Health, Spirituality and Medical Ethics

Introduction
One of the most important socio-economic changes of the 21st century is the aging of the world population [1]. It is predicted that by the year 2050, a total of 16.5% of the world’s population will be 65 years old and above, and 4.3% will be 80 years old and above. That is, the number of elderly people will reach two billion, 70% of whom will live in developing countries [2]. From a sociological point of view, old age is a period when the amount of participation and social role of a person decreases. In this point of view, retirement is considered equivalent to old age [3]. The final period of middle age and the beginning of old age, for many elderly people, is accompanied by changes and transformations that happen in their mental and physical dimensions. The available evidence indicates that in the period of old age, the amount of pressure experienced by a person and its physical and psychological consequences is more obvious than in the previous period [4] and the person may lose their job and social status. The loss of friends and relatives will lead to social isolation, which is inevitable with such changes that reduce happiness [5]. Life satisfaction means how much the basic needs of a person have been met [6].
The results of some studies have shown that the quality of life, mental, and physical health, and overall successful aging are strongly influenced by the religious beliefs of the elderly. Some researchers consider the experience of spirituality to include hope, finding meaning in life, the ability to forgive others’ mistakes, moral beliefs, and values, spiritual care, having a proper relationship with others, believing in God, being moral, being creative, and having the ability express the self [7]. When age increases, religious beliefs and spiritual health also increase [8]. Adherence to religious beliefs and instructions increases a person’s motivation to create and strengthen self-care behaviors so that the stronger an elderly person’s faith in God becomes, the better he can deal with life’s problems [9]. People who have more spiritual tendencies have a higher level of hope and satisfaction [10].
Hopeful people are healthier and happier and their immune system works better [11]. On the other hand, people who have more spiritual tendencies have a higher level of hope and satisfaction [12]. Such people by using avoidance strategies, act more effectively in some tasks, such as re-evaluation and problem-solving, and cope better with psychological and social pressures.
Iran has not successfully met this demographic change either. Statistical indicators show that the process of population aging has also started in Iran, and it is predicted that the average age of the country’s population will increase by 10 years from 2006 to 2026. Life expectancy and aging of the world population have increased the burden caused by chronic diseases. Therefore, it is important to identify the factors that cause the reduction of this burden, both from an individual point of view (which leads to the preservation of the quality of life) and from a social point of view (which leads to a reduction in the need for care resources) [13]. On the other hand, the rapid increase in the number of elderly people creates many opportunities for economic activities, including the tourism industry, and since the elderly have more free time in retirement, more savings, and fewer financial obligations, fewer professional activities and family responsibilities [14] compared to young people, they prioritize travel in their lives [15]. In domestic and foreign studies, the relationship between hope and life satisfaction has often been discussed. Moradi et al. [16] investigated the relationship between the practice of religious beliefs and hope and life satisfaction of the elderly and stated that there is a significant relationship between religious beliefs and life satisfaction, and there is also a positive and significant relationship between hope and life satisfaction of the elderly. Jamali Moghadam and Bastani [17] stated that a significant percentage of the studied elderly were satisfied with their lives. Akhoundzadeh et al. [18] stated that religion and spirituality can have a positive effect on mental and physical health. The results of Zanjari et al.’s study [19] indicated a decrease in life satisfaction in the elderly with increasing age. The results of the study by Najafi et al. [20] indicated a significant positive relationship between optimism and life satisfaction, and the two variables of loneliness and hope have a significant role in predicting life satisfaction, respectively. The study by Rezai Shaheswarlo et al. [21] indicated a statistically significant difference between the average score of hope and life satisfaction in men and women. Balderas-Cejudo and Patterson [22] stated that tourism provides the greatest advantage for elderly travelers. This is because it creates a feeling of happiness and vitality for elderly tourists. In their study, Baek et al. [23] pointed out the significant relationship between pilgrimage and the meaning of life and satisfaction with life. The results of Zhang and Zhang’s study [24] also pointed to the impact of leisure and tourism on the quality of life of the elderly and stated that many social activities, such as leisure and tourism have positive effects on the mental health of the elderly. Heo et al. [25] also stated that the level of optimism was a significant predictor of volunteerism, which had an impact on life satisfaction and psychological well-being. Moal-Ulvoas [26] investigated the travel motives of retired adults and examined the effect of aging through the effect of the spiritual dimension of the older travelers, which is characterized by their transcendence.
Myers describes spiritual experience as a continuous search for the meaning and purpose of life, a deep understanding of the value of life, the vastness of the universe, existing natural forces, and personal belief systems [27]. The higher the level of spirituality and religiosity in people, the more their mental health and life satisfaction [28]. Spirituality is a way to cope with illness, bereavement, or life pressures [29] since hope is considered a cognitive set based on the feeling of success caused by various sources (energy aimed at the goal) and paths (planning to achieve goals) [30]. Spiritual experiences and hope in the prevention and treatment of physical and psychological diseases have also attracted the attention of Western researchers. Instead of focusing on unfortunate events, hopeful people learn many things from spiritual experiences and hope and use them to pursue future goals [31].
Satisfaction with life means a person’s attitude and general evaluation of their life as a whole or some aspects of life, such as family life and educational experience. Also, life satisfaction is a reflection of a person’s wishes and their current situation [32]. Hope and developed spiritual tendencies lead to life satisfaction. Life satisfaction is one of the aspects of living a good life [33]. Therefore, according to the above-mentioned points, it is necessary to understand the importance of hope and spiritual experience in the elderly’s life satisfaction. Therefore, due to the lack of study on elderly tourists and the impact that tourism can have in this area, the present study predicts the life satisfaction of elderly tourists based on spiritual experience and hope in Shiraz City, Iran.
Methods
This cross-sectional study was conducted in Shiraz City, Iran, in 2023. The participants of the study were 384 elderly people aged 60 years and above. The Cochran formula was used to calculate the sample size. The participants were selected through random sampling among the tourists in Shiraz tourism sites. To measure life satisfaction, 5 life satisfaction items provided by Diner et al. [34] were used. This tool has been translated into Farsi by Tagharrobi et al. The Cronbach α value of this measure in the present study was 0.85 [35].
To measure hope, a 12-item questionnaire prepared by Snyder and Forsyth, was used [36]. Out of 12 questions in the questionnaire, 4 questions measure operative thinking, 4 questions measure strategic thinking, and 4 questions are deviant. The scoring method is based on the 8-point Likert scale. Scoring of deviant questions, which is to increase the accuracy of the test, is removed and the range of scores is between 8 and 64 [37]. In Golzari’s research [38], the reliability of Schneider’s hope scale was 0.89 [39].
Android’s daily spiritual experiences and fear scale were used to measure spiritual experience. This scale has 16 questions, which are scored using a 6-point Likert scale (most times a day=5 to never or almost never=1), and higher scores indicate spiritual experiences [39]. The correlation coefficient of the mentioned questionnaire in the study of Taghavi and Amiri was confirmed at 87% [40]. After collecting the data, they were entered into the SPSS software, version 22. To investigate the relationship between the two variables of hope and life satisfaction, spiritual experience and life satisfaction, and age and life satisfaction, the Pearson correlation coefficient was used, and to predict life satisfaction based on hope and spiritual experience, multivariate regression and t-test were used to check gender and life satisfaction.
Results
The number of participants was 384 elderly people aged 60 and above in the tourist sites of Shiraz City, Iran. The study of the demographic characteristics of the examined elderly people showed that the average age of the sample was 63.5 years. About 48% of the sample were retired or had income, 32% of the sample were housewives and only about 20% were still employed. In addition, 80% of the sample has a wife, and nearly 20% of their spouses had died, 21% of the elderly were illiterate, and 29% had a primary or high school education. Meanwhile, about 35% had secondary and diploma education and about 15% of the surveyed elderly had a university degree.
Table 1 shows the correlation coefficient between the components of hope and life satisfaction. The results indicate a positive and significant relationship between hope and life satisfaction (P=0.000).
Table 2 shows the correlation coefficient between spiritual experience and life satisfaction, the results indicate a positive and significant relationship between spiritual experience and life satisfaction (P=0.000).
To predict life satisfaction based on hope and spiritual experience, multivariate regression (with the “Enter” method) was used. Table 3 shows the correlation coefficient of life satisfaction, spiritual experience, and hope. The correlation coefficient between these two variables is 0.78 with a high significance level (P=0.00). This means that as the level of spiritual experience and hope increases, the level of satisfaction with life also increases. The meaning of R2 is the estimate of the variance of life satisfaction, which is explained by the independent variable. Nearly 62% of the variance (or changes) in life satisfaction is explained by independent variables.
Based on the results of Table 3, the multiple correlation coefficient between predictor variables with life satisfaction is 0.78, and hope and happiness explain 62% of the changes in life satisfaction.
The results obtained from Table 4 indicate that there is a significant difference between gender and the level of life satisfaction (P=0.0240). The mean score of life satisfaction of men is more than that of women (Table 4).
Table 5 shows the Pearson correlation between age and life satisfaction of elderly tourists. The results indicate a significant relationship between age and life satisfaction of elderly tourists (r=0.25, P=0.000) and, due to the negative correlation value, with the increase in age, the level of life satisfaction decreases.
Discussion
In the process of psychological development, old age is a period in which mental health and psychological well-being are of vital importance. As the elderly pass through their youth and middle age, they face various issues and problems in the field of social relations, and physical and mental health [41]. Among them, one of the suitable activities to improve their physical and mental health is tourism [42]. Elderly tourists choose their destination with different spiritual, recreational, leisure, and health motivations. This research was conducted to predict the life satisfaction of elderly tourists based on spiritual experience and hope. The type of cross-sectional study was conducted by survey method among elderly tourists with the age range of 60 years and above in Shiraz City, Iran. The data collection tool was a questionnaire. The sample size was determined using the Cochran formula with a confidence interval of 95% and an error level of 5%, to select 384 elderly people. The research findings indicate a positive and significant relationship between hope and life satisfaction (P=0.000), and there is also a positive and significant relationship between spiritual experience and life satisfaction (P=0.000). The results of the multiple correlation coefficient between predictor variables with life satisfaction was 0.783 and hope and happiness explained 62% of the changes in life satisfaction. There was a significant difference between gender and the level of life satisfaction (P=0.024) and the mean level of life satisfaction of men was more than women. The obtained results indicate that there is a significant relationship between age and life satisfaction of elderly tourists at a 99% confidence level.
Therefore, since the findings of the research show the relationship between hope and the life satisfaction of elderly tourists, the role of hope is so important that in the Holy Qur’an, divine promises for humans are based on the axis of giving hope and on cognitive and motivational elements. It has been emphasized [43] that more hopeful adults, count on others as sources of support that they can rely on [44] in the challenges they may face in their lives. These people experience higher happiness and are more satisfied with their lives [45]. These results are in agreement with Najafi et al. [20] who stated that there is a significant relationship between hope and life satisfaction, and high hope can increase psychosocial performance and, consequently, well-being and satisfaction. Therefore, people who have hope of achieving a goal feel satisfied even when they think of approaching it, as confirmed by the results of the studies of Rezai Shaheswarlo et al. [21] and Zanjari et al. [19].
Also, the results indicated a significant relationship between spiritual experience and life satisfaction of elderly tourists, which are similar to the studies of Moradi et al. [16], Akhoundzadeh et al. [18], Balderas-Cejudo and Patterson [22], Baek et al. [23], and Moal-Ulvoas [26]. Hope and developed spiritual tendencies lead to satisfaction in life. Satisfaction with life is one of the aspects of living well. This concept includes an important research field that is close to the main goal of psychology, which is having a better life [46].
The findings of this research indicated that the variables of spiritual experience and hope are factors affecting the life satisfaction of elderly tourists. The effect of both variables on the level of life satisfaction was increasing, and as Yaqoubi et al.’s research findings state, spiritual well-being, and hope are important factors of life satisfaction in the elderly. Considering that the elderly who live far from home and family may have less hope and life satisfaction compared to the elderly who live with their family, planning to increase hope through deep spiritual and religious education and group programs to deepen interpersonal and intra-personal feelings is necessary [44].
There is a significant difference between gender and the level of life satisfaction with the mean score of men’s life satisfaction more than women and there is a significant relationship between age and life satisfaction of elderly tourists. Due to the negative correlation value, the level of life satisfaction decreases with the increase of age. These results are in line with the results of studies by Zanjari et al. [19], Rezai Shaheswarlo et al. [21], and
Zanjari et al. [19] stating that life satisfaction is at its lowest in old age.
Conclusion
This study was conducted to predict the life satisfaction of elderly tourists based on spiritual experience and hope. The results of this research indicate that hope, spiritual experience, and life satisfaction have a significant relationship with each other, and spiritual experience and hope are important factors in the life satisfaction of elderly tourists. As indicated by many studies, life satisfaction in old age is reduced due to the experience of problems and issues. Therefore, the effort to find a new meaning and a different understanding of this era is critical, and spiritual experiences can be a solution in this regard because it is an active process that gives strength to people and makes them search for purposeful and healthy activities, and it is in the shadow of faith that a person reaches a sense of peace, happiness, and hope. Therefore, spiritual experience by energizing a person helps to find meaning in life, and due to dependence on God’s power, he does not feel powerless in the face of problems. Spiritual experience and spiritual beliefs are influential in the physical and mental health of the elderly and they play an effective role in giving peace and hope to these people. Tourism and leisure activities can play an effective role in improving the level of life satisfaction of the elderly and increasing their hope, which should be considered in planning and policy-making.
Ethical Considerations
Compliance with ethical guidelines
To comply with the ethics of the research, before administering the questionnaires, the role of the researcher, the topic, and the objectives of the research were explained to the participants, and after obtaining their permission, the questionnaires were distributed. This study was approved by the Ethics Committee of the University of Shiraz (Code: IR.US.psyedu.rec.1402.065).
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Conflict of interest
The author declared no conflict of interest.