Spiritual Health in Iranian Patients With Cardiovascular Diseases: A Systematic Review and Meta-analysis

Abstract

This systematic review and meta-analysis aimed to evaluate the spiritual health status of Iranian patients with cardiovascular diseases. A literature search was conducted in national (MagIran and Scientific Information Database) and international (Scopus, PubMed, and Web of Science/ISI) databases from inception to December 2021. A random-effects model was used to estimate the pooled score of spiritual health. Based on the eligibility criteria, 22 articles were selected for the final analysis. The pooled score of spiritual health in Iranian patients with cardiovascular diseases was 61% (95% confidence interval: 54%–68%). In subgroup analysis, the pooled score in patients with heart failure was higher than other patients (67% vs. 58%). Publication bias was not significant (p = 0.554). Results indicated that the spiritual health of Iranian patients with cardiovascular diseases was moderate. Therefore, it is recommended that proper training be provided to these patients to enhance their adaptation to the complications of cardiovascular diseases.

Keywords

spiritual health cardiovascular diseases systematic review

Introduction

Cardiovascular diseases (CVDs) are the leading cause of mortality in different countries, including Iran, and considered a significant health concern (Akbari et al., 2016; Sarrafzadegan & Mohammmadifard, 2019). Patients with CVDs experience numerous physical complications, including fatigue, dyspnea, and chest pain, which adversely affect their physical, emotional, and social wellbeing and decrease their quality of life (Moryś et al., 2016). As CVDs are classified as psychosomatic disorders, the investigation of their influential role as actors should be focused on both biological and psychological factors. In this regard, it is essential to assess psychological risk factors (Estruch et al., 2021)

Patients with CVDs often experience physical health problems and different forms of psychological disturbances, such as depression and disappointment (Carney & Freedland, 2017; Eslami et al., 2017). CVDs could also lead to adverse consequences such as anxiety, especially death anxiety (Tully & Baker, 2012). Death anxiety is a highly common psychiatric complication in patients with life-threatening conditions and among those undergoing severe mental distress (Abdel-Khalek, 2005; Soleimani et al., 2020). Predicting death is a psychosocial phenomenon, which could be stressful for patients and their families (Sarıkaya & Baloğlu, 2016) and cause negative emotions, such as fear, losing of oneself, helplessness, and loss of control (Dogan et al., 2015). Coping mechanisms and promoting spirituality could lead to acceptance of death as an inevitable matter. A spiritual outlook determines one’s coping mechanism and perception of death (Taghipour et al., 2017).

Psychological distress is more prevalent in patients with CVDs compared to healthy individuals (Heshmati et al., 2021). Consequently, these patients may have difficulty adapting to their condition (Rafiei et al., 2021). It seems that religiosity and spirituality are involved in the regulation of physiological processes (Anyfantakis et al., 2013). Spirituality could be an inherent element in the coping mechanisms and recovery of patients with CVDs (Yaghoobzadeh et al., 2018). In particular, spiritual health plays a key role in the adaptation of patients with stress and anxiety and could enhance psychological health and reduce psychological disorders. Therefore, patients should be evaluated comprehensively both mentally and physically, and special attention should be paid to all their mental aspects along with their physical condition (Koeing, 2000; Ross & Austin, 2015; Unantenne et al., 2013).

According to the literature, spiritual health could improve the quality of life of patients through a healthier lifestyle, hope, mental stability, and life satisfaction, as well as decreasing effect of psychological issues (Soleimani et al., 2020; Ghanbari Afra & Zaheri, 2017; Sheykholeslami et al., 2021). In patients with CVDs, specialists pay more attention to improving physical health (Azimian et al., 2019), but mental health states such as spirituality are not properly evaluated. Since meeting the spiritual needs of patients could accelerate the process of treatment and recovery (Moeini et al., 2012), examining the spiritual health of patients with CVDs should be considered by healthcare providers given the positive effects on the treatment process. Therefore, the aim of this study was to estimate the pooled standard score of spiritual health in patients with CVDs in Iran.

Methods

This systematic review and meta-analysis was performed based on the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) instructions with the aim of determining the percentage score of spiritual health in Iranian patients with CVDs.

PICO question

According to the PICO, the population (P) included observational articles that reported a spiritual health score in Iranian patients with cardiovascular disease, and outcome (O) was a standard score of spiritual health. Intervention (I) and comparison (C) were not applicable.

Search Strategy

Literature search was conducted in national and international databases such as Scientific Information Database (SID), MagIran, Scopus, PubMed, and Web of Science from inception to December 2021 using the following keywords: “spiritual*” OR “exorcism*” OR “spiritual healing*” OR “spiritual therapy*” OR “incorporeal*” OR “piousness, holiness” AND “cardiovascular disease*” OR “cardiac failure*” OR “hypertension” OR “high blood pressure*” OR “heart decompensation” OR “myocardial infarct*” OR “myocardial failure” OR “heart failure” OR “heart attack” OR “coronary heart disease*” OR “coronary disease*” AND “Iran*” OR “Islamic Republic of Iran”. The references and discussions of the retrieved articles were also reviewed for access to more articles. The literature review was searched from November 1, 2021 to December 21, 2021.

Article Selection and Data Extraction

The eligibility criteria were as follows: 1) observational studies; 2) available full texts; 3) articles published in Persian or English and 4) CVD patient populations. The exclusion criteria of the study were qualitative studies, interventional studies, review studies, letters to the editor, and gray literature (e.g., theses and conferences.).

Data were extracted in several steps. Initially, the identified articles were imported into the Endnote program, and duplicates were removed. Two authors independently reviewed the titles and abstracts of the collected articles and removed duplicate and irrelevant articles. The two authors then carefully read the full text of the remaining articles and recorded the essential information contained in articles such as authors’ names, year of publication, sample size, location, mean age of patients, data collection instruments, raw scores of spirituality health, and quality scores of selected articles. The raw score reported in each study became the standard score (Rezaei et al., 2020).

Quality Assessment

The STROBE checklist was used to evaluate the quality of the articles methodology. For this purpose, 10 items from this checklist were selected and articles were evaluated based on these items. If any of these items was mentioned in an article, it gets a score of one and otherwise a score of zero was assigned. The final score varies between zero and 10. Based on this score, the quality of the articles was divided into three categories: weak (score 0–4), moderate (score 5–7) and strong (score 8–10) (Vandenbroucke et al., 2007).

Statistical Analysis

Data analysis was performed using the STATA software version 16. Since the scores of spiritual health were converted into percentages, binomial distribution was used to integrate the selected studies. A forest plot was used to visually demonstrate the shared estimation of the pooled percentage scores of spiritual health at 95% confidence interval (CI). In addition, I² and Cochrane’s Q tests were applied to assess the non-homogeneity of the selected studies. Since I² was more than 75% on all the levels (I² > 75% shows high non-homogeneity) and Cochrane’s Q test was also significant (0.1), a random-effects model was used to integrate the selected studies and estimate the pooled percentage scores. In addition, subgroup analysis was used based on the type of CVD (e.g., heart failure vs. other CVDs), and univariate meta-regression analysis was carried out to assess the effect of spiritual health pooled percentage score on the mean age, year of publication, and sample size. To assess publication bias, a funnel plot was applied based on Egger’s regression test.

Results

The initial search yielded 394 articles from the Persian and international databases. After eliminating duplicates, the titles and abstracts of the remaining 226 articles were evaluated. After eliminating review studies, clinical trials, qualitative studies, letters to the editor, and books, 22 observational studies conducted on 4639 patients with CVDs were selected for the final analysis. Figure 1 depicts the selection process of the articles.

Figure 1.

Article selection process.

The maximum sample size was in the studies by Soleimani et al. (n = 500) and Yaghoobzadeh et al. (n = 500), while the minimum sample size was in the study by Taghavi et al. (n = 48). Among the studies, 12 were conducted in Region one of Iran, and 10 studies were performed in other regions. Seven studies were conducted on patients with heart failure, and 15 articles were performed on patients with other CVDs. The maximum and minimum scores of spiritual health were reported in the studies by Momeni Ghaleh Ghasemi (83.11%) and Besharat (21.58%), respectively (Table 1). According to the obtained results, the pooled estimate of the percentage score of spiritual health in Iranian patients with CVD was 61% (95% CI: 55%–67%) (Figure 2). Furthermore, the results of the subgroup analysis indicated that the pooled estimate of the percentage score of spiritual health in patients with heart failure was 67% (95% CI: 59%–75%) which was higher than other patients (58%; 95% CI: 50%–66%) (Figure 3).

Figure 2.

Forest plot of pooled percentage score of spiritual health in Iranian patients with cardiovascular diseases.

Figure 3.

Forest plot of pooled percentage score of spiritual health in Iranian patients with cardiovascular diseases by type of disease.

The pooled estimate of the percentage score of spiritual health in the studies conducted in region one of Iran (65%; 95% CI: 60%–69%) was higher than the studies performed in other regions (53%; 95% CI: 40%–67%). The results of the meta-regression analysis indicated no significant association between the pooled percentage score of spiritual health, samples size (p = 0.911), and year of publication (p = 0.127) (Figure 4). Publication bias was not significant (p = 0.554) (Figure 5).

Figure 4.

Meta-regression results based on year of publication (a) and sample size (b).

Figure 5.

Publication bias.

Discussion

Patients tend to be seen and treated as whole people, not simply as “diseases”. A whole person has different physical, emotional, social and spiritual dimensions, ignoring these causes the patient to feel imperfect, which interferes with the healing process (D’Souza, 2007). In the past decade, the medical community broke down the wall that had been separating religion from medicine and expressed enthusiasm about spirituality in health (Koenig, 2001). Iranian researchers also studied spiritual health among patients with various chronic diseases and published the results in the form of various articles. The results of this study show that the pooled standard score of spiritual health among Iranian patients with CVD was moderate. This is consistent with the study by Westlake et al. (Westlake et al., 2002).

Patients pay great attention to spiritual health because prayer and religious participation can have healing powers and promote physical and mental health. (Blumenthal et al., 2007). The results of various studies have shown that the spiritual health of heart patients is moderate, which could be due to the integrity of spirituality regardless of gender and race (Nuraeni et al., 2018; (Park & Sacco, 2017). Spirituality is used as a coping strategy in managing the consequences of chronic diseases and can lead to stress-related growth and change to a healthier lifestyle (Konopack & Mc Auley, 2012; Park et al., 2009)

In the study of Chabok et al. (2017) the standard score of spiritual health in the general population in Iran was 74%, which was higher than the standard score estimated from this study. This discrepancy could be due to differences in the physical and mental states of the participants. Spirituality could enhance the quality of life and treatment process of patients. On the other hand, a lack of spirituality could lead to poor biological, psychological, and social functions (Chabok et al., 2017; Lima et al., 2020). Therefore, emphasis should be placed on spirituality-oriented care procedures, especially in cardiovascular patients. Spirituality and religious beliefs guide the evaluation of life events and help people find meaning in life’s stressful events. Belief systems also play a beneficial role in combating physical illnesses by giving new meaning to a disease (Garsen et al., 2015).

According to the results of the present study, the pooled score of spiritual health was higher in patients with congestive heart failure compared to other cardiovascular patients. In the study by Beery et al. (2002), the score of spiritual health in patients with heart failure was reported to be 76%, which is slightly higher than our findings. On the other hand, the study by Blinderman et al. (2008), which was conducted on patients with congestive heart failure in New York city, indicated a relatively high spiritual health levels in their sample of about 75% of the total score. The study by Bean et al. (2009) was conducted in Virginia on patients with heart failure who received 76% of the spiritual score. Achieving high spirituality scores in this heart failure population, who supposedly have more severe clinical conditions due to CVD, could be a result of their better adaptation to their disease through the awareness that their condition is irreversible; and as a result, they cope with stress better by adhering to a spiritual source. Livneh et al. (2004) believe that spirituality may play a key role in coping with the stress caused by chronic diseases.

Heart failure is a debilitative disorder characterized by fatigue and high anxiety levels. When progressive disabilities appear in the patients’ life, they feel loss and inability to manage their life. By creating a positive outlook on life, spirituality helps individuals with resilience and hope, which increases their tolerance of death. Therefore, patients who properly adapt to the tensions caused by their disease will be able to face crises such as severe diseases. This will bring about a prolific life, and adaptive interventions are considered effective in this regard (Besharat & Ramesh, 2019; Mirmahdi et al., 2019).

There is a positive correlation between spiritual health and mental health in patients with heart failure, which led to positive emotions, peace and greater satisfaction (Sacco et al., 2014). One of the reasons for CVD patients to turn to spirituality is that more religiosity could increase death anxiety (Soleimani et al., 2020). Moreover, a lack of spiritual support from the healthcare team could lead to low quality of life, dissatisfaction with care, more invasive treatments, and increased costs (Gijsberts et al., 2019). The current research indicated no significant correlation between age and the pooled score of spiritual health; therefore, it could be inferred that patients of every age group are inclined toward spiritual health. According to the findings of Wink and Dillon (2003), attraction to spirituality becomes more evident with age since it could be a way for the individual to adapt better to death anxiety. Furthermore, Zimmer et al. (2016) reported that the elderly (aged more than 60 years) pay more attention to religiosity and spirituality, and there is a direct correlation between spirituality and longevity.

In critical cardiovascular patients, palliative care with a comprehensive, multidisciplinary, and evidence-based approach could enhance the quality of life concomitant with cardiovascular interventions. Spiritual care is an inherent element of palliative care. Supporting patients could alleviate pain and suffering and facilitate coping with realities such as disease, pain, and death in individuals (Gijsbrts et al., 2019; Sullivan & Kirkpatrick, 2020). In patients receiving palliative care, promoting spiritual health could mitigate issues such as wishes to hasten death (Bernard et al., 2017).

To the best of our knowledge, this is the first study to assess the spiritual health of cardiovascular patients in Iran systematically. Our findings could shed some light on the current status of CVD patients for healthcare authorities and scholars. One of the limitations of this study was that we did not present more detailed data from the reviewed studies, and further analysis was not possible (Table 1).

Table 1.

The Characteristics of Selected Studies.

First Author (year)	Sample Size	Type of Disease	Standard Score	Quality	Results
(Rafiei et al., 2021)	150	Cardiovascular disease (CVD)	54.93	10	Mean age of samples was 55.4 ± 13.6 years; 50% were male, and 50% were female; majority of samples were married (75%) and below diploma (62%); a negative significant correlation was observed between psychosocial adjustment to illness and spiritual wellbeing (r = −.21; p = .01); a significant direct correlation was observed between spiritual wellbeing and economic status (p = .02)
(Razaghpoor et al., 2021)	130	Heart failure	63.12	8	Mean age of patients was 64.2 ± 12.3 years; majority of samples (56.2%) were female; a significant positive correlation was reported between mean resilience score and mean spiritual wellbeing score (p = .001; r = .386)
(Heshmati et al., 2021)	100	Coronary artery disease	42.57	9	Mean age of patients was 44.53 ± 7.62 years; a negative significant correlation was reported between spiritual wellbeing and health anxiety (r = −.34; p < .01)
(Soleimani et al., 2020)	500	Heart disease	66.21	10	Mean age of patients was 60.68 ± 10.34 years; majority of samples were female (52.4%), married (81.2%), illiterate/semi-literate (53.2%), and had average economic status (70.6%); quality of life was positively correlated with spiritual health (r = .2; p < .01)
(Ramesh et al., 2021)	327	Coronary artery disease	54.05	9	Mean age of patients was 52.39 ± 6.23 years; majority of samples were male (58%); a negative significant correlation was observed between spiritual wellbeing and CVD severity (r = −.62; p = .010)
(Heidari Sabet et al., 2020)	200	CVD	55.03	7	Age range of patients was 50–60 years; majority of samples were illiterate; spiritual health predicted health-promoting behaviors (β < .09)
(Senmar et al., 2020)	120	Heart failure	66.2	9	Negative significant correlations were observed between perceived stress(R² = −.53; p = .001), anxiety (R² = −.389; p < .001), and depression (R² = −.388; p < .001)
(Besharat et al., 2018)	327	Arterial stenosis	21.58	7	Mean age of patients was 52.39 ± 6.23 years; majority of samples (58%) were male; a negative significant correlation was reported between spiritual health and disease severity (r = −.62; p < .01)
(Soleimani et al., 2018)	300	Acute myocardial infarction	74	8	Mean age of patients was 59.89 ± 11.94 years; majority of samples were female (57.3%), unemployed (63.9%), illiterate (51.7%), and had average economic status (71%); age was negatively correlated with death anxiety (r = −0.161; p < .01) and positively correlated with religious beliefs (r = 0.183; p < .01)
(Ahangarkani et al., 2018)	137	Cardiovascular disease	69.45	8	Majority of samples were female (58%); a significant positive correlation was reported between spiritual wellbeing and the religious needs of patients (r = .44; p = .01)
(Siah Mashtei, 2018)	60	Hypertension	44.60	7	Age range of patients was 30–60 years; a significant correlation was observed between spiritual health and blood pressure (r = −.564; p = .001)
(Sheykholeslami et al., 2018)	50	Coronary artery disease	47.50	9	Majority of samples were male (69%); spiritual health was significantly lower in patients with coronary artery disease compared to healthy subjects (p < .01)
(Mohaddes-Ardebili et ai., 2019)	207	Heart failure	73.36	9	50% of subjects were male, and 50% were female; majority of patients were married (83.10%), illiterate (55.80%), unemployed (56.1%), and had average economic status (70.8%); a significant positive correlation was observed between spiritual health and sleep quality of patients (r = −.117; p < .026)
(Yaghoobzadeh et al., 2017)	500	CVD	66.21	9	Mean age of patients was 60.68 ± 10.34 years; majority of samples were female (52.4%), married (81.2%), had no academic education (53.2%), had average economic status (70.6%), and had no near-death experience (96.6%); a weak, positive, significant correlation was reported between religious beliefs and social support (r = .107; p < .05); spiritual wellbeing was positively correlated with religious beliefs (r = .110; p < .05)
(Hedayati et al., 2016)	66	CVD	59.55	9	Mean age of patients was 68.86 ± 8.6 years; majority of samples were female (59.1%), married (63.3%), and illiterate (57.6%); a negative correlation was reported between spiritual health, state anxiety, and trait anxiety (p < .05)
(Taghavi et al., 2016)	48	Heart failure	79.54	8	Mean age of subjects was 31 years; majority of samples were male (66.7%), married (62.5%), had an associate degree (6.3%), and were unemployed (85.4%); a positive significant correlation was observed between spiritual wellbeing and quality of life (r = .329; p = .022)
(Aghaeipour Amshal et al., 2015)	384	Heart failure	70.90	7	Age range of samples was 60–88 years; majority of samples were male (54.4%), married (67.2%), had an associate degree (87.3%), had history of hospitalization (69.8%), and were unemployed (95.6%); a reverse significant correlation was reported between spiritual health and anxiety (r < −.35; p < .001)
(Siavoshi et al., 2015)	140	Chronic heart failure	72.52	8	Mean disease duration was 9.9 ± 7.7 years; majority of samples were male (51.5%), married (62.1%), and had high school education or less (84.4%); mean total score of spiritual health and age were significantly correlated (p < .01); prayer had a positive significant correlation with spiritual health (r < .63; p < .0001); total score of spiritual health was significantly correlated with marital status (p < .01); total score of spiritual health had a reverse significant correlation with education level(r < −0.112; p < .04)
(Ghanbari Afra & Zaheri, 2014)	294	Acute coronary syndrome	69	7	Mean age of subjects was 59.14 ± 8.5 years; a significant correlation was reported between depression and spiritual health (r = −.294; p = .001)
(Olad Rostam & Safavi, 2014)	150	Heart failure	44.43	8	Mean age was 55 years; majority of samples were housewives (42.2%), had primary education (59.3%), and had history of hospitalization (71.3%); spiritual health was correlated with depression (r = −0.53; p = .01), anxiety (r = −0.59; p = .01), and stress (r = −.45; p = .01)
(Momeni Ghaleghasemi et al., 2012)	85	Coronary artery disease	83.11	8	Majority of samples were male (51.8%), married (75.3%), below diploma (80%), and had history of hospitalization (84.7%); a reverse significant correlation was reported between spiritual health and anxiety (r = −0.47; p = .001)
(Jahani et al., 2012)	364	Coronary artery disease	60.11	9	Mean age of patients was 58.95 ± 1.23 years; disease duration was 6–55 years; majority of samples were male (54.4%), married (89.60%), employed (52.2%), had average economic status (54%), and had high school education (90.2%); a significant correlation was observed between quality of life and spiritual health (p = .001)

Implications for Practice

According to the results in this study, Iranian patients with CVDs have moderate spiritual health. In caring for these patients, nurses should pay more attention to spiritual care and use the Nueman System Model, which describe the human being as an open client system in physiological, psychological, socio-cultural, developmental and spiritual variables in constant interaction with the environment. Because in this model the spiritual variable affects other variables. Therefore, paying attention to spirituality in caring for these chronic patients is one of the vital factors to restore balance and promote health and well-being (Neuman & Fawcett, 2002). Religious practices with different mechanisms can affect the course and outcome of the disease. Participation in religious activities promotes a sense of mental well-being by providing opportunities for social interaction among people with similar values. Spirituality can also increase psychosocial adjustment in patients with diseases that have a poor prognosis and in their caregivers Given the religious background of Iran, spiritual health programs, relevant workshops or seminars, and providing the opportunity for promoting spirituality could be incorporated into the treatment agenda. In support programs for health care, health professionals and authorities must pay attention to the spiritual health of chronic diseases so that they would not be burdened by vulnerability, isolation, and maladaptation. The findings of the present study provide a clear picture of the state of spiritual health, based on which health measures can be taken to improve the spiritual health of patients, because higher spiritual health leads to better coping.

Footnotes

Acknowledgments

This study was part of an approved research proposal in the Kurdistan University of Medical Sciences (IR.MUK.REC.1400.230). In this regard, the researchers thanked the Research Deputy of Kurdistan University of Medical Sciences for approving this proposal. Also, all the nurses who participated in this study are thanked and appreciated.

Authors’ Contributions

HA: data collection and manuscript preparation; RGG: manuscript preparation and study conceptualization; FD and RGG: study design; ANA and RGG: final revision and grammar editing; SD and ANA: statistical analysis.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Kurdistan University of Medical Science.

Availability of Data and Material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

ORCID iD

Reza Ghanei-.Gheshlagh

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