1. Introduction1
More than 50% of Americans say they have one or more chronic illnesses or conditions [
2]. Medical conditions, illnesses, and health problems that have symptoms or entail limitations requiring medical management for long periods are considered chronic illnesses [
3]. Self-care for chronic illness can be challenging as the activities required to maintain life and enhance well-being involve long-term commitment. Well-being is related to health and can be maintained even when a person has been diagnosed with a chronic illness, such as heart failure (HF) [
4]. As health care providers, nurses work with individuals on self-care behaviors to manage their chronic illness symptoms.
Self-care was first presented in the 1950s when Orem published her theory regarding nursing and self-care [
4,
5]. Self-care is defined as the activities of daily living that are needed to maintain quality of life and well-being. Some of the self-care activities that are used with chronic illness include: following up with medical care, self-monitoring (e.g., glucose checks for diabetes, blood pressure monitoring for hypertension), taking medication properly, adhering to diet and exercise regimens, and smoking cessation [
6]. Orem described self-care deficit nursing theory (SCDNT) as:
…descriptively explanatory of the relationship between the action capabilities of individuals and their demands for self-care or the care demands of children or adults who are their dependents. Deficit thus stands for the relationship between the action that individuals should take (the action demanded) and the action capabilities of individuals for self-care or dependent-care. Deficit in this context should be interpreted as a relationship, not as a human disorder.
Depression occurs when an individual experiences depressed mood or loss of interest or pleasure along with changes in sleeping patterns, eating more or less, lack of energy, inability to concentrate, and poor self-image that reflect a change in functioning for a period of at least two weeks [
8]. When experiencing depression, a person may experience symptoms that are associated with loss of interest, feelings of worthlessness, withdrawal from social interactions, and loss of hope. Some individuals have physical symptoms, such as weight loss, insomnia, loss of energy, and decreased concentration when they are depressed [
9]. Other symptoms of depression that people may report include overwhelming sadness, a sense of futility, fear and worry regarding life and death, lack of motivation, confusion, and suicidal ideation [
10].
A report by the Cleveland Clinic [
11] indicated that depression has been associated with chronic illness. They further reported that almost one-third of people diagnosed with a chronic illness were likely to exhibit symptoms of depression. When a person is given both diagnoses (chronic illness and depression), he/she may tend to have more severe symptoms of both, greater difficulty adapting to the medical condition, and greater costs associated with medical treatment than nondepressed individuals who have a chronic illness [
12]. Artinian, Washington, Flack, Hockman, and Jen [
13] found that 21% of African Americans diagnosed with hypertension also had depression scores that were evidence of clinical depression. Women with chronic obstructive pulmonary disease tended to experience major depressive symptoms more often than men [
14].
Depression often co-exists with chronic illnesses, such as heart disease (including HF, stroke, cancer, human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), diabetes, or Parkinson’s disease [
15]. Approximately 10% of African Americans are diagnosed with a lifetime major depressive disorder (MDD). Over a 12-month period, 57% of the African Americans are diagnosed with persistent MDD, with 39% of the Caucasian population having this diagnosis [
16]. African American women with a dual diagnosis of HF and depression fail to complete self-care activities on a daily basis, leading to greater problems with their chronic illness.
“Spirituality is defined in this study as the beliefs a person holds related to their subjective sense of existential connectedness, including beliefs that reflect relationships with others, acknowledgement of a higher power, and recognition of an individual’s place in the world, that lead to participation in spiritual practices” ([
4], p. 50). Spirituality can have an effect on people’s health beliefs, practices, and outcomes. African Americans, in contrast to Caucasians, tend to use spiritual practices when coping with exacerbation of acute and chronic illnesses. According to Newlin, Knafl, and D’Eramo Melkus [
17], spiritual practices used by African Americans have had a positive effect on their health and quality of life (QOL).
“Spiritual self-care is defined as the set of spirituality-based practices in which people engage to promote continued personal development and well-being in times of health and illness” ([
4], p. 50). An individual’s mind-spirit-body connection, upbringing, moral and religious background, and life experiences that originate from faith, feelings, and emotions form the basis of spiritual self-care. Examples of spiritual self-care can include building social networks or volunteering [
18]; listening to inspirational music [
19]; meditation [
20]; and development of a sense of inner peace and quiet [
21]. Other examples of spiritual self‑care include practicing yoga or Tai Chi, attending religious services, reading sacred or inspirational texts, prayer or mediation, hiking, walking or otherwise enjoying nature, and developing or mending personal relationships [
22]. People can enhance their spiritual well-being and QOL by participating in spiritual self-care activities.
QOL is a multidimensional construct, incorporating physical, emotional, and social effects on an individual’s perception of daily life. According to the World Health Organization, QOL is defined as “an individual’s perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards, and concerns” ([
23], p. 28). As a construct, QOL often is the focus of research on chronic illness. QOL ratings are subjective and vary depending on the extent to which individuals are experiencing changes in their lifestyles from the chronic illness [
24].
White’s mid-range theory of spirituality and spiritual self-care (WTSSSC) was developed from a comprehensive review of literature on self-care practices and experience as a nurse practitioner in an urban area (see
Figure 1). The purpose of this study was to help nurses understand the importance of discussing the use of spiritual self-care practices with patients diagnosed with chronic illness as a way to decrease effects of depression on QOL. The specific aim of the study was to determine if using spiritual self-care practices could mediate the relationship between depression and QOL.
3. Results
The mediation analysis used the Baron and Kenny procedure [
30] to determine if spirituality self-care practices were mediating the relationship between depression as measured by the PHQ-9 and QOL as measured by the WHOQOL-Bref. Descriptive statistics were used to provide baseline information regarding the variables that were used in the mediation analysis (see
Table 2). The mean score for spirituality self-care practices was 3.79 (SD = 0.59), with a range from 2.31 to 4.83. Higher scores were associated with the use of more spiritual self-care practices. Depression symptoms had a mean score of 1.68 (SD = 0.67), with a range from 1.00 to 3.75. On a score of 1–4, higher scores were indicative of greater numbers of depressive symptoms. Quality life ranged from 1.72 to 4.89, with a mean score of 3.82 (SD = 0.70). Higher scores for QOLindicate participants’ perceived higher levels of well-being (see
Table 3).
The first step used depression as the predictor variable, with QOL used as the criterion variable using a simple linear regression analysis. Fifty-six percent of the variance in QOL was explained by depressive symptomology, β = −0.75,
F (1, 135) = 174.21. The relationship between depression and spirituality self-care practices tested on the second step was statistically significant, β = −0.56,
F (1, 135) = 62.49. On the third step of the analysis, the relationship between spiritual self-care practices and QOL was statistically significant, β = −0.67,
F (1, 135) = 110.15. Holding the mediating variable constant, the amount of variance in QOL that was explained by depressive symptomology was reduced to 0.20, although the relationship between the two variables remained statistically significant, β = −0.55,
F (1, 135) = 126.32. The substantial reduction in explained variance in QOL explained by depressive symptomology provided support that spiritual self-care practices was mediating the relationship (
Table 4 and
Figure 2).
4. Discussion
Chronic illness affects more than 50% of Americans, requiring medical management that involves active involvement by patients. A link was found between depression and chronic illness [
11], with approximately one-third of people diagnosed with a chronic illness having co-diagnosis of depression. The dual diagnosis of depression and chronic illness, such as HF, can result in more severe symptoms, difficulty in providing self-care for the chronic illness, and increased costs associated with medical treatment [
12].
In contrast to prior research that found a negative relationship between QOL and depression [
12,
13,
15], the present study found that spirituality self-care practices were mediating this relationship. African Americans are more likely than Caucasians to turn to spiritual practices during times of distress, such as exacerbation of the symptoms of their chronic conditions. Newlin
et al. [
17] found that these types of practices can result in positive effects on this QOL.
While the African American participants were knowledgeable about their chronic illness and the self-care procedures needed to control their symptoms, they might not always use these procedures to control the symptoms. For example, some participants during the data collection process mentioned that while they knew that they should weigh themselves daily, they did not have scales needed to weigh themselves. In addition, while they were aware of the need to refrain from using salt, they continued to include salt in their cooking.
Most of the participants recognized that religion was important in their lives. However, they were generally unaware of the benefit that performing spiritual self-care practices may have been having on their well-being. The negative relationship between depression and quality of life indicated that African Americans diagnosed with HF who had higher scores for quality of life had lower depressive symptoms. Chronic illness often is associated with depression as patients become aware of the limitations their illnesses can impose on their lives. However, in the sample of African American patients in the present study, depression was not as evident, possibly because of their use of spiritual self-care practices to mitigate the symptoms of their chronic illnesses.
Using spiritual self-care practices can serve as a buffer to alleviate feelings of depression. African Americans generally are religious and use spiritual self-care practices, even if they are unaware of their effect as self-care agents. For example, for many African Americans praying and attending Bible studies are spiritual activities, as are living a moral life, volunteering, being with family, and finding meaning in good and bad situations. These practices can improve an individual’s spirit, promote inner peace, and provide comfort when they are experiencing exacerbation of their chronic symptoms.
