Health, Spirituality and Medical Ethics

Introduction
Students are the selected talented groups of society and the builders of the future of every country, making it essential to examine their mental health [1]. According to the World Health Organization (WHO) [2], mental health means a person’s capability to interact harmoniously with others. Changing and rebuilding the personal and social environment can solve conflicts and fulfill individual desires rationally and purposefully in life [3]. Mental health is one of the crucial concepts in psychiatry and serves as a key axis for evaluating the health of different societies. It represents a state of well-being that enables individuals to realize their potential talents, cope with the usual stresses of life, experience a sense of purpose, feel productive, and participate actively in society [4]. Mental health also means psychological well-being or balanced and harmonious behavior within society, recognition and acceptance of social realities, the ability to adapt to them, flexibility, and the flourishing of inherent talents [5]. According to Liao et al., the initial onset of most mental health problems occurs before the age of 25, a time when many individuals are in university [6]. Therefore, it is necessary to pay attention to the state of mental health of students and its related factors [7]. Recently, spirituality has been noticed by psychologists as an effective strategy to deal with disturbances and distress [8].
Spirituality is one of the inner needs of humans; according to some experts, it is considered a requirement for human development in cognitive, moral, and emotional fields, as well as the continuous effort of humans to answer the reasons of life [9]. One of the most crucial outcomes associated with spirituality is spiritual well-being [10]. Spiritual well-being is one of the fundamental dimensions of overall well-being and health, serving as a coordinating and complementary force for other aspects of human health, including physical, mental, social, and emotional well-being [11]. According to Movahed et al., if an individual’s spiritual well-being is compromised, they may suffer from extensive psychological disorders, such as feelings of depression, loneliness, and loss of meaning in life [12]. On the other hand, Sawadi et al. believe that spiritual well-being is a construct that predicts depression and can facilitate coping with it when faced with depressive symptoms [13]. The relationship between the spiritual well-being and psychological well-being of students [14], their academic success [15] and their psychological resilience [16] has been confirmed in various studies.
Resilience is another factor that is crucial in the field of mental health of students, as it can protect them from risk factors [17]. Also, academic resilience is one of the dimensions of resilience in the educational environment [18]. Resilience, defined by many researchers and experts, includes the concepts of flexibility, recovery, and returning to the initial state after facing adverse conditions [19]. Resilience is also defined as the ability to successfully adapt to environmental stressors and maintain psychological well-being in the face of challenges [20]. According to Backman et al., resilience refers to the ability to succeed, live, and develop oneself under difficult conditions, despite the presence of risk factors [21]. Resilience is a meta-motivational variable related to learning styles and coping strategies, and it can predict students’ academic progress [22]. Meanwhile, academic resilience is a positive psychological construct, which has been considered in recent years in the context of developmental inadequacies [23]. Students with high academic resilience can maintain a strong motivation for progress and perform optimally despite environmental stressors and conditions that may lead to poor academic performance or dropping out, along with negative psychological consequences [24]. that may lead to poor academic performance or dropping out, along with negative psychological consequences [25-27].
Considering the research background and the explanations provided above, it seems that academic resilience and spiritual well-being are among the factors related to the improvement of mental health in students. Since no research has investigated the role of academic resilience and spiritual well-being in the psychological health of students, the present study was conducted to investigate the role of academic resilience and spiritual well-being in predicting the psychological health of Farhangian University students.
Methods
The statistical population of the present descriptive-correlational study was 2350 students from Farhangian University in South Khorasan for the academic year 2023-2024. Based on the table by Karjesi and Morgan (1970) [24], 353 student teachers were selected by stratified random sampling method and answered the research questionnaires. The inclusion criteria were being a student teacher (teaching, secretarial, counseling, and educational sciences), and not having a mental illness (although Farhangian University students are fully checked at the beginning of their admission to the university and the student’s health records are checked and they do not have specific psychological disorders, such as schizophrenia, personality disorders, bipolar disorders and other acute psychological disorders, such as anxiety and depression; it was confirmed that the students did not suffer from any of the mentioned physical and mental diseases and this was done with the consent of the student teachers) and providing informed consent to complete the questionnaire. The exclusion criteria included unwillingness to cooperate, withdrawal after providing informed consent, and submitting distorted questionnaires.
The data collection tools were as follows:
Psychological health questionnaire: Goldberg et al. [28] developed the psychological health questionnaire in 1970. The main questionnaire has 60 questions, but shortened forms of 30 questions, 28 questions, and 12 questions have been used in different studies. According to the researchers, the different forms of the public health questionnaire demonstrate high validity and reliability, with the efficiency of the 12-question form being nearly equivalent to that of the 60-question form. In the 28-question version, the questions are divided into four subscales: Physical complaints, anxiety and insomnia, social incompatibility, and severe depression, with each subscale containing 7 questions [29]. The scoring method is based on a Likert scale, where test options are scored as 1, 2, 3, and 4, resulting in a total score that ranges from zero to 84, with a lower score indicating better overall mental health [30]. The reliability of this questionnaire was reported as 0.9 in Sterling’s research [31]; Also, in this study, the validity of this questionnaire was confirmed using the test re-test method. Taghavi [32] investigated the reliability of the general health questionnaire for the first time in Iran based on three methods, including test re-test, split-half, and Cronbach’s α, which obtained reliability coefficients of 0.93, 0.7, and 0.9, respectively. In the present study, Cronbach’s α method was used to determine the reliability of the tool, and its value was estimated at 0.86.
Spiritual well-being questionnaire: Dehshiri et al. compiled and validated the spiritual well-being questionnaire [33]. This tool has 40 questions that are scored on a five-point scale from strongly disagree to strongly agree. Also, four subscales can be calculated for this questionnaire: Communication with God, communication with self, communication with others, and communication with nature [33]. In the research by Dehshiri et al. [33], the validity and reliability of this tool were examined. The Cronbach’s α of the whole questionnaire was 0.84, while the Cronbach’s α for the subscale of communication with God was 0.93, communication with nature was 0.91 and communication with others was 0.85. Also, the test re-test reliability of the whole questionnaire was 0.86, with the test re-test reliability for the subscale of communication with God at 0.81, communication with nature at 0.89, and communication with others at 0.8, all of which were significant at the P<0.01 level. Divergent and convergent validity were also used to check the validity of the questionnaire. In the research by Torkian Valashani et al. [34], Cronbach’s α coefficient of this questionnaire was calculated as 0.86. The Cronbach’s α of this tool in the present study was 0.87, indicating its reliability.
Academic resilience questionnaire: Samuels developed this 40-question questionnaire, which measures three subscales, including communication skills, future orientation, and problem-oriented/positive attitude, using a five-point Likert scale (from completely disagree (score 1) to completely agree [score 5]). The range of scores is between 40 and 200, with a high score indicating high academic resilience and a low score indicating low academic resilience. Samuels evaluated the construct validity of this questionnaire as desirable and estimated its reliability at 0.89 using Cronbach’s α method [35]. According to the Iranian standard in the study by Soltaninejad et al., the number of questions in this questionnaire was reduced to 29 questions, and the validity was confirmed through factor analysis using the main components method with Varimax rotation. The reliability of the factors of this questionnaire in the student sample ranged from 0.62 to 0.76 [36]. In the present study, the reliability was obtained using Cronbach’s α method, resulting in a value of 0.78.
The questionnaires were designed in printed form. After identifying the communication channels of the students (dormitory and non-dormitory students living in Birjand City, Iran), the questionnaires were widely distributed. Necessary explanations, including the purpose of the research, how to answer the questions and the importance of the volunteers’ cooperation in this research, were provided in the supplemental text with the questionnaire, and participation in this research was completely voluntary. Also, all the ethical principles of the research, including the confidentiality of the questionnaires, the informed consent of the research participants, and the right to withdraw from the research, were observed.
Data were analyzed using Pearson’s correlation coefficient and multiple regressions by SPSS software, version 26 at a significance level of P<0.05.
Results
Table 1 presents demographic information of the samples, including age, gender, and field of study. Table 2 presents the results of Pearson’s correlation to examine the relationship between spiritual well-being and academic resilience with psychological health. The correlation coefficients calculated between spiritual well-being and academic resilience with psychological health were positive and significant (P<0.01). This indicates that a direct relationship exists between spiritual well-being and academic resilience with psychological health.
To predict students’ psychological health through academic resilience, a multiple regression test was used. The Durbin-Watson statistic was used to check the independence of the residuals. Given that its value (2.035) falls between 1.5 and 2.5, it can be concluded that the assumption of independence of the residuals was satisfied. Tolerance indices and variance inflation factor (VIF) were used to check the presence of multicollinearity between predictor variables. According to the obtained results, no deviation from the assumption of multicollinearity was observed.
In Table 3, the F value obtained to check the regression model was equal to 116.978, which was significant at the alpha level of <0.01, which showed that academic resilience can effectively explain the changes related to psychological health and supports the appropriateness of the presented regression model. The value of R square (R2) was equal to 0.501, which showed that the components of academic resilience explained 50.1% of the variance of psychological health. The standardized regression coefficients (Beta) for communication skills (β=0.4, P<0.01), future orientation (β=0.115, P<0.05), and problem-oriented/positive attitude (β=0.327, P<0.01) were also significant. Therefore, it can be concluded that academic resilience positively and significantly predicts students’ psychological health.
To predict students’ psychological health through spiritual well-being, a multiple regression test was used. The Durbin-Watson statistic was used to check the independence of the residuals. Given that its value (2.044) falls between 1.5 and 2.5, it can be concluded that the assumption of independence of the residuals was satisfied. Tolerance indices and VIF were used to check the presence of multicollinearity between the predictor variables. According to the obtained results, no deviation from the assumption of multicollinearity was observed.
In Table 4, the F value obtained for checking the regression model was equal to 51.207, which was significant at the alpha level of <0.01. This indicates that spiritual well-being can effectively explain the changes related to psychological health and supports the appropriateness of the presented regression model. The value of R2 was equal to 0.371, which showed that the components of spiritual well-being explained 37.1% of the variance of psychological health. The standardized regression coefficients (Beta) for communication with God (P>0.05, β=0.113), communication with self (P<0.01, β=0.648), communication with others (P>0.05, β=0.038), and communication with nature (P<0.05, β=0.156) were also assessed. Therefore, it can be concluded that among the components of spiritual well-being, communication with self and communication with nature positively and significantly predict students’ psychological health.
Discussion
The present study was conducted to investigate the role of spiritual well-being and academic resilience in predicting students’ psychological health. The research results showed that spiritual well-being and academic resilience could predict students’ psychological health.
Additionally, spiritual well-being had a positive and significant role in predicting students’ psychological health. Higher levels of spiritual well-being can predict high levels of psychological health. In other words, spiritual well-being has a positive and significant correlation with students’ psychological health. The results of the studies by Bozek et al. [14], Hashemi et al. [37] and Coppola et al. [38] are consistent with ours. This research suggests that spirituality is one of the human virtues that provides meaning and ultimate purpose to life, fostering a unique way of living and establishing a connection between individuals and themselves, others, and the universe as a whole. Therefore, neglecting the spiritual dimension and self-knowledge can prevent the growth and prosperity of humans and endanger the mental health of people [39].
On the other hand, spirituality as a personal experience leads to helping others, loving and being satisfied with life, and by giving hope and giving meaning to life and encouraging people to be patient with problems, it creates a positive attitude and interpretation, which increases adaptive behaviors and improves psychological health in people [40]. Eidi and Alivandi Vafa [41] showed that spiritual well-being acts as a resistant shield for people in the face of various problems and issues in life, particularly for students enduring the difficulties of university studies. This protective effect mitigates the impact of external conditions, leading to lower levels of vulnerability to adverse circumstances due to greater internal control and enhanced self-esteem. Therefore, it can be concluded that possessing high spiritual well-being signifies an effective relationship with self, God, others, and nature while establishing peace, integration, and psychological coherence. This can be a crucial factor in improving the psychological health of students facing various psychological challenges in the university environment. The results of this research also indicate a positive and significant correlation between academic resilience and the mental health of students [41].
Our results are also consistent with those of Senger [42], Slavin [43] and Moisoglou et al. [44]. The greater an individual’s ability to cope with life’s problems and stresses, the less they are exposed to mental and emotional disturbances, resulting in higher mental health and well-being. It seems that resilient people look at problems creatively and flexibly, they design and plan more effectively to solve issues and have the necessary resources to deal with problems. These factors make a person enjoy high mental health and psychological well-being [42].
According to Slavin [43], resilience by increasing the levels of positive emotions strengthens self-esteem and successfully confronts negative experiences. Accordingly, resilience through strengthening self-esteem as an intermediary mechanism leads to positive adaptation and psychological well-being. Individuals with higher psychological well-being demonstrate greater adaptability to problems compared to those who lack this advantage, allowing them to better overcome challenges, resist stress, and mitigate psychological effects. Resilience increases by increasing personal ability to cope with distress and psychological and physical problems, ultimately leading to improved psychological health [45]. Also, students who deal with problems in the university environment with high levels of patience, a positive attitude, and resilient characteristics are likely to experience reduced anxiety and depressive behaviors.
Conclusion
The results showed that resilience and spiritual well-being could predict students’ psychological health. Therefore, paying attention to the components of spiritual well-being and resilience should be considered by university administrators.
Limitations and suggestions
This research, like any other research, had limitations. One of the most critical limitations of the research is its implementation at the provincial level; therefore, the generalization of the results of this research should be accompanied with caution. It is suggested that a larger population of students be examined at the national level in future studies. Another limitation of the research was the use of self-reporting tools. It is recommended that future research include qualitative studies on the state of academic resilience and the degree of students’ spiritual well-being (including challenges and solutions) to obtain deeper insights and interpretations. The results of the research should be considered by the counseling and lifestyle centers for students and the university community, as well as by counselors and psychologists, to develop training methods aimed at improving resilience and mental health.
Ethical Considerations
Compliance with ethical guidelines
The current research received ethical approval from the Birjand University of Medical Sciences (Code: IR.BUMS.REC.1402.201). Throughout all stages of the research, ethical principles have been adhered to.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Authors' contributions
All authors equally contribute to preparing all parts of the research.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors thank all the individuals who assisted the researchers in this research, especially the students.