María Elena Jasso-Soto,1 María Guadalupe Pozos-Magaña,1 Julio César Cadena-Estrada,2 Sandra Sonalí Olvera-Arreola2
1,2Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
1Central de Equipos y Esterilización, 2Departamento de Investigación en Enfermería
Autorizado por el Comité Local de Investigación y Ética en Salud Nº 502
CorrespondencE: María Elena Jasso-Soto
Received: February 8th 2016
Judged: August 1st 2016
Accepted: October 3rd 2016
Introduction: Heart diseases encompass several chronic diseases that can affect the quality of life (QoL) of people. In this sense, spirituality plays an important role, given that by using it patients can find the necessary strength to overcome the disease on the basis of their beliefs and practices.
Objective: To analyze the QoL and the spiritual perspective of hospitalized patients facing a heart disease.
Methods: Analytical cross-sectional study in a random sample of 297 heart disease patients of both sexes. Data were collected under informed consent with the Spiritual Perspective Scale and the WHOQOL-BREF. The analysis was descriptive. To analyze the variables quality of life and spirituality we used Pearson’s correlation coefficient and Spearman’s rank correlation coefficient, and we compared them with Student’s t test and Mann-Whitney U test.
Results: 53.5% perceived their QoL as normal, and 44.8% as good; 68% had a high level of spirituality. The QoL was related to spirituality (r = 0.164, p = 0.005), especially with the beliefs (r = 0.214, p = 0.000); the academic degree was associated with QoL (rs = − 0.288, p = 0.000), but not with spirituality (rs = −0.030, p = 0.606). Spirituality is greater in women (Z = 2.245, p = 0.025).
Conclusions: Patients with heart disease increase their practices and spiritual beliefs. This contributes to the perception of their quality of life.
Keywords: Spirituality; Quality of life; Heart diseases; Cardiovascular diseases; Nursing
Scientific and technological advances of the twentieth century have enabled the reduction of infectious diseases and thus increased life expectancies from 52 to 71.4 years in the global population and from 57 to 77 years in Mexico, according to data from the World Bank taken in 1960 and 2014, respectively. However, this has also resulted in high costs due to the increase of chronic noncommunicable diseases.
According to the World Health Organization (WHO), chronic diseases have caused approximately 38 million deaths worldwide (68%) in the first decade of the 21st century. Global health statistics (2014) cite heart disease as the leading cause of death. In Mexico, the Instituto Nacional de Estadística y Geografía (INEGI) reported in 2014 that there were a total of 121,427 deaths in the general population due to heart disease.1,2
Having a disease affects both the individual and his or her family physically, emotionally, socially, and economically. The balance of these dimensions determines one’s quality of life, defined as "the individual's perception of their position in life, in their cultural context, and according to their values, in relation to their goals, objectives, eexpectations, and fears.”3 Quality of life is determined by the dimensions of a) physical state, which takes into account variables such as pain and discomfort, medication dependence or treatment, energy and fatigue, rest and sleep, daily activity and the ability to work; b) psychological state, characterized by positive and negative feelings, spirituality or religious beliefs, learning, body image and self-esteem; c) social relations, constituted by personal interactions, sexual activity and social support; and (d) the environment, which includes physical security and protection, physical environment, economic resources, opportunities to acquire information/skills, housing, health care, and transportation.
Evidence shows that the quality of life for people with cardiovascular disease is not good and that it decreases as people age. It should be noted that male patients with low cardiovascular risk, higher income, and a superior level of studies have better quality of life and that in contrast, patients who are unemployed perceive their quality of life as lower.
In continuation, the magnitude or effect of a chronic disease on the quality of life will depend on the type of disease and the way it affects the person, the severity of the disease, its clinical manifestations, its evolution time, as well as the treatment it requires. More specifically, when a person is diagnosed with a cardiovascular disease, it changes the individual's vision of themself and/or of life and also changes their relationships family members and close friends. In some cases, an individual may use different resources such as spirituality to adapt to their illness, to face it and to overcome it, thereby bring about a change in their conceptions of health, life, and death.
From the disciplinary perspective of nursing and from a philosophical standpoint, a person has been considered to be an integral and unique unit composed of biological, physiological, social, and spiritual dimensions, even when seen from the diverse theories representative of paradigms of categorization, integration, and transformation4 that have considered spirituality explicitly or implicitly within their theories or models.
Spirituality supersedes religion because it gives meaning and depth to human existence and encompasses a relationship with God, a higher being, or a supreme power. Spiritual perspective is oriented around a search for purpose or meaning, such as the need to love, to relate to others, and to forgive. This is of great significance in people’s lives and has an influence on their conditions, ways of being, lifestyles, attitudes and feelings about sickness and death; it is even one of the factors that can influence a person’s well-being or the time of recovery from a disease.5,6
For Pamela Reed, spirituality is an important factor in decisions made in the clinic; it is a deep and more power resource, intrinsic to human nature.7 Spirituality can be considered as a basic internal guidance system, but not prerogative of the believer, and it may be detached from religion, philosophy, or practice. According to Reed and the nursing meta-paradigm, in professional practice vulnerability (environment) is defined by the awareness of personal mortality and the probability of experiencing difficult events in life; self-transcendence (person), as the ability to extend self-concept boundaries, the multidimensional fluctuations that the subject perceives externally (towards others and the environment), internally (through a greater awareness of perspectives, values and ideals), and in time (through the integration of the past and the future), so that the present is expanded and reinforced. Finally, well-being (health) is defined as a sense of integrity and health in accordance with one's conception own thereof, in other words, a sense of completeness (being complete, being oneself) and health, according to the individual’s criteria.8 It is worth mentioning that there are moderating/mediating factors that interact and can positively or negatively influence well-being, including personal and contextual variables such as age, gender, cognitive ability, life experiences, social environment, past events, and spirituality.
Therefore, spirituality is constituted by beliefs and practices. The former are determined by the traditions in which the community believes and carries out to maintain a balance between health and disease. Popular beliefs are cultural knowledge that is built on the totality of relationships, in the organization of habits, and interpersonal practices.9 On the other hand, spiritual practices are expressed in the majority of people through religious activities, relationship with nature, art, music, and in relationships with family and friends.
Other studies carried out in patients with chronic diseases in countries such as the United States;10,11 Brazil;12-17 Mexico;18 Colombia;19-22 and the United Kingdom,23 among others,24 have shown that spirituality has a positive influence on health by identifying that people who practice religious activities have better support networks; better attitudes about compliance, corporal care, and adherence to treatment; and lower rates of depression, anxiety, and stress. Religion alleviates pain or suffering, serving as a coping strategy25 as uncertainty decreases. However, in spite of published evidence, spirituality and its relationship to quality of life of the adult heart disease patients have not been widely explored in the high specialty health institutions of Mexico, so this study had the objective of analyzing the quality of life and spiritual perspective that patients have on cardiovascular disease,26 since the union of spirituality and health is undeniable and is associated with less depression, better health habits, and better health.
This study is important because few studies have been done on this subject. Additionally, as one of the premises of nursing is to contribute to the improvement of quality of life, it is intended to explore the spiritual perspective of people with cardiovascular disease based on an analysis of reality from the assumptions of theoretical nurse Pamela Reed. Based on the exploratory results, it will be possible to establish nursing interventions that allow the patient to improve their quality of life and encourage (both in the patient and in their family) a practice of their religious beliefs within health institutions, as it is a human need that requires satisfying for the patient as part of their overall health.
An analytical cross-sectional study was performed. Through simple random sampling, the sample size for finite populations was calculated based on the number of hospital discharges of the year 2013 (5665), of which 1741 patients with coronary artery disease were considered. The confidence interval was 95%; the effect size 30%; and margin of error 5%, so that a sample of 297 patients who were manually chosen by multiples of three based on the daily inpatient census diary. Only adult patients of both sexes, with coronary heart disease, regardless of length of time with the disease and of the religion they professed, oriented in their three spheres (time, place, and person), and who wanted to participate in the study freely and voluntarily under informed consent were selected. The instruments with more than 90% of the items unanswered were eliminated.
Two instruments were used for data collection, the first being WHO Quality of Life-BREF (WHOQoL-BREF), which is validated by content, criterion, (alpha>0.75) and construct in previous studies.27-29 A pilot study was performed with 30 subjects for validation with Cronbach's alpha test (alpha=0.863). It consisted of 26 questions, of which two referred to the quality of life and general satisfaction with the state of health. The remainder was distributed in four areas: physical, psychological, social relationships, and environment. Five response options were given in Likert scale type in which 1=nothing, 2=a little, 3=normal, 4=quite, and 5=extremely. The instrument provides an overall score of 1 to 130 points, with five intervals ranging from very poor to very good quality of life: very poor (1-26); poor (27-52); normal (53-78); good (79-104); and very good (105-130).
The second instrument was the Spiritual Perspective Scale, authorized for use by Pamela Reed. In previous studies, internal consistency was reported for Cronbach's alpha>0.75 and construct validation,20,26,30-32 whereas for this study Cronbach's alpha in the pilot test was 0.886. The test consists of two dimensions: spiritual beliefs and practices, which are addressed through10 Likert-type responses, ranging from never, representing 1 point, to more or less once a day with a score of 6. To determine level of spirituality, a range of 10 to 30 points was considered low; from 31 to 45 points moderate; and 46-60 points as high.
The data were analyzed in the Statistical Package for Social Sciences (SPSS) version 17, using frequencies and percentages for the variables of gender, occupation, marital status, academic degree, religion, medical diagnosis, previous hospitalizations, level of spiritual practices and beliefs, and quality of life. Ranks, quartiles, means, and standard deviation were applied for the quantitative variables such as age, time with disease, length of hospital stay and number of previous hospitalizations. Likewise, Pearson’s and Spearman’s correlation tests were performed to determine the association of variables of spirituality and quality of life with sociodemographic data. According to the distribution of the data, Student's t test, Mann-Whitney U test, and Kruskall-Wallis were applied in order to establish difference. The p-value<0.05 was considered statistically significant.
Based on the Ley General en Materia de Investigación para la Salud,33 the Marco ético legal de México para enfermeras y enfermeros en México,34 and the Nuremburg Code,35 this research is considered to be of low risk, since no intervention was performed or intentional modification of the physiological, psychological, or social variables of patients was made. Likewise, data obtained with informed consent are kept confidential, respecting the principles of beneficence, non-maleficence and respect for human dignity, which includes the right to self-determination and complete information.
Of patients with cardiovascular disease, 50.8% were women and the mean age was 48.7±18.6 years (18-88 years). 80.2% of participants were married or in free unions, and 9.8% were single, widowed, separated, or divorced. As for occupation, 37.7% worked in the home; 11.1% had no work activity; and the rest were workers, professionals, or self-employed. The predominant academic level was basic education (up to secondary school) with 58.3%.
Regarding medical diagnosis, 11.1% did not know their condition. Length of time with the disease ranged from 0 to 65 years with a mean of 5.1±8.4 and a median of 2 years. As for length of hospital stay, there were those who were admitted the same day as the survey application, and those who had been hospitalized for three months, with average 11.2±12.5 days and a median of 7 days. It should be noted that those hospitalized for over 15 days were above the quartile 75. Meanwhile 59.9% already had a history of hospitalization and had received surgical treatment.
On the other hand, when asked directly how they rated their quality of life in general, most people considered it normal (41.8%) to good (32.3%); and to the question of whether they were satisfied with their health, 42.4% said a normal amount and 29.6% were quite satisfied. However, when analyzing each of the dimensions of quality of life together, a decrease was observed in those who considered themselves to have a normal quality of life (31.3%) and an increase in those who thought they had a good quality of life (64%).
Patients' perception of the frequency with which they feel satisfied ranges from normal to frequently in categories such as sleep (67.7%); daily life activities (63.6%); life enjoyment (74.7%); meaning in life (76.4%); in personal relationships (77.8%); and in their sex life (64.6%). They feel safe (80.5%) and find their environment healthy (81.8%). However, it is striking that physical pain prevents 60.3% from making great efforts and 70.3% need medical treatment in order to function in their daily lives.
By associating the quality of life variable with each one of its dimensions, it was found to correlate more with the environment (r=0.825; p=0.000); physical domain (r=0.793; p=0.000); and psychological state (r=0.763; p=0.000). Likewise, it was determined that the higher the academic level, the higher the quality of life reported by patients (rs=0.278; p=0.000). However, there is no association between quality of life and age (r=-0.040; p=0.490); length of time with the disease (r=0.021; p=0.713); length of hospitalization (0.040; p=0.496) or number of previous hospitalizations (r=-0.015; p=0.795) (Table I).
|Table I. Sociodemographic characteristics of hospitalized patients with cardiovascular disease (n=297)|
|Age (in years)||48.7±18.6|
Divorced or separated
Self-employed (trade, merchant,
Taxi driver, mechanic)
Employee (factory, restaurant worker)
Church of the Nazarene
As for the variable spirituality, 89.6% were of the Catholic religion; 4% were Christian; 2% did not profess any religion and the rest were Evangelist; Spiritual; Jewish; Jehovah's Witness; followers of Santería; or Mormon, among others.
The majority of the population agreed that forgiveness is transcendental in their spirituality (56.2%) and is a decision-making guide in their daily lives (51.9%). Likewise, for 54.5%, spiritual beliefs are an important part of life; 49.2% frequently feel very close to God or a higher power in important moments of their lives; 49.2% feel that God influences their daily lives; and 54.2% think God answers many of the questions about the meaning of life. In practice, at least once a day 40.4% mention spiritual matters; 57.9% pray or meditate privately; and 50.9% share their problems and joys based on their spiritual beliefs. In general, the majority have a high level of spirituality (68%) and only 7.1% have a low level.
Spirituality correlates with age (r=0.226; p=0.000). According to each of its dimensions, we observed a greater association with beliefs (r=0.904; p=0.000) than with practices (r=0.860; p=0.000). On the contrary, no significant relationship was found between length of time with the disease (r=0.009; p=0.882); length of hospital stay (r=0.111; p=0.056); number of previous hospitalizations (r=0.065; p=0.265); or with schooling level (rs=-0.030; p=0.606).
Also, when analyzing quality of life and spirituality, we can observe a positive although weak correlation (r=0.172; r2=0.030; p=0.003), but more specifically, we can see that spirituality is more associated with the psychological dimension (r=0.203; p=0.000) and less strongly with the physical (r=0.156; p=0.007) (Table II). On the other hand, the quality of life is related to spiritual beliefs (r=0.222; p=0.000) (Figure 1).
Figure 1. Correlation of spiituality with the quality of life of hospitalized patients with cardiovascular disease (n=297). Simple linear regression: r=0.172; r2=0.030; p=0.003
|Table II. Association between the variables of spirituality and quality of life with each of its dimensions and sociodemographic data (n=297)|
|2. Spiritual Practices||0.560*||0.069||0.102||0.073||−0.007||0.021||0.200*||−0.009||0.129*||0.030||−0.073|
|3. Spiritual Beliefs||0.222*||0.169*||0.268*||0.102||0.143*||0.199*||0.022||0.073||0.081||−0.038|
|4. Quality of life *||0.782*||0.774*||0.739*||0.839*||−0.040||0.021||0.040||−0.015||0.278**|
|7. Social relationships||0.541*||−0.111||0.002||0.051||0.029||0.292**|
|10. Length of time with the disease||0.056||0.348*||0.032|
|11. Length of hospital stay||−0.037||−0.178|
|12. Number of hospitalizations||0.05|
|13. Schooling level||1|
|* Pearson’s test: p<0.05; ** Spearman’s test: p<0.05.|
Spirituality is greater in women (Z=-2.245; p=0.025) but there is no difference for positive or negative previous hospitalizations (Z=-1.384; p=0.166) or for cohabitation (Z=-0.982; p=0.326). This same phenomenon occurred with quality of life, since there are no different behaviors between men and women (t=0.665; p=0.965; gl=295; p=0.336), between those with or without partners (t=0.257; gl=295; p=0.798), or for previous hospitalizations (t=-0.648; gl=295; p=0.518). It should be mentioned that no differences were found between patient quality of life and low, medium, or high levels of spirituality (Chi-squared=4.079; gl=2; p=0.130) (Figure 2).
Figure 2. Comparison of quality of life according to level of spirituality of hospitalized patients with cardiovascular disease (n=297). Kruskal-Wallis test, Chi-squared=4.079; gl=2; p=0.130
Characterization of patients in terms of sex, marital status, and academic level is similar to that of other studies,5,7,14,25 which indicates an active, productive population, and a quality of life that has not yet been severely affected by the onset of a chronic disease.
The perception about good quality of life is expressed by the majority of patients, both men and women, and is more related to environment and physical state, data similar to those found by Dessotte,13 Freire de Aguiar,17 Álvarez-Gómez,18 Reyes-Martínez,27 and Sáens.36 This perception is possibly due to the fact that they feel safe, have available information, feel satisfied with health services, have the opportunity to engage in recreational activities, and because the disease possibly has not physically impaired the patient to the extent of allowing them to perform their daily living activities, sleep adequately, and have enough energy to work despite needing medical treatment. Likewise, it has not been influenced by age and length of time with the disease.
In our results it was observed that the higher the educational level of the patients, the better the quality of life. Thus, it is important to consider these results with great caution, since successful application of educational strategies for the patient and primary caregiver depend to a large extent on their ability to understand terms and knowledge, as well as on consensus among health professionals about treatment and information provided by the multidisciplinary team. Therefore, greater capacity for self-care, greater patient participation, and greater awareness of the importance of treatment and care prescribed by the nursing professional can influence treatment adherence.
In relation to the quality of life of people with cardiovascular diseases, previous studies have described its decreases with age,10-13 but we did not find a correlation between these variables, since we perceive in our participants a good quality of life for being a relatively young population. Therefore, it is supposed that their physical state allows them to carry out a life without too many limitations, even to satisfy their sexual needs. However, it is striking that for most, pain is a symptom that prevents them from doing activities that require great effort and, therefore, this majority believes that they can only function properly with medical treatment.
According to the evidence,6,7,20,21 patients with chronic disease present a high or moderate level of spirituality, data that are in agreement with our study's findings, confirming that religious or spiritual beliefs acquire great significance when a disease arises and more so when it is known to be chronic, since it is a critical moment in the life of the individual. In this way, the disease and all that it entails becomes more acceptable: it is then that one learns to share his health condition with others, as Reed points out.37 Therefore, it is fundamental that the nursing professional values this human need that potentially alters and requires diagnosis and intervention. This may generate coping mechanisms.
For cardiac patients in this study, asking a supreme being for forgiveness; feeling close to a higher being; praying or meditating; as well as sharing with his loved ones (family, caregiver, friends) those events that worry or give them joy, are the main practices and beliefs of spirituality, data that coincide with that reported in other studies.7,15,22,23,38 It is evident that the spiritual component of the human being is altered by disease, so the nursing professional should consider in the intervention plan that patients are able to express their religious faith during their hospitalization, as well as consider the act of prayer, active listening, presence and compassion, in addition to allowing family participation, since the religious dimension contributes to the development of mourning, reduction of anguish and anxiety, even positive interpretation of events, and tackles the tragic triad: guilt, suffering, and death in a more effective way, as mentioned by Santo16 and Nixon.23 This fact is also important if one considers that in Mexico, a predominantly Catholic country with a majority of believers— 82.7% devout followers, and only 4.7% of the population does not belong to any religion—one of the practices is to ask for help or to thank a supreme being for specific problems such as illness.35,36
In our study population, spirituality was found to be associated with age and quality of life and we can even say that it is apparently more prevalent in women. These data are similar to those found in several studies of patients with chronic disease. Such studies have shown that spirituality associated a higher being and faith in a greater power have a positive influence on health, since people with religious activities have better social support networks, a positive attitude towards therapeutic compliance, corporal care, and adherence to treatment. Likewise, lower rates of depression, anxiety, and stress are observed. In this way, spirituality becomes a coping strategy.27 Therefore, it is fundamental that the nursing professional consider respect for the spiritual beliefs of each patient and satisfaction of the need for spirituality, allowing patients and their families to practice religious activities in a comfortable place to find meaning in the experience of health, in relating and forgiving, which has a great transcendence in people's lives and influences their conditions, ways, and lifestyles, attitudes, and feelings regarding illness and death, since, according to Reed,7,8 there are personal and contextual variables (environment) that when interacting can influence the process of self-transcendence (person) or the well-being (health) of people.
Based on the results obtained, it can be concluded that patients who are hospitalized for cardiovascular disease have a high level of spirituality, which is positively associated with quality of life, and confirms that when people face chronic diseases as is the case with this study population, their practices and spiritual beliefs increase, regardless of religion, age, academic degree, length of time with the disease, and number of previous hospitalizations. One way of practicing spirituality is to pray or meditate in private, a matter most observed in women. Likewise, spiritual beliefs and practices correspond to a supreme being facing disease; this shows the influence of spirituality on health status and quality of life.
This study provides an overview of spirituality, both in the beliefs and practices of the adult population with some form of cardiovascular disease during hospitalization. However, studies are required to verify and establish cause-and-effect relationships that have several independent variables with spirituality and quality of life, so these results should be carefully considered in nursing practice.