Health, Spirituality and Medical Ethics

Introduction
The outbreak of COVID-19 was a critical and shocking event that not only damaged people’s physical health but also threatened other dimensions of their health by imposing conditions, such as social distancing, increasing loneliness, and decreasing interpersonal communication [1]. Mental health, as a facilitating factor in effectively coping with diseases, is one of the crucial issues to be considered in disease conditions, especially during epidemics, because a pandemic can significantly disturb people’s mental health and aggravate the damage caused by the disease [2]. Humans usually feel helpless and vulnerable against adverse conditions, dangers and hardships; therefore, it is essential to possess sufficient resilience to withstand risks and challenges. Resilience, as one of the components of mental health, can be effective in helping individuals resist mental injuries [3]. Resilience is a factor that enables people to face and adapt to difficult and stressful life situations while protecting them from mental disorders and life problems. Resilient individuals demonstrate a high level of adaptation to environmental stressors in their lives [4]. Connor considered the level of resilience of each person as the determining factor in their ability to deal with stressful situations and factors that threaten mental health. Thus, people with high resilience adapt to conditions more quickly, possess the ability to plan for long-term goals, recover more rapidly in the event of illness or injury, and experience less anxiety and disturbance when faced with difficulties [5].
Resilient people do not have narcissistic behaviors; they are emotionally calm and can deal with adverse situations. However, resilience is affected by other factors, with spirituality being one of the most crucial. Components of spirituality, such as religious beliefs and values, ethics, self-awareness, patience, hope and wisdom, significantly affect resilience [6]. Evidence indicates a positive relationship between resilience and spirituality [7], as well as spiritual health [8]. It shows that patients whose spiritual dimension is strengthened can effectively adapt to their illness and navigate the final stages of their condition more successfully [4, 5].
Spiritual health is one of the basic dimensions of health, which is considered a determining and effective factor along with physical, mental and social dimensions of health [9]. It is considered a protective factor in promoting health and preventing diseases and can be described as a successful and helpful strategy for human life across all stages and areas, including high-stress situations, illnesses, and even death. According to studies, spiritual health is considered a crucial facilitating factor in the treatment process for patients [10]. Spirituality is defined as an inner and satisfying feeling combined with constructive communication with oneself and others, as well as a transcendent existence within the specific cultural framework of each society. This leads to a sense of meaning in life and death, and there is strong evidence supporting the relationship between spiritual health and mental health [11]. When spiritual health is significantly compromised, individuals may experience mental disorders, such as loneliness, depression, and a loss of meaning in life [9]. Many studies indicate a significant relationship between religious orientation and resilience, which confirms that spirituality can increase resilience against dangerous diseases [11]. By increasing the ability to cope with challenges and improving both people’s physical and mental health, spirituality fosters hope in patients [12] and contributes to a better quality of life (QoL) [13]. Therefore, utilizing spiritual factors to address patients’ issues, considering the cognitive, emotional, and behavioral aspects of individuals, is one of the strategies to promote resilience.  This highlights that support received from spiritual or religious sources—especially the relationship with God—can enhance the QoL [5]. Considering the importance of resilience in patients with COVID-19, especially those who have experienced special care conditions or prolonged stays in medical centers, this study was conducted to evaluate the relationship between spiritual health and resilience in patients with COVID-19 in medical centers of Qom City.
Methods
Research design
The current cross-sectional analytical study was conducted in Qom City and educational and therapeutic hospitals (Amir Al-Momenin, Shahid Beheshti and Kamkar-Arabnia hospitals) affiliated with the Qom University of Medical Sciences in 2021. The researcher explained the goals of the project to the patients who met the inclusion criteria, and the patients participated with informed consent. Each participant completed three questionnaires, including a demographic information checklist, Plotzin and Ellison’s spiritual health questionnaire and Connor-Davidson’s resilience questionnaire.
Research population
The statistical population included patients with COVID-19 who were hospitalized for more than a week, or had the experience of being hospitalized in the intensive care unit of one of the studied hospitals. The inclusion criteria included having COVID-19, being hospitalized in the general ward for more than a week, or having a history of being hospitalized in the intensive care unit, willingness to participate in the study, and the ability to complete the questionnaire (Equation 1).
1. n=3+()2

Sample size calculation
The convenience sampling method was used. The sample size was calculated based on the formula for determining sample size according to the correlation test Considering the correlation between spiritual health and resilience in the study by Balochi et al. [14], which was found to be 0.19, and with alpha and beta values set at 0.05 and 0.2, the required sample size was calculated to be 215 participants. Data collection continued until the questionnaires were completed by the calculated number of participants.
Research tools
In this research, the following tools were used to collect data:
Demographic information checklist
This questionnaire contained information, including age, sex, marital status, level of education, occupation, economic status, underlying disease, and duration of hospitalization or hospitalization in the intensive care unit, all of which were self-reported by the patients.
Plotzin and Ellison spiritual health questionnaire
This questionnaire contains 20 questions with a score range of 20 to 120, whose answers are based on a six-point Likert scale (from completely agree to completely disagree). Ten questions assess religious health, while the other ten questions evaluate existential health. The validity and reliability of this questionnaire were investigated and confirmed by Farahaninia et al. who reported the reliability of the questionnaire using Cronbach’s α coefficient as 0.82 [15].
Connor-Davidson resilience questionnaire
This questionnaire consists of 25 questions scored on a Likert scale ranging from zero (completely false) to five (always true). The psychometric analysis of this scale has been conducted across six groups, including the general population, patients seeking primary care, psychiatric outpatients, patients with generalized anxiety disorder, and two groups of patients with post-traumatic stress disorder. The validity and reliability of this questionnaire have been confirmed in previous studies [5]. In the research conducted by Samani et al. the reliability of this questionnaire in the student population was found to be 0.87, as determined by Cronbach’s α  coefficient [16].
Data analysis
To analyze the data from this study, both descriptive and inferential statistics were calculated using SPSS software, version 26. The Shapiro-Wilk test was used to check the distribution of data for each variable. Non-parametric tests, including Spearman, Kruskal-Wallis, and Mann-Whitney tests, were utilized to examine the correlation of demographic variables with the variables studied in this research.
Results
A total of 215 patients with a mean age of 67.13±17.595 years were included in the study. The maximum and minimum age of the study participants was 99 and 17 years, respectively. Among the 215 participants in the study, 110 were women and 105 were men. Also, the average length of hospitalization for patients in the hospital wards was 10.81±5.983 days. Table 1 presents the demographic characteristics of the participants.
The mean score of spiritual health was 77.77±17.79, and the mean resilience score of the patients who completed the questionnaire was calculated as 58.065±17.79. Table 2 presents the level of spiritual health and resilience of the participants by gender, marital status, education, inpatient department, economic status of the family, underlying disease, and occupation.
None of the demographic variables had a significant relationship with spiritual health and resilience. Also, to investigate the correlation between age and length of hospitalization with spiritual health and resilience, Spearman’s non-parametric test was used (Table 3).
The mean spiritual health score of the patients was 77.77, while the average resilience score was 58.06. First, the normality of the distribution of the spiritual health and resilience variables was assessed using the Shapiro-Wilk test, and the results indicated that the distribution of these variables was not normal. Subsequently, Spearman’s non-parametric test was employed to examine the correlation between the variables. The correlation coefficient between the spiritual health score and resilience was calculated to be 0.585, and the P of the test was <0.05, indicating a significant correlation between the spiritual health score and resilience (Figure 1).

Discussion
This study was conducted to investigate the relationship between spiritual health and resilience of patients with COVID-19. The obtained results showed a significant relationship between spiritual health and the level of resilience of patients with COVID-19. In other words, these two variables have a significant positive correlation with each other. A similar study conducted in Turkey in 2020 showed a significant positive relationship between spiritual health and resilience, showing that individuals with a higher level of spiritual health exhibited greater resilience during the COVID-19 pandemic [17]. Also, another study conducted in Pakistan confirmed the effect of spirituality on resilience in frontline workers providing health services to COVID-19 patients [18]. Beyond the relationship between spiritual health and resilience among health system employees, similar studies have been conducted in various patient groups, yielding comparable results. One such study, which aimed to determine the relationship between spiritual well-being and resilience among 134 hemodialysis patients in Turkey, found a correlation between resilience and hope concerning the patients’ spirituality, consistent with the findings of our study [12]. Another study determined the relationship between spiritual well-being and psychological resilience in liver transplant patients, revealing a positive and significant correlation between resilience and spiritual well-being. These findings align with the results of the present study [8].
Other studies conducted in Iran indicate the impact of maintaining the spiritual health of individuals, families, and society on increasing physical and mental resistance, reducing anxiety and depression, increasing resilience, and instilling hope in critical situations during the epidemic and recovery of patients with COVID-19 [19]. Given the influence of spiritual health on the treatment of patients with COVID-19, it is essential to integrate spiritual health services into holistic treatment and care, and training for employees in this area is also necessary [20]. In addition, the effect of integrating a model of spiritual and cognitive counseling on the resilience of patients showed that spiritual counseling has a significant effect on improving the resilience and self-efficacy of patients [21]. The positive and significant relationship between the meaning of life, spiritual health, and resilience, as well as their connection to the mental health of patients, is another finding consistent with this study. This suggests that perspective, values, and goals—considered meaningful components of life—lead to increased resilience, resulting in reduced mental disorders and enhanced mental health [14].
Other studies have investigated the relationship between resilience and various spiritual concepts and constructs, such as the direct and significant relationship between spiritual intelligence and resilience, especially in stressful situations [22]. Additionally, research has shown the effectiveness of spiritual health education in increasing patients’ hope [23] and the impact of group spiritual therapy on enhancing the resilience of patients [24]. Therefore, it seems that any effort aimed at the meaningful development of life, education, and personal growth in patients can be considered an effective preventive interventions by increasing their hope.
Despite the positive and significant relationship between resilience and spiritual health demonstrated in this study, these two concepts did not have a significant relationship with any of the participants’ demographic variables. In other words, in the present study, no significant relationship was observed between the spiritual health score and the level of resilience of the participants concerning their gender, age, marital status, and level of education. This result is consistent with some previous studies, including the study by Seyed Mahmoudi et al., which found no significant relationship between gender and marital status with resilience [25]. However, conflicting findings have also been reported. For example, Amiri et al. reported a significant relationship between marital status and spiritual health and showed that married people with children had a higher level of spiritual health. This finding also applied to the significant relationships between age, education, and duration of illness with spiritual health, showing that as education level, age, and duration of illness increased, spiritual health also improved significantly [26]. It seems that this difference can be due to the difference in the statistical population of the two studies. Finally, in the present study, no significant relationship was found between any of the variables, including economic status, employment status, underlying disease, and the inpatient department of the patients, and their spiritual health score and resilience. It seems that the significant positive relationship between resilience and spiritual health, despite the absence of a statistically significant relationship between the two and the demographic characteristics of the participants, indicates a strong and fundamental connection between the two main concepts studied in this research [27]. This relationship exists regardless of differences related to gender, age, marital status, occupational and economic status, and level of education. On the other hand, the unique conditions of the COVID-19 crisis and the threat to people’s lives, regardless of their individual and social differences, led to an increased tendency toward spirituality among many individuals [28]. This trend may serve as another factor justifying the results of this study.
Conclusion
Considering that a significant relationship and positive correlation exist between the level of spiritual health and the level of resilience in patients with COVID-19, it is appropriate to integrate spiritual health services into treatment and holistic care in Iranian hospitals. Additionally, personnel should be trained to provide these spiritual health services.
Limitations
Since spirituality is a sensitive issue among the Iranian population, the refusal of patients to provide correct information was one of the significant expected limitations, which was addressed by explaining that this information was only for a research project and that responses would be received anonymously. Another limitation was related to the convenience sampling method, which reduces the capability of the results to be generalized to the broader population compared to other sampling methods.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Biomedical Research Ethics Committee of Qom University of Medical Sciences (Code: IR.MUQ.REC.1400.066). By obtaining and presenting the letter of introduction to the relevant authorities, the researcher received permission to enter the research environment. After obtaining informed consent for non-interventional studies from the participants and assuring them of the confidentiality of their information and statements, the researcher proceeded to collect the research data, which were gathered anonymously. In the next stages of data analysis, the ethical standards of the research were upheld.
Funding
This article is taken from the general medicine thesis of Amir Irvani, approved by Qom University of Medical Sciences, Qom, Iran.
Authors' contributions
Study design: Seyedhassan Adeli and Amir Iravani; Data collection: Akram Heidari; Writing: Morteza Heidari; Final approval: All authors.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors express their gratitude to all the participants in this research. The authors also appreciate the cooperation of the respected employees of the studied hospitals.