Health, Spirituality and Medical Ethics

Introduction
One of the periods in human life is middle-age period which is defined as being between the ages of 30 and 59 [1]. Certainly, if a person do not pass this period safely, s/he will not be ready to move to the next stage of life (old age) which requires psychological and physical abilities more than ever [2]. With increasing age, the quality of mental health changes [3]. Mental health in this period is vulnerable due to many biological, physical, psychological, and social changes that occur [4]. In middle-age, more physical changes are seen in women, one of which is menopause, the period in which women face changes in hormones affecting their mental and nervous systems [5]. Women feel despair, hopelessness, stress, and anxiety during this period [6]. On the other hand, factors related to health and everyday stressful events may play a role in causing depression during menopause [7].
Spirituality has always been an important part of human life [8]. There is a relationship between the spiritual well-being of people and their mental health; those with better spiritual well-being have a better psychological health [9, 10]. In recent decades, the religious and spiritual growth in humans has received increasing attention by psychologists, psychotherapists, and mental health professionals. The complexity of today’s modern society and the ever-increasing problems of machine life and the changes in lifestyles in the post-modern age have caused the spiritual needs of human beings to become more important compared to material desires and needs. Despite the anti-religious propaganda in the past and present and the promotion of secularism, people are more inclined towards religion and spiritual values ​​than in the past, even in developed countries. Experts have found out that the existing treatment methods are not enough to reduce people’s emotional, mental, and physical disorders.
Life expectancy or hope is one of the important indicators; not only itself is affected by many factors, but also indicate cultural, social, economic, and health growth of each society. Life expectancy at birth represents the average number of years that a newborn is expected to live. It increases the power of adaptation and is a sign of mental health [11]. Numerous studies have shown that people with spiritual attitudes and religious behaviors have more hopeful attitude in life. Considering the increasing stress and anxiety for various reasons and the relative efficiency or sometimes inefficiency of above solutions (because their realization depends on external factors such as social support) and the impact of spiritual health and spirituality on mental health [12], and given that scant research has been conducted on spiritual health, depression, and hope in middle-aged people, this study aims to evaluate the relationship of spiritual well-being with depression and hope in middle-aged women.
Method
The is a descriptive-analytical study with a cross-sectional design conducted on 100 middle-aged women aged between 40-60 years referred to the community health centers in Qom, Iran in 2021. Using the correlation coefficient in the G*Power software and according to the study by Momeni Ghaleghasemi et al. [13] who reported a correlation of -0.47, and considering a type-1 error of 5% and test power of 95%, the minimum sample size was determined 90. Considering the possibility of dropout, it was increased to 100. Participants were selected using a convenience sampling method. The inclusion criteria were willingness to participate in the study, being Iranian, not having severe depression in the past 6 months for reasons such as the death of loved ones, no mental and emotional illnesses and chronic diseases, good visual and hearing ability.
To collect information, four questionnaires were used, including Paloutzian and Ellison’s spiritual well-being scale (SWBS), Beck’ depression inventory (BDI), adult hope scale (AHS), and a demographic form. The SWBS has 20 items, 10 measure existential well-being and 10 assess religious well-being. The range of score for each subscale is from 10 to 60. The total score is obtained by summing up of the scores of two subscales, which ranges from 20 to 120. The answers are rated on a six-point Likert scale from “completely disagree” to “completely agree.” In the negative questions, scoring is reversed. Based on the total score, spiritual well-being is divided into three levels: Low (score 20-40), moderate (score 41-99), and high (score 100-120). In Iran, this questionnaire was used by Seyedfatemi et al. and reported a Cronbach alpha coefficient of 0.82 [14, 15].
The BDI has 21 items measuring feelings of sadness, being discouraged, failure, loss of pleasure, guilty, being punished, self-dislike, self-criticism, self-harm, crying, being irritated, social isolation, difficulty in making decisions, worthlessness, loss of energy, sleep problems, tiredness, decreased appetite, weight loss, lack of concentration, and decreased interest in sex. Each item is rated on a 4-point scale from 0=no symptoms to 3=severe symptoms. Total score ranges from 0 to 63. Score 1-15 or 1-18 show no depression, score 16-31 or 18-28 show mild depression, score 32-47 or 29-35 show moderate depression, and score 48-62 or 36-63 show severe depression [16]. For the Persian version of BDI, a study showed that the Cronbach alpha coefficient for assessing the internal consistency was 0.87, the reliability using the Spearman-Brown correction formula was 0.83, and the test-retest reliability with a 3-week interval tested on 59 male students was 0.49 [17]. In Rajabi et al.’s study, the depression subscale of Minnesota Multiphasic Personality Inventory was used for assessing the validity of BDI. The obtained correlation coefficient between the two scales was 0.60 [18].
The AHS has 12 multiple-choice questions rated on a 4-point Likert scale from 1 (Strongly disagree) to 4 (Strongly agree). The total score ranges from 8 to 32. Four items are related to the agency thinking subscale and four items (i.e. 3, 5, 7, 11) are related to the pathways thinking subscale, while four questions are fillers and are not scored. The sum of the scores of the two subscales determines the total score of hope. In Golzar’s study, the internal consistency of the Persian version of this scale using Cronbach’ alpha coefficient was reported 0.89 [19].
The questionnaires were completed by a skilled interviewer on behalf of participants through interview. After collecting the data, they entered into SPSS software version 21 and described using the statistics of mean, standard deviation, frequency, and percentage. The normality of data distribution was examined using the Kolmogorov-Smirnov test. The data were analyzed using the Pearson correlation test and linear regression analysis. The significance level was set at 0.05.
Results
The Mean±SD age of participants was 48.16±4.81 years, ranged from 40 to 59 years. Most of them were married and 79% had 3 children or less. Most of them had a monthly income level<1 million Tomans and an educational level lower than high school, living in their own houses (Table 1). The mean total score of SWBS was 73.43±1.25; the mean total score of BDI was 31.10±0.91, and the mean total score of AHS was 16.26±0.34. Spiritual well-being, depression, and hope had no significant relationship with demographic factors of age, educational level, monthly income level, and housing status.
There was a significant negative relationship between spiritual well-being and depression such that with the increase of spiritual well-being, depression decreases, and vice versa (Table 2). There was a significant positive relationship between spiritual well-being and hope such that with the increase of spiritual well-being, the hope increases (Table 3). Moreover, spiritual well-being and hope had a significant relationship with depression such that with the increase of spiritual well-being and hope, the depression decreases, and vice versa (Table 4).


Discussion
The results of the present study showed a significant relationship between spiritual well-being and depression in middle-aged women; with higher spiritual well-being, less depression occur. Eyvan Baga et al. also showed a negative and significant relationship between the overall score of depression and spiritual well-being among students of Khalkhal University of Medical Sciences [20]. Momeni et al. showed that the level of depression was lower in breast cancer patients with higher scores of spiritual well-being [21]. Ghanbari et al [9] also confirmed these results. The findings of a study on the effect of spirituality and religion on the severity of depressive symptoms in patients at the final stages of life in the metropolitan area of New York indicated the existence of beneficial aspects of spirituality and spiritual well-being in reducing depressive symptoms and better compliance with final stages of life [22]. Consistent with our findings, Fasihi Harandi showed a significant and negative relationship between depression and spiritual well-being [23].
The findings of this study showed a significant positive relationship between hope and spiritual well-being in middle-aged women; with higher spiritual well-being, the women can have higher hope in life. In Moghimian et al.’s study, a significant relationship was also observed between spiritual well-being and hope in patients with cancer [24]. The elderly with higher spiritual well-being are less susceptible to internal conflicts, aimlessness, hopelessness, and worries [25]. Spirituality is a way to create meaning during problematic events; spiritual and religious beliefs create a source of meaning and hope in humans [26]. In the study by Dehbashi et al. on examining spiritual well-being and hope in patients with hemodialysis in Zahedan, a positive and significant relationship between spiritual well-being and hope was also reported [27]. Kenne Sarenmalm et al. concluded that the focus on increasing hope can increase self-confidence and meaning in life, reduce anxiety and depression symptoms, and help patients deal with disease recurrence. Patients who perceive hope as an important source in their lives can overcome barriers and difficulties and continue fighting against adverse conditions. Hope can be an important factor in reducing disease-related symptoms and pain [28]. Our results are also consistent with the results of Jafari et al. [29]. According to Alexis Carrel, “Only in prayer do we achieve that complete and harmonious assembly of body, mind, and spirit which gives the frail human reed its unshakable strength” [10]. People who pray more and pay more attention to spirituality in their lives are more optimistic about future. The presence of an infinite power and relationship with God can reduce fears of the future and increase hope about the future.
A significant relationship was observed between hope and depression in the present study; with higher level of hope, middle-aged women can have less depression. This finding is consistent with the findings of Makiyan et al. [11] who reported a significant correlation between high hope and positive emotions and between low hope and negative emotions. Lower hope predicts symptoms of depression which is independent of diagnostic symptoms and other coping skills [11].
One of the limitations of this study was that the samples were from among middle-aged women visiting health centers in Qom city; therefore, the results cannot be generalized to all middle-aged women of Iran. Moreover, the causes of depression were not surveyed; hence, it is recommended that future studies investigate the predictors of the relationship between depression and spiritual well-being in middle-aged women. Moreover, interventional studies are needed to improve spiritual well-being and hope and reduce depression in middle-aged women. The results of this study can be used in planning to improve the spiritual well-being and life expectancy of middle-aged women in Iran.
Conclusion
There is a significant relationship between spiritual well-being and depression and between spiritual well-being and hope in middle-aged Iranian women. Therefore, it is recommended to pay more attention to the importance of spiritual well-being to maintain mental health and increase hope in these women.
Ethical Considerations
Compliance with ethical guidelines
This research has the ethics code IR.QUM.REC.1399.292 from the ethics committee of Qom University of Medical Sciences

Funding
This research was supported by the research project (No.1691), Funded by Qom University of Medical Sciences.
Authors' contributions
Conceptualization and Supervision: Zohre Khalajinia, Elaheh Ali Bakhshi Motlagh; Methodology: Zohre Khalajinia, Elaheh Ali Bakhshi Motlagh, Zahra Bagheri; Analysis: Zahra Bagheri, Fatemeh Sadat Izadkhah; Writing-Original Draft Preparation, Writing-Review & Editing: Zohre Khalajinia, Elaheh Ali Bakhshi Motlagh, Zahra Bagheri, Fatemeh Sadat Izadkhah; Project Administration: Zohre Khalajinia.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors would like to thank the health deputy of Qom University of Medical Sciences and all women who participated in this study.