Religion and Spiritual Health in Patients With and Without Depression Receiving Hemodialysis: A Cross-Sectional Correlational Study

ABSTRACT Background Hemodialysis is the most common therapy for managing patients with end-stage renal disease. Depression is one of the most common psychological problems faced by dialysis patients, and there is limited research on the influences of religion and spirituality on dialysis patients. Purpose This study was designed to compare religion and spiritual health status between hemodialysis patients with and without depressive symptoms. Methods A cross-sectional survey was conducted on 137 hemodialysis patients living in Taiwan. The self-report instruments used included the Religious Beliefs Scale, Spiritual Health Scale-Short Form, and Beck Depression Inventory-II. Data were analyzed using t test, chi-square test, point-biserial correlation of variance, and logistic regression. Results Most (63.5%) of the participants were classified with depression, of which most were male (70.1%), older (mean = 62.56 years), and unemployed (73.6%) and had less formal education. Fifty-two of the participants with depression had a 1- to 5-year duration of hemodialysis, whereas the nondepressed group had a higher mean score for number of religious activities, positive religious beliefs, and total score for spiritual health. Logistic regression showed an increased odds ratio (OR) of depression for participants with a duration of hemodialysis of 1–5 years (OR = 3.64, 95% CI [1.01, 13.15]). Participants with higher scores for spiritual health had a lower risk of depression (OR = 0.82, 95% CI [0.75, 0.90]), indicating a positive association between spiritual health and lower depression risk. Conclusions/Implications for Practice The prevalence rate of depression in hemodialysis patients is higher than that in the general population. Providing screenings for spiritual health and depression as part of routine medical care for hemodialysis patients is recommended to detect spiritual distress and depression early.


Introduction
Hemodialysis (HD) is the most common therapy for managing patients with end-stage renal disease (ESRD).Patients with ESRD are in the last stage of chronic kidney disease (CKD), which is the point when kidney functions have ceased.Unless a kidney is available for transplantation, patients with ESRD require regular long-term dialysis to survive.Regardless of the form of dialysis (HD or peritoneal dialysis), patients with ESRD have a lower health-related quality of life than the general population.Several variables contribute to a lower health-related quality of life in patients with ESRD, including decreased physical function and social activities; increased risk of psychological distress; and symptom distress such as frailty, restless legs, itching skin, and fatigue (Ng et al., 2021).Moreover, the lifelong dialysis treatments needed to sustain the life of patients with ESRD significantly affect their physical and mental functions (Fradelos et al., 2021).According to a recent report, Taiwan had the highest prevalence of dialysis (3,593 per million population) and the second-highest incidence of treated ESRD (525 per million population) in the world in 2020 (U. S. Renal Data System, 2022).
Depression is one of the most common psychological problems faced by dialysis patients, with a prevalence rate ranging from 22.8% to 39.3% (Ma & Li, 2016), which is higher than the 12.9% reported for the general population (Lim et al., 2018).Dialysis patients with depression have higher mortality and hospitalization rates than patients without (L.Chan et al., 2017).Antidepressants, psychotherapy, dietary supplements, acupressure, and exercise therapy have been shown to be associated with reduced depressive symptoms, although the effect size is limited (Wen et al., 2020).Therefore, further studies examining additional factors associated with depression among dialysis patients with CKD and ESRD are needed.
A significant association between religion/spirituality and health-related conditions in the population of patients with CKD has been shown (Bravin et al., 2019).For example, Santos et al. (2017) surveyed 161 patients with CKD and found positive religious and spiritual coping scores to be negatively correlated with scores for depression and an independent protective factor for depression.Ramirez et al. (2012) reported similar findings, showing negative religious coping as positively associated with depression in HD patients.In addition, spiritual well-being has been shown to be negatively correlated with depression in patients receiving HD (Alradaydeh & Khalil, 2018).However, the studies on religion/spirituality in patients with CKD and dialysis are limited, and the definition of spirituality has been inconsistent, with spirituality and religion often used interchangeably and related measures not sufficiently comprehensive (Jugjali et al., 2018;Pilger et al., 2016).In the integrative literature review of Pilger et al., several studies were described that measured the concept of spirituality by organized and nonorganized religious activities, religiosity, or religious coping.
Although spirituality and religion are often considered synonymous, they are conceptually distinct and not interchangeable.First, spirituality emphasizes the realization of unique personal values and the meaning of life, whereas religion focuses on a set of beliefs that helps settle one's spirit and mind and is linked to a system of worship and a structured organization (Hsiao et al., 2013).In addition, most measurement scales for spirituality include spiritual and religious subscales that include items focused on religiosity, which may not be applicable to those who are not religious (Hsiao et al., 2013).
To the best of our knowledge, the influence of religion and spirituality on depression has not been investigated in the same study.Therefore, in this study, religion and spirituality were investigated separately.For religion, three categories used to measure religiosity in previous studies were used (Chiang et al., 2020a;Koenig et al., 2012), including religious affiliation, religious activities, and religious beliefs.Religious affiliation assesses if an individual associates themselves with a specific religious faith such as Catholicism, Judaism, Muslim, or Buddhism.Religious activities are defined as attending public or private activities associated with a religion such as praying or reading religious texts.Religious beliefs refer to the perception that adhering to articles of faith associated with a religion is an important aspect of one's life.These three domains were used to offer a more comprehensive assessment of the concept of religion in this study.
Although previous studies have explored the associations between depression and religion/spirituality in patients receiving HD, their participants were from primarily from Western countries (Bravin et al., 2019;Loureiro et al., 2018).Eastern countries, including Taiwan, are grounded in cultures and belief systems that differ from Western countries, which largely draw on Judeo-Christian religious beliefs.Thus, there are gaps in the literature regarding religion/spirituality-related variables that may impact depression in patients on long-term HD in Taiwan.To fill this gap, differences in religion and spirituality between patients receiving HD in Taiwan with and without depression were explored and elucidated.
Guided by the prior literature, the aims of this study were to (a) examine religion using measures of religious affiliation, religious activities, and religious belief; (b) examine the total score and the five subscale scores of a spiritual health instrument; and (c) determine the significant sociodemographic, diseaserelated, religion-related, and spiritual-health-related variables.Our three hypotheses were as follows: (a) Variables for the three religion-related measures differ between the two groups; (b) variables of spiritual health (total score and subscale scores) differ between the two groups; and (c) sociodemographic, disease-related, religion-related, and spiritual-health-related variables are predictors of depression in patients receiving HD.

Study Design, Setting, and Participants
A cross-sectional correlational study was conducted on a convenience sample of patients with CKD at an HD clinic of a nephrology department in northern Taiwan.Data were collected from July to November 2020.The results were reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology checklist.The inclusion criteria were as follows: (a) over 20 years old, (b) receiving dialysis regularly for CKD for more than 3 months, (c) absence of a cognitive disorder and able to communicate verbally, and (d) voluntary participation.The exclusion criteria were as follows: (a) a diagnosis of psychosis or other psychiatric disorder and (b) use of an antidepressive medication.The sample size was estimated post hoc using G*Power Version 3.1.9.2.The statistical power for logistic regression analysis was > .80(.87), which indicated a sample size of 137 patients was appropriate.

Instruments
The data were collected using a sociodemographic and diseaserelated questionnaire, religion measurement, spiritual health measurement, and depressive tendency scale.All of the measurements had established acceptable validity and reliability for self-reported data.

Sociodemographic and disease-related questionnaire
The sociodemographic and disease-related information collected included age, gender, marital status, educational level, The Journal of Nursing Research job status, source of economic support, duration of HD, and number of chronic diseases.

Religion measurement
As described below, we used validated instruments to assess the following three aspects of Eastern religions considered components of "religion": religious affiliation, participation in religious activities, and religious beliefs.

Religious affiliation
Religious affiliation was established using the Religious Affiliation Scale of Chang and Lin (1992), which distinguishes between three religious affiliation categories: primary, secondary, and atheist.The populations of Taiwan and many other ethnically Chinese societies tend to be multireligious.Therefore, participants were not categorized by a specific religious following such as Catholicism, Judaism, Muslim, Taoism, or Buddhism.Instead, participants were asked to rank themselves by the level of the religions they practiced.The participants were given three choices: primary, which is described as having a belief in a higher spiritual power or god and a very clear perception of their religious affiliation and religious practice; secondary, which is described as having no firm religious affiliation but having a belief in a higher spiritual power or god and participating in some religious activities; and atheist, which is described as having no belief in a god or higher spiritual power and not participating in religious activities.

Religious activities
Religious activities were assessed using a five-item instrument originally developed by Chiang et al. (2020a) to evaluate the spiritual life of clinical nurses.Five items are used to assess level of involvement in various religious activities over the past 6 months, including participating in religion-related events, praying, reading the bible/religious texts, meditating on religious incantations, and seeking religious guidance to make decisions.The validity of this instrument was established using exploratory factor analysis with one extracted factor explaining 48.0% of the variance, and factor structure validity was verified using confirmatory factor analysis.A 4-point Likert scale was used for scoring, with scores ranging from 4 = often to 1 = never.The total possible score ranges from 5 to 20, with higher scores indicating greater participation in religious activities.The Cronbach's alpha of the scale was .87 in this study.

Religious beliefs
The 17-item Religious Beliefs Scale (RBS) developed by Chiang et al. (2017) was designed to measure positive and negative religious beliefs.The RBS has acceptable reliability and validity, has a Cronbach's alpha of .87,and is composed of four subscales.The first two, "religious effects" and "divine," are categorized as positive religious beliefs (with 12 items, e.g., "obtain support and assistance from religious groups," "believe that happiness and peace are gifts from god/higher power").The second two, "religious query" and "religious stress," are categorized as negative religious beliefs (with five items, e.g., "Sometimes, I feel God is unfair to me," "I worry about being punished by god if I do not comply with religious rules").Each subscale item is scored on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree.The Cronbach's alpha of the RBS was .81 in this study.

Spiritual health
Spiritual health was defined in this study as one's own inner forces and resources that allow their developing a unique meaning of the "self," which is reflected through their connections with themselves, others, and/or a higher being (Hsiao & Huang, 2005).The Spiritual Health Scale-Short Form developed by Hsiao et al. (2013) was used in this study to assess spiritual health.This instrument is composed of 24 items with the following five subscales: connection to others (four items), such as "I like to help solve problems for family members"; meaning derived from living (six items), such as "I think about how to have a more fulfilled life"; transcendence (six items), such as "I see setbacks as a type of challenge"; religious attachment (four items), such as "I hope to be blessed by God"; and self-understanding (four items), such as "I believe I am a person with value."Each item is scored on a 5-point Likert scale.Responses range from 1 = strongly disagree to 5 = strongly agree, and total scores range from 24 to 120, with higher scores indicating better spiritual health.In this study, the Cronbach's alpha of the Spiritual Health Scale-Short Form was .92.

Depressive tendency
The 21-item Beck Depression Inventory-II (Beck et al., 1996(Beck et al., / 2000) ) assesses depressive symptoms over the previous 2-week period.The Chinese version of the Beck Depression Inventory-II (C-BDI-II) translated by H. Y. Chen (2000) for use in Taiwanese populations was applied in this study.This 21-item self-report scale consists of questions aimed at measuring the presence and severity of depressive symptoms using a 4-point Likert scale with item scores ranging from 0 to 3. The total scores ranges from 0 to 63 points, with higher scores indicating greater depression severity.The total score may be used to distinguish among four different levels of depression: 0-13, no depression; 14-19, mild depression; 20-28, moderate depression; and 29-63, severe depression.In this study, participants with scores ≤ 13 were assigned to the nondepressed group, and those with scores > 13 were assigned to the depressed group.In this study, the Cronbach's alpha for the C-BDI-II was .71.

Data Collection Procedures
After providing informed consent, the participants completed the questionnaire during a clinic visit.If the patient was unable to complete the questionnaire in writing, a researcher asked each question orally and filled in the answers.All of the questionnaires were coded with a number to ensure data anonymity.

Ethical Considerations
This study was approved by the research ethics committee of the participating hospital (IRB No. 202000959B0).All of the eligible patients were provided with oral and written information by the first author about the study and procedures and were assured that participation was voluntary and that no impact on their care would result because of their decision to participate or not.Furthermore, they were assured they could withdraw from the study without consequence at any time and for any reason and that the anonymity of their data would be maintained.All of the collected questionnaires were stored in a locked box in the office of the principal investigator.

Data Analysis
The data were analyzed using SPSS 23.0 software (IBM Inc., Armonk, NY, USA).Descriptive statistics included mean and standard deviation (SD) for continuous variables and frequencies and percentages for categorical variables.With regard to inferential statistics, independent t tests and chi-square tests were used to compare sociodemographic and disease-related characteristics between the nondepressed and depressed groups.Independent t tests were used to compare differences between the groups, whereas point-biserial correlations (r pbi ) were employed to measure the relationship between groups on religious activities, positive and negative religious beliefs, and total and subscale scores for spiritual health.Logistic regression analysis was used to examine the relationship between depression and potential predictor variables.Significant predictors for risk of depression in the model were presented as odds ratios (ORs) to indicate the odds of depression compared with the odds of no depression.The potential predictors of depression were identified as variables that differed significantly between the two groups.Significance was set at p < .05.

Participant Characteristics
One hundred thirty-seven HD patients participated in the study.The mean age was 60.28 (SD = 13.83)years.Most were male (63.5%) and unemployed (65.7%) and had a primary or secondary religious affiliation (57.7% and 22.6%, respectively).Half (51.1%) of the participants had 7-12 years of formal education.The 37.5% who scored ≤ 13 on the C-BDI-II were assigned to the non-depressed group, and the 87 (63.5%) who scored > 13 were assigned to the depressed group.The participants in the depressed group were significantly older, less educated, and more likely to be male, unemployed, and atheist than their nondepressed peers.No significant difference in source of economic support or number of chronic diseases was found between the groups.More than half (59.8%) of the depressed group had been on dialysis for 1-5 years, compared with 32% for the nondepressed group.Details of the characteristics for all participants and for each group are shown in Table 1.

Between-Group Differences in Terms of Religion and Spiritual Health
Scores for religious activities and positive or negative religious beliefs as well as total and subscale scores for spiritual health for all of the participants and for the two groups are shown in Table 2. Mean scores for the nondepressed group were higher than those for the depressed group for religious activities (t = 3.42, p < .001),with scores positively correlated with nondepression status (r bpi = .28,p < .01).Positive religious beliefs were found to be higher in the nondepressed group than the depressed group (t = 4.14, p < .001)and positively correlated with nondepression (r bpi = .34,p < .001).Conversely, negative religious beliefs were found to be lower (t = −4.80,p < .001) in the nondepressed group and negatively correlated with nondepression (r bpi = −.38,p < .001).In addition, mean total scores for spiritual health (t = 9.17, p < .001)and the five subscale scores (t = 4.69-7.40,all ps < .001)were all higher in the nondepressed group and were all correlated positively with nondepression (all ps < .001).

Association Between Religion, Spiritual Health, and Depression
A logistic regression of the significant demographic, clinical characteristic, religion-related, and spiritual-health-related variables was used to identify the predictors of depression (Table 3).The model was significant (w 2 = 76.15,p < .001),providing evidence that all of the variables account for variance in depression, a moderate level of correlation (Nagelkerke R 2 = .58).The goodness-of-fit index based on the Lemeshow and Hosmer test (used for the logistic regression analysis) was 7.36 ( p > .05).Regression results showed risk of depression as higher for participants with 1-5 years of HD treatment than for those with treatment durations > 5 years (OR = 3.64, 95% CI [1.01, 13.15]).Religion-related variables were not found to correlate with depression.Risk of depression was shown to be lower in participants with higher spiritual health total scores (OR = 0.82, 95% CI [0.75, 0.90]).

Discussion
This was the first study designed to explore the association of the two spiritual dimensions of religion and spirituality in depressed and nondepressed HD patients.Religion-related (religious affiliation, religious activities, and positive and negative religious beliefs) and spirituality-related (total and subscale scores for spiritual health) variables differed between the nondepressed (scores on the C-BDI-II ≤ 13) and depressed (> 13 on the C-BDI-II) groups, supporting the first and second hypotheses.The third hypothesis was supported by logistic regression analysis, which found the shorter HD duration (1-5 years) to be associated with a greater risk of depression.In addition, risk of depression was shown to be lower in those with high total spiritual health scores.

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Sociodemographics, Disease-Related Characteristics, and Depression
On the basis of a cutoff score of ≤ 13 on the C-DBI-II, 63.5% of participants in this study were identified as depressed, which is higher than the reported 12.9% in the general population (Lim et al., 2018).This finding echoes Silva et al. (2014), who found a rate of depression of 68.2% among patients with ESRD receiving HD treatment.The psychological impact of HD stems from the need for long-term dialysis to prolong life, which affects patients' physical functions.Treatment needs coupled with diet and lifestyle restrictions make depression a common side effect experienced by patients on HD (J.Chen et al., 2021).
In terms of sociodemographic characteristics, participants in the depressed group were mostly male, were older and less educated, and had a higher rate of unemployment than their peers in the nondepressed group.Lower socioeconomic status may limit treatment resources and options, which may increase risk of depression.
The participants in the depressed group were more likely to have a duration of HD of 1-5 years than their nondepressed group peers.This may be explained by patients with ESRD receiving dialysis during the first 5 years experiencing psychological reactions that reflect the five stages of coming to terms with death and dying described by Elisabeth Kübler-Ross (2009).These stages include denial, anger, bargaining, depression, and acceptance.Patients who had received dialysis for > 5 years may already have reached the acceptance stage.In this study, 38% of the nondepressed group had received dialysis for > 5 years, whereas only 18.4% in the depressed group were in this category.

Religion and Depression
The nondepressed group had higher average scores in the following three domains of religion than the depressed group: religious affiliation (primary), number of religious activities, and positive religious beliefs.These findings are similar to previous studies on patients receiving dialysis (Al Zaben et al., 2015;Loureiro et al., 2018;Santos et al., 2017) and echo many previous studies that have shown religion to be significantly associated with health and well-being (Koenig et al., 2012).Our findings may be attributable to the increased social support an individual receives from their religious community when they feel part of a religious group and frequently participate in religious activities.
Most people in Asian societies, including Taiwan, hold to faiths other than Christianity.The 74% of participants in the nondepressed group who noted having a primary religious affiliation is similar to the general population of Taiwan (80%), with many affiliated with Chinese folk, Buddhist, and Taoist beliefs (Grim et al., 2018).Religious affiliation information was not collected in this study.The concepts of "Zhuy-in" (fatalism), "Ye" (karma), and "Inn-kuo" (cause and effect) are deeply rooted in Chinese belief systems, which wield greater effect on individuals when faced with death, a serious illness, or an adverse event (Liu, 2009;Yen, 2013).Therefore, the participants in the nondepressed group may feel they receive luck and peace from a god or gods, religious activities, and thanks/respect for a god or gods, which may prevent or alleviate depression.The higher number of participants with negative religious beliefs in the depressed group than the nondepressed group may be explained by the findings of Chiang et al. (2020a), who reported doubts about religion and stress/discomfort regarding religious rules as associated with adverse health outcomes in Taiwan.Patients with negative religious beliefs are also more likely to experience depression because of feelings that deeds performed in the past or in past lives are the cause of their disease (Lin et al., 2005).Negative religious beliefs have also been shown to be associated with increased risk of depression in women with breast cancer (Gall & Bilodeau, 2020) and with risk of depression and lower levels of happiness in the general population in the United States (Abu-Raiya et al., 2016).

Spiritual Health and Depression
Total scores and subscale scores for spiritual health were higher in the nondepressed group and positively associated with lack of depression in all of the participants, which is consistent with the results of a study by Sadeghifar and Mehrabian (2017) on patients receiving HD in Iran.The depression experience includes feelings of hopelessness, worthlessness, and guilt (Beck et al., 1996(Beck et al., /2000)).Spirituality can provide individuals with inner strength, resources, and coping strategies to help find unique meaning and value to adjust to CKD (Moura et al., 2020).The five subscales are measures of these values.All subscale scores were higher in the nondepressed group, which have also been associated with lower rates of depression in patients on HD (Tavassoli et al., 2019).In addition, an integrative literature review by Bravin et al. (2019) supports the findings of this study.They reported patients on HD with high levels of spirituality had fewer depressive symptoms.Therefore, providing patients with ESRD interventions to increase levels of spirituality during the lengthy period of HD may help alleviate depressive tendencies.

Predictors of Depression
The logistic regression model identified only two variables as significant predictors of depression: duration of HD of 1-5 years

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(vs. > 5 years) and the total spiritual health score.Understanding that the duration of dialysis is a predictor of depression suggests that appropriate support strategies to mitigate or alleviate depression should be provided as soon as dialysis begins to allow time to develop the coping skills necessary to control depression during the first 5 years of HD.In addition, future longitudinal studies should be conducted to better understand the long-term trend of depression among patients with ESRD during the process of dialysis.Participants with higher scores for spiritual health were found to have a lower risk of depression.Therefore, spiritual health was found to be a negative predictor of depression and may act as a protective factor against developing depression among patients receiving HD.Our findings suggest interventions to increase spirituality in patients with ESRD be developed to reduce depression during dialysis.Spiritual interventions have been shown to be effective in patients with cancer or who are terminally ill.A meta-analysis of 24 studies conducted by Bauereiß et al. (2018) showed spiritual-related interventions had significant moderating effects on meaning of life, quality of life, hope, and self-efficacy in patients with cancer.However, interventions should target the spiritual needs of patients with ESRD who receive HD, which may differ from those of patients with cancer.
In addition, because of the unique spiritual philosophy of East Asian societies, interventions for patients in Taiwan should integrate appropriate concepts of spirituality that consider Confucian-based interpersonal relationships, Taoist-based concepts on the dissolution of person and nature, and Buddhist-based denunciations of greed and attachment (C.L. W. Chan et al., 2006).An intervention for spiritual health was developed by Hsiao et al. (2013) to improve the spiritual competency of nursing students in Taiwan (Chiang et al., 2020b).That intervention aimed to improve spirituality as defined by Eastern cultures, which includes knowing oneself, establishing relationships with others, receiving support from faith, and finding the meaning and value of life by transcending adversity.This intervention may be modified for the needs of patients with ESRD undergoing HD with the goal of reducing depression.
Despite the strengths of our findings, this study was affected by three notable limitations.First, patients were recruited through convenience sampling, and therefore, the findings may not be generalizable to all patients receiving HD.Second, this was a cross-sectional study, which prevents the determination of any causality regarding the correlations detected among religion, spiritual health, and depression.Third, most of the participants in this study were older adults with relatively low levels of education, which may have impacted their overall understanding of the questions posed on the self-report instruments.Finally, although we did not note who completed the questionnaires on their own or with assistance, having participants  complete the questionnaire without assistance from the researcher may have increased the risk of inaccurate responses.

Conclusions
The results on patients from an Eastern culture receiving HD are consistent with findings from Western studies on the association between spirituality/religion and depression.Although the distribution of participants for several demographic and diseaserelated variables differed between the depressed and nondepressed groups, only duration of HD treatment was found to be a significant predictor of depression.Finally, although mean scores for religion and spiritual health were higher for nondepressed participants than their depressed peers, only spiritual health was shown to be a negative predictor of depression.On the basis of the results of the logistic regression analysis, we recommend depression screening be included in the regular clinical care regimen given to patients with ESRD immediately after the initiation of dialysis.Thus, psychological support may be provided early, which may lower the incidence of depression.The development of an intervention for improving spirituality in patients should also be considered to further investigate whether increasing spirituality can alleviate depression in HD patients.
Note.CI = confidence interval.a Reference.b The model w 2 indicates the comparison between the default model and the baseline model (with intercept only).c The Hosmer-Lemeshow goodnessof-fit index indicates p values are nonsignificant, confirming a good fit for the linear regression model(Agresti, 2007, pp.146-147).*p < .05. **p < .01. ***p < .001.

Table 1
Characteristics of All Participants and Differences Between Nondepressed and Depressed Groups (N = 137) Note.Religious affiliation = identified on the Religious Affiliation Scale.a A score ≤ 13 on the Chinese Beck Depression Inventory-II.b A score > 13 on the Chinese Beck Depression Inventory-II.c Divorced, widowed, or separated.*p < .05. **p < .01.

Table 2
Scale Scores for Religion and Spiritual Health: All Participants (N = 137) and Comparison Between Nondepressed and Depressed Participants

Table 3
Logistic Regression Analysis: Factors Associated With Depression