Health, Spirituality and Medical Ethics

Ali Kazemi Daluee1 , Fatemeh Shahhabizadeh1* , Maryam Nasry3 , Ali Akbar Samari1
1. Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran.
* Corresponding Author:
Fatemeh Shahhabizadeh, PhD.
Address: Department of Psychology, Faculty of Humanities, Birjand Branch, Islamic Azad University, Birjand, Iran.
Phone: +98 (915) 3319855
E-mail: f_shahabizadeh@yahoo.com
Research Paper:
Effectiveness of ACT with and without Mindfulness
plus Exercises on Spiritual Health in Hemodialysis
Background and Objectives: Spirituality and psychological interventions are effective in
promoting mental health and treating patients undergoing hemodialysis. The present study seeks
to evaluate the effectiveness of treatment based on acceptance and commitment therapy (ACT)
before dialysis, with and without mindfulness exercises during dialysis, on the spiritual health
of these patients.
Methods: The research design was quasi-experimental with a control group (two experimental
groups and one control group) and a two-month follow-up. The study population included all
patients on hemodialysis referring to hospitals affiliated to Imam Zaman Hospital in Mashhad
City, Iran, from July to December 2020. A total of 60 patients were selected by a purposive
sampling method based on the inclusion criteria. Then, they were randomly divided into three
groups. The research instrument included a spiritual health questionnaire, and data analysis was
performed by repeated-measures analysis of variance.
Results: The results showed that both experimental groups of ACT before dialysis (P<0.001),
with or without mindfulness plus exercises during dialysis (P=0.004), were effective on spiritual
health in patients on hemodialysis.
Conclusion: ACT alone as an effective intervention can be used in medical centers to increase
the spiritual health of patients on hemodialysis.
A B S T R A C T
Keywords:
Acceptance and commitment
therapy, Hemodialysis,
Mindfulness, Spirituality,
Health, Exercise
Please cite this article as Kazemi Daluee A, Shahhabizadeh F, Nasry M, Samari AA. Effectiveness of ACT with and
without Mindfulness plus Exercises on Spiritual Health in Hemodialysis. Health, Spirituality and Medical Ethics Journal. 2021;
8(3):171-180. http://dx.doi.org/10.32598/hsmej.8.3.6
: http://dx.doi.org/10.32598/hsmej.8.3.6
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Article info:
Received: 13 Apr 2021
Accepted: 22 Jul 2021
Publish: 01 Sep 2021
172
September 2021. Volume 8. Number 3
Introduction
oday, 2% to 3% of the world’s population
suffers from chronic renal failure.
It has a gradual onset and eventually
causes irreversible damage to the kidney
tissue [1]. The prevalence of chronic renal
failure globally is 8%-16% and is increasing, especially
in developing countries [2]. One of the alternative
therapies for kidney malfunction is hemodialysis, which
is a stressful process associated with psychosocial problems
[3]. It lowers the quality of life of these patients [4].
On the other hand, spirituality is part of the quality
of life [5]. In a broad sense, spirituality is one of the
sources of human coping and adapting to problems and
even incurable diseases. It can be considered a factor of
psychological support in difficult situations [6] by creating
hope. Therefore, among the factors affecting mental
health, spirituality [7] is essential. Spirituality, with its
role in people’s health [8], is an essential element of clinical
care in patients on hemodialysis [9]. Compromising
religious faith in chronic diseases may disrupt adaptation
mechanisms, and a spiritual crisis may appear in the
individual [10], which in turn can be associated with a
decrease in positive therapeutic motivations [11]. Spiritual
health includes the two concepts of satisfaction with
God and existential wellbeing. It has been scrutinized by
researchers in recent decades as a positive psychological
construct [12]. Therefore, it is necessary to evaluate the
effectiveness of psychological interventions for promoting
the spirituality of patients who are mainly suffering
from chronic diseases.
Over the past two decades, Acceptance and Commitment
Therapy (ACT) and mindfulness-based cognitive
therapy, which are different forms of cognitive-behavioral
therapy, have developed [13]. ACT focuses on accepting
unpleasant thoughts and feelings and clarifying
values and goals, and committing them [14]. ACT is
effective in addressing a wide range of psychological
problems [15] and promoting spirituality [16-18]. However,
in these studies, the target population was not patients
on hemodialysis.
On the other hand, mindfulness in the ACT is a kind
of specific, purposeful attention in the present time and
without judgment [19]. Although in the ACT, people
must accept their experiences without judgment and be
actively involved in the values of their life and practice
them, mindfulness interventions revolve around identifying
and reinforcing positive experiences [20]. However,
studies have also shown the effect of mindfulness in reducing
psychological symptoms [21] in patients, such as
those with chronic renal failure [22-25]. In addition to the
effectiveness of psychological interventions, exercise is
also effective in recovering dialysis patients [26]. Therefore,
it seems that synchronizing sports exercises with
mindfulness improves people’s performance [27]. Thus,
in the present study, mindfulness and exercises were used
alongside ACT. In general, due to the independent effects
of each intervention of ACT and mindfulness plus exercise,
the present study compares the effectiveness of ACT
with and without mindfulness exercise in a specific group
of patients. In this multidimensional research, we seek to
determine the effectiveness of treatment based on ACT
before dialysis, with and without mindfulness exercises
during dialysis in two separate experimental groups to
measure their effect on spiritual health.
Methods
The present study is a quasi-experimental with pretestposttest
design, a control group, and a 2-month followup
period. The statistical population included all patients
on hemodialysis covered by Imam Zaman Hospital in
Mashhad City, Iran, from July to December 2020. They
were undergoing dialysis three sessions a week. In the
present study, the code of ethics was obtained from the
University of Medical Sciences of South Khorasan Province
(IR.BUMS.REC.1399.116) and the code of clinical
trial (IRCT20200604047657N1). According to Stevens
Table [28] for reviewing and comparing the three groups,
considering the minimum test power of 78%, the average
effect size of 0.4, and the probability of error of 0.05,
20 people were considered for each group. They were
randomly assigned to three groups. By targeted sampling
method, 60 people were selected based on the inclusion
criteria and randomly divided into three groups (two experimental
and one control group). The first group received
ACT before dialysis and exercise combined with
mindfulness exercises during dialysis. The second group
received ACT before dialysis, and the third group was
the control without receiving an intervention.
It should be noted that the interventions of the two experimental
groups lasted five weeks and then, a follow-up period
was performed for all three groups after two months.
The procedure was conducted in the first experimental
group in 5 weeks, two sessions per week, and each session
for 40 minutes. ACT was performed for 10 sessions
on odd days. Besides, mindfulness training was also presented
for 10 sessions (two sessions per week) 20 minutes
before dialysis. Overall, each session lasted 60 minutes
(40 minutes of acceptance and commitment intervention
and 20 minutes of training mindfulness techniques). Also,
T
Kazemi et al. Act and Mindfulness in Spiritual Health. Health Spiritual Med Ethics J. 2021; 8(3):171-180
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September 2021. Volume 8. Number 3
during dialysis, lower extremity exercises were performed
for 10 sessions (two sessions per week for five weeks)
with the performance of previously trained mindfulness
techniques. In the second experimental group, who received
only the ACT intervention, this intervention was
performed in 5 weeks, two sessions a week on even days,
for 10 sessions, and each session lasted 60 minutes. It is
noteworthy that in this group, patients did not perform
mindfulness plus exercises during dialysis and were only
on dialysis. On the whole, both groups were homogeneous
in the number of sessions per week and the duration of
each session, and the beginning and end of interventions.
Also, the participants in both groups received interventions
on different days and were not in contact with each
other. The statistical analyst also did not know how the
groups were doing and the type of interventions.
The control group did not receive training and, of
course, at the end of the training pamphlet, they received
self-care behaviors, mindfulness, and exercise to observe
ethical considerations. It should be noted that after the
initial selection of the samples based on the inclusion and
exclusion criteria, they were homogenized into groups
based on education and employment. After classifying
patients based on variables, each person from each class
was randomly placed in a group. According to the experts,
the type of dialysis membrane was constant for all
patients at the study time, and flux types were selected.
Besides, the size of the membranes, the circumference of
the device, and the blood flow of the patients were kept
constant during dialysis. The inclusion criteria included
having efficient arterial and venous fistula; completing
the consent form; showing physical ability in the walking
test; having at least a diploma; being between 20 and
60 years old; being on hemodialysis for 6 months; not
participating in concurrent other psychological courses;
lacking experience of kidney transplantation, chemotherapy
or radiotherapy, lung disease; needing for oxygen;
no underlying disease of diabetes and hypertension,
history of a heart attack in the last three months; being
aware of place and time. The exclusion criteria included
hospitalization at the time of intervention, catching infection
and foot ulcer, developing high blood pressure
of higher than 110/110 and lower than 90 mm Hg, being
absent of more than two sessions.
Acceptance and Commitment Therapy(ACT)
In this study, the ACT protocol [29] in Table 1 was
used. The ACT intervention was performed in 10 sessions
for 5 weeks (two sessions per week).
Mindfulness techniques
Mindfulness-based interventions are one of the third
generation or third-wave cognitive-behavioral therapies.
In the first experimental group, mindfulness exercises
were continued for up to 15 sessions equal to dialysis
sessions at the time of dialysis. Training of mindfulness
techniques of each series was done for 30 minutes before
the start of dialysis for 10 sessions and was practiced during
dialysis (15 sessions of dialysis). Accordingly, mindfulness
was done exercises in 15 sessions during dialysis
in the first two hours of dialysis (the first half-hour and
the third half-hour of receiving sports intervention with
mindfulness techniques and half an hour in the middle of
rest). In this study, the mindfulness protocol described in
Table 2 was used [30].
Half-hour limb exercises during dialysis
To improve blood flow to the limbs, especially the
lower limbs, and the function of the cardiovascular system,
the following exercises were performed three times
a week in two short intervals in the first half-hour hour
and the third half-hour after dialysis. In the first half-hour
hour, there were alternating contraction and expansion of
both legs for 10 minutes, then raising and lowering each
leg in turn (without bending the knee) for 10 minutes,
and finally cycling the legs for 10 minutes. In the third
half-hour, the first and second 10 minutes were the same
as in the first half-hour, but in the last 10 minutes, the legs
were rotated in and out without lifting due to the possibility
of eating and preventing pressure on the abdomen.
The method of performing the exercise steps was taught
to each patient in person and by preparing an educational
pamphlet. It should be noted that mindfulness techniques
were also performed for the patient at the beginning and
during the exercise process. Mindfulness plus exercise
intervention continued in 15 sessions for 5 weeks.
Research tools
Spiritual Health Questionnaire (SHQ)
In 1982, Palutzin and Ellison designed the spiritual
health questionnaire. It includes 20 questions and two
subscales of religious wellbeing and existential wellbeing.
The questions are scored on a 6-point Likert scale
from “strongly disagree” to “strongly agree”, and a
higher score indicates greater spiritual health. In a study,
Palutzin and Ellison reported the Cronbach α coefficient
of the whole scale 0.93 [31]. The reliability of this scale
was reported by Dehshiri et al. [32] on male and female
students through Cronbach α for the whole scale as 0.90
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September 2021. Volume 8. Number 3
Table 1. Acceptance and commitment-based therapy protocol
Sessions Subjects, Contents, and Purposes
First
Familiarity of the members with the therapist and each other, explaining the group rules, familiarity, and
general description of the therapeutic approach. Homework: list 5 examples of basic problems that patients
have encountered in life.
Second
Assessing the task of the previous session, evaluating patients’ problems from the ACT perspective (extraction
of avoidance experience, mixing, and individual values).
Homework: prepare a list of advantages and disadvantages and ways to control problems.
Third
Examining the task of the previous session, specifying the inefficiency of controlling adverse events using
metaphors, and teaching the tendency towards negative emotions and experiences.
Homework: record the cases in which patients have succeeded in abandoning inefficient control methods.
Fourth
Examining the task of the previous session, teaching the separation of evaluations from personal experiences
(bad cup metaphor), and adopting an observational position of thoughts without judgment.
Homework: record the cases in which patients have succeeded in observing and not evaluating experiences
and emotions.
Fifth
Examining the task of the previous session, relating to the present, and considering oneself as a background
(chess page metaphor), teaching mindfulness techniques.
Homework: record the cases in which patients can observe thoughts using mindfulness techniques.
Sixth
Assessing the task of the previous session, identifying patients’ life values , and measuring values based on
their importance.
Homework: prepare a list of obstacles to progress in the realization of values.
Seventh
Examining the task of the previous session, presenting practical solutions in removing obstacles while using
metaphors and planning for a commitment to pursue values.
Homework: a report of the steps to pursue values and think about the achievements of the meetings.
Eighth Summarize and replicate the concepts explored during the sessions, ask members to tell their achievements
to the group, and plan to continue living.
Ninth Summarize and replicate the concepts explored during the sessions, ask members to tell their achievements
to the group, and plan to continue living.
Tenth Repeating and practicing the tasks of the previous sessions and resolving the ambiguities and possible
problems, and evaluating.
Table 2. Mindfulness-based protocol
Sessions Subjects, Contents, and Purposes
First Automatic guidance: eat a raisin with awareness, meditation, and body inspection
Second Dealing with meditation barriers: Body examination, ten minutes of mindful breathing, exercises of thoughts and
emotions
Third Mindfulness of breathing (and body in motion): conscious movement, the practice of stretching and breathing,
defining the calendar of pleasant experiences, distinguishing thoughts from reality
Fourth Staying in the present: 5-minute mindfulness of observing or hearing, meditating, mindful walking, cognitive distortions
Fifth Accept and allow: meditation sitting, awareness of breathing and body, time machine, and examining previous
thoughts and predictions
Sixth Thoughts are not realities: sitting meditation, awareness of breathing and body, distinguishing thought from fact,
practicing moods, alternative thoughts, and views
Seventh How can I take the best care of myself?: meditation sitting; awareness of breathing, body, sounds, thoughts, and
emotions; recognizing the connection between activity and mood; creating constructive solutions
Eighth Apply what you have learned to apply in the future: body meditation, final meditation, overview the most valuable
things in your life that practice can help you with?
Ninth Practice and repeat the protocol steps and monitor their proper implementation
Tenth Resolve problems and ambiguities of patients in how to implement the protocol
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and by the retest method as 0.85. In the present study,
the total score was considered. The data of this study
were analyzed in two parts: descriptive (demographic
data) and inferential. In addition, the Chi-square test and
analysis of variance were used to examine the homogeneity
of the groups. The statistical method of repeated
measures analysis of variance was used to analyze the
data using SPSS25. It should be noted that before each
analysis, the hypotheses of repeated measures analysis
of variance, including Box’s M statistic, sphericity hypothesis,
and Levene’s test, were reviewed and reported.
Results
Demographic data for age, education, employment, and
duration of illness are as follows (Table 3). According to
the results of the 1-way analysis of variance, no significant
difference was observed between the mean age of
the groups (P=0.81). The results of the Chi-square test
showed that no significant difference between the groups
in terms of education (P=0.80), employment (P=0.75),
and duration of illness (P=0.39). Descriptive indicators
of spiritual health are listed in Table 4.
For analysis, univariate repeated-measures analysis
of variance was used. To ensure normalcy, the Shapiro-
Wilk test was performed separately in groups and at all
three time points. Considering that the level of Shapiro-
Wilk test statistic error was higher than 0.05 (between
the range of 0.03 to 0.72), the assumption of normality
was confirmed in all groups. The Box’s M test was used
to evaluate the equality of covariance matrices. According
to the test results, Box’s M statistic (P=0.003,
F(12,15746.15)=2.47) is equal to 32.31, indicating that the
above hypothesis has not been confirmed. Still, because
the groups are equal, the Wilks’ lambda effect was used
to investigate the effect of time points and the interaction
effect of the time*group. The results of univariate
F’s Wilks’ lambda effect showed time effect (P<0.001,
F=14.73), with effect size of 0.35 and interaction
time*group effect (P=0.046, F=2.37) with an effect size
of 0.15 are significant. However, in the repeated measures
analysis of variance, the interactive effect was significant.
It can be said that spiritual health has changed
during the treatment to follow-up period and has also
been different over time in the three groups studied. To
investigate the effect of within-groups in the repeatedmeasures
analysis of variance, we tested the assumption
of sphericity. The result of Mauchly’s test (P<0.001,
X2
(2)=23.91) was 0.65, so the sphericity hypothesis was
rejected. Therefore, to evaluate the effect of the subjects,
the Greenhouse–Geisser epsilon index of 0.74 for spiritual
health was used. As shown in Table 5, the significance
level of time effect (P<0.001) and time*group effect
(P=0.01) was less than 0.05, so spiritual health is
different both time and time* group effect in different
groups. To evaluate the effect of between-groups and
examine the equality of variances of time-variable error
during the treatment period, the results of Levene’s
spiritual health test for pretest (P=0.92, F(2,57)=0.39),
posttest (P=0.008, F(2,57)=5.22), and follow-up (P=0.12,
F(2,57)=2.13) were obtained at the non-significant level of
0.01, indicating the confirmation of the assumption. In
examining the between-subjects effect, Table 5 shows
that the effect of the group is significant.
To determine the effect of the group and the difference
between the means of the three groups, the Bonferroni
post hoc test was used. The results showed no significant
difference between the two experimental groups on spiri-
Table 3. Descriptive indicators of demographic variables
Groups
Age Education, No. (%) Employment
Status, No. (%) Disease Duration, No. (%)
Mean±SD Illiterate Under
Diploma Diploma Bachelor
Unemployed
Employed
6
Months
to 1 Year
One
Year to 3
Years
Over
Three
Years
ACT before
dialysis 50.9±10.6 6(30) 9(45) 5(25) - 12 (60) 8(40) 9(45%) 7(35%) 4(20%)
Pre-ACT and
mindfulness
exercise during
dialysis
48.75±12.09 4(20) 10(50) 5(25) 1(5) 12(60) 8(40) 4(20%) 8(40%) 8(40%)
Control 49.2±10.7 5(25) 8(40) 7(35) - 14(70) 6(30) 9(45%) 6(30%) 5(25%)
Statistical
index
F=0.21,
P=0.81 χ2=3.09, P=0.80 χ2=0.57, P=0.75 X2=4.09 p=039
ACT: Acceptance, and Commitment Therapy.
Kazemi et al. Act and Mindfulness in Spiritual Health. Health Spiritual Med Ethics J. 2021; 8(3):171-180
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September 2021. Volume 8. Number 3
tual health at the level of 0.05. But a significant difference
was seen between the mean scores of “ACT before
dialysis” and “ACT before dialysis with mindfulness plus
exercises during dialysis” with the control group (respectively;
the difference in mean=6.50 [P<0.001]; mean difference=
3.5 [P=0.004]), which indicated the effectiveness
of both interventions. To evaluate the stability of the
interventions in experimental groups during the three time
points (pretest, posttest, and follow-up stage), we used the
Bonferroni test and made two-by-two comparisons of the
means by groups in these three points. As Table 6 shows,
in the two experimental groups, the average scores in the
posttest and follow-up were significantly higher than the
pretest scores. Still, the mean scores of follow-up and
posttest stages are not significantly different.
Discussion
The present study results showed the effectiveness of
“pre-dialysis ACT” and “pre-dialysis ACT with mindfulness
plus exercises during dialysis” on increasing
spiritual health over time in both posttest periods and follow-
up. But there was no difference between the two interventions
over time, which indicates the effectiveness
of ACT in increasing spiritual health. This increase has
been stable over time. The findings of the present study
are in line with the findings of Siadat, Khajevand, and
Akbari [16], Karkala and Konstantin [17], and Nemati,
Dokanee Fard, and Behbodi [18]. These studies show
the effectiveness of ACT on promoting spiritual coping
[17], spiritual attitudes [16], and spiritual health [18]. Although
in these studies only ACT was compared with the
control group, one study [18] showed that there is no significant
difference between the ACT and emotion-based
therapy plus ACT, and ACT alone is effective. In this
regard, this finding is consistent with the present study’s
findings, which showed that the ACT with or without the
intervention of mindfulness plus exercises has the same
results in increasing spirituality.
In the ACT, patients are helped to experience disturbing
thoughts and feelings only as a thought, become aware
of the ineffectiveness of current programs, and instead of
controlling negative thoughts and feelings, do what is im-
Table 5. Results of repeated measures analysis of variance in explaining the effects of within-subjects and between-subjects
spiritual Health
Effects of Within- and
Between-subjects
Source of
Changes
Sum of
Squares Type
4
Degrees of
Freedom
Mean of
Squares Statistics F P Squared
Eta
Effect of withinsubjects
Time 273.14 1.48 184.05 21.86 0.0001 0.27
Time * Group 98.88 2.96 33.31 3.96 0.01 0.12
Error 711.96 84.59 8.41
Effect of betweensubjects
Width of
origin 807484.09 1 807484.09 29126.45 0.0001 0.99
group 1269.67 2 634.84 22.89 0.0001 0.45
Error 1580.23 57 27.72
Table 4. Mean±SD of spiritual health variables in the pretest, posttest, and follow-up stages
Groups
Mean±SD
Pretest Posttest Follow-up
ACT before dialysis 67.50±3.60 71.25±3.29 71.70±3.22
Pre-dialysis ACT and mindfulness plus exercises
during dialysis 64.90±2.97 67.95±5.06 68.55±4.33
Control 63.40±2.96 63.45±3.37 64.10±3.59
ACT: Acceptance, and Commitment Therapy.
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September 2021. Volume 8. Number 3
portant in life in line with values [14], one of which can be
spiritual health for a person. Spiritual health is one of the
concepts in how the patient copes with the problems and
stress caused by the disease. This coping leads the person
to satisfaction, peace, inner balance, and purpose in life
[33]. However, since the decrease in spiritual health is
associated with an increase in grief [34], and on the other
hand, due to the high level of psychological stress caused
by chronic diseases [35], psychological interventions to
reduce grief and as a result, increasing spiritual health is
essential. Therefore, the goal of ACT is to reduce empirical
avoidance along with increasing psychological
flexibility (not avoiding unwanted events and not trying
to change and control them) and thus reduce suffering.
In other words, by receiving this intervention, patients
spend their energy on the values of life instead of coping
with avoiding pain and unwanted internal events [36]. In
other words, ACT is a spiritually and religiously sensitive
treatment. This approach aims to discover a person’s
values (including spiritual and religious values), help the
person to accept any experience that has no control over
it. Due to the commitment to the values of life, which can
be spiritual values for religious people, the promotion of
spirituality is possible [17].
But another significant result in this study is that performing
mindfulness plus exercises during dialysis in a
group that received ACT did not increase the effectiveness
of ACT in promoting spiritual health. This result is
inconsistent with other studies on the effectiveness of
mindfulness interventions [22-25]. However, it should
be noted that in these studies, mindfulness intervention
was not compared with other interventions. However, it
cannot be concluded that mindfulness intervention was
ineffective because, in this study, one of the groups received
both mindfulness intervention and ACT. Therefore,
it is not possible to compare the two treatments of
mindfulness and ACT.
On the other hand, in this study, mindfulness was performed
along with sports activities during dialysis. In
this regard, a study showed that exercise alone [26] or
with mindfulness [27] increases dialysis adequacy and
the level of motor balance, respectively [27]. There are
two points to consider in this regard. The first point is
that there are differences between this study and the
present study, including the fact that this study [27]was
not performed on dialysis patients and comparison with
other interventions [26, 27]. Most importantly, in the
mentioned studies, the non-psychological structure, i.e.,
adequacy of dialysis and motor function of the individual,
were considered, while in the present study, spiritual
health was examined as a psychological/spiritual structure.
It seems that mindfulness plus exercises cannot directly
affect spiritual health.
The second point is that in the present study, two separate
interventions of ACT and mindfulness plus exercises
were not examined, and the aim was not to compare the
two interventions. Instead, the goal was whether mindfulness
plus exercise could increase the effectiveness of
the ACT intervention, which results were not confirmed.
However, this finding does not mean that mindfulness
plus exercises have not been effective, but they may be
equally effective, with both targeting the underlying psychological
mechanisms. However, what can be seen in
this result is that the effectiveness of the ACT has not
been increased with the presence of mindfulness. Still, it
does not mean the ineffectiveness of mindfulness. Maybe
in other areas related to the mechanism of effectiveness
of mindfulness plus exercises, including the dialysis
adequacy [26], it could be effective, which was not examined
in this study.
In other words, although mindfulness exercise helps
people identify situations that cause anxiety and stress
and gain a better understanding of themselves [37], and
provide a new way to get rid of dysfunctional cognitive
patterns, just like ACT [19], the present results showed
that the mindfulness does not increase the effectiveness
of ACT on spiritual health, which indicates the importance
of ACT in this regard. Of course, it is likely that the
Table 6. Bonferroni test results of comparing the study groups
Time
Means Difference
ACT Before Dialysis Pre-dialysis ACT and Mindfulness
Exercises During Dialysis Control
Means
Difference SD P Means
Difference SD P Means
Difference SD P
Pretest
Posttest -3.75 0.97 0.003 -3.05 1.15 0.04 -0.05 0.36 1
Follow-up -4.20 0.97 0.001 -3.65 1.11 0.01 -0.7 0.5 0.54
Posttest Follow-up -0.45 0.37 0.73 -0.6 0.62 1 -0.65 0.48 0.59
ACT: Acceptance, and Commitment Therapy.
Kazemi et al. Act and Mindfulness in Spiritual Health. Health Spiritual Med Ethics J. 2021; 8(3):171-180
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September 2021. Volume 8. Number 3
efficacy of ACT interventions combined with mindfulness
plus exercises on other psychological constructs, including
disease-related negative emotions, will vary. We
suggest that these areas be investigated in future research.
However, it can be noted that mindfulness is considered
part of ACT. Besides, in ACT, one must accept one’s experiences
without judgment and actively engage in the
values of one’s life and practice them. At the same time,
mindfulness interventions revolve solely around identifying
and reinforcing positive experiences, so it is worth
pondering why ACT without mindfulness plus exercises
can also increase patients’ spiritual health. Also, the lack
of increase in the effectiveness of ACT intervention by
mindfulness exercises may be due to the small sample
size and limited duration of exercise in this group. These
gaps suggested that future research should consider them.
Conclusion
According to the present study results, the ACT has
adequate efficiency without mindfulness plus exercises
and can be done in dialysis centers to promote spiritual
health in patients on hemodialysis. However, the present
study has some limitations, like a short follow-up period
and the use of self-report questionnaires.
Ethical Considerations
Compliance with ethical guidelines
The ethics code was obtained from South Khorasan University
of Medical Sciences (IR.BUMS.REC.1399.116)
and the code of clinical trial (IRCT20200604047657N1).
Funding
The paper was extracted from the PhD dissertation, Department
of Psychology, Faculty of humanities, Birjand
branch, Islamic Azad University, Birjand.
Authors' contributions
Study design and idea: Fatemeh Shahabizadeh; Scientific
advisor: Fatemeh Shahabizadeh, Ali Akbar Samari,
and Maryam Nasri; Data collection and analysis: Ali Kazemi
and Fatemeh Shahabizadeh; Preparing, compiling,
and editing the educational program: Ali Kazemi and
Fatemeh Shahabizadeh; Writing, compiling, and editing
the article: Fatemeh Shahabizadeh and Ali Kazemi.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors express their sincere gratitude for the cooperation
of the staff of Imam Zaman Hospital of Mashhad
City.
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