Background
With the global outbreak of COVID-19 on January 12, 2020, and the highly contagious nature of this virus, the World Health Organization issued protocols for limiting community interactions worldwide [1]. While individuals of all ages are susceptible to COVID-19, The high incidence of infection in older people, the greater severity of the disease, and the increased mortality are significant challenges in implementing appropriate preventive measures and future strategies to protect against this disease in the geriatric population [2, 3]. According to the US Centers for Disease Control and Prevention, 31% of COVID-19 cases, 45% of hospitalizations, 53% of intensive care unit admissions, and 80% of COVID-19-related deaths in the United States occur in the elderly [4].
During the COVID-19 crisis, elderly people required various forms of assistance, including telephone and digital visits, with most of these services provided by family members [5], Park (2021) reported that long-term caregivers (> 1 year) had more negative somatic physical symptoms (headaches, body aches, and abdominal discomfort), worse mental health, and more significant fatigue than non-caregivers [6]. Family caregivers can only provide up to 80% of the required care to seniors with Multiple chronic conditions in the community, and they are also responsible for the majority of the costs and shoulder the related burden. This increased reliance on family caregivers has, in turn, heightened their care burden. The burden of care is a significant issue globally, with millions of individuals taking on caregiving responsibilities for their loved ones. The care burden encompasses various dimensions, including time-dependent, evolving, physical, social, and emotional aspects, making it a complex and highly individualized concept [7]. It often results from a negative imbalance between caregiving responsibilities and other obligations [8].
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In Iran, like in many other countries, this burden can have profound implications on caregivers’ physical, emotional, and financial well-being. By introducing the concept of spiritual health into the discourse, we aim to shed light on a potentially overlooked aspect that could provide additional support and resilience to caregivers. Statistics indicate that caregivers who report a strong sense of spiritual well-being often exhibit lower levels of stress, anxiety, and depression, highlighting the importance of addressing this dimension in caregiving research. The existing literature on caregiver burden focuses mainly on caregiving’s physical and emotional aspects. While these studies provide valuable insights, there is a noticeable gap in understanding the role of spiritual health in mitigating the burden of care. Further exploration is needed to investigate how spiritual well-being can influence the overall caregiving experience and contribute to the well-being of the caregiver and the care recipient. In Iranians’ religious and national culture, the elderly hold a revered position and are highly respected. Reflecting on this cultural perspective, the Prophet of Islam stated, that respecting older people of my community is the same as respecting me [9]. This cultural context is evident in the fact that 86.4% of elderly individuals in Iran, according to statistics from the welfare organization, live with their children and spouses [10]. However, when caregiving responsibilities increase, they can overshadow the multiple health dimensions of the older people’s family members, including physical, psychological, social, and spiritual aspects. Coping strategies, such as spiritual-religious approaches, are often employed to manage the challenges [11].
There are two dimensions to spiritual health: religious and existential. Religious health refers to how a person understands his or her spiritual well-being when connected to a higher power. Conversely, existential health centers on an individual’s capacity for adaptation to their being, the societal landscape, and the broader environment [12]. In the past, the significance of spirituality in effectively managing stress was often underestimated; however, recent years have seen increased attention from researchers [11, 13, 14]. It is important to note that the understanding of spirituality is influenced by culture and religion, and its implications may vary for different individuals [15]. The current research gap lies in the lack of comprehensive studies that assess the intersection of spiritual health and care burden in the Iranian caregiving landscape. While some research exists on the broader topic of spirituality and health, there is a need for targeted investigations that consider the unique cultural and religious factors that shape the Iranian perspective on caregiving. Understanding these nuances can provide valuable insights into how spiritual care practices can be effectively integrated into support systems for caregivers in Iran. To the best of our knowledge, no previous study has investigated the impact of religious-spiritual care training on the spiritual health and care burden of family caregivers of older people during the COVID-19 pandemic. Given the critical role of nurses as caregivers for family and elderly health along with their supportive function [16], it is essential to identify caregivers at risk during critical situations and address their spiritual needs as part of community-oriented care. The study aimed to examine the impact of religious spiritual care training on the spiritual health and caregiving burden of older family carers during the COVID-19 pandemic. By thoroughly exploring the relationship between spiritual health and the caregiving burden of older family carers, we aim to identify potential strategies and interventions that can improve the well-being of caregivers and the overall quality of care provided to care recipients in Iran.
Methods
Study design
This study utilized a randomized controlled field trial design. The choice of a field randomized controlled trial for this study provides a rigorous and systematic approach to evaluating the effectiveness of a spiritual health intervention on care burden among Iranian caregivers. This design ensures internal validity, generalizability, and ethical soundness, thereby strengthening the overall quality of the research findings.
Participants and data collection
Participants were selected from the home care department of the comprehensive rehabilitation service center for the elderly in Mohammadieh, Bushehr City (affiliated with the welfare organization), and four comprehensive urban health centers in Bushehr Port, specifically Kheybar, Quds, Meraj, and Shohada centers. The inclusion criteria encompass caring for elderly individuals who showed a degree of dependence in at least one of their six daily activities, as defined by Katz’s criteria for activities of daily living (ADL). Additionally, caregivers had to possess literacy skills (reading and writing), with at least six months having elapsed since the commencement of their caregiving responsibilities. Furthermore, inclusion criteria require a family relationship between caregivers and elderly individuals in their care, cohabitation with older people, and delivering at least 40 h of care per week. Caregivers had to be at least 18-year-old Shia Muslims. The exclusion criteria dictated that the caregivers be excluded from the study under certain conditions, including the death of either the caregiver or the elderly individual during the study, refusal to continue participation in the study, the presence of neurological and psychiatric diseases, or the use of neuropsychiatric drugs, self-reported drug or alcohol addiction, or prior involvement in a spiritual-religious educational program related to elderly care.
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Sample size
Based on the effect sizes observed in the studies by Hosseini et al. (2016) [17], Mahdavi et al. (2016) [18], and Moeini et al. (2012) [19], with a Type I error rate of 0.50 and a power of 80%, and using the G Power 3.1.9.2 software, the required sample size for the two-group test was approximately 80 individuals, with 40 participants in each group. Eligible elderly family caregivers were selected from available candidates and randomly assigned to either the test or control group (Fig. 1). Randomization was done using Random Allocation software and by a person who did not know the participants and did not know their characteristics.
Fig. 1
Consort diagram
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Instruments
The data collection instruments used in this study consisted of a demographic information form, along with the spiritual health questionnaire developed by Paloutzian and Ellison (1982) and the care burden questionnaire designed by Novak and Guest (1989).
Demographic information form
This form collected information about the caregiver, including age, number of children, family relationship to older people, level of education, occupation, income, and type of housing.
Spiritual health questionnaire (Paloutzian and Ellison, 1982)
The Spiritual Health Questionnaire, developed by Paloutzian and Ellison in 1982, is widely used to assess an individual’s spiritual well-being and beliefs. This questionnaire consists of 20 items that explore different aspects of spirituality, including beliefs, practices, values, and experiences. Participants are asked to respond to statements about spirituality on a six-point Likert scale, with responses to agree strongly or to disagree strongly. This questionnaire includes two subscales: (1) Religious well-being (10 items): This subscale assesses how an individual’s religious beliefs, values, and practices contribute to their overall well-being and sense of purpose. (2) Existential well-being (10 items): This subscale focuses on the individual’s sense of meaning, purpose, and connection to something greater than themselves, regardless of religious affiliation. Each subscale receives a score from 10 to 60. The spiritual health score is the sum of these two subscales and ranges from 20 to 120. In Iran, during the research conducted by Parvizi et al. (2000), the reliability of this questionnaire using Cronbach’s alpha coefficient was 0.82 [20]. In Hamdami et al.‘s research (2015), Cronbach’s alpha coefficient of the total spiritual health score was 0.79 [21].
Care burden questionnaire (Novak and Guest, 1989)
The Care Burden Questionnaire, developed by Novak and Guest in 1989, is a widely used instrument for assessing the burden experienced by caregivers who provide care to individuals with chronic illnesses or disabilities. Caregivers are asked to respond to a series of statements concerning caregiving burden on a Likert scale, with response options typically ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). The maximum score that can be attained on this questionnaire is 96, while the minimum score is 0. The questionnaire includes five sub-scales designed to capture a specific aspect of the burden. These include time demands, emotional stress, social isolation, financial strain, and conflicts with other responsibilities. In Iran, in the study of Abbasi et al. (2013), the Cronbach’s alpha coefficient of this questionnaire was 0.90, and its subscales ranged from 0.72 to 0.82 [22].
Procedures
Baseline test
Before the intervention, research sessions were initially scheduled to occur in person; however, the coronavirus pandemic rendered it impractical to conduct face-to-face training sessions. As a result, spiritual and religious training was carried out online without impacting b behavioral therapy (CBT) and stress management techniques. It was structured to address the emotional, social, and physical dimensions of caregiver burden while simultaneously fostering coping strategies and self-care practices. The intervention framework was informed by existing research on caregiver interventions, CBT, and stress management. Studies have shown the effectiveness of psychoeducational programs in reducing caregiver burden and enhancing well-being. The incorporation of CBT techniques aimed to help caregivers identify and reframe negative thought patterns, while stress management strategies were included to help caregivers better cope with stressors.
In the test group, the intervention took the form of spiritual care based on the model of Richards and Bergin, which was aligned with Islamic teachings. This model featured six key steps: First, caregivers were guided to pay attention to spiritual-cultural sensitivities. Second, they were trained to establish an open and secure spiritual relationship. Third, potential ethical challenges were addressed. Fourth, caregivers conducted a religious and spiritual assessment of clients. The fifth step involved defining suitable goals for spiritual therapy, and the final step focused on properly implementing spiritual interventions [23]. The educational sessions covered various dimensions of the care burden, including physical, mental, social, and financial elements, as well as facets of spiritual health, which included the religious dimension (about communication with a transcendent higher power) and the existential dimension (encompassing communication with oneself, creation, and all living beings). These educational sessions were delivered via pre-recorded video presentations developed by a specialist in geriatric nursing and religious education. Participants engaged in four virtual sessions offline, conducted through WhatsApp social messenger, with two sessions held per week. Each session involved the following activities: (1) Following up on the previous session’s topics; (2) providing feedback to participants; (3) summarizing and outlining previous topics to create a connection between the topics discussed; and (4) offering explanations and summaries related to the new session’s topic. One month after the end of the intervention, test and control group participants completed the Mental Health Questionnaire and the Carer’s Burden Questionnaire again. The control group continued with their daily lives as usual throughout the study. Upon its conclusion, the educational materials on spirituality and its various concepts, which had been shared via WhatsApp Messenger, were made available in alignment with the ethical principles that govern such research. The educational content for the sessions was developed by a multidisciplinary team consisting of a nurse psychiatrist, a gerontologist, and a Specialist in Quran and Hadith. The educational content was designed and compiled by the research team to improve practical skills, stress management, self-care, and communication, based on the model of Richards and Bergin and according to the teachings of Islam and the Shia religion. To ensure the accuracy and reliability of the content, the educational materials underwent a rigorous review process involving experts from diverse fields, including caregiving, psychology, and Quranic and Hadith sciences. Feedback from caregivers and pilot testing were also used to refine and validate the content before implementation. A pilot study was conducted to test the intervention’s feasibility, acceptability, and initial effectiveness. The pilot study involved a small group of caregivers who received the intervention, and their feedback was used to refine the program before full implementation. All contributors implementing the intervention received comprehensive training on the educational content and intervention protocols. These trainings were followed daily by viewing the participants’ WhatsApp to receive educational content and listening to audio files, making daily phone calls, and asking them questions over the phone to understand the content and express their questions. The intervention was implemented by a team of trained healthcare professionals, including a social gerontologist, a nursing gerontologist, and a medical-surgical nursing student with a master’s degree. They all had relevant qualifications and expertise in mental health and caregiving support. Potential challenges for implementers could include caregiver resistance, emotional distress, not receiving training materials on time, or difficulty engaging participants. The plan for dealing with such situations included regular monitoring of caregiver progress, open communication, and flexibility in the delivery of sessions. For participants who required more specialized training or support beyond the scope of the intervention, referrals were made through telephone communication with the training session facilitators. Response data from the instruments, such as the Care Burden Questionnaire and other assessment measures, were collected through self-report questionnaires and standardized rating scales administered by trained assessors. Caregivers were asked to respond based on their experiences before and after the intervention. To handle ambiguities in the response data, assessors were trained to clarify any uncertainties or ambiguities in the questions with caregivers. This involved providing clear explanations, and examples, and ensuring that caregivers understood the questions before responding. A specific post-intervention assessment time point was established to standardize the time after the intervention for all participants. This time point was determined based on the intervention duration and the optimal timeframe for assessing the intervention’s impact on caregiver burden based on past studies [24, 25]. Caregivers were scheduled for the post-intervention assessment at this standardized time point to ensure consistency across all participants.
Ethical considerations
This study originated from a master’s thesis in internal surgical nursing at the Faculty of Midwifery Nursing, Bushehr University of Medical Sciences, with an ethics code number of IR.BPUMS.REC.1399.042. It is also registered with the Clinical Trial Centre of Iran under IRCT20150529022466N16. The caregivers were furnished with comprehensive information about the study, encompassing its objective, methodology, potential hazards and advantages, confidentiality protocols, and their entitlement to withdraw from the study at any point. Informed consent was obtained from all participants before they participated in the study. Measures were taken to ensure the confidentiality of participants’ personal information and data collected during the study. Participants were assured that their responses would be anonymized, stored securely, and only accessed by authorized research staff.
Data analysis
Due to the peak of the Corona pandemic and the closing of universities in person, the possibility of consulting statistics professors and performing data analysis was delayed for eight months. The data collected during the study were analyzed using SPSS version 19 software. The Shapiro-Wilk test was used to check the distribution of the data. An independent t-test, or Mann-Whitney test, was used to compare quantitative demographic variables between two groups. A Chi-squared or Fisher’s exact test was used to compare qualitative demographic variables between groups. To test the hypotheses above, a paired t-test was employed to ascertain the mean of the primary variables in question, before and after the intervention in each group. An independent t-test was utilized to determine the mean of the variables between groups, and Cohen’s d was calculated as the effect size. Independent t-tests were conducted to compare the mean scores of the changes. The significance level was assumed to be less than 0.05 in all cases.
Findings
No statistically significant differences were detected between the groups in terms of demographic variables, suggesting group homogeneity (p > 0.05) (Tables 1 and 2). Regarding spiritual health, within the intervention group, the post-test average score for total spiritual health was significantly higher than the pre-test score (p = 0.007), in contrast within the control group, the post-test average score was considerably lower than the pre-test score (p = 0.003). No statistically significant differences were observed between the two groups in terms of mean posttest spiritual health scores (Table 3) still, changes in overall spiritual health increased in the intervention group and decreased in the control group, with statistically significant differences between the two groups (p = 0.002) (Table 4). The Cohen’s d effect size for the difference in spiritual health between the intervention and control groups was 0.415, indicating a moderate effect of the intervention (Table 3). Within-group analysis showed no statistically significant differences between pre-and post-test scores for total care burden in either group. Furthermore, no statistically significant differences between the two groups were observed in terms of average care burden scores (p < 0.05) (Table 5). Likewise, the average changes in care burden scores between the intervention and control groups showed no statistically significant differences (p < 0.05) (Table 6). The Cohen’s d effect size for the difference in caregiving burden between the intervention and control groups was 0.366, indicating a moderate effect of the intervention on caregiving burden, although not statistically significant (Table 5).
Table 1
Comparison of quantitative demographic variables between intervention and control groups
Variable | Intervention group | control group | t or Z* (P value) |
|---|---|---|---|
Mean ± SD | Mean ± SD | ||
Patient dependency score | 3.03 ± 1.91 | 3.08 ± 1.99 | -0.114(0.909) |
Caregiver age | 46.23 ± 8.45 | 46.23 ± 11.10 | 0.001(0.999) |
Duration of care per week/hour | 71.45 ± 29.24 | 71.45 ± 29.24 | -0.796(0.429) |
Number of children | 1.70 ± 1.49 | 2.03 ± 1.75 | -0.920*(0.357) |
Table 2
Comparison of the frequency of different levels of qualitative research variables between the intervention and control groups
Variable | Variable levels | group | X2 or fisher*(P value) | |
|---|---|---|---|---|
Intervention | control | |||
N (%) | N (%) | |||
Sex | Men | 11(27.5) | 8(20.0) | 0.621(0.600) |
Women | 29(72.5) | 32(80.0) | ||
Caregiver marital status | Single | 10(25.0) | 6(15.0) | 2.308*(0.274) |
Married | 29(72.5) | 34(85.0) | ||
Divorced | 1(2.5) | 0(0.0) | ||
Education | High school | 3(7.5) | 4(10.0) | 0.481*(0.999) |
Diploma | 17(42.5) | 16(40.0) | ||
Associate degree | 6(15.0) | 6(15.0) | ||
Bachelor’s degree | 8(20.0) | 7(17.5) | ||
Master’s degree and higher | 6(15.0) | 7(17.5) | ||
Caregiver employment status | Housewife | 15(37.5) | 11(27.5) | 7.471*(0.147) |
Employee | 16(40.0) | 14(35.0) | ||
Student | 0(0.0) | 2(5.0) | ||
Unemployed | 0(0.0) | 2(5.0) | ||
Retired | 2(5.0) | 7(17.5) | ||
Freelance job | 7(17.5) | 4(10.0) | ||
Caregiver-to-elderly ratio | Child | 31(77.5) | 22(55.0) | 4.951*(0.070) |
Spouse | 1(2.5) | 1(2.5) | ||
Others (bride, granddaughter, etc.) | 8(20.0) | 17(42.5) | ||
Family income | Less than 3 million tomans | 3(7.5) | 3(7.5) | 2.153*(0.575) |
Three million to four million nine hundred tomans | 7(17.5) | 6(15.0) | ||
Five million to six million nine hundred tomans | 13(32.5) | 19(47.5) | ||
Seven million and more | 17(42.5) | 12(30.0) | ||
Housing type | House | 22(55.0) | 27(67.5) | 1.317(0.359) |
Apartment house | 18(45.0) | 13(32.5) | ||
Homeownership | Private property | 36(90.0) | 36(90.0) | 0.001(1.000) |
Rental property | 4(10.0) | 4(10.0) | ||
Housing | Home for the elderly | 33(82.5) | 30(75.0) | 0.627(0.412) |
Caring home | 7(17.5) | 10(25.0) | ||
Financial independence of the elderly | Yes | 26(65.0) | 31(77.5) | 1.526(0.323) |
No | 14(35.0) | 9(22.5) | ||
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Table 3
Between-group and within-group comparisons of the spiritual health and its areas in the participants
Variable | Intervention group | Control group | Between-group comparison | |
|---|---|---|---|---|
Mean ± SD | Mean ± SD | t(P-value) | Cohen’s d | |
Existential health pretest score | 44.25 ± 11.66 | 44.33 ± 10.84 | -0.030(0.976) | 0.007 |
Existential health post-test score | 47.65 ± 9.77 | 43.95 ± 10.85 | 1.603(0.113) | 0.358 |
t(P-value) for within-group comparison | -3.440(0.001) | 2.733(0.009) | - | - |
Religious health pretest score | 51.48 ± 7.01 | 51.20 ± 5.91 | 0.190(0.850) | 0.043 |
religious health post-test score | 53.13 ± 4.93 | 51.10 ± 5.97 | 1.654(0.102) | 0.370 |
t(P-value) for within-group comparison | -1.790(0.081) | 0.892(0.378) | - | - |
Total spiritual health pre-test score | 95.73 ± 17.70 | 95.53 ± 15.46 | 0.114(0.909) | 0.012 |
Spiritual health post-test score | 100.78 ± 13.80 | 95.05 ± 15.43 | 1.749(0.084) | 0.415 |
t(P-value) for within-group comparison | -2.872(0.007) | 3.128(0.003) | - | - |
Table 4
Between-group comparison of the mean changes scores of the spiritual health and its area between the intervention and control groups
Variable | Intervention group | Control group | Between-group comparison | 95% CI for the mean difference |
|---|---|---|---|---|
Mean ± SD | Mean ± SD | T (P value) | ||
Existential health | 3.40 ± 6.25 | -0.38 ± 0.87 | 3.784(0.001) | 1.76;5.79 |
Religious health | 1.65 ± 5.83 | -0.10 ± 0.71 | 1.885(0.067) | -0.13; 3.63 |
Total spiritual health score | 5.05 ± 11.12 | -0.47 ± 0.96 | 3.130(0.002) | 2.01; 9.04 |
Table 5
Between-group and within-group comparison of care burden variable and its area
Variable | Intervention group | Control group | Between-group comparison | |
|---|---|---|---|---|
Mean ± SD | Mean ± SD | t(P-value) | Cohen’s d | |
Time-dependent care burden pretest score | 17.80 ± 5.10 | 19.23 ± 4.22 | -1.362(0.177) | 0.305 |
Time-dependent care burden post-test score | 18.35 ± 4.46 | 19.10 ± 4.28 | -0.767(0.446) | 0.171 |
t(P-value) for within-group comparison | -0.988(0.329) | 1.302(0.200) | - | - |
Developmental care burden pretest score | 11.08 ± 6.74 | 12.50 ± 5.63 | -1.026(0.308) | 0.228 |
Developmental care load post-test score | 11.05 ± 5.94 | 12.43 ± 5.49 | -1.075(0.286) | 0.241 |
t(P-value for within-group comparison | 0.046(0.964) | 0.902(0.372) | - | - |
Physical care load pre-test score | 8.63 ± 4.40 | 10.45 ± 4.72 | -1.788(0.078) | 0.398 |
Physical care load post-test score | 9.05 ± 4.03 | 10.50 ± 4.59 | -1.502(0.137) | 0.335 |
t(P-value) for within-group comparison | -1.054(0.298) | -0.628(0.534) | - | - |
Emotional care load pretest score | 8.63 ± 4.40 | 9.23 ± 3.73 | -1.855(0.067) | 0.147 |
Emotional care load post-test score | 9.05 ± 4.03 | 9.43 ± 3.86 | -1.889(0.063) | 0.096 |
t(P-value for within-group comparison | -0.404 (0.688) | -3.122(0.003) | - | - |
Social care burden pre-test score | 10.25 ± 5.42 | 12.23 ± 5.44 | -1.626(0.108) | 0.364 |
Social care load post-test score | 10.08 ± 5.40 | 12.33 ± 5.31 | -1.878(0.064) | 0.420 |
t(P-value) for within-group comparison | -0.404(0.678) | -1.433(0.160) | - | - |
The total score of the care burden pre-test | 55.58 ± 21.30 | 63.63 ± 20.35 | -1.728(0.088) | 0.386 |
The total score of the care burden post-test | 56.50 ± 19.69 | 63.78 ± 20.00 | -1.639(0.105) | 0.366 |
t(P-value) for within-group comparison | -0.571(0.571) | -0.684(0.497) | - | - |
Table 6
Comparison of the mean changes of the care burden variable and its aria between the intervention and control groups
Variable | Intervention group | Control group | Between-group comparison | 95% CI for the mean difference |
|---|---|---|---|---|
Mean | Mean | t (P value) | ||
Time-dependent care burden | 1.65 ± 5.83 | -0.10 ± 0.71 | 1.194(0.239) | -0.47; 1.82 |
Evolutionary care burden | 3.40 ± 6.25 | -0.38 ± 0.87 | 0.091(0.928) | -1.06; 1.16 |
Physical care load | 5.05 ± 11.12 | -0.47 ± 0.96 | 0.912(0.367) | -0.45; 1.20 |
Changes in emotional care burden | 0.38 ± 1.15 | 0.00 ± 0.00 | -0.133(0.895) | -0.81; 0.71 |
Social care burden | -0.03 ± 3.14 | 0.05 ± 0.45 | -0.630(0.532) | -1.16; 0.61 |
Total care burden | 0.05 ± 2.46 | 0.08 ± 0.57 | 0.474(0.638) | -2.53; 4.08 |
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Discussion
This study aimed to evaluate the impact of religious spiritual care training on the spiritual health and care burden experienced by elderly family caregivers in Bushehr during the COVID-19 pandemic. The findings of this study suggest that a religious and spiritual intervention approach can effectively promote existential health and overall spiritual well-being. However, it was observed that this approach did not yield a notable impact on religious health or care burden. The Scores for existential health and overall spiritual health increased in the intervention group after the training, while they decreased in the control group. The mean change in religious health scores between the two groups did not reach statistical significance. These findings are consistent with the study conducted by Sayyadi et al. (2018) [26], who also observed an increase in spiritual health following a religious psychotherapy intervention. In this study, most family caregivers in the experimental and control groups initially demonstrated moderate to high levels of spiritual health. Similarly, Sayyadi et al. (2018) found higher spiritual health scores in medical and nursing students compared to other student populations. To explain and interpret the consistent findings regarding the positive effects of spiritual health on caregivers in the study by Sayyadi et al. and the current study on the impact of religious spiritual care training on elderly family caregivers, we can consider several factors that may contribute to these findings: (1) Spiritual health is often associated with providing a sense of support, purpose and coping mechanisms during challenging times. Caregivers facing the stress and demands of caregiving may benefit from a solid spiritual foundation to help them navigate their roles and find meaning in their experiences. Studies may have highlighted the role of spiritual health as a resource for caregivers to cope with the emotional and psychological challenges they face. (2) Spiritual health can help to build resilience and foster hope in individuals, including caregivers. By nurturing their spiritual well-being, caregivers may develop a sense of resilience that enables them to cope with adversity and maintain a positive outlook. Studies may have observed the positive impact of spiritual health on caregivers’ resilience and hope, leading to improved well-being and outcomes. (3) Spiritual health is often linked to personal growth and making sense of one’s experiences [27]. Caregivers possessing a robust spiritual foundation may engage in meaning-making processes, facilitating the discovery of purpose and significance within their caregiving journey. Studies may have underscored the role of spiritual health in promoting personal growth and facilitating meaning-making among caregivers. These factors, alongside the consistent focus on spiritual health across studies, provide a robust framework for understanding the positive impact of spiritual health on caregivers. Recognizing the importance of spiritual well-being within the broader context of caregiver health, and integrating interventions that specifically address spiritual needs, can contribute to improved outcomes and well-being for caregivers. This is supported by the findings of both Sayyadi et al. and the present study. It is important to note that the religious health scores did not increase after the intervention in the current study. The intervention, centered on religious and spiritual care training, had a significant impact on both existential well-being and overall spiritual health. The caregiver survey of palliative care patients will likely target different aspects of spiritual well-being, such as hope and general well-being. In interpreting these results, it is essential to consider the unique components of each intervention and how they may have influenced different aspects of spiritual health. On the other hand, Casalerio et al. (2024) in the study: Promoting Spiritual Coping of Family Caregivers of an Adult Relative with Severe Mental Illness: Development and Test of a Nursing Intervention, reported that the spiritual and religious intervention for caregivers increased their spiritual health dimension and their religious dimension [28]. These contrasting religious findings with the current study suggest that the effectiveness of religious and spiritual interventions may vary depending on the specific focus and approach of the intervention. Caregivers’ responses to such interventions may be influenced by factors such as the nature of the caring role, the context of the carer’s condition, and individual preferences regarding spirituality and religiosity. Further research and tailored interventions may be needed to address the diverse spiritual needs of caregivers in different care contexts.
Regarding the care burden, the results of the current study demonstrated no statistically significant differences in the average care burden scores within and between the groups. This result contrasts with previous studies by Polat et al. (2024), Xavier et al. (2023) [13, 29], Partovirad et al. (2024) [11], Hekmatpour and colleagues (2018) [30], Shoghi et al. (2018) [31], which showed reductions in the care burden following intervention models and the current study care burden result align with previous studies by Khalili et al. (2024) [32], Salmoirago-Blotcher et al. (2016) [33], and Karadag Arli (2017) [34]. One of the reasons why the present study did not show the same effect of spiritual and religious interventions in reducing caregiver burden as similar studies have shown is probably due to the high caregiver burden in the relevant situation. In the present study, caregiver burden had increased due to the conditions of the Corona pandemic, and reducing caregiver burden may require more extended, and more social interventions. One potential explanation for the lack of reduction in care burden scores in the current study is the influence of social interaction theory and attachment theory. These theoretical frameworks emphasize the significance of the dynamic interplay between caregiver and care recipient, particularly highlighting the role of mutual appreciation and non-violent communication in mitigating caregiver burden [35]. The physical and mental conditions of care recipients, coupled with their inability to engage in appropriate interactions with caregivers during the COVID-19 crisis, may have intensified the care burden. Furthermore, a review of similar studies reveals that most interventions aimed at reducing care burden were conducted over longer periods than our study. These studies typically involved a higher number of sessions, ranging from 8 to 12 (e.g., Mohammadi and Babaei (2018) [36], Rahgooy et al. (2018) [37], Sotoudeh et al. (2018) [38] and Salehinejad et al. (2017) [39] Consequently, the shorter duration and fewer sessions in our study may have limited the effectiveness of the intervention in reducing the care burden. Additionally, the limitations imposed by social distancing measures may have exacerbated the needs of elderly individuals, leading to an increased caregiver burden. Furthermore, a review of similar studies reveals that most interventions aimed at reducing care burden were conducted over more extended periods than our study. These studies typically involved a higher number of sessions, ranging from 8 to 12 (e.g., Mohammadi and Babaei (2018) [30], Rahgooy et al. (2018) [32], Sotoudeh et al. (2018) [39] and Salehinejad et al. Consequently, the shorter duration and fewer sessions in our study may have limited the effectiveness of the intervention in reducing the care burden.
Limitations
This study had limitations. The limitations imposed by the pandemic, including the need for social distancing, made it impossible to conduct face-to-face training sessions and deprived participants and carers of the opportunity for close, face-to-face communication during the spiritual and religious intervention. This limitation may have affected the participants’ internal beliefs, emotions, and motivations. The restrictions imposed by the pandemic, through the utilization of routine telephone communications and collaboration with pertinent academic staff, exemplify adaptability and ingenuity in maintaining communication with participants. This multi-channel approach may have helped to ensure continued engagement and support for participants throughout the intervention. Despite the challenges posed by the lack of face-to-face communication, the study managed to keep participants engaged through alternative means. The regular phone calls and coordination with the professors may have fostered a sense of connection and support, potentially enhancing participants’ overall experience and engagement with the intervention. The lack of face-to-face interaction during the spiritual and religious intervention may have limited the depth of participants’ engagement and the impact on their internal beliefs and motivations. This limitation could affect the validity of the study findings, as face-to-face communication is often crucial for building trust and rapport in interventions of this nature. The short duration of the intervention and the constraints imposed by the pandemic may have limited the generalizability of the study results. Further research utilizing more extended intervention periods and more diverse participant groups may enhance the generalizability of the findings to a broader population. Utilizing virtual platforms for interactive sessions and group discussions could facilitate the replication of the advantages of face-to-face communication and cultivate a sense of community among participants. Conducting long-term follow-up studies to track the sustained effects of spiritual and religious interventions on caregiver burden could provide valuable insights into the lasting impact and effectiveness of the intervention over time.
Conclusion
Based on the study, the results were mixed. The religious and spiritual intervention was effective in improving existential health and overall spiritual health but did not have a significant impact on religious health and caregiving burden. The training in religious and spiritual care was determined to be effective in enhancing the existential well-being of elderly family caregivers, as evidenced by an increase in their sense of meaning, purpose, and fulfillment in the caregiving role. The intervention demonstrated effectiveness in improving caregivers’ overall spiritual health, suggesting positive outcomes in terms of emotional well-being, connectedness, and resilience. Notwithstanding the favorable outcomes in existential and general spiritual well-being, the intervention did not demonstrate a notable impact on religious well-being and caregiver burden, underscoring domains that may warrant further investigation and the development of alternative intervention strategies. It is crucial to recognize the intricate nature of caregiving dynamics and the various ways in which spirituality and religion can impact the well-being of caregivers. The result of the study indicates that integrating religious and spiritual care training could effectively enhance the existential and holistic spiritual well-being of elderly family caregivers. Practitioners and caregivers can utilize this intervention to foster a greater sense of meaning and spiritual well-being within the caregiving context. In addition, the study highlights the importance of personalized interventions that consider individual differences in spiritual beliefs and coping strategies. In conclusion, while the religious and spiritual intervention showed promising results in improving certain aspects of the spiritual health of elderly family caregivers in Bushehr, further research is needed to address the nuances of religious health and care burden. By carefully considering these key findings and implications, practitioners and researchers can tailor interventions to better support caregivers’ holistic well-being in the face of challenges such as the COVID-19 pandemic.
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Acknowledgements
We would like to express our gratitude to the Student Research Committee, the Persian Gulf Martyrs Hospital’s Clinical Research Development Center, and all the elderly caregivers who participated in this research, as their contributions were invaluable.
Declarations
Ethical approval and consent to participate
The research has an ethics code number of IR.BPUMS.REC.1399.042 from the Research Vice-Chancellor of Bushehr University of Medical Sciences. All study participants provided written informed consent.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
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