Health, Spirituality and Medical Ethics

Introduction
Health is like a precious jewel known as an invaluable source for effective life (1). Health improvement is the center of health care due to its important role. Regarding the high costs of health care, the necessity for changing the therapeutic approach into the preventive approach is getting more highlighted. In addition, the World Health Organization (WHO) emphasizes that people should try to prevent the diseases through adopting a health-oriented lifestyle (2).
Healthy lifestyle is a voluntary action and as a valuable resource decreases the prevalence and effects of hygienic problems, improves coping with stressful factors of life, and as a result enhances the quality of life (3).     
The concept of lifestyle was first proposed in 1920 and entered scientific studies since 1970. Lifestyle is creating approaches for life and achieving the targets considering the facilities, socioeconomic status, as well as the personal and social limitations that an individual might have.(4).
It should be noted that the health-oriented lifestyle includes various aspects, namely exercise, proper and improper nutrition, self-control, spiritual health, social environment, and preventive measures (5). Nowadays, most health problems, different diseases, and the related mortality are associated with changes in lifestyle (6). Amini et al. concluded in their study that health-oriented lifestyle can improve patients’ health (7).  
With this background in mind, it is of great importance to find interventions that might effectively enhance people lifestyle. Spiritual-religious interventions are among the approaches assumed to have the potential for improving lifestyle (8). Concerning the major role of spirituality in individuals’ health, WHO has introduced the spiritual feature as one of the main components of health (9).    
The religion and spirituality aspects are among the most important cultural factors that make the experiences, behaviors, and values of human meaningful and purposive (10). Kim and Seidlitz (11) state that spiritual-religious beliefs can be a potent approach for facing life stresses. Moreover, these beliefs may create a healthy lifestyle by raising self-confidence, inducing hope, giving meaning to life, and satisfying natural needs.
Considering the effective role of spirituality in mental health, several researchers have studied efficiency of this psychotherapy type. Koszycki et al. (12) demonstrated that spirituality-based interventions are highly influential in treating generalized anxiety disorder.    
Koupani and Taghavi (13), as well as Yaghoubi et al. (14) showed that spiritual-religious interventions can be applied for preventing and behavioral and cognitive disorders. Barrera et al. (15) and Stanley et al. (16) also reported the impacts of spiritual-religious treatment on reducing anxiety and depression. Moreover, the literature in Iran indicated that spiritual therapy leads in decreased mental disorders (10), death anxiety (17), and psychiatric symptoms of schizophrenic patients (18).    
Consequently, providing trainings and interventions toward health-oriented lifestyle might have an effective role in preventing diseases, improving individuals’ health, and reducing the costs.  In addition, the lifestyle of university students should get more attention due to their active role in the country. Neglecting the lifestyle of young generation might result in a society with an ill and anxious generation. On the other hand, these people are the future parents and will also nurture ill and anxious children.
Considering the literature, as well as the religious values in the country, it seems that people lifestyles can be enhanced through interventions related to the spiritual-religious aspect. Therefore, the current study aimed to investigate the efficacy of spiritual-religious treatment based on Islamic instructions on the components of health-oriented lifestyle in female students of Hormozgan University, Iran. 
 
Materials and Methods
Design and Participants
This experimental pretest-posttest study with control group was performed on the statistical population consisting of all the female undergraduate students of Hormozgan University, Hormozgan, Iran during 2017-2018. It has been recommended that experimental studies have group sizes of at least 15 people (19). Therefore, 30 individuals were selected from the statistical population through random sampling and were randomly assigned to the two equal groups of test and control.
Firstly, the researchers announced this therapeutic program and numerous female students enrolled for participation and the results of interviews and evaluation of inclusion criteria showed that many students could cooperate. As a result, 30 people were randomly selected out of the suitable volunteers, followed by random division into the two groups of experiment and control.  
     The inclusion criteria entailed: 1) being female, 2) being undergraduate student, 3) being single, 4) not being satisfied or low satisfaction with their health-oriented lifestyle according to the interview, 5) not being addicted, and 6) not being affected by severe psychotic disorders. Moreover, interviews were held at the end of fourth and eighth sessions in order to evaluate the control group, state the needed points and recommendations about the study and program, acknowledge the participants, and excluding the people who met the exclusion criteria.
The exclusion criteria for both groups included: 1) changing the address whether temporarily or permanently (leaving the university dormitory), 2) using medication, consults, and other psychotherapy services during the study, and 3) lack of tendency for participating in this training-research program.   
Ethical Considerations
The required information regarding the therapeutic sessions were presented following coordination with the consult center of Hormozgan University. The researchers requested that the individuals participate in the sessions in case of personal consent. When the sessions were completed, books about Islamic lifestyle were given to the participants for acknowledging.
Sessions and Interviews
The participants in test group received a therapeutic package according to the protocols of  Shafiei and Jazayeri (20), Esmaeeli et al. (21), Bagheri et al. (10), in addition to Koupani and Taghavi. It should be noted that the program was confirmed by the psychology and religious education professors of Hormozgan University.  
The treatment was conducted as eight three-hour sessions once a week for the individuals in experiment group. The participants of control group did not receive any trainings during the test. A summary of the training sessions is presented here:
Session one: greetings, giving explanations about the concept and aims of the study, determining the timing and duration of the sessions, discussing choosing and importance of lifestyle, talking about spirituality and religion, as well as their impact on people lives, the characteristics of spiritual-religious people, and giving exercises.   
Session two: checking exercises of the previous session, theism, god-oriented life, the role of belief and trust in god in life, telling religious aphorisms about the impact of trust in god on mental peace, in addition to talking about the relation between prayers with peace and life quality. Session three: self-knowledge, self-belief, relation with yourself and listening to the inner voice, optimism, patience and its effects in Islamic aphorisms.
Session four: talking about the role of dispensations of god in life, discussing lack of conflict between god satisfaction with prayers and effort, training the approach for achieving god satisfaction, relations with all that is sacred. Session five: talking about death, concept and objectives of life by telling related aphorisms. Session six: discussing and training the concept of forgiving ourselves and others, as well as humanitarianism and its consequences. 
Session seven: identifying the reality of universe, telling Islamic aphorisms based on universal realities from the religious point of view, the role of hope and contentment in mental peace, and telling the related Islamic aphorisms. Session eight: releasing emotions and feelings, forgiveness, acknowledging and praying the creator of universe, reviewing the program and aims, evaluating the stated subjects, getting feedbacks from the participants, questions and answers, concluding the whole program, distributing and completing the questionnaires again, finishing the session.  
Data Collection Tool
The health-promoting lifestyle profile II (HPLP-II) questionnaire was utilized for this study. Walker et al. presented this modified version of HPLP questionnaire that evaluates health-oriented lifestyle by focusing on inventive practices and understanding of the person. These factors maintain or enhance the level of health, self-actualization, and self-satisfaction (22). The original version of this questionnaire contains 52 questions and six subscales scored as a four-point Likert scale (1=never, 2=sometimes, 3=often, and 4=always).  
Walker and Hill-Polerecky reported the Cronbach’s alpha coefficient for this questionnaire as 0.94 for the whole scale and 0.79-0.94 for the subscales. In addition, the reliability of the test was reported as 0.89 by test-retest method (23). In Iran, Mohammadizeidi et al. modified the questionnaire and 48 questions remained after confirmatory factor analysis. The questions assess six aspects of nutrition, exercise, health accountability, stress management, interpersonal support, and self-actualization by 6, 6, 10, 7, 7, and 13 questions, respectively. 
After confirming the content validity of this questionnaire, Mohammadizeidi et al. reported the Cronbach’s alpha coefficient as 0.82 for the overall scale and 0.64-0.91 for the subscales (24). In the present study, the Cronbach’s alpha coefficient for the overall scale was obtained as 0.89 and as 0.68, 0.73, 0.78, 0.75, 0.81, and 0.84 for the subscales of nutrition, exercise, health accountability, stress management, interpersonal support, and self-actualization, respectively.  
Statistical Analysis
For statistical analysis of the study data the descriptive index of mean and standard deviation, in addition to multivariate analysis of variance (MANOVA) were used. All the data were analyzed utilizing SPSS version 22.   
 
 
Results
According to the results of descriptive analysis, the mean age and standard deviation for the test and control groups were 21.36±2.49 and 21.1±2.85 years, respectively. Furthermore, the participants of both groups reported their financial status as average.
 
Table 1: Pre-test and post-test descriptive indices of health-oriented lifestyle components in the control and experiment groups

Components	Step	Group
		Experiment				Control
		Mean	SD	Minimum	Maximum	Mean	SD	Minimum	Maximum
Nutrition	Pre-test	12.2	5.28	6	21	12.73	4.97	6	21
	Post-test	13.13	4.92	6	21	11.93	5.52	6	21
Exercise	Pre-test	11.86	3.85	6	19	12.73	4.36	6	20
	Post-test	17.86	2.44	14	21	13.13	4.68	6	21
Accountability	Pre-test	20.53	6.66	12	35	21.26	6.25	12	35
	Post-test	26.13	6.3	16	37	20.66	6.17	13	32
Stress management	Pre-test	14.13	4.26	8	22	13.8	3.98	8	22
	Post-test	17.53	3.56	11	24	14.36	4.04	8	22
Interpersonal support	Pre-test	14.66	3.03	9	20	15.33	2.94	9	20
	Post-test	19.73	4.9	12	27	16.13	2.32	11	21
Self-actualization	Pre-test	26.66	8.91	15	40	25.46	5.99	16	38
	Post-test	34.93	9.81	18	50	27.26	6.99	17	41
Lifestyle	Pre-test	100.06	16.07	75	135	101.33	16.69	76	125
	Post-test	129.33	15.8	108	156	103.4	14.85	79	137

 
Table 1 demonstrates the pre-test and post-test descriptive indices of health-oriented lifestyle components in both control and experiment groups. Based on the findings, the mean and standard deviation of test group lifestyle is 100.06±16.07 and 129.33±15.8 in pre-test and post-test, respectively. The latter result indicates that the post-test scores of experiment group have considerably changed, compared to the pre-test scores. On the other hand, comparing the means of control group shows no significant changes in the control group. Moreover, the mean and standard deviation of health-oriented lifestyle components can be observed in Table 1.
In order to perform MANOVA, distribution of the scores should be normal and Shapiro-wilk test was used to test the normality of scores’ distribution. Results of this test indicated that the variable of health-oriented lifestyle and all its components had normal post-test distribution in both groups (P>0.05). In addition, the Levin’s test was applied to examine the homogeneity of variances and the results showed that the variances were equal (P>0.05).  
Table 2: Results of multivariate analysis of variance for evaluating the effect of intervention on health-oriented lifestyle components

Variable	Source of changes	Sum of squares	Freedom degree	Mean of squares	F coefficient	Significance	Power
Nutrition	Intercept	4712.53	1	4712.53	172.11	0.001	0.86
	Post-test	10.8	1	10.8	0.394	0.535	0.014
	Error	766.66	28	27.38	-	-	-
Exercise	Intercept	7207.5	1	7207.5	515.52	0.001	0.948
	Post-test	168.03	1	168.03	12.01	0.002	0.3
	Error	391.46	28	13.98	-	-	-
Accountability	Intercept	16426.8	1	16.426.8	422.32	0.001	0.938
	Groups	224.13	1	224.13	5.76	0.023	0.171
	Error	1089.06	28	38.89	-	-	-
Stress management	Intercept	7584.3	1	7584.3	509.66	0.001	0.948
	Groups	80.03	1	80.03	5.37	0.028	0.161
	Error	416.66	28	14.88	-	-	-
Interpersonal support	Intercept	9648.13	1	9648.13	654.63	0.001	0.959
	Groups	97.2	1	97.2	6.59	0.016	0.191
	Error	412.66	28	14.73	-	-	-
Self-actualization	Intercept	29016.3	1	29016.3	399.46	0.001	0.934
	Groups	440.83	1	440.83	6.06	0.02	0.178
	Error	2033.86	28	72.63	-	-	-
Lifestyle	Intercept	406236.03	1	406236.03	1726.84	0.001	0.984
	Groups	5044.03	1	5044.03	21.44	0.001	0.434
	Error	6586.93	28	235.24	-	-	-

Table 2 demonstrates the result of multivariate analysis of variance for evaluating the effect of intervention on health-oriented lifestyle variable and its components. According to the obtained results, health-oriented lifestyle was significantly different between the two groups of test and control (P<0.05, F=21.44). Furthermore, a significant difference was observed between the two groups, regarding the aspects of this lifestyle, such as exercise (P<0.01, F=12.01), accountability (P<0.01, F=224.13), stress management (P<0.01, F=5.37),  interpersonal support (P<0.01, F=97.2), and self-actualization (P<0.05, F=0.394). However, the nutrition component difference was not significant between the two groups (P>0.05, F=0.394).
Considering the results obtained in this study, it can be concluded that spiritual-religious psychotherapy based on Islamic instructions has the potency to enhance health-oriented lifestyle features, except for nutrition.     
 
 
 
Discussion
The present study aimed to investigate the efficacy of spiritual-religious psychotherapy based on Islamic instructions on components of health-oriented lifestyle in female students of Hormozgan University. Our findings demonstrated a significant difference between the two groups of test and control concerning health-oriented lifestyle and its aspects, including exercise, health accountability, stress management, interpersonal support, and self-actualization. However, the nutrition component was not significantly different between the experiment and control groups. These results show that spiritual-religious treatment based on Islamic instructions leads in improved health-oriented lifestyle of female university students.   
Considering the various cognitive, behavioral, emotional, and existentialistic components, spirituality and religion can play a major role in personal approaches. In addition, religious practices, such as saying prayers and involvement in delightful spiritual activities might cause favorable behavioral alterations. Moreover, the person is more likely to adopt approaches that reduce physical and mental discomfort.     
Khaleghipour et al. (25) performed a study on people affected by depression and their results are consistent with the findings of the present study. They concluded that Islamic spiritual therapy can be effective in enhancing people lifestyles and augments physical, mental, spiritual, and social health. Furthermore, they indicated that spiritual therapy is able to induce changes in white blood cells and their composing factors resulting in disease prevention. Their findings supports the considerable effects of Islamic spiritual therapy on physical and mental health, as well as the general lifestyle of the individual.   
 The feelings induced due to the spiritual-religious attitudes and behaviors affects the whole body physiology through secreted neuropeptides and causes improvement of body organs, as well as immune system. Religious practices and growth of spiritual knowledge result in enhancement and adoption of raising lifestyle by activating the frontal lobe, especially prefrontal cortex that accompanies cognitive function (26). The spiritual and religious practices lead in increased release of some neurochemical mediators in brain, namely GABA, melatonin, and serotonin that ameliorate mental and psychotic function (27).    
It could be inferred that there is a strong relationship between spiritual-religious practices with peace, mental function, and lifestyle. In this regard, the studies conducted by Barrera et al. (15), Stanley et al. (16), and Bagheri et al. (10) revealed that spiritual-religious treatment may result in considerable changes in lifestyle. These changes are related to reduction in psychotic discomforts, depression, anxiety, and stress, in addition to increase in peace and mental health of the individual. 
Religious and spiritual behaviors, such as prayers diminish the harmful effects of stress through creating supportive networks and improving health behaviors. In addition, spirituality and religious beliefs facilitate confronting the problems and stress by understanding the temporary nature of psychotic discomforts or life sufferings and provides a sense of control for the person.  
All the spiritual traditions of different religions encourage their believers to a healthy lifestyle and health-improving behaviors by their inhibitory and prescriptive rules and orders. For instance, alcoholic drinks and drugs are inhibited in most religions and spiritual traditions. On the other hand, different behaviors, such as healthy recreations, nutrition, exercise, prayers, and ethical behaviors about not harming yourself and others are recommended.  
    Internalization and absorption of these behaviors in the daily life of people forms a healthy lifestyle, that is effective in reducing mortality and drug abuse, as well as elevating health and welfare (9). Thuné-Boyle et al. found in their study that spirituality causes people to follow approaches, by which they can properly face the conditions harming their health. For example, when they are affected by diseases, such as cancer, they can adopt behaviors compatible with their disease (28).
Other researches show that people who have spiritual beliefs and participate in religious customs are less affected by diseases and drug abuse, and are more involved with physical activities leading in better general health (29, 30). These results are indicative of choosing the health-oriented lifestyle in spiritual-religious people.  
Spirituality causes people to have positive attitude toward life and be hopeful about future. Spirituality helps individuals to consider their mental and physical aspects by affecting their beliefs and attitudes and makes them accountable against these features. This point of view causes people to adopt a lifestyle that ends in their health and self-actualization.
Esmaeeili et al. performed a study on women with addicted husbands. The authors concluded that spiritual-religious psychotherapy based on Islamic instructions can change their views and cause flexibility and patience, in addition to enhancing their quality of life (21). Shafiei and Jazayeri revealed in their study on married women that spiritual-religious treatment might actualize women (20).  
The current study showed that spiritual-religious treatment did not change the nutritional behavior of the participants and did not improve this aspect in them. In health-oriented nutritional behaviors, the person tries to have a suitable food pattern and choose foods that ameliorate their health (24). It could be mentioned that the participants of the present study resided in student dormitories and had limitations in choosing food type and pattern in this environment. Therefore, it seems rational that no significant change was observed in this regard and it could be considered as a limitation for this study.  
Conclusion
Overall, it could be concluded that spiritual-religious psychotherapy based on Islamic instructions provides female university students with proper approaches and enhances spiritual and religious bases in this group. Therefore, these people follow suitable approaches and adopt behaviors that lead in enhanced health-oriented lifestyle and prevents diseases. However, the findings of this study should be generalized cautiously. Follow up was not possible due to some limitations, such as time limitation. Regarding the rate and intensity of the injuries and health issues, in addition to the importance of health-oriented lifestyle in university students, sufficient attention from the ministries of science and health is required.  Consequently, research in the area of lifestyle in university students and performing interventions at suitable times, such as spiritual-religious treatment can be a valuable step in changing lifestyle and providing health in this effective group of society. Therefore, it is recommended that regarding the results of this study, the people in charge consider this therapeutic approach. As a result, the health-oriented lifestyle will get enhanced in the university students and their quality of life will be improved.       
 
Acknowledgement
The authors would like to extend their gratitude to all the female students who participated in this study, deputy and personnel of Hormozgan University, consult center. In addition we would acknowledge all the professors of Hormozgan University and all people who supported this study. 
 
Conflicts of interests
The authors of present study declare no conflicts of interests.
 
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