The present study was quasi-experimental research conducted before and after, in control and intervention groups. It evaluates the effect of spiritual self-care training independent variable on the amount of care giving strain in mothers of mentally retarded children, who went to Elahi Mentally Retarded Rehabilitation Center in Quchan City between August 2015 and April 2016. This study was conducted after it received the ethical approvement from Zabol University of Medical Science and got the agreement from the head of Rehabilitation Center. The population under study consists of all the mothers of mentally retarded children hospitalized in Elahi Rehabilitation Center in Quchan who had the inclusion criteria for this research. Mothers who met the following criteria were included in the study: having a mentally retarded child, being Muslim, primary school education (minimum), having filial and parental relationship, lack of definite depression diagnosis, and non-use of antidepressants and narcotics. The exclusion criteria were as illiteracy, having half-mother-child relationship, definite depression diagnosis, using antidepressants and narcotics, and rejecting to participate in the study. The sample size was calculated based on the results of pilot study [22] to determine approximately 32% of the difference in the difference of caregiving strain score variation percentage in the two groups with and without intervention. Considering 10 percent sample dropping, the study evaluated 0.05 % type one error and 90% statistical power of 30 people in the intervention group and 30 people in the control group. The samples were selected using convenience sampling and after the subjects were qualified and the informed consent from the research community was obtained, they were randomly assigned to the intervention and control. For blinding (single blind) of the study, two groups were separately invited to explain the aims and methods of the research.

The data collection tools in this study were as follows: Demographic characteristic questionnaire conducted after studying books and articles and consulting with 10 teachers of the Zabol Medical Science University. Test-retest method was used in order to assess the repeatability and reliability of the questionnaire. The questionnaire included 13 questions related to mother’s personal information, namely, age, residence, marital status, number of children, number of mentally retarded children, education, insurance, occupation, income, having occupational disease, years of caring for the child, and child personal information, namely, age, sex and having occupational disease.

Multidimensional Caregiver Burden Inventory which has 24 points and was invented by Novak and Guest in 1989 [23] is a questionnaire which has 5 sub-scales including: a) time-based caregiving strain (choices 1 to 5) which is indicative of the time a caregiver spends looking after their patient; b) Evolutionary caregiving strain (choices 6 to 10) which indicates the amount of pressure put on the caregiver during their different life cycles (like maturity) due to caring for the patient; c) Physical care giving strain (choices 11 to 14) which reveals the physical strain and exhaustion caused during the time the care giver spends looking after their patient; d) Social care giving strain (choices 15 to 19) that represents social life aspects caused during the time the caregiver spends looking after their patient; e) Emotional caregiving strain (choices 20 to 24) that represents the caregiver’s emotions and feelings caused during the time the caregiver spends looking after their patient. This questionnaire measures the caregiver’s response using 5-point Likert scales (Strongly Disagree (1), Disagree (2), Undecided (3), Agree (4), and Strongly Agree (5) choices scores between 24 and 56 were judged as poor, 56–88 average, and 88–120 good [22]. Internal and external studies confirmed the validity and reliability of caregiving strain questionnaire. Ali Abasi et al., used content validity in order to determine the validity of the questionnaire with its content validity index based on relevance 91.8%, clarity 90.2%, simplicity 93.6%, and in total is 93.6%. They also showed that reliability analysis using Alpha coefficient internal consistency for full-scales is 0.90% and the Alpha coefficient for the sub-scales is from 0.76 to 0.82 % [8]. Mc Cleery et al., also reported the reliability of the questionnaire using Cronbach’s alpha coefficient for each of the following sub-scales, time-based caregiving strain, evolutionary caregiving strain, physical caregiving strain, social caregiving strain, and emotional caregiving strain. They determined Cronbach’s alpha coefficient for the whole questionnaire to be 0.80% [24].

Training intervention of this study was performed based on Richards and Bergin’s religious-spiritual strategies [25] and conducted in line with Islamic approach in such topics as self-awareness, invocation, reliance and resort, patience, forgiveness and praise after training content was confirmed by religious authority (educator). The educator was studied in seminary and has M.A, covered in Islamic dress and based on the languages spoken in the region was fluent in three languages, namely, Persian, Turkish, and Kurdish. The training was conducted during six 45-minute sessions, for a 2-week period every other day (3 sessions on the even days of the week on morning work shift) [Table/Fig-1].

Mothers were randomly assigned to intervention and control groups for data collection. Mothers of both groups completed demographic characteristic questionnaire and caregiving strain questionnaire. Furthermore, after the completion of all training sessions, mothers, again, filled out caregiving strain questionnaire in both groups.

SPSS Version 20 was used for data analysis. Demographic variable consistency of the groups was examined by Chi-Square test and Independent t-test (Mann-Whitney U test) for comparing the means and impacts of intervention on the mother caregiving strain repeated measure test was employed. Moral considerations such as data confidentiality and patient’s right to opt out anytime they want were also taken into account. Moreover, after the completion of the study, the training content was placed on an educational CD and was presented to the control group in a training session.

The study consists of 60 people, who were divided equally in the intervention group and in the control group. Results of the study showed that the mean age was 6.815±39.37 and 10.176±42.6 in the intervention and control groups, respectively{within the age range of 51-60 (8%), 41-50 (21%), 31-40 (24%) and 21-30 (7%)}. The mean SD age of the children was 7.10±3.43 and 10.43±3.081 in the intervention and control groups, respectively [Table/Fig-2]. The mean of years of caring for the child was 8 in both the intervention and control groups. The results of independent t-test (Mann-Whitney U test) showed that the child age and years of caring for the child in the intervention and control groups were significantly different [Table/Fig-3]. The results of Chi-square test showed that among other pieces of information including child sex, marital status, education, income, occupation, residence, mother physical disease, and child physical disease, only the marital status between the two groups was significantly different [Table/Fig-4].

Based on [Table/Fig-2], in the beginning of the study only the marital status between the intervention and control groups was significantly different.

Based on the results, the total mean±SD of caregiving strain in all the subjects, before the intervention was 78.17±21.36 According to the independent t-test results, comparison of the mean scores of mothers’ caregiving strain in the two groups showed no significant differences before the intervention, in fact, the two groups were similar. The results of repeated measure test and comparison of the mean scores of caregiving strain in the intervention and control groups showed no significant differences before and immediately after the intervention. However, according to the repeated measure statistical test, the mean scores in the two groups was significantly different two weeks after the intervention. It also determined that after two weeks, the intervention group’s scores were slightly decreased to 87.21% which was not statistically significant given the length of time (p=0.0001) before the intervention. However, the subject scores in the control group were increased 5% with the length of time which was not statistically significant (p=0.4). Also, Mann-Whitney U test results showed that 21% and 5% variation was statistically significant difference in the intervention and control groups, respectively (p=0.0001).

It can be concluded that self-care training, significantly reduced mother’s caregiving strain score in the intervention group in comparison with control group two weeks after intervention [Table/Fig-5]. The observed differences between the groups were also statistically significant even after controlling the effects of such intervening factors as marital status, children age, and the years of caring for children based on repeated measure test (P=0.001).

In the present study, spiritual self-care training showed no effects on caregiving strain in mothers having mentally retarded children immediately after the intervention. However, two weeks after the training, statistically significant difference was observed in the scores of mothers’ caregiving strain in the intervention and control groups. This shows the positive effects of spiritual self-care training on the reduction in mother’s caregiving strain. Also, the given training provides no immediate effect; rather it needs longer period of time to bring about significant effects. The present study showed the positive effects of spiritual self-training on the follow-up stage.

The results of Lotfi Kashani et al., study corresponding with this study also showed that spiritual intervention reduces distress in mothers having a child with cancer and this reduction continues up to the follow-up stage [26]. In addition, spiritual intervention in Lotfi Kashani study was 6 sessions of psychotherapy based on spiritual intervention proposed by the Islamic of Richards and Bergins. In it, distress variable had a close relationship with caregiving strain [26]. Andrews suggested that the relationship between symptoms of distress and caregiving strain was statistically significant [27] while for Gratao et al., caregiving strain was a distress risk factor [28]. For Reyhani et al., spiritual self-care training reduces psychological stress and increases distress tolerance in mothers of a premature baby [14]. Although its population and variable, under study, are different with the present study, it is compared with the present study because both studies indicate the positive effects of self-care training. Furthermore, Ahmadi et al., determined that there is a positive significant relationship between secure attachments to God and resiliency and parental mental health of educable mentally retarded children. They concluded that the variation in people’s quality of attachments to God can improve their mental health [29]. Moreover, Mosadegh et al., explained spiritual understanding component training as an approach to mental health in mothers with children having mild mental retardation [16]. Despite the differences with the present study, their results are close to this study since they define the role of spiritual dimension strength in improving parental mental health of mentally retarded children. Mosadegh’s study, similar to the present study, focused on the positive effects of spiritual understanding component training. This kind of training would strengthen the subjects’ spiritual beliefs and help them better cope with impending situations. As the results of Rahnama et al., study showed, communication with God and religious beliefs have a positive effect on the adjustment of the participants in the study and therefore they suggested putting emphasis on these beliefs during religious consulting sessions [30]. Mc Nally et al., in one of their qualitative studies entitled “Taking care of caregivers of retarded children” identified the theme of caregivers’ beliefs as an adaptive mechanism [31]. In this regard, Lotfi Kashani et al., quoted that spiritual beliefs can help people prevent distress and anxiety in facing with life uncontrollable events such as death or severe disease [26]. This study identified that mothers of mentally retarded children were under caregiving strain due to caring for their children to the point that more than half of them had a score higher than the mean of caregiving strain. Child’s deep attachment to the mother in all matters and all the time possibly affected such results. According to Bartolo et al., there is a significant inverse relationship between caregiver’s caring strain and patient autonomy performance [21]. Chang et al., also observed that caregivers who spent more hours during the day caring for their patients experienced more caregiving strain and had lower mental health [32]. Likewise, for Abbasi et al., the more time patients needed to be cared for, the more caregiving strain caregivers endured [32,33]. All these conducted studies correspond to the results of the present study.

Sampling time restriction and the long spiritual self-care training process were limitations in the present study which limited the possibility of doing research with bigger sample size.

The present study showed that spiritual self-care training can reduce mother’s caregiving strain of mentally retarded children during six 45-minute sessions, for a 2-week period. Thus, strengthening mother’s spiritual beliefs and backgrounds can greatly reduce the strain caused by caregiving problems of mentally retarded children as well as reduce their adaptation to the related problems. Iran’s religious background provides the ground for conducting such training and parents are advised to use this kind of training in Mental Retardation Rehabilitation Centers.