‫ﺑﺎ ﻣﺤﻮﺭﻳﺖ ﺳﻼﻣﺖ‬
KOWSAR
Islamic Life Center Health.2013;1(2):17-21. DOI: 10.5812./ilch.8575
The Relationship Between Spiritual Health and Quality of Life in Patients
with Coronary Artery Disease
Ali Jahani 1, Nahid Rejeh 1*, Majideh Heravi-Karimooi 1, Asghar Hadavi 1, Farid Zayeri 2, Ali
Reza Khatooni 3
1 Shahed University, Tehran, IR Iran
2 Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
3 Kermanshah University of Medical Sciences, Kermanshah, IR Iran
A R T I C LE
I N FO
Article type:
Research Article
Article history:
Received: 11 Aug 2012
Revised:02 Sep 2012
Accepted: 04 Sep 2012
Keywords:
Spiritual Health
Spirituality
Quality of Life
Coronary Artery Disease
Intensive Cardiac Care Unit
AB S TR AC T
Background: According to the increase of patients with coronary artery disease, paying
more attention to the quality of life seems to be important. One of the factors affecting
the quality of life is spiritual health. Spiritual health as one of the main aspects of health
is usually ignored.
Objectives: The current study was performed to determine the relationship between
spiritual health and quality of life in patients with coronary artery disease.
Patients and Methods: The current study was a sectional correlation type survey and
346 patients with coronary artery disease were selected by available sampling method
as the study population. Data was gathered by Ellison & Palutzian spiritual health, and
“Nottingham Health Profile” quality of life questionnaires. SPSS software version 16 was
employed to analyze the data by Pierson correlation index and independent T test at
0.05 level of significance, P < 0.05.
Results: The results of the current study indicated that the average level of spiritual
health in these patients was 82.11 ± 2.90. Also, the average of quality of life in patients
with coronary artery disease was at medium level 61.4 ± 18.62; and the quality of life in
women patients was significantly higher than that of men with the same disease (P =
0.001). Besides, the results indicated a significant correlation between spiritual health
and quality of life in the patients with coronary artery disease (P = 0.001).
Conclusions: According to the results of the current study, it is necessary to consider the
factors related to the quality of life in patients care. Relation between spiritual health
and quality of life indicated the need to consider this factor in the care of patients with
coronary artery disease. This key point can be considered with specific priority in a
country, like Iran, with rich religious and cultural belief to design the treatment-care
programs for these patients.
Published by Kowsar Corp, 2013. cc 3.0.
Implication for health policy/practice/research/medical education:
Giving an appropriate treatments and services to the patients with coronary artery diseases.
Please cite this paper as:
Jahani A, Rejeh N, Heravi-Karimooi M, Hadavi A, Zayeri F, Khatooni AR. The Relationship Between Spiritual Health and Quality of
Life in Patients with Coronary Artery Disease, Quran and Medicine. Islamic Life Center Health. 2013; 1(2): 23-7. DOI: 10.5812./ilch.8575
* Corresponding author: Nahid Rejeh, University of Shahed, Tehran, IR Iran. Email: [email protected]
DOI: 10.5812/ilch.8575
© 2013 Ministry of Health’s Quran and Etrat Center; Published by Kowsar Corp.
Translated Version of http://dx.doi.org/10.5812/ilch.8575
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Jahani A et al.
Spiritual Health in Patients with Coronary Artery Disease
1. Background
Cardiovascular diseases (CVD) and, on top of
them,coronary artery diseases (CAD) are the most serious
health problems which cause disabilities in developed
and underdeveloped countries (1, 2) and also are the first
cause of death in the world. According to the world health
organization (WHO) statistics 2007, 33.7% death worldwide resulted from cardiovascular diseases. According to
the latest official statistics based on recent researches, announced by WHO, more than 80% of cardiovascular diseases happen in the countries with low and medium level
of income. Predictions indicate that until 2020, cardiovascular diseases will be the main reason of more than
75% death worldwide. In the case of continuity of death,
before 2030 around 23.4 million people lose their lives
due to these diseases (2, 3). Evidences show the increased
prevalence of coronary artery diseases in Iran. An epidemiological research in 2005 evaluated the prevalence of
this disease among Tehran mature residents above 30
years, around 21.8%. According to the official statistics
of Iran 2007, out of each 100’000 heart disease cases 167
lead to death (4). Considering the fact that easy access to
proper treatment is far from reality, the debilitating and
progressive nature of coronary artery diseases, and the
effect of various factors on exacerbation or treatment affect the quality of life in these patients. Therefore, considering the quality of life in patients with coronary artery
diseases is one of the main goals in their treatment and
care taking (5). High prevalence of chronic diseases such
as coronary artery diseases leads to increasing attention
toward evaluating the quality of life (6). Evaluating the
quality of life in these patients is applicable in the assessment of chronic conditions resulted from these diseases,
improvement of patient-physician relationship, evaluating the effect of different treatments, health-treatment
policies, researches, economic evaluation and distributing resources (7). Besides, evaluating the factors affecting
the quality of life can help the improvement and preservation of the quality of life in such patients (8). If the
medical staff have good knowledge of related variables to
the quality of life they can have a better performance to
improve the quality of life (9). Conditions and daily situation of patients with coronary diseases is influenced by
the trend of the disease. In other word, the quality of life
in these patients is highly affected by their disease (10).
Quality of life is a multidimensional structure which includes physical, mental, functional, social and spiritual
health (9). To encounter difficulties and stresses resulting from diseases, several definitions exist. One of these
definitions is the spiritual health. Spiritual health, which
as an aspect of health causes integrity in other aspects, includes existential and religious aspects. Religious health
is defined as feeling satisfaction regarding the relation
with a superior power, and existential health is referred
18
to an attempt to understand the concept and aim of life
(11). In patients with chronic and debilitating diseases,
who encounter the acute health crises, poverty and chagrin, spirituality is the main factor to find a goal and the
concept of life and therefore to improve the life (8).
In the last two decades, spirituality has been underlined
as an important factor to evaluate the quality of life. Some
of the researches indicated the relationship between
spirituality, physical and mental health, and more compatibility with diseases (12). In Allah-bakhshian Farsani
et al. (2010) on multiple sclerosis (MS) disease patients
(13), and Litwinczuk on Aids patients (2007) (14) it was indicated that in the patients which found the concept of
life in the heart of spirituality, the quality of life during
the illness was higher than the diagnosis time. In a study
on cancer patients, significant relationship was found between health, spiritual health, spirituality and functional
health (11), and also in a study on Leukemia patients, positive relation was reported between spiritual health and
quality of life (15). Researchers of the latter two studies
emphasized on the need to evaluate the relation between
spiritual health and quality of life. They also recommended the same evaluation for other chronic diseases such as
heart failure and spinal cord injuries (SCI) (12). Since few
researches have been conducted on spirituality and its
relation with health and quality of life in patients with
chronic diseases, evaluating the relation between spiritual health and different aspects of life in patients with
coronary artery diseases seems to be necessary.
2. Objectives
The current study aimed to determine the relationship
between spiritual health and the quality of life in patients with coronary artery diseases.
3. Patients and Methods
The current study was a sectional correlation type survey performed in the medical educational centers of
Tehran and Shahid beheshti universities of medical sciences equipped with cardiac care units (CCU) in2012. 364
patients with coronary artery diseases participated in the
study, continuous sampling method was employed. After
initial sampling of 15 patients, based on the estimated
correlation index 0.16, 95% trust level, and 80% test ability 364 patients were selected. Inclusion criteria were as
follows: diagnosis of stable and unstable pectoral angina
by physicians and recording in the profile, no history of
heart attack, left ventricular ejection fraction of more
than 40%, over 18 years old, residing in Tehran and willing
to cooperate with the research. On the other hand, suffering from cancers, chronic renal failure, and brain stroke
associated with diagnosed disabilities and mental disorders were the exclusion criteria of the current study. After receiving the official permission, and explaining the
Translated Version of http://dx.doi.org/10.5812/ilch.8575
Islamic Life Center Health. 2013;1(2)
Spiritual Health in Patients with Coronary Artery Disease
Jahani A et al.
aim of the research to the approved subjects and receiving the informed consent to participate in the study, they
were assured about respecting the privacy of their information. Then, information questionnaires were filled
through interview. In the current study, besides gathering the demographic information, to determine the level
of spiritual health, the 20-item spiritual health questionnaire of Ellison & Palutzian, including 10 religious health
and 10 existential health items, was used. The score of
spiritual health was calculated by summing the scores of
the two aspects, ranging from 20 to 120. The answers were
designed as 6-option Likert scale from completely agree
(6 scores) to completely disagree (1 score). It is noteworthy that in the options with negative verbs, scoring scale
was designed reversely. Therefore, spiritual health scores
were divided in to three levels as follows: low (20 - 40),
medium (41 - 99) and high (100 - 120) (16). Validity and reliability of the main text, and also the Persian version of
the mentioned questionnaire were approved (17).
To determine the level of quality of life, the 38-item
Nottingham Health Profile was used. This questionnaire
includes 6 aspects as follows: energy, pain, emotional
reactions, sleep, social isolation and physical activities.
The answers are designed as a 6-option Likert scale and
include: always, most of the times, sometimes, a few, rarely, never. Nottingham Health Profile scoring is from 0 to
100. In any aspect, scores 100 and 0 mean the highest and
the lowest level of quality of life, respectively. Validity and
reliability of the main text (18, 19), and also the Persian
version of the mentioned questionnaire were approved
(20). SPSS software version 16 was employed to analyze
the data by descriptive statistics, central indexes and infernal statistics including Pierson correlation index and
K-square statistical tests, for all of the tests at 0.05 level
of significance.
4. Results
In the current study, 364 patients with coronary artery
disease, residence of Tehran participated. 54.4% of the
subjects were men and 45.6% were women. The age range
of subjects was 18-87 (58.95 ± 1.23) and time of illness was
6-55 years. 47.81% of the subjects were unemployed and
52.19% were employed. 54% of subjects expressed their
economic situation as “relatively desirable”, 29% as “undesirable” and 17% as “desirable”. 16.20% had high school
diploma, 10.20% university education, 28.80% guidance
school education, 28.60% primary school education,
and 16.20% were illiterate. In 34.30% of subjects left ventricular ejection fraction was of 50-55. Among spiritual
health items, the statement “I believe God loves me and
is watching me” with (5.59 ± 0.76) and among religious
health items, the statement “communication with God
helps me not to feel alone” (4.21 ± 1.82), and the statement “I believe there is a specific purpose for my being
Islamic Life Center Health. 2013;1(2)
alive” (4.20 ± 1.81) from existential health got the highest
scores. Statistical Independent T-test indicated that the
average religious health score of patients (41.67 ± 14.90)
was higher than that of the existential health (40.61 ±
15.19) (P = 0.002). There was a significant relation between spiritual health scores and quality of life in heart
patients. Hence, according to the statistical analyses,
Pierson correlation index was around 0.940 (P = 0.002).
Although the average score of women spiritual health
(63.08 ± 22.90) was a little higher than that of men
(59.20 ± 23.56), statistical independent T-test showed no
significant difference between gender, spiritual health
and its aspects (P = 0.25).
Statistical independent T-test showed that the average
of quality of life was (24.58 ± 9.11) and was (23.57 ± 8.75) in
women and men, respectively (P = 0.28); also the results of
the present study indicated that the average of quality of
life in the subjects under study was (61.04 ± 18.62). Results
of the current study indicated that the average of quality
of life was (61.04 ± 18.62), and among different aspects of
quality of life, “emotional reactions” (71.00 ± 21.21) and “energy” (44.17 ± 27.35) had the highest and the lowest averages, respectively. Findings are shown in Table 1.
Table 1. Comparing the Different Aspects of Quality of Life Regarding Gender
Aspects
Patients,
Mean ± SD
Women,
Mean ± SD
(n = 166)
Men,
Mean ± SD
(n = 198)
Energy
51.84 ± 25.91
47.66 ± 25.60
56.03 ± 26.22
Pain
57.38 ± 32.97
53.42 ± 36.85
61.35 ± 29.09
73.96 ± 19.42
76.92 ± 17.63
71.00 ± 21.21
Emotional
tion
Reac-
Sleep
54.59 ± 23.56 53.02 ± 22.63
56.17 ± 24.50
Social Isolation
61.13 ± 23.68
56.55 ± 23.54
Physical Activities
46.93 ± 23.89 44.17 ± 27.35
Quality of Life
61.04 ± 18.62
66.08 ± 23.83
49.70 ± 20.43
63.08 ± 22.90 59.20 ± 23.56
Statistical independent T-test and Pierson correlation index indicated a significant relation between spiritual health
(r = 0.940; P = 0.0001); religious health (r = 0.921; P = 0.0001);
existential health (r = 0.925; P = 0.0001) and the quality of
life. Statistical independent T-test showed no significant difference between the quality of life in men and women under study. Findings are shown in Table 2.
Table 2. Correlation Between Spiritual Health and Quality of Life
Pierson Correlation Test
Quality of Life
P
R
Spiritual Health
0.001
0.940
Existential Health
0.001
0.925
Religious Health
0.001
0.921
Translated Version of http://dx.doi.org/10.5812/ilch.8575
19
Jahani A et al.
Spiritual Health in Patients with Coronary Artery Disease
5. Discussion
According to the findings of the current study, spiritual health of subjects was evaluated at medium level
and scores of quality of life regarding the aspect of emotional reactions was higher than that of other aspects.
Religious and existential aspects of spiritual health
showed significant relation with the quality of life. Results of some studies such as Fisch et al. (2003) confirm
the relationship between spiritual health and the quality
of life (21). Results of the current study was compatible
with the findings of Rezai et al. (2008) which showed
that the score of religious health in patients with cancer
was higher than their existential health score (22), but
it was incompatible with the results of Allah-bakhshian
Farsani et al (2010) regarding the higher score of existential health than that of religious health in patients with
cancer (13). Comparing the study of Bussing (2007) with
some researches on patients with multiple sclerosis (MS),
it seems that in patients with low spiritual health, new
hopes for treatment cause increase of life expectancy and
quality of life (23). Allah-bakhshian Farsani (2008) indicated that the diseases can open a new window to spiritual awakening and can be the occasion for changing.
People with spiritual beliefs, even in the storm of crises,
can find the aims and concepts of their lives (13), and in
transition period can tolerate the disease suffers better
(24). Religious health score in patients with coronary artery disease was higher than their existential health score
which can have roots in the cultural and religious conditions of Iranians. These conditions have led the people
to show more tendency towards religion to cope with
critical conditions (13). Livneh et al. (2004) showed that
spirituality plays an important role in coping with stressful conditions resulted from diseases (25). Findings of the
present study indicated that spiritual health in women
was higher than that of men. It was compatible with the
results of the following studies: Fernsler et al. (1999) on
patients with colorectal cancer; Allah-bakhshian Farsani
et al. (2010) on patients with multiple sclerosis (MS);
Rezai at al. (2008) on cancer patients; and was incompatible with the results of Bussing et al. (2007) (13, 22, 23, 26).
According to the results of the current study, the average
score of quality of life regarding “emotional reactions”
was higher than other aspects and it was higher in women than men; and the average scores of men in the “sleep”
and “physical activity” aspects was higher than those of
women. Lukkarinen (2001) on the evaluation of quality
of life by Nottingham Health Profile indicated that the
physical aspect had the lowest score regarding quality
of life (19). Findings of the current study indicated that
existential health had a stronger relationship with the
quality of life rather than religious health. Results of the
current study complied with those of the following studies: Bekelman et al. (2007) on heart patients and Litwinc-
20
zuk (2007) on Aids patients (19, 27). The relationship between spiritual health and quality of life has been proved
in different studies. The following studies also supported
this idea: Burkhardt at al. (1998) on evaluation of chronic
diseases; Allah-bakhshian Farsani et al. (2010) on patients
with multiple sclerosis (MS); Finkelestine (2007) on
chronic renal failure patients; Bussing (2007) on cancer
patients; and also Ficsh et al. (2003) on evaluation of different conditions (12-14, 21, 23, 27-29). According to the
findings of the current study, the effect of spirituality, as
the main factor, on different aspects of life in creating life
expectancy, increasing the compatibility, coping with suffers of incurable diseases and existential crisis resulted
from life-threatening diseases can be understood. In
Eastern Societies, people have rich religious and ancient
cultural beliefs. Therefore it seems that in these societies,
paying attention to the spirituals is an easy and desirable
way to the multidimensional humane protections; hence
to improve the quality of life and compatibility with lifethreatening physical disabilities, spiritual needs of patients should be considered. The population under study
has been limited to the patients with coronary artery diseases from the metropolitan of Tehran. Hence, according
to the lack of information regarding the quality of life
and spiritual health of patients with coronary artery diseases in other countries, performing similar researches is
recommended. Performing the triangulation and qualitative researches, in order to have better understanding
of the effect of spirituality on health and the way to improve the quality of life in patients with coronary artery
diseases, is recommended. Also, to have a better understanding of the spiritual health concept, performing the
phenomenological studies, explaining the formation
procedure using Grounded theory and finding desirable
ways to improve the spiritual health and quality of life by
action research is suggested.
The quality of life score is “emotional reactions”, therefore it is needed to pay more attention to the emotional
and mental aspect, planning and consulting to improve
the spiritual health of patients. According to the results
of the current study and the significant relationship between quality of life and spiritual health in existential aspects, to improve the quality of life and protect humane
and moral dignity, and also provide better services and
proper cares for patients with coronary artery diseases,
specifying programs and approaches to achieve them is
recommended. According to the importance of improvement trend of coronary artery diseases and its effects
on spiritual health of these patients, it is suggested to
evaluate the relationship between spiritual health and
improvement trend in further studies.
Acknowledgements
The current study is a part of MS thesis of nursing with
Translated Version of http://dx.doi.org/10.5812/ilch.8575
Islamic Life Center Health. 2013;1(2)
Spiritual Health in Patients with Coronary Artery Disease
Jahani A et al.
critical care orientation. This study was conducted in
Nursing and Midwifery Faculty of Shahed University. Authors hereby would like acknowledge their gratitude and
appreciation to the University of Shahed, and managers
and staffs of hospitals that participated in the research
and all the people who helped them.
Authors’ Contribution
Ali Jahani: study plan, research guide, data gathering,
Nahid Rejeh: study plan, research guide, supervising,
the research implementation, data analysis, preparing
and codification of the article,
Majideh Heravi- Karimooi: study plan assistant, preparing and codification of the article,
Farideh Zayeri: statistic consultation,
Asghar Hadavi: religious consultation,
Alireza Khatooni: article preparation assistant.
Financial Disclosure
None declared.
Funding/Support
This research was performed by financial supports of
University of Shahed.
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