Health, Spirituality and Medical Ethics

 

Introduction

S

pirituality is a vital principle of human existence and has been accepted by many religions, cultures, and traditions around the world. Spirituality is the essence of humans' nature which denotes the meaning of life and sense of connection to a transcendent phenomena (e.g., the universe or God). This connection may or may not be part of any religion (1). Spiritual well-being is a sense of satisfaction that comes from peoples' inner-self and is directly associated with their quality of life (2). According to the related literature, spiritual well-being refers to having a sense of acceptance, positive feeling, adherence to moral codes, and a sense of mutual connection with a sacred and supreme power. Spiritual



well-being is achieved through a dynamic and harmonious process of cognitive, emotional, action-related, and personal improvements. Spiritual cognition, spiritual emotions, spiritual actions, and spiritual achievements can also be mentioned as the main components of spiritual well-being (3).
Tourism as a dynamic and systematic activity provides the tourists with opportunities to evolve and renovate what they desire (4). According to the World Tourism Organization, one of the goals that can motivate tourists to travel is to travel to restore health (5). According to Norman (2012), spiritual tourism can be divided into five categories that can provide such experiences: healing, experimentation, search for personal discovery and knowledge or solitude, and collectivism. Currently, health has a higher priority in daily life and wellness activities (6).
From an ethnographic point of view, the only appropriate way to study social and cultural phenomena is to study them during the process. Ethnography is a qualitative methodology through which the researcher describes the values, behaviors, beliefs, and common language of a cultural group (7). Since pilgrimage plays a significant role in treatment, healing, and spiritual well-being, tourists attempting to improve their lives choose pilgrimage. The current study with the help of ethnography examined the sacred places and their role in the therapy and spiritual well-being of the Tourists.
Studies in Iran and other countries focused on the impact of spirituality on lifestyle and quality of life, and some of these studies have explored the concept of spirituality. In explaining the concept of spirituality in tourism using content analysis, Shafi'a (4) argues that the increasing curiosity of modern tourists to grasp new concepts has altered the previous solely earthly view into a fresher point of view of the spiritual tourism. In a study entitled "healthy society depends on spirituality (with emphasis on the role of pilgrimage)", Vasokalaie (8) suggests that praying is one of the fundamental and important ways with which human beings can prevent physical, mental, and social illnesses.
Warfid et al. (9) studied the therapeutic value of pilgrimage travels and found that pilgrimage has social, psychological, and spiritual therapeutic values. Pargament and Maton (10) found that performing religious duties, such as pilgrimage reduces anger and anxiety. Neis and Vintrab (11) concluded that people participating in religious rituals (e.g., pilgrimage and worship) had decreased mental disorders (12). In a study conducted by Morris (13) it was indicated that patients' symptoms significantly decreased after the pilgrimage and the reduction continued for at least 10 months after returning from pilgrimage. In another study, Prim (14) examined places of spiritual importance and studied their association with therapy. In addition, MacGettigan (15) in the study entitled “walking labyrinths: spirituality, religion, and wellness tourism” showed that the growing number of pilgrims is the response to the need for spirituality to confront materialism and chaos of our time.
Considering the related literature and to the best of the researchers' knowledge, As far as we have examined, no study has been conducted regarding therapy, spirituality, and spiritual well-being of pilgrims of the holy places. Accordingly, the present study aimed to examine that how spiritual well-being is achieved through going on pilgrimage to holy places and how it affects all aspects of a person's life.
Methods
Research methodology is the most important part of any research (16). The present research was performed using a qualitative method and an ethnological approach. There are different forms of ethnography and the most common of these is realist ethnography and critical ethnography (17).
According to the purpose of the current study, realist ethnography was selected. Since the present research was determined to conduct an in-depth study of the subject under discussion to understand why women visit these holy places and are attracted to them. The term ethnography is rooted in cultural anthropology. Ethno means people or ethnicity and graph means describing one thing. Clifford Geertz, an American anthropologist, believes that thorough and accurate description is an important part of ethnography. It means a rich description of specific cases (as opposed to summarizing, standardizing, generalizing or working with variables).
An in-depth description of a three-minute event can fill multiple pages and such a description can express what happened, reveal the latency of the event, and provide a multi-faceted interpretation (18). One of the most prominent aspects of this method is reliance on participant observation. The researcher can collect data through observing the context of the place with regard to its culture, examining the behaviors and events that take place in that place, and using the observations of others (e.g., peoples’ accounts of the sacred place) (19).
Therefore, for the study of sacred places in the present research, places that were already ignored in such studies were selected. Such a method can reveal the depth of tourists’ attitudes toward these sites and determine the reasons for their attraction to these places. To achieve this goal, the most visited holy places of Shiraz, Iran, were selected.
According to the purpose of the present study, the participants were selected based on a purposive sampling of the tourists of the following holy shrines of Hazrat Ahmad bin Musa (PBUH), Sayyed Alaeddin Hussein (PBUH). Statistically, these shrines had the most tourists, yearly. Therefore, regarding the research ethics, tourists who were willing to participate based on the required characteristics such as age, gender, and pilgrimage travel experience were entered into the study.
According to the available statistics, since women engage in religious pilgrimage rather than men and they constitute the main pillars of society, they were selected as the sample population. In addition, women who had experience of pilgrimage and were willing to express their feelings were selected. In this regard, age diversity was also taken into consideration and it was attempted to select women of different ages (e.g., young, middle-aged, and old) and in different decades of life (from forty to seventy). In-depth interviews and participant observation were carried out to collect information. Furthermore, thematic analysis and content analysis were used to analyze the collected data.
Participant observation is one of the most common ways for collecting qualitative data, as well as it is one of the most difficult methods that requires a researcher to participate in the culture, context, and environment of the subject that s/he wishes to observe. As a result, the researcher of the current research has been present in the selected sacred places a year prior to the time of conducting the study and has examined the field and its culture. Interviews start with general questions of why do you go on a pilgrimage? Why did you choose this place? What do you expect of this place? Then continues with exploratory questions to obtain more in-depth information.
Interviews were recorded after obtaining permission from the participants, then transcribed and themed. The researcher who had a prior qualitative research background and acquired the necessary skills and training on how to conduct qualitative research by maintaining the dignity of the holy place and the dress code that is customary for these sites were present during all the research stages and interviewed all the participants.
In order to obtain accurate data, validity, reliability, and transferability of the collected information were verified (20). To ensure the validity of the findings, the researcher took sufficient time to collect the data and maintained a long-term involvement in the process by visiting the sacred places repeatedly. In addition, to strengthen the validity of the extracted content, a number of coded interviews were returned to the participants to allow for member reviews. The reliability of the findings was assured through professors' reviews. (i.e., after the interviews, the professors who were not involved in the data collection process, listened to the interviews, compared them with the written text, and applied the necessary changes.
In order to verify, the researcher tried to not enter his/her assumptions in the data collection and analysis processes. The transferability of the data was assured through revision by five women who were not involved in the research process. The interviews lasted 50-90 min and sampling continued until saturation of the data.
Concurrent with the data collection process, data analysis was performed. At first, each interview transcript was read several times and the initial codes were extracted. Thereafter, the participants' phrases and keywords were identified and then the initial codes were revised into analytical codes. Then, after modifications, the codes were organized into basic theme, organic theme, and global theme. In the content analysis phase, the researcher extracted a series of fundamental concepts and patterns and then categorized the obtained data. Finally, the global theme of seeking treatment through spiritual means was extracted.
Prior to conducting the interview, the role of the researcher, subject, and purpose of the research were explained to the participants. The interviews were recorded after obtaining the permission of the subjects, and in any part of the interview, if the participants were unwilling to let their voices to be recorded, interviews were paused and the researcher took notes.
Result
A total of 30 female tourists with the age range of 18-55 years participated in the present study. The subjects’ educational background varied from diploma to PhD. The findings of the current study showed that the concept of pilgrimage was composed of eight themes and the global theme was seeking treatment through spiritual means. Table 1 demonstrates an overview of the global theme (seeking healing through spiritual means), organizing themes (discovering existential meaning, sense of place, spiritual action, emotionalism, connection, miraculous treatment, renewal and remembrance, and purposefulness). In addition, it presents the main themes of the present research.
Based on the findings of the present research and the thematic and multi-step analysis that followed the multiple and repeated coding of the research findings, the global theme of the pilgrimage was “to seek treatment through spiritual means”. Therefore, pilgrimage as a phenomenon that heals and treats the tourists is analyzed and interpreted. The themes that constitute this organic theme are “discovering existential meaning, sense of place, spiritual action, emotionalism, connection, expectation, miraculous treatment, renewal and remembrance, and purposefulness”.
Based on the findings of the study, we found that sacred places provide ways to improve and cure tourists at some levels. According to the participants’ accounts, pilgrimage and visiting the sacred places push tourists to discover their existential meaning, through reflection in a spiritual place and the spiritual actions that they perform. Holy places help them to reach an inner satisfaction and through the connections and expectations of the sacred place, they could reinforce their beliefs and fulfill their wishes. In addition, the holy places help them to restore their psychological, mental, and even physical health at any stage of the travel, including before the travel, during, and at the sacred place.

Table 1. global Theme of Seeking treatment through spiritual means
Organic Themes	Basic themes	Examples
Discovering existential meaning	Self-observation Self-reflection	Discovery of meaning, internal and external transformation, contemplation, freedom from material structures
Sense of place	Spiritual atmosphere Magnetic force Realm of silence	Presence of Imamzadeh, architecture, fragrant atmosphere, solitude, spiritual energy
Spiritual action	Ritualism transaction Acceptance	vow, sadaqah, charity, endowment, waqf
Emotionalism	Relief Emotional energy Excitement	Peacefulness, spiritual need, a surge of emotions, impressiveness
Connection	Spiritual connection Earthly connection	Good mood, connection, interaction with other pilgrims
Miraculous treatment	Healing Karamat Miracle	Cure, freedom, treatment, peacefulness, solved problem
Renewal and remembrance	Religious beliefs vow	Faith in God, become innocent, servitude
Purposefulness	Inner satisfaction Excellence Rebirth	Personal growth, meditation, promotion, personal growth self awareness,

 
Discovering the existential meaning
Regarding the discovery of the existential meaning, extracted themes from the participants’ opinions included self-observation and self-reflection. Search for meaning drives mankind toward different places (e.g., known and unknown, far or near, man-made and natural) (21). Participants stated that visiting these sacred sites provided an opportunity to contemplate their own existence and to make some evaluations. The participants’ search for privacy was in line with this reflection and contemplation.
Self-observation
In the ethnographic experience of these places, some tourists engaged in dialogues or laughter and empathy, and some with patience and confidence examined their actions and behaviors, sometimes even they did not feel the passage of time and were trapped in their spiritual realm of their inner world.
Marzieh, 30-year-old:
"I always try to find a place of solitude, to look for a cozy place, then I start to speak with God, I talk about my actions, behaviors, and all the things I've done, I tell everything"
Self-reflection
There are different categorizations of the holy places’ tourists and the common characteristic among them is that they believe visiting holy places is an opportunity for contemplation. The value of this reflection and thinking is not less than worshiping and performing the rituals. It is this reflection and thought that helps the tourists to lead a better life.
Mahsa, 25-year-old:
"In my opinion, these places are not just for worship and pray, I come here to think, to see what I’ve done and what should I do, what I can do to change, to get better; so, here I am trying to feel free, I'm not looking for boundaries, as if here gives you an opportunity to just sit down and think”
Sense of place
Search for spirituality drives people to different places. It is the influences that these places have on people that show the power of these holy and sacred sites. Holy places possess an intrinsic property of attracting the seekers and quenching their thirst for the truth. Pilgrimage travels change a person and reinforce their adherence to performing good deeds. The combination of reflection, contact, prosperity, and well-being give people the required energy to understand and affirm higher human goals. After understanding their place in the system of existence, these travelers find themselves compelled to question everything and open-mindedly devote themselves to harmonizing with the society and environment and to pay attention to the welfare of all three components of (self, society, and environment). Spiritual journeys help one to be free his heart and soul and understand the meaning of life. Spiritual pilgrimage enables individuals to see themselves and others as one and to join a network of homogenous communities (21).
Spiritual atmosphere
Light, color, mirroring, fragrant atmosphere, and architecture of the holy places and the energies that resulted from the presence of tourists in these places create a special spiritual atmosphere and it affects the tourists’ behaviors. They felt affected from the moment they stepped into the place and their zeal for pilgrimage doubled healing all of their difficulties. A tourist’s account of this experience in the form of a semi-structured interview is as follows:
One-hour interview with 45-year-old Zainab:
“Spirituality and architecture of these places are very influential, they completely change your mood, when you enter into these places, you feel relaxed and it is like a cool breeze across your face”.
Magnetic force
Elements that made the sacred places to look impressive along with the provision of a relaxed and hospitable environment for reflection and thinking emitted positive energies. Tourists referred to these energies as magnetic forces, energies that pulled them toward these holy places and encouraged them to perform the religious rituals with special enthusiasm.
Throughout the conversation, Taherah enthusiastically referred to the design, architecture, and coloring of the shrine. Elements that make the tourists feel that they entered into a totally special and different environment. Tahereh’s narration is as follows:
Tahereh, 22-year-old:
"All the elements in this place are like magnets, they all attract you, from glassworks to the zarih".
Realm of silence
The participants believed that visiting a sacred place should be accompanied by special practices and rituals, including the expression of humility and servitude in the presence of the Almighty and keeping silent before him. Consequently, some people believed that visitors should not behave in any way that disturbs the peace of these sacred places or prevents the rituals from being performed correctly.
Fatima's experience of being in the holy place referred to escaping from the hustle and bustle of the outside and searching for a place that comforts her.
Fatima, 26-year-old:
"I love the ceremonies in the holy shrine, but all of them are performed in groups. I'd like to be where I can sit back in silence and think. Sometimes the whispers of the other visitors disturb me, but I want to be left alone".
Spiritual action
Spirituality was always present in each action or behavior in sacred places. Given the intentions and motivations of the tourists for traveling to sacred places, they performed practices that had influence both on themselves and others. Therefore, these practices are considered to be invaluable.
Ritualism
Religion consists of two basic elements of beliefs and deeds. Beliefs are ideas and deeds are ways of social action. Some of the religious practices (e.g., rituals) are an integral and important part of any religion which can be the source of many developments in social life (22). The ritual dimension "encompasses the specific religious practices that followers of any religion are expected to perform" (23).
Tourists believed that they were bound to perform religious rituals that began before the pilgrimage and continued them until after the pilgrimage. They believed that they should perform certain rituals before traveling to a holy place, while at the place, and after the pilgrimage. The degree of their adherence to the rituals is based on their passion for the holy place and Imamzadeh.
Performing these rituals, in addition to assuring them that they have performed their religious deeds as God ordered, also provide them with a degree of reassurance:
Haniyeh, 49-year-old:
"From the moment that I step out of my home by the time that I get to the shrine, I pray. I feel like if I don't do this, my pilgrimage will not be accepted, I will not feel good otherwise”.
Transaction
Some tourists bargain for the fulfillment of their wishes and sometimes it is very important to them to evaluate how important their wish is, to give more assets. This exchange is made in forms of gift, sadaqah, charity, endowment (i.e., waqf).
Mahin, 54-year-old:
"Last time that I came here I made a vow that if I heal, I will donate the carpet that I’ve weaved. Alhamdulillah, I've got what I wanted. So, this time I brought the carpet, I'm very happy".
Acceptance
Tourists believe that unlike other places, there are special requirements for getting invited into sacred places. Those who are invited should ask for permission to be allowed to enter into the sacred place. For some tourists, it is extremely important that they feel that they have received permission to enter into the holy place and they understand whether they have the permission or not through changing their moods or feelings.
The feeling of wanting and being invited created special joy in the visitors’ hearts. Shabnam was one of those visitors who spoke enthusiastically in this regard:
Shabnam, 39-year-old:
“You should be invited to such places, you can’t go on your own. Then after you are invited, there are some rules that you have to obey, you should ask for permission and then they may accept you. In this way both you and they wanted you to be here”.
Emotionalism
Emotion is an integral part of religion, as religiosity always encompasses emotions. Emotion is both personal and relational, private and social, living and cultural. Religious emotion is built not only through social communication but also through beyond social communication as well (e.g., sacred affairs, sacred industries, and sacred texts) (24). Many tourists experience different emotions when they are in a sacred place and they show these emotions in various ways. These feelings are promising since they are signs that tourists will benefit from visiting these holy places.
Relief
Being present in sacred places and experiencing different kinds of feelings has brought some transient or permanent relief to the visitors. They were so relieved that even some of them stated that they have forgotten what reason brought them to these holy places in the first place. This peacefulness transferred them from a tumultuous outer world to a safe haven.
Fattaneh, 36-year-old:
"I prefer the shrine of the Imams and Imamzadehs, their holiness gives me peace, a while ago I was disturbed but now I feel so relaxed that I do not know why I came here in the first place."
Emotional energy
Faith and belief as sources of emotional energy guide the visitors to perform their religious duties and interact with other tourists and help them to express themselves in different ways by showing their emotions.
Sakineh, 19-year-old:
"In this place, I feel more and more that I have faith in the power of God. I believe that I can rely on him, this makes me feel his presence; therefore, I’m sure that he hears my prayers, solves my problems, and helps me to feel good”.
Excitement
Pilgrimage is often accompanied by specific emotions and excitements that affect visitors. Some participants mentioned specific emotions that had only been experienced in the sacred places and they did not experience these emotions before, and others spoke of their own emotional experiences.
Marjan, 21-year-old:
“Ever since I arrived here I start crying from happiness, I got goose bumps, the moment I saw the Zarih I could not swallow back my tears anymore and burst into tears, I just wanted to cry out loud"
Connection
Pilgrimage provides a platform for people to spiritually connect to each other. It makes them feel spirituality and start some inner transformations in themselves. Visitors regard this connection as a starting point for the transformation. In their view, for achieving an effective connection, some conditions are required and sometimes these conditions are related to the intentions of starting pilgrimage travel.
Spiritual connection
The connection of religious tourists in the sacred place is sometimes purely psychological and spiritual and this connection is achieved through the connection between the heart of the pilgrims and God and Imamzadeh. Their effects are manifested through the expression of emotions and excitements.
Safura, 19-year-old:
"I try to get in touch with the God or Imamzadeh anytime possible, I feel this connection when my heart is broken, especially when I ask for permission to enter into the holy places and I say that if you don't want me to come I will return to where I came from and by saying this I burst into tears”.
Earthly connection
A significant part of the connections in the sacred places is through bonding and interaction with other visitors which plays a significant role in the improvement of the mental state and healing of visitors, thereby transmitting one's religious and social experiences to one another. It has an important role in changing people's moods and lifestyles.
Mahin, 29-year-old:
"In this place, not only can you talk to your God, there are times when you try to interact with the person who sat next to you, you can even befriend her".
Miraculous treatment
Tourists have turned interest to pilgrimage therapy. They believe that pilgrimage provides an opportunity for different people with different opinions to assemble in a sacred place and to develop a spiritual and social connection. The result of this assembling and connection is the achievement of the psychological relaxation that has its effects on various aspects of visitors' life.
Healing
Many visitors believe in healing and seek healing from sacred places. They visit these places to pray for the health of themselves, their friends, and relatives and to ask the Imamzadeh to mediate between them and God.
Soraya, 52-year-old:
"I came here since I want my daughter to be healed, I am sure my presence here on this blessed month was not without reason, I am sure that I see a miracle"
Karamat
Some visitors believed in the Imam's karamats and they aspired to be bestowed by these karamats.
Safia, 47-year-old:
"God have mercy on me, solve my problems, I hope he forgives me, I do not want to return empty-handed"
Miracle
And some others believed in miracles because they had no other choice. On one hand, they were disappointed with others and on the other hand, they considered their desire so enormous that thought only an ultimate power capable of granting miracles could fulfill their wishes.
Zinat, 35-year-old:
"All doctors said that they ran out of options, they said they can't do much, but I believe in miracles, today is the fifth day that my husband is in a coma, I have no one except him. The moment doctors said that they can't help anymore I bought a ticket to come here and to be here at this Friday night which is Kamil prayer night, I do believe in his miracles".
Renewal and remembrance
People who visit the sacred places are looking forward to renewing their experiences and religious practices. Since they want to break free from routineness and lethargy of modern life, they look for a source to gain spiritual energy. Consequently, they visit the holy places.
Religious beliefs
Religious beliefs of the visitors constitute an integral part of the pilgrimage, which remind them by their presence in the sacred places and they show themselves actively and dynamically in prayers and religious duties.
Fatima, 20-year-old:
"Pilgrimage is a reminder of the faith, the things you have learned, things may have now faded, you remember these kinds of things in these places, especially when you pray or read the biography of Imamzadeh".
Vow
Visitors mentioned a mutual renewal of covenants with the Almighty God. They believed that this covenant was attributed to the Imams and Imamzadehs.
Zakieh, 53-year-old:
"I vowed that if the Imamzadeh interceded and God hears my prayers, I would come here once a year, but not just come once or twice, try to keep it going".
Purposefulness
Visitors stated that they started the journey with pilgrimage purposes and sought to attain internal and ethical development by acquiring epistemological knowledge; therefore, achieving inner excellence and satisfaction.
Excellence
The visitors acknowledged that their goal of the pilgrimage was to reach excellence, which was often accomplished by growing and changing themselves.
Hamide, 48-year-old:
"I hoped that pilgrimage would make me change for the better, both mentally and socially. I've learned so much from my travels".
Inner satisfaction
Satisfaction resulting from pilgrimage can bring inner peace to visitors and it is very effective in improving their mental health.
Razieh, 24-year-old:
"When I take a break from daily life, I sense that I have a special feeling as if I have been comforted from the inside and I've got whatever I wanted"
Rebirth
Pilgrimage creates an opportunity for tourists to reborn. After the pilgrimage ends, they feel clean and new in the body and soul. They believe that since they feel like they were born once again; therefore, when they back to their daily lives and they will apply this sense of freshness into their daily routine and personal lives.
Marzieh, 55-year-old:
"Today that I'm coming back from the holy shrine, I'm relieved, I feel like I was just born, I'm feeling carefree, with no sadness, I feel so good that I can't express".
Discussion
Tourists are mostly interested in visiting sacred sites and having unique experiences. There are numerous incentives that encourage people to choose sacred places as a traveling destination. Apart from happiness, other motivations are including, healing and wellness. Health is one of the top priorities in daily life and the sacred places are where recovery is expected to be achieved through social, emotional, and spiritual interactions until the person reaches his/her desires.
Given the importance of sacred places and peoples’ expectations from them, the purpose of the present study using ethnography and thematic analysis technique was to answer the following question of how spiritual therapy and spiritual well-being is achieved through visiting the sacred places.
The recording of women's narratives showed that sacred places were important sites that provided a good platform for women to reach self-knowledge, interact socially, act emotionally, and transform internally.
In addition, the participants indicated that these places had special features that attracted them, such as unique design, security, peacefulness, and collaborative action.
The researcher’s observations demonstrated that these days, pilgrimage travels play a key role in the treatment and healing process, and sacred places are of prime importance regarding this matter.
In the current study, women stated that they seek to discover their existential meaning through contemplation and self-observation in the sacred places, particularly the sense of being in a spiritual place was important to them.
Pilgrimage of a sacred place is like a journey in search of truth, a journey to a place that is a reflection of divine power and providence. In other words, the search for truth and enlightenment entwined with the divine and sacred concepts inspires people to visit these places as they go beyond ordinary daily life. In such places, one does not consider the basis of the relationships as materialistic; however, "metaphysical and supernatural searches throughout history" draw people to places where they feel free from the mundanities of the earthly life (28) with the aim of getting out of confusion. In fact, the sacred places provide an opportunity for tourists to contemplate, away from the chaos of everyday life and to gain insights and discover their existential meaning. Therefore, to become remote from the sense of absurdity that sometimes engulfs them.
Holy and sacred places evoke a unique feeling encompassed by different experiences. Internal and external needs bring people to these places and a set of elements that exist in these places have an influence on tourists and create an aspiration in them to fulfill their desires and expectations. Ultimately, these spiritual atmospheres and received spiritual energies from these realms of reflection provide tourists a sense of well-being or inner- exterior-peace.
The created connections are spiritual and materialistic connections that on the one hand, affect the spirit of the tourists and on the other, connect them with others, which they are regarded as a source of comfort. Pilgrims build a closer relationship with God by going on pilgrimage and visiting sacred places gives them a sense of psychological security. A sense of closeness to God leads to a greater satisfaction with life and they promise to stay away from deviations (25).
The results of the current study indicated that part of the women's intention for entering into the religious sites was to perform spiritual activities that some of which play a major role in filling the women's emotional and spiritual void. Turki showed that a place of worship is where people become detached from the mortal and materialistic worlds, say prayers, and reach spiritual comfort (25). The abovementioned findings were in line with the results of a study conducted by Vasokalaie (26).
Furthermore, visiting sacred places makes tourists spiritually relaxed. The resultant spiritual change of the visitors is demonstrated through different emotions. It renews the feeling of vitality and happiness in them and shows its effects in other parts of the journey and the visitors' lives and assures them that the purpose of the journey has been fulfilled.
Hope in mankind is what makes his efforts meaningful and gives strength to him. According to the surveys, every living creature performs its daily activities with hope (27). Since treatment sometimes is received miraculously from the sacred places, the participants of the present study stated that they sought it through pilgrimage. In fact, sacred places become places for demanding the fulfillment of their needs. Although these desires and ways of fulfilling them may require extraordinary powers (e.g., miracles), the pilgrims' hope, faith, and belief make them attainable. They believe that everything is in God's hand.
The results of the present study indicated that from the beginning of the pilgrimage, tourists expect that every step that they have taken in order to visit the Imamzadeh will help them to be forgiven after death. Therefore, they keep their vows and renew them by continuously visiting holy places.
As it was shown in the study carried out by Warfield, the pilgrimage had a significant impact on the visitors' views of their lives, relationships, identities, and their future plans. From the perspective of mental health service providers, access to knowledge about previous (or sacred) travel is important (9). The current findings also confirmed that the pilgrimage begins with a purposeful journey and visitors plan for their journey from the beginning. Female visitors stated that spiritual excellence mattered the most to them. This spiritual excellence is achieved through faith, strengthened communication with the Almighty, and remembrance and renewal of beliefs.
The categories of the discovery of existential meaning, sense of place, spiritual action, emotionalism, connection, expectation, miraculous treatment, renewal and remembrance, and purposefulness form a global theme of seeking treatment through spiritual means.
Traveling to sacred places for the sake of therapy reflects a desire to be present and have access to places beyond the confined spaces of daily life. Places that enable individuals to focus on their physical, emotional, and spiritual pursuits and expect them to become fulfilled. Achievement through spirituality is the way that they seek their healing. The categories of the discovery of existential meaning, sense of place, spiritual action, emotionalism, connection, expectation, miraculous treatment, renewal and remembrance, and purposefulness are among the means that pave the way for achieving this purpose.
Conclusion
Based on the findings of the current study, healing and spiritual well-being are achieved through visiting sacred places. Since these holy sites provide an appropriate context for interactions, actions, ritual and worship, and emotional evacuation. Some of these practices are in the form of collective cultural programs and some individually. In the meantime, the tourists' expectations of being in such cultural and spiritual setting and the impact that the atmosphere has on them should be considered. This expectation is that they believe cure and improvement will be achieved by visiting these places.
The results of the present study indicated that sacred places by providing a secure environment drag the tourists out of the chaos of the outside world and help them to have a deep transition and begin a profound transformation. In the meantime, the impact of this atmosphere entwined with cultural and spiritual programs is very influential to let the tourists to emotionally evacuate themselves. Emotional states that are created under the influence of the sacred places are very important in establishing the earthly and spiritual connections, because the stronger the spiritual connection is, the more they fulfill their purpose of pilgrimage. As the purpose of visiting the sacred places is to heal through receiving karamat and transformation of their inner feelings.
Presence in the sacred sites is accompanied by the renewal and remembrance of religious beliefs. It is a renewed covenant with the almighty and a way of avoiding laziness. Ultimately, at the end of the pilgrimage, reaching their goal that they have started the journey for, is the only thing that is important to the tourists. This goal is a sense of inner satisfaction. This satisfaction is not only effective in improving the psychological well-being of the tourists but also it is regarded as an opportunity to feel reborn. Now, s/he is born once again physically and mentally and returns to his/her personal life with a different sense of purpose.
Accordingly, it can be stated that spirituality in tourism and pilgrimage is of great importance today and there have been efforts to improve and ameliorate different aspects of life. Therefore, resulting in attraction of attention toward pilgrimage tourism. Today more than ever, the search for healing through spiritual means attracts the seekers of spiritual well-being to itself due to the inability of the earthly means to provide the most essential of human needs, namely peace.
Understanding the relationship of healing, spirituality, and spiritual well-being with the sacred places can promote a very different perspective that helps us to provide solutions, to help, and treat believers and even non-believers. Because believers, those who are in search of meaning and spiritual well-being can accomplish their wishes through the reinforcement of hope, faith, purpose, and pilgrimage travels, as well as they can achieve spiritual and psychological healing. Moreover, the non-believers can be comforted and soothed through contemplation and emotional evacuation. Therefore, most people these days search for healing through spiritual means to ensure their spiritual well-being.
Conflict of interest
The author declared no conflicts of interest regarding the current research project.
 
Acknowledgements
The authors' sincere appreciations go to those who assisted us in conducting the current research, especially to the authorities of holy places in Shiraz who issued the approval to carry out the present project. Furthermore, our sincere gratitude goes to the tourists participating in this research.
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