Exploring spirituality in Iranian healthy elderly people: A qualitative content analysis

Abstract

Background:

Spirituality is recognized as a personally important matter to the elderly, and there are evidences of its impact on their health. The aim of this study was to explore the concept of spirituality from the perspectives of Iranian healthy elderly individuals.

Materials and Methods:

A conventional qualitative content analysis of carried out with 21 healthy elderly people from both male and female genders were chosen using a purposive sampling method in Tehran in 2010-2011. Data collection was done through semi structured interviews. A qualitative content analysis was used to analyze the participants’ experiences and perceptions on spirituality, using a central question ‘what characterizes the spirituality in the Iranian healthy elderly people?’

Results:

The following categories emerged from the data analysis: (1) Spiritual health, with four sub categories including saying prayer as a calming factor; beneficence as a way to God; loss of psychological and spiritual support; faith as a way to happiness; (2) spiritual beliefs, with three sub categories including seeking help from God in difficulties; God's power over life and death; doing good deeds is the God's will; and (3) religious practice with three sub categories including saying prayer; reading Quran; and going to mosque, religious ceremonies and pilgrimage.

Conclusions:

In this study was found that spirituality was a fundamental element in elderly individuals’ lives that help them to adapt with daily living conditions.

INTRODUCTION

Older people have particular spiritual needs that are distinct from those of others, particularly in times of ill health and death and dying.[1] It has been reported that spirituality has a positive effect on health outcomes and welfare of the elderly.[2] Nowadays, aging phenomenon and relevant problems with its complexities are important issues that have attracted the attention of social and medical scientists to investigate the spiritual needs of the elderly.[3]

Spiritual health is a dimension of health that is portrayed as the validation of life in relation to God, fellow human beings, and the environment. Spirituality is the representative of the basic values that guide a person in searching to find answers to the crucial questions of life, such as the purpose and meaning of life, reality, love, good and bad, disease, and death.[4,5]

Over the past three decades, spirituality, religion, and prayer have turned into a subject of large interest for researchers in medicine, nursing, gerontology, physical health and mental health disciplines,[6] often in conjunction with complementary and alternative medicine.[6,7] Medical science professionals now have more interest in spiritual needs of elderly people. This tendency has been stimulated by research demonstrating physical and psychological benefits of spiritual and religious involvements.[8]

In fact, approximately 96% of adults in the United States expressed their belief in God, and 72% of identified religion and spirituality as having the most important influence in their lives.[9] Saying prayers is a regular daily task for Muslims which begins at the age of puberty and continues throughout the life. It is a time getting rid of the material world and approaching the world beyond, as well as, to the inner self. In Iran, elderly people are more religious than younger ones, and this is a norm of this culture. A recent national survey of the Iranians’ values and attitudes found that over 80% of the Iranians practice prayer regularly as a part of their religion.[10,11] One might argue that this is a true reflection of individual culture where prayer and religious beliefs are a part of people's everyday life. However, prayer can go beyond just performing a religious duty, and based on one's wishes, take different forms of formal and informal practices.

It has been shown that disease prevalence, incidence and mortality rates differ from one population to another. This is partly ascribed to their disparities in lifestyle, dietary habits and other characteristics that are somehow affected by culture, especially religious traditions and experiences.[12]

During the past two decades some studies have been carried out and the associations between religious beliefs or experiences and various types of physical illnesses, mental health, and mortality have been examined.[12] Spirituality is viewed as personally important matter to the older people and it has been proved that it is highly related to older people's health outcomes.[13]

However, there has not been adequate experiential research on the relationship between religious or spiritual factors and healthy lifestyle behaviors, and their impact on the adult's well-being. Scientists believe that probing the effects of religious and spiritual factors as well as healthy lifestyle behaviors may be decisive. Additionally, social science and medical research have concurrently reported that older adults are more inclined to take spiritual chase than younger people are.[3]

Spirituality is imperative to elderly people suffering from illness.[8]

Kotrotsiou-Barboutal et al.(2006) indicated that older adults are remaining members of religious associations without necessarily participating regularly in services, as there are numerous issues that can diminish the active participation in religious events, such as transportation intricacies, bad sound, or the illegibility of small font text in books of prayers available at mosques or religious centers. In spite of those complexities, many elderly manage to find out a way to come up to God through prayer. It is stated that prayer increases the feelings of personal value of an elderly by reducing the feelings of loneliness and desertation, while television and radio provide support for spiritual life.[4]

In this regard, researchers have shown that some groups of elderly people with inadequate and difficult livelihood situations communicate their problems by putting their trust in God. Moreover, more than half of the elder patients practiced spiritual needs throughout their hospitalization period, with the most prominent need of being in the search of the meaning of life.[4]

Extensive epidemiological studies have shown that higher levels of religiousness are related to lower mortality rates.[14] Studies identified the multidimensional nature of religiousness and spirituality and investigated various religious dimensions, for instance private religious behaviors, devotion, spiritual transcendence, and religious adaptation. They came up with generally optimistic findings. For example, it was indicated that some aspects of religiousness predicted lower rates of disability and illness, alcoholism, cardiovascular disease, hypertension, and myocardial infarction.[14,15,16] Furthermore, clinical research has suggested that spirituality can play a vital role in the recovery of patients suffering from physical and psychological diseases.[4]

It seems that religious obligation has a crucial role in averting physical and mental diseases, recovery promotion, and disease adaptation. Numerous studies have revealed the positive involvement of spirituality and religious indexes on different aspects of health such as cardiac surgery, mortality, immunity system function and self esteem.[17,18]

Above all, religious involvement can be useful for psychological well-being and physical health. Additionally, supporting the effect of spirituality may become more and more prominent in later life as a result of declining health, social and financial sources.[18] Researchers have proposed numerous psychological, social, and physiological interveners that may explain the spirituality-health association.[19]

Quantitative measurements and the evaluation of spiritual beliefs are difficult because quantitative studies neither reveal the content, components of the beliefs, and its factors, nor the contexts that might be included. Therefore, implementing qualitative research that explores the personal and experiential aspects of beliefs seems crucial, and may shed light on a range of important issues which can be investigated in detail on larger samples by further quantitative studies in future.[6,20]

Spiritual or religious beliefs may affect the decisions of individuals that make about their health and illness.[21] Thus, recognizing and understanding the spiritual and religious behaviors within the context of cultural influence by a qualitative research is critical for nurse and other health-care providers. The main strengths of the present study are that it focuses on the spiritual life of healthy elderly people. Therefore, the present study aimed to explore the concept of spirituality from the perspectives of Iranian healthy elderly people. The central question of the paper was ‘what characterizes the spirituality in the Iranian healthy older people?

MATERIALS AND METHODS

Design

In this research, a qualitative approach was adopted using conventional content analysis of unstructured interviews carried out with 17 healthy elderly people in Tehran in 2010-2011. It is worth noting that spirituality is underpinned by personal and cultural context in any community; therefore, qualitative research is the best method to study cultural context-bound subjects.[22]

Selection

Initially purposeful sampling was used and continued with purposeful sampling according to the codes and categories emerged from data. The study consisted of 17 healthy elders within the age range of 65-86. Criteria for selection were having age above 65, living with family, not having any cognitive problems, not having any physical limitation in ADL, and willingness to participate in the study. All participants were Shia Muslims.

Data collection

In order to achieve the wide range of experiences and perceptions of elderly participants, some field notes writing and 21 interviews were conducted according to emerged codes and categories from data.

The first researcher communicated with each of the participants to describe the purpose of research and research questions. The interview was scheduled according to the participant's agreement. Based on the participants’ preference, the interviews were performed in a private room at the house of elderly, park, worksite, or mosque, using an individual semi-structured interview format and this was primarily the main method for data collection. Interview query consisted of open-ended questions to allow respondents thoroughly to describe their opinions, perceptions, and experiences. The participants were asked to describe one day of their life and then to explain their own experiences and perceptions about “spirituality in elderly adults”. The main foci of the interviews’ questions were: ‘What is your experience concerning the spirituality in later age?’ and ‘what is the meaning of spirituality in your experience?”

Analysis

Each interview was transcribed verbatim and analyzed before the next interview was done, so that each interview supplied bearing for the next. Data analysis was done by MAXQDA qualitative software. Coding was carried out line by line, and comparative analysis of the quotations was carried out. All interviews were conducted in a single session, at the request and preference of participants, except for two cases that took two sessions. Each interview session ranged from 30 minutes to 90 minute with an average of 55 minutes. Data were collected and analyzed over a six-month--period in 2009. In the first phase, subcategories and their domains in the data were identified and classified into categories. The coding process was iterative, and categories evolved (inserted, deleted and combined) as re-readings were completed and analyses progressed. In the second phase, the subcategories and domains were regrouped into major categories.

Data trustworthiness

Credibility was recognized through prolonged engagement with the participants, field note writing, the participants’ revisions using member checking procedure, and peer checking. The findings and explanations of this study were reviewed by two supervisors who were associate professors in nursing having a good background in qualitative research methodology. Also, maximum variation of sampling established the conformability and credibility of the data. This study provided sufficient descriptive data for researchers to criticize whether the findings were transferable that established applicability.

Ethical considerations

Permission to conduct this study was obtained from the ethics committee of Tarbiat Modares University. Other ethical issues in this study included the assurance of confidentiality and anonymity of the participants and their responses. All participants were aware of the purpose of the study, and their participation in the study was optional.[23] Informed consent form was obtained from the participants who agreed to participate in the study according to the provisions of the Declaration of Helsinki.

RESULTS

The participants of the study were 11 males and 10 females, within the age range of 65-86. Also, 15 out of 21 were married, four were widowed, and one was single. Five participants were illiterate, four were primary degree holders, eight had a diploma, two had bachelor degrees, and two had MSc degree in Human sciences. In terms of their occupation status, two were employees, 13 were pensioners, two was manual worker, and three were housewives.

Three main categories emerged from the data and 3-4 distinctive subcategories within each category were identified. These categories and their subcategories represent the main factors influencing the spirituality in Iranian elderly people. The categories were: Spiritual health, spiritual beliefs, and religious practice. These categories and their subcategories are shown in Table 1.

Table 1.

Main categories and subcategories

Spiritual health

One of the main categories that emerged from data analysis was “spiritual health”. Four subcategories; “saying prayer as a calming factor”, “beneficence as a way to God”, “loss of psychological and spiritual support”, and “faith, a way to happiness”, emerged from the participants’ experiences. Also many of the participants considered the prayer time as an opportunity for purification which made them more tolerant to the adversities and has a calming effect on them.

“I want to say that waking up early in the morning, having the spirit for things like prayer, citing Quran verses, thanking God for his blessings and doing exercise would make you quiet and happy until the end of the day”. (Male)

Most participants believed that dealing with the affairs of the elderly and giving them a helping hand in their lives have positive consequences for the servers. They also believed that doing good things to older adults will lead them to pray for the servers which in turn cause good things in the servers’ lives. They said that man would receive God's blessings as a consequence of his/her deeds in the world. Additionally, they believed that the ultimate consequence of good deeds was good in return.

“I do everything that my mother wants me to do. If she asks me to fix her air conditioner you can be sure that I’ll do it. This is because I think that by doing this I make her happy and she prays for me. I think her prayers are very helpful for me”. (Female)

Moreover regarding “loss of psychological and spiritual support”, the participants said that in Iran the elderly people feel psychologically and spiritually alone and they do not receive any institutionally based mental and spiritual support.

“When I think about my life, I feel that I don't have any support from my children. Also in the street and road we don't have appropriate social respect and I want to say that in our society there is limited support and backing for people like me.” (Female)

The elderly participants’ lived experiences disclosed the subcategory of “faith, a way to happiness” in life. One of participants described that having strong faith was very important over the elderly life and adopting a healthy life style depended mostly on their faith and beliefs. Also, they stressed that faith will lead them to a sense of physical and mental welfare and happiness.

“The one who has strong faith and beliefs is always happy and confident. In my opinion, it does not matter if a person is poor. Worshiping God, praying, fasting, reciting Quran, purity and attending mosques are important elements in life, and bring happiness to your life and set your soul free”. (Male)

Spiritual beliefs

“Spiritual beliefs” was a main category that emerged from the participants’ lived experiences of spiritual concept and This category was further subcategorized into three subcategories including “seeking help from God in difficulties”, “only God's power over life and death”, and “doing good deeds is the God's will”.

Regarding the subcategory of “seeking help from God in difficulties”, the participants believed that wishing for and seeking help from God can help the elderly people to deal better with life difficulties, disperses and stresses. This desire results in God's attention to elderly and also creates sense of trust in older adults. Some statements said by participants are:

“I really believe in having trust in God. When I’m trapped in a complicated situation, I believe that this is God who helps me and I only trust in God.” (Male)

One participant believed that spirituality was a vital component of older people lives. Also, he believed that God was the ultimate source to affect my life or death and He controls everything.

“We’re all waiting to see when the angel of death arrives and takes us away. Everything is in the hands of God, and so is death”. (Male)

Concerning the subcategory of “doing good deeds is the God's will”, the participants believed that trust in God guided them to many positive activities in their lives. They believed that calling the name of God while getting out of house, remembering Him throughout the daytime and praying will lead them to prosperity. One participant said that trust in God, submitting to God's will and thinking about God all the time helped him to work and deal with anybody without any behavioral problems.

“When I want to get out of my house for work, ^the first thing that comes to mind is that” Oh God I believe in you and I trust you. “My dear God: Bestow upon me everything which is good for me and while I’m out working, I do my best not to misbehave or do anything bad to anybody.” (Male)

Religious practice

Another most important category that emerged was religious practice with three distinctive subcategories including: Saying prayers, reciting Quran, and going to mosque, religious ceremonies and pilgrimage.

The majority of the participants indicated that they had good knowledge of Quran, said prayers regularly, and went to mosque for religious and social activities. Also they mentioned more positive effect of doing religious practice on your life conditions. For example one participant said that participating in religious settings and ceremonies led her to find new friends and got her out of loneliness.

We eat lunch and take a short rest and then we go to mosque. We hold sessions in mosque and we are members of the mosque council. We go to Quran classes twice a week. We go to Quran classes on Friday mornings also”.(Male)

“I have so much interest for pilgrimage and saying daily payers at the earliest recommended time when call for prayer is announced. I go to the religious rites with the my friends and peers, and I want to get out of loneliness. (Female)

Thus, it can be concluded that all of the participants rose early to start their religious acts of devotion, prayers, and worship in their home or mosque.

DISCUSSION

This qualitative study describes the concept of spirituality and its impression on Iranian elderly people daily living behaviors. Spiritual health was one of the main categories emerged from this study. The findings are significant as they reveal that the living experiences of saying prayer as a calming factor, beneficence as a way to God, loss of psychological and spiritual support, and faith, a way to happiness, are the most important domain and subcategory of spiritual health of elderly people, which can positively affect their health. On the other hand spiritual health is an important dimension of human health and it can determine the individual integrity.[24] Also spiritual health is a power that coordinates physical, mental and social dimensions and is necessary in coping with diseases.[25] When spiritual health will is at serious risk, individuals may be stricken by mental disorders such as loneliness, depression, and loss of meaning. There are a number of studies that support the beneficial effects of spirituality on health.[26] These health benefits include both physical and mental well-being.[9]

Behaviors such as reliance on God, pilgrimage and praying create hope and positive attitudes that lead to internal serenity, peacefulness and meaningful life. Most faithful people describe their relationship with God as a relationship with an intimate friend and believe that they can control the effect of irrepressible situations by having recourse to God. All in all, religious adaptation relies on beliefs and religious activities and help people to control their stress and physical disorders. Having meaning and goal in life, sense of belonging to a sublime source, hope for Gods’ support in time of trouble and social and spiritual support are among the sources that help religious people to suffer less from hardships of life.[27,28,29] In the Iranian society context, where the majority of the population are Muslim, and a religious culture is dominant in the society, it is expected that tendency to spirituality could be affect their health.

Prayer is a spiritual activity of the human spirit reflecting connectedness with God. Prayer is described as both influencing and being affected by one's spirituality.[30]

Praying is the expression of soul and a deep human instinct that arises from human soul and is uttered with profound words.[31] It is neither dependent upon any particular spirituality nor entailed in any time and place.[32] The content of praying includes confession of sins and weakness, pleading for forgiveness, bliss and closeness to God.[33]

One of main category that emerged from our data related to prayer. Prayer has significant relationship with meaning of life and spiritual health. Praying reduces mental and psychological pains, releases personal emotions, leading individual to attain eternal source of power. Weeping that often comes with praying greatly helps a person to release his or her distress and emotions. Also Prayer helped participants to cope with disease and gave them calm, hope and inner strength.[33] In this regard, Quran has put it magnificently: “Those who have faith in God and inundate their hearts with name of God, surely God remembrance ascertains their hearts” ((Quran, Chapter 13: Sureh 13, Al-Rad) Verse 28). Many Americans, regardless of their health status, rely on their religious and spiritual beliefs to cope with stressful life events.[9]

Another category that emerged from participants experience was spiritual beliefs. The present study has demonstrated that one of the most important factors that help elderly in confronting with difficulties was seeking help from God. Several studies noted that spirituals beliefs had positive influence on welfare and personal and social life of elderly people.

Effective spiritual coping strategies help individuals find meaning and purpose in their life, problems and difficulties. For instance, one study showed that healthy older adults believed that a higher power supports them and that having a relationship with God forms a foundation for their psychological well-being. Thus, spirituality plays an important role in the lives of healthy individuals, too.[9]

Believing in support from spiritual/religious resource and connectedness with a higher power is beneficial and it can affect issues of control, quality of life, spiritual well-being, coping, depression, decision-making, and possibly health outcomes.[34] For instance, it has been reported that healthy older adults believe that a higher power supports them and that having a relationship with God forms a foundation for their psychological well-being. Thus, spirituality plays an important role in the lives of healthy individuals.[9] In the result of our study a sense of God's power over life and death and doing good deeds is the God's will were derived from participants experience around spiritual beliefs. All the participants talked about the importance of God and belief to God's power in their life. Moreover, the findings reveal that God's power was very important in personal and private experiences. In this regard, Roff et al.(2009) in a qualitative study through a thematic content analysis identified God's power in the lived experiences of women who were suffering from breast cancer.[35]

Also, in another qualitative study by Taleghani et al. (2006) belief to God's will was a important key in acceptance of disease.[36] Furthermore, Maynard et al. (2002) suggested that personal variables such as the concept of God and perception of others’ beliefs played important mediating roles in religious coping with stress situations.[37]

Religious practices were a subcategory that emerged from the lived experiences of elderly participants in this research. Furthermore, the results of study by Keefe et al. (2001) showed that individuals who reported frequent daily spiritual experiences had higher levels of positive mood, lower levels of daily negative mood, and higher levels of all of the social support domains.[38] The findings of these studies are in harmony with our study's results.

Another subcategory that emerged from participants experience was going to mosque and religious ceremonies. In this regard, Palinkas (1982) found that Religious ceremonies are supportive for individuals because liberating and curative friendships relevant to spiritual states brings about psychological health for them. Attending religious ceremonies and shrines also reduces individuals’ anxieties and sense of loneliness.[39] These results are in accordance with our study findings which show that elderly women who participate in religious ceremonies, are relieved from loneliness.

Also Koenig (1998) suggested that religious practices, attitudes and coping behaviors are prevalent among hospitalized medically ill older adults and are related to social, psychological and physical health outcomes.[40] Pilgrimage was one of the main religious practices of Iranian elderly people. Morris (1983) examined the relationship between anxiety and pilgrimage and found that people with religious devotion experienced significantly lower rates of anxiety disorder compared to the non-religious group. In addition, pilgrimage could promote the hope and religious faith of elderly people.[41] These results conformed with our findings.

Every Muslim learns their prayers from a young age and prays five times a day. In addition, those who seek guidance from the holy Quran and believe that it has power over every aspect of their lives, expect and welcome any eventualities in their lives (Quran, Chapter Balad, Verse 4).

It seems that elderly people have more tendencies to religious and spiritual subjects than young people. Koenig et al. (2004) in his study showed spirituality and religion as an important factor in their lives more often than younger ones.[42]

In present study Prayer was a main religious practice that emerged from participants experiences. They believed that prayer could affect their life over the life span and doomsday. Several experimental studies have been conducted that showed positive effects of prayer on the management of physical symptoms of illness.[43] Kwilecki (1986) assessed the effect of prayer on stress and anxiety and found that 42% of participants report that saying prayer can diminish the stress and anxiety.[44]

Also Salehi (2001) found that individuals who pray regularly, experienced significantly lower rates of anxiety disorder and depression, psychological balance and hopefulness,[45,46,47,48,49] compared to the non-prayer group.[50] Azizi (1996) found that more than 90% of prayers attained psychological tranquility and relaxation after saying prayer.[51]

Several studies noted moderately positive correlations between indicators of physical health and prayer activities.[42,43] Also several studies have shown that prayer can play an important role in the recovery of patients who suffer from cardiac disease, HIV, arthritis rheumatoid, and CVA attack,[52] cancer cases, treatment of addiction,[53] and physical, mental and social well-being.[48,54] Furthermore, evidence suggests that patients with strong religious beliefs and high levels of religious activity experience lower levels of pain, have better immune function, lower death rates from cancer, fewer incidences of heart disease, lower blood pressure and levels of cholesterol, better health behaviors, and greater compliance with medical treatment.[42,55]

Our findings suggest that spirituality is a very important agent in Iranian elderly people. The practical relevance of this study may conduct future work to further explicate and clarify the linkages between spirituality and physical and mental health and life style.

Suggestions

Future empirical research and new methods of investigation such as concept analysis, grounded theory, and action research are needed to develop the new models of caring for management of this group. In the life style area, future research should focus on the effects of spirituality on elderly people lifestyle domains and on the development of valid and reliable instruments to measure these effects. Also, this study was conducted in a sample of healthy elderly people. It is important to conduct such research in different samples, such as unhealthy elderly people (frail, ill, and sick elderly people).

CONCLUSION

In summary, we found that elderly people describe several elements in their illustration of spirituality in healthcare settings. Spiritual health, spiritual beliefs, and religious practice intentionality were the main components of concept of spirituality in this group experiences. One of the main categories that emerged from our data was related to prayer. Prayer has significant relationship with the meaning of life and spiritual health. Also, the findings of this study made it clear that spirituality has a considerable effect on the health and life of Iranian elderly people and is a major supportive resource for their physical and psychosocial health. It can reduce mental distress and induce inner peace and hopefulness. Because of the significant influence of spirituality on all domains of health of elderly people, it is critically important that health care providers understand how spirituality can considerably influence elderly people throughout their life.

These findings will assist health professionals such as nurses, physicians, and social workers to recognize the spiritual needs and value the role of spirituality in promoting health and well-being among elderly people from different religions and cultures worldwide.