Factors related to spiritual health in Chinese haemodialysis patients: A multicentre cross‐sectional study

Abstract Aim This study aimed to investigate the current situation of the spiritual health of maintenance haemodialysis (MHD) patients in China and analyse the influencing factors. Methods A total of 418 patients who underwent maintenance haemodialysis in three grade A tertiary hospitals were selected. The influencing factors were evaluated with demographic questionnaire, the Functional Assessment of Chronic Illness Therapy‐Spiritual Well‐Being (FACIT‐Sp‐12), Family APGAR Index, Herth Hope Index (HHI) and Acceptance of Illness Scale (AIS). Results Spiritual health was positively correlated with the HHI, Family APGAR and AIS scores. Nationality, HHI score, Family APGAR score and AIS score were independent influencing factors of spiritual health. MHD patients had a moderate level of spiritual health. Nationality, hope, family function and acceptance of illness were significant predictors of spiritual health. Patients who have higher hope levels, better family functioning and better illness acceptance may maintain better spiritual health.


| BACKG ROU N D
With the progress of medicine, the connotation of health has been gradually enriched to include not only physical health, mental health and social health but also spiritual health. Spiritual health is a subjective, abstract and complex concept. It is considered the ability to discover and understand one's basic purpose in life; learn to experience love, happiness, peace and contentment; and help oneself to achieve one's full potential when facing the problems and stress caused by disease (Dehbashi et al., 2015). Spiritual health enables people to have strong faith and hope to constantly transcend adversity and achieve their life goals. Spiritual health is the same for everyone; it does not apply only to religious people but is also related to each person's subjective will (Yang, Yen, & Chen, 2010). The WHO added spiritual health as an important part of health, pointing out that the overall health of patients in body, mind, society and spirit should be emphasized and improved (Dhar, Chaturvedi, & Nandan, 2011). Thus, spiritual health is increasingly valued by medical staff. Studies have found that spiritual health promotes health in all dimensions and positively affects quality of life (Hammermeister & Peterson, 2001;Wallace & Forman, 1998).
Spiritual health has become an important factor in predicting the quality of life of haemodialysis patients (Alshraifeen et al., 2020).
Haemodialysis treatment changes the daily life of patients by requiring a specific diet associated with fluid restrictions and low potassium intake; in addition, the arteriovenous fistula and haemodialysis catheter change the appearance of patients, which may affect their level of hope (Ottaviani et al., 2014). Higher spirituality scores have been found to be correlated with lower symptomatic pain, higher levels of hope, better mental health and greater satisfaction with life (Tanyi & Werner, 2008). Although relevant studies have been performed in other countries, the factors associated with spiritual health remain poorly understood in Chinese MHD patients. Little is known about how spiritual health affects the course of illness. Therefore, it is important to determine the factors influencing spiritual health and meet patients' spiritual needs to improve their spiritual health and quality of life. Due to differences in living environment and economic and social conditions, the present study aimed to highlight the factors of spiritual health in MHD patients from multiple haemodialysis centres in mainland China.

| Sample
This study was a multicentre cross-sectional survey and the sam-

| Data collection
Investigators were uniformly trained by the researchers. Before the investigation, patients were informed that the study was conducted under the principles of anonymity and confidentiality and the patients voluntarily signed the informed consent form. In addition, the researcher introduced the purpose and significance of the study to the patients. The questionnaires were distributed through the Questionnaire Star app, and the researchers instructed the patients to scan the QR code and complete the survey while undergoing MHD in the haemodialysis centre. For patients without smartphones, the researchers administered and collected the survey on the spot.

| Instruments
The demographic questionnaire was designed by the researcher according to the research objectives and collected information such as age, gender, nationality, marital status, education level, type of medical insurance and religious belief. The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12) consists of 3 dimensions (12 items) and uses a 5-point Likert scale ranging from 0-4 (from very inconsistent to very consistent) (Canada, Murphy, Fitchett, Peterman, & Schover, 2008). The total score ranges from 0-48, and the higher the score is, the better the patient's spiritual health is. A score <24 indicates a low level of spiritual health, 24-35 a medium level of spiritual health and ≥36 a high level of spiritual health. Cronbach's alpha coefficient in this study was 0.921.
The Family APGAR Index was designed by Smilkstein (1978) and is used to test individuals' satisfaction with their family functioning.
There are five items in this scale; the possible responses are "usually" (2 points), "sometimes" (1 point) and "almost never" (0 points).
The total score is between 0-10; 7-10 indicates a functional family, 4-6 indicates a moderately dysfunctional family, and 0-3 indicates a severely dysfunctional family. The retest reliability of the questionnaire is 0.80-0.83. The APGAR has been widely used in Chinese families and shows good reliability and validity (Lv, Zeng, Liu, Zhong, & Zhan, 1999). In this study, Cronbach's alpha coefficient for the Family APGAR Index was 0.943.
The Herth Hope Index (HHI) (Herth, 1992) includes 12 items and 3 dimensions: positive attitudes towards reality and the future (4 items), taking positive actions (4 items) and maintaining close relationships with others (4 items). The total score of the scale ranges from 12-48, with scores ranging from 12-23 indicating a low level of hope, 24-35 indicating a medium level and 36-48 indicating a high level. The higher the score of the patient is, the higher the level of hope is. Cronbach's alpha coefficient was 0.87 in this study.

The Acceptance of Illness Scale (AIS) was developed by
American scholar Felton, Revenson, & Hinrichsen (1984). This scale is used to measure the degree of acceptance of a disease in adult patients by taking patients with chronic diseases as the research object. The scale contains eight items that are scored using a 5-point Likert scale ranging from 1 ("strongly agree")-5 ("strongly disagree"). The total score is 8-40 points, and the higher the total score is, the better the patient can accept the discomfort brought on by the disease. A score below 20 indicates low acceptance of the disease, 20-30 moderate acceptance and above 30 high acceptance. Cronbach's alpha coefficient of the scale was 0.849 in this study.

| Study design
This multicentre cross-sectional study used convenience sampling and was conducted at the HD centres of three grade A tertiary hospitals in Sichuan Province, China. The questionnaire and data were kept confidential and used for this study only.

| Statistical methods
SPSS 24.0 software was used for data analysis. Measurement data were expressed as x̅ (SD); t tests and one-way analysis of variance (ANOVA) were used to test the differences in spiritual health scores of patients with different characteristics. The influencing factors of spiritual health were analysed by using multiple linear regression, where the variable medical expense payment was changed to a dummy variable. Pearson correlation analysis was used to investigate the correlation among the influencing factors. p < .05 was considered statistically significant.

| Ethical considerations
This study was approved by the Institutional Review Board and complied with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (Appendix S1). Participants were informed of the purpose and significance of the research and signed an informed consent form.

| RE SULTS
A total of 423 haemodialysis patients meeting the inclusion criteria were included in this study. After they gave informed consent and completed the questionnaire, 423 questionnaires were recovered, among which 418 were eligible for inclusion, for an effective rate of 98.8%. The demographic data of the patients were obtained, and the average age was 48.07 (SD 14.55) years.

| Spiritual health scores of MHD patients with different characteristics
The independent-samples t test and one-way ANOVA were used to test the differences in the spiritual health scores of MHD patients with different characteristics. The results showed that there were statistically significant differences in health scores among people in different ethnic groups, using different medical payment methods and with different religions, hope levels, Family APGAR scores and AIS scores (p < .05; Table 1).

| Spiritual health scores of the MHD patients
The total spiritual health score of the MHD patients was 30.16 (SD 10.74), and the scores for each dimension were as follows: peace (11.43 SD 3.78), meaning (9.92 SD 3.56) and faith (8.81 SD 3.42; Table 2).

| Multiple linear regression analysis of the spiritual health of the MHD patients
The variables with statistical significance in the difference test were taken as independent variables and the spiritual health scores as dependent variables, and multiple linear regression was carried out.
Among them, the multicategory discontinuous variables, such as the medical payment method, were converted into dummy variables and the assignment of independent variables is shown in Table 4. The results showed that the independent variables nationality, hope level, Family APGAR score and AIS score all positively predicted the spiritual health scores (p < .05; Table 5).

| D ISCUSS I ON
The results of this study showed that the total spiritual health score of the MHD patients was 30.16 (SD 10.74), indicating a moderate level of spiritual health; it was lower than the results of studies performed in other countries (Alradaydeh & Khalil, 2018  The results of this study showed that the hope level was an influencing factor of the spiritual health of haemodialysis patients and was positively correlated with spiritual health. The higher the hope level was, the better the spiritual health of the patients was, and the difference was statistically significant (p < .05), which is consistent with a previous study (Tavassoli, Darvishpour, Mansour-Ghanaei, & Atrkarroushan, 2019). Hope is a state associated with positive expectations, an important regulatory mechanism for chronic disease and a powerful multidimensional and underlying factor for recovery and effective adaptation. In other studies, it tends to be referred to as a factor that predicts the development of severe disease (Baljani, Kazemi, Amanpour, & Tizfahm, 2011). The changes in patients' daily lives caused by dialysis can easily cause them to lose hope. If dialysis patients have hope for the future, they will feel better about their quality of life in different respects and having an ideal life can also increase their sense of hope (Fouladi, Ebrahimi, Manshaei, Afshar, & Fouladi, 2014). Raising the level of hope is an effective way to improve the quality of life of patients with chronic diseases. The enhancement of hope can improve the spiritual health and quality of life of patients.
The results showed that family function was a positive predictor of the spiritual health of MHD patients, and the better the family function, the better the spiritual health. Family is the core of society and provides not only material support but also spiritual and emotional support. Studies have shown that good family support improves the spiritual health of patients (Spinale et al., 2008), which is consistent with our study. Family function plays a crucial role in the growth of individuals. If the family does not perform its basic functions in its operation, family members will have a variety of problems. It is believed that the level of family function is a reflection of a family's ability to meet the needs of its members and good family care can effectively relieve or alleviate the psychological symptoms of patients, which is helpful for the treatment of haemodialysis patients (Cicolini, Palma, Simonetta, & Di Nicola, 2012). However, with the prolongation of the course of the disease and time on dialysis of haemodialysis patients, family members will experience burnout; this may affect the degree of family care and even cause conflict or intensify conflicts between family members, cooling family relations (Çelik, Annagur, Yılmaz, Demir, & Kara, 2012

| Limitations
The limitation of this study is that only three hospitals in Sichuan Province were investigated, which may affect the representativeness of the samples, and the sample size needs to be expanded in the future to investigate the spiritual health of patients from different regions. In addition, qualitative research can be carried out to further understand the factors affecting patients' spiritual health to provide a reliable reference for spiritual health intervention and construct spiritual care models.

ACK N OWLED G EM ENTS
The authors would like to acknowledge the nurse team at the Hemodialysis Center in the First People's Hospital of Liangshan Yi Autonomous Prefecture and the Second People's Hospital of Liangshan Yi Autonomous Prefecture, for the assistance in collection of the questionnaires.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflict of interest.