Health, Spirituality and Medical Ethics

Introduction
In today’s world, societies are facing challenges. Natural disasters, unknown diseases, economic turmoil, terrorism, and successive wars are some of the human challenges. How can a good life, personality growth, happiness, and hope be achieved with all these fears? Three psychological reactions occur when a person experiences a trauma or an unwanted change, including surrender to the stressor, resilience or improvement, and post-traumatic growth [1].
Resilience is a person’s ability to maintain or restore relatively stable mental and physical functioning during stressful events and distress [2]. Resilience is an interactive structure between biological, psychological, social, and environmental systems that helps individuals when challenging threatening and stressful factors [3]. Successful interventions to increase resilience reduce risk and threat factors and increase protective factors that modulate individuals’ responses to adversity and threats [4]. Tolerance and resilience training improves adaptation and mental health in children and patients [5, 6].
Another variable that impacts people’s mental and physical health is the level of hope. Hope means the determination to achieve goals (agency) and the belief that many paths can be created [1]. High-hope people provide more adaptive emotional responses by creating new and alternative ways to achieve or use surrogate goals. In this way, when faced with obstacles, they are flexible and pursue another goal or focus on other areas of their lives [7].
The research results show a significant effect of hope and resilience on each other, mental health, and physical and psychological well-being. Adolescents who have more hope show more resilience [8]. By increasing resilience and happiness through education, it is possible to improve the life quality of patients with breast cancer and increase the level of hope [9]. As a result, people’s level of hope is affected by their level of resilience [10].
But religiosity, one of the structures in positive psychology, is a factor in preventing disorders and maintaining mental health. Religiosity is participation in organized and special religious activities such as prayer, contemplation, and belonging to a place of worship [11]. Jung emphasized the role of religion in providing mental health by proposing the function of religion as a support base against the deprivations of life [12]. A person’s positive image of God can play a fundamental calming role in people’s lives, and a person’s negative image of God leads to frustration, hatred, and negative moods [13].
Positive godliness leads to hope. It is an obstacle to anxiety, stress, despair, and depression [14]. Spiritual health and religious confrontation can predict death anxiety in patients. Strengthening the spiritual dimension can reduce the anxiety of death due to disease [15]. But high-risk behaviors among non-religious youth are more prevalent than those who believe in God and give religion a valuable and significant role [16].
The most crucial concept in most religions is the relationship between man and God, and man’s perception of God is a central concept in spirituality and religion [17]. As individuals’ faith increases, their hope also increases, and as a result, their health increase [18, 19]. However, according to the studies conducted, no significant study is conducted on the role of mediators of religiosity in the effect on hope and productivity. Therefore, this study was conducted to answer the question of whether religiosity mediates hope and resilience.
Methods
This study is descriptive and correlational with simple random sampling. The statistical population of this study included all the students at Azad University of Qom City, Iran studying in 2018 (which was announced by 10 000 students). This research was conducted with a sample size of 375 students. According to the sampling method and its framework, a list of students has been prepared. Based on the table, random numbers were randomly selected from the list, and the questionnaires were provided to the students.
The inclusion criterion in this study was studying at Qom Azad University and the student’s willingness to participate in the research. And the exclusion criterion was incomplete answers to questionnaires and students present at this university as guests. The tools used to collect the information required for this study were the Connor and Davidson Resilience Scale (CD-RISC), the religious attitudes of Glock and Stark, and Snyder hope questionnaire.
Data collection tools
Connor and Davidson Resilience Scale (CD-RISC)
This questionnaire was designed in 2003 by Connor and Davidson [20] by reviewing the research resources from 1979-1991 about resilience. The psychometric properties of this scale were evaluated in 6 groups of the general population of patients referred to the primary care ward, psychiatric outpatients, patients with generalized anxiety disorder, and two groups of patients with post-traumatic stress disorder.
The authors of this scale believe that this questionnaire can distinguish resilient people from non-resilient people in clinical and non-clinical groups and can be used in research and clinical situations. Connor & Davidson resilience questionnaire [20] is scored on a Likert scale between zero (completely incorrect) and four (always correct).
Questionnaire for Measuring Religious Attitudes
The questionnaire for measuring the religious attitudes of Muslims based on the Glock and Stark model has been adapted to Islam and mainly to Shiite [21]. This questionnaire consists of 26 terms that measure four dimensions (subscale) of religiosity.
1. Belief dimension: Beliefs that the followers of that religion are expected to believe (such as doomsday, etc.).
2. Religious dimension: The experience or emotions that refers to the emotions, perceptions, and feelings related to the relationship with God.
3. Consequential dimension: The effect of religious beliefs, practices, experiences, and knowledge on the daily life of the followers of that religion (such as hijab, etc.).
4. Ritual dimension: Certain religious practices such as worship and prayer, participation in certain religious rituals, fasting, etc., which the followers of any religion are expected to do (such as prayer, etc.).
All questionnaire expressions were rated on a five-point Likert scale from strongly agree to strongly disagree. Sharifi (2002) estimated the total reliability of this test using the bisection method and Cronbach’s alpha as 0.75 and 0.78, respectively, and its validity as 0.45 (by measuring the correlation between the scores of this questionnaire and their self-reporting of religiosity) (P<0.001). It should be noted that the reliability and validity of all dimensions were also significant (P<0.001), and the level was satisfactory.
Snyder Hope Questionnaire
Snyder’s hope scale [22] is a scale that assesses a person’s hope as a relatively constant personality trait, and by modifying the initial sample, 14 high-correlation items remained. Among these materials, 4 items with the most relationship with factorial thinking and 4 others with the most relationship with strategic thinking were isolated and calculated. The internal cases of each factor showed a correlation between 0.75-0.38. This test consists of 12 items and 2 factorial and strategic thinking subscales.
The subjects must indicate their agreement or disagreement with each statement on an 8-point Likert scale from strongly agree to strongly disagree. The test scores range from 8 to 64. In the construct validity study using factor analysis, both factors of this scale explained a 0.51 variance of hope.
Data were initially analyzed using SPSS software version 22 at two descriptive and inferential levels. Mean±SD, frequency tables, and appropriate graphs were used at the level of descriptive statistics. At the level of inferential statistics, Pearson’s correlation test (to examine the relationship between variables), linear regression (to check the predictability of variables), and path analysis (to investigate the role of the mediating variable) were used to test the research hypotheses. AMOS software was used to test the main hypothesis via the path analysis method.
Results
Sampling was performed on 375 students; 65.3% were men, and 34.7% were women; 68.8% were undergraduate students, and 31.2% were master’s students; 48.8% of technical and engineering students, 44.5% of humanities students, and 6.7% of medical students were the sample group; 42.4% of the sample group were married; 57.6% were single, of which 45.1% were employed, and 54.9% were unemployed.
The results of correlation coefficients between the variables of hope and religiosity with the variable of resilience are presented. The results showed a positive correlation coefficient between the components of hope (factorial and strategic thinking) and religiosity with the resilience variable. It was significant at the alpha level of 0.01. The correlation between hope and religiosity was also positive and was significant at the alpha level of 0.01 (Table 1).
To test the research model of path analysis, AMOS software was used. Before using path analysis, univariate outflow data were analyzed using box diagrams, and multivariate outflow data were analyzed using Mahalanobis statistics and excluded from the data set. Skewness and kurtosis of the distribution of scores of the variables were calculated using SPSS software version 22 and the results showed that none of the values of skewness and kurtosis is more than 1%.
The normality of the data was assessed using the Kolmogorov-Smirnov test. The results showed that all model variables’ scores are normal (P<0.05). The hypothesis of error independence was examined by Durbin-Watson statistics to calculate the regression equations of the research model. The obtained value indicates the establishment of this assumption. The hypothesis of alignment between variables was investigated using Pearson correlation between pairs of variables. Since the correlation between two variables of 0.8 and above indicates alignment, this problem was not observed in this study data.
In addition, tolerance statistics and variance inflation factors were calculated to investigate multiple alignments. The results showed that none of the statistical tolerance values were less than the permissible limit of 0.1, and none of the variance inflation factor values were more significant than the permissible limit of 10. Therefore, based on the two mentioned indicators, multiple alignments were not observed in the data. After examining the hypotheses and ensuring their validity, path analysis was used to evaluate the studied model.
Figure 1 shows the standard coefficients of the proposed model to investigate the mediating role of religiosity in the relationship between hope and resilience. By examining the demographic characteristics, it was found that religiosity plays a mediating role in the relationship between hope and resilie
The model fit indices are the Root Mean Square Error of Approximation (RMSEA) equal to 0.072, and the Standardized Root Mean Square Residual (SRMR) equal to 0.061, which is less than the criterion (0.08) and confirms the fit of the model. The Incremental Fit Index (IFI), the Goodness of Fit Index (GFI), Comparative Fit Index (CFI), and Normal Fit Index (NFI) indices are more significant than the desired criterion (0.9). The obtained coefficients indicate the optimal fit of the model (Table 2).
Factorial and strategic thinking positively affect resilience, directly and indirectly, via religiosity. Religiosity also has a direct positive effect on resilience. Also, the model results showed that 3.5% of the religiosity variance and 19.2% of the resilience variance could be explained using the variables in the model (Table 3).
Discussion
The study’s results showed a significant correlation between the component of hope, resilience, and religiosity. Religiosity also plays a mediating role in the relationship between hope and resilience and predicts resilience and hope. Many research results confirm these results. In a field study of students, Bonab concluded that believing that there is a God who controls situations and oversees servants reduces anxiety caused by the situation because these people believe that uncontrollable situations can be handled by relying on God [23].
In this regard, separate studies by Bonab and Kennedy confirm the significant effect of religiosity on the level of hope [24, 25]. Also, in a clinical study on patients, the effectiveness of religiosity in increasing the ability of specific patients in health has been confirmed. This study results, which analyzed the role of spiritual vitality in the relationship between social capital and social support with employees’ resilience to the COVID-19 epidemic, concluded that spiritual vitality has a facilitating role in increasing resilience and the relationship between the individuals’ level of religiosity and their story of hope was confirmed [26].
Regarding the importance of hope from a religious perspective, the importance of hope has been emphasized in all divine religions, especially the religion of Islam. Those who consider themselves religious have higher hopes than those who do not consider themselves religious [27]. Sar Abadani and Jan Bozorgi, by studying the factors that increase expectancy, concluded that negative and inefficient theories are formed with low spiritual transformation. And instead of hope and activity, it creates fear and despair in the individual and provides the ground for depression, anxiety, and tension [13].
Hopeful young people who experience more hope are more resilient in the face of short-term problems and issues [8]. In a study that taught resilience to participants, the results suggest that resilience-focused training has made a person more resilient to stressors. Emotional regulation affects people’s responses in different situations, especially in critical cases [28].
The results confirm the mediating role of religiosity in the relationship between hope and resilience in individuals. Among the consistent results of this research, we can point to Merhamati and Khormaei, which examined the direct effect of religiosity on moral welfare, hope, and patience [29]. In today’s tense and complex world, if religious beliefs and rituals were accompanied by hope and patience, it would create a better living environment for young people. To create a welfare environment, it is suggested to work on religious beliefs (such as divine knowledge) and spiritual affection (such as attachment to God) more than religious rituals and consequences [30]. Arab Ismaili’s research showed that students’ level of hope, resilience, and spiritual intelligence can affect their quality of life [31]. As a result, given that resilience is an interactive structure between biological, psychological, social, and environmental systems, it can help individuals when challenging one or more threatening and stressful factors. In Iran, Rahimi et al. reported the reliability of the Connor and Davidson resilience scale using Cronbach’s alpha method to be 0.89, and the validity of this scale to be 0.87. Resilience is achieved via learning and documentation and increases with age [32, 33]. Also, based on these studies that reported the significant effect of values and ethical principles on individuals’ resilience [34, 35], in situations where the resilience of individuals is higher, negative events were considered more flexible and more realistic, and problems were usually regarded as temporary and transient [36].
People who have a higher sense of spiritual vitality are more relaxed and can better regulate their emotions and have a greater ability to deal with them [34]. Park believes that religiosity as a multidimensional construct can influence general and fundamental beliefs [35]. This attitude makes students with higher levels of religiosity experience higher hope for the future and social hope [33].
Conclusion
According to the results, increasing the level of hope influences people’s resilience. Also, if people experience a higher level of religiosity, their hope and resilience will increase. Due to hope, resilience, and especially religiosity on the mental health of society, it is suggested that organizations, educational and cultural centers should pay more attention to increase the quality and quantity of matters related to religion and religiosity in life. And training and skills packages in this field should be prepared by higher education and cultural centers and provided to individuals.
In this regard, questions, beliefs, social problems, and related challenges should be institutionalized in the seminary and higher education centers in educational courses and critique seats to strengthen religiosity and its effects on improving the mental health of the community.



Ethical Considerations
Compliance with ethical guidelines
To comply with ethical principles, the participants in this study were assured that their answers would be confidential. Maintaining fidelity in receiving the information of the participants, the obscurity of the answers, and the consent of the participants for cooperation have been the priorities of the researchers.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Authors' contributions
All authors equally contributed to preparing this article.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors appreciate the students and professors who helped them complete the questionnaires and conduct this research.