Abstract
Background
Adherence to treatment regimen is one of the behaviors related to diabetes, which has predicted successful control of the disease and reduced its intensity as well as negative consequences. This study aimed to determine the relationship between spiritual well-being and hope, and adherence to treatment regimen in patients with type II diabetes referred to diabetes clinics.
Methods
In this descriptive-correlational study, 227 diabetic patients referred to healthcare centers and diabetes clinics affiliated to Shiraz University of Medical Sciences were selected via cluster sampling (clinics) followed by convenience sampling (patients). The study data were collected using a demographic information form, spiritual well-being scale developed by Ellison and Paloutzian, Herth hope scale, and adherence to treatment regimen questionnaire. Then, the data were entered into the statistical software and were analyzed using descriptive and inferential statistics.
Results
The results indicated that most participants had moderate spiritual well-being, high hope, and low adherence to treatment regimen. Additionally, spiritual well-being was directly associated with hope and reversely related to adherence to treatment. A significant reverse correlation was also observed between hope and adherence to treatment.
Conclusion
Considering the fact that spiritual well-being and hope were reversely associated with adherence to treatment regimen, further studies should be done in this field. Also patients’ image of God and their interpretations of being sick might not be appropriate and need correction.
Keywords: Spirituality, Hope, Treatment adherence and compliance, Diabetes mellitus
Introduction
Due to its numerous complications, diabetes has been considered to be a costly disease all around the world [1]. The chronic nature of diabetes and the resultant complications impose a great economic burden and reduce the quality of life of the patients as well as their families [2]. According to the International Diabetes Federation (IDF), the prevalence of diabetes was 9% among individuals aged above 18 years, and nearly 422 million adults suffered from diabetes around the world in 2014. This measure has been predicted to reach 642 million by 2040 [3]. The prevalence of diabetes has also considerably increased in the East Mediterranean region. This measure has been estimated to increase from 9.7% in 2014 to 11.6% by 2040 [4]. The prevalence of diabetes has also increased by two folds in Iran as an East Mediterranean country during the past three decades [5]. The results of a national study indicated that the prevalence of diabetes was 13.8% in 2013 [6]. Another subnational study also revealed that the incidence of diabetes was nearly 1% in Iran [7]. It has been predicted that the annual growth rate of diabetes in Iran would gain the second rank in the region by 2030 [8].
Since diabetes is a chronic and incurable disease, patients need self-care and lifestyle change to control their disease all through their lives [9–11]. Adherence to treatment regimen is among the behaviors, which predict the successful control of the disease and decrease its intensity and negative consequences [9, 12]. A large number of patients with chronic diseases do not adhere to their treatment regimens because of exhaustion resulting from long-term treatments and disappointment from a definitive treatment [13]. Moreover, nearly half of patients with chronic disorders fail to adhere to their treatment regimens [9]. Non-adherence to treatment regimen has been defined as non-conformity of individuals’ behaviors to health or treatment advices. It is a complicated behavioral process, which is affected by various factors, including patients’ characteristics, patient-physician relationship, healthcare system [14], and a combination of personal, spiritual, behavioral, and religious beliefs [15–17].
The importance of spirituality in humans’ physical health has increasingly attracted the attention of health specialists during the past decades. Thus, scientific investigation of the role of spiritual well-being has become one of the main issues in health sciences [15, 18, 19]. In this context, spiritual well-being has been introduced as one of the dimensions of health alongside physical, mental, and social health [20]. Spiritual well-being is able to coordinate physical, mental, and social dimensions and create an integrated relationship among internal forces. It is indeed an important dimension that can strengthen individuals’ psychological function and compatibility [21], promote other dimensions of health [22], and improve the quality of life [23]. It causes individuals to seek for the meaning of life at the time of diseases [23]. In addition to spiritual well-being, mental issues are of particular importance among patients suffering from diabetes. Investigation of diabetes map in mental disorders has indicated that mental problems could affect the treatment and quality of life among diabetic patients [24]. In this context, hope has been considered to be a major factor and a prerequisite for compatibility during the course of the disease [25]. Generally, hope is a coping strategy for compatibility with problems and refractory disorders. Hope, as a multifaceted, dynamic, and strong sanative agent, can also play a critical role in compatibility [21, 26]. Hopeful people usually believe in their physical and mental improvement [25]. In fact, hope results in compatibility in chronic diseases. It has also been considered to be a complex, multifaceted, and potentially powerful factor in improvement and effective compatibility. Hope helps patients physiologically and emotionally to tolerate the disease crises [27]. Evidence has revealed a relationship between spiritual well-being and hope. In communities with rich cultural and religious beliefs, the positive relationship between spiritual well-being and hope implies that patients feel the existence of God in their lives and believe that the Creator guides their lives, provides the ground for their happiness, and supports them whenever they need Him [25]. Therefore, spiritual health can enhance the level of health behaviors, reinforcing effects on physical status, patient’s compatibility with the disease, and follow-up of the treatment process [28]. A previous research explored the effects of spirituality and religion on the adherence to antiretroviral therapy among adult HIV patients and came to the conclusion that both spirituality and positive religious coping could have positive impacts on desirable adherence to the treatment regimen [29]. The results of another study indicated that the mothers with children suffering from cystic fibrosis who believed in God and considered their children’s bodies as the manifestation of the presence of God were more determined to adhere to their children’s treatment measures and drugs consumption. These behaviors were confirmed by the Theory of Reasoned Action, as well. Based on this theory, intentions are the best predictors of behaviors. Indeed, intentions have their roots in beliefs and beliefs are affected by several underlying factors including spirituality [30]. Hence, it can be concluded that belief in God and hopefulness may play a role in patients’ lives [31]. Nonetheless, contradictory results have been obtained regarding the effect of spiritual health on adherence to treatment regimen [32, 33]. Thus, further studies are recommended to be conducted in this field.
The results of a research in Iran demonstrated that adherence to treatment regimen was associated with age, education level, and healthcare expenditures in patients with diabetes. The results also revealed a significant relationship between adherence to treatment and belief in controllability of the disease, beliefs related to disease complications, self-efficacy, and concerns associated with consumption of medications [27].
Considering the importance of spiritual well-being and hope in promotion of compatibility with chronic diseases and the limited number of studies conducted in this regard in Iran, performance of a research in this field can help identify some variables associated with adherence to treatment. Therefore, the present study aims to determine the relationship between spiritual well-being and hope, and adherence to treatment regimen among patients suffering from type II diabetes.
Materials and methods
Study design and setting
This descriptive, cross-sectional study was conducted on patients with type II diabetes. The research population included all patients with diabetes referred to educational treatment centers. The study was conducted in healthcare centers and diabetes clinics affiliated to Shiraz University of Medical Sciences from May to August 2018.
Sampling and participants
Based on the previous studies [27, 34, 35] and considering error rate < 5% and measurement accuracy = 0.05, a 210-subject sample size was estimated for the study. Considering loss rate and in order to increase accuracy, 227 patients were enrolled into the research. The sampling was done in two stages; cluster sampling in the first phase and convenient sampling in the second phase. In the first phase, a list of diabetes clinics was made by the investigators to randomly select one diabetes clinic as a cluster. Then, the participants were selected through convenience sampling. The inclusion criteria of the study were having suffered from type II diabetes for at least one year, having been registered in the diabetes clinic, consuming blood glucose-lowering drugs (oral or injectable), aging above 18 years, and eagerness to take part in the research. The exclusion criterion was suffering from a persistance disease, which was difficult to treat or remedy.
Variables
Most of potential factors assumed to have an association with spiritual well-being, hope, and adherence were assessed. Diabetes was defined as Fasting Plasma Glucose (FPG) ≥ 126 mg/dl or HbA1C ≥ 6.5 and taking anti-diabetic medications. Age and duration of diabetes were reported by mean and standard deviation. Gender was classified as male or female. In addition, education level was classified as primary and secondary school, diploma, higher than diploma, and bachelor’s degree. Besides, marital status was categorized as single, married, divorced, and widowed. Monthly income was also presented as low, moderate, and high according to the participants’ self-reports. Health status was categorized as bad, moderate, good, and excellent. Insurance coverage, family history of diabetes, and history of other disorders were reported as yes or no. Indeed, type of medication was classified as oral, insulin, or both.
Life-satisfaction was measured by a single question rated on a 0–10 numerical scale: “What do you think, how satisfied are you at present – all things considered – with your life?”. A 11-point Likert scale [from 0 = worst to 10 = best] was used to score this question. In all these cases, the measurement procedure results in a frequency distribution of a discrete response variable in the sample [36].
Finally, spiritual well-being, hope, and medication adherence were reported as low, moderate, and high.
Data measurements
The participants were interviewed by trained nurses to complete demographic, spiritual well-being, hope, and adherence to treatment regimen questionnaires. The demographic questionnaire included information about age, sex, marital status, education level, income level, disease history, satisfaction with health status, and life satisfaction.
Spiritual well-being was assessed using the spiritual well-being scale developed by Ellison and Paloutzian. This scale contained 20 items responded via a 6-point Likert scale. Accordingly, 1–6 scores were assigned to completely disagree, disagree, somehow disagree, somehow agree, agree, and completely agree responses, respectively. It should be noted that nine items were scored reversely [1, 2, 5, 6, 9, 12, 13, 16, 18, and]. The total score of the scale could range from 20 to 120. Accordingly, spiritual well-being could be divided into three categories as follows: low [20–40], moderate [41–99], and high [100–120]. Face, content, and structural validity of the spiritual well-being scale were approved in the study conducted by Soleimani et al. to assess its psychometric properties among patients with acute myocardial infarction. Its reliability was also evaluated using internal consistency method, revealing Cronbach’s alpha >0.8 [37].
Hope was assessed using Herth hope scale. This scale contained 12 questions responded via a 4-point Likert scale. Accordingly, 1–4 scores were assigned to completely disagree, disagree, agree, and completely agree responses, respectively. It should be mentioned that questions number 3 and 6 were scored reversely. The total score of the scale could range from 12 to 48, with higher scores representing higher hope status. The validity of the scale was confirmed in the study performed by Balijani et al. [38] in 2011. Its reliability was also approved by Cronbach’s alpha = 0.82 [27].
Adherence to treatment regimen was evaluated using the eight-item Morisky Medication Adherence Scale (MMAS-8) developed by Morisky, Ang, Wood et al. This scale contained eight questions seven of which had dichotomous answers (yes/no) receiving 1 and 0 scores, respectively. It should be noted that question number 5 was scored reversely. Question number eight was also scored reversely using a Likert scale with the following options: never [0], rarely [1], sometimes [2], usually [3], and always [4]. The total score of the questionnaire could range from zero to eight, with scores above six representing desirable adherence to treatment [39]. The internal consistency of this instrument was approved in the studies conducted in other countries (Cronbach’s alpha = 0.675). Its external consistency was also confirmed by test-retest method (p < 0.001) [40]. In Iran, this scale was utilized in the study by Kooshyar et al. in 2013, approving its content validity and confirming its reliability with Cronbach’s alpha = 0.68 [9].
Data collection
After gaining the required reference letters and obtaining the approval of the Ethics Committee of the Vice-chancellor for Research Affairs of Shiraz University of Medical Sciences (95–01–08-13,909-99,914), one of the researchers referred to the study settings identified through cluster sampling. The participants were then selected from the diabetic patients referred to these centers according to the inclusion and exclusion criteria. Totally, 257 patients were eligible to take part in the research. However, 30 ones did not have time, were sick, or were not willing to participate in the study and were excluded.
After the participants were provided with explanation about the study objectives and were reassured about the confidentiality of their information, they were required to fill out the questionnaires. The researcher was also present at the time of completion of the questionnaires and in case the participants were not able to fill them out, she read the questions to them and reflected their opinions in the forms. It took 20–30 min to complete the questionnaires. Sampling was continued until completion of the sample size, which lasted for three months. At the end, the authorities and participants were acknowledged and ascertained that they would be provided with the results upon request.
Statistical analysis
The study data were entered into the SPSS statistical software, version 22 and were analyzed using descriptive and inferential statistics, including chi-square, t-test, and correlation test. P values <0.05 were considered to be statistically significant.
Results
The results indicated that more than half of the participants were female (74.8%) and married (69.6%). The mean age of the participants was 52.25 + 14.89 years. Besides, the majority of the participants had diploma and below diploma degrees (90.7%) and reported that their expenditures exceeded their incomes (75.7%) (Table 1). Moreover, 65% of the participants had the family history of diabetes and 65.5% suffered from other disorders, as well. Indeed, nearly 49% of the participants consumed oral medications, while 23% used both oral medications and insulin.
Table 1.
The relationship between the scales and the study variables (n = 227)
| Variables | Frequency (%) | Spiritual well – beingMean (SD) | Hope Mean (SD) | Medication adherence Mean (SD) | |
|---|---|---|---|---|---|
| Sex | Female | 169(74.8) | 96.3 (12.5) | 36.5 (5.0) | 3.1 (1.2) |
| Male | 57(25.2) | 93.0 (12.7) | 36.4 (4.7) | 3.2 (1.5) | |
| P value | 0.08 | 0.85 | 0.59 | ||
| Education level | Bachelor’s degree | 7(3.1) | 100.8 (14.4) | 39.8 (4.7) | 4.4 (1.5) |
| Higher than diploma | 14(6.2) | 96.7 (16.19) | 37.9 (4.7) | 2.5 (1.0) | |
| Diploma | 47(20.7) | 93.7 (12.7) | 35.6 (5.2) | 2.9 (1.4) | |
| Primary & secondary | 158(70) | 95.5 (12.6) | 36.5 (4.8) | 3.2 (1.2) | |
| P value | 0.53 | 0.12 | 0.01 | ||
| Marital status | Single | 51(22.8) | 94.1 (10.7) | 36.3 (3.5) | 1.2 (0.17) |
| Married | 156(69.6) | 96.4 (13.0) | 36.7 (5.3) | 3.2 (1.3) | |
| Divorced | 8(3.6) | 87 (19.2) | 33.5 (6.4) | 3.2 (1.4) | |
| Widowed | 9(4) | 96.3 (5.6) | 36.8 (3.2) | 2.7 (1.2) | |
| P value | 0.17 | 0.32 | 0.80 | ||
| Monthly income | High | 7(3.1) | 100.0 (17.1) | 42.4 (2.3) | 2.4 (0.7) |
| Moderate | 48(21.2) | 95.9 (12.8) | 37.4 (5.1) | 3.1 (1.4) | |
| Low | 171(75.7) | 95.0 (12.8) | 36.0 (4.8) | 3.2 (1.3) | |
| P value | 0.57 | 0.001 | 0.31 | ||
| Health status | Excellent | 7(3.1) | 93.2 (7.9) | 38.8 (4.5) | 3.0 (1.7) |
| Good | 77(34.1) | 95.8 (13.0) | 36.5 (4.7) | 3.0 (1.3) | |
| Moderate | 93(41.2) | 97.8 (13.4) | 37.6 (4.8) | 3.1 (1.2) | |
| Bad | 49(21.7) | 89.8 (10.6) | 33.9 (4.6) | 3.4 (1.2) | |
| P value | 0.005 | <0.0001 | 0.29 | ||
| Insurance | Yes | 215(94.7) | 95.3 (13.1) | 36.4 (5.0) | 3.2 (1.3) |
| No | 11(5.3) | 95.6 (7.0) | 37.0 (4.8) | 2.7 (1.1) | |
| P value | 0.93 | 0.74 | 0.22 | ||
| Suffering from other disease | Yes | 146(65.5) | 95 (12.7) | 36 (4.8) | 3.32 (1.3) |
| No | 77(34.5) | 96.2(13.6) | 37.5 (5.0) | 2.92 (1.3) | |
| P value | 0.51 | 0.03 | 0.03 | ||
| medication | oral | 108 (48.6) | 97.1 (12.7) | 37.2 (5.1) | 3.18 (1.3) |
| insulin | 62 (27.9) | 92.6 (11.5) | 35.6 (4.9) | 3.13 (1.3) | |
| Oral & insulin | 52 (23.4) | 95.0 (14.6) | 36.1 (4.5) | 3.25 (1.2) | |
| P value | 0.09 | 0.09 | 0.88 | ||
The results indicated that most participants had moderate spiritual well-being (63%), high hope (87.2%), and low adherence to treatment regimen (88.5%) (Table 2).
Table 2.
Scale items in the sample (n = 227)
| Scale item | Minimum- maximum | Mean (SD) | Category | N (%) |
|---|---|---|---|---|
| Spiritual well–being | 54–120 | 95.6 (14.2) | Low | 0 (0) |
| Moderate | 143 (63) | |||
| High | 84 (37) | |||
| Hope | 20–48 | 36.7 (5.1) | Low | 4 (1.8) |
| Moderate | 25 (11) | |||
| High | 198 (87.2) | |||
| Medication adherence | 0–7 | 3.2 (1.3) | Low | 201 (88.5) |
| Moderate | 25 (11) | |||
| High | 1 (0.4) |
The results showed no significant relationships between spiritual well-being and sex, education level, marital status, and insurance coverage. However, a significant association was observed between spiritual well-being and overall health status (p = 0.005), in a way that the highest spiritual well-being was seen in the participants with the excellent health status. Besides, hope was associated with income level (p = 0.001) and overall health status (p < 0.0001). The results also demonstrated a significant relationship between adherence to treatment and education level (p = 0.01), in a way that the highest adherence was seen in the participants with bachelor’s degrees. Adherence was also associated with suffering from other diseases (p = 0.03) (Table 1).
Based on the study results, spiritual well-being was directly associated with hope (r = 0.66, p < 0.0001) and life satisfaction (r = 0.46 p < 0.0001) and reversely related to adherence to treatment regimen (r = −0.20, p = 0.002). In addition, hope showed a direct relationship with life satisfaction (r = 0.49, p < 0.0001) and a reverse relationship with adherence to treatment regimen (r = −1.99, p = 0.003). Moreover, life satisfaction was reversely associated with adherence to treatment regimen (r = −0.17, p = 0.008) (Table 3).
Table 3.
Correlation coefficients of spiritual well-being, hope, and medication adherence
| Spiritual well–being | Hope | Medication adherence | Life satisfaction | |
|---|---|---|---|---|
| Spiritual well–being | r = 0.66 p < 0.0001 | r = −0.20 P = 0.002 | r = 0.46 p < 0.0001 | |
| Hope | r = −1.99 p = 0.003 | r = 0.49 p < 0.0001 | ||
| Medication adherence | r = −0.17 p = 0.008 | |||
| Life satisfaction | ||||
Discussion
The result of the study exhibited that spiritual well-being was directly associated with hope and life satisfaction and reversely related to adherence to treatment regimen. Also, participants with the excellent health status have the highest spiritual well-being.
The results revealed that most patients with diabetes had moderate spiritual well-being, which is consistent with the results of the study by Dehbashi et al. [41]. However, these results were in contrast to those obtained by Moghimian [42], which revealed low spiritual well-being scores among cancer patients. Spiritual well-being among patient with chronic disease such as diabetes may create a great encouraging result in order to overcome life management challenges [43]. The result of a systematic review showed that spiritual and religious beliefs are being associated with adherence to medication regimes [44].
The present study participants had high hope levels, which is in agreement with the results of the studies by Shamsalinia et al. [45] and Balsanelli et al. [46], but not with those of the research performed by Dehbashi [41] among dialysis patients. These contradictory results might be due to differences in types of diseases, cultural and religious statuses of societies, and possession of more facilities that would result in higher quality of life and satisfaction. Although diabetic patients have lower quality of life compared to people without chronic disorders, they have a better status in comparison to those suffering from other chronic diseases with serious complications [47]. The findings of the current study revealed a relationship between spiritual well-being and hope. Other studies have also noted a relationship between these two variables. Findings of the researches showed that individuals with higher hope levels are more optimist, have greater control over their lives, possess better problem-solving skills, have higher self-confidence, are less likely to suffer from depression, and have higher compatibility with diseases [48].
The present study findings indicated that the participants had low adherence to treatment regimen, which is in line with the results of the studies by Rwegerera et al. [49], Gholamaliei et al. [27], and Fadare [50], but not with those of the research by Mashrouteh [51]. The difference between the findings might result from enrollment of volunteer samples in the study by Mashrouteh [51]. In other words, those participants referred to the treatment centers on a regular basis. Thus, it could be concluded that individuals with good medication adherence were enrolled into the study. Variations in education level and economic status could have played a role, as well.
Non-adherence to treatment might result in waste of medications, progression of diseases, reduction of functional abilities, decreased quality of life, increase of consumption of medical services, frequent hospitalizations [52, 53], and emergency hospitalizations [54, 55]. Research has indicated that the rate of rehospitalization is two folds higher among the patients who do not adhere to their treatment regimens compared to normal individuals. Thus, in addition to the consequences for individuals, non-adherence to treatment regimens imposes a great burden on healthcare systems. In this context, healthcare staff including physicians, pharmacists, and nurses play a key role in promotion of the patients’ adherence to treatment regimens [56]. Non-adherence to treatment regimens might result from weak relationships between patients and caregivers, insufficient knowledge of medications and their usage, not being convinced about the necessity of using medications and adherence to treatment, fear from side-effects, long-term pharmacotherapy, complex treatment regimens with various medications and dosages [57, 58], costs, and access barriers [59]. Additionally, studies have revealed relationships between non-adherence to treatment and age, sex, low education levels, culture, marital status, living alone, race, income level, occupation, number of dependents, IQ, and personality type [60–62].
The results of the current study showed no significant relationships between spiritual well-being and sex, education level, marital status, monthly income level, and insurance coverage. These results were consistent with those of the studies by Shahdadi et al. [63] regarding education level, Allahbakhshian [64] concerning sex, and Asayesh [65] regarding economic status. On the contrary, Dehbashi [41] reported a significant relationship between spiritual well-being and age, sex, and marital status. Rezaei [66] and Habibi [67] also found a significant relationship between spiritual well-being and education level. In the same vein, Shahbazi [68] disclosed that increase in education level was accompanied with increase in spirituality. The discrepancies among the results might be attributed to the type of disease, environmental, cultural, and religious variations, and duration of suffering from the disease.
The current study findings revealed a significant association between spiritual well-being and the overall health status. Some studies have indicated that increase in religious and spiritual activities, particularly taking part in religious activities, and the social support provided by religious groups were associated with improvement of health status. Indeed, informal activities such as praying and reading the Holy Book could affect individuals’ mental health by empowering emotions such as hope and forgiveness and consequently affect their physiological processes and physical health [69]. However, Campbell et al. [70] conducted a study on patients with cancer, those suffering from stroke, and those undergoing rehabilitation after traumatic head injury and reported no significant relationships between religious activities and physical health.
In the present study, hope was only associated with monthly income level and the overall health status. In the research by Motaghi [71] also, high income level was related to hope. Accordingly, high income level enhanced hope directly. Shamsalinia [45] also reported that the people who suffered from disease complications had lower hope levels, which indicated the importance of this issue.
In the present study, a significant relationship was observed between adherence to treatment regimen and education level, which is in agreement with the results obtained by Nouhjah [72] and Gholamaliei [27]. They also reported that individuals with higher education levels had better adherence to treatment regimens. Patients’ ability to read and understand medical orders is a major factor in adherence to treatment regimens. Thus, patients with low education levels might face problems in understating medical orders, which could in turn decrease their adherence to treatment regimens [60].
The current study findings indicted a direct relationship between spiritual well-being and hope, which is consistent with the results of the research by Samadifard. That research also showed a direct relationship between spiritual well-being and hope; the higher the patients’ spiritual well-being, the higher their hope would be [73]. In addition, several studies have demonstrated a relation between strong religious beliefs and high hope scores. Most people feel higher hopefulness, tranquility, and support when they connect with God at the time of problems [45].
The present study results revealed a significant, direct relationship between spiritual well-being and life satisfaction. Romero et al. [74] and Younger et al. [75] also showed a positive correlation between spirituality and life satisfaction. Patients benefitting from spiritual well-being usually have healthier lifestyles, are more hopeful, have higher mental stability, and feel more satisfied with life [73].
In the current study, spiritual well-being was reversely associated with adherence to treatment regimen. Similar results were also obtained by Duke et al. [32] They stated that although spirituality led to compatibility with the chronic condition of the disease, it was not accompanied with appropriate self-care behaviors, because the participants believed that God’s will would protect them against the disease. In the same line, Habte [33] disclosed that religious beliefs and healing practices could result in replacement of medical measures with religious activities. For instance, Orthodox Christians made use of the holy water instead of antidiabetic drugs, which led to short- or long-term disruption of medications consumption. In contrast, Alvarez [76] reported a significant relationship between spirituality and adherence to treatment regimen. On the other hand, Heidari et al. [77] and Shahdadi et al. [63] indicated no significant relationship between spiritual well-being and blood glucose control as the final result of adherence to treatment regimen. The results of the study by How et al. [78] showed that Muslims had higher HBA1C and fasting blood glucose levels in comparison to the followers of other religions, which represented improper blood glucose control. In this respect, Bodenheimer [79] stated that Muslims believed in God and, consequently, did not have appropriate control over their diseases. Naeem [80] also disclosed that Muslim Kashmiri diabetic men did not have proper self-care behaviors due to their beliefs and attitudes. Nonetheless, HBA1C level was low in some Muslim groups with strong beliefs in spite of their high Body Mass Index (BMI) and irregular sport activities [81]. This could be attributed to their motivation for successful diabetes control as well as the indirect effect of religious beliefs, including not smoking cigarettes, not consuming alcohol, exercising, and following appropriate diets. Indeed, religion and spirituality are great compatibility strategies for coping with stresses and disappointments, creating the feeling of internal tranquility and life satisfaction, having emotional and social supports, and having resources and consultation during crises [81]. The discrepancy among the findings might be attributed to cultural, environmental, and religious variations as well as differences in type of disease, age, duration and intensity of disease, and spiritual well-being level.
The present study results revealed a significant, direct relationship between hope and life satisfaction. This was supported by the results of the study by Adams [82], which revealed a positive correlation between hope and life satisfaction. Hope is a positive force that enhances motivation, compatibility, and progression of goals [83]. It has the ability to create and maintain energy in life. Thus, hopeful individuals may have stronger stimulants and more energy to follow their goals, which probably result from their motivation to actively take part in problem-solving processes and conduct behaviors leading to their growth and development. Hence, it can be claimed that hope is an important source of flexibility in life [84]. Bluvol [85] showed that hopeful thoughts caused stroke patients to feel that they had control over their lives, eventually causing them to value their lives positively.
The current study findings reveled a significant, reverse relationship between hope and adherence to treatment regimen, which is in agreement with the results of the study by Habte et al. [33] They reported hope as a barrier against adherence to antidiabetic drugs among some study participants. They also disclosed that disease perception, particularly weakness of symptoms, hope for curability of the disease, and limited complications, resulted in non-adherence to treatment regimen [33]. In contrast, Treadaway et al. [86] conducted a study on patients with multiple sclerosis and demonstrated that non-adherence to treatment regimen was more probable among depressed patients and those with low hope levels. Hopeful individuals normally have a deeper insight into their disease, have a positive perception of medications, and believe that medications can improve their health, which can eventually foster their health-promotion behaviors [87]. Although in the present study the severity of symptoms was not examined, but it seems that the relationship of strictness of symptoms and adherence to treatment regimen should be scrutinized in future investigations.
The present study results revealed a direct relationship between spiritual health and hope. This might be attributed to the fact that individuals with higher hope levels have higher transcendental attitudes due to their spirituality. Hence, they may think that their disease will be treated by relying on God and no treatment and adherence will be needed.
The current study findings indicated a significant reverse relationship between life satisfaction and adherence to treatment regimen. Review of the literature revealed no similar studies on diabetic patients. In the study by Grao-Cruces [88], the young adults who adhered to Mediterranean diets had healthier lifestyles and higher life satisfaction levels. The difference among the results might be attributed to variations in disease type. Additionally, higher life satisfaction among the individuals who did not adhere to treatment regimens might result from their lower encounter with problems and difficulties associated with obligatory adherence to regimens, including food restrictions. Yet, further investigations in this field are warranted.
One of the limitations of this study was employing the convenience sampling method and selecting the samples from a single city, which restricted the generalizability of the results. Thus, further studies are recommended to be carried out in various cities using random sampling method. One other study limitation was that the data were collected through self-report within a particular time period. Thus, determining the causal relationships between the variables was not possible. Hence, future longitudinal and interventional studies are recommended to be conducted on the issue.
One of the limitations of the present research was that all variables associated with adherence to treatment regimen were not assessed. Future studies are suggested to investigate various dimensions of adherence to treatment regimen.
Conclusion
In the present study, most of the participants had moderate spiritual well-being, high hope status, and low adherence to treatment regimen. The results indicated that spiritual well-being was directly associated with the overall health status, hope, and life satisfaction and reversely related to adherence to treatment regimen. Indeed, hope had a direct relationship with monthly income level, overall health status, and life satisfaction and a reverse relationship with adherence to treatment regimen. Besides, a significant positive relationship was found between adherence to treatment regimen and education level. A significant reverse relationship was also observed between life satisfaction and adherence to treatment regimen. Considering the fact that spiritual well-being and hope were reversely associated with adherence to treatment regimen, further studies should be done in this field. Also patients’ image of God and their interpretations of being sick might not be appropriate and need correction. The patients should also be notified that although spiritual measures can lead to better diabetes control, they should not substitute the major treatments.
Acknowledgments
The authors would like to express their sincerest gratitude towards Shiraz University of Medical Sciences for financially supporting the research (grant No. 95-1-08-13909). They would also like to appreciate the deans of the diabetes clinics in Shiraz and all patients who cooperated in the study. Thanks also go to Ms. A. Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interests.
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Sorur Javanmardifard, Email: soror.javanmardi@yahoo.com.
Shiva Heidari, Email: communityhn@gmail.com.
Mahnaz Sanjari, Email: mahnaz.sanjari@gmail.com.
Mohammad Yazdanmehr, Email: yazdanmehr.my@gmail.com.
Fatemeh Shirazi, Email: shirazi_1393@yahoo.com.
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