Health, Spirituality and Medical Ethics

Introduction
Disability is a global phenomenon that has existed throughout history and across all societies. According to the world report on disability by the world bank and the World Health Organization (WHO), there are over one billion people with disabilities worldwide [1]. In addition, 10% to 15% of people in developing countries have disabilities, and between 4% and 4.5% of people have severe disabilities that must receive special services [1]. In Iran, according to the statistics of the Vice-Chancellor for Rehabilitation at the State Welfare Organization, there are about two million and eight thousand disabled people.
Mental retardation is associated with a lack of growth in various physical, mental, developmental, social and educational dimensions. Children with intellectual disabilities struggle to learn expected behaviors, and parents’ efforts to teach new skills and manage inappropriate behaviors are often ineffective. Therefore, accepting and adapting to this fact requires more effort from parents than those of typically developing children [2, 3]. The different needs of care, education, and rehabilitation for mentally retarded children affect the adjustment process of parents [4].
When a disabled child is born, the family often experiences a wide range of emotions, including anger, sadness, crying, and mourning. Meanwhile, compared to fathers, mothers of children with special needs are more involved with the child’s behavioral problems and experience more stress and psychological crises. Mothers are also more prone to depression than other family members [5]. In this regard, life expectancy can play a significant role in supporting them.
Hope is an emotional force that energizes and equips people, and acts as a catalyst for work and activity. Hope gives people flexibility, vitality, and the ability to get rid of the blows that life imposes on them and increases satisfaction with life [6]. Mothers with mentally retarded children experience less hope compared to mothers of typically developing children. Also, a low level of hope (despair) is associated with an increased risk of mental health problems, such as anxiety, depression, and post-traumatic stress disorder [6, 7]. Many variables may be related to the life expectancy of mothers with mentally retarded children, one of which is emotional adjustment [8]. Mothers who do not have the necessary adaptability emotionally, in the face of everyday problems and failures, cannot control their emotions and may show inappropriate and unusual behavior. As a result, they may exhibit inappropriate or unusual behaviors, such as irritability or passivity. These emotional difficulties can lead to anxiety, stress, various types of fear (e.g. panic, social phobia, or fear of crowded places), feelings of loneliness, and depression [9].
Psychological well-being is crucial for mothers with mentally retarded children [10]. Examining the psychological well-being of mothers with mentally retarded children and mothers with normal children showed that mothers of mentally retarded children have lower psychological health and well-being compared to mothers of normal children [4].
Also, religious beliefs and practices can directly affect a person’s health in stressful situations. When a person has spiritual beliefs, it is easier for him/her to determine spiritual values, and he/she shows more adherence to these values and their implementation [11].
While there have been studies examining the prediction of hope based on emotional adaptability, psychological well-being, and spiritual beliefs, few have specifically focused on mothers of children with intellectual disabilities. Also, the researcher did not find any research regarding mothers with mentally retarded children. Therefore, the present study was conducted to predict hope based on emotional adaptability, psychological well-being and spiritual beliefs in mothers with mentally retarded children in Qom City, Iran.
Methods
The current research was descriptive-correlational. The statistical population of the research included all mothers with mentally retarded children who were selected from seven exceptional elementary schools, occupational therapy centers, and autism centers in Qom City, Iran, during the 2022-2023 academic year. The sample size was 375 people determined using Morgan’s table and accounting for a 10% dropout rate. These participants were selected from the aforementioned centers using a convenience sampling method.
The inclusion criteria included having a diploma or higher education for the mother, informed consent to participate in the research and the exclusion criteria included a mental illness and also incompletely completing the questionnaire. The inclusion criteria were: The mother having a diploma or higher education, providing informed consent to participate in the study, and exclusion criteria included the presence of a mental illness or incomplete questionnaire responses.
Data were collected using questionnaires. To test and measure hope, the hope questionnaire prepared by Schneider et al. [12] was used. This self-report questionnaire has 12 questions and is scored on a five-option Likert scale (I completely agree: 5, I agree: 4, I have no opinion: 3, I disagree: 2, I completely disagree: 1). Questions 3, 5, 7, and 11 are scored in reverse. Therefore, the respondent’s total score ranges from 12 to 60, with higher scores indicating higher levels of hope. This questionnaire measures two subscales of agent and strategy. Initial evidence on the validity and reliability of this test was provided by Schneider et al. The Cronbach’s α for the scale is between 0.74 and 0.84 and its re-test reliability is 0.8 over ten weeks [13]. In a study conducted on 120 undergraduate students in Ardabil City, Iran, the Cronbach’s α coefficient of this scale was 0.79 [14]. In the research by Kermani et al., Cronbach’s α for the entire scale was 0.86, for the agency subscale was 0.77 and for the pathways subscale, it was 0.79 [15].
To test and measure social-emotional adjustment, the emotional-social adjustment scale (Bell, 1961) was used, in which there are 32 questions related to the emotional adjustment dimension. Respondents answer each question with “yes” or “no.” For each correctly answered question, a score of one is given, and for incorrect answers, a score of zero is considered. Therefore, the range of scores was between 1 and 32. The lower the score, the better the subject’s adjustment, and vice versa. In Michaeli and Madadi Emamzadeh’s research, the overall reliability of this test was 0.84, and its validity was 0.8 [16].
In addition, the psychological well-being questionnaire created by Ryff (1989) [17] was used. It has 18 questions and evaluates and examines psychological well-being from different dimensions (independence, mastery of the environment, personal growth, positive relationship with others, purposefulness in life, and self-acceptance). The scoring system is based on a six-point Likert scale: 1=completely disagree, 2=somewhat disagree, 3=slightly disagree, 4=slightly agree, 5=somewhat agree, and 6=completely agree. Questions 1, 3, 4, 5, 9, 10, 13, and 17 are scored in reverse. To achieve the total score of the questionnaire, the total score of each question should be summed. Higher scores indicate higher psychological well-being in the respondent and vice versa [17]. In Khanjani et al.’s research, the results of the single-group confirmatory factor analysis showed that the six-factor model of this scale (self-acceptance, environmental mastery, positive relationships with others, having a purpose in life, personal growth, and independence) had a good fit for both genders in the entire sample. The internal consistency of the six factors using Cronbach’s α is as follows: Self-acceptance (0.51), environmental mastery (0.73), positive relationships with others (0.75), having a purpose in life (0.52), personal growth (0.73), and independence (0.72), with an overall scale Cronbach’s α of 0.71 [18].
George developed the George’s religious beliefs questionnaire (1998) without any sectarian orientation and without any ritual or religion. Its content is solely focused on expressing the relationship with God. The 33-item scale measures subjects’ belief in God. Lawrence et al. reported the reliability of the test to be 0.97 using the Spearman-Brown correction [19]. Also, the validity and reliability of this questionnaire were confirmed by Rajaee et al. [20]. For this purpose, its validity was examined and confirmed by a panel of experts, and Cronbach’s α coefficient for the total score of the questionnaire was calculated as 0.96, which indicates the high internal consistency of this scale. The scoring of this questionnaire is based on the Likert scale from 1 to 5 (from completely agree to completely disagree).
In the present study, participants were assured of confidentiality of their personal information, and the purpose of this study was explained to them. Informed, written consent was obtained from all participants, who were also informed that they could choose to withdraw from the study at any time. They were free to omit their names or any identifying information from the questionnaire. The participants were reminded that the information would remain confidential to the researcher, and the coding method was used to identify the questionnaires. Data analysis was performed using SPSS software version 26 at two levels of descriptive and inferential statistics. In the descriptive part, statistical indicators, such as minimum, maximum, Mean±SD and in the inferential part, Pearson’s correlation coefficient and multiple regression analysis were performed simultaneously.
Results
The results showed that 282(75.2%) of the mothers were in the age group of 35-45 years and 212(56.5%) had an associate degree (Table 1).
The mean scores of hope and psychological well-being were 41.4±5.4 and 80.06±8.14, respectively (Table 2). Additionally, the mean scores of spiritual beliefs and emotional adjustment were 32.14±10.09 and 21.77±6.15, respectively.
The Pearson correlation coefficient between hope and the variables were as follows: Between hope and social adjustment (0.135), between hope and psychological well-being (0.116) and between hope and spiritual beliefs (0.141) These results showed a significant positive relationship between the variables (P>0.05) at the 0.01 error level and with 99% confidence. This means that with the increase in the level of emotional adjustment, psychological well-being and spiritual beliefs in mothers with mentally retarded children, the level of hope also increases and vice versa (Table 3).
The results of regression analysis showed that all three variables of social adjustment, psychological well-being, and spiritual beliefs could predict hope (P<0.05). With 95% confidence, the contribution of social adjustment is 0.134, the contribution of psychological well-being is 0.12, and the contribution of spiritual beliefs is 0.138. Therefore, with 95% confidence, we can conclude that spiritual beliefs had the greatest contribution in predicting the hope of mothers with mentally retarded children (Table 4).
Discussion
The results showed a significant relationship between hope and emotional adjustment, psychological well-being, and spiritual beliefs. Specifically, the higher the level of emotional adjustment, psychological well-being, and spiritual beliefs in mothers of children with mental disabilities, the higher their level of hope, and vice versa. Also, regression analysis showed that all three variables of social adjustment, psychological well-being, and spiritual beliefs could predict hope. In the study by Mohammad Zadeh et al. [21], a significant relationship was observed between life expectancy and emotional adjustment, which is consistent with the results of our study.
 In explaining this finding, it can be said that the parents of children with mental retardation face additional responsibilities in terms of the issues and problems that the child’s illness imposes on them. On the other hand, they cannot provide the necessary facilities and time to fulfill their child’s educational, educational, and health responsibilities. This issue causes double pressure on parents and has destructive effects on their self-esteem and psycho-social interaction. Kumar et al. [22] investigated the adjustment patterns of parents of children with mental retardation, and found that effective adjustment in these families is impaired, and providing information to families and training parents, especially mothers with a lower education level, is highly needed. Sapkota et al. also found that the level of social adjustment of mothers of mentally retarded girls is significantly lower than mothers of normal girls. Mothers who lack emotional adjustment may struggle to control their emotions when faced with daily challenges and may respond with inappropriate or passive behaviors. The results of these studies are consistent with the results of the present study [23].
Our results showed a direct and significant relationship between hope and the components of psychological well-being, including independence, mastery of the environment, personal growth, positive relationships with others, purposefulness in life, and self-acceptance. The higher the levels of independence, control over the environment, personal growth, positive communication with others, purposefulness in life, and self-acceptance in mothers of children with intellectual disabilities, the greater their level of hope will be, and vice versa. This result is consistent with those of Azadyekta et al. [24], Kazemi et al. [10], Bouani et al. [25], Hickey et al. [26], Shan et al. [27], Frantz et al. [28]. In explaining this result, it can be said that psychological well-being is essential for mothers of mentally retarded children. Mothers usually experience more psychological pressure than fathers due to their special role in the birth and care of a disabled child. The double challenge is that even as the children mature, the parents’ lack of adjustment to their disabilities persists, leading to ongoing emotional pressures such as shame or guilt. Mothers face more psychological problems due to their close relationship and more responsibilities toward their mentally retarded children.
The results of the present study showed a direct and significant relationship between hope and spiritual beliefs. This result is consistent with those of Talebi et al. [11] and Safara et al. [6]. Studies have shown that teaching spiritual skills can positively impact life expectancy, with one such study by Kamari et al. [29] demonstrating that spiritual training based on positivity significantly improves life expectancy and life satisfaction in teenagers. In explaining these results, it can be said that religion and spirituality are vital factors in creating a sense of health in people, which gives meaning to human values, behaviors, experiences, and structure and it seems that faith and tradition can play a key role in helping individuals achieve personal fulfillment.
Conclusion
The results of the study showed a significant relationship between hope with emotional adjustment, psychological well-being, and spiritual beliefs. People with high well-being deal with stressful events with optimism, self-expression, and self-confidence. As a result, they see these events as controllable. Optimistic attitudes make information processing more effective and these people use more effective adaptation strategies and have an increased ability to cope with difficult situations. Therefore, based on the results of the study, welfare education is needed to increase hope in mothers with mentally retarded children. Positive religious beliefs can give meaning to people’s lives and encourage them to adopt the positive values of society. Also, religion and religious beliefs help maintain a positive attitude in mothers of mentally retarded children and act as a maintainer of their mental and social health in all stages of life. It is suggested to pay more attention to religion and religious beliefs and to create a positive orientation for mothers of mentally retarded children so that we can have a healthy society free from mental disorders and social harm. Also, educational workshops should be held to raise awareness about mental retardation, and officials, experts, and community workers should develop a codified and comprehensive program to increase awareness about the emotional adjustment, psychological well-being, and spiritual beliefs of these mothers in the community.
Limitations
This study had limitations. Conducting this study on mothers with mentally retarded children in Qom City was one of the limitations of this study. Therefore, caution should be taken in generalizing the results. Also, data collection through a questionnaire and challenges, such as recalling the past situation, accuracy in answering questions, and other related factors are some other limitations. It is recommended that similar studies be conducted in cities to compare results and gain more insights into potential differences and their underlying causes. It is also suggested to use other methods, such as observing people in situations, in-depth clinical interviews, and projection methods.
Ethical Considerations
Compliance with ethical guidelines
After explaining the objectives and process of the study to the participants, their consent to participate in the research was obtained and they were assured of compliance with the principle of confidentiality of information, and they were informed of their freedom to participate in the study.
Funding
This study was taken from the master thesis of Faezeh Shahriari, approved by Islamic Azad University, Qom Branch (Code: 162694795).
Authors' contributions
Conceptualization: Amin Arabshahi; Data collection: Faezeh Shahriari; Data analysis and writing: Amin Arabshahi, and Faezeh Shahriari; Compilation of the theory: Zabih Elah Qarlipour.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors thank all the university officials and people who cooperated in this research.