Spiritual well-being, resilience, and health-promoting lifestyle among older adult hypertensive patients: a cross-sectional study

Abstract

Background

Hypertension, commonly known as the silent killer, is one of the most prevalent cardiovascular disorders among older adults and represents a significant burden on healthcare systems worldwide. Spiritual well-being appears to play a critical role in fostering resilience and facilitating the adoption of a health-promoting lifestyle in older hypertensive patients. Consequently, this study was undertaken in southern Iran to investigate the associations among spiritual well-being, resilience, and a health-promoting lifestyle in this population.

Methods

In this descriptive-analytical, cross-sectional study, 230 older adult hypertensive patients attending the Fasa Cardiac Clinic in southern Iran were recruited using convenience sampling. Data were collected via a demographic information form and three self-report questionnaires: The Health Promoting Lifestyle Profile, the Paloutzian and Ellison Spiritual Health Scale, and the Connor-Davidson Resilience Scale. Statistical analyses were performed using SPSS version 25, employing descriptive statistics, Pearson correlation coefficients, and linear regression analyses, with significance determined at p < 0.05.

Results

The mean age of the participants was 64.36 ± 6.06 years, with the majority being male (66.90%) and residing in urban areas (94.80%). Among the participants, 70.44% were married and 41.74% were employed in government positions. The mean scores for the health-promoting lifestyle, spiritual well-being, and resilience measures were 127.70 ± 17.30, 83.30 ± 18.40, and 62.50 ± 14.10, respectively. Furthermore, significant direct correlations were observed between spiritual well-being and resilience (r = 0.37, p < 0.001) and between spiritual well-being and a health-promoting lifestyle (r = 0.47, p < 0.001). Additionally, a robust positive correlation emerged between health-promoting lifestyle and resilience (r = 0.52, p < 0.001), with spiritual well-being proving to be a significant predictor of both a health-promoting lifestyle and resilience in this cohort.

Conclusion

In light of the demonstrated predictive role of spiritual well-being in enhancing both resilience and the adoption of health-promoting behaviors, interventions aimed at bolstering spiritual well-being may serve as a valuable resource. This approach holds promise for improving the overall health of older adults and potentially reducing the incidence of chronic diseases often linked to unhealthy lifestyle choices.

Introduction

Hypertension, commonly known as high blood pressure, poses a significant global health challenge and stands as a leading risk factor for cardiovascular disease, stroke, and kidney failure in adults—particularly among older individuals [1–2]. According to available data, approximately 77% of older adults are affected by elevated blood pressure [3], while studies conducted in Iran have reported that the prevalence of hypertension among older adults reaches up to 42% [4]. As the global population ages, the incidence of hypertension is expected to rise at an alarming rate, thereby imposing a substantial burden on societies and healthcare systems worldwide [5].

Lifestyle factors and health-promoting behaviors serve as pivotal determinants of overall well-being and are widely recognized as fundamental elements in both maintaining and enhancing health while preventing the onset of numerous chronic ailments [6, 7]. Notably, unhealthy lifestyle choices—including smoking, physical inactivity, poor dietary habits, and disrupted sleep patterns—have emerged as the primary contributors to morbidity, mortality, and preventable complications among older adults [8]. Health-promoting lifestyles encompass a broad spectrum of self-initiated, sustained, and routine activities aimed at optimizing individual health; these practices typically include dimensions such as self-care, regular physical activity, balanced nutrition, spiritual well-being, social interactions, and effective stress management [9].

Attention to spiritual needs is recognized as a critical component of a healthy lifestyle that can mitigate harmful behaviors. Numerous studies have underscored the interrelationship between a health-promoting lifestyle and spiritual well-being, demonstrating that adherence to healthy behaviors not only improves physical and mental health but also enhances spiritual well-being [10]. Conversely, spiritual well-being is increasingly viewed as a protective factor in promoting overall wellness and preventing disease, serving as an effective means of coping with stressful situations and as a valuable therapeutic adjunct in patient care [11]. Spirituality is defined as the inner reservoir of forces and resources [12], and as a way of being in the world in which an individual experiences a profound sense of connectedness to oneself, to others, and/or to a higher power or nature—thereby endowing life with meaning and enabling transcendence beyond the self, everyday existence, and suffering [13].

Spiritual health is widely recognized as a fundamental dimension of human existence, intricately intertwined with physical well-being. It serves as a potent source of resilience, empowering individuals to navigate the myriad challenges and transitions inherent in aging [14]. Empirical research has demonstrated that spiritual health can indirectly bolster the resilience of older adults, enabling them to effectively cope with age-related challenges—including the onset of chronic diseases, functional decline, diminished independence, social isolation, and financial difficulties [15]. Resilience, defined as the capacity to adapt to challenges and changes [16], is closely associated with positive outcomes across physical, psychological, and spiritual domains [12]. Notably, resilience may manifest in either an active or a passive form; active resilience entails the deliberate cultivation of skills to manage adversity and the transformation of stress into an opportunity for growth, whereas passive resilience involves simply recovering and returning to baseline without proactive self-enhancement [16]. In essence, resilience functions as an internal reservoir of strength that mitigates the adverse effects of stress, prevents the onset of mental and physical health disorders [17], and is directly linked to the adoption of health-promoting lifestyles among the elderly [18]. For instance, Springfield et al. [19], demonstrated that resilience motivates the maintenance of cardiovascular protective behaviors—such as healthy eating and regular physical activity—in older adults. Recognizing one’s level of resilience and its connection to a healthy lifestyle can exert a profound impact on both personal and professional well-being, as well as on the mitigation of mental health challenges [20].

Despite the rapid growth of the older adult population and the high prevalence of hypertension within this demographic, no comprehensive study has yet been conducted to examine the concurrent relationships among spiritual well-being, resilience, and a health-promoting lifestyle in hypertensive older adults. Furthermore, in light of the strong associations between cultural values and individual lifestyles [21] and the influence of culture on spiritual well-being and resilience particularly under conditions of stress and disease [22]. The present study aims to investigate the interactions among these variables in this population. In addition to delineating the associations among spiritual well-being, resilience, and health-promoting lifestyle factors, the study underscores the significance of cultural context by integrating cultural perspectives into its analytical framework, thereby potentially advancing our understanding of effective hypertension management among older adults.

Methods

Design

This descriptive-analytical study employed a cross-sectional design.

Setting

The research was conducted at the Cardiac Clinic in Fasa, Fars Province, southern Iran, from September 2023 to December 2023.

Sample, sampling

Participants were selected through a convenience sampling method based on the following inclusion criteria: individuals aged 60 years and above, a confirmed diagnosis of hypertension, a willingness to participate, and the ability to communicate effectively.

We calculated the sample size using the formula used in a previous study (β = 0.2, α = 0.05, correlation coefficient: r = 0.27) [23]. The sample size was estimated 250 individuals aged. Due to the possibility of incomplete completion of questionnaires by the study participants, we considered more samples. A total of 300 individuals aged were selected using convenience sampling. In the present study, 230 participants filled out and returned the questionnaires. Thus, the response rate was 76.66%.

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Data collection

Data were gathered using a comprehensive demographic information form—which recorded variables such as age, gender, marital status, place of residence, employment status, and education level—alongside three additional questionnaires. Participants completed these instruments through self-report, with the researcher providing assistance in cases where visual impairments or mobility issues affected the participants’ ability to complete the questionnaires unaided.

Health-promoting lifestyle profile

To assess health-promoting lifestyle behaviors, the present study employed the Health-Promoting Lifestyle Profile II (HPLP-II) developed by Walker et al. [24]. This rigorously validated instrument evaluates health-promoting behaviors across six dimensions: Health Responsibility (8 items), which examines the degree to which individuals assume accountability for their own health and well-being; Physical Activity (13 items), which assesses engagement in regular exercise and the maintenance of an active lifestyle; Nutrition (11 items), which gauges the adoption of healthy eating habits and informed dietary choices; Spiritual Growth (6 items), which measures the pursuit of purpose, meaning, and spiritual fulfillment; Stress Management (6 items), which evaluates the ability to recognize stressors and implement effective coping strategies; and Interpersonal Relationships (8 items), which assesses the quality and strength of social connections. The HPLP-II utilizes a 4-point Likert scale ranging from “never” [1] to “always” [4], yielding total scores between 52 and 208, with separate subscale scores computed for each dimension. Walker et al. [24] reported Cronbach’s alpha coefficients ranging from 0.88 to 0.90 for the subscales and 0.94 for the overall questionnaire, while an Iranian validation study by Maroutii Sharifabadi et al. [25] documented a Cronbach’s alpha of 0.87 for the Persian version.

Given that health-promoting behaviors are pivotal in the management of chronic conditions such as hypertension, the HPLP-II was selected to provide a comprehensive assessment of the lifestyle factors influencing health. This instrument facilitates the exploration of the interplay among health-promoting behaviors, spirituality, and resilience in managing hypertension among older adults, thereby offering deeper insights into their synergistic contributions to overall well-being.

Paloutzian and Ellison spiritual health scale (PESH)

Spiritual health was evaluated using the Paloutzian and Ellison Spiritual Health Scale (PESH), a 20-item instrument designed to independently assess both religious and existential dimensions of spiritual well-being. Employing a 6-point Likert scale that ranges from “strongly disagree” to “strongly agree,” with reverse scoring applied to negatively worded items, the scale yields subscale scores ranging from 10 to 60, such that higher scores denote greater well-being in each domain. The overall spiritual health score is derived by summing these subscales, resulting in a total score that spans from 20 to 120 and categorizes spiritual health into three distinct levels: low [20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40], moderate (41–99), and high (100–120) [26]. The content validity and reliability of the PESH in Iran were corroborated by Seydfatmi et al. [27], who reported a Cronbach’s alpha of 0.82. Recognizing that spiritual well-being plays a crucial role in influencing health behaviors and enhancing resilience, this study incorporated the PESH to provide a comprehensive understanding of how spirituality may underpin a healthy lifestyle in older adults with hypertension. By concurrently measuring religious and existential dimensions of well-being, the instrument facilitates an exploration of the extent to which spiritual health may bolster resilience and inspire positive lifestyle modifications, thereby aligning with our overarching objective of elucidating the intricate interconnections among spirituality, overall well-being, and health-promoting behaviors in this population.

Connor-Davidson resilience scale (CD-RISC)

The Connor-Davidson Resilience Scale (CD-RISC) was utilized to assess resilience levels, comprising 25 self-report items rated on a Likert scale from 0 (completely disagree) to 4 (completely agree), which together yield a total score ranging from 0 to 100; higher scores correspond to greater resilience. Factor analysis has revealed that the instrument encompasses five key factors: perceived self-competence; tolerance for negative emotions and resilience to stress; positive acceptance of change coupled with secure relationships; control; and spiritual influences. Specifically, scores between 0 and 33 indicate low resilience, those between 34 and 67 suggest moderate resilience, and scores from 68 to 100 reflect high resilience. The psychometric robustness of the CD-RISC has been well established; Connor and Davidson [28] reported high internal consistency for the overall scale (α = 0.71), with the resilience subscale demonstrating strong reliability (α = 0.89) and a test-retest reliability of 0.87 over a four-week interval. Moreover, Mohammadi et al. [29] further confirmed the instrument’s validity and reliability in an Iranian context, reporting a Cronbach’s alpha of 0.89. Given that resilience is instrumental in facilitating adaptation to chronic conditions such as hypertension, the inclusion of the CD-RISC in this study is intended to elucidate the interrelationship between spiritual well-being and health-promoting lifestyle choices. By examining how resilience underpins positive behavioral change, this research aims to shed light on the psychological mechanisms that may enhance the effective management of hypertension in older adults.

Data analysis

Data were analyzed using SPSS software version 25. Descriptive statistics—including means, standard deviations, frequencies, and percentages—were computed, and analytical techniques such as the Pearson correlation coefficient and linear regression analysis were employed. A p-value of less than 0.05 was considered statistically significant.

Results

A total of 230 older adult hypertensive patients participated in the study. The mean age of the participants was 64.36 ± 6.06 years, with a predominance of males (66.95%). Most participants resided in urban areas (94.80%), and a substantial proportion were married (70.44%). Additionally, 41.74% of the participants were employed in government positions. Detailed demographic characteristics are presented in Table 1.

Table 1 Frequency distribution of sociodemographic characteristics of the study participants

The study findings indicated that the mean (± standard deviation) scores for spiritual health and resilience were 83.30 ± 18.40 and 62.50 ± 14.10, respectively, suggesting that both domains were at moderate levels. Furthermore, the mean total score on the health-promoting lifestyle scale was 127.70 ± 17.30. Given that the scale ranges from 52 to 208, this mean score falls within the upper-moderate range (see Table 2).

Table 2 Mean, standard deviatin, minimum and Maximom of spiritual Health, Resilience, and Health-Promoting lifestyle scores in the study population

Correlation analyses revealed statistically significant direct associations between spiritual well-being and resilience (r = 0.37, p < 0.001), as well as between spiritual well-being and health-promoting lifestyle (r = 0.47, p < 0.001). Moreover, a significant positive correlation was found between health-promoting lifestyle and resilience (r = 0.52, p < 0.001) (Table 3).

Table 3 The relationship between spiritual health, resilience, and Health-Promoting lifestyle

Subsequent linear regression analysis demonstrated that age, gender, and spiritual health were the most significant predictors of resilience. In addition, among the older adult participants, gender, marital status, educational level, and spiritual health emerged as the primary predictors of a health-promoting lifestyle (Table 4).

Table 4 Linear regression results of health-Promoting lifestyle on spiritual health and resilience among older adults (N = 230)

Discussion

The current study investigates the associations among spiritual well-being, resilience, and a health-promoting lifestyle in older adult hypertensive patients. Our findings indicate that the majority of these patients exhibit moderate levels of spiritual well-being. Spiritual well-being, defined as a state that encompasses positive feelings, behaviors, and cognitions regarding one’s connection to oneself, others, nature, and a higher power, is widely acknowledged as a crucial component of overall health. As delineated by Motamedi et al. [30], this construct is inherently two-dimensional, comprising a vertical aspect—religious well-being, which reflects a sense of connection to a higher power—and a horizontal aspect—existential well-being, which signifies a sense of purpose and satisfaction in life independent of any specific religious affiliation.

A growing body of research suggests that a robust sense of spiritual well-being facilitates the coping process and enhances the management of chronic diseases by promoting harmony among the physical, mental, and social dimensions of health. This is achieved by reinforcing self-esteem, instilling a sense of meaning in life, and augmenting hope and psychological tranquility. Although spiritual health does not directly cure disease, it can ameliorate mood, mitigate certain health complications, and foster greater acceptance of one’s condition [31]. Moreover, it is important to recognize that spirituality is profoundly influenced by sociocultural factors [32]. In this regard, the inherently religious nature of Iranian society—with its emphasis on a close relationship with God and the strong religious convictions held by many older Iranians—likely exerts a significant influence on their spiritual well-being [33].

Supporting these observations, Kodariyah et al. (2020) highlighted the relationship between spirituality, religiosity, and blood pressure regulation in elderly hypertensive patients at the Putri Ayu Health Center [34]. Similarly, Jiang’s (2018) study of older Chinese individuals with chronic obstructive pulmonary disease (COPD) reported moderate levels of spiritual well-being, paralleling the results of the present investigation [35]. However, it is essential to distinguish between COPD—a progressive lung disease—and hypertension, a chronic cardiovascular condition, as the distinct pathophysiologies, treatment strategies, and coping mechanisms associated with these diseases may differentially influence patients’ experiences of spiritual fulfillment and resilience. Although both studies report analogous levels of spiritual well-being, the nature of the illness and its corresponding management strategies may account for some of the observed variations.

In contrast, Yousefi et al. (2019) reported that most older adults in their study demonstrated high levels of spiritual health [36], a discrepancy that may be attributable to differences in sample size and community selection across the studies.

The findings of the present study revealed that the resilience of older adult participants was moderate, with age, gender, and spiritual well-being emerging as the most significant predictors. The extant literature on resilience among older adults indicates that resilience is generally moderate, particularly in our country, a finding that is consistent with our results [37, 38, 39]. Conversely, Khalili et al. [40] reported notably higher levels of resilience among the elderly in Ardebili, a discrepancy that may be attributable to the distinct cultural and religious milieu of Ardebili, where families traditionally exhibit a high degree of reverence for older individuals.

Furthermore, our study aligns with the findings of Ma et al. (2016), who identified gender as a significant predictor of resilience among patients at risk of chronic kidney disease (CKD) [41]. Similarly, Górska et al. [42], in a systematic review, reported that gender was the sole sociodemographic variable correlated with resilience, with women demonstrating higher resilience scores. In addition, previous studies have consistently shown that age and gender are significantly associated with resilience among the elderly, with resilience tending to decline with increasing age, while a female gender appears to confer a protective effect across all models [43, 44].

Moreover, researchers have reported that factors such as social support and spirituality play a crucial role in enhancing resilience among older adults [45]. The predictive influence of spiritual health on resilience may be explained by the capacity of spiritual beliefs and practices to foster wisdom and positivity, thereby cultivating a robust spiritual orientation. Consequently, by engendering a profound sense of awareness and meaning, a well-developed spiritual attitude promotes a positive reinterpretation of life’s challenges and facilitates the adoption of optimistic coping strategies in adverse situations, ultimately enhancing resilience against unchangeable events.

Health-related behaviors play a pivotal role in the older adult population by enhancing longevity, preventing chronic diseases, improving functional capacity, and mitigating the progression of functional limitations [46]. The findings of the present study indicate that the health-promoting lifestyle among older adult participants is moderate, with spiritual well-being, gender, educational level, and marital status emerging as the most salient predictors. These results are consistent with those of Pakpour et al. (2016) [37] and Norouzi et al. (2017) [20], who also reported moderate health-promoting lifestyle scores.

Moreover, our findings revealed a statistically significant association among spiritual well-being, health-promoting behaviors, and resilience in older adults. Notably, spirituality appears to facilitate the adoption of a healthy lifestyle, as individuals with elevated spiritual well-being tend to employ positive coping mechanisms when confronting illness and embrace lifestyle choices that contribute to effective disease management [46, 47]. In alignment with our results, other studies have similarly corroborated the positive relationship between health-related behaviors and spirituality [46, 48].

In addition, female gender, higher educational attainment, and age—encompassing both early and late adulthood—have been identified as significant correlates of health-promoting behaviors within the general population [49]. Although several studies have documented a higher prevalence of such behaviors among women [46, 50, 51], other research has reported elevated levels among men [52, 53], and some investigations have not detected any significant gender differences [54]. These gender-based disparities may be attributable to prevailing social roles and stereotypes, which traditionally encourage women to be more health-conscious while leading men to downplay health concerns and exhibit a greater tolerance for risky behaviors.

The present study’s outcomes also align with previous research indicating that individuals with higher educational levels generally demonstrate increased health vigilance [46]. Furthermore, in older adult populations, higher educational attainment is consistently associated with the adoption of health-promoting behaviors designed to enhance cognitive function, broaden knowledge, and facilitate the acquisition of new skills [50, 55].

This observation is well-founded: higher education appears to elucidate the importance of health and encourages individuals to engage in health-promoting behaviors. Indeed, education enhances individuals’ ability to comprehend and utilize health resources and information regarding nutrition, physical activity, and stress management, thereby facilitating improvements in overall well-being [56]. Moreover, educated individuals often exhibit greater psychological resilience when confronted with health challenges, leading to more rapid treatment acceptance and improved adherence to medical recommendations [57]. Consistent with our findings, Abdolkarimi et al. [58] identified marital status as a predictor of a health-promoting lifestyle. Married individuals tend to demonstrate a stronger commitment to health-related behaviors than single individuals, possibly due to factors such as emotional support, spousal monitoring of health practices, and a heightened motivation to maintain health for the sake of family care [59, 60]. Furthermore, existing research indicates that spousal social support can positively influence the management of chronic diseases, enhance physical activity, and promote adherence to a healthy diet [61]. In contrast, single individuals may experience higher levels of stress and social isolation, which can detrimentally affect quality of life and hinder the adoption of healthy behaviors [62]. Therefore, the findings of this study, in conjunction with previous research, underscore the pivotal role of marital status in the adoption and maintenance of a healthy lifestyle among older adults. Given the influential role of marriage in fostering health-promoting behaviors, it is advisable to develop support programs and social policies that encourage sustainable marital relationships and create conducive social and cultural conditions for remarriage among the elderly, particularly for those who have lost their spouses.

Limitations

The study was subject to several notable methodological limitations. Primarily, the relatively small sample size, compounded by the use of convenience sampling from a single clinic, may have compromised the external validity of the findings and, consequently, their generalizability. Moreover, the simultaneous administration of four self-report questionnaires constitutes an additional limitation, as the time-intensive nature of this data collection method may have induced respondent fatigue, potentially diminishing the quality of participants’ responses. Furthermore, given that the study’s conclusions rely heavily on the validity of self-report instruments, future research would benefit from incorporating more objective data collection methods—such as direct observation and structured interviews—to enhance the methodological rigor of the investigation. The cross-sectional design of our study limits the ability to establish causal relationships among the variables examined. To deepen our understanding, future research should employ longitudinal designs and prospective cohort methodologies across diverse regions in Iran and other countries. Also, as the study was conducted in the south of Iran, the findings may not be transferrable to other parts of the country. Thus, it is suggested that similar studies be conducted in other regions of Iran and other countries.

Conclusion

This study identified moderate levels of spiritual well-being, health-promoting lifestyles, and resilience among older adults with hypertension. Furthermore, the analysis revealed a significant association between spiritual well-being and both health-promoting lifestyles and resilience, with spiritual well-being serving as a predictor for the latter variables in this demographic. Therefore, enhancing spiritual well-being may be a valuable strategy for promoting overall well-being and mitigating chronic diseases linked to unhealthy lifestyles in older adults. It is recommended that spiritually-based interventions—such as meditation, prayer, or mindfulness practices like yoga or tai chi, as well as facilitating access to religious services or spiritual counseling tailored to individual beliefs—be integrated into routine care at health clinics. Moreover, collaboration among various healthcare professionals, including geriatricians, psychologists, and social workers, is essential to provide comprehensive care. Establishing partnerships between healthcare organizations and community or religious centers to create spaces where older adults can engage in spiritually enriching activities while receiving peer support is also crucial. By incorporating these strategies into existing healthcare frameworks, we can enhance the overall well-being of older adults, particularly those with hypertension, thereby allowing the positive effects of spirituality to influence their lifestyle and resilience.