Health, Spirituality and Medical Ethics

Introduction

The influence of father absence during adolescence is a complex issue. Growing up without a father has different impacts on the psychological, intellectual, and behavioral development of adolescents [1]. Studies have shown that the majority of veterans’ children experience disturbances in mental health, including a decrease in happiness and life satisfaction [2]. They have elevated scores of depression, tension, apprehension, and anxiety [3], which show a weaker mental quality of life. It has also been reported that adolescents whose fathers are absent are twice as likely to have to repeat a school year and that adolescents who present aggressive behavior at school are 11 times more likely not to be living with their fathers than are the adolescents whose behavior is not aggressive [4].

Recently, family dysfunction, like parent absence, has been an area of treatment that was transferred from the deficits model to the strengths model. In this model, focusing on internal factors, such as positive character traits, is assumed to be the center of attention [5]. Resilience is a way of working on positive individual traits [6] that has a special position in positive psychology, family psychology, and mental health. Connor and Davidson defined resilience as the capability to establish a biological-mental balance in challenging situations. They consider resilience as not merely strength during threatening conditions, but also as active participation in the environment [7].

Resilience refers to how people cope with, manage, and overcome stress and adversity, which are crucial topics in the psychological well-being literature [8]. Spirituality is one of the components of psychological well-being. In spirituality, it is assumed that humans and other creatures are made of something beyond the material [9]. In other words, it is best to use creativity and curiosity to find reasons related to living, surviving, growth, and transcendence [10]. In the next section, we review the effects of spirituality on mental health.

Kamari and Fooladchange [11] showed the effect of spiritual therapy based on positive psychology on adolescents’ hope and life satisfaction. In their study, they focused on forgiveness, altruism, appreciation, and mindfulness. Ahmed et al. [12] found a positive relationship between spirituality and life satisfaction among Indian adolescents in their studies. In addition, Akbayram and Keten [13] found that spiritual programs are associated with higher psychological well-being.

Momeni et al. [14] showed a significant relationship between resilience, spirituality, coping strategies, and psychological well-being. Kaviani et al. [15] showed that religious-based cognitive-behavioral therapy sessions for married women referred to a counseling center resulted in a significant increase in their resilience.

Some other texts believe that spiritual development starts during adolescence to establish a meaningful system of communication with networks. Spiritual experiences can involve forgiveness, inner peace, empathy, understanding God, and self-transcendence. All of these experiences may help adolescents use their skills to create a better world [16].

According to the literature review, using spirituality concepts to empower fatherless adolescents’ mental health is a new idea. Spirituality was selected because these adolescents belong to a special population whose fathers were killed in war. Therefore, the current study tested: 1) the impact of spiritual-based education (SBE) on psychological well-being in post-test and follow-up, 2) the impact of SBE on resilience in post-test and follow-up, and 3) comparisons of post-test and follow-up changes. The answers to these questions could increase our knowledge of the advantages of spirituality-based education for improving mental health and developing coping strategies among adolescents. Furthermore, the results could also explain whether changes in resilience levels are related to long-term psychological well-being.

Methods

The population in this study consisted of 726 female adolescents aged 14-18 years (studies in high school and pre-university grades, Mean±SD, 14.95±0.21 in Isfahan City, Iran, during the 2013-2014 academic year. In this study, a multi-stage cluster sampling method was used. One of the educational districts (as a cluster) was randomly selected from the six educational districts in Isfahan. Research staff interviewed potential participants to determine their eligibility for inclusion and exclusion criteria. Adolescents were given a written description of the trial and were offered participation in the study if they met the following criteria: 1) 14-18 years old; 2) not meeting DSM-5 criteria for psychosis, mania, depression, current substance abuse and dependency; 3) no other psychological treatment for the duration of the study; 4) being female (In Iran there is no co-ed system. Martyrs’ children usually go to special schools, and only female therapists can work there); 5) no medical disease. After completing the spirituality and spiritual care rating scale (SSCRS), 60 female students who scored highly on the SSCRS (indicating a higher level of perception of spirituality) were selected and randomly assigned to either an education condition (n=30) or a no education condition (n=30). The adequacy of the sample size was determined according to eta power [17]. The study was conducted in accordance with both institutional and international ethical regulations and guidelines [18].

Measures

Ryff scales of psychological well-being: The Ryff inventory consists of 84 questions (long-form). This form consists of a series of statements reflecting six areas of psychological well-being: Autonomy, environmental mastery, personal growth, positive relationships with others, purpose in life, and self-acceptance. Respondents rated statements on a scale of 1 to 6, with 1 indicating strong disagreement and 6 indicating strong agreement [19]. Bayani et al. conducted a study on Ryff’s psychometric characteristics among the Iranian population, and they found good internal consistency for it (α=0.82) [20].

Psychological resiliency questionnaire: Conner-Davidson resiliency scale (a 25-item instrument that measures resiliency phenomenon in the form of five-point Likert scales from zero to four). The results of a pilot study assessing the psychometric properties of this scale confirmed its reliability and validity [21]. In addition, the results of the exploratory factor analysis confirmed the existence of five factors: 1) competencies/personal strength, 2) trust in personal instincts/negative emotions tolerance, 3) adoption of positive emotions/safe relationships, 4) inhibition, and 5) spirituality. The reliability and validity of the Persian version (Cronbach’s α index of 0.86) of the resiliency scale have also been reviewed among normal and patient subjects [22].

SSCRS: SSCRS was developed by McSherry et al. [23]. It consists of 17 items rated on a 5-point Likert scale. The scale measures individual spiritual views regarding participation in spiritual activities and belief in special spiritual moralities and meanings. The Cronbach’s α coefficient for the scale in Akgün et al. study [24] was 0.80.

Summary of spiritually based education sessions

In this study, SBE refers to a set of intellectual skills introduced in previous studies [25]. The experimental group received eight 90-minute group-based psycho-education sessions. The control group did not receive any spirituality-based education. Table 1 presents a description of the sessions.

Procedure

The study comprised a 2×3 mixed design (education vs no education),(pre vs post vs follow-up) ryff’s psychological well-being questionnaire and davidson resilience scale were administered after completion of consent forms. Participants in the Education condition attended eight 90-minute sessions per week over a two-month period. Each session consisted of SBE (Table 1). Participants in the no education condition received no training, only tests at the same three times as the education condition participants; before education, immediately after, and as a four-month follow-up.

Data analysis

To identify any pre-existing differences between the groups, a one-way analysis of variance (ANOVA) was computed for pretreatment measures. To identify differences between groups at pre-test, post-test, and follow-up, repeated-measures multivariate analysis of variance (MANOVA) with one between and one within-subjects factor was used to detect any overall differences between related means. All data were analyzed using SPSS software, version 23. Assuming a medium-sized effect, an alpha error level of 5%, two groups, and a sample size of n=60, the test power (1-β) was ≥0.85 and therefore sufficient according to Cohen [26].

Results

Demographic differences

Table 2 presents demographic characteristics of the participants. All the participants were women. Ninety-five percent of the participants were around 15 years old. All participants lived in Isfahan City and were Muslims. At the post-test assessment, only one participant in the SBE condition had discontinued the last four sessions of education.

Descriptive and inferential statistics

In relation to the research questions, descriptive statistics of psychological well-being and resilience, and repeated-measure multivariate analysis of variance (MANOVA) results are presented. As observed in Table 3, the mean psychological well-being and resilience in the education condition increased from pre-test to post-test, whereas they remained relatively unchanged in the no-education condition. Mean of psychological well-being and resilience in educational condition in the follow-up was decreased. To determine the significance of these changes, a repeated-measure analysis was applied.

According to Table 4, significant differences were observed between education and no-education conditions (P<0.002) and time series (P<0.001) for resilience scores. The interaction between time and group (Figure 1) was significantly quadratic (inverted U curve) for the resilience scale (P<0.001). However, the main effect of total subjective well-being was not significant (P<0.7). However, the interaction between time series and groups was statistically significant for subjective-wellbeing (P<0.03). Based on within-subject factor (time series) analysis, significant differences were observed for self-acceptance (P<0.04), positive relationship with others (P<0.04), and personal growth (P<0.05) subscales of subjective-wellbeing.

Post hoc comparisons using the Bonferroni correction revealed a significant difference in resilience values between the pre-test and post-test (P<0.001) on one hand and between the post-test and follow-up (P<0.001). These findings indicated that education gains were maintained after a 4-month follow-up. Thus, the research hypothesis was confirmed. The effect size (21% of the total variance) showed that applying SBE improved the subjects’ resiliency.

Also, our findings demonstrated significant differences in self-acceptance (P<0.006), positive relationship with others (P<0.01), and autonomy (P<0.008) between pre and post-test (Table 4). According to Table 4, no significant difference was observed following four months for subjective wellbeing both between and within the two groups. SBE maintenance decreased and finally vanished after a couple of months.

Table 5 indicates the differences between the mean scores in the post-test, pre-test, and follow-up. According to Table 5, the differences between the pre-test and posttest were greater than those between the pre-test and follow-up. In addition, differences between post-test and follow-up scores are negative for all (sub) scales in the education condition. This means that positive changes in psychological well-being and resilience were not sustained over time.

Discussion

As hypothesized, the overall findings demonstrated that the main effect of SBE was significantly tied to an increase in resilience, and there was a quadratic significant interaction of group and time. Smith et al. [27] suggested that spirituality may be related to increase in resilience and positive emotions. Considering the inverted U-shaped interaction between time and group, individual performance changes over time [28]. Some of these changes may be caused by temporal variables, such as life situations, unexpected events, and exams. Temporal variables are indirectly related to general concepts such as well-being, achievements, and relationships. A recent systematic review and meta-analysis showed that religion and spirituality are positively correlated with life satisfaction [29].

On the other hand, our results showed a significant interaction (ordinal type) between group and time for subjective well-being; however, the main effects of time and group were not statistically significant. This means that different groups act differently at different times. These findings are not consistent with those of Kamitsis and Francis [30], Litwinczuk and Groh [31], Koenig [32], and Ai and Park [33] who found a positive relationship between spirituality and mental health states. The possible description for the non-significant effect of spirituality on well-being is related to the duration of education. As observed in significant interaction, the simultaneous effect of time and group on well-being is not additive. The effect of the group variable may depend on the level of the time variable. We cannot see the maintenance of spiritual education in follow up; consequently, the necessity of increasing the number of education sessions is suggested.

To determine the cause of the significant interaction, two-by-two comparisons between the two groups are necessary at all three time points. In the present study, three subscales of psychological well-being showed significant improvement in the post-test evaluation, specifically in self-acceptance, positive relationships with others, and personal growth (main effect of time). In contrast, the other domains of well-being (purpose in life, environmental mastery, and autonomy) showed no significant changes as a function of spiritual based education. According to positive psychology, self-acceptance can change by stopping self-criticism and accepting the imperfect parts of oneself. As we have in spiritual beliefs to develop individual potentialities. Those with self-acceptance abilities seek to create many positive, harmonious relationships with others, such as relationships with God, and other people would naturally be attracted to them. According to Lun and Bond [34], spiritual practices increase socializing with others through attending ceremonies.

Not affecting other subscales of well-being might be reflective of external-centered factors, such as environmental mastery, which needs much time and energy making changes. Adolescence is a period of prominent changes, such as physical, social, and personality changes. Adolescent brain maturation occurs due to hormones synthesis. These powerful neuropsychological developments might be responsible for immature and impulsive behaviors that continue until 24 years of age [35]. A review study showed that only 25% of the studies reviewed had a positive association between religiosity/spirituality and mental health [36].

Regarding the effectiveness of this psycho-education on personal growth, as stated earlier, Hill et al. [37] argued that it includes a search for the sacred. They described ‘search’ as trying to identify, express, keep, or transform. It can be inferred that as an individual performs these steps, they start to break their boundaries and grow, actively and willingly creating a process of change and, therefore, involving their personal growth. As a manifestation of these ideas, Caldwell [38] suggested that personal growth initiative might be an intervening factor influencing the change of attitude (negative or positive) an individual has towards spirituality following a distress. Finally, Wink and Dillon [39] found a positive association between spirituality and aspects of personal growth related to well-being. They found that a tendency towards personal growth leads to highly spiritual individuals who serve as role models for others.

By examining the different aspects of spirituality in terms of their connection to different aspects of psychological well-being, the study indicated that both self-acceptance and personal growth, which concern the well-being of an individual, were maintained in both SBE and no-education conditions. These findings may be attributed to the stress levels of the participants due to the final exams. Psycho-education was performed during student’s exams. Another possible interpretation may be related to study’s screening phase. Participants were not selected based on probable factors that are effective in spirituality-based education, such as personality traits, family value systems. On the other hand, our findings demonstrated a positive relationship between spirituality and resilience, replicating many past findings about the positive relationship between spirituality and resilience. As stated by Masten [40]: “The great surprise of resilience training is the ordinariness of this phenomenon.”

In the current study, SBE was provided in the form of learning skills to increase awareness of spiritual experiences and searching for the meaning of life through the lens of the relationship with God. We found that resilience can act as a factor, decreasing the negative effects of stressful situations. Consequently, the mechanism underlying this pattern of correlations may be understood in terms of changing the person’s attitude toward the world more positive. Spiritual beliefs, in turn, lead to a higher level of adaptation in less predictable situations [41]. As mentioned earlier, resilience can be a crucial support for an individual’s adaptation despite adverse environmental conditions [24].

Conclusion

The present study found no significant changes after the 6-month follow-up, and adolescents may require additional sessions to review their new skills and learn how to apply them in their daily lives. Such outcomes indicate the importance of conducting multi-factorial studies to examine the relationship between different aspects of personality and the understanding of spiritual concepts. Future research should explore the effects of such education in different cultures.

Ethical Considerations

Compliance with ethical guidelines

The study was approved by the Research Ethics Committee of University of Isfahan, Isfahan, Iran.

Funding

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions

Conceptualization: Maryam esmaeili; Implementation, data collection, writing, review, editing and final approval: All authors.

Conflict of interest

The authors declared no conflict of interest.

Acknowledgments

The authors thank the respected authorities of the schools involved in this study, the Central Department of Education of Isfahan Province, and the Department of Education of the third district of Isfahan City for supporting this research.