| Abstract|| |
End-stage renal disease (ESRD) introduces physical, psychological, social, emotional, and spiritual challenges into patients’ lives. Spirituality has been found to contribute to improved health outcomes, mainly in the areas of quality of life (QoL) and well-being in especially in terminal, life-threatening, and chronic diseases. The current study was planned to assess the effect of Spiritual therapy in patient undergoing hemodialysis (HD). Post approval from Ethics Committee, the study was commenced at Dialysis Center, Bhaktivedanta Hospital and Research Institute and conducted for 12 weeks. Participants were divided into two groups (one with spiritual intervention and other being control). Spiritual chanting and listening to it was the intervention. The outcome was assessed by kidney diseases QoL (KDQoL), spiritual well-being [Functional assessment of chronic illness therapy (FACIT) Sp 12] score, certain components of ESRD targeted area, 36 item health survey, and laboratory and nutritional parameters. Statistical analysis was done using IBM SPSS Statistics version 20.0 at 5% significance. A total of 100 participants were included in study; males were outnumbered. KDQoL, ESRD targeted areas, components of 36-item health survey, and FACIT Sp 12 scores were significantly different on better side in interventional group at six weeks and 12 weeks. There was no significant difference in laboratory and nutritional parameters. The findings from this study contribute knowledge to increase our understanding of the influence of spirituality on the health outcomes and general well-being of patients with ESRD currently receiving HD treatment. The current study adds to the evidence in support of the use of spiritual therapy in chronic kidney disease patients on HD.
|How to cite this article:|
Dalal K, Sankhe A, Zope J. A Prospective, Controlled Study to Assess Effect of Spiritual Therapy in Patient Undergoing Hemodialysis at Bhaktivedanta Hospital. Saudi J Kidney Dis Transpl 2021;32:1570-6
|How to cite this URL:|
Dalal K, Sankhe A, Zope J. A Prospective, Controlled Study to Assess Effect of Spiritual Therapy in Patient Undergoing Hemodialysis at Bhaktivedanta Hospital. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Aug 15];32:1570-6. Available from: https://www.sjkdt.org/text.asp?2021/32/6/1570/352417
| Introduction|| |
Chronic kidney disease (CKD) is a type of kidney dysfunction where there is a gradual loss of optimal kidney function over a period of months or years. At initial stage, it does not show any symptoms but during the later stage, it can present with pedal edema, raised blood pressure, and deranged renal parameters. The management includes symptomatic treatment. With increasing life expectancy and prevalence of lifestyle diseases, US has seen a 30% increase in the prevalence of CKD in the last decade. Unfortunately, from India, there is no longitudinal study and limited data on the prevalence of CKD. CKD is an important public health problem with a tremendous burden and social-economic implications.
The technological and therapeutic advances in dialysis have contributed to the increase in chronic renal patient survival, without, however, providing quality of life (QoL). Those patients, who depend on advanced technology to survive, have limitations in their daily lives, and experience numerous biopsychosocial losses and changes that interfere with the quality of their lives, such as job loss, changes in body image, and diet and fluid restrictions.
Traditionally, spirituality refers to a religious process of re-formation which “aims to recover the original shape of man,” oriented at “the image of God” as exemplified by the founders and sacred texts of the religions of the world. In modern times the emphasis is on the subjective experience of a sacred dimension and the “deepest values and meanings by which people live” often in a context separate from organized religious institutions. Modern systems of spirituality may include a belief in a supernatural (beyond the known and observable) realm, personal growth, a quest for an ultimate or sacred meaning, religious experience, or an encounter with one’s own “inner dimension.”
Waaijman discerns four forms of spiritual practices:
1. Somatic practices, especially deprivation and diminishment. Deprivation aims to purify the body. Diminishment concerns the repulsement of ego-oriented impulses. Examples include fasting and poverty
2. Psychological practices, for example, meditation
3. Social practices. Examples include the practice of obedience and communal ownership
4. Spiritual. All practices aim at purifying ego-centeredness and direct the abilities at the divine reality.
Spiritual practices may include meditation, mindfulness and prayer, the contemplation of sacred texts, ethical development, and spiritual retreats in a convent. Love and/or compassion are often described as the mainstay of spiritual development.
Spirituality is an important contributor to health-related QOL (HRQL) for patients with life-limiting illnesses. Recent research highlights the importance of spirituality to patients with advanced CKD,,,, and has demonstrated that the existential domain of spirituality is an important determinant of their HRQL.,, The existential construct of spirituality involves the need for finding satisfactory answers to questions about the meaning of life, illness, and death; it may or may not involve a belief in a higher being or an organized religion.
Raga Chikitsa is defined as “the knowledge of how to use raga for the purposes of healing. It includes the proper use of the elements (basis of Raga Chikitsa) to balance the nature of the imbalance within human body. Raga Ranjani is believed to help in cure kidney diseases.
Most importantly, the literature has identified that there are substantial unmet spiritual needs in patients dying with advanced CKD. This area of research is still not much explored and with this backdrop, the current study was planned to assess the effect of Spiritual therapy in patient undergoing hemodialysis (HD).
| Materials and Methods|| |
Approval from in-house Institutional Ethics Committee was taken before the initiation of study. All the potential participants were explained about the study and were enrolled only after their voluntary written informed consent.
This was a pilot study including a total of 100 participants (50 participants in each group) conducted at Dialysis Centre, Bhaktivedanta Hospital and Research Institute, Thane, Maharashtra. The study was conducted over a period of 12 weeks.
1. Patient of either gender with the age ranging from 18 years to 75 years
2. Patient undergoing HD (for any stage of CKD), at least twice a week at Bhaktivedanta Hospital.
1. Patients are not willing to participate in the study.
Group A [Spiritual (Test) Group] - 50 participants received spiritual care along with routine standard medicinal therapy including HD.
Group B: (Control Group - 50 participants received only routine medical treatment including HD.
Intervention allocation was done to test group first i.e. all 50 eligible participants were allotted to group with spiritual intervention. Following completion of first group allotment, 50 more eligible participants were enrolled in the control group.
Listening to spiritual chanting for a period of total 90 min (recorded audio) for every HD seating during 12-week period which includes
1. Varah Kavacham
2. Sudarsham Ashtakam
4. Surya Mantras Aditya Hridaya Mantra
5. Hare Krishna Mahamantra
6. Raga Anandbhairavi’
7. Raga Ranjani which was found efficient in kidney diseases as mentioned in ancient literature.
Participants were given leaflet which contained meaning of all these mantras in acceptable language and requested participants to understand meaning of it.
Audio CD recording all mantra were given to the participants and asked them to hear it at least once a day for the study duration.
All the participants were screened and were evaluated for vital signs, nutritional status, and laboratory parameters at the screening. Group A was administered intervention while Group B was provided only with medical care including HD. All participants were provided with the diary card to be filled. All the participants were followed up at six weeks and 12 weeks for vital signs, nutritional status, and laboratory parameters. Diary cards were reviewed at follow-up visits.
1. Participants who shall hospitalize during study duration for any events
2. Participants who miss more than three consecutive dialysis therapy during the study duration
3. Participants who do comply to schedule for 90 min mantra meditation as per investigator’s discretion
1. Kidney Diseases QoL (KDQoL) − Pre therapy and posttherapy at six weeks and 12 week
2. Spiritual well-being score − Functional assessment of chronic illness therapy (FACIT)-Sp 12 Questionnaire Pretherapy and posttherapy at six weeks and 12 weeks
3. End-stage renal disease (ESRD) targeted area − Components of ESRD targeted area namely effect of kidney disease, cognitive function, sexual function, patient satisfaction, and kidney disease score pre therapy and posttherapy at six weeks and 12 weeks
4. 36-item health survey − Components of 36-item health survey namely physical functioning, role physical, general health, role emotional and energy fatigue pretherapy and posttherapy at six weeks and 12 weeks
5. Laboratory parameter - Complete blood count, serum creatinine, serum protein. Pretherapy and posttherapy at six weeks and 12 weeks
6. Nutritional parameter-Body mass index, skinfold thickness, arm circumference thigh circumference. Pretherapy and posttherapy at six weeks and 12 weeks
| Statistical Analysis|| |
Both descriptive and inferential statistics were used. Demographic data were presented in frequency and proportions. Quantitative data (Scores) were assessed for normality of distribution and was expressed as mean and standard deviation. The difference between KDQoL scores was compared using the Friedman test. FACIT-Sp 12 scores were compared using one way ANOVA test with Bonferroni’s post-test correction. All the statistical analysis was done at 5% significance using IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA).
| Results|| |
A total of 100 participants were enrolled in the study. They were divided into two groups. Group A (Spiritual group) and Group B (Control group) both had 50 participants each. In the present study male participants outnumbered females as shown in [Figure 1].
In Group A, four participants did not complete the study (3 - lost to follow-up, 1 −withdrawn). In contrast to this, all the participants completed the study in Group B. Both the groups were comparable at the baseline for all the laboratory and physical parameters as displayed in [Table 1].
Table 1. Characteristics of study participants.
SBP: Systolic blood pressure, DBP: Diastolic blood pressure, BMI: Body mass index.
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Kidney diseases quality of life
KDQoL V 1.3 was used for assessing the QOL scoring. The score of both groups (Group A and B) were comparable at baseline (P = 0.6). There were significant changes in the all components of KDQoL scoring of the spiritual intervention group at six weeks (P = 0.0001) as well as 12 weeks (P <0.0001) pointing toward the effectiveness of the spiritual CARE intervention as compared to control group.
End-stage renal disease targeted area
ESRD components such as the effect of kidney disease, cognitive function, sexual function, patient satisfaction, and kidney disease score were comparable across the intervention and control group at baseline. Significant changes in scores were observed at the end of 12 weeks of spiritual CARE intervention for the mentioned components.
36-item health survey
For certain components of 36-item health survey questionnaire namely physical functioning, role physical, general health, role emotional, and energy fatigue, scores were comparable at baseline. However, they were significantly different at six weeks (P <0.0001) and at 12 weeks (P <0.0001). This is suggestive of the effectiveness of the spiritual CARE intervention as compared to the control group.
Health score complete form
There was a significant increase in the complete health score of spiritual intervention group at six weeks (P <0.0001) along with at 12 weeks (P <0.0001). This point towards the beneficial effects of spiritual intervention as compared to the control group.
Functional assessment of chronic illness therapy-spiritual well-being (Sp12)
Spiritual well-being has emerged as an important aspect of health-related QoL (HRQoL) and the FACIT Spiritual Well-Being; the 12-item Spiritual Well-Being Scale (FACIT-Sp-12) is widely used measure of spiritual well-being. There was a significant difference in the FACIT-Sp 12 scores at six weeks (P <0.001) and at 12 weeks (P <0.001)] adding evidence to the effectiveness of spiriual intervention as compared to the control group.
Certain laboratory values such as complete blood count, serum creatinine, and serum protein values were comparable at pre-therapy recordings. These parameters did not change significantly over the time period (P >0.05).
Nutritional parameters such as weight, body mass index, skinfold thickness, arm, and thigh circumference were comparable at baseline between two groups. These parameters did not change significantly over 12 weeks in either groups (P >0.05).
| Discussion|| |
In the present study, male participants were more as compared to female participants. This is in contradiction to the findings of Goldberg and Krause which says the prevalence of CKD tends to be higher in women, whereas the disease in men is more severe. This difference can be attributed to the heterogeneity of the population pool from which the sample was drawn. Furthermore, a study with a single-center tends to provide skewed results.
We found that the compliance with the spiritual intervention was lesser as compared to the control group. This finding can be explained by the fact that compliance to the treatment is a multifactorial which includes the ability to deal with the disease state itself, family support, socio-economic status of family, and emigration.
In the current study, KDQoL and health scores changed significantly in spiritual CARE intervention group over the study duration. These results were in favor of the effectiveness of the spiritual intervention. These are comparable to the findings of Finkelstein et al wherein a strong correlation was seen between spirituality scores and various aspects of QoL. Thus, it generates additional evidence to support the effectiveness of spiritual therapy in patients undergoing HD for CRF.
In the present study, ESRD scores improved significantly in spiritual CARE intervention group over the study duration. This points towards the effectiveness of spiritual intervention. In the current scenario of increased cases of ESRD worldwide, this is a ray of hope for tackling ESRD more effectively.
Components of 36-item health survey questionnaire were found to be improving over time in the spiritual intervention group. This gives a better edge to spiritual intervention group as compared to the control group. These findings contribute knowledge to increase our understanding of the influence of spirituality on the health outcomes.
FACIT Sp 12 score was used by the investigator to evaluate the spiritual well-being of the participants in the study. Results points toward the effectiveness of spiritual therapy. FACIT Sp is the worldwide accepted and used brief metric for assessing spirituality. The subjective nature of its responses makes it bit difficult to evaluate actual outcome. However, FACIT Sp is being used and translated, and validated in various languages worldwide.
Laboratory parameters along with few nutritional parameters did not show any betterment along the study duration course. It will not be a wrong to interpret it as spirituality has nothing to do with physical parameters. However, it is more of a psychological component of well-being.
Raga Chikitsa is considered one of the better options for reducing stress in modern days of anxiety, tension, and high blood pressure. Within Raga Ragini Vidya, Ananda Bhairavi Raga is associated with control of blood pressure, reduction in stomach pain, and reduction in kidney problems. Furthermore, Raga Ranjani is believed to help in CKDs. Also, Sankhe et al observed that spiritual care therapy significant improvement of symptoms in anxiety and depression patients. Adding to the evidence of the effectiveness of the spiritual care therapy, improvement in the level of spiritual as well as general well-being was observed by Zwingmann et al in cancer patients and their primary caregivers.
Spirituality is a multidimensional concept incorporating different levels of meanings and experiences. It is an important domain of the QoL, especially in terminal, life-threatening, and chronic diseases. It has been recognized as an important aspect of human health. Thus, an increasingly worldwide research interest on this domain has been observed in the past decades.
| Limitations|| |
This is a single-center study. However, another multicenter study with larger sample size in view of more homogeneity of the population will produce better results.
| Conclusion|| |
There is growing research in the field of spiritual interventions along with medical care in the clinical settings. The findings from this study contribute knowledge to increase our understanding of the influence of spirituality on the health outcomes and general well-being of patients with ESRD currently receiving HD treatment. The current study adds to the evidence in support of the use of spiritual therapy in CKD patients on HD.
| Ethical approval|| |
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee at which the studies were conducted (IRB approval number EC/NEW/INST/2019/245) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Conflict of interest: None declared.
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Bhaktivedanta Hospital and Research Institute Srishti Complex, Thane, Maharashtra, India.
Source of Support: None, Conflict of Interest: None