Study design and participants
The method of the current study was correlational path analysis. The study population included all the elderly with CVD living in Kermanshah city in 2022, of whom 298 (181 men and 117 women) elderly with CVD referring to Imam Ali Hospital with a stable condition were selected using convenience sampling. Regarding the sample size, it is necessary to explain that in the analysis of Stevens [61], 15 cases for each predictor variable in the multiple regression analysis with the standard least squares method are considered a rule of thumb. Accordingly, it can be stated that because path analysis is completely related to multivariate regression in some aspects, 15 items for each measured variable in path analysis is not unreasonable. Loehlin [62] states that for models with two or four factors, the researcher should plan on collecting at least 100 cases or more, about 200. Therefore, taking into account 15 subjects for each component and considering that the current research included 18 components, the minimum number of samples required to conduct the study is 270. By taking into account factors such as incomplete or distorted questionnaires, 10 percent was considered a dropout, and the questionnaire was given to 300 people. Inclusion criteria included (1) age 60 and above, (2) informed consent, and (3) a diagnosis of cardiovascular disease. Exclusion criteria include (1) open heart surgery (CABG), (2) heart failure, (3) history of myocardial infarction in the past 6 months, (4) history of drug abuse, (5) cancer diagnosis, (6) presence of congenital heart disease, (7) experience of bereavement of loved ones in the past 6 months, (8) Corona disease in the last two months, (9) history of previous hospitalisation due to heart disease, and (10) the presence of any severe psychological disorder based on the medical records of the individuals (in order to check this criterion, the participants were asked if there was a history of diseases such as Alzheimer’s disease or dementia in their records.
Measures
Demographics Collection Sheet
Using this sheet, we asked participants to provide their demographic information, including age, level of education, marital status, occupation, and income.
Quality of Life Questionnaire (Short Form)
The 12-item version of the QOL questionnaire, designed by Ware et al., has eight subscales (four physical and four psychological) [63]. The physical component includes the overall perception of one’s health, physical functioning, physical health, and physical pain. The psychological component includes emotional problems, social functioning, vitality and vital energy, and mental health. Due to the small number of items, the individual’s overall score is often used. To fill out the questionnaire, participants rate the items on a 5-point Likert scale from 1 to 5. The minimum and maximum scores are 12 and 60, respectively, with a higher score indicating a better quality of life. Using Cronbach’s alpha coefficient, Ware et al. showed that the reliability of physical and psychological components was 0.89 and 0.76, respectively [63]. In Iran, Montazeri et al. reported the reliability of physical and psychological components based on Cronbach’s alpha coefficient to be 0.73 and 0.72, respectively [64]. In the current study, the Cronbach’s alpha coefficients for the physical and psychological components were 0.77 and 0.74, respectively.
Sense of Coherence Questionnaire (Short Form)
The SOC questionnaire, prepared by Antonovsky [65], has 29 items. In this study, the short form of the questionnaire, with 13 questions, was used. Participants rate the items on a 7-point Likert scale from 1 to 7. A score between 13 and 26 means a low SOC; a score between 26 and 52 means a medium SOC; and a score above 52 means a high SOC. In a systematic review of 458 scientific articles and 13 doctoral theses between 1992 and 2003, Eriksson et al. concluded that the SOC questionnaire (29 questions and 13 questions) is reliable and valid [66]. In Iran, the 13-question form has been validated by Mahammadzadeh et al., and its Cronbach’s alpha was 0.77. In the current study, the Cronbach’s alpha coefficient for the SOC questionnaire was 0.79 [67].
Spiritual Well-Being Scale (SWBS): Paloutzian and Ellison created this questionnaire, which consists of 20 items, 10 of which assess religious health and the remaining 10 assess existential health.Participants' responses to the items on a 6-point Likert scale ranged from strongly disagreeing (1 point) to strongly agreeing (6 points). The minimum and maximum scores are 20 and 120, respectively. Spiritual health is classified into three levels: low (40–20), medium (99–41), and high (120–100). Paloutzian and Ellison considered this questionnaire valid and reported Cronbach’s alpha coefficients for religious and existential health and the total score as 0.91, 0.91, and 0.93, respectively [68]. In Iran, Allahbakhshian et al. reported a Cronbach’s alpha of 0.82 for the total score of this questionnaire [69]. In the current study, Cronbach’s alpha coefficients for religious health, existential health, and spiritual well-being were 0.81, 0.76, and 0.80, respectively.
Short Form of Self-Compassion Questionnaire (SCS-SF): The SCS-SF, developed and validated by Raes et al., has 12 items and three subscales: self-kindness-self-judgement, common humanity-isolation, and mindfulness-overall. The items have been scored on a 5-point Likert scale, from never (1) to always (5) [70]. The minimum and maximum scores are 12 and 60, respectively, with a higher score indicating higher self-compassion. Raes et al. [70] calculated the internal reliability of the SCS-SF using Cronbach’s alpha coefficient to be 0.86 and stated that it has an adequate correlation with the long form of this questionnaire. In Iran, Khanjani et al. reported Cronbach’s alpha coefficient for the subscales of self-kindness and self-judgement, common humanity and isolation, and mindfulness and overidentification, as well as the total score, to be 0.68, 0.71, 0.86, and 0.79, respectively [71]. Khanjani et al. also reported test-retest reliability with a one-week interval to be 0.90. In the current study, Cronbach’s alpha coefficient for the total score was 0.84.
The Pain Self-Efficacy Questionnaire
This questionnaire, compiled by Nicholas based on Bandura's theory, evaluates the patient’s belief in his ability to perform various activities despite the presence of pain. This questionnaire evaluates the efficiency and sufficiency of a person's life with pain. Participants responded to this single-factor questionnaire on a 6-point Likert scale, ranging from zero (I am not sure at all) to six (I am completely sure), with scores ranging from 1 to 61. A higher score indicates a strong belief in doing daily activities despite the presence of pain [51]. Asghari & Nicholas considered the validity and reliability of the Persian version of the PSE questionnaire using confirmatory factor analysis in a sample of 348 patients with chronic pain; the results showed that the single-factor version of the PSE questionnaire has a good fit in the studied population [72]. Asghari & Nicholas also reported the Cronbach’s alpha of the PSE questionnaire to be 0.92 [72]. Abedi Ghelich Gheshlaghi et al. reported the reliability of the questionnaire using three methods of test-retest with a three-day interval, Cronbach’s alpha coefficient, and halving to be 0.81, 0.78, and 0.77, respectively, which indicates the satisfactory reliability of the questionnaire [73]. Cronbach's alpha was calculated to be 0.78 in the current study.
Procedure
After obtaining permission from the Ethics Committee of Kermanshah University of Medical Sciences and obtaining other necessary permissions to conduct the research from competent authorities, the preliminary stage of the research was carried out. As several questionnaires were available for measuring the variables of this research, the existing questionnaires were considered, and among them the questionnaires whose questions and subscales were closer to the objectives of the study were selected. Meanwhile, taking into account that patients with CVD, especially the elderly, are in special physical and mental conditions due to the burden of the disease, and in order to increase the accuracy of the study and receive more correct and accurate answers, we tried to use the shortest form of the questionnaires, if possible, to conduct this study. The questionnaires having been designed in the Digit system (an online questionnaire on the web), a trained interviewer invited eligible patients to participate in the research and complete the questionnaire by referring to the inpatient departments. After justifying the research to the subjects, explaining the objectives, and obtaining the consent form, as well as reassuring them about the confidentiality of the answers and the need not to mention names, it was emphasised that the subjects complete and accurately fill out the questionnaires.The participants were requested to ask the researcher for further explanation if they encountered a problem such as ambiguity in the questions in the process of completing the questionnaire. Moreover, patients were asked to answer the questions when they had the right conditions. After collecting information and removing two distorted questionnaires (a software problem in data recording), Therefore, the data of 298 participants was analysed using Pearson's correlation coefficient and path analysis in SPSS 26 and LISREL 10.2 software. It needs to be mentioned that the sex and age of the participants were considered to be control variables.