Health, Spirituality and Medical Ethics

Introduction
Chronic renal disease is one of the health problems in today's world, and hemodialysis is currently the most commonly used renal replacement therapy in Iran (1). Hemodialysis is a stressful process and, in addition to many psychological and social problems, leads to mental disorders (2). The patients undergoing dialysis are often at risk of depression and loss of happiness, which can discourage the cases from the treatment continuation. In this regard, hope in the future can be a good incentive for these patients (3). In chronic diseases, hope is an important adjustment mechanism, which is defined as a multidimensional factor in effective healing and adaptation. Despair, followed by loss of resilience, is a common outcome in the cases with chronic renal failure (4). The results of a study carried out by Pourghaznyn et al. (5) on renal transplant recipients revealed that the majority of these patients were at low levels of hope for life. Therefore, health care providers are obliged to consider the creation, maintenance, and promotion of hope in their care programs.
 
One of the therapeutic approaches to reduce mental health problems and increase the hope for life is trust in God, which is observed in people through different ways. Trust in God includes trust and confidence in God in all affairs and redeem everything to the Lord. Trust in God, which is an inexhaustible source of strength and ability, increases human resistance to problems and difficult life events (6). On the other hand, another factor in the promotion of hope is resilience, which is beyond survival in the stresses and difficult life events and correlates with growth, adaptability, and the achievement of an equilibrium level after a disorder in previous equilibrium condition (7). Horton TV and Wallander in their studies found out that social hope and support as resilience factors were considered as an effective factor in the reduction of maternal mental stress in caring for the children with special needs.
Considering the increasing rate of chronic renal failure in Iran, high prevalence of depression and anxiety in these patients, importance of epidemiological findings in improving the provision of psychiatric services to these cases, with regard to the role of trust in God and resilience in increasing the hope for life, along with the lack of adequate studies on the effect of the mentioned variables in hope for life of hemodialysis patients, this study aimed to evaluate the role of trust in God and resilience in hope for life of these cases. The main question raised in the present study concerned with the possibility of the relation between trust in God and resilience in hope for life of hemodialysis patients and the potentials of trust in God and resilience to anticipate the hope for life of hemodialysis cases.
 
 
Materials and Methods
This descriptive, correlational, and cross-sectional study was conducted on a total of 227 hemodialysis patients in two Khatamolanbia (n=107) and Ali-ibn Abi Talib (N=120) hospitals in Zahedan, Iran, during the first three months of 2018. In total, 140 patients were chosen based on Morgan table using the convenience sampling method (70 cases from each hospital). The inclusion criteria were end-stage chronic renal failure confirmed by a specialist, the awareness of the disease diagnosis and prognosis, dialysis experience for a minimum of six months, mental and physical readiness to answer the questions, lack of mental problems diagnosed by a specialist, and the least reading and writing skills. The exclusion criteria were the lack of willingness to cooperate in the project due to any reasons and hospitalization due to the recurrence of the disease.
 
 
Measurement tools
 
1. Trust in God Questionnaire: This 40-item questionnaire was designed by Bolhari, Ehsanmanesh, and Karimi Kaisami (9) and is scored based on a five-point Likert scale (from completely true=5 to completely false=1). The reliability of the scale was estimated using Cronbach’s alpha coefficient (α=0.71). In addition, in order to estimate the test-retest reliability of this questionnaire, a pretest and a posttest were conducted on 30 medical students with a 10-day interval, rendering a correlation coefficient of 0.65 (9). In a study performed by Behdani et al. (6), the reliability was calculated utilizing Cronbach’s alpha (α=0.78). Moreover, the reliability of the questionnaire was confirmed with a Cronbach’s alpha coefficient of 0.74 in the present study.
 
2. Resilience Scale: This 25-item scale was designed by Connor and Davidson (10) scored based on a five-point Likert scale (from completely false=0 to completely true=5). Therefore, the score range is from 0-100, in which higher scores are indicative of more resilience. The results of factor analysis demonstrated that this test encompasses five factors, including five subscales of individual competence imagination (10-12, 16, 17, 23-25), confidence in the individual instincts of negative emotional tolerance (6, 7, 14, 15, 18-20), positive acceptance of change and safe relations (1, 2, 4, 5, 8), control (13, 21, 22), and spiritual effects (3, 9).
 
 
The investigation of psychometric properties of this scale was performed in six groups, namely general population, the cases referring to primary care ward, psychiatric outpatients, subjects with generalized anxiety disorder, and two groups of patients with post-traumatic stress disorder. Connor and Davidson (10) reported a Cronbach’s alpha coefficient of 0.89 for the resilience questionnaire. In addition, the reliability coefficient obtained from test-retest method with a four-week interval was 0.87. In a study carried out by Samani, Jokar, and Sahragard (11) conducted on students, the reliability of the scale was reported as 0.93, and its validity was confirmed (through content, convergent, and divergent validities) by test designers in various normal or at-risk groups (11). In the present study, the reliability was estimated rendering a Cronbach’s alpha coefficient of 0.81.
 
3. Hope Scale: This 12-item scale was prepared by Snyder and Anderson (12) and its goal is the evaluation of hope for life in individuals. The scale is scored based on an eight-point Likert scale (from disagree=1 to completely agree=8). This questionnaire has been designed for 15-year-old cases. The items of the scale are used to assess factor thinking (items: 2, 9, 10, 12), strategic thinking (items: 1, 4, 7, 8), and four deviant items (3, 5, 6, 11). Therefore, this questionnaire measures two subscales, namely factor and strategy (13). Snyder reported the validity of the scale as 0.85, 0.81, and 0.74 for the total scale and subscales of factor thinking and strategic thinking, respectively. In another study, the validity of the scale was calculated rendering Cronbach’s alpha coefficients of 0.70 and 0.74 through test-retest after one month.
Internal consistency was estimated rendering Cronbach’s alpha coefficients of 0.74 and 0.62 for the subscales of factor thinking and strategic thinking, respectively (14). In the present study, the reliability of the scale was estimated rendering a Cronbach’s alpha coefficient of 0.71. The subjects were ensured of the confidentiality terms regarding their personal information, and the written informed consent was obtained from the participants prior to the study. The data analysis was performed in SPSS software (version 22) using descriptive (i.e., frequency, percentage, and mean) and inferential statistics (i.e., Pearson’s correlation coefficient and multiple regression), respectively.
 
Results
In total, 76 and 64 subjects were female and male participants, respectively. In terms of age, 14, 31, 42, 29, and 24 subjects were within the age range of 30-35, 31-40, 41-45, 46-50, and above 50 years, respectively. Regarding the educational level, 28, 41, 49, 22 subjects had below diploma, diploma, BSc, and MSc or higher degrees, respectively. Table 1 tabulates the descriptive findings along with matrix of correlation variables.
 
Table 1. Relationship between trust in God and resilience components with hope for life

Variables	Mean±Standard deviation	1	2	3	4	5	6	7	8
1. Trust in God	8.33±59.36	1
2. Imagination of individual competence	20/19± 3.314±19.20	**0.267	1
3. Confidence in individual instincts	3.606±17.31	*0.188	**0.619	1
4. Positive acceptance of change	3.541±12.47	**0.249	**0.558	**0.645	1
5. Control	3.414±9.15	**0.234	*0.122	*0.127	**0.332	1
6. Spiritual effects	1.470±6.63	**0.416	**0.602	**0.643	**0.713	*0.210	1
7. Total score of resilience	11.593±64.76	**0.337	**0.778	**0.815	**0.864	**0.499	**0.789	1
8. Hope for life	5.330±37.89	**0.297	**0.552	**0.585	**0.633	**0.319	**0.621	**0.715	1

 
*Level of significance (0.05)           ** Level of significance (0.01)
 
                                                                                                                                                           
According to Table 1, there was a positive relationship between hope for life and trust in God. Obtaining positive coefficients was indicative of a direct association between trust in God and hope for life. In other words, the cases with a higher level of trust in God had a higher level of hope for life, compared to others. In addition, the correlation coefficients between resilience and its components with the variable of positive hope for life were positive and significant (P<0.01). The positive coefficients showed a direct association between resilience and hope for life, and the patients with higher level of resilience showed a higher hope for life, compared to others. According to the multiple regression results, the standardized regression coefficient (Beta) for trust in God was equal to 0.297, whereas the standardized regression coefficients were reported as 0.171, 0.183, 0.213, 0.159, and 0.213 for the components, including the imagination of individual competence, confidence in individual instincts, positive acceptance of change, control, and spiritual effects, respectively (P<0.01). Therefore, it could be concluded that trust in God and the components of resilience can predict positively and significantly the hope for life of hemodialysis patients.
 
Discussion
The present study aimed to evaluate the role of trust in God and resilience in the hope for life of hemodialysis patients. According to the findings, there was a positive relationship between trust in God and hope for life. The positive coefficients were indicative of a direct association between trust in God and hope for life, and the patients with a higher level of trust in God had a higher level of hope for life, compared to other cases. Moreover, it was reported that trust in God could anticipate positively and significantly hope for life in hemolysis patients.
In this regard, the obtained results are in line with previous studies, including a study conducted on the level of hope for life in religious women in Taiwan, in which a positive and significant relationship was observed between religion and hope for life (15). Furthermore, Aghajani, Morasaee, and Mirbagher (16) marked a positive and significant correlation between religious beliefs and patients’ hope in a study on regions beliefs and its association with hope in hemodialysis patients. In addition, a linear positive and significant relation was noticed between religious beliefs, patients’ age, and the number of children with hope.
In a study carried out by Jannati et al. (17) on hemodialysis patients, it was revealed that most of the subjects had a moderate level of spiritual health and their religious level was slightly higher, compared to mental-physical health. In addition, spirituality and religious behaviors (e.g., praying) play an important role in the acceptance of diseases. In another study, Hojati (18) marked a significant relationship between prayer frequency and spiritual health. Furthermore, Yang and Mao (19) reported that having purpose and meaning in life, feeling of belonging to the supreme meaning, hope in God's help in the most difficult situations of life, and enjoying social and spiritual protection are all the ways, which can be used among religious people to experience the least harm facing stressful life events.
 
In addition, Fountoulakis, Siamouli, Magiria, and Kaprinis (20) suppose that belief in the fact that there is a God who is dominant and monitors the servants reduces the anxiety associated with situations to a large extent. In other words, they believe that unmanageable situations can be controlled by relying on God; therefore, trust in God provides high level of hope for life. It can be said that the individuals with strong religious beliefs that using positive coping methods in their daily lives, such as forgiveness, search for spiritual relation with God, friendship with religious people, receiving spiritual-social support, and the recognition of God as being benevolent and kind, can recover with a faster pace and have higher level of hope for life, compared to other people (21).
 
Religious beliefs through saying prayers and attending mosque, which are in line with belief in God as the infinite power, and the fact that the remembrance of God makes individuals calm, in addition to the Quran anticipation of the existence of eternal life after death, and this inner peace, create hope in life. Hope in life makes the meaning of life and change a person's attitude toward tolerating psychological problems. According to the obtained results of the present study, there was a positive and significant relationship between resilience and its components with hope for life. The positive coefficients showed a direct relationship between resilience and hope for life, and those who have a higher level of resilience will show higher level of hope for life, compared to other cases. Furthermore, it was demonstrated that the components of resilience could predict positively and significantly hope for life. Therefore, it could be stated that the patients with a higher level of resilience will have a higher level of hope for life, compared to other patients.
 
In this regard, the findings of this study are in line with some other studies (22), which showed a direct and significant association between resilience against stress with the sense of humor and hope for the future. Moreover, the evaluation of the components of hope for life indicated that both of the components (i.e., factor thinking and strategic thinking) anticipated resilience against stress in students.
According to the results obtained by Liu et al. (23), resilience and social support played an important role in the reduction of depression in patients undergoing hemodialysis. In a study carried out by Freire de Medeiros et al. (24), resilience, religion, and religious adherence affected commitment to treatment in hemodialysis cases. Lloyd and Hastings (25) marked that hope as a factor of resilience affects the parents with mentally retarded children.
 
To explain the aforementioned results, the patients with high level of resilience favorably used a coping strategy to deal with stress due to having a specific sense of control. Wolff (26) affirmed that resilience is determined with some features, such as social ability, the capability of efficient problem solving, purposefulness, and hope for future, which correlate with hope for life and led to an improvement in hope for life. On the other hand, high levels of resilience help individuals show positive emotions to enhance their self-esteem and positively adjust to the environment; moreover, these features can improve hope.
 
It could be stated that resilience is one of the most important features that can increase the mental health of individuals. In other words, it seems that a firm belief in a better future, sense of hope and purpose, the belief in the control of life and future, and possible obstacles cannot stop people. On the other hand, the individuals with hope for the future have a positive belief in their own abilities to achieve goals; consequently, they show greater resistance and tolerance in face of problems and tensions in life, compared to other people.
 
 
 
Conclusion
According to the results of the present study, there was a positive and significant relationship between trust in God and resilience with hope for life in hemodialysis patients. In addition, resilience and trust in God predicted hope for life in hemodialysis patients. Therefore, the obtained results revealed the importance of trust in God and resilience in hope for life among hemodialysis patients regarding their treatment improvement. Major limitations of the present study were self-report nature of the tools, cross-sectional nature of the study, and the convenience sampling method. Considering the role of trust in God and resilience in the hope for life in hemodialysis patients, it is suggested to address the efficacy of group therapy and radiotherapy components in hemodialysis patients. The results of the present study revealed the importance of these variables in hemodialysis patients’ community in more planning regarding health improvement.
 
Conflicts of Interest
The authors declare that there is no conflict of interest.
 
Acknowledgments
The authors extend their gratitude to the hemodialysis patients and personnel of both Khatamolanbia and Ali-ibn Abi Talib hospitals for their cooperation with this project.