Introduction
Multiple sclerosis (MS) is one of the most common debilitating diseases and demyelinating disorders of the central nervous system (Andreoli et al. 2001). In this chronic autoimmune disease, inflammation leads to damage to the protective tissue around the nerves in the brain and spinal cord. In areas of the brain and spinal cord affected by MS, signals transmitted through the nerves are slowed or blocked, causing neurological symptoms that can lead to reduced quality of life and disability. Symptoms of MS include fatigue, blurred vision and pain in the eyes (optic neuritis), weakness or changes in sensation in parts of the body such as the face, arms, or legs, dizziness, trouble with balance, impaired memory or thinking, and problems with bladder control. Also, patients with MS are at increased risk of depression and anxiety (Marcus 2022). The incidence of MS is increasing worldwide along with the social and economic effects of this disease (Dobson and Giovannoni 2019). A total of 2.8 million people worldwide live with MS (35.9 per 100,000) (Walton et al. 2020). The prevalence of MS in the United States is estimated at 900,000 people (Marcus 2022) and in the Iranian population it is about 15-30 per 100,000 people (Masoudi et al. 2008). Women are at 2 times higher risk of developing this disease than men (Stuifbergen et al. 2006). The common age of occurrence of the disease is 20-35 years; therefore, the peak incidence of MS coincides with personal and professional responsibilities and dealing with situations such as family formation, career development, and financial security (Bishop et al. 2007).
People living with MS experience a lower quality of life due to various physical and psychosocial symptoms (Ali et al. 2019). This disease not only affects the functioning of the sensory and motor system, but it can cause many psychological symptoms such as depression and anxiety, chronic fatigue, suicide, self-harm, anxiety, and irritability in affected people (Henry et al. 2019). Psychological factors and physical symptoms are often related to each other and affect the progression and outcome of the disease (Ghafoori et al. 2020). For this reason, people suffering from this disease need to be able to cope with the challenges of their chronic disease (Bassi et al. 2021). Coping with MS refers to cognitive and behavioral efforts to manage stress caused by the disease (Young et al. 2022). Coping with chronic diseases depends on the effectiveness of coping, which moderates the process of coping with MS (Lode et al. 2009). The unpredictability of the course of the disease, the variety of symptoms, the lack of treatment, the limited access to medical treatment, and the unclear future effects on the physical health of the person can affect the coping with disease (Pourhosein 2020). These patients cannot find a way to solve their problems and improve their quality of life and maintain their physical and mental health (Allahbakhshian et al. 2011). It seems that the clinical features of MS, including the clinical stage of the disease, have an effect on the person’s coping with disease. Studies have shown that people with newly diagnosed MS use coping strategies less than the general population (Lode et al. 2009, 2010). Ožura and Šega (2013) reported that people with MS have less capacity to cope with daily needs than healthy people, and compared to normal people, they have less mental and emotional abilities to plan and solve problems and daily stress. Also, in the study of McCabe and Di Battista (2004), lower levels of coping were reported in people with MS compared to the general population. Coping with disease is known to be an important mediator for psychological well-being in chronic diseases (Goretti et al. 2010). Studies have shown that ineffective coping with disease can cause MS relapse (Mohr et al. 2002; Warren et al. 1991). Therefore, it is possible that the use of effective coping strategies can moderate the frequency of disease recurrence. Also, coping can act as a moderator of MS symptoms, including depression, cognitive dysfunction, and fatigue (Keramat Kar et al. 2019).
There are various psychological and social factors related to coping with disease in patients with MS. One of these factors is spiritual well-being. Spiritual well-being, as one of the dimensions of health, causes the integration of its other dimensions, and it includes two dimensions: existential and religious. Religious health refers to the satisfaction resulting from communication with a higher power, and existential health refers to the effort to understand the meaning and purpose in life (Riley et al. 1998). Debilitating and chronic diseases confront a person with questions about meaning and purpose in life. Many patients recognize spiritual well-being as a factor that creates meaning and purpose in life and promotes purpose in life (Mauk and Scnemidt 2004). Since religion and spirituality create a framework to understand the incompatibility and mental disorders created during the disease, the patient can better manage the complications caused by the disease (Giovagnoli et al. 2019). Recent studies have shown that spirituality is an important factor in the lives of people with MS (Camic and Knight 2004; Shaygannejad and Mohamadirizi 2020; Nsamenang et al. 2016). The results of McNulty’s study showed that spiritual well-being has a significant effect on coping with MS disease (McNulty et al. 2004). Since spiritual well-being is effective in various dimensions of chronic diseases, and considering that coping with disease in MS is very important and plays a decisive role in improving the quality of life of these patients, this study was conducted with the aim of determining the association between spiritual well-being and coping with disease in MS patients.
Material and methods
The current research is a cross-sectional analytical study that was conducted from April to December 2022 with convenience sampling and the participation of 201 MS patients of members of the MS Society of Jahrom and Fasa cities (south of Iran). The inclusion criteria included being over 18 years old, having the disease for at least 6 months according to a neurologist, and being willing to participate in the research. Patients with psychological disorders and other chronic diseases were excluded from the study. In order to collect data, three questionnaires were used: a demographic and disease-related information questionnaire, the spiritual well-being questionnaire of Paloutzian-Ellison, and the questionnaire of coping with MS disease by Dehghani et al.
Dehghani et al.’s (2017) coping with MS questionnaire has 35 questions and 5 dimensions of self-efficacy (17 questions), self-regulation (6 questions), acceptance of the current situation (6 questions), seeking treatment and compliance (4 questions) and emotional stability (2 questions). In all dimensions, the coping levels are divided into three categories of low, medium, and high coping. The validity and reliability of this questionnaire were confirmed by Dehghani et al. in 2017. The validity of this questionnaire has been determined using face, content, and construct validity (exploratory factor analysis). The content validity index (CVI) and content validity ratio (CVR) of the questionnaire were calculated as 0.95 and 0.91, respectively. Reliability was also calculated and confirmed by 20 MS patients using Cronbach’s α, and its rate was 0.95 in this questionnaire (Dehghani et al. 2017).
The Spiritual Well-Being Scale (SWBS) was designed by Paloutzian and Ellison (1982). This questionnaire has 20 items that have two subscales. Its ten items measure existential health and ten items measure religious health. The dimension of religious health concerns how people perceive health in their spiritual life when they are connected to a higher power; and the existential health dimension concerns how people adapt to themselves, society, or the environment. The subscales of religious and existential health are not graded, and judging is based on the obtained score. The score of spiritual health is the sum of these two subscales, and its range is 20-120. The answers to the statements are categorized on a Likert scale from one (completely disagree) to six (completely agree). A higher score is a sign of higher religious and existential health. The total scores obtained are categorized as follows: low spiritual well-being (20-40), moderate spiritual well-being (41-99), high spiritual well-being (100-120). Paloutzian and Ellison reported Cronbach’s α coefficient of religious health and existential health and a total score of 0.91, 0.91, 0.93, respectively (Masoumy et al. 2016; Jahromi et al. 2022). Abbasi et al. (2004), after Persian translation and determining the content and structure validity of the questionnaire, reported its reliability through Cronbach’s α coefficient of 0.82.
Statistical analysis
SPSS version 21 software and descriptive (frequency and percentage/mean and standard deviation) and inferential (Spearman correlation coefficient) tests were used for data analysis.
Ethical considerations
This study was approved by the Ethics Committee of Jahrom University of Medical Sciences with the ethics code IR.JUMS.REC.1396.133. All participants signed the written consent form and ensured the confidentiality of the information. The researcher provided information related to the subject of the study, and then the questionnaires were completed by the patients. If the patient was unable to complete the questionnaire, the researcher read the questions to him and their answers were accurately recorded.
Results
In this study, 201 MS patients with an average age of 33.46 ±9.74 were examined. 31.8% of patients were male and 67.7% were female. 29.9% of the patients had less than a diploma, 28.9% had a diploma, and the rest had a higher education (Table 1).
The findings showed that the majority of patients had a moderate level of spiritual well-being (49.2%), 48.8% of patients had a high level of spiritual well-being, and 2% of patients had a low level of spiritual well-being. The level of coping of patients with the disease was high in the majority of people (60.2%), 31.3% of patients had moderate coping with their disease, and 8.5% of patients had low coping with the disease (Table 2).
In this study, 58.2% of women had a high level of spiritual well-being, while 41.5% of men had high levels of spiritual well-being, and the majority had a moderate level of spiritual well-being (52.3%). Married patients had a higher level of spiritual well-being, so that 61% of married patients and 38% of single patients had a high level of spiritual well-being. Regarding the level of education, 60% of patients with a diploma, 55.1% of patients with a higher diploma, and 48.3% of sub-diploma patients had a high level of spiritual well-being. Also, the findings showed a significant positive correlation between the age of patients and spiritual well-being. No correlation was found between the history of disease experience and spiritual well-being.
Also, the majority of the women (59.5%) had a high level of coping with disease, while only 32% of the men had a high level of coping. Married patients had higher coping with disease, so that 70.3% of married patients and 50% of single patients had high coping with disease. Regarding the level of education, 59% of the patients with a diploma, 67.2% of the patients with a higher diploma, and 53.3% of the sub-diploma patients had high coping with disease. No correlation was found between the age of the patients and coping with disease. Also, no correlation was found between the history of disease experience and coping with disease.
The results of Spearman’s statistical test revealed a significant positive correlation between spiritual well-being and coping with disease in MS patients (p = 0.001, r = 0.641). This means that with an increase in the level of spiritual well-being, the level of coping with disease also increases in MS patients (Table 3).
Discussion
This study aimed to determine the association between spiritual well-being and coping with disease in MS patients. The results revealed a significant positive relationship between spiritual well-being and coping with disease in MS patients. In other words, people with better spiritual well-being are likely to be more able to cope with disease. In line with these results, the study of Kütmeç Yılmaz and Kara (2021) showed that coping with chronic diseases is directly related to a higher level of spiritual well-being. Also, several studies have examined the effect of spiritual well-being on treatment adherence and healthy lifestyle behaviors and reported that spiritual well-being affects self-evaluation and self-efficacy, which is a component of coping with disease (Yılmaz and Çolak 2018; Alvarez et al. 2016). In addition, Najafi et al.’s study (2022) showed that spiritual well-being has a significant effect on coping with disease and recovery, and mental health indicators are strongly dependent on spiritual well-being. Zarei et al. (2015) studied MS patients and identified a significant correlation between spiritual well-being and self-management of the participants. In explaining this finding, it can be suggested that spirituality provides people with a sense of meaning, purpose, and hope in dealing with problems. When people are faced with a chronic illness such as MS, they may experience feelings related to spirituality, such as questions about the meaning of their lives and the purpose of their suffering (Gultekin et al. 2019; Fry 2003). Spirituality can provide a framework for understanding these questions and ultimately a sense of comfort. In other words, beliefs and spirituality can help people to maintain a connection with purpose and meaning in the face of diseases and problems in their lives, reduce negative emotions, and gain hope and motivation. This spirituality as a source of motivation and morale enhancement can be effective in improving coping with chronic diseases. In addition, strong foundations of spirituality may promote the strengthening of psychological resilience and give individuals a better ability to find meaning even in the midst of physical and emotional challenges (Burkhardt 1989). In general, the findings of the present study and other studies presented show that the use of religious and spiritual resources in order to cope with disease is common in patients with MS and life-threatening diseases. People with MS can deal with the symptoms of depression, anxiety, and physical complications and even the side effects of the drugs consumed in their body by turning to worship and communication with God Almighty (Sharif and Ong 2019). Therefore, this study suggests that high spiritual well-being helps the patient cope with disease and people with strong spirituality are more successful in managing chronic disease.
In this study, most of the patients were found to have a moderate level of spirituality. In this regard, the studies of Najafi et al. (2022) and Shaygannejad and Mohamadirizi (2020) showed that the level of spirituality of patients with MS is at a moderate to high level. However, Ariapooran et al. (2020) in their comparative study found that spiritual well-being and its components (religious well-being and existential well-being) were lower in patients with MS than healthy people. One possible reason for the differences in the results of these studies is the difference in sample size: in the study of Najafi et al., the sample size was larger than in Ariapooran’s study. The level of spirituality in this study can be used as an effective coping strategy and act as a protective shield against diseases caused by stress and even treatment complications in these patients (Larsen 2012). From another point of view, the high level of spirituality might due to the fact that in the region where the study was conducted, the majority of the population are religious and shape their lives based on religious values and face their diseases with a fateful attitude (Puchalski 2001).
In this study, the level of coping of patients with disease was high in the majority of people. In line with the present results, Nasiry Zarrin Ghabaee et al. (2021) found that the coping of patients with chronic disease was higher than the mean. Also, Karatepe et al.’s study (2020) showed that coping with disease was at a high level. However, Yılmaz and Çolak (2018) found that 72.6% of patients with chronic disease over 65 years of age did not adhere to drug treatment. In addition, Mosleh and Darawad (2015) reported that most patients with coronary artery disease did not adopt healthy behaviors and the level of coping with disease was not good. A potential reason for the difference between the results of these studies and the results of the present study may be related to several variables that affect coping with disease in people. Such variables may include the different types of diseases, their complications, and different needs, which may cause the level of coping with disease to vary among different people (Tanyi 2002).
In this study, spiritual well-being was found to depend on several factors, and the study showed that women had a higher level of spiritual well-being compared to men. In line with these results, several studies have found that women have higher spiritual well-being than men (Rassoulian et al. 2021; Oláh and Koronczai 2021). Theories to explain these differences have focused on biological, social, or general personality differences between women and men (Reid-Arndt et al. 2011). The results of this study showed that married patients had a higher level of spiritual well-being, which is in line with the results of several other studies (Safa and Moradi 2020; Dronkolaei 2016). Having a life partner can help a person in facing mental and emotional challenges. Increasing the spiritual support of couples to each other can lead to a deeper connection with the life partner, and this connection can help to strengthen the spiritual aspects of life. The results of the study showed that most patients with a diploma level of education had a high level of spiritual well-being, which is in line with other studies (Kütmeç Yılmaz and Kara 2021; Asgari et al. 2022; Hasanshahi and Mazaheri 2016). In explaining this finding, it can be speculated that people with a higher level of education may be better able to access various spiritual resources. These sources can include spiritual books, religious centers, and spiritual groups that help in meditation on spiritual issues (Zarei et al. 2015). Also, the findings included a significant positive correlation between the age of patients and spiritual well-being, and as the age of patients increases, spiritual well-being also increases. The results of some studies have been different. One study on patients with high blood pressure showed that spiritual well-being decreased with increasing age (Duru Aşiret and Okatan 2019). Two other studies found that there was no significant relationship between age and spiritual well-being (Aktürk and Aktürk 2020; Torabi et al. 2017). In explaining this finding, it can be suggested that over time, people gain many experiences in their lives. These experiences may include positive and negative experiences, facing challenges and life changes, and experiencing important spiritual events that have an impact on their spiritual well-being (Toivonen et al. 2018).
The results showed that there is higher coping with disease in women than in men. A possible explanation is that men and women have important biological differences. For example, women’s hormones and immune system may work differently, and this can affect coping with diseases (Oertelt-Prigione 2012). The study showed that married patients had a higher level of coping with disease. This suggests that marriage may help improve patients’ coping and interaction in the face of illness. This is probably due to having additional support from the spouse and family, or due to providing more social and emotional support from the spouse. Marriage can lead to the improvement of mental and physical coping of patients (Revenson 2003). In this study, it was observed that with the increase in education level, the patient’s coping with disease also increased. Similarly, other studies have shown that a higher level of education was associated with greater coping (Kütmeç Yılmaz and Kara 2021; Karatepe et al. 2020). An increase in the level of education may lead to greater awareness of health and diseases and allow people to effectively manage the problems they experience during illness and treatment (Gultekin 2019).
Study limitations
This study was conducted only on a limited group of patients with MS in two cities of Iran, and information is not available about the spiritual well-being status and coping with disease of MS patients in other cities. Research with larger and more diverse samples is suggested. Also, this study was conducted in a country with a rich history of religious beliefs, and in order to generalize the results, more research is needed in other countries.
Conclusions
In this study, a significant positive relationship between spiritual well-being and coping with disease in patients with MS was observed. People who had better spiritual well-being seem to have greater ability to cope with disease and establish a more effective adaptation to it. These results point to the importance of paying attention to the spiritual aspects of health and coping in the management of chronic diseases. To better understand the association between spirituality and coping with disease, qualitative research is suggested. Also, conducting intervention studies with the aim of promoting spiritual well-being and assessing the level of coping with disease can be effective in determining the relationship between these two variables.
Availability of data and material
Data are not and will not be made available elsewhere. A data set could be obtained on request if required through the corresponding author via email: ali.dehghani2000@gmail.com.
Acknowledgements
We gratefully thank all MS patients who participated in this research.
Disclosures
This study was funded by the Jahrom University of Medical Sciences in Iran.
The study was approved by the Bioethics Committee of the Jahrom University of Medical Sciences (Approval No. IR.JUMS.REC.1396.133).
The authors declare no conflict of interest.
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