Rev Cuid. 2024; 15(2): e2797

https://doi.org/10.15649/cuidarte.2797

RESEARCH ARTICLE

Religious/spiritual coping in people with chronic kidney disease: A cross-sectional study

Afrontamiento religioso/espiritual en personas con enfermedad renal crónica: un estudio transversal

Coping religioso/espiritual em pessoas com doença renal crônica: um estudo transversal

Universidade do Estado da Bahia. Senhor do Bonfim- BA. E-mail: jessicatinel@hotmail.com Jéssica Sena Tínel
Universidade Soberana. Petrolina-PE. E-mail: janacristovam@yahoo.com.br Correspondence Author Djenane Cristovam de Souza
Universidade do Estado da Bahia. Senhor do Bonfim-BA. E-mail: jrequiao@uneb.br Joice Requião Costa de Santana
Universidade do Estado da Bahia. Senhor do Bonfim-BA. E-mail: christiellealencar@yahoo.com.br Christielle Lidianne Alencar Marinho

Highlights

 

How to cite this article: Tinel, Jéssica Sena; Souza, Djenane Cristovam de; Santana, Joice Requião Costa de; Marinho, Christielle Lidianne Alencar. Religious/spiritual coping in people with chronic kidney disease: A cross-sectional study. Revista Cuidarte. 2024;15(2):e2797. https://doi.org/10.15649/cuidarte.2797

Received: July 2th 2022
Accepted: March 3rd 2024
Published: May 1th 2024

CreativeCommons 

E-ISSN: 2346-3414

Abstract

Introduction: Chronic kidney disease (CKD) is considered a public health problem due to its high morbidity and mortality rates. Objective: To assess religious/spiritual coping in people with chronic kidney disease as a strategy for coping with the disease. Materials and Methods: This quantitative exploratory research was conducted out in a hemodialysis clinic. The sample consisted of 100 people with chronic kidney disease, undergoing hemodialysis treatment. The study used a socioeconomic demographic questionnaire and the Religious/Spiritual Coping Scale. Results: Altogether, 100 people participated in the study, with a mean age of 55.6 years and predominantly male (58%). Among religious/spiritual coping variables (positive, negative, total), the mean value of total religious-spiritual coping was the highest. The means of positive and negative coping indicate that the former is more used. Patients whose religion was Candomblé had higher positive coping, whereas Evangelical patients had higher negative coping, and Spiritists had higher total coping. Discussion: Religious/spiritual coping in the study population was high, demonstrating its importance for coping with chronic kidney disease. Conclusion: The kidney patients who participated in this study were quite adept at using religious/spiritual coping expressively and positively, pointing out the importance of this practice in coping with kidney disease.

Key Words: Renal Insufficiency Chronic; Adaptation Psychological; Nursing.

Resumen

Introducción: La enfermedad renal crónica (ERC) se considera un problema de salud pública debido a sus altos índices de morbimortalidad. Objetivo: Evaluar el afrontamiento religioso/espiritual en personas con enfermedad renal crónica, como estrategia de afrontamiento de la enfermedad. Materiales y Métodos: Investigación exploratoria, con enfoque cuantitativo, realizada en una clínica de hemodiálisis. Los participantes fueron personas con enfermedad renal crónica, en tratamiento de hemodiálisis, siendo 100 participantes en total. Se utilizó un cuestionario demográfico socioeconómico y la Escala de Afrontamiento Religioso-Espiritual. Resultados: Participaron del estudio 100 personas, con una edad promedio de 55,6 años y predominantemente del sexo masculino (58%). Entre las variables de afrontamiento religioso-espiritual (positivas, negativas, totales), el valor medio del afrontamiento religioso-espiritual total fue el más alto. Entre los promedios de afrontamiento positivo y negativo, el primero parece ser el más utilizado. Los pacientes que tenían como religión el Candomblé mostraron un mayor afrontamiento positivo, el afrontamiento negativo fue mayor en los pacientes evangélicos y los espiritistas mostraron un afrontamiento total mayor. Discusión: El afrontamiento religioso-espiritual en la población estudiada fue alto, representando la importancia de esta práctica para el afrontamiento de la enfermedad renal crónica. Conclusión: Los pacientes renales que participaron en este estudio fueron muy hábiles en el uso del afrontamiento religioso-espiritual, de manera expresiva y positiva, señalando la importancia de esta práctica en el afrontamiento de la enfermedad renal.

Palabras Clave: Insuficiencia Renal Crónica; Adaptación Psicológica; Enfermería.

Resumo

Introdução: A doença renal crônica (DRC), é considerada um problema de saúde pública, devido às suas taxas elevadas de morbimortalidade. Objetivo: Avaliar o coping religioso/espiritual em pessoas com doença renal crônica, enquanto estratégia de enfrentamento da doença. Materiais e Métodos: Pesquisa exploratória, de abordagem quantitativa, realizado em uma clínica de hemodiálise. Os participantes foram pessoas com doença renal crônica, em tratamento hemodialítico, sendo 100 participantes no total. Foi utilizado um questionário socioeconômico demográfico e a Escala de Coping Religioso Espiritual. Resultados: Participaram do estudo 100 pessoas, com média de idade de 55,6 anos e predominantemente do sexo masculino (58%). Entre variáveis do coping religioso-espiritual (positivo, negativo, total) a média dos valores do Coping Religioso Espiritual Total foi o mais alto. Já entre as médias do coping positivo e negativo, o primeiro se mostra mais utilizado. Pacientes que tinham o candomblé como religião, apresentaram maior coping positivo, O coping negativo foi maior nos pacientes evangélicos e os espíritas apresentaram um coping total maior. Discussão: O coping religioso espiritual na população estudada foi elevado, representando a importância desta prática para o enfrentamento da doença renal crônica. Conclusão: Os pacientes renais que participaram desse estudo mostraram-se bastante adeptos ao uso do coping religioso espiritual, de forma expressiva e positiva, apontando a importância dessa prática frente ao enfrentamento da doença renal.

Palavras-Chave: Insuficiência Renal Crônica; Adaptação Psicológica; Enfermagem.

Introduction

Chronic kidney disease (CKD) is considered a public health problem due to its high morbidity and mortality rates1. It is characterized by various changes that result in a progressive decrease in kidney function and has several causes and risk factors, including diabetes, high blood pressure, and behavioral and lifestyle factors2.

The total number of patients on chronic dialysis in Brazil in July 2021 was estimated at 155,7813. Treatment is necessary to maintain these patients’ lives. However, it significantly affects their quality of life, the frequency of treatments, changes in routine, withdrawal from work activities, physical changes, and restrictions on water and food intake, which culminate in physical and emotional impacts1. All these factors can cause conflicts, including psychological ones, affecting spiritual skills, and interfering with coping with the disease4.

Hence, developing coping strategies is essential to carry on the treatment. Coping is a term that designates various cognitive and/or behavioral methods that individuals can use to face situations considered stressful5, with particular attention to those related to religiosity and/or spirituality6. American psychologist Kenneth Pargament was responsible for developing the theory on religious/spiritual coping (RSC), defined as the use of religiosity and/or spirituality to face moments of difficulty and stress in one's life7. It is essential to evaluate RSC, as these strategies can be crucial in the treatment and management of these patients and a great ally for health professionals who monitor them8.

Fear and anxiety arise when dealing with life-threatening situations, so the individual turns to a supreme being, according to their beliefs, hoping to improve their health status. The search for religiosity/spirituality increases when the person faces difficulties such as financial ones, loss of health, or loss of people, making them realize the brevity of life, which leads people to search for meaning in life and/or emotional support9.

The relationship between religious/spiritual coping and CKD has been extensively studied, and research shows that spirituality and/or religiosity provide the ability to better cope with pain and treatment, decrease depressive symptoms, and strengthen hope4,6. Spirituality is related to the sacred and/or divine, and may or may not extend to a religion10. Religiosity is related to traditions, celebrations, and knowledge of sacred books, which is a partial manifestation of spirituality1.

Health professionals who care for these patients should understand the importance of addressing these coping measures and offering adequate support as they go through the disease11. Nursing professionals are the ones who have the most contact with these patients, so they must be treated holistically, encouraging involvement with religiosity and spirituality to better accept their pathology, and reduce the appearance of complications, such as mental ilnesess12.

Thus, this study aimed to assess religious/spiritual coping in people with CKD.

 

Materials and Methods

This cross-sectional quantitative study was carried out in a hemodialysis clinic in a city in inland Bahia, Brazil. The study participants were CKD patients undergoing hemodialysis treatment. The eligibility criteria were patients diagnosed with CKD, over 18 years old, undergoing hemodialysis treatment for at least 6 months, able to communicate, and with no difficulty responding to the instruments. During the study period, there were 198 participants eligible to participate in the research. The number of participants was estimated based on the sample size calculation, considering a 95% significance level and a 5% margin of error, totaling 110 patients. However, data were collected from 100 patients through nonprobabilistic convenience sampling. The losses were due to social isolation because of the COVID-19 pandemic, which broke out during the study development.

Data were collected from July 2019 to February 2020. Patients were approached at the dialysis service, in a private location, to inform them about the research objectives and procedures and explain the informed consent form, which they signed.

The database was stored on Mendeley Data13. The questionnaires were typed into 2010 Microsoft Excel, with the coding variables to be analyzed. Data were processed on R 4.0.2 (statistical programming language software). Univariate analysis was performed to describe the profile of patients who participated in the study. Next, nonparametric statistical tests were applied to independent samples to verify whether there was significant evidence of association between the variables of interest.

The study used a socioeconomic and demographic questionnaire prepared by the authors with data on sex, age, marital status, number of children, education level, income, and religion. Data on coping were collected with the Religious/Spiritual Coping Scale.

The Religious/Spiritual Coping Scale was developed and validated in Brazil and aims to assess how individuals use religion/spirituality to deal with stressful situations. The instrument has 87 items, of which 66 are distributed across eight factors of the Positive Religious Spiritual Coping (PRSC) dimension, represented by P1, P2, P3, P4, P5, P6, P7, P8 (P1 – Transformation of self and/or of one’s life; P2 – Actions in search of spiritual help; P3 – Offering help to others; P4 – Positive attitude towards God; P5 – Personal search for spiritual growth; P6 – Actions in search of the institutional other; P7 – Personal search for spiritual knowledge; P8 – Distancing through God, religion, and/or spirituality). The other 21 items are distributed across four factors of the Negative Religious Spiritual Coping (NRSC) dimension, represented by N1, N2, N3, N4 (N1 – Negative reevaluation of God; N2 – Negative attitude towards God; N3 – Negative reevaluation of meaning; N4 – Dissatisfaction with the institutional other). The classification between positive and negative RSC strategies arises from the consequences they have for those who use them14.

The following parameters were used to analyze and interpret the RSC scores according to the participant’s use: none or negligible = 1.00 to 1.50; low = 1.51 to 2.50; average = 2.51 to 3.50; high = 3.51 to 4.50; very high = 4.51 to 5.00.

The data were transcribed into the 2013 Excel for Windows and then transferred to the Data Analysis and Statistical (STATA) software, version 14.0, to perform descriptive analyses and statistical inference, creating frequency tables and measures of position for sociodemographic data.

The positive, negative, and total coping variables were associated with religion and age. The Shapiro-Wilk test was used to check the normality of the variables. The ANOVA and Kruskal-Wallis tests were used for associations between coping variables and religion, and the Pearson Correlation and Spearman Correlation (rO) were used for the correlation between age and coping. The confidence interval was set at 95%, and p-values < 0.05 were set as significant.

This study followed the criteria according to Resolution no. 466/12 of the Brazilian National Health Council, which regulates human research, and was approved by the Research Ethics Committee of the State University of Bahia, according to evaluation report no. 3.374.401/2019.

 

Results

The study sample comprised 100 people, with a mean age of 55.60 years, predominantly males (58.00%). There was a prevalence of low income, as 79% received up to one minimum wage, and 50.00% were married.

They had been on hemodialysis treatment for a mean of 5.9 years. Most participants were Catholics (66.00%), followed by Evangelicals (24.00%) (Table 1).

 

Table 1. Sociodemographic characteristics of patients with chronic renal disease on hemodialysis – Senhor do Bonfim, BA, Brazil, 2020 (n = 100)

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The mean value of Total Religious Spiritual Coping (TRSC) was the highest (3.91) of its three variables (positive, negative, total). Also, PRSC was more used than NRSC, with a higher mean (3.06). Among the eight PRSC factors, P4 (Positive attitude towards God) had the highest mean (3.54) and factor P2 (Actions in search of spiritual help) had the lowest one (2.22). In NRSC, N2 (Negative attitude towards God) stood out with the highest mean (2.76), while N1 (Negative reevaluation of God) had the lowest mean (1.44) (Table 2).

 

Table 2. Assessment of positive, negative, and total religious/spiritual coping (RSC) and patients' positive and negative RSC factors – Senhor do Bonfim, 2020 (n = 100)

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Table 2. Assessment of positive, negative, and total religious/spiritual coping (RSC) and patients' positive and negative RSC factors – Senhor do Bonfim, 2020 (n = 100)

Mean ± SD Interquartile range
Positive RSC 3.06 ± 0.80 3.05 (2.75 - 3.40)
Negative RSC 1.82 ± 0.50 1.76 (1.49 - 2.00)
Total RSC 3.91 ± 0.46 4.00 (3.62 - 4.24)
RSC dimensions
P1 - Transformation of self and/or of one’s life 3.15 ± 0.70 3.25 (2.67 - 3.64)
P2 - Actions in search of spiritual help 2.22 ± 0.70 2.13 (1.75-2.50)
P3 - Offering help to others 3.25 ± 0.85 3.29 (2.86- 3.71)
P4 - Positive attitude towards God 3.54 ± 0.60 3.55 (3.27-3.91)
P5 - Personal search for spiritual growth 3.04 ± 0.90 3.00 (2.40- 3.80)
P6 - Actions in search of the institutional other 3.00 ± 0.80 2.90 (2.50-3.50)
P7 - Personal search for spiritual knowledge 2.43 ± 0.80 2.32 (1.80- 3.00)
P8 - Distancing through God, religion, and/or spirituality 3.49 ± 0.78 3.50 (3.00- 4.00)
N1 - Negative reevaluation of God 1.44 ± 0.54 1.25 (1.00-1.75)
N2 - Negative attitude towards God 2.76 ± 0.84 2.75 (2.25- 3.25)
N3 - Negative reevaluation of meaning 1.91 ± 0.85 1.80 (1.20- 2.30)
N4 - Dissatisfaction with the institutional other 1.51 ± 0.68 1.25 (1.00-1.75)

CI: confidence interval; SD: standard deviation

 

The results of the association between religions and PRSC, NRSC, and TRSC showed significant differences. Patients whose religion was Candomblé had higher PRSC (4.11), Evangelical ones had higher NRSC (2.04), and Spiritists had higher TRSC (Table 3). Moreover, significant correlations were found between age and NRSC and TRSC. Age was negatively correlated with NRSC (rO = -0.209) and positively correlated with TRSC (rO = +0.206) (Table 3).

 

Table 3. Association between coping and religion and correlation between coping and age of chronic kidney disease patients on hemodialysis – Senhor do Bonfim, BA, Brazil, 2020 (n = 100)

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Table 3. Association between coping and religion and correlation between coping and age of chronic kidney disease patients on hemodialysis – Senhor do Bonfim, BA, Brazil, 2020 (n = 100)

PRSC NRSC TRSC
Meanp-valueMeanp-valueMeanp-value
Religion 0.014* 0.011† 0.0072†
    Catholic 3.04 ± 0.51 1.75 ± 0.64 3.98 ± 0.54
    Evangelical 3.24 ± 0.56 2.04 ± 0.10 3.68 ± 0.92
    Spiritist 3.32 ± 0.00 1.19 ± 0.00 4.62 ± 0.00
    Candomblé 4.11 ± 0.00 2.00 ± 0.00 3.90 ± 0.00
    Others 2.65 ± 0.79 1.97 ± 0.21 3.80 ± 0.20
    No religion 2.32 ± 0.79 1.58 ± 0.14 4.28 ± 0.12
Age. rO 0.0237 0.81‡ -0.209 0.03§ 0.206 0.03§

*ANOVA †Kruskal-Wallis ‡Pearson Correlation §Spearman Correlation §Correlação de Spermam

PRSC: Positive Religious Spiritual Coping NRSC: Negative Religious Spiritual Coping TRSC: Total Religious Spiritual Coping

 

Discussion

The predominance of males among CKD patients is commonly found in both national and international research. Most participants in this study were Catholics, which corroborates similar research carried out in a renal replacement therapy unit in inland São Paulo to assess hemodialysis patients’ attitudes toward pain and their relationship with spirituality4. This may be related to the fact that the Catholic religion is the most prevalent in this country.

The mean age was 55.60 years, and there was a prevalence of low education level and income, which was equivalent to up to one minimum wage. Also, 50% were married. These data are in line with a Brazilian study that investigated the association between religiosity/spirituality and happiness in patients undergoing hemodialysis – they were predominantly middle-aged adults (57.8%) and had a low education level, as 60.90% only finished middle school10.

The study population had high RSC, indicating the importance of this practice for coping with kidney disease. Data from a Brazilian study that sought to demonstrate the relationship between RSC and hope in patients undergoing chemotherapy treatment showed that all patients in the study used RSC as a coping strategy15. The greater the use of RSC, the greater the beneficial effects on patients' lives, highlighting improvements in general health, greater vitality, and increased hope16. Quality of life and spiritual well-being are better developed in those who rely on religion/spirituality1.

When evaluated separately, PRSC was higher than NRSC, which shows that patients use more of the positive strategy. This data is consistent with a study carried out in Minas Gerais, which evaluated the spiritual well-being and RSC of patients on hemodialysis, showing that the PRSC had a high mean score (3.34) and was used more than the NRSC1. Greater use of NRSC is expected to be more linked to feelings such as spiritual distress17. A Brazilian study carried out in Fortaleza with patients with chronic obstructive pulmonary disease shows a significant relationship between NRSC and depressive symptoms10.

Using coping to deal with the disease helps reduce anxiety because the belief that God, a greater being, is in control of the situation, acting in times of illness, brings a sense of relief. It can also be used to ease these patients’ pain symptoms, as it brings a feeling of comfort. RSC is also associated with improved quality of life and reduced depression in hemodialysis patients16.

The influence of spirituality and beliefs provides support when facing daily changes brought on by the disease. Spirituality brings a greater feeling of inner strength18. Among the PRSC and NRSC factors, the greatest positive highlight was P4 (Positive attitude towards God), in which one has God as a foundation, seeks Him, makes supplications, and works together with Him; they try to positively reassess their condition through God14. The belief in a superior being, who can control the external events of their life, helps the individual feel safer and reduces the focus on their pathology and the limitations it can bring19.

Factor N1 (Negative reevaluation of God) stood out in NRSC, which occurs when the individual begins to question the existence or love of God and believes that God is punishing them for some personal reason14. As they face suffering, the individual may feel abandoned by God and/or stop believing in his existence, thus experiencing a negative spirituality/religiosity19. This negative feeling is very common at the beginning of treatment, during the process of accepting the diagnosis. This period can be marked by doubts regarding religiosity and the transfer of responsibility for the disease to God, who is seen as the one who caused it20.

Age had a significant relationship with coping. The older the person, the more religiosity and spirituality they used to cope with stress during treatment. Older people use these mechanisms as a strategy to deal with adversities, such as loneliness, distance from family members, and physiological changes resulting from aging. Hence, the refuge of religiosity/spirituality brings a feeling of security and protection21. Furthermore, the level of spirituality is lower in the younger group, which may interfere with the use of coping17.

Candomblé was the religion with the highest PRSC, whereas NRSC was higher in Evangelical patients. A Brazilian study with 129 participants that investigated the relationship between spiritual anguish and RSC use showed that non-Catholic patients had greater use of NRSC17.

When a person believes in something greater, divine, even in an afterlife, and that their illness is only part of the journey, they tend to have greater acceptance of the illness and deal better with suffering6. A study carried out in Jordan with 218 patients undergoing hemodialysis treatment showed that participants who made greater use of spirituality were less likely to develop depression and anxiety. They used religion as a mechanism, aiming to achieve well-being and have greater comfort and security22.

Various studies highlight that the multidisciplinary healthcare team, especially nursing, must know about the influence of spirituality/religiosity on patients' lives. It is necessary to know the patients' experiences regarding this aspect and how each one understands the concepts, and how they use it to cope with the pathology and its treatment. Professionals must encourage these practices, which can bring a feeling of support, establishing a greater bond between professionals and patients1-10.

This is a rather significant health topic, especially in nursing, as they are generally the professionals who have the most contact with these patients. Understanding the influence that RSC has on the lives of these patients is crucial, knowing their needs, not just focusing on one aspect of these individuals' lives, but seeing it holistically, giving due importance to the psychological and spiritual aspects as well. Thus, further studies should address this topic, investigating the importance of religion, spirituality, and RSC in these living conditions, and also considering a qualitative approach, which can complement the results with the patient's perception of the topic. The cross-sectional design stands out as a limitation of the study, as it addressed a single moment and a single hemodialysis center, which does not allow extrapolation of the results.

 

Conclusion

The kidney patients who participated in this study were quite adept at using RSC expressively and positively, pointing out the importance of this practice in coping with kidney disease. Age was positively correlated with PRSC and negatively correlated with NRSC. Candomblé was the religion with the highest PRSC, Spiritists had a higher TRSC, while NRSC was more used by Evangelical patients.

This topic has been increasingly studied, highlighting its importance in the face of various chronic pathologies, in which patients need numerous strategies to face their health conditions. Therefore, health professionals should know about this topic, its influence on better acceptance of chronic disease, and know how to approach it, helping patients to use it. Brazil is a quite religious country – hence, it is greatly important to study this topic. Further studies are needed to cover this subject, which can highlight the influence and impact that coping has on the lives of CKD patients and investigate health professionals’ experience on this subject.

Conflicts of interest: The authors declare that they have no conflicts of interest.

Financial support: This research did not receive any source of funding.

 

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Santos LDA, Martins PG, Santos TR, Ramalho MF, Leal GS, Pilger C. Religiosidade e enfrentamento religioso e espiritual de idosos participantes de um centro de convivência. Cienc Cuid Saúde. 2020;19;e45723. https://doi.org/10.4025/ciencuidsaude.v19i0.45723

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Referencias

Musa AS, Pevalin DJ, Al Khalaileh MAA. Spiritual well-being, depression, and stress among hemodialysis patients in Jordan. J Holist Nurs. 2018;36(4):354-65.http://dx.doi.org/10.1177/0898010117736686

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  15. Costa DT, Silva DMR, Cavalcanti IDL, Gomes ET, Vasconcelos JLA, Carvalho MVG. Coping religioso/espiritual e nível de esperança em pacientes com câncer em quimioterapia. Rev Bras Enferm. 2019;72(3):672-8. https://doi.org/10.1590/0034-7167-2018-0358

  16. Santos PR, Capote Jr JRFG, Filho JRMC, Ferreira TP, Filho JNGS, Oliveira SS. Religious coping methods predict depression and quality of life among endstage renal disease patients undergoing hemodialysis: a cross-sectional study. BMC Nephrol2017; 18(197):1-8. https://doi.org/10.1186/s12882-017-0619-1

  17. Silva GCN, Reis DC, Miranda TPS, Melo RNR, Coutinho MAP, Paschoal GS, et al. Religious/spiritual coping and spiritual distress in people with cancer. Rev Bras Enferm. 2019;72(6):1534-40. http://dx.doi.org/10.1590/0034-7167-2018-0585

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  19. Gomes MV, Xavier ASG, Carvalho ESS, Cordeiro RC, Ferreira SL, Morbeck AD. “Waiting for a miracle”: Spirituality/Religiosity in coping with sickle cell disease. Rev Bras Enferm. 2019;72(6):1554-61.https://doi.org/10.1590/0034-7167-2018-0635

  20. Kunz JA, Conde CR, Lemos TMR, Barros AES, Ferreira MLSM. A Religiosidade e Espiritualidade de Mulheres com Câncer de Mama Submetidas a Tratamento Cirúrgico. Revista Enfermagem Atual. [internet] 2018; 86(24). Disponível em: https://revistaenfermagematual.com.br/index.php/revista/article/view/80/9

  21. Santos LDA, Martins PG, Santos TR, Ramalho MF, Leal GS, Pilger C. Religiosidade e enfrentamento religioso e espiritual de idosos participantes de um centro de convivência. Cienc Cuid Saúde. 2020;19;e45723. https://doi.org/10.4025/ciencuidsaude.v19i0.45723

  22. Musa AS, Pevalin DJ, Al Khalaileh MAA. Spiritual well-being, depression, and stress among hemodialysis patients in Jordan. J Holist Nurs. 2018;36(4):354-65.http://dx.doi.org/10.1177/0898010117736686