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J Edu Health Promot 2023,  12:298

The effect of “Narrative writing reflection” method on the hope of patient with COVID-19: A health promotion intervention

Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission05-Nov-2022
Date of Acceptance16-Mar-2023
Date of Web Publication31-Aug-2023

Correspondence Address:
Dr. Shahla Mohamadirizi
Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jehp.jehp_1590_22

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BACKGROUND: Corona virus disease disease as a life-threatening respiratory disease causes psychological problems including hopelessness in patients. So the aim of this study was to determine the effect of Narrative writing reflection on hope of patient with COVID-19.
MATERIALS AND METHODS: The study was experimental with a pre-test-post-test and with the control group design. The subjects were randomly divided into the intervention (n = 30) and control (n = 30) groups. The intervention group received Narrative writing reflection. The control group was receiving routine care. Before and after the intervention, the patients were asked to complete the 12-item Herth Hope Index. Data were analyzed with by using spss software and paired t test and independent t-test with a significance level of P < 0.05.
RESULTS: Independent t-test showed that the hope scores before intervention in both intervention and control groups were not statistically significant (P > 0.05), whereas there was a significant difference between two groups after the intervention (P < 0.05).
CONCLUSION: The results of this study showed that the use of mindfulness methods such as narrative writing in hospitalized and quarantined patients who are unable to communicate with the outside environment could increase the hope in patient.

Keywords: COVID-19, health promotion, hope, narrative writing, Iran

How to cite this article:
Rafiei M, Mohammadi Z, Mohamadirizi S. The effect of “Narrative writing reflection” method on the hope of patient with COVID-19: A health promotion intervention. J Edu Health Promot 2023;12:298

How to cite this URL:
Rafiei M, Mohammadi Z, Mohamadirizi S. The effect of “Narrative writing reflection” method on the hope of patient with COVID-19: A health promotion intervention. J Edu Health Promot [serial online] 2023 [cited 2023 Sep 26];12:298. Available from: https://www.jehp.net//text.asp?2023/12/1/298/384700

  Introduction Top

In December 2019, a new type of coronavirus was detected in the city of Wuhan, China, and quickly spread throughout the world.[1] COVID-19 also spread rapidly in Iran. COVID-19 also spread rapidly in Iran. According to statistics, 4,833,135 confirmed cases of COVID-19 and 104,716 deaths have been reported in Iran from January 3, 2020, to August 27, 2021.[2],[3] Many studies have confirmed that the global pandemic, with the increase in cases and deaths and the lack of definitive treatment, has caused a wide range of psychosocial problems.[4],[5] Some studies have shown that COVID-19 patients have obvious adverse psychological effects such as fear, anxiety, depression, stress, and hopelessness after being discharged from the hospital.[4],[5],[6],[7] In this regard, Epstein et al.[8] emphasizes that although most of the world's attention is focused on the respiratory and cardiovascular complications of COVID-19 disease, many patients are facing psychosocial problems. In addition, patients are worried about transmitting the infection to their family and friends. All these feelings may aggravate the clinical patient's condition.

The fear of the coronavirus is intensified when the patient is hospitalized.[9] A study showed that most of the corona patients suffered from post-traumatic stress symptoms before being discharged.[10] The results of Shokri et al.,[11] 2020 study also showed that the level of stress and fear significantly increased after the COVID-19 crisis. Khademian et al.,[12] 2021 also pointed out the possibility of increasing psychological problems, including the level of stress, anxiety, and depression in the Iranian population during the outbreak of COVID-19.

Meanwhile, a positive attitude towards the future and hope for the future are known as coping factor in crisis.[13] Hope is a positive motivational state whose high levels are directly related to psychological health, high self-esteem, and positive thinking. Hope helps patients physiologically and emotionally to endure the crisis of the disease. Hope involves people's imaginations and attention to the future and leads to effort with the expectation of positive results. Hope is a multifaceted, dynamic, forward-looking, and process-oriented concept.[14]

Hopeful people can tolerate long and painful treatments and adhere better to treatment regimens. Having a clear understanding of the psychological well-being factors, including hope and providing a care plan with the aim of increasing hope in these patients is important. Evidence shows that hopelessness in patients causes more psychological damage.[15],[16] Therefore, healthcare providers especially nurses have to pay more attention to the hope concept in patients.[17],[18],[19]

Hopelessness people do not believe in their abilities and have an unfavorable idea to the future, and become frustrated and passive.[18] Having good health is one of the affecting factors on hope. However, the coronavirus has faced patients with a complex and potentially stressful situation, including isolation, uncertainty about treatment and prognosis, fear of death and infection of family, which leads to decrease their hope. In this regard, nurses are in a special position in using appropriate interventions, including narrative writing, to increase hope in these patients.[20]

Narrative writing is known as a powerful intervention to discover the abilities of people in different life situations. In this method, action and thought are linked together and is the basis for the feelings and emotions expression. It is a therapeutic method based on mindfulness that reduce distress, stress, and depression and increase the quality of life and emotional health of patients and their caregivers.[21] The results of Fan et al.[22] study showed that narrative exposure therapy had a positive effect on PTSS of COVID-19 patients. Considering the importance of the physical and psychological health of patients with the coronavirus and also considering that no study has been conducted to investigate the effect of narrative writing on the hope of patients with the coronavirus in Iran, the researcher decided to conduct this research.

  Materials and Methods Top

Study design and setting

This before—after, 2 groups—experimental study was conducted in 2021–2022 in 9th Dey of Manzariyeh Hospitalaffiliated to Isfahan University of Medical Sciences, Isfahan, Iran.

Study participants and sampling

The statistical population of the study consisted of 60 patients with COVID-19 who hospitalized to the 9th Dey of Manzariyeh Hospital. Inclusion criteria included having a informal consent; admission to the COVID-19 department; the stability of the patient's vital signs based on the patient's clinical information, not severe stress and death of a family member in the last 6 months, no history of drug abuse, Iranian nationality; and the ability to speak, read and write in Persian. Exclusion criteria included discharge earlier than 6 days from the time of hospitalization. Sample size was calculated using the following formula and parameters, n = (Z1 + Z2) 22S2/d2; Z = 1.96, Z2 = 84%, d = 0.5 S, it was estimated a total of 30 subjects per group were needed.

Data collection tool and technique

The data collection instrument consisted of two parts. The first part was a demographic data form included 4 questions (including: age, gender, Level of Education, marital status); the second part was the Herth Hope Index1. It consists of 12 items with four-point Likert-type scale, from one (completely disagree) to four (completely agree). The overall score of this scale ranges from 12 to 48. Kazemi et al. 2018,[23] confirmed its content validity,[24] and reported its alpha coefficient as 0.82.

In the intervention group, patients hospitalized in the COVID-19 ward were requested to complete their daily events for 5 to 7 days based on the narrative form in a personal notebook at least once a day. Questions in this form including: What was the best and worst feeling today? What was the most stressful event?? AND …

In the control group, patients received routine care. Before and after the intervention, the patients were asked to complete the Herth Hope Index1.

Data were analyzed using version 16 of the SPSS software (Statistical Package for the Social Sciences software, version 16, SPSS Inc, Chicago, IL, USA). The paired t-test was used for within-group comparison of the mean scores. The independent t-test was also used for between-group comparisons the mean scores. The level of statistical significance was P < 0.05.

Ethical considerations

The study protocol and its ethical considerations were approved by the applied research council and ethics committee of Isfahan University of Medical Sciences (IR.MUI.NUREMA.REC.1400.189). Permission was obtained from the hospital authorities and the purpose of the study was explained to all participants and they all signed the written informed consents before participation. They were also assured of the data confidentiality and all the questionnaires were kept anonymous.

  Results Top

In this study, 68.3% were female, 55% were single, and 48% had diploma. There were no statistically significant differences between the control and the intervention groups respecting age, gender, educational level, and the hope index score (P >0.05) and the two groups were homogeneous [Table 1]. [Table 2] shows that the mean hope index score within two groups intervention and control, after the intervention in compared to before the intervention has increased significantly (P < 0.05).Also the independent t test results showed a significant difference in the hope score after the intervention in the two groups (P < 0.05). So that the mean score of the hope in the narrative writing group was significantly higher than the control group [Table 2].
Table 1: Demographic characteristics of patients participated in the study

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Table 2: Comparison of mean scores of HHI before and after intervention in two groups

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  Discussion Top

Based on the results of this study, narrative writing has been significantly effective in increasing patients' hope compared to the control group. Narrative writing by focusing on stories and good life events and expressing negative life events increases hope in hospitalized and quarantined patients. This technique activates the brain physiologically and reduces nervous disorders. Narrative writing is a therapeutic method based on mindfulness, and patient reach a better state of psychological health by writing down their positive and negative emotions. In general, narrative writing is one of the self-management methods that is used to express feelings and emotions.[20] This method is a powerful tool in discovering the patients' needs by themselves. The results of the present study showed that narrative writing leads to improvement of hope in patients with COVID-19. The results of Beshrpour's study showed that narrative exposure therapy, since the intervention is based on expressing and retelling the details of the traumatic event in a safe therapeutic environment can be a suitable treatment plan to reduce post-traumatic symptoms in cancer patients.[20] The results of Tavasli's study also showed that narrative writing as an effective supportive intervention has an important role in reducing the stress of in mothers of neonates admitted to the intensive care unit. Therefore, this treatment method can be used as an effective and low-cost intervention in nursing care in the newborn department.[21] The effect of emotional narrative writing may be different depending on the severity of the disease, social context, and culture. The results of Bagherzadeh et al. study showed narrative writing reduces the severity of stress in hospitalized patients in ICUs.[20]

One of the reasons for the effectiveness of narrative writing is that patient learn to accept responsibility for their behavior. Storytelling increases motivation for action and teaches people that their past, despite their failures and bitterness, does not determine their future, but what they do now determines their future. In this study, the participants gained a better understanding of the situation by relying on the positive points and expressing the negative points and creating a logical thinking. This focus on positive points promotes hope in these patients. In addition, patients in the hospital environment, especially in the era of Corona have less communication with the family members and the outside environment, so, the use of narrative writing could be promoting their hope.

Limitation and recommendation

The limitations of study were the physical condition of the patients, which probably had an effect on their narrative writing style, therefore, patients who had a stable physical condition were invited. Lack of proper cooperation in completing the questionnaires by the patients was the next limitation, and we tried to minimize the limitations by giving gifts for the participants and getting their participation.

  Conclusion Top

The results of this study showed that the use of mindfulness methods such as narrative writing in hospitalized and quarantined patients who are unable to communicate with the outside environment could increase the hope in patient.


This study was a part of a research project approved in 2021 (research number of IR.MUI.NUREMA.REC.1400.189) in IUMS and was financially sponsored by Vice Chancellery of research in the related university. We greatly appreciate the support and cooperation of this Vice Chancellery, as well as all patient with COVID-19.

Financial support and sponsorship

This study was financially supported by IUMS (research number of IR.MUI.NUREMA.REC.1400.189).

Conflicts of interest

There are no conflicts of interest

  References Top

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  [Table 1], [Table 2]


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