Spirituality: A Panacea for Patients Coping with Heart Failure.

BACKGROUND: Many patients with heart failure grapple with related problems that threaten their feeling of well-being and quality of life. Patients look for ways to cope with the new situation. The present study aimed to explore religious coping from the perspective of patients with heart failure.
METHODS: This qualitative study used the content analysis of the semi-structured interviews. The data were collected from 18 participants referring to training hospitals in Kerman University of Medical Sciences in southeastern Iran. The data were analyzed using Lundman and Graneheim qualitative content analysis.
RESULTS: The main theme of "Spiritual coping, a dominant strategy" was extracted with two categories: 1- "religious belief" having the sub-categories of "inner faith" and "search of meaning" 2- "connection to God as the supreme power" with sub-categories of "seeking healing through supplication and rituals", "worship as a barrier to the flood of problems", and "submission to and trust in God".
CONCLUSION: The findings suggest that a spiritual strategy helps the patients effectively to cope with heart failure. Patients learn to use religious beliefs and faith to accept the reality of the disease and its stages and to manage their condition with patience, tolerance, and hope calmly and confidently for a bright future.

INTRODUCTION

Heart failure is an inability of the heart to meet the metabolic demands of the body.[1] Almost 23 million people worldwide suffer from heart failure. Each year in the US, more than 550000 people are diagnosed with heart failure and 1 out of 5 people is exposed to risk.[2] The number of heart failure patients in Iran is around 3337 cases per 100 thousand people.[3]

Outcomes of heart failure are a high rate of hospitalization and increased mortality; more than 40% of patients die within a year of initial hospitalization. Moreover, the cost of caring these patients can impose a heavy economic burden on patients, their families, and the community.[4] This makes heart failure a major public health problem; its incidence increases with age.[5,6] Despite recent advances in the treatment of heart failure, most patients suffer debilitating and long-term symptoms.[7] Chronic physical symptoms include shortness of breath, chest pain, fatigue, lack of energy, and sleep disorders.[8,9] Difficulty coping with the disease and the feeling of being close to death that most patients with heart failure experience cause psychological distress, anxiety, depression, and fear.[10] These complications have a damaging effect on the quality of life.[7,11]

An important goal of the treatment of heart failure is preserving and improving the quality of life by controlling the symptoms and promoting useful life activities.[9-12] Coping with the new situation is key to achieving this important goal because living with heart failure and maintaining the treatment regimen are stressors with which patients must cope.[13] Several studies found that patients who can cope with their new reality improve their physical and mental performance.[9,14,15] Coping with new circumstances for patients with chronic heart failure is challenging because their physical, psychological, social, cultural, and religious aspects are affected. Mere emphasis on the physical aspect is not adequate for patients’ health and welfare; contribution of other strategies including religious coping ones is required.[16] Religion is an important aspect of health care and attention to religious needs has been increasingly emphasized by healthcare professionals.[17] The strength and comfort obtained from one’s faith in a personal relationship with God as a higher power include a sense of meaningfulness and well-being.[16] Religious coping strategies and a sense of meaning help the patients suffering from chronic diseases to trust their strengths, accept new conditions, and cope through finding their inner selves. This makes spirituality and religion an integral component of comprehensive care.[17] Religious beliefs take a more prominent role as the age of the patient increases. Because most patients with chronic serious diseases are older, it is not surprising that a large number are spiritual.[18]

Ebadi et al. suggested a prominent role for religious beliefs when coping with the disease, finding a sense of well-being, and in decision-making for the care and treatment of chronic diseases.[19] Numerous studies described that religion and spirituality are the main sources of coping for chronic and life-threatening diseases. However, all religions affirm spirituality as a relationship with God and with others to improve mental health and cope with chronic disease.[5,20] Understanding the experiences of patients in religious coping with chronic diseases highlights the patients’ spiritual needs and reduces the barriers to coping. Also, understanding spiritual beliefs in the cultural context by health care providers is very important.[21] Johnson et al. found that a deep understanding of differences in cultural and religious beliefs and their effect on treatment preferences improves the relationship and reduces conflict in patient care for any race or background.[22]

Islam is the major religion in Iran and Islamic teachings help form an approach to spirituality.[23] In Iran, 98% of people are Muslim and 90% are Shia. Religion and culture are intertwined with the lifestyle of the Iranian people and religious beliefs have an important role in the lives of Iranian Muslims, especially under chronic forms of stress.[24]

MATERIALS AND METHODS

This is a qualitative study using content analysis; qualitative content analysis largely focuses on theme and context and emphasizes the similarities and differences between codes and classes.[25] In the qualitative study, the researcher has the freedom to explore the phenomena in the context of the individual’s culture.[26] Because spirituality depends on the cultural context of the society,19 qualitative research is an appropriate method to examine this issue. [27]

This study was conducted in Kerman from July 2013 to September 2015. Kerman is the largest city in southeast of Iran. There are a variety of religious beliefs in Kerman but most people are Muslims. In this city, there are two teaching hospitals (Shafa and Afzalipour) related to Kerman University of Medical Sciences where heart patients are admitted. As a qualitative research, there were no absolute rules determining the estimated number of participants, so sampling continued until data saturation so that no new information was achieved. In this study, data saturation was achieved after 18 interviews. The participants were selected through purposive sampling from the cardiovascular departments of training hospitals. With the agreement of the participants, time and place of the interview was determined. Seventeen participants were interviewed in their homes and one interview was done in the hospital. To capture rich and diverse information, patients with different characteristics such as age, gender, class of illness, duration of illness, marital status and educational status were chosen. The inclusion criteria were having at least six-month experience of living with symptomatic heart failure and the ability to communicate in Persian. Exclusion criteria were confirmed mental disorders and lack of willingness to participate in the study. Semi-structured, in-depth, face-to-face individual interviews were conducted by the first researcher. This study was carried out with a research question: how do religious beliefs effect the adjustment of patients with heart failure? Initially, the researchers asked a few questions to get familiar with the participants and create a friendly environment. Then, the interview was directed toward the purpose of the study. Some of the questions posed were: What do you feel? How do you deal with your problems? What effect does heart failure and religious beliefs have on each other? The interviews lasted for 45 to 60 minutes. [28]

Analysis of the data was performed according to the method proposed by Graneheim and Landman. Initially, each interview was transcribed verbatim and read several times to achieve a general understanding of the content. In the second step, the text was divided into meaning units. Then, the meaning units were condensed and labeled. In this step, sub-categories appeared. In the next step, the categories were extracted as the main feature of content analysis. In the final step, the theme was formulated as the expression of the latent meaning of a text. [29]

The validity and reliability of the study were tested using the criteria proposed by Guba and Lincoln. To establish credibility and conformability, there was sufficient cooperation and interaction between the author and participants. Reviews were conducted by external supervisors using additional comments by professors. The researchers examined the trust and confidence data in consultation with supervisors and experts. The validity of the findings was confirmed by the participants. [30]

This study was approved by the Ethics Committee of Kerman Medical Sciences University (number: k.93.246 /4.10.2014). Oral and written informed consent was obtained from participants before participation in the study and recording of the interviews. Participants were free to enter and withdraw from the study whenever they wished. They were assured of the confidentiality of the information and were allowed by the researcher to have phone calls and send e-mails regarding any questions or information.

RESULTS

Participants in this study were 18 patients with heart failure, 10 males and 8 females aged between 31 and 85 years. shows the characteristics of the participants. Table 1

Table 1

Characteristics of the participants with heart failure

Participant	Gender	Age (year)	NYHA functional class	Duration of illness (year)	Marital status	Educational status	Occupation
P1	Male	53	III	6	married	Diploma	Employed
P2	Female	85	III	7	widow	Illiterate	housewife
P3	Male	70	II	3	married	Illiterate	Retired
P4	Male	83	IV	8	married	Primary	Retired
P5	Female	68	III	4	married	Primary	housewife
P6	Male	67	II	2	married	Middle	Self employed
P7	Female	68	III	3	married	middle	housewife
P8	Male	54	III	2	married	Bachelor	Self employed
P9	Female	75	IV	6	widow	Illiterate	Retired
P10	Female	61	III	2	married	middle	housewife
P11	Male	54	III	3	married	Diploma	employed
P12	Male	65	III	7	married	middle	Retired
P13	Female	65	II	4	married	Illiterate	Retired
P14	Male	58	III	1	married	Diploma	Self employed
P15	Female	31	IV	3	married	Bachelor	housewife
P16	Female	71	III	6	widow	middle	Retired
P17	Male	80	II	7	married	Illiterate	Retired
P18	Male	73	III	8 month	widow	Illiterate	Retired

The main theme of “spirituality, a dominant strategy for coping” was extracted with two categories of “religious belief” having the sub-category “inner faith” and “search of meaning” and “connection to God as the supreme power” with sub-category “seeking healing through supplication and rituals”, “worship as a barrier to the flood of problems”, and “submission to and trust in God” (Table 2)

Table 2

The category and subcategory related to the experiences of patients about spiritual coping with heart failure

Theme	Category	Sub-category
Spirituality, a dominant strategy for coping	Religious belief	Inner faith
		Search of meaning
	Connection to God as the supreme power	Seeking healing through supplication and rituals
		Worship as a barrier to the flood of problems
		Submission to and trust in God

1. Religious Beliefs

1.1 Inner Faith

In the majority of patients with heart failure, the supporting force for coping with the disease was the power of inner faith. From their perspective, strong convictions and faith helped them not to give up and choose a proper coping method. Participants expressed that belief in a supernatural strength has been the most important factor that has led them to control and manage their condition

One participant in this regard said: “Everything is under the will of a supreme power. You should attain this belief, understand it, and touch it. Severe problems of living with heart failure have taught me to believe in this and manage my life with this belief.” (P3)

From the perspective of the participants, a positive attitude to death is formed as a result of positive religious beliefs, causing to accept the death as a fact. Accepting the reality of death makes them not to be afraid of it. Since heart failure patients are constantly faced with recurrent symptoms, feeling close to death can provide them with fear and anxiety. These patients stated that this consequence had a great value for them. Accepting the reality of the disease created peace of mind and serenity in them. Even in a group, this kind of attitude made them be grateful for every moment of their life and try to have a better life.

One of the participants said: “God did man a great favor and created death for him. My heart is weak and every moment death is near me; if there were no death, I would have to remain disabled and paralyzed for years. It was too hard, so death is a great blessing.” (P5)

The majority of participants expressed that faith and positive convictions not only prevented their fear but also created and reinforced a positive attitude and changed their approach in all aspects of life. Therefore, this outcome is very important because heart failure is a chronic disease and requires follow-up. These promoted self-confidence in the patients with heart failure and made them hopeful to continue to live and make correct decisions to take care of themselves and cope with the new situations and the problems with patience which led to peace, satisfaction and better coping.

One participant mentioned: “I’m living with shortness of breath, sleep disorder; I have trouble in my family life. Faith was the major factor that helped me to cope with my troubles. Faith increased my patience and tolerance.” (P11)

1.2 Search of Meaning

A group of participants, knew the disease as God’s will or God’s test and this belief prevented the suffering of negative thoughts and made them better cope with the problems and be satisfied with the current situation and try to get better.

One participant said: “This is my fate and I should be appreciative. I believe that my long suffering because of heart failure is God’s will; it could be worse; for example, it could be cancer.” (P12)

The majority of participants stated that positive attitudes as the result of faith in God’ would make them trust in God, because trust in the will of God as a source of comfort and strength made them feel that they had a strong supporter who helped them all the time. So they could better tolerate the suffering caused by the symptoms and complications of heart failure, and gain more motivation to take care of themselves and cope with their problems with energy, comfort and hope.

One of the participants said: “I have had both experiences. For a time I was always complaining and angry and I couldn’t cope with the situation, but now I have concluded that trust in God reinforces my morale and tranquility.” (P13)

Some participants acknowledged that since they have been involved in heart failure for a long time, suffering from the chronic disease has led to their mental growth and development. In other words, they saw the disease as a blessing which made them more perfect. For example, it increased the tolerance against problems, changed their perspective on life, and made them consider the disease as a flip and try to live well, or consider the suffering as a base for peace after death.

For example, one participant said: “I concluded that one should miss something to get better things; I suffered a lot because of my heart, but I’ve achieved greater things. I have a better understanding of life; I live with 10% of my heart, but I am taking full advantage of what I have.” (P15)

Because heart failure is a long and painful illness, some participants knew the consequences of living with heart failure as making reparation for sins and expressed that the difficulties caused by disease has reduced the burden of sin, and this understanding led them to better coping with the situation and a good planning for life.

One of the participants stated: “I think my heart disease may be the result of my sins. I thank God and give in charity every morning when I get up and see that I am alive.” (P18)

2. Connecting to God as the Supreme Power

2.1. Seeking Healing Through Supplication and Rituals

One factor that had a major effect on heart failure patients’ ability to cope with their situation, from the perspective of the participants, was worship and supplication to God. Despite their physical problems, patients tried to perform rituals with the purpose of asking God for good health directly through prayer and sometimes indirectly by supplicating and making vows to the Prophet and the Imams. And this made them be more hopeful about the future and find the needed motivation for self-care.

?? One of the participants said: “I appeal to the Prophet and the Imams and make vows for them to ask God for my health, I am confident, because love of Imams is in my heart, so my heart does not stop” (P7)

2.2. Worship as a Barrier to the Flood of Problems

Since the symptoms such as breathlessness, chest pain and persistent fatigue are the causes of stress in heart failure patients, they need to relax. Most participants knew worship as the source of peace and believed that remembering God is an important factor to maintain and improve their morale, because worship made them less concentrated on the disease and problems and consequently they had less stress and more self-care, resulting in a stronger feeling of well-being.

One participant said: “I will never cease prayer for a moment, because remembrance of God reinforces my morale and is an incentive to take care of myself. Basically, I have had nothing without God.” (P17)

A major objective of worship, from the perspective of the participants, was an increasing tolerance of symptoms and related problems such as readmission, disability and the high costs, followed by a sense of hope, and even protection from mental and crisis-related problems.

One of the participants stated: “Heart failure is an incurable and disappointing disease, Prayer makes me confident, give me hope, and a nice feeling.” (P1)

Others have stated worship as a means to distract one from focusing on disease and related problems resulting in less stress.

One participant said: “I pray to distract my thoughts from the symptoms of heart failure, such as breathlessness” (P2)

Due to the frequent recurrence of symptoms of heart failure, some participants also expressed that when they had anxiety, fear of death as a result of symptoms or psychological state, prayer acted like a drug and they could overcome their fears and relaxed by a relationship with God. Others have argued for their religious beliefs that since they were ready to travel to the other world, they needed to have provisions for the journey and worship was the best.

In this regard, one participant said: “Whenever worrisome thoughts come to me, and I have fear and anxiety, I pray to achieve tranquility, during worship I put my hand on my heart; my heart rate is reduced” (P14)

2.3. Submission to and Trust in God

One major effect that most participants acknowledged was that surrendering to and trusting in God was an important way to cope with the new situation, because heart failure creates a lot of changes in the lifestyle of heart failure patients.

One of the participants stated: “In spite of much care, my heart failure is still continuing; I finally came to the conclusion that I must surrender to my God; this feeling helped me a lot.” (P10)

Some participants acknowledged that by surrendering to and trusting in God, they have been able to accept the reality of the disease and cope with its complications. In this case, one participant said: “The first time that I was informed that I am suffering heart failure, I knew that heart failure has no definitive treatment; I doubted the wisdom of God in the beginning of the disease and this doubt really bothered me. But when I trusted in God and surrendered to His will, I could cope with the reality of my disease.” (P12)

Some knew that surrendering to and trusting in God would reduce anxiety, sadness, and produce a feeling of well-being in coping with heart failure.

One of the participants said: “I don’t know how to say it; I have surrendered to God, so I feel well and my worries are alleviated. You should be in my position and experience this feeling to be able to understand it.” (P15)

Since heart failure, as a chronic disease, can greatly reduce the quality of life, worship can be the key helper in this case. Some believed that surrendering to and trusting in God resulted in contentment with their situation and increased their quality of life.

One of the participants maintained: “I always say to God that I’m satisfied with my current position. ‘I could have a worse disease, so I’m satisfied with Your will.’ Now I try to enjoy my life, find a rational solution to my problems, and do not complain.” (P13)

DISCUSSION

The present qualitative research showed that spirituality is a key for patients with chronic heart failure to better cope with the disease and deal with their multiple problems. Several studies found that religious belief certainty allows the patients to believe in God as a source of power that can control them. [19,21,24-31]Since the heart failure creates a critical situation for patients, belief in God as the supreme power prevents a feeling of desperation in patients in the new situation, changes their perspective on the issues, and helps them manage the consequences of the disease with a positive attitude and experience good outcomes. Numerous studies noted that religion makes the patients with chronic diseases such as heart failure able to manage stress; by trusting in God and the use of problem-solving strategies, they manage life events to minimize adverse effects of the disease, such as depression, anxiety, low quality of life, and lack of communication with family and friends. [17,18,31]

The findings of this study showed that tranquility, increased tolerance, patience, and hope were benefits that the participants had gained through spirituality and faith. These outcomes are important for heart failure patients because these patients have to contact with the disease for a long time and experience physical and psychological symptoms. In support of the above point, Marques et al. state that there is a deep connection between spirituality, hope, and satisfaction. Hope as goal-directed thinking increases the capacity and motivation of a person to reach the target; it is considered to be a power that neutralizes the negative effects of a life crisis.[32]

Due to the frequent relapse symptoms, a factor that often hurts the patients with heart failure is the fear of death, so a positive attitude toward death as a fact and a blessing from God, in addition to helping them come to terms with the disease, overcome fear, and create peace raised the abilities of patients to cope with the disease and made them thankful for every moment of their lives. These results were in the same line with those of the studies that concluded that faith, spirituality, and religious beliefs of patients have an important role in coping with negative attitudes about death.[16,21,33] Conflicting results were reported that a group of patients held contradictory intellectual beliefs in relation to death that caused fear and unrest and reduced life expectancy.[34] It appears that attitude was the result of extreme worry arising from fear of the unknown world after death and a lack of awareness or incorrect understanding of religious teachings. Accordingly, researchers have expressed that the spirituality strategies applied to patients with chronic disease must be logical, correct, and consistent with their religious beliefs so that the result is not fear of death.[31]

Since heart failure is a chronic and debilitating disease and patients need to use coping strategies, faith in God’s will and in their illness being a test from God made the patients consider the disease as a gift from God and perhaps exoneration of their sins. These patients better tolerated the pain of the disease, tried to trust in the fate that was intended by God for them, coped with the new situation by trusting in God, and had greater recognition of their experiences. These results were in line with the results of Ebadi et al. who stated that Muslims consider the challenges and hardships of life as God’s test and will and God is the supreme power.[19]

It appears that the attitude of patients toward this issue is very important. For example, a study showed that when patients with chronic diseases consider the disease to be a gift from God and have a positive attitude, they hold themselves responsible for their condition and are more likely to adhere to proper care and management.[35] In contrast, when a group of patients with a chronic and debilitating disease do not believe they have received an answer to their prayers to and worship of God, they begin to doubt and hesitate and constantly ask, “Why me?” They may consider the disease to be the result of their sins and believe that God is punishing them; they become depressed and cannot rely on their religious beliefs, which can have an adverse effect on health outcomes.[36] It is recommended that, in such circumstances, patients facing spiritual conflict receive religious counseling by experts.

The results showed that the participants asked for healing through religious rituals such as prayer and participation in religious ceremonies. This increased their hope and motivation to take care of themselves. Self - care is a key factor for the survival and quality of life in patients with chronic heart failure. Several research reported that a God-centered perspective in patients prompted them to ask God for healing through supplication and recitation of the Qur’an or indirectly by human factors, including Imams, family, and friends.[19-37]

The results indicated that the purpose of worship was coping with mental health problems caused by the challenging situation of chronic heart failure, what patients call a source of peace and a barrier against crises. This reduces depression, overcomes hidden fears and distraction, reduces anxiety, maintains morale and hope for the future, and promotes self-esteem. Such patients are able to solve problems, are motivated, take care of themselves, follow the doctor’s orders, and have a sense of well-being. It is obvious that each of these issues plays a key role in a patient’s ability to cope with the condition. A number of researchers stated that patients with chronic heart failure need to cope with the situation, follow the doctor’s orders, and take care of themselves in order to manage their lives [5,9,11,38,39] Religious activities effected the physical, mental, and social aspects that help the patients act more responsibly and encourage well-being.[14,40]

It appears that compliance with medical recommendations is influenced by religious beliefs. In some highly religious regions of the world, the patients may face conflict with treatment. For example, some Christian sects may oppose the use of medication and medical procedures, preferring prayer and religious ceremonies to promote healing. [18]

The results showed that the outcome patients obtained as a result of the connection to spirituality was trust in God and submission to Him. When facing multiple problems, patients with heart failure require a fulcrum with the necessary power. They are then able to accept, cope with, and find a sense of confidence and satisfaction with the current situation. These results were consistent with those of Rahnama et al. who showed that patients with chronic disease felt a sense of well-being and satisfaction by trusting in God and relying on and obeying Him. [21]

In general, findings of this study showed that religious belief is one of the key strategies in heart failure patients’ compliance with the new situation. Because heart failure is a chronic disease with multiple complications such as physical disability, depression, repeated hospitalization, high costs and social isolation, such patients felt a greater sense of well-being when they could benefit from the power of religious faith and related activities. They were more satisfied with their daily lives, could more easily cope with new, and ultimately benefitted from a better quality of life.

This study had a limitation. It lacked the required racial and cultural diversity. Therefore, the provided results might not represent the general population of heart failure patients.

CONCLUSION

The findings of this study suggest that spirituality is a rich resource to deal with the problems and better compatibility in patients with chronic heart failure. Due to the growing number of heart failure patients, and its unpleasant consequences for patients, families and even society, empowering these patients is essential in coping with the disease. The results of this study are useful for nurses, social workers, counselors and health managers to learn more about the religious beliefs of patients, and improve these beliefs to facilitate the adaptation process in them.

This study could be a starting point to further investigate on coping strategies in different cultures and aid the development of spiritual interventional procedures to cope with the disease and its complications in patients with chronic disease.