Health, Spirituality and Medical Ethics

Introduction
Humans possess various cognitive, emotional, social and spiritual dimensions that are interconnected. The growth and development of each of these dimensions will affect the growth of other human capabilities and capacities [1]. Spiritual health is one of the four dimensions of health that, along with physical, mental and social dimensions, promotes overall health [2], increases adaptive capacity, enhances psychological functions, and improves quality of life [3-5]. Self-compassion influences the dimensions of general health in the field of health psychology, which is derived from the development of cognitive-behavioral therapies. Self-compassion is considered a protective and effective factor for developing emotional flexibility, which increases social support and improves social adjustment through an approach to oneself and others [5-7]. Self-compassion-based training, along with other new therapeutic approaches in the field of third-wave psychology, aims to reduce pain, suffering, anxiety, and depression, thereby strengthening psychological capabilities and capacities [8, 9].
Self-compassion is a healthy form of self-acceptance that reflects the degree to which one accepts both the desirable and undesirable aspects of oneself and one’s life. Self-compassion involves the interaction between three components: 1) Self-compassion versus self-judgment (the tendency to have self-care insights versus self-destructive judgments); 2) Altruism and a sense of human community versus isolation (the understanding that all humans may fail at some point and should not sever their relationships with others because of this failure); and 3) Mindfulness versus overidentification [10, 11]. Self-compassion enables individuals to be emotionally supportive of themselves and others when faced with difficult circumstances or human shortcomings [12] and under favorable psychological conditions, promotes overall growth and well-being, thereby improving the quality of life.
The spiritual dimension, as one of the dimensions of health, is related to biological, psychological, and social dimensions. Spiritual health, as a foundation for promoting health, provides a balance among physical, psychological, social and spiritual aspects, leading to peace of mind and a sense of wholeness and human well-being. Spiritual health is characterized by attributes such as peace, stability and a sense of close connection with oneself and God, which implies two existential and religious dimensions. Existential health is defined as discovering the meaning of life and how to achieve perfection, while religious health is defined as commitment and connection to a specific religious belief [10]. Some studies have shown that Islam considers spiritual health to be a matter that extends to human life in this world and the hereafter and that human spiritual health in this world is not separate from one’s health in the hereafter. Furthermore, in the religion of Islam, the significance of spiritual health underscores the sanctity, importance, and authenticity of this dimension of human health, which is a dynamic effort to realize human happiness [13, 14]. Spiritual health means having a sense of acceptance, positive emotions, morality, and a sense of positive mutual connection with a sovereign and superior sacred power, which is achieved through a balanced and harmonious cognitive, emotional, behavioral, and personal consequence process [14].
Evidence shows that people with high levels of spiritual health tend to have greater psychological capacities, and support from spiritual resources and connection to a higher power can improve their quality of life while reducing and controlling mental disorders [15]. In this regard, studies have shown that spiritual practices increase social health and social interactions, leading to improved social functioning [2, 16].
Social acceptance is one of the psychosocial needs of humans. Acceptance among friends and peers, as well as inclusion in social groups, is of great importance to the well-being of individuals. In this respect, when an individual receives the acceptance they are seeking, they feel satisfied, which can lead to an improvement in both individual and social quality of life [17]. Social acceptance is a process of socialization for an individual in a civil society, the main characteristic of which is the acceptance and adoption of the norms and values of that society. Therefore, social acceptance results from social influence, conformity, social judgment, and feedback from others, leading individuals to perform behaviors that are favored by others based on their cultural norms [18]. Having a perception of social acceptance causes an individual to develop a positive attitude and feelings toward themselves and their life, prompting them to seek positive and constructive interactions with others in their social environment [19, 20]. Research on social acceptance indicates that acceptable social acceptance leads to improved positive functioning, high academic self-efficacy [21] and enhanced social skills [22] among young people.
Spiritual health and social acceptance play an effective role in individual and social functioning, and weaknesses in both areas may cause many problems in terms of adaptation for individuals. However, the use of positive and effective psychological interventions can provide a platform for the normal individual and social development of young people. Therefore, given the lack of interventional research in this field, it appears that the implementation of effective interventions can lead to favorable outcomes in promoting comprehensive health. Thus, the main purpose of the present study is to investigate the effect of self-compassion training on students’ spiritual health and social acceptance.
Methods
The present quasi-experimental study used a pre-test -post-test design with a control group. The statistical population of the study comprised students referred to the Psychological and Counseling Services Center of Islamic Azad University, Mahabad Branch. Using the convenience sampling method and based on the inclusion and exclusion criteria, 30 individuals were selected as a sample and randomly assigned to two groups: An experimental group and a control group (15 participants per group). The sample size was determined using the Cochran formula.
The inclusion criteria were as follows: 1) A score below the cutoff point on the spiritual health questionnaire (score of 50), 2) A score below the cutoff point on the social acceptance questionnaire (score of 8), 3) Not receiving psychological treatments concurrently with the research, 4) Willingness to participate in the research, 5) No history of psychotic illnesses, 6) No addiction to psychotropic drugs and 7) Not receiving drug treatments or psychotherapy under the supervision of a psychiatrist or psychologist. Meanwhile, the exclusion criteria were 1) Absence from more than two sessions, 2) Irregular attendance at educational sessions and 3) Unwillingness to continue cooperation.
Self-compassion training sessions were provided to the experimental group, while the control group did not receive the training. After completing the training sessions, the subjects in both the experimental and control groups were given a post-test. The average post-test scores of the groups were then compared to determine whether the experimental intervention was effective. To comply with ethical principles, training sessions were also provided to the control group after the completion of the training.
The self-compassion training program was presented to the subjects in the experimental group in seven 60-minute sessions over one month, based on the steps outlined by Lutz et al. [8]. The sessions were conducted in the form of group discussions and were managed by the researcher. At the end of each session, feedback was obtained from the members regarding the usefulness of the training sessions (Table 1).
Study instruments
Paloutzian and Ellison spiritual health scale
The spiritual health scale (SWBS) was introduced by Paloutzian and Ellison. The spiritual health score is the sum of the scores from the two subgroups of religious health and existential health. The scores are rated based on a 6-point Likert scale, ranging from strongly disagree to strongly agree. The range of scores for both religious and existential health is 10-60 each. The total spiritual health score falls within the range of 20-120. According to Sharepour et al. [22], the internal reliability of this tool is valid, and reported Cronbach α coefficients for religious health, existential health, and the total scale as 0.91, 0.91 and 0.93, respectively [22]. In the present study, the Cronbach α coefficients obtained for the religious health and existential health subscales, as well as for the total scale, were 0.83, 0.85, and 0.90, respectively. This questionnaire was administered in Iran by Farahaninia et al. [15] to 283 nursing students from Tehran and Shahid Beheshti Universities, with the reliability of the questionnaire reported to be 82% based on Cronbach α coefficient.
Marlowe–Crowne social desirability scale (MC–SDS) 
The MC–SDS questionnaire was developed by Crowne and Marlowe (1960) for youth and adult age groups. It consists of 33 questions that include yes and no answers, which are scored as zero and one. A score of zero indicates an undesirable state, while a score of one indicates a desirable state. After scoring the questionnaire, the total score was calculated as the sum of the scores for the questions. The social acceptance score for each participant was categorized as follows: 0 to 8 indicates no social acceptance, 9 to 19 indicates moderate social acceptance (for people whose behavior is likely to conform to social rules and norms) and 20 to 33 indicates high social acceptance (for people who are safe from rejection by others and behave according to social rules and norms). Accordingly, the range of scores for this questionnaire is between 0 and 33, with a score of less than 20 indicating a low perception of social acceptance 23]. Crowne and Marlowe (1960) reported the construct validity of the social acceptance questionnaire as favorable, with a value of 0.91 [23]. Additionally, the reliability of the questionnaire, using the Cronbach α coefficient, was reported as 0.89 [24]. In the present study, the overall reliability coefficient of the questionnaire was obtained as 0.82 using the Cronbach α method.
In this study, descriptive and inferential statistics were used to analyze the data. At the descriptive level, the mean and standard deviation were utilized, while at the inferential level, the Shapiro-Wilk test was employed to examine the normality of the distribution of variables. The M-box test was used to assess the equality of variances, regression analysis was conducted to examine the slope of the regression line, and analysis of covariance was performed to evaluate the research hypothesis. The statistical results were analyzed using the SPSS software, version 26.
Results
Of the 30 participants in this study, 18 were female, and 12 were male. The mean age of the women was 22.50±1.60 years, and the mean age of the men was 24.20±1.20 years. Additionally, 88% of the subjects were single, and 24% were married. The mean age of the students in the experimental group was 17.25 years, while it was 16.70 years in the control group (Table 2). To examine the assumption of normality of the data, the Shapiro-Wilk test was used, which showed that the data distribution was normal (P>0.1).
According to (Table 3), the interaction between the group and the pre-test of spiritual health was not significant, and the data support the hypothesis of homogeneity of regression slopes (P=0.104 and F=2.872). Additionally, the interaction between the group and the pre-test of social acceptance was not significant, and the data support the hypothesis of homogeneity of regression slopes (P=0.694 and F=0.156).
According to (Table 4), the significance levels of all four statistics were significant, indicating that there was a significant difference between the two experimental and control groups in at least one of the dependent variables (spiritual health and social acceptance; P<0.01). The results of the analysis of covariance are presented below to examine the differences in dependent variables between the research groups (Table 5). 
The observed F value for spiritual health (118.095) was significant in the post-test phase (P<0.01). The effect size of this intervention was 0.67. Additionally, the observed F value (791.62) for social acceptance was significant in the post-test phase (P<0.01). The effect size of this intervention was 0.52; therefore, self-compassion training had a significant effect on students’ spiritual health and social acceptance.
Discussion 
The purpose of this study was to investigate the effectiveness of self-compassion training on students’ spiritual health and social acceptance. The results showed that self-compassion training was effective for spiritual health. According to these results, there was a significant difference in spiritual health between the experimental and control groups. This finding is consistent with the results of other studies [13-15]. In this regard, Lutz et al. [8] demonstrated the effectiveness of self-compassion training in enhancing spiritual health and improving adjustment, which aligns with our results. Additionally, Finlay-Jones et al. [6] showed that self-compassion and its training can lead to increased health and mental hygiene for individuals. Furthermore, in other related studies, Soysa and Wilcomb [9] indicated that self-compassion training can improve the psychological, social, emotional, and well-being components of individuals. In self-compassion therapy, external soothing thoughts, factors, images, and behaviors must be internalized. In this case, the human mind, just as it reacts to external factors, will also maintain its peace in the face of these internal stimuli and exhibit fewer negative emotions and thoughts [10]. Moreover, in self-compassion, individuals learn not to avoid or suppress their painful feelings but to recognize and accept their experiences. Based on a sense of self-compassion, they refrain from habitual and impulsive behaviors of self-blame [11]. Self-compassion-based therapy seeks to enable individuals to learn strategies such as attentive sensitivity, caring motivation, distress tolerance, and a non-judgmental perspective while freeing themselves from mental traps and cognitive errors [25]. People with higher self-compassion tend to have positive relationships with others, are more autonomous, have greater control over their environment, and exhibit less self-destructive behavior, self-criticism, and rumination, which in turn leads to fewer negative emotions. In this regard, spiritual health, as a foundation for promoting well-being, balances physical, psychological and social aspects, leading to peace, a sense of wholeness and coherence in individuals. Spiritual health, characterized by a close connection with oneself and God, peace, meaning in life, altruism and religiosity, acts as a protective factor against elements that threaten health and well-being and possesses a high degree of coherence [10, 26]. For this reason, the religion of Islam presents spiritual health as a concept that encompasses the entirety of a person’s life in this world and the hereafter. When a person successfully accepts themselves with compassion and progresses through certain stages, they are on the path to spiritual health and elevation, which indicates significance and authenticity [13, 14].
Self-compassion training affected students’ social acceptance. There was a significant difference in social acceptance between the experimental and control groups. This finding is consistent with the results of Karimi et al. [27] and Varmarzyari and Golpour [28] regarding the effectiveness of self-compassion on individuals’ social acceptance and support, as well as improving social adjustment. Self-compassion training helps individuals, based on their abilities and social capacities, to reduce the vicious cycle of negative self-image and self-criticism. With a conscious and compassionate outlook, they can redesign more realistic standards and achievable expectations that align with their abilities [22]. Self-compassion is a positive psychological trait that enhances well-being and acceptance of others [17]. People with higher levels of self-compassion tend to exhibit greater self-acceptance, a sense of human connection, and mindfulness. They are more effective at regulating and balancing emotions and often employ more adaptive strategies to deal with stressful life situations without overreacting [11, 18]. In addition, self-compassion and a compassionate attitude help individuals feel connected to themselves and others; through this sense of connectedness, they can overcome the fear of social rejection and engage in more adaptive social behaviors [7, 8]. Self-compassion therapy teaches individuals to develop capacities such as social acceptance and connection instead of avoiding or escaping social relationships, thereby preventing social isolation while maintaining their social connections.
Any type of applied research is associated with limitations for the researcher due to the presence of influential external and internal variables, which the present study also encountered. The main limitation of this study is the lack of random sampling, which restricts the generalizability of the results. Additionally, the absence of long-term follow-up of the results represents another limitation of this study. Therefore, it is suggested that this research be conducted with other student populations to enhance the generalizability of the results. It is also recommended that random sampling methods be employed in future studies. Furthermore, a follow-up phase should be implemented.
Conclusion 
Self-compassion has a significant impact on students’ spiritual health and social acceptance. Therefore, by training the level of self-compassion skills, which are considered part of positive psychological abilities, we can expect to improve both spiritual health and social acceptance, ultimately leading to greater satisfaction and well-being.
Ethical Considerations
Compliance with ethical guidelines
All ethical principles, including obtaining informed consent from participants, avoiding any insistence or coercion, refraining from recording identifying information to reassure the subjects, maintaining the confidentiality of personal information, and granting them the right to withdraw from the study, were considered in this research. The present study was approved by the Department of Psychology, Faculty of Literature and Humanities Science, Mahabad Branch, Islamic Azad University, Mahabad, Iran (Code: 16620705941003).



Funding
The present study was derived from the master’s of Arazo Babakhani, approved by the Department of Department of Psychology, Faculty of Literature and Humanities Science, Mahabad Branch, Islamic Azad University, Mahabad, Iran. This research did not receive any external funding.
Authors' contributions
Conceptualization and supervision: Kord; Methodology: Babakhani, and Kord; Data collection: Babakhani; Data analysis: Kord; Funding acquisition, resources, investigation, writing the original draft, review & editing: All authors.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The cooperation of the participants in this study, including professors and students, is gratefully acknowledged.