Health, Spirituality and Medical Ethics

 

Introduction

T

here has been an increase in the number of elderly people in the world, especially in developed and developing countries owing to the advances in the health and control of communicable diseases. According to demographic surveys, it is shown that the world's population is aging, and this trend will be faster in the future. However, the proportion of the aging population in the world was 7% in 2006; this figure would be doubled by 2050 (equal to 15.6%) (1). In Iran, the population over 60 years of age in 2021 is



anticipated to account for more than 10% of the total population of the country and will be more than 20% of the population in 2050 (2).
Elderly people are increasingly exposed to various illnesses. A high percentage of the elderly (86%) have at least a chronic disease. More than 70% of those older than 80 years of age and resident in the community have at least two chronic conditions. Nearly 40% of the elderly in the community experience some constraints related to chronic diseases (3). The nature of the disease and its long-term course contribute to many of the symptoms, as well as physical and psychological problems of these patients. Moreover, they influenced different dimensions of health in affected patients (4).
Religion and spirituality are among the factors affecting adaptation to reduce stressful situations and have the ability to overcome the difficult and unwanted conditions of the environment (5). Spirituality-religion facilitates adjustment through meaning and purpose and is associated with better psychological health, such as reduced depression, stress and anxiety, as well as increased emotional excitement.
One of the components of a healthy life is the consideration of spiritual needs that is one of the deepest human needs, the identification and supply of which has a special place in promoting health and developing a response to disease (6). Stallwood and Stoll define spiritual needs as follows: "factors necessary to establish and/or maintain a person’s dynamic relationship with God or supernatural being to experience forgiveness, love, hope, trust, meaning, and goal in life” (7).
Spiritual needs guide people toward achieving a calm and divine life and form their personality. In addition, the ultimate goal of this concept is to achieve divine perfection. For instance, "remembering God" is a spiritual need, which brings emotional and mental calmness. Today, the identification of spiritual needs has become significantly important. The assessment of spirituality and patient's mental needs to provide effective spiritual services is essential (8).
According to the results of a study conducted by Höcker et al., nearly all cancer patients (94%) reported at least a spiritual need among which the need for inner peace and active/productive forgiveness was the most important (9). In a study carried out by Büssing et al., the underlying condition had a significant relationship with the spiritual needs of the patients (10). In another study, it was reported that for unmet spiritual needs, there is a need for multiprofessional teams to meet the multifaceted needs of patients (11).
To date, limited studies have been conducted to assess the spiritual needs of elderly people with chronic diseases, and most of the studies in this field were performed in the United States and Europe. Despite the fact that the World Health Organization added spirituality dimension to health definition about a quarter century ago, currently, it has been overlooked in medical departments. On the other hand, no comprehensive study has been conducted on the spiritual needs of patients and effective factors in their implementation in Iran.
Since the present study can add to the existing knowledge on this issue through the examination of spiritual needs and relevant factors, it was conducted to identify the spiritual needs and their correlation with anxiety and depression in elderly people with chronic diseases. Therefore, the path would be paved for future studies and it provides the basis to perform spiritual care.
Methods
This cross-sectional descriptive analytical study was conducted in Qom in 2017. The study population included all elderly people with chronic diseases hospitalized in Shahid Beheshti and Kamkar hospitals in Qom, Iran. In total, 100 patients with chronic diseases (e.g., cardiovascular disease, hypertension, diabetes, and kidney failure) over the age of 60 years were selected through convenience sampling method. Inclusion criteria were the lack of cognitive problems, known chronic disease, ability to communicate in the Persian language, and willingness to participate in the study. Exclusion criterion was the lack of full participation in the completion of the questionnaire. Informed consent was obtained from all the patients prior to the study.
After obtaining the permission from the Research Deputy of Qom University of Medical Sciences, required licenses were issued for the implementation of the study. The researchers referred to the selected units on a daily basis, and the questionnaires were completed after explaining the research objectives to the patients. If a participant was unable to complete the questionnaire due to illiteracy, the questions would be read by the researcher and then answered by the case.
 
In this study, the required information was collected via interviews using three questionnaires. The first questionnaire was related to the demographic characteristics of individuals, including age, gender, educational level, marital status, residency status, occupational status, smoking status, underlying diseases, and diagnosis duration. The second research tool was a spiritual need questionnaire used to measure the spiritual needs of the participants.
The above-mentioned questionnaire was designed by Büssing et al. in 2010 for diagnostic and research applications. In addition, the questionnaire can be applied as a diagnostic tool for the purpose of which there are 27 items. Moreover, it can be used as a 19-item research tool (some of the items are optional). In the present study, the full version of the questionnaire was employed. The questionnaire consists of four different factors as follows:
1. Religious (α=0.90): Including praying for others and with others and by themselves, attending religious ceremonies, reading spiritual/religious books, and asking for help from the superior existence (e.g., God and angels)
2. Inner calmness (α=0.83): The desire to live in quiet and calm places, being immersed in the beauty of nature, gaining inner peace, talking with others about fears and concerns, and the love and affection of others (to the person)
3. Existential (deep thinking/meaning) (α=0.84): To think about the past life, talk with someone about the meaning of life/suffering, reveal some aspects of life, and talk about the possibility of another life after death
4. Active forgiveness/productivity (α=0.82): To have an active or automatic intention to sympathize with others, transfer life experiences to others, and ensure that life has been meaningful and valuable (12)
The validity and reliability of the Persian version of the questionnaire were confirmed by the researcher (13). The third questionnaire was the hospital anxiety and depression scale, which measures anxiety and depression in the patients. This 14-item tool evaluates seven anxiety items and seven depression items. Each item is scored based on a four-point scale (almost never=zero, sometimes=1, most times=2, and almost always=3). In the end, receiving higher than 8 out of 21 in each section would be interpreted as the presence of anxiety and depression. The validity and reliability of its Persian version were also confirmed (14).
Data analysis was performed in SPSS software (version 16). The mean score of depression and anxiety scale, mean and standard deviation, as well as percentage and frequency, were used to describe the total score of spiritual needs and its items. Furthermore, multiple stepwise regression was utilized to determine the predictive variables of spiritual needs. The total score of spiritual needs was regarded as a dependent variable, whereas the scores related to demographic, clinical, and psychological characteristics were recognized as independent variables. In addition, P-value less than 0.05 was considered statistically significant.
Result
In this study, the mean age of the subjects was reported as 65.4±5.2 years. In terms of gender, 51 subjects were female and 49 individuals were male. Most participants (72%) were illiterate or married with primary educational level (71%). In addition, 83 participants lived in their personal houses. However, only 29 cases were employed, and the rest were retired or unemployed. Moreover, 17% of the participants were former smokers. The mean score of disease duration was obtained at 8.58±8.02 years. Regarding the medical records, 28%, 48%, 55%, and 20% of the subjects had a history of diabetes, hypertension, cardiovascular diseases, and kidney failure, respectively.
The mean score of spiritual needs in the elderly was 44.65±12.18. All the patients were reported at least with a spiritual need. In this regard, the highest score was related to the item of "asking for help from God" with the mean value of 2.31±0.76, whereas the lowest score was associated with the item of "talking with others about life after death" with the mean score of 0.66±0.98. In addition, the highest level of need was related to the item of "receiving support from the family" (52%) while the lowest degree was associated with the item of "understanding the meaning of the disease and suffering" (5%) (Table 1).

Table 1. Spiritual needs of the elderly with chronic diseases
Item		Mean ± standard deviation	Never	Slightly	Severely	Extremely severe
1	Talking about your fears and concerns with others	07.1±1.05	41	22	26	11
2	Your family support and take care of you	43.1±1.10	31	12	40	17
3	Thinking about your past	1.21±1.13	38	20	25	17
4	Revealing some aspects of your life	0.91±0.86	46	25	26	3
5	Immersing in the beauty of nature	1.88±1.09	18	12	34	36
6	Living in a calm place	1.71±1.04	17	22	34	27
7	Having inner peace	1.87±1.06	15	19	30	36
8	Understanding the meaning of a disease and suffering from	0.86±0.86	40	39	16	5
9	Talking with another person about the meaning of life	0.89±0.67	56	27	11	6
10	Talking with someone else about the life after death	0.66±0.98	63	16	13	8
11	Asking for emotional help from others	1.24±1.13	36	23	22	19
12	Giving something to someone	1.68±1.09	21	18	33	28
13	Sympathizing with others	1.83±1.04	16	16	37	31
14	Forgiving someone who have made you upset in the past	1.62± 1.11	21	25	25	29
15	Someone you made upset forgiving you	1.26±1.10	33	26	23	18
16	Praying along with others	1.83±0.91	9	24	42	25
17	Someone else praying for you	2.14±0.79	7	4	57	32
18	Praying for yourself	2.20±0.68	0	15	50	35
19	Participating in religious ceremonies	2.01±0.90	9	13	46	32
20	Reading spiritual/religious books	0.89±1.09	53	17	18	12
21	Asking for help from God	2.31±0.76	3	9	42	46
22	Having security	2.01±0.86	6	18	44	32
23	Feeling connected to the family	2.29±0.90	7	9	32	52
24	Sharing life experiences with others	1.87±0.89	7	26	40	27
25	Being ensured of the worth and meaning of life	1.83±1.01	12	24	33	31
26	Being involved in life problems of the family	1.90±1.06	16	14	34	36
27	Receiving more support from the family	2.10±1.01	11	12	32	45

 
The mean score of depression and anxiety were reported as 11.67±3.76 and 11.67±3.33, respectively. Among the patients, 81% and 62% had anxiety and moderate to high levels of depression, respectively. There was a significant negative correlation between disease duration and disease frequency with spiritual needs (r=0.36, P<0.01). Moreover, the results of independent t-test demonstrated that the mean score of the religious dimension of spiritual needs was significantly higher in men, compared to that in women (t=1.48, P<0.05).
According to the results of one-way analysis of variance, it was shown that married people were reported with significantly higher religious needs, compared to single individuals, as well as widows or divorcees (F=2.64, P<0.05). The findings of multiple regression analysis indicated that among the demographic, clinical, and psychological variables that entered into the model (P<0.15), two variables of depression (β=0.27, P=0.011) and disease duration (β=-0.26, P=0.019) had a significant correlation with spiritual needs (Table 2).

Table 2. Results of stepwise regression in explaining effective factors in spiritual needs of the elderly with chronic disease
P-value	R²	R	Beta	Standard error	B	Variables
0.001	0.072	0.268	----	2.97	24.95	Constant	1
0.011			0.27	0.27	0.70	Depression
0.001	0.129	0.36	----	3.20	28.24	Constant	2
0.011			0.26	0.26	-0.69	Depression
0.019			-0.24	0.16	-0.39	Disease duration

Discussion
The present study aimed to evaluate the spiritual needs of elderly people with chronic disease using a quantitative approach. Considering the spiritual powers as a need that gives the elderly a peace of mind and joy is of paramount importance. Studies have emphasized the necessity of informing the healthcare teams about the importance of spiritual needs in various cultures. The spiritual needs should be considered in the treatment of the elderly, which requires the recognition of these needs in this group of people.
According to the results of the present study, the most important spiritual needs of the elderly were related to the items of "asking for help from God" and "receiving more support from the family". This result is in line with the findings of the previous studies in which researchers demonstrated a positive correlation of various aspects of spirituality (e.g., spiritual activities, spiritual beliefs, and self-excellence) with psychological health and life satisfaction in the elderly (15-17).
To explain this finding, it can be said that the elderly seek to connect with God in order to satisfy their needs, individual growth, social development, and ultimately personal calmness. Through communication with God, they can deal with problems and obtain some benefits (15). In a study carried out by Ghahremanian et al. (2016), most cancer patients expressed their main spiritual needs to be as God, thinking about God, trusting God, witnessing the happiness of others, attempting to manage the disease in life, and requiring kindness, as well as helping others (18).
In another study conducted by Höcker et al. (2014), the need for inner peace and active/productive forgiveness was more important. In a study performed by Erichsen and Büssing, religious and existential needs had a low level of importance, whereas the need for "inner peace" and "need for the survival of the generation" were the most relevant ones (19).
The obtained results of a study carried out by Dedeli et al. demonstrated that the most common spiritual needs of cancer patients were the management of premortality issues, a sense of calmness, as well as satisfaction, and companion (20). In a study conducted by Haussmann et al., the important spiritual needs of cancer patients were the need for completeness and security, need for social support, need for forgiveness and preservation of inner peace, as well as the possibility of talking about anxiety and sadness.
Moreover, the results showed that religion/spirituality could be an important source to fight against cancer (21). In a study performed by Vilalta et al., two spiritual needs were reported as the most important ones for cancer patients, including their need to be recognized as a person until death and their need to know the truth about their disease. The lowest spiritual needs were identified as the need for continuity and life after death, release from pain and suffering, release from sins, as well as the need for reconciliation, and a sense of amnesty for others (22).
According to the results of a study carried out by Palmer et al. in the United States, most elderly people in the community acknowledged that their spiritual needs have been met. Enough sleep, pain release, someone to talk to about death, strong and supportive family relationships were potential factors that improved the spiritual needs of this population and may enhance their health outcomes (23).
To clarify this finding, it can be said that social support reduces the impact of stress and minimizes the adverse effects of an unpleasant experience by increasing the perception of stressful events. Moreover, it creates interrelationships where the person has a sense of being loved and cared, self-esteem and being worthy all of which have a direct correlation with health outcomes. Social support from family, friends, and acquaintances can improve the level of life satisfaction among the elderly. In addition, hoping for help from God in difficult life conditions, receiving social protection, and so forth are all among the resources religious people can use to be less harmed in dealing with stressful life events.
According to the obtained results of the present study, depression and disease duration were the important predictors of spiritual needs after controlling clinical and psychological demographic variables. It means that older people with more depressive symptoms were reported with more spiritual needs. The patients suffering from depression may experience psychological problems due to low self-esteem, negative attitudes toward life's goals, as well as daily life problems, and may suffer from spiritual crises (24).
Different studies have suggested that spiritual-religious beliefs and a purposeful life play an effective role in the improvement of the disease and tolerance of high-risk diseases. In a study carried out y Höcker et al., anxiety was reported as the strongest predictor of spiritual needs in cancer patients (9). In another study conducted by Offenbächer, spiritual needs, especially the need for inner peace and existential needs, were associated with different fields of mental health, particularly anxiety (25).
This study also had some limitations, including its cross-sectional nature, which did not provide an understanding of the causal relationship between variables. Furthermore, the collection of data and evaluation of the cognitive status of the subjects through self-report may not reflect the actual performance of the individuals. Moreover, the nonrandom sampling and limited number of the samples in the present study reduced the generalizability of the findings. Therefore, it is suggested to carry out similar studies on a larger sample size to eliminate this limitation.
Conclusion
According to the obtained results of the present study, the unmet spiritual needs in the elderly with chronic diseases were high, and the variables of depression and disease duration were the effective factors in the spiritual needs of these individuals. Consequently, it seems necessary to strengthen spiritual needs with regard to the two mentioned components, especially depression in educational and clinical interventions. It is recommended to consider mental aspects and other dimensions, including psychological, social and in particular spiritual ones in health assessment and care.
Conflict of interest
The author declares no conflict of interest.
Acknowledgements
Hereby, we extend our gratitude to all the participants for their help in the present project.
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