Health, Spirituality and Medical Ethics

Introduction
Hardiness, as one of the personality traits, has been noticed by psychological theorists, especially positive psychologists, with the growing awareness in the field of psychology and the emergence of new areas of the concept of hardiness. In this framework, hardiness is defined as a combination of attitudes and beliefs that motivates and encourages a person to make hard and strategic attempts in the face of stressful and difficult situations. Such conditions open a path to growth and excellence from among the events that can potentially have disastrous and unpleasant consequences and provide growth opportunities [1].
Hardiness as a personality trait can increase the performance and level of mental health of a person despite experiencing stressful and stressful situations [2]. In their initial studies, Kobasa introduced this psychological personality structure based on the findings collected from people who are facing major psychological pressure and as a general orientation toward oneself and the surrounding world, including the following three components: Commitment, control, and struggle [3].
The psychological hardiness of resilient people does not simply originate from the individual influence of these three components but rather results from a specific coping style that is consistent with the dynamic combination of these three components [4]. Hardiness is a single structure that integrates its components; in other words, hardiness eliminates the distinctions of its components and creates homogeneity [5].
One of the factors affecting psychological hardiness, which is an emotional supporter and a means for a positive interpretation of life events, is religious attitude. Religious attitude has a fundamental importance in most people’s lives and affects the way they perceive life and the world. Since spirituality plays an important role in the mental health of humans, it has been noticed by researchers, especially psychologists [6]. Religious attitude is the whole interpretation that explains the relationship of man with himself, with other people, and with all the phenomena of the universe [7]. A good religious attitude can play an effective role in the peace of a person in all situations, assessing the situations, cognitive assessment of the person, coping activities, support resources, and so on. It can also reduce mental distress. Accordingly, it has long been believed that there is a positive relationship between religion and mental health, and recently spiritual psychologists have attracted much empirical support in this area [8].
While many researchers and psychologists believe that spirituality reduces cognitive errors and leads to a sense of inner security, a group believes that spirituality also has a therapeutic and educational effect [9]. Salsman et al. examined the relationship between religious attitude and psychological adjustment with optimism and concluded that there is a significant relationship between religious attitude and adjustment with optimism [10]. Darvishi et al. [11] and Koeing [12] have shown a positive relationship between spirituality and mental and physical health. Habibi [13], Ball et al. [14], and Maselko and Kubzansky [15] demonstrated that adherence to spirituality is related to physical and mental health.
Another factor that can play a role in hardiness is spiritual intelligence. Behavioral intelligence is adaptive problem-solving that is oriented toward facilitating practical goals and adaptive growth [16]. High spiritual intelligence can strengthen the spiritual dimension of religiosity and help people know the moral, aristocratic, and emotional roots of religions [17]. Jung believes that in many people, after the age of 35 years, major changes take place in the unconscious, which may influence the process of spiritual intelligence. Humanity today is looking for a religion that, while providing spirituality, has also a solution for its social life [18]. The rapid progress of psychology in the field of religion and spirituality in recent decades has confirmed the revelation of the wide role of religion in all aspects of human life, especially its role in promoting peace, health, and mental health and even its serious effect in reducing and improving mental disorders and abnormalities. Social issues have caused the development of psychological studies in the field of spiritual intelligence [19].
Only a few studies have been conducted on the relationship between spiritual intelligence and hardiness. Farhangi et al. [20] concluded that there is a relationship between spiritual intelligence and psychological hardiness. Azmoudeh et al. [21] showed a relationship between religious orientation and psychological hardiness. Yasmin-Nejad and Golmohammadian [22] concluded that religious orientation predicts the psychological hardiness of students. Shirzadi et al. [23] concluded that there is a significant relationship between lifestyle and spiritual intelligence. Tamnnaifar and Hosseinpanah [24] indicated a positive relationship between the components of spiritual intelligence and happiness.
According to the above-mentioned contents, the importance and necessity of discussing the issue of spiritual intelligence and religious attitude in the psychological hardiness of women can be felt from different aspects in the new era. Mental health in a woman means a lack of mental illnesses and showing correct reactions and flexibility. Women’s coping with deep issues of life, with themselves and others, show their mental health, which can play a significant role in their sense of accomplishment and self-confidence, as well as women’s self-improvement and empowerment. Spiritual health, which is based on spiritual intelligence is one of the most important factors related to women’s mental health. With spirituality, integration, and harmony between internal forces, i.e. body and mind, and mind and spirit are created. This integration leads to stability in women’s lives, peace, a sense of closeness to themselves, God, society, and the environment, and guarantees their mental health. The re-emergence of spiritual trends, as well as the search for a clearer understanding of faith and its application in daily life, and the need to pay attention to the role of spirituality and religion in all aspects of human life, add to the importance of research variables that focus on spiritual topics and attitudes toward religion. Currently, research on spirituality is progressing in various fields, such as medicine, psychology, anthropology, and cognitive sciences [25]. Considering the research background and the determining role of religious attitude and spiritual intelligence in psychological hardiness, the present study investigates a conceptual model using the path analysis method. In other words, the main question of the present research is whether the proposed model related to the direct and indirect effect of religious attitude on psychological toughness is suitable (Figure 1).
Methods
This study used a descriptive correlation method. The statistical population of the research included all women aged 15 years and above from Ardabil City, Iran. The inclusion criteria were having the age over 15 years and the ability to read and write. Meanwhile, the exclusion criteria were incomplete completion of the questionnaire and age less than 15 years old. A total of 384 women were selected from the statistical population based on the Cochran formula by random sampling. Among these, 16 incomplete questionnaires were removed. The following tools were used to collect information.
Religious attitude questionnaire
To collect data on religious attitudes, the questionnaire by Khodayari Fard et al. (1998) was used. This questionnaire has 40 questions answered based on a 5-point Likert scale from completely disagree (1) to completely agree (5). This questionnaire has six components related to religious attitude including worship, ethics and values, the effect of religion on human life and behavior, social issues, worldview and beliefs, and science and religion. The reliability of this questionnaire has been reported at 0.92 by Khodayarifard and 0.86 in this research. The validity of the questionnaire has been reported at 0.85 [26].
Spiritual intelligence questionnaire
To collect data related to spiritual intelligence, the questionnaire by Abdollzadeh et al. (2017) was used. First, a preliminary questionnaire of 30 questions was prepared by the researchers and filled by 30 students. The reliability of the test in the preliminary stage using the α method was 0.87. Item 12 was removed in the question analysis using the loop method. The final questionnaire was arranged with 29 items, which measures two components of understanding and connection with the source of existence and the other one measuring spiritual life or relying on the inner core [27]. The reliability of the questionnaire in the present study was 0.81. The validity of the questionnaire was determined by the content method and also obtained by the factor analysis method confirming the two above-mentioned components.
Psychological hardinessquestionnaire
Pollett et al.’s (1989) psychological hardiness questionnaire (1989) was used to collect data on hardiness which includes 45 questions translated and standardized by Khorasani and Ebadi. In this questionnaire, the respondent can select a range of answers. The Cronbach α coefficient of the total scale of psychological hardiness in the present study was 0.85. The concurrent validity coefficient of this scale has been reported at 0.82 using the Kubasa test [28].
The obtained data were analyzed using the Pearson correlation test and multiple regression with step-by-step method and path analysis using the SPSS software, version 21, and LISREL software, version 8.80. The significance level of 0.01 was also considered.
Results
Table 1 presents the descriptive findings of the research participants.
According to Table 1, out of 384 women, 86 had an under-diploma degree (22.4%), 158 had a diploma (41.1%), and 140 had a university degree (36.5%). Also, 220 people (57.8%) were between the ages of 15 and 40 years and 164 (42.2%) were 40 years old and above (Table 1).
The regression results (Table 2) showed that spiritual intelligence (β=0.203, P=0.001), social issues (β=0.238, P=0.001), ethics and values (β=0.238, P=0.001), and worship (β=0.309, P=0.001) is a significant predictor of women’s psychological Hardiness.
In this research, multivariate regression was used to draw the path analysis diagram. First, one variable was considered the dependent variable (psychological hardiness). Then, β values were obtained for all variables using the computer output. Subsequently, the non-significant β values of the variables were removed and among the remaining βs, those with the largest values entered the regression model in the first step as the independent variable (spiritual intelligence), and the last remaining variables were considered as external variables. Finally, the following arrangement was obtained (Table 2).
The β coefficient of worship on spiritual intelligence equaled 0.145 and the β coefficient of ethics and values ​​on spiritual intelligence was 0.201. In addition, the β coefficient of social topics on spiritual intelligence was 0.144.
As shown in Figure 2, the three variables of worship, ethics and values, and social issues have an indirect effect on psychological hardiness and a direct relationship with spiritual intelligence. Spiritual intelligence also has a direct effect on psychological hardiness (Figure 2).
Table 3 shows that the chi-square ratio with degrees of freedom equal to 2.09 is less than 3. Also, the value of the root mean square error of the approximation index is 0.3 and less than 0.8. The value of the goodness of fit and adjusted goodness of fit indices is close to one, and the value of the root mean square residual is 0.03 which is considered small. Therefore, the values of these indices have a good fit (Table 3).
Discussion
In this study, the relationship between religious attitude and spiritual intelligence with the mediating role of psychological hardiness among women in Ardabil City, Iran, was investigated. One of the findings of the research indicates a significant relationship between religious attitudes and women’s hardiness. This significant relationship has a positive relationship with the components of ethics and values, the effect of religion on human life and behavior, ideology and beliefs, and science and religion. This finding is consistent with previous results in this area [11, 12, 14]. This problem can be due to the cultural and social climate of Iran. Contrary to the opinions and hardiness of some Western theorists, there is a different cultural atmosphere and discourse in Iran, and more care should be taken in generalizing the results to Islamic Iran, considering the scientific nature of Islamic countries and the prevailing interpretations of religion. A religious person believes in a supreme source and worships him. Religious and spiritual beliefs and attitudes have influenced people’s cognitive components, including the interpretation of events, optimism or pessimism, and their type of thinking, and these components also affect their well-being and physical and mental health through the immune and neuro-psychological systems.
Another finding of this study showed a significant relationship between spiritual intelligence and psychological hardiness of women using the Pearson correlation coefficient. The results of this research are consistent with the findings of previous research [20-24] regarding the relationship between spiritual intelligence and mental hardiness. To interpret such results, spiritual intelligence combines the structures of spirituality and intelligence and creates a newer structure. This intelligence, which entered the psychology literature at the end of the 20th century, can predict a person’s performance and adaptation to the surrounding environment. This intelligence gives people the opportunity to be sensitive to material and spiritual realities. Spiritual intelligence can have a relationship with hardiness, but this does not mean a cause-and-effect relationship. Therefore, cause-and-effect relationships should not be considered in the interpretation of such data.
Another finding of the research indicated that the components of religious attitude (worship, social issues, and ethics and values) and spiritual intelligence were included in the model and predicted women’s psychological hardiness. Also, the results of the path analysis also show that worship, social issues, and ethics and values ​​affect women’s hardiness indirectly but spiritual intelligence influences women’s hardiness directly. In other words, worship, social issues, and ethics and values ​​affect women’s hardiness through spiritual intelligence. Women who use these components will perform better in their soul and spirit. The results of this research are consistent with the findings of other studies [11-14, 12]. According to regression analysis and path analysis in the interpretation of such findings, spiritual intelligence will bring physical health in addition to mental health. A person with a positive religious attitude and high spiritual intelligence behaves in social and individual relationships in such a way that both he and others feel a sense of peace and comfort when he is with them. This makes the style of intelligence righteous, respects the right, makes justice holy, makes hearts kind to others, establishes mutual trust among people, and connects and unites all members of the society like members of one body. It is faith in God that is a guiding attribute in life and becomes the source of good personal and social behavior [21]. In other words, based on the findings of this research, the belief dimension and ritual dimension of religion are some predictors of public health. People who adhere more to religious principles, branches, orders, and rules and emphasize these rules and principles more in practice, have a lot of strictness in their lives. Faith in God makes a person’s attitude toward the whole existence purposeful and meaningful. Lack of faith in God causes a person to lack coherence and peace, and this causes weakness. Religion causes patience tolerance, empathy, and flexibility in relationships with others. According to psychologists, people with stronger beliefs and faith benefit from higher mental health and strength. Religion and religious beliefs are the components that play an important role in promoting positive mental capacities and cultivating potential mental talents. True attachment and faith in God give man incredible and enormous power, a constant source of youthful energy, which helps man in preventing the harsh and destructive attacks of the environment and its materialistic orientations, as well as social and psychological disturbances.
Conclusion
Considering the findings of this study, religious teachings and beliefs and strong religious beliefs can guide a person toward perfection and excellence and thus improve health and increase the benefit of a person from positive psychological characteristics, such as hardiness. The existence of spiritual experiences of people, the determination of special areas and territories in nerves, and the architectural structure of the brain in problem-solving give grounds for the belief in the existence of spiritual intelligence. Cultivating spirituality can help women pay attention to their spiritual experiences and use them to solve problems and understand the value and meaning of life. The review of the studies conducted in Iran shows that there has not been any research on psychological hardiness from the perspective of religious attitude and spiritual intelligence, and most of the current researchers have not investigated the role of religion in the psychology of religion. However, it is suggested that more studies with different scales and different samples are necessary to generalize such findings. It is hoped that the results of the investigations carried out in these fields help mental health planners to use the rich and huge spiritual and religious resources to use the scientific method without political, sectarian, and national tendencies to improve the quality of life and mental health of people in society as a worthwhile step.
Ethical Considerations
Compliance with ethical guidelines
Ethical principles of research such as informed consent, anonymity, confidentiality, and the possibility of withdrawing from the research were considered.
Funding
This research has not received any financial support from the public or private sectors.
Authors' contributions
All authors contributed equally to the preparation of this article.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors hereby express their sincere gratitude to all the women who helped them in conducting this research by completing the questionnaires.