and disabling diseases.Epilepsy is the most common chronic disorder of the nervous system, which occurs due to abnormal electrical discharge in a group of brain neurons, and causes frequent seizures (1,2).The annual incidence of epilepsy is estimated to be 2-4 per 100,000 population in adults and 17-23 per 100,000 population in children (3).Epilepsy may occur at any age, but about 75% of cases occur before the age of 20 years (4).Typically, the onset of a disease, especially chronic disease, in children, causes a family crisis, because in this situation, the child's parents are often responsible for his/her illness and feel anxious, guilty, helpless, and ineffective, and as a result, their function and ultimately the function of the whole family is affected (5).In this regard, mothers are more and more deeply affected by the crisis, but fathers are comparatively more stable and gradually recover (6).Psychological disorders, especially stress and anxiety, are some of the problems that parents of children with epilepsy deal with.Therefore, the family members, as with the patient, may need to adapt to stressors in order to maintain their internal balance (7).The concept of coping refers to the application of various types of approaches including adaptive or maladaptive (ineffective) strategies to adapt to a threat to create a psychological balance (8).According to Lazarus and Falkman, two main strategies of coping include problem-focused coping and emotion-focused coping.Most people use both strategies in coping with tensions (9).Therefore, individuals must use different sources of coping for stress, such as internal control, positive beliefs, humor, supportive systems, and religion (10).The religious attitude of individuals and the role of religion in their lives comprise one of these strong sources.Religion has been defined as an attempt to cultivate sensitivity towards oneself, others, non-humans, and God (Supreme Force), or quest for what is needed for human beings, as well as a search for full humanity (11).Religious intervention has been considered an effective therapeutic approach in recent years.Attitude includes three cognitive, behavioral, and emotional dimensions: Cognitive dimension refers to individual information and knowledge, emotional dimension refers to a feeling of being good and bad, positive and negative, useful and non-useful, and behavioral dimension addresses the readiness of individuals to do things.The interaction of these three factors comprises the attitude of individuals.Similarly, in religion, the interaction of these three factors comprises one's attitude toward religiosity and the role of religiosity in life (12).The nature of epilepsy will be accompanied by persistent stress because of its chronicity, and therefore it is imperative that mothers recognize the ways of reducing or coping with stress and its associated factors.Religious attitudes affect various dimensions in every person's life, and can be used to improve the quality of life.Because stress is found in the lives of mothers of children suffering from chronic diseases (e.g., epilepsy) and each of them adopts different strategies to cope with stress, the present study was conducted to determine the relationship between religious attitudes and coping strategies for stress in mothers of children with epilepsy in Kerman, Iran.

Methods
The study population of this descriptiveanalytical, cross-sectional study consisted of all mothers who were admitted to Shafa and Afzalipour Hospitals in Kerman, and Hazrat Ali Ibn Abi Taleb in Rafsanjan in 2016-2017 and fulfilled the inclusion criteria.Eligible mothers were selected as samples of the study by using convenience sampling method.Inclusion criteria included a family with a child with epilepsy at the age of 1 to 20 years, having been definitely diagnosed with epilepsy at least one year ago, and lack of suffering from any other underlying disease.The questionnaires that were not appropriately filled out were excluded from data analysis.
Sample size was determined 115 according to the statistical indices, Cochran's sample size formula, and the sample size of correlational studies, 15 of whom were excluded due to lack of appropriately filling out the questionnaire.
Three questionnaires were used to collect information.The first questionnaire addressed demographic information of the family (including age, sex, number of children, the birth order of the child with epilepsy, economic status, place of residence, and parental occupation).The second questionnaire was related to religious attitudes and the third questionnaire was Coping Inventory for Stressful Situations (CISS) developed by Endler and Parker.
The Religious Attitude Questionnaire was first presented by Khodayarifard et  higher religious tendencies.In other words, the higher the total score of the respondent on this scale, the higher his/her attitude and beliefs about religion and religious beliefs.The reliability of this questionnaire, by Cronbach's alpha coefficient, was derived 0.807 and confirmed.
The CISS consists of 48 questions, with three main subscales, i.e., problem-focused coping, emotion-focused coping, and avoidance coping coping.This questionnaire was prepared by Endler and Parker (1990) and translated by Akbarzadeh (1998).The items of this questionnaire are rated on a 5-point Likert scale, with minimum and maximum possible scores of 1 and 5, respectively, for each item.That is, any behavior with comparatively higher score attained represents the coping skill of the respondent.To calculate the reliability and validity of the CISS by Cronbach's alpha and to calculate the correlation between the factors of the questionnaire, Pearson correlation coefficient was used (14).
For the original version of the Andler and Parker's CISS, the internal consistency coefficient was determined 0.92.The coefficients of the three main subscales, i.e., problem-focused coping, emotion-focused coping, and avoidance coping, have been reported 0.90 and 0.92, 0.85 and 0.82, and 0.82 and 0.85 for boys and girls, respectively, and the coefficients of the two subsidiary subscales, i.e., confusion and turning to society, 0.77 and 0.80, respectively (15).The reliability of this questionnaire was calculated and validated by Cronbach's alpha test in this study (0.79).
After completing the questionnaires and collecting data, statistical analysis was performed by using the SPSS version 18.Because data were normally distributed, descriptive (curve plotting, frequency distribution tables, and descriptive indices) and inferential (one-way analysis of variance) statistics were used.This study was approved by the Ethics Committee of the Isfahan University of Medical Sciences (ethics code: IR.MUI.REC.1395.9017).Before completing the questionnaire, written informed consent was obtained from the participants after the research purposes were explained to them and they were assured that they could withdraw from the study whenever they wished without providing any reason and without any effect on treatment course.

Result
In the current study, the study population consisted of mothers with children with epilepsy in Kerman province in 2016-2017, from whom 100 people were studied.Regarding the gender of children with epilepsy, 49 (49%) were male and 51 (51%) were girls.Sixty eight mothers were housewives and 32 were employed.Most of the children with epilepsy were the first child of the family (n:52), 44 were the second child, 3 were the third child, and 1 was the fourth child.
According to the results, families were economically divided into four groups; excellent, good, medium, and poor.Most families (59%) had a moderate economic status, 29% of families had a poor economic status, 11% had a good economic status, and 1% had an excellent economic situation (Table 1).province in 2016-2017 was strong based on our study findings and considering the Likert scale.
In other words, mothers of children with epilepsy had high spiritual attitude and also high spiritual attitude subscales (Table 2).
None of the different subscales of religious attitude including religious beliefs, religious affections, religious behaviors, and social manifestations were significantly correlated with demographic variables (number of affected children, child's age, child's gender, economic status, place of residence, and mother's occupation) (P>0.05)(Table 2).Therefore, it can be concluded that demographic variables had no significant correlation with subscales of religious attitude in mothers.
Regarding coping behaviors in mothers of children with epilepsy, the situation was somewhat different.The age and gender of the children with epilepsy showed a significant correlation with emotion-focused coping or concentration on emotional responses (P=0.000 and 0.011, respectively) (Table 2).The place of residence of the family (urban/rural) and the age of the affected child also showed a significant correlation with the coping behavior or problem avoidance by the mothers (P=0.002 and 0.036, respectively).There was no significant correlation between coping behaviors and other demographic variables (P>0.05).
The mean score for problem-focused coping or active coping with the problem in order to manage and solve it, was 45.1±3.9 out of 80, for the emotion-focused coping or focusing on emotional responses to the problem was 46.6±4.7, and for the avoidance coping or problem avoidance was 48.3±4.9.The types of coping strategies for stressfull conditions in mothers of children with epilepsy in Kerman province in 2016-2017 were in a way that the majority of them chose to escape from the problem, followed by the emotion-coping skill, and the number of mothers who adopted active coping with the problem and made effort to solve the problem was less than the number of those who adopted the other two types of strategies (Table 3).
In addition, to investigate the relationship between different subscales of religious attitude and coping behaviors in mothers of children with epilepsy, ANOVA was used (Table 4).Based on the results, it was determined that the general score of religious attitude, religious beliefs, religious affections, and religious behaviors had a significant effect on coping behavior (problem-oriented coping, emotion-focused coping, and avoidance coping) in mothers of children with epilepsy (P < 0.05).But social manifestations of religious attitudes in mothers did not have any significant effect on their coping behaviors (P > 0.05).
According to the results, the relationship between the spiritual attitudes and the types of coping strategies with stressful conditions in mothers of children with epilepsy was in a way that mothers with higher religious affections (compared with those who had religious beliefs, religious behaviors, and social manifestations) were significantly more successful in coping with the stress due to their child's disease (P = 0.04) (Table 3).

Discussion
In this study, religious attitudes as predictive variable of coping strategies for stress in mothers of children with epilepsy were investigated.The results of this study showed that in general, religious attitudes could increase the ability of mothers with children with epilepsy to cope with stress and stressful conditions resulting from child care in the home, work environment (for employed mothers), and the community.The results of this study also showed that religious beliefs, religious affections, and religious behaviors, as different subscales of religious attitude, in mothers with children with epilepsy, had a direct, significant effect on coping skills in them, but regarding social manifestations of religious beliefs, no effect was observed.Although no similar research on the impact of religious attitudes on coping skills for stress has yet been conducted, the findings of this study are consistent with the findings of some studies, including the study of Bahreinian (2010) to investigate the attitudes of patients on the impact of spirituality in their treatment process, Showed that religiosity and spirituality of patients had a direct, significant relationship with their quality of life.Besides that, the belief in the effect of spirituality on treatment was observed to be significantly associated with terms of religiosity and spirituality of patients (14).The study of Asghari and Safarzadeh (2013) showed that religionbelieving people recovered more quickly than non-religious people during illness, experience lower levels of negative emotions and depression, less anxiety and higher social support, and mental health, with most of them enjoying higher levels of mental health (16).Rasic et al. (2011) studied the relationship between religious and spiritual worship with severe depression, anxiety disorders, and suicidal ideation, and found that acting according to religious and spiritual beliefs, which involves a greater sense of security and self-esteem and a sense of hope for the future, could make one's interactions and relationships with others more effective, and reduce the tendency to develop anxiety and depression (17).The results of this part of the study are consistent with the findings of other studies on the role of faith in God and religious belief in difficult and intolerable periods, including facing hard physical illnesses and calming down human beings.
In explaining these results, it can be argued that religion can be a strong factor for the psychological stability of patients with severe illness, whether such religiousness is measured by participating in religious ceremonies, or whether it is measured by the level of their belief in God.Given that religious attitude refers to the coherent and unified monotheistic beliefs that are God-centered and regulate the values, ethics, customs, and behaviors of human beings with one another and with their nature (18), and prevent negative attitudes in life (17).In fact, religious beliefs, in addition to preventing the occurrence and outbreak of mental illness, can reduce the morbidity due to diseases, reduce the duration of the disease, and increase longevity (19).
In order to determine the type of coping strategies for stressful conditions in mothers with children with epilepsy, the results showed that 50% of mothers in stressful situations Downloaded from jhsme.muq.ac.ir at 12:43 IRST on Tuesday December 18th 2018 chose avoidance coping or escaped from the problem, 36% adopted emotion-focused coping, and 14% adopted problem-focused coping.Wojtas et al. (2014) in a study to investigate the severity of negative emotions and coping strategies for stress in parents of children with epilepsy found that anxiety in the parents was a prevalent feeling.Parents were found to use more strategies to cope with stress following emotional and/or instrumental support.There was also a correlation between the level of severity of negative emotions and social support, as well as the relationship between social support and coping strategies for stress (20).
Safavi et al. ( 2010) investigated mental health and stress coping strategies in the families of epileptic patients referring to the Iranian Epilepsy Society, and found that 50% of them adopted problem-focused coping strategies, 70.7% adopted emotion-focused coping strategies, and 67.3% adopted less efficient and ineffective strategies (21).The results of this part of the study are consistent with the findings of Safavi on coping strategies for stress in the families patients.In other words, the number of mothers who were active in coping with the problem and made attempt to solve the problem was less than the number of the mothers who used the other two types of strategies.
In explaining these results, it can be argued that parents usually tend to have healthy children and expect them to adapt to social issues.When they encounter children with chronic illness, they exhibit a negative reaction.Among all the chronic conditions, epilepsy is a unique challenge for the child and his or her family because they have encountered a chronic illness whose attacks are not predictable and should help their children and other family members adapt epileptic attacks (2).It should be noted that coping strategies play an important role in reducing stress and therefore mental health; and the concept of stress alone, without considering individuals' coping skills, has a limited value in explaining and predicting their conditions.In other words, the more resources people use to cope, the less likely they are to be affected by situations that could lead to harm (22).Individuals respond to stress in different ways because of individual differences, and the intensity of perceived stress and how they respond to it depend on their interpretation of stress (23).
Regarding the relationship between spiritual attitude and the type of coping strategies with stressful conditions in mothers with children with epilepsy, the results showed that mothers with a higher religious attitude were significantly more successful in coping with the stress due to their child's disease (p=0.04).
Lotfi et al. ( 2013) investigated the effectiveness of spiritual therapy in reducing anxiety, depression, and distress in women with breast cancer who referred to Valiasr Hospital and Mehraneh Charity Institute in Zanjan.The results showed that spiritual therapy was effective in reducing anxiety, depression, and distress in women with breast cancer (12).The study of Bahreinian (2010) also showed that religious spirituality has an inverse, significant correlation with the level of stress and response to it, that is, the higher the level of spirituality of the person, the lower the level of stress he/she experiences in coping with the problems, which is consistent with the findings of other research (14).The results of this section of the study consistent with the findings of other scholars on the relationship between religious attitudes and types of coping strategies.
In explaining these results, it can be argued that religion is effective in reducing the stress of patients' companions, and on the other hand, it indicates that by satisfying the companions' psychological needs and responding to their spiritual needs, their stress can be reduced Therefore, considering the relationship between religious beliefs and the stress coping strategies in mothers with children with epilepsy, it is recommended that this issue be especially considered by the relevant experts and the programs for strengthening religious beliefs to help mothers with an epileptic child cope with stress be used in counseling sessions.Considering the high level of religious attitude in mothers with children with epilepsy and also the effectiveness of religious attitude and all of its subscales including religious beliefs, religious affections, and religious behaviors (except for social manifestations) in coping with stress due to epilepsy of children, we conclude that the religiosity of the mothers is associated with the stress due their child's disease, mothers with a higher religious attitude are significantly more successful in coping with the stress due to their child's disease, and mothers who have a lower religious attitude show the least level of conscious effort to cope with stress (p<0.05).This suggests that religious attitudes can make interactions between mothers with children with epilepsy and their specific needs more effective, and reduce predisposition to stress.The results also showed that increasing the level of religious attitude of mothers and increasing the positive attitude toward epilepsy could have a significant effect on choosing the appropriate strategies to cope with stress and lead mothers toward improving their child's treatment course.

Conclusion
One of the limitations of this study is that the results of this research are limited to Kerman province, so the generalization of the results to other regions and cities should be done cautiously.Other limitations of our study include the research methodology being to a correlational design that merely examined the relationship or correlation of the variables, and the probable bias of some participants in answering the items.

Table 2 :
Mean scores of religious attitude and its subscales and mean scores of different coping skills for stressful conditions (from 80) in mothers

Table 3 :
Score of religious attitude and its subscales for types of coping strategies for stress