Health Science

Communication

Biosci. Biotech. Res. Comm. 9(4): 750-755 (2016)

Perceived stress and its relationship with spiritual

health in patients with diabetes in the city of

Urmia, Iran

Moradali Zareipour¹, Mehdi Abdolkarimi², Rohollah Valizadeh³, Hasan Mahmoodi

Zahra Khazir

, and Mousa Ghelichi Ghojogh

PhD student of HealthEducation andHealthPromotion, Health Center of Urmia, Urmia University, Urmia, Iran

PhD student of HealthEducation andHealthPromotion, Faculty of health, Shahid

SadoughiUniversityofMedical Sciences, Yazd, Iran

MSc student of Epidemiology, Student research committee, Urmia University of Medical Science, Urmia, Iran

PhD student of HealthEducation andHealthPromotion, Faculty of health, TabrizUniversityofMedical

Sciences, Tabriz, Iran

PhD student of HealthEducation andHealthPromotion, Faculty of health, Shahid

SadoughiUniversityofMedical Sciences, Yazd, Iran

Graduate of Epidemiology, Urmia University of Medical Science, Urmia, Iran. And Member of Young

Researchers Club and the elite Islamic Azad University Branch Zahedan, Iran

ABSTRACT

Psychological factors not only affect quality of life but also on the often determine the result of dealing with a

chronic illness can play an important role. According to the paradox results in the  eld of the relationship between

mental health and spiritual health and limited studies about perceived stress and its relationship with spiritual health

of patients with diabetes, the aim of this study was to investigate the relationship between perceived stress and

spiritual health of patients with diabetes in the city of Urmia. This cross-sectional study (descriptive - analytical)

conducted with 330 patients with type 2 diabetes in rural health centers by random cluster sampling. Perceived Stress

and spiritual health questionnaire was used to collect information. Data using descriptive statistics and independ-

ent t-test, ANOVA and Pearson correlation coef cient were analyzed in SPSS v.21 software. The results of this study

showed that the majority of the patients’ perceived stress (70.9%) were in low level and the perceived stress mean of

them were in the low level (7.6±24.22) too. In terms of the level of the spiritual health, all patients were in medium

750

ARTICLE INFORMATION:

*Corresponding Author: mghelichi2000@yahoo.com

Received 23

Sep, 2016

Accepted after revision 21

Dec, 2016

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2015: 3.48 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

Moradali Zareipour et al.

to high and mean score of spiritual health were in moderate level (95.6± 14.2) .There was statistically signi cant and

reverse relationship between perceived stress and spiritual health and its dimensions using Pearson correlation test

(p = 0.001, r =-0.48). According to the results of this present study, it is suggested to develop programs and approaches

to improve the spiritual health of patients with diabetes in order to improve their quality of life.

KEY WORDS: DIABETES, PERCEIVED STRESS, SPIRITUAL HEALTH

INTRODUCTION

According to the World Health Organization (WHO)

in 1947 Health is a state of complete physical, men-

tal and social well-being and not merely the absence

of disease or in rmity. (Butler, 1994) Mankind have

various dimensions such as cognitive, emotional,

social and spiritual, which lack of attention to each of

these dimensions leads to omission of important part

of human (Farahaninia, Abbasi, Givari, & Haghani,

2006). These dimensions interact with each other and

affect each other (Nejat, Montazeri, Holakouie Naieni,

Mohammad, & Majdzadeh, 2006). In most health mod-

els, spiritual health has been entered as one of the basic

dimensions (“Spiritual well-being.,”). Spiritual health is

an important dimension that strengthens the individual

adjustment and mental functioning and promotes other

dimensions of health (Mehrabiyan, 2016).

At the time of the occurrence of crises, spirituality is

a powerful resource that is a serious obstacle in front

of the psychological pressure and depression as well as

by encouraging individual to health behaviors, improves

overall health (“Promoting mental health.,”). Spiritual

health includes both religious and existence dimen-

sion, religious health is satisfaction caused by contact

with a superior power and existence health is trying to

understand the meaning and purpose of life. Chronic

and debilitating illnesses encounter person with ques-

tions about meaning and purpose of life (Jafari et al.,

2010).

Nowadays 347 million around the world are suffer-

ing from diabetes that 90% are type 2 (CORSER, 2010).

The prevalence of this disease in 1995, is estimated 4

% and it is anticipated to be 5.4% in the 2025 (Poro-

jan, Poanta, & Dumitrascu, 2012). According to World

Health Organization statistics, prevalence of diabetes

type 2 is 2% in Iran (World Health Organization-NCD

Country Pro les, 2011). On the other hand half of cases

of diabetes is unknown in the world and more than 5

million people in the world and 38 thousand die in Iran

are dying due to the complications of diabetes. Statistics

also show that the prevalence of diabetes is on the rise

in the world (Zimmet et al. 2014).

Psychological factor was considered as one of the

most important factors among more research in recent

years about the etiology, prognosis and treatment of

diabetes. One of the most important psychological fac-

tors affecting the occurrence of physical diseases such as

diabetes is stress, (Davadzah 2009). Psychological factors

not only affect quality of life but also often determine

the result of dealing with a chronic illness, especially in

diabetes care which is dependent on psycho-social fac-

tors to manage and achieve the proper control of this

disease (Kent et al., 2010).

Results of the study of Surwit and colleagues showed

that stress has a negative impact on health, particularly

in diabetics and can directly impair the control of dis-

ease by effect on diet, exercise and other self-learning

behaviors, so that life style and stress management is

accompanied with reduction in glycated hemoglobin

(glycosylated hemoglobin) (Surwit et al., 2002).

The results of another showed reverse signi cant

relationship between spiritual health and anxiety and

depression in cancer patients in the  nal stages of life

(McCoubrie & Davies, 2006).The  ndings of the study

of McMahon also showed the existence of a signi cant

relationship between spiritual health and anxiety in

cancer patients (McMahon, 2004). But con icting stud-

ies have also been reported for example a study in Eng-

land on about 250 patients showed that patients who

had much more powerful and higher status in terms of

spiritual beliefs within 9 months of continuous follow-

up after discharge from the heart and women, had worse

prognosis and status than other patients (Beery et al.

2002).

Therefore, despite the paradox results in the  eld

of the relationship between mental health or spiritual

health in the absence of a study on perceived stress and

its relation with the spiritual health in patients with dia-

betes, it seems to be important the identi cation of the

relationship between these two variables and should be

considered by care providers, policy makers, planners

and economists of our health system.In addition to the

comments raised about the spiritual health, it can be

related as a motivational factor on the adoption of effec-

tive health. The relationship between health behaviors

including control of stress with spiritual health can lead

to a more desirable quality of life in the elderly that

have a lot worth and more priority in clinical decisions

and health policies. This study aimed to examine the

perceived stress and its relationship with spiritual health

in patients with diabetes in the city of Urmia.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS PERCEIVED STRESS IN DIABETIC PATIENTS 751

Moradali Zareipour et al.

MATERIAL AND METHODS

This study was a cross-sectional study (descriptive – ana-

lytic) that 330 patients with type 2 diabetic of 10 rural

health centers were selected by cluster random sampling

method. Then, they were invited to interview and com-

plete a questionnaire. Before conducting research were

given enough explanation about subjects of study and

attracted their interest to participate in the study. After

signing a written consent of the research, questionnaires

completed using self-reporting method and questioner’s

guide, in the case of illiterate people questionnaires were

completed by health workers and through interview.

Questions related to demographic and blood sugar

and body mass index were registered from the  les

of the patient by health workers. Questionnaires were

completed in a step using self-reporting method. The

information collection tool in this study, apart from

demographic (age, sex, education level, economic sta-

tus, occupation, duration of diabetes, type of treatment

and smoking) and disease including two questionnaires

the perceived stress questionnaire and spiritual health

questionnaire.

Perceived stress was measured by questionnaire pro-

vided by Cohen et al in 1983. This tool is very suitable

to determine the level of recognition of your stress in

front of unpredictable and uncontrollable events of life

including 14 questions from 0 to 4 with Likert scale that

answers are classi ed as 0 (never), 1 (rarely), 2 (some-

times), 3 (more times) and 4 (all the time).

It should be noted in the case of positive questions

(4.5.6.7.9.10.13), scoring can be calculated reversely. In

total, the scope of scores is considered 0-56. Scores less

than 28 were included in the low perceived stress group

and equal or higher than 28 in the high perceived stress

group (17). As well as the spiritual health variable using

the scale of spiritual well-being provided by Ellison and

Paloutezain in 1983, was measured that includes 20 Lik-

ert 6 pointed questions from completely agree (score 6)

to completely disagree (score 1).

It is worth noting that scoring was reverse in the

phrase with the negative verb forms. This scale is

divided into two subscale, existence health and religious

health, which each one included 10 phrase and 10 to

60 score. The total score is the sum of these two groups

20 to 120 that is a form of low spiritual health (20-40),

medium (41-99) and high (100-120) (Wang, Snyder, &

Kaas, 2001).

In this study, the Cronbach’s Alpha for the perceived

stress questionnaire obtained 0.88 and for the spiritual

health obtained 0.80. Data analyzed using the SPSS v.

21. Biographical information and diseases using descrip-

tive statistics methods were evaluated. As well as analy-

sis of variance and the t-test and Pearson correlation

coef cient were used for the purpose of analysis (signi -

cance level p < 0.05).

RESULTS AND DISCUSSION

The results of this study showed that 69.1% and 30.9

were participated male and female, respectively and the

mean age, BMI, FBS and HbA1C of patients were 60.4

± 73.08, 28.4±5.7, 158.7±140 and 7.86±1.8, respec-

tively. The majority of patients in terms of the education

were illiterate (52.1%) and elementary (39.4 %), 66.1 %

housewives, 63.9 % with moderate economic status and

77.2% with overweight and obesity. Duration of diabe-

tes in the majority of patients (89.4%) was less than 10

years (table 1).

The majority of patients (70.9%) have reported their

perceived stress in low level and the mean perceived

stress in them was low (24.22 ±7.6) (table 2). As well

as the results of the study showed that there was a sig-

ni cant relationship (p = 0/003) between the perceived

stress of patients and the sex variable that the mean

perceived stress scores of females was higher than males.

The results showed that there was a signi cant relation-

ship (p = 0/005) between the perceived stress of patients

and the occupation variable so that the mean per-

ceived stress in housewife group was higher than other

groups.

On the other hand in the group of patients that the

duration of the disease was more than 10 years, the

mean score of perceived stress was higher than other

groups and there was a signi cant statistically differ-

ence between the mean scores of perceived stress and

duration of diabetes (p = 0.008). In the case of other

individual variables and disease, the results suggest that

there were no signi cant statistically relationship among

the mean scores of perceived stress and complications

arising from the disease (p = 0.841), smoking (p = 0.523),

level of education (p = 0.075) and marital status (p =

0.111) while there was a signi cant statistically relation-

ship between mean perceived stress and economic status

(p = 0/001) and type of treatment (p = 0.028).

In terms of the level of the spiritual health, all patients

were moderate to high and spiritual health score was in

moderate level (table 2). As well as there were a statisti-

cal signi cantly relationship among spiritual health and

variables in terms of sex (p = 0.045), duration of disease

(p = 0.008), type of treatment (p = 0.028), economic sta-

tus (p = 0.001) and occupation (p = 0.005) while this

relationship was not observed among spiritual health

and complications of disease (p = 0.122), smoking (p =

0.611), marital status (p = 0.111) and the level of educa-

tion (p = 0.075). According to Pearson correlation test,

there was a signi cant and reverse relationship between

752 PERCEIVED STRESS IN DIABETIC PATIENTS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Moradali Zareipour et al.

Table 1: Demographic and disease information of diabetic patients

Variable levels Frequency (%)

Sex Male

Female

(30.9)102

(69.1)228

Education level Illiterate

Elementary Diploma

Collegiate

1/52)172

(4/39)130

(6/7)25

( (9/0)3

Occupation rancher

self-employed

employee

housekeeper

others

(2/18)60

(10)33

(5/1)5

(1/66)218

(3/4)14

Marital status Single

Married

Divorced

Widow

(1/2)7

(9/83)277

(3/0)1

(6/13)45

Duration of diagnosed diabetes (year) Less than 2

5-2

9-6

More than 10

(17)56

(1/49)162

(3/23)77

(6/10)35

Economic status Low

Moderate

Good

(7/19)65

(9/63)211

(4/16)54

Treatment type Insulin

Pill

Food

Food and Pill

(2/11)37

(2/74)245

(3/7)24

Smoking Yes

(9/10)36

(8/88)293

BMI Less than 18.5

24.9-18.5

29.9-25

More than 30

(5/1)5

(2/21)70

(8/44)148

(4/32)107

Table 2: Frequency distribution of Spiritual health and perceived stress in diabetic patients

Factor level Range SD± Mean % Frequency

Perceived stress <28

28≤

Total

55-6 7.6±24.22

70.9

29.1

100

234

330

Spiritual health Moderate (99-41)

High (120-100)

Total

119-57 14.2±95.6 46.1

53.9

100

152

178

300

Table 3: Correlation between spiritual health and

perceived stress in patients with diabetes

Spiritual health dimensions Blood sugar

Existence health p=0/31 r=-0/07

Religious health p=0/35 r=-0/06

Spiritual health(Total) p=0/27 r=-0/07

perceived stress and its dimensions (religious and exist-

ence health) (table 3).

The results of this study showed that 70.9 % of the

patients had low perceived stress that implies symptoms

of mental health in patients with diabetes and only 29.1

%reported high perceived stress that based on the study

of wang and colleagues can be associated with problems

and the complexity of the issues related to the physical

condition of the patients and familial problems (Wang

et al., 2001).

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS PERCEIVED STRESS IN DIABETIC PATIENTS 753

Moradali Zareipour et al.

Unlike the study of Bastani (1) and Malek (Malek,

Poorafkary, Dadashzadeh, & Safaeeyan, 2008), there

was no signi cant relationship between perceived stress

and age in this study. There was a signi cant relation-

ship between the status of occupation and perceived

stress, as in housewife group perceived stress was higher

than employed group that is consistent with the study

of Shoja and colleagues. Considering that people with

speci c occupation involved in a string of job activities

and are associated with participation in different social

environments and various people more than those who

have not job. Occupation can affect their mental health

(SHOJA, 2013).

In this study, despite the lack of a meaningful rela-

tionship between education level and perceived stress,

mean perceived stress scores on patients with college

education was less than patients who had not diploma.

It represent that education can reduce perceived stress

and anxiety of people in personal affairs and social role

and  nally mental health by increasing the con dence,

as well as an increase in social communication. On the

other hand social and cultural limitations and as well as

the inability of individuals to use effective ways to deal

with stress factors in people with a lower education level,

can be main reason of the high stress that these results

are consistent with the results of other study (Bastani

et al. 2005; Habibi et al 2008; Harpham et al.2004) on

the other hand, in this study the mean perceived stress

scores in patients who have had speci c diet was sig-

ni cantly high compared with patients who have had

insulin and pills diet that it’s reason can be dif culty of

compliance of speci c diet and fear and stress resulting

from adherence to the diet.

Based on the results of this study, 53.9 % of patients

have reported their spiritual health in high levels, while

in the study of Bastani et al (2005) 43.9% of patients had

moderate spiritual health (Bastani et al., 2005). In this

study, similar to the results of Jadidi study (Jadidi, Fara-

haninia, Janmohammadi, & Haghani, 2011), there was

no a signi cant relationship between spiritual health

and age of the patients, while in other studies (Bastani

et al., 2005; Zarei et al. 2015) a signi cant and direct

relationship between spiritual health and age of the

patients were reported, so that whatever the age of the

patients is increased, the tendency towards spirituality

will be more. In our study, unlike the results of the study

of Bastani (Bastani et al., 2005), there was a signi cant

relationship between spiritual health and sex of patients.

There was a reverse relationship between perceived

stress and spiritual health dimensions in this study. In

other words, patients who had higher perceived stress,

had lower spiritual health and conversely patients who

had lower perceived stress, had higher spiritual health.

These results were consistent with the results of McCou-

brie & Davies, (2006). While Beery et al., (2002) showed

that patients who had higher and powerful status in

terms of spiritual beliefs, had worse prognosis than other

patients within 9 months of continuous follow-up after

discharge from the heart and women wards

CONCLUSION

Based on the  ndings of this study, perceived stress were

low in the patients with diabetes mellitus with higher

scores of spiritual health. So it is necessary to be paid

attention to the psychological and spiritual dimensions

of health in patients with diabetes in order to improve

the quality of care. It can be used in accordance with

the results of this study the importance of paying atten-

tion to the spiritual beliefs in life to deal with prob-

lems arising from chronic diseases. Care is beyond cure

and attention to the various dimensions of the human

being in the care of chronic disease seems quite impor-

tant. The dominant religious culture in Iranian society is

also facilitator to achieve the comprehensive approach

to care. According to the results of the present study,

it is suggested to compile programs and approaches in

order to promote the spiritual health and quality of life

in patients with diabetes.

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