Despite notable advancements in current medical technology, the challenges of addressing chronic diseases persist, and the issue of "multiple comorbidities" among the aging population has garnered significant attention. Individuals with diabetes are more susceptible to experiencing two or more simultaneous chronic diseases. According to a survey conducted by the Health Promotion Administration of the Ministry of Health and Welfare in 2015, titled "Longitudinal Survey on Physical, Physiological, and Social Aspects of Middle-aged and Older Adults," 88.7% of older adults reported suffering from at least one chronic disease, while 51.3% experienced three or more chronic conditions [1]. According to the "2017 Taiwanese Older Adults Health Condition Survey Report," 35% of older adults with chronic diseases expressed that their physical or emotional problems affected their social interactions. Additionally, 22% of individuals faced limitations in their work or daily activities due to physical health concerns [2]. Notably, chronic diseases were the leading causes of death in Taiwan in 2018, encompassing eight diseases of malignant tumors, heart disease, cerebrovascular disease, diabetes, chronic respiratory disease, hypertensive disease, nephrotic syndrome and nephropathy, as well as chronic liver disease and cirrhosis. This underscores the importance of prioritizing non-communicable diseases prevalent among older adults (e.g., cancer, heart disease, diabetes, hypertension, and other chronic conditions) in future healthcare strategies [3].
The prevalence of chronic diseases not only imposes a financial and healthcare burden on a nation but also implies an increased likelihood of individuals developing chronic, severe, and life-threatening diseases as the average life span increases in an aging society. Navigating the diagnosis and treatment processes of these conditions often entails physical discomfort, negative emotions, and changes in personal relationships. Nevertheless, patients who undergo Life-transforming changes (LTC) due to their illnesses can experience positive Psycho-social-spiritual (PSS) changes, even if the treatment outcomes are unfavorable [4, 5]. "Spiritual health" refers to an individual's behavioral beliefs or principles that achieve a sense of inner peace, reflect personal values, or acknowledge a higher power beyond faith, facilitating self-realization [6]. Promoting spiritual health is similar to providing social support, enabling individuals to cope effectively with life, particularly during times of stress and crisis. Spirituality has a multi-faceted impact on individuals, operating on three levels. It promotes positive health habits, fosters improved social support systems, and enhances mental well-being [7]. Individuals who experience spiritual growth or have their spiritual needs met tend to exhibit a reduction in harmful health habits, lower stress hormone levels, and strengthened immune systems. This in turn can lead to a reduction in suicide, cancer, digestive system diseases, and cardiovascular diseases [8]. In other words, individuals who engage in a more spiritually active lifestyle can elevate their spiritual well-being, consequently bolstering their immune system and contributing to overall health improvement. Spirituality plays a preventive role in illness and health promotion, aiding in disease healing and assisting individuals in coping with diseases and adversity [9]. Spiritually healthy individuals exhibit more positive behaviors related to cancer screening, exercise, and dietary habits [10]. As a result, good spiritual development and spiritual health not only provide psychological comfort and promote self-realization but also exert a profound influence on physical health. This includes facilitating disease recovery, encouraging positive health behaviors, and fostering overall health promotion.
However, as noted above, aging and chronic diseases can lead to feelings of helplessness and significant changes in self-image, often resulting in spiritual struggles. These spiritual needs tend to revolve around learning to coexist with diseases, seeking understanding in the midst of suffering, requiring support and care, facing solitude, preserving personal value and self-esteem, discovering the meaning of life and self-realization, and preparing for death [11]. Despite the progress in medical technology, which has enabled patients with chronic diseases or cancer to extend their lives, these individuals may still encounter psychological challenges and spiritual distress due to shifts in the disease trajectory, different treatment approaches, and changes in physical conditions [12]. Given that chronic diseases not only bring physical challenges but also profoundly impact mental and spiritual well-being, research has begun to further explore how spiritual well-being can alleviate anxiety, depression, and improve the overall quality of life for patients [13, 14]. While spiritual health can have a positive impact on promoting overall health, the physical pain caused by illnesses, the fear of death, and a lack of hope for life can lead to spiritual struggles and challenges for patients with diseases. For instance, terminal cancer patients may experience despair due to the impending threat of death. Even in cases of chronic diseases that do not immediately endanger life, the prolonged duration of the illness can erode hope for the future and impose the stress of learning to live with the condition over an extended period. Given these circumstances, it becomes imperative to focus on how to support older adults and chronically ill patients in addressing spiritual issues, enhancing their spiritual health, and comprehending the factors influencing spiritual well-being. Regulating one's lifestyle and fostering healthy behaviors, improving self-worth, establishing social support, cultivating positive emotions, and strengthening health beliefs through the enhancement of spiritual health may lead to a gradual recognition and appreciation of the value of spiritual well-being. Prior literature has reported the importance of psychological factors, such as "self-efficacy," in effectively predicting patients' self-care behaviors [15, 16, 17, 18]. Higher levels of self-efficacy or confidence in one's success drive greater effort and persistence in performing self-care activities, ultimately leading to better self-care outcomes [19].
Past research has revealed that "spiritual health" serves as a protective factor for overall well-being. It is regarded as a unifying force, capable of integrating other dimensions of health, much like a core connecting and serving as a fundamental resource for various health domains. Individual spiritual health plays a vital role in preventing diseases and promoting health, facilitating recovery from illnesses, overcoming adversities, and aiding individuals in finding meaning in life. In Taiwan, there is an increasing focus on research and practical initiatives concerning spiritual care in long-term care settings. However, limited attention has been given to studying the factors that influence spiritual health in the context of chronic diseases. Existing research primarily concentrates on major diseases, terminal cancer, and end-of-life stages. Therefore, the present study focused on factors impacting the spiritual health of older adults with chronic diseases. Furthermore, existing publications on spiritual health in Taiwan predominantly consist of literature reviews, with only a limited number of empirical research studies. To address this gap, this study aimed to review past relevant literature and then propose a new research model based on psychological factors such as self-efficacy, utilizing a structural equation model (SEM) to identify predictors for the spiritual health of elderly individuals with chronic diseases at the psychological level. The study outcomes offer valuable empirical data, laying the groundwork for constructing future models of spiritual health and spiritual care tailored to older adults. The research findings will be made available to practitioners in the field of spiritual care and other relevant practical fields for reference. This will aid them in formulating effective spiritual health promotion and spiritual care plans for the future.