1. Background
The end-stage renal disease (ESRD) is an important health problem worldwide. Advances in chronic hemodialysis have improved the survival of ESRD patients (1). However, patients with ESRD suffer from several physical and psychosocial symptoms, and conventional treatment can impair quality of life (QOL) in these patients. Thus, the strategies that patients use to cope with these challenges are of prime importance (2-4).
Religious coping is an important strategy that can be used to cope with stressful situations (5). This is described as “the use of cognitive and behavioral techniques, in the face of stressful life events” (6). Religious coping is a multidimensional construct and can have both positive and negative effects on outcomes (7). Thus, not all religious coping strategies are useful. Positive religious coping is thought to be associated with benefits in psychosocial adjustment, whereas negative religious coping leads to poorer consequences and is therefore considered maladaptive (8).
In several studies, religious coping has been consistently found to be an important factor affecting QOL in most chronic conditions, including breast cancer (9), chronic pain (10), cancer (11), pulmonary disease (12), and human immunodeficiency virus (HIV) (13). However, limited research has been done on the effects of religious coping and QOL in hemodialysis patients. Recently, Lucchetti evaluated 205 hemodialysis patients and found that religiousness was positively associated with QOL in Brazilian dialysis patients (14). In addition, Zamanian et al. found that the religious dimension of spirituality was positively associated with health-related QOL (15). QOL could also be related to religion and culture, but no studies have evaluated the relationship between religious coping and QOL among patients with ESRD in Muslim countries, such as Iran.
2. Objectives
The purpose of this study was to assess the relationship between religious coping and QOL in hemodialysis patients.
3. Methods
3.1. Design and Patients
This cross-sectional study was conducted from June 2012 to July 2013 in Qom, a holy city in the central region of Iran. A group of ESRD patients referred to the main hemodialysis centers in the city were selected via the convenience sampling method. Patients were included in the study if they were aged 15 and above, had a hemodialysis history of more than 3 months without previous transplantation, and had no previous psychiatric disease or psychoactive medicine use. Patients were asked to complete the study questionnaires.
3.2. Instruments
We used a four-part questionnaire, as follows:
3.2.1. Part 1
Collected clinical and sociodemographic information. The questionnaire consisted of questions about age, marital status, educational status, economic and status employment, comorbidity, number and duration of hemodialysis, smoking, and body mass index (BMI).
3.2.2. Part 2
In part 2, QOL was measured using the SF-36. This has eight subscales, namely physical functioning, body pain, general health, vitality, social functioning, role limitations due to physical problems, role limitations due to emotional problems, and mental health. Scores in each subscale range of 0 - 100, with 0 representing the worst conditions and 100 representing the best possible score. Previous evaluations of the original and Persian versions of SF-36 indicated good reliability and validity (16).
3.2.3. Part 3
In part 3, religious coping was measured using the brief religious coping (RCOPE). It is a 14-item questionnaire that was developed by Pargament in older US populations. The instrument categorizes religious coping into seven positive attributes (e.g., looked for a stronger connection with God) and seven negative attributes (e.g., questioned God’s love for me). Each attribute is rated on a four point Likert scale ranging from 1 to 4 (1 = not at all, 2 = rarely, 3 = sometimes, and 4 = a great deal) (17).
3.2.4. Part 4
Finally, in part 4 the hospital anxiety and depression scale (HADS) was applied to evaluate anxiety and depression occurring in the hemodialysis patients. The HADS consists of seven items for anxiety and seven for depression. Items are scored on a 4-point scale from 0 (not present) to 3 (considerable) and scores are added, giving subscale scores on the anxiety and the depression from 0 to 21 (18).
3.3. Ethical Considerations
The research followed the tenets of the declaration of Helsinki, and it was approved by the ethical committee of Qom University of Medical Sciences. All patients were included after providing informed consent. Participation in this study was voluntary; patients were free to withdraw at any time without any effect on their treatment process.
3.4. Statistical Analysis
All analyses were performed using SPSS version 16. Descriptive statistics were used to explore the data. An independent t-test and one-way analysis of variance were used for comparison. Logistic regression analysis was performed to assess the relationship between religious coping and health-related QOL while controlling for sociodemographic characteristics, clinical variables, and anxiety and depression.
4. Results
4.1. Patient Characteristics
In all, 120 patients with ESRD were approached. Of these, 95 individuals agreed to participate in the study (response rate, 79.1%). The mean age of patients was 50.4 (standard deviation [SD = 15.72) years; 61% were male, and 76.8% were married. The mean time on hemodialysis was 37.83 (SD = 39.14) months. The characteristics of the study participants are shown in Table 1.
| No. (%) | |
|---|---|
| Age, y, Mean (SD) | 50.40 (15.72) |
| Gender | |
| Male | 58 (61.1) |
| Female | 37 (38.9) |
| Educational status | |
| Illiterate | 30 (31.5) |
| Primary | 30 (31.5) |
| Secondary | 28 (29.4) |
| Higher | 7 (7.6) |
| Marital status | |
| Single | 12 (12.6) |
| Married | 73 (76.8) |
| Divorced/widowed | 10 (10.6) |
| Employment status | |
| Employed | 21 (22.1) |
| Unemployed/housewife | 74 (77.9) |
| Place of living | |
| Urban | 88 (92.6) |
| Rural | 7 (3.4) |
| Comorbidity | |
| Yes | 55 (57.9) |
| No | 40 (42.1) |
| Body mass index, Mean (SD) | 20.16 (3.11) |
| Economic status | |
| Poor | 45 (47.3) |
| Intermediate | 40 (42.1) |
| Good | 10 (10.6) |
| Smoking status | |
| Smoker | 16 (16.8) |
| Nonsmoker | 79 (83.2) |
| Time on dialysis, mo, Mean (SD) | 37.83 (39.14) |
| Dialysis number, Mean (SD) | 2.92 (0.30) |
Clinical and Sociodemographic Information of the Study Sample (N = 95)
4.2. Patient Quality of Life and Religious Coping
The mean score for health-related QOL variables and religious coping are presented in Table 2. Higher and lower scores were seen for social functioning (59.37 ± 26.57) and role limitations due to physical health problems (30.91 ± 35.15), respectively. The mean scores for positive and negative religious coping were 23.38 ± 4.17 and 11.46 ± 4.34, respectively.
| Mean (SD) | |
|---|---|
| Religious coping, possible score range from 7 to 28a | |
| Negative | 11.46 (4.34) |
| Positive | 23.38 (4.17) |
| Quality of life scores, possible score range, 0 - 100b | |
| Physical functioning | 43.82 (27.60) |
| Role physical | 30.91 (35.15) |
| Bodily pain | 45.51 (29.52) |
| General health | 39.54 (19.76) |
| Vitality | 37.44 (23.74) |
| Social functioning | 59.37 (26.57) |
| Role emotional | 45.31 (41.81) |
| Mental health | 47.23 (23.23) |
Descriptive Statistics for Quality of Life and Religious Coping
4.3. Linear Regression Analysis
To assess the relationship between QOL and religious coping, multiple logistic regression analysis was performed. Each subscale was treated as a dependent variable; religious coping, as well as the sociodemographic, clinical, and anxiety and depression variables were considered independent factors. The results obtained from the multiple logistic regression model showed that negative religious coping was associated with worse physical functioning (odds ratio [OR]= 0.72; P = 0.009), role physical (OR = 0.79; P = 0.04), vitality (OR = 0.62; P = 0.005), social functioning (OR = 0.69; P = 0.007), and mental health (OR = 0.58; P = 0.01) after controlling for sociodemographic, clinical, and anxiety and depression variables. There was no association between positive religious coping and the QOL subscales.
| PF, OR (95% CI) | P | RP, OR (95% CI) | P | BP, OR (95% CI) | P | GH, OR (95% CI) | P | VT, OR (95% CI) | P | SF, OR (95% CI) | P | RE, OR (95% CI) | P | MH, OR (95% CI) | P | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Socio-demographic variables | ||||||||||||||||
| Age | 0.95 (0.90 - 1.02) | 0.19 | 1.02 (0.97 - 1.08) | 0.32 | 0.96 (0.90 - 1.03) | 0.30 | 0.93 (0.88 - 0.99) | 0.04 | 0.99 (0.94 - 1.05) | 0.96 | 0.89 (0.82 - 0.97) | 0.009 | 1.02 (0.96 - 1.08) | 0.37 | 1.04 (0.96 - 1.12) | 0.26 |
| Gender, Male 1.0 (ref) | 1.63 (0.28 - 9.37) | 0.58 | 0.54 (0.10 - 2.92) | 0.47 | 4.17 (0.74 - 23.34) | 0.10 | 0.33 (0.06 - 1.80) | 0.20 | 1.51 (0.24 - 9.38) | 0.65 | 1.93 (0.29 - 12.64) | 0.49 | 0.59 (0.11 - 3.20) | 0.54 | 11.10 (0.83 - 148.71) | 0.06 |
| Marital status | 0.09 (0 - 1.35) | 0.08 | 0.64 (0.07 - 5.20) | 0.67 | 0.19 (0.01 - 2.26) | 0.18 | 0.35 (0.03 - 3.40) | 0.36 | 3.40 (0.29 - 39.91) | 0.33 | 0.01 (0.01 - 0.34) | 0.01 | 1.49 (0.16 - 13.50) | 0.71 | 6.10 (0.32–114.85) | 0.22 |
| Education | 1.33 (0.74 - 2.39) | 0.32 | 1.48 (0.85 - 2.56) | 0.16 | 1.44 (0.84 - 2.46) | 0.17 | 0.84 (0.48 - 1.45) | 0.53 | 1.13 (0.60 - 2.12) | 0.69 | 1.08 (0.59 - 1.99) | 0.78 | 1.43 (0.80 - 2.54) | 0.22 | 0.91 (0.39–2.09) | 0.82 |
| Employment status | 1.16 (0.22 - 5.94) | 0.85 | 1.99 (0.42 - 9.39) | 0.38 | 0.25 (0.04 - 1.31) | 0.10 | 0.67 (0.14 - 3.18) | 0.62 | 0.23 (0.04 - 1.33) | 0.10 | 1.43 (0.23 - 8.67) | 0.69 | 0.99 (0.19 - 5.05) | 0.99 | 0.06 (0.01 - 0.59) | 0.01 |
| Clinical variables | ||||||||||||||||
| Time on dialysis | 0.99 (0.97 - 1) | 0.26 | 1.02 (0.98 - 1.02) | 0.84 | 1.01 (0.99 - 1.03) | 0.21 | 0.98 (0.97 - 1) | 0.17 | 0.98 (0.97 - 1.06) | 0.18 | 1.02 (0.99 - 1.05) | 0.07 | 1.03 (1.01 - 1.05) | 0.01 | 0.99 (0.97 - 1.01) | 0.42 |
| Number of dialysis | 2.60 (0.26–25.88) | 0.41 | 0.64 (0.27 - 1.53) | 0.32 | 0.16 (0.01 - 1.79) | 0.14 | 0.05 (0.004–0.90) | 0.04 | 1.46 (0.11 - 18.56) | 0.76 | 1.72 (0.18 - 15.78) | 0.62 | 1.73 (0.12 - 24.98) | 0.68 | 0.49 (0.03 - 7.77) | 0.62 |
| Current smoker | 0.95 (0.14 - 6.28) | 0.95 | 1.12 (0.16 - 7.55) | 0.90 | 1.73 (0.05 - 53.92) | 0.54 | 0.33 (0.03 - 3.46) | 0.35 | 0.53 (0.04 - 6.05) | 0.61 | 0.45 (0.05 - 3.79) | 0.46 | 2.82 (0.36 - 21.77) | 0.31 | 0.08 (0.01 - 3.23) | 0.18 |
| Comorbidity, Yes | 0.15 (0.03 - 0.62) | 0.008 | 0.76 (0.22 - 2.55) | 0.37 | 0.57 (0.16 - 2.01) | 0.38 | 0.30 (0.08 - 1.05) | 0.06 | 0.34 (0.09 - 1.32) | 0.12 | 0.25 (0.05 - 1.11) | 0.06 | 0.31 (0.08 - 1.10) | 0.07 | 0.04 (0.01 - 0.34) | 0.003 |
| Psychological distress | ||||||||||||||||
| Anxiety | 1.02 (0.76 - 1.37) | 0.86 | 0.95 (0.73 - 1.24) | 0.75 | 0.69 (0.49 - 0.98) | 0.03 | 0.83 (0.62 - 1.10) | 0.19 | 0.83 (0.61 - 1.13) | 0.24 | 0.73 (0.52 - 1.02) | 0.06 | 0.66 (0.47 - 0.94) | 0.02 | 0.47 (0.27 - 0.83) | 0.01 |
| Depression | 1.08 (0.80 - 1.47) | 0.59 | 1.21 (0.88 - 1.66) | 0.22 | 0.94 (0.70 - 1.26) | 0.69 | 0.97 (0.72 - 1.30) | 0.84 | 1.03 (0.76 - 1.41) | 0.81 | 1.11 (0.80 - 1.54) | 0.52 | 1.31 (0.96 - 1.78) | 0.08 | 1.02 (0.69 - 1.50) | 0.90 |
| Religious coping | ||||||||||||||||
| Negative religious coping | 0.72 (0.57 - 0.92) | 0.009 | 0.79 (0.62 - 0.99) | 0.04 | 0.99 (0.83 - 1.19) | 0.95 | 0.96 (0.82 - 1.12) | 0.64 | 0.62 (0.45 - 0.86) | 0.005 | 0.69 (0.52 - 0.90) | 0.007 | 1.02 (0.87 - 1.19) | 0.78 | 0.58 (0.38 - 0.88) | 0.01 |
| Positive religious coping | 0.86 (0.72 - 1.01) | 0.08 | 0.88 (0.75 - 1.02) | 0.10 | 0.95 (0.81 - 1.10) | 0.51 | 1.01 (0.87 - 1.18) | 0.84 | 0.90 (0.75 - 1.07) | 0.23 | 1.05 (0.89 - 1.24) | 0.55 | 0.97 (0.83 - 1.14) | 0.75 | 0.93 (0.74 - 1.16) | 0.54 |
Results of Logistic Regression Analysis
5. Discussion
According to our study results, greater use of negative religious coping was associated with worse QOL in most of domains among hemodialysis patients. ESRD not only destroys the physical wellbeing of the patients, but it also threatens their social, functional, and emotional wellbeing. This condition causes patients to ask about themselves and the meaning of their lives, creating a sense of disconnectedness with the religious community and an unstable relationship with God. This negative coping leads to poorer QOL. Our study findings are consistent with previous studies in populations facing advanced illnesses, such as acquired immunodeficiency (AIDS), advanced cancer (19), schizophrenia (20), breast cancer (21), epilepsy (22), asthma (23), and ESRD (24). In their study of hemodialysis patients in Brazil, Ramirez et al. reported a reverse significant correlation between religious struggle and QOL, while positive religious coping was associated with improved QOL (24). Another study including 170 patients with advanced cancer found that greater reported use of negative religious coping was related to poorer overall QOL (11). In addition, Tedrous indicated negative coping is associated with a reduced QOL (22).
We did not find any significant relationships between positive religious coping and QOL. Perhaps this was the result of other variables, such as social support and self-efficacy, which we did not control for in the study. Another reason may be the low sample size in our research. However, negative religious coping would be more consistently predictive of health outcomes than positive religious coping. In a cross-sectional study of 69 patients with advanced cancer, religious coping was associated with improved QOL in multivariate analyses. However, in their study of AIDS patients, Michael et al. found no significant correlation between positive religious coping and QOL (25), which is congruent with the present study.
5.1. Conclusion
In conclusion, the findings from the study highlight the importance of religious coping for QOL of hemodialysis patients. Negative religious coping predicts worse quality of life in patients with ESRD. This indicates the need for psychosocial and religious support in caring for Iranian hemodialysis patients.
5.2. Limitations of the Study
Several limitations of this research should be noted. This cross-sectional study did not allow for measurement of variables over time. The nonrandom sampling and limited sample size reduced the generalizability of the findings in this study; carrying out a study with a larger sample size could help to address this limitation. Moreover, a longitudinal study should be performed that controlled for other variables, such as depression, anxiety, self-efficacy, and physical and psychological symptoms, to generate a better understanding of the effects of religious coping on health and how to improve hemodialysis patients’ QOL. Despite these limitations, the current study appears to be unique in that we assessed QOL, religious coping, and their association among hemodialysis patients in an Islamic context.
