Spirituality and religiosity in patients with systemic arterial hypertension

Systemic arterial hypertension is a major risk factor for complications such as acute myocardial infarction, cerebrovascular accident, and chronic kidney disease, which results in an important public health problem in Brazil, generating high medical and socioeconomic costs due to such complications. Systemic arterial hypertension associated with aspects such as spirituality and religiosity has been the subject of several studies. Thus, a descriptive, exploratory, cross-sectional study was conducted in order to assess the spirituality and religiosity of 65 hypertensive patients of a Service Center for Chronic Diseases. The domains “forgiveness” and “self-assessment” received better scores, with an average of 1.42 and 1.46, respectively. Whereas the “organizational religiosity” domain resulted in a higher average among respondents (3.00). Spirituality and religiosity of hypertensive patients are important dimensions that must be considered in developing a holistic treatment plan.


Spirituality and religiosity in patients with systemic arterial hypertension
http://dx.doi.org/10.1590/1983-80422016242134Systemic arterial hypertension (SAH) is a multifactorial clinical condition characterized by sustained high blood pressure (BP) levels, having as clinical criteria, in individuals over 18 years of age, blood pressure levels equal or higher than 140 mmHg × 90 mmHg.It is often associated with functional and/or structural disorders in target organs (heart, brain, kidneys and blood vessels) and metabolic disorders, thus, with increased risk of fatal and non-fatal cardiovascular events 1 .
SAH is the most frequent condition among cardiovascular diseases.It is also the main risk factor for chronic kidney disease, in addition to the most common complications, such as cerebrovascular accident and acute myocardial infarction 2 .It is a controllable chronic disease and therefore it must be treated in order to prevent complications.Most patients can reduce their blood pressure by means of non-pharmacological treatment, i.e., general re-education measures, also known as lifestyle changes 1,3 .
Although, primary SAH-related causes have not been fully understood, they have a significant impact on public health.Its origin has multiple factors and causes, having relations with genetic, hypertensinogenic (obesity, insulin resistance, alcohol intake) factors and influence over intermediate phenotypes (sodium intake, vascular reactivity and heart contractility).Knowing all involved factors is crucial for a preventive and therapeutic plan 4 .
Due to its potential long-term worsening of conditions, SAH causes significant transformations in the life of people, either in the psychological, family, social or economic scope.These transformations reinforce the thesis that aspects related to the disease cannot be analysed independently from other social and cultural dimensions, which give sense to these experiences 5 .
In this context, Lucchetti et al 4 state that the frequency of produced scientific studies focused on the relationship between hypertension and religious and spiritual aspects has increased in recent years 4,6 .Religiousness and spirituality are fields of subjective elaboration in which most Latin-American people -and, mainly Brazilian people -build the meaning of their lives in a symbolic manner and seek motivation to overcome existential crisis arising from the disease and other life circumstances 7 .
The definitions of religiousness and spirituality are not a consensus in the literature.Although there is a juxtaposition between spirituality and religiousness, the latter is different for the clear suggestion of a specific adoration/doctrinal system shared with others 8 .The religiousness, spirituality and personal beliefs of patients need to be inserted in the understanding of the healthcare professional's clinical practice in order to establish a holistic and integrative treatment 9 .
Thus, a study was conducted, which aimed at evaluating the spirituality/religiousness of SAH patients, registered at a centro de atendimento a doenças crônicas (healthcare centre for chronic diseases) (Cadoc) located in the southern region of the state of Minas Gerais, Brazil.

Method
This is a descriptive, exploratory and cross-sectional study.The sample had 65 SAH patients, which are treated at Cadoc of the Municipal Health Council of Alfenas, a municipality in the state of Minas Gerais, Brazil.Only patients who were diagnosed with diabetes mellitus and psychiatric disorders were excluded from the study.Data collection was carried out between May and September 2015 by means of semi-structured interview.
Cadoc, the secondary healthcare service, started its activities in 2014, in the city centre.SAH patients from primary healthcare units of the municipality are sent to this service, where a multidisciplinary team provides healthcare and promotes self-care.
After approval by the research ethics committee of the institution, two instruments were applied: a) a semi-structured survey, containing socio-demographic, religious and life habit variables; and b) brief multidimensional measure of religiousness/spirituality.This measure is a transcultural adaptation of the brief multidimensional measure of religiousness/spirituality to the Brazilian reality, conducted by Miarelli 11 as a master's degree dissertation in bioethics presented at the University of Sapucaí Valley (Universidade do Vale do Sapucaí), in Pouso Alegre (Minas Gerais), and validated by Curcio 12 as a master's degree dissertation in Brazilian health presented at the spirituality and health research centre of the Federal University of Juiz de Fora (Universidade Federal de Juiz de Fora -UFJF) in Minas Gerais.
The measure -originally proposed by Idler et al 13 and developed as a resource that could provide an extensive list of questions related to religiousness and spirituality, relating them to health -has been used in many studies worldwide and was validated for application in different populations, including teenagers from the US and Ireland, and US undergraduate and postgraduate students 12 .The validation of the original version was made in 1998 with a nationally representative sample from the US population, by means of the 1998 General Social Survey (GSS) 11 , as informed by Miarelli.
The measure is organized by domains, identified by sections describing their relationship with health: A) daily spiritual experiences; B) values/beliefs; C) forgiveness; D) private religious practices; E) religious and spiritual resilience; F) religious support; G) religious/spiritual history; H) commitment; I) organizational religiousness; J) religious preferences; and K) global self-assessment 11 .The response options are arranged in Likert scale, ranging from 1 to 8, 1 to 6 and 1 to 4. The scores of each dimension is specific, and the lower the score, the higher the degree of the dimension in question, i.e., the level of spirituality and religiousness.

Results
Regarding the 65 respondents, 69.2% of them are women, 56.9% are senior citizens, over 60 years of age or older; and 60% of respondents are married.There was a predominant number of hypertensive patients with household income equal or lower than two minimum wages (86.2%) and 49.2% respondents are pensioners, as per Table 1.
Amongst the respondents, 90.7% of them live with their families.A total of 49.5% live with their spouses and 41.2% respondents live with their children.The borough of Aparecida, where Posto de Saúde da Família (Caensa Family Healthcare Centre) (PSF) is located, is the centre with the highest number of patients who frequent Cadoc (32.3%), and one should consider its location near Cadoc and that this borough has a predominantly elderly population.Other boroughs often mentioned in the study were Recreio Vale do Sol (21.5%),Pinheirinho (12.3%),Nova América (9.2%), Vila Betânia (6.2%),City Centre (6.2%) and Boa Esperança (6,2%).
As for religion, there was a predominance of patients who declared themselves as Christians (55.4%, n = 36), followed by spiritualists (21.5%, n = 14), Catholics (15.4%, n = 10), and Jehovah witnesses (6.2%, n = 4), and 1.5% respondents (n = 1) did not answer this question.As for the SAH diagnosis, 43.2% (n = 28) respondents have been living with the disease for up to 39 years, with a mean of 15 years.Regarding the treatment, 100% patients had pharmacological treatment, and 1.5% (n =1) respondents have pharmacological and non-pharmacological treatment.In addition to SAH, 76.9% (n = 50) respondents have another chronic disease and 16.9% (n = 11) have been hospitalized in the last twelve months; a total of 4.6% (n = 3) of them due to a hypertensive crisis.In regard to all respondents, 70.8% (n = 46) had already experienced some significant health-related event in their lifetime.These patients seldom indulge in leisure activities: 63.1% (n = 41) denied having any kind of leisure activity; and out of 36.9% (n = 24) respondents who stated their leisure habits, only 12.3% (n = 8) engage in leisure activities twice a week.Table 2 shows the score according to the domains of the brief multidimensional measure of religiousness/spirituality.
In domain G, "religious and spiritual history", 80% respondents stated to have had a life-changing religious/spiritual experience and 100% reported to have been rewarded for their faith.Only 10.8% respondents said they had lost a Spirituality and religiosity in patients with systemic arterial hypertension http://dx.doi.org/10.1590/1983-80422016242134bit of their faith after being diagnosed with SAH.Amongst all domains, item C stands out, related to "forgiveness" and item K "global self-assessment", which presented the lowest means -1.42 and 1.46, respectively -and, as per Table 2, the highest mean was observed in domain I, related to "organizational religiousness" (3.00).

Discussion
The results show that the study respondents were, in their majority, senior citizens aged 60 years or more and women.This may be due to the fact the more than half of the world's population is comprised by women and because woman are the ones who often seek health services 14 .In addition, this population has a higher prevalence of SAH in the country and large Brazilian regions 3 .
The monthly household income of respondents does not exceed two minimum wages.This is a matter of concern, since the study conducted by Schmidt 15 shows that the morbidity and mortality rates derived from non-communicable or chronic diseases are higher in lower-income populations.In Brazil, it is estimated that half of senior citizens have a personal income equal or lower than one minimum wage, and a fourth of this income is spent with drugs.Moreover, when these senior citizens retire, their income is reduced, which means a change in their life standards.In this context, expenses with drugs and medical treatment can become burdensome for the elderly 16 .
It was found a predominant number of married patients, many of them living with their spouses and children.This is a significant issue, because with the increased prevalence of chronic diseases -among them, SAH -the family takes more responsibilities for the health conditions of the elderly person 16 .However, in certain cases, the family lives with the elderly person because of the regular payment of their pensions, which ends up becoming a financial support to children and grandchildren in moments of hardship.
The time since the SAH diagnosis is an important aspect, because the longer the time for hypertension manifestation, the lower the quality of life 17 .Chronic diseases, especially cardiovascular diseases, are the main cause of death among senior citizens, in addition to representing a high economic and social cost.SAH is one of the cardiovascular diseases that most affect senior citizens worldwide 17 .
The results show that a large part of patients suffered, in addition to SAH, from another chronic disease.Pimenta and Caldeira 18 claim that approximately 80% of people with SAH have comorbidities such as diabetes, dyslipidemia and atheromatosis.Despite the total number of respondents who make use of pharmacological treatment, such as antihypertensive drugs, it was found the occurrence of hypertensive crises, characterized by acute high blood pressure, classified as emergency and urgency.Hypertensive emergencies are conditions where there is a critical rise in the blood pressure, associated with lesion of target organs and imminent death risk.Hypertensive urgencies are characterized by a relevant BP rise (> 180 mmHg×120 mmHg)) in clinically stable patients, without acute impairment of target organs 1 .
In relation to the brief multidimensional measure of religiousness/spirituality, the score of each dimension is specific and, the lower the score, the higher the degree of dimension in question.It was observed that the lowest score in all sections occurred in domain C, "forgiveness" (mean = 1.42).This domain focused on three types of questions: 1) self-forgiveness; 2) forgiveness to those who offend you; and 3) God's forgiveness.The results show that respondents emphasize the importance of forgiveness, which corroborates the study conducted by Pinto and Oliveira 19 on happiness and forgivenessconsidering differences on gender, age and culture Spirituality and religiosity in patients with systemic arterial hypertension http://dx.doi.org/10.1590/1983-80422016242134-which found that the elderly forgive more easily, followed by adults and teenagers.As for gender, in our study, there were no significant differences between men and women regarding forgiveness.
The highest score (mean = 3.00) was in domain I "organizational religiousness", which showed two questions on the attendance to religious services (rituals, mass, cults and celebrations) and participation in other church activities.This demonstrated that respondents devoted little time to those activities.Old age and comorbidity of most respondents hamper their locomotion to churches, in general, located far from their homes.Often, these senior citizens depend on buses or other persons to take them to church.This also hinders attendance to religious services.
Rocha and Ciosak 16 conducted a study in which respondents with chronic diseases stated that they regularly attend church services and meetings, among others.The weekly religious practice was associated with a lower prevalence of high blood pressure compared to respondents that did not attend religious services.To Giovelli et al. 8 , religious beliefs and practices of patients with chronic diseases are sources of social support.
Studies show a relationship between religiousness and spirituality and clinical and laboratory results, including the reduction of cortisol levels and mortality rates 4,9 .Another study shows minor BP reactivity in patients with greater religiousness, suggesting that religious beliefs can be an important variable for the study of patients with arterial hypertension, particularly the elderly 20 .Furthermore, other studies depict lower diastolic arterial pressure in hypertensive patients who were the recipients of spiritual intervention or who participated in religious services 21,22 .
A study described by Silva et al 23 aimed at analysing the prevalence of high blood pressure in patients who were members of the Seventh-day Adventist church in the capital and countryside cities of the state of São Paulo, and found a lower number of hypertensive patients in this population compared to national studies.Lower blood pressure rates were found in the capital of the state than in the countryside, possibly due to better socioeconomic conditions and lifestyle.
It is also worth highlighting that religiousness and spirituality have a close relationship with different aspects of the ageing process, ranging from a successful ageing process to end-of-life care 24 .Spirituality is the topic that promotes a union between balance and harmony.Religious beliefs and practices can reduce loss of control, stress and a sensation of helplessness, allowing the cognitive structure reduce suffering and making treatment more effective 25 .In the case of chronic diseases such as SAH, spirituality can be the cognitive mediator for the interpretation of adverse events in a positive manner, promoting adjustment and adaptation of individuals to health conditions 26 .
The results show that spirituality, religiousness and faith have a positive influence whilst patients cope with life obstacles and hardships, in addition to increasing patients' resilience, thus, improving their condition.Spirituality can be used as a strategy to tackle critical life circumstances, because it can increase one's sense of purpose and life meaning, associated with a greater resistance to stress-related diseases 27 .
In addition to spirituality, the act of praying can add optimism to the process of addressing chronic diseases.The practice of praying is beneficial in several ways, because, in addition to requests to God, prayers are often made in order to thank life, health and family, which results in greater feelings of gratitude.The impact of coping with critical situations happens when the spirituality of the individual is applied to daily life and inherently to their most intimate values, ideals and beliefs 28 .Prayer allows human beings to get in touch with their deepest self and leads to the belief of self-control and control of their bodies and minds.The simple fact of believing that they can control something that goes beyond defined explanations gives men a sense of self-sufficiency.Hence, it is worth noting that religiousness and spirituality are important dimensions for the well-being of hypertensive patients, particularly, in order to cope with diseases.The study described by Lucchetti et al 24 highlights that the search by the physician for information about the spiritual history of hypertensive and cardiac patients can favour treatment and its integrative approach.However, a better qualification is necessary, not only of the physician, but also of other healthcare practitioners for the whole care of the individual and their families 29 .

Final considerations
The results found in this study point to a challenging research area in the field of religiousness and spirituality, which seems to gain relevance in the care to hypertensive patients, mainly the

Research articles
Spirituality and religiosity in patients with systemic arterial hypertension http://dx.doi.org/10.1590/1983-80422016242134elderly.Therefore, an in-depth knowledge of religious and spiritual beliefs is necessary, since they may influence treatment and recovery.The multidisciplinary healthcare team can benefit from the assessment of the religious and spiritual history of patients with systemic arterial hypertension in order to implement a more integrative therapeutic project and which considers the holistic view of human beings in their biopsychosocial and spiritual context.

Table 1 .
Socio-demographic data of hypertensive patients of the Healthcare Centre for Chronic Diseases (Alfenas/MG, 2015) *Minimum wages.In November 2015, the minimum wage in Brazil was equivalent to BRL 788.00 (USD 202.72).

Table 2 .
Score according to the domains of the brief multidimensional measure of religiousness/ spirituality (Alfenas/MG, 2015)