Does Islamic spiritual program lead to successful aging? A randomized clinical trial.

CONTEXT: Successful aging is a pattern of aging that has gained much attention during recent years. One factor that has a negative impact on successful aging variables is hypertension. The phenomenon of aging when accompanied with hypertension promotes spiritual needs. The aim of this study was to examine the effect of the Islamic spiritual program on successful aging in elderly patients with hypertension who were referred to health centers of Isfahan, Iran, in 2014. SETTINGS AND
DESIGN: This study was a randomized clinical trial.
MATERIALS AND METHODS: The participants (52 elderly patients with hypertension) were randomly divided into experimental and control groups. While the control group received training related to health promotion, the Islamic spiritual program was implemented in the experimental group for eight sessions in two health centers of Isfahan. The data collection tools consisted of the 12-item General Health Questionnaire developed by Goldberg and the satisfaction with life scale developed by Diener. The questionnaires were completed in three steps; pretest, posttest, and follow-up (1-month). STATISTICAL ANALYSIS USED: Data were analyzed using SPSS statistical software version 20 and Chi-square, independent t-test, and repeated measures ANOVA.
RESULTS: Statistical tests showed that the mean score of general health and life satisfaction of the experiment group had a meaningful difference from that of the control group in the posttest stage (P < 0.001). This difference was also meaningful in the follow-up stage (P < 0.001).
CONCLUSION: The results of the study indicated the effectiveness of an Islamic spiritual program on successful aging variables.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

The number and proportion of older people in every country worldwide, both developed and developing, are increasing. The United Nations, in 2009, outlined a total of approximately 750 million elderly worldwide and reported that this number will reach 2 billion people in 2050. According to this organization, in 2009 in Iran, about 5 million people, meaning 7% of the total population, were over 60 years of age. This number will reach about 27 million people, which is 28% of the population, in 2050.[1] This important topic requires future planning in order to control the issues related to this group of the population.[2] Currently, the main concern of researchers is not only to deal with increased life expectancy, but also to live a life with high quality.[3] One of the most common words that describes an ideal aging process is successful aging.[4] In the definition provided by Palmor, factors affecting successful aging were survival, well-being, and life satisfaction.[5] Therefore, based on Palmor's definition, a successful elderly is a person who has a good general health and who is satisfied with his/her life. In Iran, Motamedi et al. and Motamedi and Egei have also used this definition in their studies.[67] A considerable proportion of people who come close to their elderly ages or start this period are faced with a decline in physical and mental health signs of general health.[8] In addition, numerous problems, such as loneliness, physical illness, and financial problems, will affect life satisfaction in the elderly.[9]

Statistics showed that in Iran and the world, the majority of the elderly have at least one chronic disease.[10] According to the results of the study by Young et al., elderly patients with chronic diseases can also achieve successful aging by strengthening both mental and social aspects of health.[11] Even in chronic diseases, successful aging is comprehended.[12] Among chronic diseases, cardiovascular diseases are the most common,[1314] and one of the main causes of their increased rate worldwide is the increase in the rate of hypertension.[1516] According to the World Health Organization (WHO) statistics, high blood pressure was the cause of 7 million deaths/year. According to statistics obtained by the Ministry of Health and Medical Education in 2005, 27% of individuals of 45–69 years of age and about 42% of individuals over 70 years had hypertension.[17] Hypertension has high care and treatment costs.[18] It also has negative effects on the proposed variables of successful aging. High blood pressure not only reduces the physical ability of the elderly, but it also plays an important role, as a risk factor, in causing cardiovascular and mental complications, and psychological problems such as depression, anxiety, reduced cognitive ability, and severe drug dependence.[19] The results of the study by Steffen et al. also suggested the negative impact of hypertension on life satisfaction of the elderly.[20] Health counselors suggest for patients with chronic diseases to seek help in spiritual beliefs in order to cope with the illness, and maintain disease control, hope, and a sense of meaning and purpose in life.[21]

The importance of human spiritual and intellectual growth is to the extent that the WHO, in defining the dimensions of human existence, mentions the physical, mental, social, and spiritual dimensions, and discusses the fourth dimension, spiritual dimension, in terms of human growth and development. Spirituality is a dimension which illustrates humanity's connection and integration with the universe, by which one can understand the meaning of one's life.[22] Koenig et al. believe that spirituality can affect one's social functions and emotions, and in turn, affect the immune system and endocrine glands. Therefore, spiritual beliefs and practices are associated with healthy behaviors, stronger immune function, better cardiovascular conditions, and a longer life.[23]

In the elderly, spirituality and satisfying the spiritual needs are among the nursing care priorities. Spirituality can be a source of mental peace for these people and result in their greater stability against physical and mental illnesses. Previous studies also suggested that spirituality, as a force which provides the elderly with ineffable peace, strength, and joy, has attracted the attention of nursing theorists.[24] Therefore, it is necessary for nurses to have the required knowledge regarding spirituality and its role in providing peace for elderly patients. In addition, researchers found a relationship between spirituality, health, and life satisfaction among the elderly.[252627] On the other hand, spirituality and religious activities play an important role in controlling and managing blood pressure in patients with hypertension.[2829]

The spiritual therapies that have been used for prevention and treatment of physical and mental illnesses include prayers, meditation, and exercises like yoga.[26] However, Islamic spiritual therapies are combinations of cognitive, emotional, behavioral, and spiritual practices derived from the Holy Quran and hadiths. The main feature of this method is its holistic view and harmony with human nature.[30] This method, compared with other spiritual interventions, is more consistent with the Iranian religion and culture. From the perspective of Islam, the only thing that can satisfy the human need for peace is spirituality.[31] Islamic spirituality is based on religion, and its sources are the Holy Quran and the statements of the Holy Prophet Muhammad (SAW) and the Infallible Imams.[32] The Holy Quran teaches practices such as trust in God, patience, prayer, forgiveness, and gratitude with the aim to relieve pressure experienced by man in dealing with disasters and accidents and to provide him with the ability to meet the desired results.[33]

A number of studies have shown the positive impact of spiritual interventions on public health and its dimensions and life satisfaction.[3435363738394041] However, some contradictory studies about the impact of spirituality on public health and its dimensions have also been found.[4243] The existence of such results, the importance of successful aging and high quality-of-life of the elderly in the current era, the importance of the role of religion and spirituality in the Iranian culture (especially among the elderly), and lack of internal research evidences on Islamic spiritual interventions in elderly patients with hypertension led to the conducting of this study. This study aimed to determine the effects of an Islamic spiritual program on successful aging in elderly patients with hypertension who referred to health centers in Isfahan, Iran.

MATERIALS AND METHODS

This study was a randomized clinical trial. The study population consisted of elderly patients with hypertension who referred to health centers in Isfahan. From the list of all the health centers in Isfahan, two centers were selected through simple random sampling. Thus, half of the subjects were selected from one center and the other half from the second center using simple random sampling. After visiting the centers and examining the inclusion criteria closely, the subjects were selected. The inclusion criteria included age of 60–75 years, blood pressure of <159.99 and >140.90 (based on the information in the medical file), lack of physical or acute mental illness (based on approval of Physician), and lack of participation in psychic and spiritual education. Explanations regarding the study were provided for the subjects. They were informed that they were able to withdraw from the study whenever they desired. Written informed consents for participation in the study were obtained from subjects. In the final step, random allocation of samples into control (n = 26) and experiment (n = 26) groups was conducted for each center using a table of random numbers. After the pretest, the Islamic spiritual program, which was drawn from the thesis of Fatahi,[22] and based on the Holy Quran and hadith with a focus on concepts such as trust, gratitude, patience, forgiveness, participation in charitable activities, prayers, and pilgrimage [Table 1], was performed for the experiment group. It included 8 sessions, once a week, and each session lasted 60–90 min and consisted of five sections. The first part of each session consisted of 5 min feedback on the previous session. The second part consisted of 10–15 min of discussion regarding the previous weeks’ activity and assignments. In the third part of each session, a new spiritual skill, how to use this skill, and its impact on daily life, mental health, and satisfaction with life were discussed for 20–30 min. After this part, a 10-min break was given to the participants, and they were served with snacks. In the fourth part, the next session's assignments were discussed for 5–10 min. As their assignment, the participants practiced the new spiritual skill and offered evidence of this skill in their own life in the next session of the class. In the fifth part, feedback was obtained from the participants. The control group received training regarding health promotion through hypertension control, nutrition, exercise, and physical activity in the health centers. To present the content, lectures, question and answer, and group discussions were used. The elderly expressed their ideas and opinions on the topic of each session and shared their experience regarding the intellectual skill discussed in the previous session with the other participants. A training booklet was provided for the experiment group at the end of each session. Immediately and 1-month after the intervention, all of the subjects were invited to refill the 12-item General Health Questionnaire (GHQ-12) and the satisfaction with life scale (SWLS). At the end of the study, a question and answer session was held for the control group in connection with the Islamic spiritual program. Furthermore, an instructional booklet containing the discussions covered during the sessions was provided for the control group, and the researchers expressed their appreciation for their participation. In this study, sample loss did not occur, and the study continued until the follow-up stage and ended with 52 subjects, including 26 subjects in the control group and 26 subjects in the experiment groups.

Table 1

The topic of the Islamic spiritual program meetings

Based on the operational definition of successful aging that Motamedi et al. provided based on Palmor's theory, the SWLS and GHQ-12 can be used to measure successful aging.[6] These two questionnaires were used in the present study. The SWLS was designed by Diener in 1985 with five questions to measure satisfaction with life and previous studies have confirmed its validity and credibility.[44] This questionnaire has a validity of 84% among Iranian elderly.[6] The GHQ-12 was developed by Goldberg in 1972 and is provided in four forms with 12, 28, 30, and 60 items. The 12-item form is widely applicable to different people, and it is as valid as the other forms of the GHQ-12.[45] The GHQ-12 has been used in numerous studies on the measurement of one component of successful aging. Although the 28-item form is more widely used, when the analysis does not consider the GHQ subscales, using the GHQ-12 is more appropriate. The results of previous studies have confirmed its reliability and validity. This questionnaire has a validity of 87% among Iranian elderly.[6] Data analysis was performed using descriptive and analytical statistics, such as independent t-test, and repeated measures ANOVA, with SPSS software Version 20.0 (IBM Corp.: [Armonk, NY]).

Findings

Demographic characteristics of both experiment and control groups can be seen in Table 2. As observed in Table 2, the two groups were nearly identical in terms of demographic characteristics. The mean and standard deviation scores for general health and life satisfaction of both experimental and control groups, and the comparison of these scores in three stages of pretest, posttest, and follow-up (1-month) are presented in Table 3. The independent t-test showed a significant difference between the mean score of life satisfaction and overall health immediately after (P < 0.05) and 1-month after the intervention (P < 0.05) in both experimental and control groups. The Islamic spiritual program outcomes on the mean changes of the two variables of general health and life satisfaction in the experiment and control groups separately at 3 different times using repeated measures ANOVA are presented in Table 4. Test results showed a significant difference between the mean score of general health and life satisfaction at 3 different times in the experiment group (P < 0.05). However, this difference was not significant in the control group (P > 0.05).

Table 2

Demographic characteristics of the participants

Table 3

Determining and comparing the mean scores of life satisfaction and general health of elderly patients with hypertension in experimental and control groups at pretest, posttest, and follow-up stages

Table 4

Determining and comparing the mean scores of general health and life satisfaction of elderly patients with hypertension in the pretest, posttest, and follow-up stages in the intervention group and the control group

DISCUSSION AND CONCLUSION

Test results showed that the demographic characteristics of the respondents were almost identical. This result was expected based on the random allocation of the subjects into two groups. Other studies also showed no significant differences related to the demographic data of the subjects. In the study by Rajagopal et al.,[46] on the effect of spirituality-based interventions on the reduction of anxiety and depression in the elderly, no significant differences were observed in demographic characteristics between test and control groups.

Results of independent t-test showed that the two groups were not significantly different regarding the mean score of general health before the intervention (P = 0.51). This result was expected due to the use of random allocation of subjects and nonintervention. The mean score of the general health of the experiment group immediately after and 1-month after the intervention was less than the control group and this difference was statistically significant (P < 0.001). It was found that the intervention reduced the mental health score and improved the mental health status of the study participants. Therefore, it can be concluded that the Islamic spiritual program has resulted in the promotion of general health. In support of these findings, no study that directly examined the impact of Islamic spiritual interventions on successful aging and its variables (general health and satisfaction with life) in the elderly was found. The existing studies had mentioned the impact of spiritual therapy on different social classes, age groups, and illnesses. The results of these studies and their comparison with the present study results will be discussed in the following section.

The results of the study by Fallah et al. in Iran, entitled the effectiveness of spiritual group intervention on promoting hope and mental health in women with breast cancer, showed that spiritual group interventions have an impact on the mental health of women with breast cancer.[34] Results of the study by Mohamadi, on the effect of spiritual therapy on depression in elderly residents of a nursing home, showed that spiritual therapy had a positive impact on depression in older women.[36] The results of the study by Bowland, on the impact of psychosocial-spiritual intervention on anxiety, depression, physical, and spiritual well-being of the elderly survivors of interpersonal trauma symptoms, also showed that psychosocial-spiritual interventions were effective on anxiety, depression, and somatic symptoms of the elderly.[47] The study by Tavan and Jahani, on the effect of participating in the familiarity with Quran workshop on the mental health of nurses, showed that this intervention reduced the mental health score and promoted the mental health status of the participants.[48] The study by Harooni et al., on the relationship between perceived social and religious support and the health status of elderly women and men, showed that a higher perceived religious support in the elderly resulted in a more satisfactory mental health status.[49] The findings of the study by Motamedi et al. also showed that religious beliefs have a significant role in successful aging.[6] The results of the present study were consistent with that of previous studies. The present study indicated that the Islamic spiritual program has been effective on the general health of elderly patients with hypertension (P < 0.001).

The study by Liu et al., on the impact of spiritual group therapy on anxiety, depression, and general health of women with breast cancer, showed that spiritual group therapy was effective on anxiety in women with breast cancer, but it had no effect on depression and general health.[43] This was not in agreement with the findings of the present study. The researcher believed that the difference in results achieved was due to the heterogeneity of the two studies regarding the participants, religious and cultural differences in the study population, and type of spiritual intervention and questionnaire used. The independent t-test results showed that before the intervention the control and experiment groups were not significantly different in terms of mean life satisfaction scores (P = 0.19). This result was expected due to random allocation of the subjects and not using any intervention. The mean life satisfaction score immediately after and 1-month after the intervention in the experiment group was higher than the control group. This difference was statistically significant (P < 0.001). It was found that the intervention increased the life satisfaction score, and thus, it can be concluded that the Islamic spiritual program has resulted in an increase in life satisfaction in older people. In support of these findings, the study by Fallah et al., on the effect of spiritual group therapy on hope, happiness, and life satisfaction of women with breast cancer, showed that spiritual group therapy was effective on life satisfaction of women with breast cancer.[41] The results of the study by Cowlishaw et al., on spiritual and life satisfaction among the elderly, showed that spirituality has a positive impact on life satisfaction of the elderly.[39]

Findings from the study by Christensen, on the relationship between spirituality and successful aging (successful aging meaning hope, life satisfaction, and lack of depression), showed that the more daily spiritual experiences the elderly have, the greater their life satisfaction will be.[26] The study of Mimandi and Barghamandi, on the relationship between the practice of religious beliefs and life satisfaction among the elderly, showed that life satisfaction was greater in the elderly who performed more religious practices.[50] These results were also consistent with the results of the present study.

The results of the present study can be explained by referring to the effects of spirituality on the improvement of individuals’ attitude toward and interpretation of life. This causes the elderly to see negative life events as opportunities instead of threats and gives them a stronger sense of control.[51] In other words, spirituality helps the elderly not to focus on what is being missed, but to seek meaning despite their illness and despair. Therefore, life is meaningful under any circumstances from the perspective of spirituality. Meaning and purpose in life are factors which strengthen mental health. It seems that spirituality influences other aspects of health by influencing mental health.[29] Spirituality can also help the individual achieve new circumstances and life satisfaction by reducing the gap between their reality and ideal. Strong moral concepts such as gratitude, faith, forgiveness, and patience compensate for their weaknesses and make them strong and powerful. According to Diener's theory, such powerful feelings may help individuals to cope with difficult situations and gain greater satisfaction.[52] However, due to the cultural and social characteristics of Iranians and the history of spirituality in the culture of this country, spirituality is an effective support for individuals in difficult and critical situations. Thus, based on research findings, the implementation of Islamic spiritual programs by nurses was effective on factors of successful aging which were general health and life satisfaction. Thus, it is an appropriate approach to enhance general health and improve the satisfaction of life. Nurses can use spiritual intervention to help the elderly population in reaching an ideal and successful aging.

At present, for various reasons, this reasonable need of the elderly is not provided by health care services. Nevertheless, this need can be provided by implementing a low-cost compiled program to provide the basic needs of the elderly. Nurses, as a member of the healthcare team in medical centers, have the most connection with elderly patients with chronic diseases, and thus, have more opportunities to engage in their spiritual matters. Through spiritual interventions, they can provide this basic need of the elderly and use their inner potential to increase their general health and life satisfaction.

The limitation of this study was the limited time for such interventions. It is suggested that further research be conducted with greater sample size in longer duration. Moreover, further studies should be performed on the effectiveness of Islamic spiritual programs on other chronic diseases, among people with different social and economic levels and different age groups.

Financial support and sponsorship

Vice challencer for research of Isfahan Medical University.

Conflicts of interest

There are no conflicts of interest.