Health, Spirituality and Medical Ethics

Introduction
In recent years, there have been many discussions about the mental health of students in higher education, because according to studies, mental health problems have a serious effect on students’ achievements, progress, and academic results [1-4]. Students who experience mental health problems are less likely to complete or pass a course or curriculum [5], more likely to drop out of college [4], and less likely to achieve higher grades [6].
Regarding more severe forms of mental illness, spirituality can interact with schizophrenia symptoms and act as a risk factor or a protective factor. Many spirituality-tailored therapies have been offered in healthcare settings, and their effectiveness in improving psychological outcomes has been supported by meta-analyses. Spirituality is a distinct, potentially creative, and universal dimension of human experience that emerges both in the mental consciousness of individuals and within societies [7]. According to Cao, Pettit, and Cook [8], spirituality is experienced as a fundamental or ultimate importance and thus relates to issues of meaning and purpose in life, truth, and values.
Most of the studies indicate that the promotion of spiritual and religious quality as well as values ​​and resources affect health and intervention. The findings of Pant’s review analysis [9] show that spirituality and religiosity have a significant and strong relationship with both mental health and quality of life (QoL). In addition, gender, age, educational stream, and socioeconomic status play an important role in determining spirituality, mental health, and QoL.
Garssen et al. [10] believe that a religious or spiritual belief system enables people to find meaning in stressful life events that are otherwise difficult to explain. From their point of view, this helps maintain a sense of control and predictability of the world. Spirituality is the insight and awareness of the human soul and existence and brings the potential capacities in a person [11]. Cook [7] have defined spirituality as a sense of meaning and having a purpose and mission in life, a balanced understanding of values, and a belief in improving the world.
Spirituality includes the components of religious adherence, reason, and the concept of God, which have received attention in recent years and help improve people’s mental health in various fields [7]. In this research, we intend to focus on the concept of God among these components.
God concept refers to the description of God based on a person’s mental images [12]. A positive perception of God is related to positive emotions, such as optimism, purpose in life, generosity, and altruism [13]. The idea of ​​God is considered an important thing in the development and formation of people’s religious beliefs, therefore, in the last five decades, more studies and investigations have been done in this area. The concept of God forms one of the most central aspects of the belief system of believers [12].
Genia believes that human understanding of spirituality, like many other concepts, is influenced by the levels of psychological evolution. Based on this, in his theory, he introduces five stages of psychological and spiritual transformation including self-intermediate religion, dogmatic faith, transitional faith, reconstructed faith, and transcendent faith. Also, they believe that each of the levels of psychological-spiritual development has its spiritual and psychological characteristics, and people at higher levels have more mental health [14].
Although much research has shown the increasing or decreasing effect of spirituality on mental health, no research was found specifically considering the relationship between the concept of God and the effect of this component. Accordingly, in this research, we investigate how the God concept has an increasing or decreasing effect on mental health, considering the mediating role of mental-spiritual transformation.
Methods
This was a descriptive type of structural equation modeling. The statistical population consisted of university students in Qom City, Iran. A multi-stage cluster sampling method with an estimated sample size (300 people) was used to select the study participants.
To measure spiritual psychological transformation, God concept, and mental health in students, the psycho-spiritual transformation scale, the general health questionnaire by Goldberg and Hiller (1979), and the God concept scale by Janbozorgi were used.
Psycho-spiritual transformation scale
The psycho-spiritual transformation scale was developed by Janbozorgi et al. (2013) [15] based on the clinical criteria of psychological clients reported by Genia [14], with cultural and religious orientations. This tool has 15 items and each item has 4 options corresponding to the stages of psychological and spiritual evolution. To check the internal consistency of this scale in the Iranian population, Deljo et al. [16] administered it to 341 female students and obtained a Cronbach α of 0.88. To check the internal consistency of this scale in the Iranian population, Sarabadani Tafreshi and Janbozorgi [17] administered it to 341 female students and obtained the Cronbach α coefficient of 0.88. The Mean±SD of scores were reported at 10.44 and 6.701, respectively. Also, the validity and reliability of this questionnaire were examined in the preliminary part of the research [18] using a sample of 172 participants, and the Cronbach α was obtained at 0.74 and the test-retest reliability coefficient was 0.71.
General health questionnaire
This questionnaire was compiled by Goldberg and Hiller in 1979. Currently, there are 60-, 30-, 22-, and 12-item forms of this questionnaire. The 22-item form of the general health questionnaire, which is used in this study, has four subscales (physical symptoms, anxiety, social dysfunction, and depression), and the sum of the scores of these four subscales is a total score for mental health. The items of this questionnaire are answered on a 4-point Likert scale.
The 22-item questionnaire developed by Golberg using the factor analysis method on the long form has 4 subscales, each scale has 7 items. The first subscale is physical symptoms, including items about how people feel about their health status and feeling tired (items 1, 2, 3, 4, 5, 6, 7). The second component is anxiety characterized by 7 items related to the measurement of anxiety (items 8, 9, 10, 11, 12, 13, 14). The third component is disruption in social functioning. This scale measures the extent of people’s ability to deal with professional demands and daily life issues and reveals their feelings about how to cope with common life situations (items 15, 16, 17, 18, 19, 0, 21). The fourth component is depression related to severe depression and suicidal tendencies (items 22, 23, 24, 25, 26, 27, and 28). The duration of completing the Persian version of the general health questionnaire-28 is 8 min on average, and subjects who spend more than 12 min answering the questions are probably showing resistance and trying to show their situation differently. As a result of the implementation of the questionnaire, 5 points are obtained for each person, 4 points are related to the subscales and 1 point is related to the entire questionnaire materials, the best situation and the most suitable method is to use the simple Likert method with a score of 1, 0, 2 and 3 for the options of the questionnaire.
Mehrdadi [19] reported the reliability coefficient of the general health questionnaire at 0.94. Taqvi [20]obtained the reliability coefficient of the general health questionnaire based on three methods of retesting, split-half, and Cronbach α at 0.93, 0.70, and 0.90, respectively. Also, the concurrent validity of the general health questionnaire was reported at 0.55 through simultaneous implementation with the Middlesex Hospital questionnaire, and the correlation coefficients between the subscales of this questionnaire with the total score were satisfactory and ranged from 0.72 to 0.87. Therefore, the mental health scale has good reliability and validity.
God perception scale
The God perception scale was developed by Janbozorgi (2008) based on Islamic religious concepts and the cultural and religious orientation of the author. This questionnaire is used to measure the level of self-made conceptions of God (God concept) as well as conceptualization based on authentic sources (Holy Quran) of God (true conceptualization of God or God concept), and self-concept (self-conceptualization from others’ perspective) and active and real conceptualization of self (self-concept) [17]. These concepts have been processed based on the theoretical framework of multidimensional spiritual therapy by Janbozorgi and Gharavi [21]. This tool has 40 questions, of which 25 questions are related to the idea of ​​God and 15 questions are related to self-concept, based on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). To check the internal consistency of this scale in the Iranian population, it was implemented on 628 undergraduate students. The reliability of the questionnaire using the test-retest method is 0.806 in the God concept and 0.582 in the self-concept. The Cronbach α coefficient of the questionnaire was also obtained at 0.815. Factor analysis using the principal components method identified 4 factors, including 7 items for self-concept, 8 items for self-concept, 14 items for God-concept, and 11 items for God-concept.
Data analysis
To analyze the data, the Mean±SD were used to express descriptive statistics. Correlation, regression analysis, and structural equation modeling were used to test the hypotheses. Statistical calculations were performed using SPSS software, version 26 and AMOS software, version 24.



Results
According to the results, the mean age of the participants was 31.9±5 years. Regarding the participants’ gender, 204(68%) were girls and 96(32%) were boys (Table 1).
Table 2 shows the Mean±SD of the research variables.
The Kolmogorov-Smirnov test for the normality of data distribution was used to check the normality of data distribution, as one of the necessary conditions for performing parametric tests, including the structural model (Table 3).
The values ​​in this table show that the significance level of all variables is greater than α=0.05; that is, P>0.05. Therefore, all distributions follow the assumption of normality and the data distribution is normal. Hence, it is desirable to perform parametric tests.
Table 4 shows the correlation matrix of the mental health variable and its components, the God concept variable, and the psychological and spiritual transformation variable. The correlation between God concept and mental health variable (physical symptoms, anxiety, social functioning, and depression) is equal to -0.264, -0.259, 0.451, and -0.272, respectively, and it shows that the God’s concept component is associated with four components of mental health (physical symptoms, anxiety, social functioning, and depression) at a significance level of 0.01. Also, there is a positive correlation between psychological-spiritual transformation and mental health (physical symptoms, anxiety, social functioning, and depression) at -0.254, -0.312, 0.215, and -0.302, respectively, showing a significant relationship between this variable and mental health at a 0.95 confidence interval level. It is noteworthy that an increase in the general health score indicates a lower mental health.
Figure 1 shows the theoretical model of the research. To determine the fit of the theoretical model with the experimental data obtained from the research, the structural model of the non-standard estimation mode was drawn in Figure 2 and the standardized estimation mode in Figure 3, and the values of the path coefficient were obtained.
According to Table 5, the value of fit indices indicates the appropriate fit of the model, and the value of the chi-square ratio divided by the degree of freedom is equal to 2.643 and smaller than the permissible value of 3, and the value of the second root of the variance estimation error of approximation is equal to 0.07 and smaller than 0.08 and the value of the comparative fit index is equal to 0.97 and greater than 0.9. Based on these values ​​and data extracted from the estimation of the AMOS model, it can be concluded that the fit of the model is in a suitable state.
As shown in Table 6, the correlation between God concept and mental health is 0.659 with a significance level of 0.01. Therefore, there is a relationship between the God concept and mental health, and the degree of correlation is strong and the direction of correlation is positive. It means that mental health increases with an increase in belief in God.
It was also tested using structural equations and the standardized factor loading of the concept of God component is 0.60 the β value of this component is 0.71 the β value of the psychological-spiritual transformation is 0.69 and the significance level is 0.01. Based on this, psycho-spiritual transformation predicts 69% of the relationship between God concept and mental health. In other words, the level of psychological-spiritual transformation predicts the relationship between God concept and mental health.
Discussion
The results of this study showed that there is a relationship between God concept and mental health. It may not be possible to directly compare the results of this study with previous research. However, the results of this research can be compared with Sarabadani Tafreshi and Janbozorgi [17], Ghobari Bonab et al. [22], Farhoush et al. [13], and Pant [9]. The findings of Sarabadani Tafreshi and Janbozorgi [17] showed a negative, inverse relationship between psychological-spiritual transformation and depression, anxiety, stress, and God concept, and between God concept (the self-created idea of ​​God) and depression, anxiety, and stress. There was a significant positive and direct relationship. The level of psychological transformation has an important contribution to predicting depression. The concept of God plays an important role in predicting depression, anxiety, and stress, and all these variables play an important role in a person’s mental health. Also, the research results of Ghobari Bonab et al. [22] indicated that the style of attachment to God and keeping God in mind in life increases patience as a good predictor of students’ self-esteem. From the point of view of Farhoush et al. [13], a positive perception of God is related to positive emotions such as optimism, purposefulness in life, generosity, and altruism. Pant’s findings [9] also showed an important relationship between spirituality and the health and well-being of a person’s life. In addition, researchers also find a strong relationship between spiritual and religious practices and QoL.
In explaining the results of this research, in examining the semantics of the concept of God, establishing a spiritual relationship with the Almighty God assures a person that a force beyond always supports us. By giving a spiritual dimension to problems, these people cope with problems better and suffer less stress and anxiety. Also, believing in the support and help of Almighty God gives people more hope for getting rid of problems. Also, a positive perception of God is related to positive emotions, such as optimism, purpose in life, honesty, generosity, and altruism. These characteristics deal with persistent and problematic cognitions and behaviors for mental health.
The idea of God is considered an important issue in the development and formation of religious beliefs of people. The knowledge and understanding of God along with having a correct idea of ​​Him is the basic condition and one of the important bases for the formation of the type of relationship with God, and the knowledge and how we imagine God strongly affects our behavior and interaction with God. The idea that people can form God concept is divided into positive and negative ideas. In a positive conception of God, God is thought to be kind, supportive, a guide, etc. which can play a calming role. In a negative conception of God, God is conceived with negative terms such as rejecting, punishing, unkind, etc. which make people despair and experience hatred and negative mood. Therefore, people who have a higher level of psychological-spiritual transformation seem to have an accepting and positive image of God and as a result, have better mental health. However, those with a lower level of psychological-spiritual transformation have a negative and conflicting mind about God and as a result, they have lower mental health.
Considering that previous research has shown the increasing or decreasing effect of the idea of ​​God on mental health, this research, confirming the results of previous studies, added the mediating role of mental-spiritual transformation in the relationship between these variables.
Conclusion
The results indicated that the God concept will have an increasing or decreasing effect on mental health regarding the mediating role of mental-spiritual transformation. Therefore, the effect of the relationship between God concept and mental health is not the same considering the level of mental-spiritual transformation of people. The results of the present study showed that the higher the level of mental-spiritual transformation, the more people enjoy mental health. Therefore, paying attention to the level of mental-spiritual transformation in the relationship between God concept and mental health is of special importance. When this variable is entered as a mediating variable, as shown in the present research, the relationships between variables will change. Therefore, it is important to pay attention to the spiritual variables of clients in examining the relationships between variables.
These findings show that helping the clients to pass through sensitive spiritual-psychological stages is of great importance and provides the basis for preventing problems and damage to the return of vision and also increasing mental health. Because traditional psychological professions are at odds with conventional religious beliefs and practices [14], some mental health providers may automatically assume that clients with strong religious beliefs are psychologically unhealthy. Exposure to information about religion and mental health can address an uncritically scrutinized anti-religious bias.
However, there is a relationship between spirituality and mental health, and the results of various studies have confirmed this relationship. What plays a more important role in explaining this relationship is the level of psychological and spiritual transformation of the people of the society, which should be planned to improve the level of their psychological and spiritual evolution. Therefore, it is suggested to include psychological-spiritual transformation in the content of educational programs of schools and universities, to increase the level of psychological-spiritual development of students and the general population.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Qom Branch, Islamic Azad University (Code: IR.IAU.QOM.RES.1402.148).

Funding
The present article was extracted from the PhD dissertation of Marzieh Azizimoein, approved by Department of Psychology, Faculty of Humanities, Qom Branch, Islamic Azad University.
Authors' contributions
All authors equally contributed to preparing this article.
Conflict of interest
The authors declared no conflict of interest.