Health, Spirituality and Medical Ethics

Introduction
The coronavirus has been recognized as a crisis for public health, and its consequences have overshadowed health, mental well-being, and adaptation in all age groups, including students [1]. Resilience is one of the vital and fundamental factors that determine people’s health in critical situations because it makes people use their capacities to achieve success and growth in their individual lives under challenging situations despite the presence of dangerous factors and use it as an opportunity to empower themselves [2]. Therefore, resilience helps improve a person’s ability to establish biological and psychological adaptation in critical and threatening conditions, including the COVID-19 crisis [3].
The importance of resilience and its effects on people’s lives can determine the value of addressing factors related to it. Among these cases, we can mention mindfulness, the importance of resilience, and its effects on people’s lives, which can determine the value of addressing related factors. Mindfulness is defined as receptive attention and awareness of the experiences and events of the present time. This means seeing thoughts as an event in awareness and emotional care without trying to change them with calmness and patience [4]. Research has shown that resilience is higher in individuals with outstanding mindfulness, and resilient individuals can better respond to challenging situations without automatic and non-adaptive reactions [5, 6]. Studies indicate the relationship between mindfulness and resilience [7, 8].
On the other hand, having spiritual experiences makes a person resistant to despair [9]. Spiritual experiences relate to an individual’s perception of a superior force in daily life and encompass experiences, such as connection, pleasure, transcendence, power, and comfort about God [10]. Regardless of people’s religious orientation, spiritual experiences include their inner understanding of God’s presence and relationship with Him and their feeling of responsibility towards others as sources for belonging and relying on a higher source [11]. These experiences are an essential part of a person’s life, including understanding the meaning of life, positive experiences, and happiness and satisfaction with life. It can also help empower a person’s belief in coping with stressful situations by creating meaning and a feeling of belonging and hope [12]. Research has confirmed the relationship between daily spiritual experiences and teachers’ resilience [13] and the role of spiritual experiences on students’ resilience [14, 15].
The COVID-19 pandemic, with its quarantine, restrictions, stress, and other effects, has affected all age groups’ mental well-being and adaptability [1]. On the other hand, resilience is one of the essential and vital constructs in positive psychology, which refers to the growth of a person and gaining experience from adverse conditions, which protects a person from the adversities of life and helps to maintain their mental health when facing risk factors [16]. Also, considering the role of spiritual experiences and mindfulness and the lack of research on the relationship between the variables above in the target society, the present study deals with predicting the resilience of students in the era of COVID-19. It seeks to answer the question of whether mindfulness and spiritual experiences play a role in predicting students’ resilience or not.
Methods
The current research was a descriptive-correlational and applied method. The statistical population included 900 male and female undergraduate students of Farhangian University of Qazvin Province, Iran in the academic year 2019-2020; based on the Morgan and Gujersi Table, 269 people were selected by convenience sampling method and online (social media, e.g. Telegram, WhatsApp, Instagram, etc.) and answered the study questionnaires.
In order to analyze the data in the descriptive part, Mean±SD were used and in the inferential part, Pearson correlation test and multiple regression were used with the help of SPSS software, version 24 at a significance level of 0.05.
The inclusion criteria included informed consent to participate in the study, aged 19-23 years, and the exclusion criteria included incompleteness and distortion of the questionnaire. The data collection tools included the following questionnaires:
Mindfulness questionnaire: Chadwick et al. (2017) prepared this 15-question questionnaire, including the three factors of ‘conflict with thoughts’ (questions 8, 13, 3, 6, 2, and 15), ‘acceptance’ (questions 12, 4, 11, 7 and 10) and ‘awareness of thought’ (questions 1, 14, 9 and 5) on a 7-point Likert scale, measures from 0 (strongly agree) to 6 (strongly disagree).
The range of scores is between 0 to 96, with higher scores indicating higher mindfulness and vice versa. In Chadwick’s study, the concurrent validity has shown that this questionnaire has a positive and significant correlation with the Barvan and Ryan's mindfulness scale. (0.60). Also, a positive correlation was observed between the scores of this questionnaire and the positive emotion scale (0.27) and a significant negative correlation between negative emotion and psychiatric symptoms, which were -0.62 and -0.34, respectively. Furthermore, the reliability coefficient according to Cronbach’s α method was 0.89 in the average population and 0.82 in the clinical group [17].
In Foroughi et al.’s study, three factors were found in the exploratory factor analysis that explained a total of 50.51 percent of the total variance of mindfulness, adequate convergent validity with self-compassion (0.59), positive emotion (0.40), adequate divergent validity with negative emotion (-0.35), depression (-0.36), anxiety (-0.30), and stress (-0.51). Also, reliability using Cronbach’s α coefficient method for the factor of conflict with thoughts was 0.78, the acceptance factor was 0.69, the awareness factor was 0.62, and the total reliability was 0.76 [18]. The present study obtained total reliability using Cronbach’s α method as 0.79.
Questionnaire of spiritual experiences: Underwood and Tersi designed this 16-question questionnaire and included three factors of ‘feeling the presence of God’ (questions 1, 2, 4, 5, 6, 8, 9, 10 and 11), ‘communication with God’ (questions 3, 7, 8, 12 and 15) and ‘sense of responsibility towards others’ (questions 13, 14) on a 6-point Likert scale (most times of the day=6 and rarely=1). Therefore, the range of scores is between 16 and 96, and higher scores indicate more spiritual experiences. While confirming the validity, Underwood and Tersi have reported the scale’s reliability using Cronbach’s α as 0.94 [19]. Taghavi and Amiri reported the scale’s validity using concurrent validity methods and factor analysis in Iran. The reliability of the test re-test method was 0.96, and the Cronbach’s α method was 0.91 [20]. The current study obtained total reliability using Cronbach’s α method at 0.83.
Resilience scale: Connor and Davidson created this 25-question questionnaire, with five components of ‘perception of personal competence’ (questions 10, 11, 12, 16, 17, 23, 24 and 25), ‘trust in personal instincts’ (questions 6, 7, 14, 15, 18, 19 and 20), ‘tolerance of negative emotion’ (questions 1, 2, 4, 5 and 8), ‘evidence’ (questions 13, 21 and 22), and ‘spiritual influences’ (questions 3, 9) and scored on a 5-Likert scale between 0 (completely false) and 4 (always true) and gives an overall score of resilience. The range of scores is between zero and 100, with higher scores indicating greater resilience. Conner and Davidson reported the test re-test reliability of this questionnaire as 0.87. The convergent validity of this questionnaire using Kubasa’s stubbornness questionnaire (1979) was 0.83 [21].
In Keyhani et al.’s study, simultaneous narrative correlation coefficient results indicated a negative and significant correlation between resilience and aggression and a positive and significant correlation between self-efficacy and life satisfaction. Also, in calculating the reliability, the values of Cronbach’s α and split-half Spearman-Brown were obtained as 0.669 and 0.665, respectively [22]. In the present study, the overall reliability was obtained using Cronbach’s α method of 0.84.
Results
Table 1 presents the results related to the demographic information of the research sample.
Based on the results of the Pearson correlation test from Table 2, all the calculated correlation coefficients between mindfulness and spiritual experiences with resilience were positive and significant at the alpha level of 0.01, and the positive coefficients obtained indicate a direct relationship between mindfulness and spiritual experiences with resilience (P<0.01). The multiple regression test was used to predict students’ resilience through mindfulness. Durbin-Watson statistic was employed to check the independence of the residuals. Considering that its value (1.731) is between 1.5 and 2.5, it can be said that the assumption of independence of the residuals was met. Tolerance indices and variance inflation factor (VIF) were used to check the multicollinearities between the predictor variables, and according to the obtained results, no deviation from the multiple collinearity assumption was observed.
In Table 3, based on the results of the multiple regression test, the F value obtained to check the regression model was equal to 74.923, which was significant at the alpha level of <0.01, which showed that mindfulness can explain changes related to resilience well, which revealed the appropriateness of the presented regression model.
The adjusted R-squared value was 0.453, showing that the components of mindfulness explain 45.3% of the variance of resilience. The values of the standardized regression coefficients (Beta) were as follows: For the element of conflict with thoughts, it was (P<0.01, β=0.239), for the acceptance, it was (P<0.01, β=0.411), and for the awareness of thought, it was (P<0.01, β=0.204). Therefore, it was concluded that mindfulness predicts students’ resilience in a positive and significant way.

A multiple regression test predicted students’ resilience through spiritual experiences. Durbin-Watson statistic was employed to check the independence of the residuals. Considering that its value (1.621) is between 1.5 and 2.5, it can be said that the assumption of independence of the residuals was met. Tolerance indices and VIF were used to check the presence of multiple collinearity between the predictor variables. According to the results, no deviation from the multicollinearity assumption was observed.
In Table 4, based on the results of the multiple regression test, the F value obtained to check the regression model was equal to 90.566, which was significant at the alpha level less than 0.01, which showed that spiritual experiences can explain the changes related to resilience well; it also indicated the appropriateness of the presented regression model.
The adjusted R-square value was equal to 0.501, which showed that the components of spiritual experiences explain 50.1% of the variance of resilience. The value of standardized regression coefficients (Beta) was as follows: For the element of feeling the presence of God, it was (β=0.340, P<0.01), for the relationship with God, it was (β=0.222, P<0.01), and for the feeling responsible for others, it was (β=0.313, P<0.01). Therefore, it was concluded that spiritual experiences predict students’ resilience in a positive and significant way.
In Table 5, based on the results of the multiple regression test, the F value obtained for checking the regression model was 63.972, which was significant at the alpha level of <0.01. It also showed that mindfulness and spiritual experiences can well express resilience-related changes, which revealed the appropriateness of the presented regression model. The adjusted R-squared value was equal to 0.585, which showed that the components of mindfulness and spiritual experiences explain 58.5% of the variance of resilience.
The value of the standardized regression coefficient (Beta) was as follows: For the component of involvement with thoughts, it was (P<0.001, β=0.227), for acceptance, it was (P<0.001, β=0.187), for awareness of thought, it was (P<0.001, 155 β=0.00), for the feeling presence of God, it was (P<0.001, β=0.286), for a relationship with God, it was (β=0.148, P<0.003), and for the feeling responsibility towards others, it was (P<0.001, β=0.174). Therefore, it was concluded that mindfulness and spiritual experiences predict students’ resilience in a positive and significant way.
Discussion
The current study was conducted to examine the role of mindfulness and spiritual experiences in predicting students’ resilience. The results showed a direct and significant relationship between mindfulness and resilience, revealing that mindfulness positively and significantly predicts students’ resilience. It can be concluded that students’ resilience increases with the increase in mindfulness.
This study’s results are consistent with the results of previous studies in this field. For example, Sediqi Arfai and Namaki Bidgoli found that mindfulness can promote student resilience [7]. Another study showed that mindfulness has a significant effect on the resilience of diabetic patients [8]. However, it is not consistent with Badri and Najarian’s research results, which found no significant relationship between mindfulness and resilience [3]. In the explanation above, it can be said that a higher level of mindfulness may help people to overcome difficult situations and achieve a higher level of resilience. Mindful people can better respond to challenging situations without engaging in involuntary and non-adaptive behaviors. They are open to new perceptions, are more creative, and can better deal with difficult situations, thoughts, and feelings without weakness and discomfort [23]. When a person faces a complex emotional or physical condition, by not judging the experiences, he becomes more aware of what he sees and is and what should be. As a result of this awareness, he can show more resilience [24].
Another research results showed that the correlation between spiritual experiences and resilience is positive and significant, and spiritual experiences positively and significantly predict students’ resilience. In other words, resilience is increased by applying spiritual experiences in life. The result obtained is consistent with the results of previous studies. For example, the results of Bagheri Karaji and Kermani’s study showed a positive, direct, and significant correlation between daily spiritual experiences with teachers’ mental health and resilience and daily spiritual experiences (feeling the presence of God, communication with God, and feeling responsibility towards others) has a significant effect on teachers’ mental health and resilience [13].
The results of another study on students showed that spiritual experiences and their components have a significant positive correlation with resilience, and among the components of spiritual experiences, finding meaning in life, socio-religious activity, and transcendent mystical experiences can predict the variance of the resilience variable [15]. According to the above results, unique feelings are obtained through daily spiritual experiences, such as communication with God, experiencing the presence of God, feeling responsibility towards others, and experiencing increased hope, optimism, and positive emotions. People with daily spiritual experiences can give a new meaning and concept to their lives in problems and crises and improve their health. On the other hand, it makes it possible to reinterpret uncontrollable events, and as a result, events seem less stressful and controllable [13].
Furthermore, it can be noted that the religious context of society and the emphasis on patience and resilience in the face of difficulties, as well as encouraging individuals to search for meaning and purpose in events that occur, increases the sense of control and power of individuals and provides a better opportunity to adapt to difficult conditions. It seems that components, such as finding meaning, religious activities, and mystical experiences that explain the variance of resilience are more concretely related to people’s loss, and people face difficulties more by praying and searching for goals and so on during problems. Also, having spiritual experiences strengthens a person’s relationship with God. It makes a person feel more responsible towards himself, God, and people [25], promoting greater resilience.
This research faced limitations, such as the lack of in-person access to students, the impossibility of considering intervening variables, such as socio-economic status, academic semester, native and non-native status, and using a questionnaire as the only data collection tool. Also, the research was conducted online, and the researchers did not fully supervise the implementation; therefore, caution should be taken in generalizing the results to people who do not use the Internet. According to the research results, it is suggested that the officials have a more comprehensive view of the student’s spiritual needs and provide them with more complete and appropriate services and care in the shadow of preserving their human and moral dignity. It is also suggested that educational programs and courses be held to improve spiritual experiences and mindfulness for better health and resilience.
Conclusion
The results showed that mindfulness and spiritual experiences can predict students’ resilience during the COVID-19 era; thus, it is recommended that educational and counseling programs focus on enhancing mindfulness and spiritual experiences to improve the resilience of the students targeted by the educational system.
Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Qazvin University of Medical Sciences (Code: IR.QUMS.REC.1400.070).
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Authors' contributions
Study design: Azam Mohammadifakhr; Data interpretation and statistical analysis: Ameneh Rezaian Deylami; Writing the original draft and editing: Shirin Mehranfa; Supervision, review and editing: Ahmad Usefynezhad.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors thank to all the students and teachers who participated in completing the questionnaires.