INTRODUCTION
As the elderly population increases worldwide, there is a corresponding rise in age-related illnesses, which in turn highlights the growing need for home care services [1,2]. Home care service is a type of service that requires a serious and planned organization, is open to external factors, requires a separate team and training, and is relatively difficult to control. In this process, the family may experience economic, social and psychological distress due to living with a patient continuously. For the informal caregiver, daily activities such as providing proper care to the sick person, giving medications at the right time, ensuring personal hygiene, and feeding the patient may be difficult and may create pressure on the person [1,3]. Interventions for emergencies can be difficult as there may ot always be a healthcare professional with the patient [4].
Psychological well-being can be defined as the ability of individuals to manage the situations they encounter in their lives that come from their existence [5,6]. Although psychological wellbeing is evaluated as the absence of negative conditions (anxiety, depression, etc.) in people, it is stated that this situation does not meet the full meaning. Ryff and Keyes [7] put forward a model of psychological well-being. There are six dimensions in this model [6,7]. Psychological well-being is of great importance for individuals receiving home health care services [7].
Death is inevitable for all human beings; the important thing is to come to terms with this reality so that growth and development can continue [8]. At this point, death education can be effective in reducing death anxiety and changing negative attitudes towards the care of the terminally ill patient by raising the nurse’s awareness of the phenomenon of death [9]. Death education programs first started in the United States of America (USA) and then became widespread in countries such as Canada and the UK, and advanced death education programs were established [9,10]. Death anxiety is a lifelong feeling that starts from birth and lasts throughout life, and develops after the realization that the person will no longer exist, that he/she may lose himself/herself and the world, that he/she may be nothing. It is defined in different ways in the literature and sometimes confused with fear of death or used in a similar sense [11]. Age, gender, personality traits, sociocultural factors, developmental process, religious beliefs, and terminal illness were found to be associated with death anxiety [12]. Spirituality refers to all the inner resources to which an individual is connected. Even if an individual does not believe in any religion or power, the importance and balance he/she attaches to life and inner peace is the content of spirituality. Spirituality is not necessarily related to religion. Spirituality is an important phenomenon that affects psychological well-being and death anxiety processes [12-14].
In this study, impact of death anxiety and spirituality on psychological well-being of geriatric home care patients will be determined. This study focuses on elderly individuals receiving home care, a population often overlooked in previous research on death anxiety, spirituality, and psychological well-being. By addressing this gap, the study contributes to the literature by highlighting how these factors are associated in a vulnerable group and by drawing attention to an underexplored aspect of geriatric healthcare. We propose two hypotheses.
H1: Spirituality has an effect on psychological well-being in elderly home care patients.
H2: Death anxiety has an effect on psychological well-being in elderly home care patients.
H01: Spirituality has no effect on psychological well-being in elderly home care patients.
H02: Death anxiety has no effect on psychological well-being in elderly home care patients.
METHODS
Research design
The study was planned in a descriptive cross-sectional design. The research data were collected by the researchers between January 30, 2024 and June 30, 2024 by face-to-face survey method. The population of the study consisted of 735 elderly patients aged 65 years and over registered in the home care unit of a state hospital located in a province in eastern Türkiye. The sample size was 253 home care patients with alpha= 0.05, 95% confidence interval in case the population was known. The study was completed with 280 home care patients. Following the study, a post hoc power analysis was conducted based on the results obtained from 280 participants, revealing that the study’s power is 99% at a medium effect size and a 95% confidence level [15]. The STROBE guideline was used in the reporting of this research paper [16].
Participants and procedure
Inclusion criteria
Individuals aged 65 years and older who were registered in the home care unit had no communication problems, and voluntarily agreed to participate in the study were included.
Exclusion criteria
Individuals under the age of 65 years, those who declined to participate, those diagnosed with severe psychiatric disorders, and those with advanced-stage cancer were excluded from the study.
Data collection: the researchers first informed the participants about the purpose of the study and then asked them to give written informed consent. Then, together with the home care nurses, they conducted face-to-face interviews with them at home (approximately 15-20 minutes) and asked them to fill in the data collection forms prepared by the researcher for this purpose.
Measurements
“Personal information form,” which was developed by the researchers after the literature review and “Spiritual Orientation Scale,” “Psychological Well-being Scale,” and “Death Anxiety Scale” were used as data collection tools. The personal information form prepared by the researchers consists of questions (age, gender, education level, income level, etc.).
The Spiritual Orientation Scale developed by Kasapoğlu [17] was used to assess their spiritual orientation. The Spiritual Orientation Scale consists of 16 questions determined with a 7-point Likert scale. In this study, the scale items were designed according to the perspective of belief in a higher power, meaning and search, and prayer/meditation, which are accepted as the basic criteria of spirituality. A high score on the scale indicates a high level of spiritual orientation. Cronbach’s α coefficient of the scale was found to be 0.87 [17]. In our study, Cronbach’s α value of the scale was found to be 0.94.
The Psychological Well-being Scale was developed by Diener et al. [18] to measure socio-psychological well-being as a complement to existing well-being measures. The scale was adapted into Turkish by Telef [19]. The items of the Psychological Wellbeing Scale are answered between 1-7 in the form of strongly disagree (1) to strongly agree (7). All items are expressed positively. Scores range from 8 (if strongly disagree with all items) to 56 (if strongly agree with all items). A high score indicates that the person has many psychological resources and strengths. Cronbach’s α coefficient was 0.80 [19]. In our study, Cronbach’s α value of the scale was found to be 0.93.
The scale created by Sarıkaya and Baloğlu [20] consists of 20 items and measures death anxiety. The items of the scale are evaluated on a 5-point Likert scale. The lowest score that can be obtained from the scale is 0 and the highest score is 80. The range of 0-12 points indicates very low death anxiety, 13-29 points indicates low death anxiety, 30-47 points indicates moderate death anxiety, 48-64 points indicates high death anxiety, and 65-80 points indicates very high death anxiety. The scale consists of 3 sub-dimensions: uncertainty of death, exposure, and suffering. The uncertainty of death sub-dimension includes questions 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 of the scale. The highest score that can be obtained from this sub-dimension is 40 and the lowest score is 0. Exposure sub-dimension consists of questions 11, 12, 13, 14, 15, 16, and 17. The highest possible score for this subscale is 28 and the lowest possible score is 0. Suffering sub-dimension consists of questions 18, 19, and 20 of the scale. The highest possible score for this sub-dimension is 12 and the lowest possible score is 0. Cronbach’s α coefficient was 0.95 and test-retest reliability was 0.82 [20]. In our study, Cronbach’s α value of the scale was found to be 0.95.
Statistical analysis
The analysis of the study data was performed by using SPSS 22.0 (IBM Corp.), and G*Power 3.1 Statistical package software (Heinrich-Heine-Universität Düsseldorf). Percentage, arithmetic mean, standard deviation, and minimum and maximum values were calculated using SPSS 22.0. Necessary normality tests were performed in the process of analyzing the data and it was understood that the data showed normal distribution (kurtosis and skewness, -1.5 to +1.5) [21]. p-value of <0.05 was considered statistically significant. Predictive analyses were performed with R programming language version 4.1.3 (R Core Team). In addition to conventional statistical analyses, machine learning techniques were employed to explore the relative importance of predictors and to provide a complementary analytical perspective for understanding the factors associated with psychological well-being.
Ethics approval
Ethical approval for the study was obtained from a university scientific research and publication ethics committee in Türkiye (Date and Number: 08.11.2023-116369). Then, institutional permission (Approval no. 24.01.2024. E-35465298- 619-235024677) was obtained from the Provincial Health Directorate where the research was conducted. Written informed consent was obtained from all participants with the voluntary consent form after they were informed about the purpose of the study, the procedures involved, and their voluntary participation. Throughout the research process, the researchers adhered to the principles outlined in the Declaration of Helsinki. Publication permission was obtained from the participants.
RESULTS
In our study, 55.0% of the individuals were women, 36.8% were primary school graduates, 55.7% had less income than expenses, 56.8% had poor health perception, 87.9% received support, 43.2% had received home care services for 0-2 years, 31.8% had cardiovascular disease, 87.5% used assistive devices, and the mean age was 75.77±8.73 years (Table 1).
The results of the hierarchical regression models, conducted to reveal the effects of death anxiety and spirituality on psychological well-being were examined.
Statistical estimates for Model 1 show that the model is significant and usable (F(1,278)=23.509, p=0.001). Death anxiety level explains 7.5% of the total variance of psychological well-being level. In the regression model, when the t-test results regarding the significance of the regression coefficient were analyzed; it was found that the decrease in the level of death anxiety of the participants (t=-4.849, p<0.001) caused a statistical increase in the level of “psychological well-being.”
Statistical estimates for Model 2 show that the model is significant and usable (F(2,277)=23.834, p=0.001). Death anxiety and spirituality explain 14.1% of the total variance of psychological well-being. In the regression model, when the t-test results regarding the significance of the regression coefficient were examined, it was found that the decrease in the level of death anxiety (t=-4.253, p<0.001) and the increase in the level of spirituality (t=4.728, p<0.001) caused a statistical increase in the level of “psychological well-being” (Table 2).
The dataset used in this study focuses on the Psychological Well-being Scale. The dataset is divided into 70.0% training and 30.0% test data for training and testing the model, so that the training set has 197 observations and the test set has 83 observations. The models built for Psychological Well-being Scale prediction and the determination of the best hyperparameters based on logarithmized train data are given in Figure 1.
The metrics (root mean squared error and mean absolute error) used to compare the hyperparameter values are given in Figure 2. In the analysis, the random forest method found the most successful result.
The prediction performance of the model on the test data is shown in Figure 3.
According to the Shapley variable, Spirituality Scale was determined as the most important variable in the prediction of the Psychological Well-being Scale variable (Figure 4). In addition to conventional statistical analyses, machine learning analysis using the random forest algorithm was performed to further evaluate the predictive importance of the variables. The results of the Shapley value analysis indicated that spirituality was the most influential predictor of psychological well-being, followed by death anxiety. These findings support the results obtained from the hierarchical regression analysis and provide additional insight into the relative contribution of the predictors.
The distribution, interaction, and density graph of the variables Psychological Well-being Scale, Death Anxiety Scale, and Spirituality Scale are given in Figure 5.
DISCUSSION
In our study, we aimed to determine the effect of death anxiety level and spirituality level on psychological well-being in geriatric home care patients. In this section, the findings are discussed in the light of the literature.
In our study, there is a significant relationship between death anxiety level and psychological well-being. As the level of death anxiety decreases, psychological well-being increases. The result of this study supports the result of Eslami and Omranian [22] that death anxiety has a direct and significant effect on wellbeing and that death anxiety is a factor that reduces psychological well-being. In a study, it was also found that there was a weak negative relationship between death anxiety and psychological well-being [23]. In addition to these studies, Nagaraj and Nithyanandan [24] also found a significant negative relationship between death anxiety and psychological well-being. Shukla and Rishi [25] found an inverse relationship between death anxiety and well-being in those who reported higher levels of death anxiety, which supports the results of our study.
In our study, there is a significant relationship between spirituality level and psychological well-being. As the level of spirituality increases, the level of psychological well-being increases. In a study, it was found that there is a significant relationship between spirituality and psychological well-being [26]. The result that spirituality is related to psychological well-being is in parallel with our study. In a different study, it was also emphasized in their study that although high levels of spirituality are not protective, low levels of spirituality can harm psychological well-being [27]. In our study, the increase in psychological wellbeing with increasing spirituality level supports this result. Akbayram and Keten [28] showed that spirituality has a positive effect on psychological well-being and psychological resilience. Singh and Sharma [29] also showed a positive relationship between psychological health and spirituality. Similar results were found in the literatüre [30-33]. In a study, it was found that religiosity and spirituality are important predictors of psychological well-being, in contrast to demographic factors and traditional factors such as social resources and physical health [34]. When we look at our study findings and the studies conducted, it shows that the level of death anxiety and spirituality level affect the level of psychological well-being.
In light of previous studies, our findings extend the literature by examining the combined effects of death anxiety and spirituality, specifically in geriatric home care patients. Unlike studies conducted in general elderly populations or institutionalized settings, this research highlights the psychosocial determinants of well-being in a home-based care context. This novel focus provides new knowledge to inform the design of holistic interventions and underscores the need for integrating spiritual and psychological support into community and home healthcare models.
Conclusions
With the increase in the elderly population, the number of individuals receiving home care services is gradually increasing. Spirituality, psychological well-being and death anxiety are among the most important issues in geriatric individuals. As a result of this study, it was determined that the decrease in the level of death anxiety of the participants receiving elderly home care services caused a statistical increase in the level of “psychological well-being.” In this study, it was determined that the decrease in the level of death anxiety and the increase in the level of spirituality of the participants caused a statistical increase in the level of “psychological well-being.” In line with the research findings, formal and informal caregivers who take care of elderly individuals should help to meet the spiritual needs of the elderly. The effects of death anxiety and spirituality on psychological well-being should be taken into consideration. Health professionals should provide health services without ignoring the spirituality, death anxiety, and psychological well-being of the geriatrics. In conclusion, this study not only demonstrates the interplay between death anxiety, spirituality, and psychological well-being in home care patients but also fills an important gap in the literature by focusing on a neglected population.
Limitations
This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design limits the ability to infer causal relationships between death anxiety, spirituality, and psychological well-being. Second, the data were collected using self-report scales, which may introduce response bias and social desirability effects. Third, the study sample consisted only of elderly individuals receiving home care services in a single province in eastern Türkiye, which may limit the generalizability of the findings to other populations or healthcare settings. Future studies using longitudinal designs and more diverse samples are recommended to strengthen the generalizability of the results.
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