Identification of dimensions and indicators of spiritual health: A qualitative study

Abstract

INTRODUCTION:

Spiritual health is considered one of the important dimensions of health and has been given serious attention by the scientific community, World Health Organization, health discourse, and medical education. However, despite these considerations, there is a controversy in defining the nature of this category and its dimensions and indicators. The purpose of this study is to identify the indicators and dimensions of spiritual health for medical students.

MATERIALS AND METHODS:

This qualitative study with exploratory approach utilized conventional content analysis and individual in-depth interviews with experts in the area of spiritual health and spirituality in medical sciences selected through purposeful sampling. The study was conducted at Aja University of Medical Sciences in Tehran in 2018. The semi-structured interview was a tool used to achieve data saturation, that interviewed with 19 experts. Member check, credibility, and reliability were measured to increase the validity and reliability of the results. Inductive content analysis was used for the analysis of data in three main phases: preparation, organization, and categories and creating categories.

RESULTS:

Based on the findings of the interviews, 52 indicators were identified.Then, the indicators of spiritual health were identified in the following four categories) relationship with God, relationship with himself, relationship with others, relation with the environment (and these categories were divided inthree dimentions (cognitive, attitudes and emotions, behavioral)

CONCLUSION:

The findings of the present study showed that in order to have spiritual health, it is important to pay attention to one's relationship with God and one's relationship with oneself, one's relationship with others, and one's relationship with the environment, and it is necessary to pay attention to it in medical science curricula.

Introduction

During the past few decades, attention to spirituality and spiritual health in the health system has become as a clique of policy makers and thinkers in the field of health and Medical Education. As the World Health Organization points out spiritual health as a dimension of health and refers to the physical, psychological, social, and spiritual dimensions in defining the dimensions of human existentialism, and also poses the spiritual dimension in evolution and development of human. Today, attention to the spiritual dimension of health has been considered in many definitions of health, moreover many suggestions for the inclusion of mental health has been presented as one of the dimensions of health in the World Health Organization's definition of health The authors look at spirituality from different angles and offer different definitions of it, so that it can be said that there is no consensus on the definition of spirituality.[1]

Spiritual health is the self-awareness; the acquisition of divine reverence; the purification of the soul from any vice and filth; the feeling of humility toward divine mercy, trust, resort, and submission, and submission to God and understanding of the meaning, the feeling of peace and hope, the purpose of life in the direction of approaching God in the field of vision and thought, the sense of feelings and emotions, and the nature of own self-behavior is based on the power of God and the use of his divine power, patience, and forbearance.[2]

Quoted from Clements and Koenig in a qualitative research, Langlmann et al. examined and identified the characteristics and properties of spirituality and spiritual health. In this study, they define spirituality and spiritual health as “a mysterious sense of attachment, harmony, and coherence between themselves, others, nature, and the transcendent existence, which is achievable through a process of dynamic and sustainable development,” which leads to the recognition of the ultimate goal and meaning of life.[3]

According to Azizi, in the field of spiritual health, we should pay attention to the factors and conditions affecting health in the divine dimension and individual, social, and natural areas and identify the indicators of spiritual health in all these areas.[4]

Researchers have come up with various definitions for spiritual health. However, they have not been able to provide a comprehensive definition for this term, so the main challenges related to spiritual health are providing a comprehensive definition for it and identifying the components and indicators of spiritual health.[5,6]

Weathers et al. and Larsen stated that the analysis of the concept from different perspectives and within different cultures shows other common features and helps to achieve a clear definition of spiritual health.[7,8] It is necessary to pay attention to the medical group and respond to the needs of patients’ spiritual care, and the realization of this requires a fundamental change in the theoretical and practical training of medical students and it requires a rethinking of ongoing health and medical education programs.[9]

Today, there is arrival of spiritual health in educational programs in many countries of the world. However, in spite of these attentions, spirituality needs to be strengthened and institutionalized among medical students during the period of education and training. Due to the importance of using spiritual health to promote other aspects of health and the lack of adequate studies in this field, the present study was conducted with the aim of explaining the dimensions and indicators of spiritual health for students of specialized courses (postgraduate) in medical sciences from the perspective of experts in the field of spiritual health in Iran.

Materials and Methods

This research was designed and implemented as an exploratory qualitative research. Due to the fact that no research has been done on identifying the dimensions of spiritual health, a qualitative research approach has been used to gain a deeper understanding of the subject. The study was conducted at Aja University of Medical Sciences in 2018. The statistical population constituted specialists and professors of medical sciences universities, who were experts in the field of spirituality and spiritual health. The study participants included experts in the area of spiritual health in various fields such as ethics, psychiatry, psychology, health, philosophy, and medical ethics of universities in Tehran. Sampling was performed purposefully with snowball technique. Data collection tools in this study were semi-structured interviews. In this research By conducting a semi-structured interview with 19 experts, we came to the saturation of the data in the sense that no new data were obtained.When we reached data saturation, further interviews did not lead to new data,. Each individual in-depth interview with experts lasted between 30 and 90 min.

The main questions of the interview were:

1. What is your definition of spiritual health?

2. What are the spiritual health indicators from your point of view?

3. What are the most important indicators?

Data analysis was performed by Strauss and Corbin.[10] The text of the interviews was fully recorded. After the recording, the interviews were completed and typed so that it can be used and coded more easily. The typed text was again matched to the recorded information. After each interview, the analysis was conducted. In this way, the following steps were carefully followed in the data analysis. The meaningful sentences related to the main subject matter of the research and had been of great importance were marked. The main concept of meaningful sentences was extracted as code. In the next step, the classification of the codes began. In this way, codes with a common concept were placed under one category and were named. Using a continuous comparative analysis process, each datum was compared with all data. The coded data were compared with each other. In this way, with each new interview, previous classes of revision and similar classes could be merged or new classes could be created. Then, by using an experienced colleague in the analysis of qualitative data, the classification and naming classes were reviewed. Thus, by forming the classification, the main categories of the study were extracted and the relationship between classes was determined. To ensure the accuracy of the trustworthiness classes, apart from the long-term mental engagement of the author with the problem (prolonged engagement. The results of the analysis of the interviews were presented to several qualified professors for qualitative research (peer debriefing). The proposed amendments were made after adequate discussion, if necessary, and finally a relative consensus on the final decision was made. In order to check the validity of the interview questions, the opinion of the professors was used.

Ethics considerations

In this research, moral considerations (informed consent, reason for recording interviews, and confidentiality of the identity of the interviewed person) were observed. This article is part of the results of a research project with registration number (8097) approved by the Vice Chancellor for Research and Technology of Aja University of Medical Sciences.

Results

According to the demographic profile, 19 faculty members and experts in the field of spiritual health participants in the study were included, of which 6 were women and 11 were men. Based on the demographic characteristics, 19 experts and faculty members participating in the study were 6 women and 11 men, of these, there were 4 professors, 6 were associate professors, and 9 were assistant professors. Based on the survey, in total, 12 indicators were obtained for the mental health spawn dimension, 15 indicators for the emotional dimension, and 24 indicators for the behavioral dimension. After implementing the text of the interviews and analyzing the interviews, 250 initial codes were extracted, with the elimination of repetitive codes and the integration of similar cases, 51 concepts or indicators was extracted from interviews with specialist and experts. Then, in the second phase the primary concepts extracted in the previous step were classified into four main categories These major categories are abstract in the level higher than the concepts of the previous stage and include: (1) relationship with God, (2) relation to self, (3) relations with others, and (4) relations with the environment. Finally, in the third stage, which is called selective coding, three dimensions or pivotal categories, namely (1) cognitive, (2) emotional, and (3) behavioral, as the final categories n selective coding, were extracted in this stage, which are shown separately in Table 1.

Table 1.

Dimensions, categories and indicators of the spiritual health for medical students

Dimensions or pivotal components (selected codes)	Components or categories (pivotal codes)	Concepts or indicators (open codes)
Cognitive	Relation with God	A true knowledge of God
		Have certainty
		Understanding the attributes of God
	Relation with himself	Preservation of inner value of itself
		Identify itself divine talents
		Self-knowledge of inner well-being
		Understanding own inner refinement
	Relation with others	Understanding the rights of persons
		Understanding social moral qualities
		Social expression or self-knowledge to the society
	Relation with the environment	Awareness of facilities and environmental constraints
		Understanding the proper operation of the environment
Emotional	Relation with God	Believe in God
		Trust in God
		The love of the God
		God satisfaction
	Relation with himself	Desire for excellence or progress
		Self-satisfaction
		Confidence and certainty
		Having peace of mind
		Having a goal in life
	Relation with others	Divine satisfaction in interacting with others
		Altruism
		Commitment to the affairs of others
		Human beings as divine trusts
	Relation with the environment	Having an attitude to objects as divine trusts
		Attitude toward nature as the source of effort and work
Behavioral	Relation with God	Doing divine assignments
		Divine fear
		Behavior and actions of the individual for God
	Relation with himself	Divine reverence
		Do not cruel yourself
		Self-care
		Not having spiritual illness like pride and arrogance
		Rest and peace
		Responsibility for individual affairs
	Relation with others	Respect for the right to others, respect for others, honesty, participation in the good affairs, amnesty from others’ mistakes, peaceful coexistence with others, sacrifice in the rights of others, manifestation of good deeds in relation to others, association with society, oralogical ethics, family satisfaction, creating satisfaction with colleagues, social responsibility
	Relation with the environment	No damage to nature and animals
		Healthy relationship with animals
		Healthy relationship with the world

Cognitive dimension

This dimension of spiritual health refers to the knowledge of humankind towards God, himself, others, and the environment. In fact, the cognitive domain deals with rational knowledge and skills. According to the findings of the analysis of interview data in the category of communication with God, the indicators of “a true knowledge of God,” “have certainty,” and “understanding the attributes of God;” in the category of relation with himself, indicators of “preservation of inner value of himself,” “identify himself divine talents,” “self-knowledge of inner well-being,” and “understanding own inner refinement;” in the category of communication with others, indicators of “understanding the rights of persons,” “understanding social moral qualities,” and “social expression or self-knowledge of society;” and in the context of relation to the environment, indicators of “awareness of facilities and environmental constraints” and “understanding the proper operation of the environment” were coded after the analysis.

In the opinion of the participants, having the correct knowledge and cognition of the creator of existence, the self-knowledge and knowledge of others and the world helps to make a reasonable and correct connection. The healthy human being is someone who is thinking about the creator of the world. He recognizes his abilities and limitations and communicates with others and the rational society, recognizing the capabilities and potential of the environment and planning how to use it correctly without harming its vital resources.

The interviewee of code (001) stated: About the relationship between the individual and the God, that the person believes in God, to have a proper knowledge of God, to do the duties assigned by God to the individual, and how much he does.

One of the important dimensions of spiritual health is having an attitude and understanding of God. A person who has spiritual health believes that the universe has a creator and that God is capable and that all creatures are His world. Such a person who has spiritual health is trying to obtain god's satisfaction.

One of the fundamental requirements of spiritual health is self-knowledge. In fact, self-knowledge is one of the most obvious and important characteristics of people with spiritual health. Self-knowledge is preceded by theology; man does not know himself and cannot know God. Before recognizing God and the world around him, man must recognize himself and discover the treasures of his nature and body. In fact, the perfection and prosperity of humans is not possible without self-knowledge, when a person recognizes his abilities and talents, he will know his position in the community, he will know the society, and he will recognize both good and bad, and how he will know deal with others and the environment .

The interviewee of code (008) also stated: I think one of the indicators is that the person has confidence and self-confidence, and in the sensual aspects of the person, He is pleased with himself, a kind of self-knowledge with religious aspects that can be the source of other spiritual indicators., that is, if we have the rest, will make the satisfaction of health and spirituality.

Spiritual health helps a person to have a close and coordinate relationship with God, himself, others, and the environment. In fact, spiritual health as an internal mechanism contributes to individual adaptation to situations and conditions. Spiritual health helps people to have a positive attitude and vision for the universe. The interviewee of code (0010) stated: One of the indicators of a healthy spiritual human being is the self-knowledge that What this person knows about himself, what status of his body and mind is, what does the prayer that he calls knows what he is saying? Self-awareness is one of the basic characteristics of spiritual well-being.

The interviewee of code (0012) stated: Spiritual health suggests that human beings believe in supremacy or not, which my perception is that there must be and what is its supreme being, what is the existence, Controller is a being that cares for humans.

Emotional dimension

This dimension of spiritual health refers to the feelings, emotions, and attitudes of the individual towards God, himself, others, and the peripheral environment. In fact, in the emotional sphere, interests, motivation and attitudes, appreciation, or values are desired.

According to the findings of the analysis of interview data in the category of communication with God, the indicators of “believe in God,” “trust in God,” “the love of God,” and “God satisfaction;” in the category of relationship with himself, the indicators of “desire for excellence or progress,” “Self-satisfaction,” “confidence and certainty,” “having peace of mind,” and “having a goal in Life;” in the category of communication with others, indicators of “divine satisfaction in interacting with others,” “altruism,” “commitment to the affairs of others,” and “human beings as divine trusts;” and in relation to the environment, indicators of “having an attitude to the objects of divine trust” and “attitude toward environment as the source of effort and work” After the analysis were coded.

Another dimension of spiritual health is emotion and feeling dimension. When a person becomes aware of the creator, himself, others, and the natural world, emotions and feelings are also created in accordance with the cognition, and depending on the amount of knowledge and awareness of emotions and feelings, they will also be different. when one recognizes God as the creator of the world, and recognizes the attributes of God and realizes that all being is under the sovereignty of god, inwardly, inside herself, seeking love for God.

Spiritual health reduces negative emotions, tension, and anxiety. Participants believe that having emotions and feelings and a positive attitude toward the creator of world, itself, others, and nature, are signs and indicators of spiritual health. In this case, the interviewee code (0010) stated: From the indicators of spiritual health (1) Having no spiritual illness, that is, it does not have a person pride, strangulation and selfishness; (2): In order to balance spirituality, not excess nor negligence; (3) In the direction of spiritual excellence, that is, the person who is spiritual in the direction of the excellence of spirituality and moving on the basis of this day to day.

A person's awareness of God, herself, others, and the environment affects her behavior. Spiritual health helps a person to love God, love himself, and value himself for himself., love the others and the community in which they live and love their environment. , Such a human being is positive, optimistic, and hopeful. In this connection, the interviewee of code (0011) also told us: It's not worrying about the illness that the people's attitude to the disease is a positive attitude, which this attitude and insight are considered to be spiritual health.

Spiritual health helps human beings to have a proper attitude toward the universe and its phenomena. In fact, spiritual health brings about love and friendship to others, society, and nature. The interviewee of Code (0012) stated: In relation to the health dimension of the existence of the right person to die, considers death as the continuation of life, no end to life, and do not fear death, and have a positive view of that world, That, given that we think that God is omnipotent and that the existence of that world is purely absolute of himself, and that it is merely its own ruling, not the other, then there is no reason to worry. So in existential health we should not be troubled. And that people should be kind to others, apart from being in person and in their personal communication and anyone who needs help should help him.”

Behavioral dimension

Behavioral dimension of spiritual health includes one's behavior in relation to God, himself, others, and the peripheral environment.

According to the findings of the analysis of interview data in the category of communication with God, the indicators of “doing divine assignments,” “divine fear,” “behavior and actions of the individual for God,” and “divine reverence;” in the category of communication with himself, index “do not cruel yourself,” “self-care,” “not having spiritual illness like pride and arrogance,” “rest and peace,” and “;responsibility for individual affairs” in the category of communication with others, the indicators of “respect for the right to others,” “respect for others,” “honesty,” “participation in the good affairs,” “amnesty from others’ mistakes,” peaceful coexistence with others,” “sacrifice in the rights of others,” “manifestation of good deeds in relation to others,” “association with the society, “oralogical ethics,””family satisfaction,” “creating satisfaction with colleagues,” and “social responsibility;” and in relation to the environment, indicators of “nondamage to nature and animals,” “healthy relationship with animals,” and “healthy relationship with the world,”. After the analysis were coded.

The third dimension of spiritual health is considered a behavioral dimension. When a person acquires a relative cognition in relation to God, himself, others, and nature, emotions and feelings are formed in which the connection between cognition and emotions and emotions is reflected in the field of action, that is, the action of each person comes from knowledge and emotion. In other words, a healthy human being is a human being whose spiritual knowledge and spiritual emotions will stimulate spiritual behaviors. For example, when one achieved his self-knowledge, and emotions were formed within himself, his actions and behaviors were shaped in terms of cognition and emotions. For example, the interviewee of code (001) stated: In relation to the individual's relationship with himself that the individual maintains its internal refinement, it preserves its inner worth, and the same is true of the relation of one's person to others, and to Do not hurt others and. Perhaps the most important sign that God strongly emphasizes is the right to people that here is the treatment and the same health of the sick.

The obvious manifestation of spiritual health is in the behavior and actions of the individual. That is, when one recognizes knowledge of God, himself, others, and the surrounding environment in which he lives, and consciousness and feelings and emotions are formed in him, then he appears in his behavior and actions. Such a person respects himself and others, uses his talents and abilities correctly, will behave correctly with others and the community, will work for divine satisfaction, and will use the facilities appropriately. In this connection, the interviewee of code (004) states: A healthy spiritual person does not belong to the world., but I think that he should love the world, because God has created to use it and do all his teachings and take care of himself. Do not cruel himself, do not stop his labor, be merciful with others, be ethical, where being the prophets’ mission, He does not harm nature and loves animals, loves humans and. those One who does these things for divine affinity is a healthy spiritual person.

According to the participants’ viewpoints, the actions and behaviors of individuals indicate that they have a degree of spiritual health. In particular, in Islamic religion, actions and behaviors are centered on the religion of Islam and Islamic teachings. In this case, the interviewee of code (008) stated: The acts and behaviors that a person has Grouping for himself in the religious aspects can be used in these attributes, that in fact, in the first place, is all acts and behaviors for God; that this can be an indicator, At a later stage, human behavior is based on the pattern and criteria of the Prophet, Mohammad, and Imams. This can also be one of the characteristics, and after that, the satisfaction of the God, in the direction of spirituality, indicators such as family satisfaction in the direction of spirituality, satisfaction of the work of the individual and his colleagues, etc., all this can be.

Spiritual health helps the person to have a sense of social responsibility. Individuals with intellectual health in any situation have the ability to understand the problems of their peers and try to resolve their problems. In fact, they have a commitment to the society and their social environment. The interviewee of code (0012) states… Other than this, they should have a social responsibility, that is, if I know the decision is made at the macro level that it is damaging, It's a damaging to the country or a number of people. I have to have a sense of social responsibility to actually oppose, criticizing, apart from, everyone wants to be. This dimension, in my opinion, is different from the dimension of communication with others. Although this dimension is very valuable, but neglected, I do not have the right to stay silent when I know is wrong decision is made.

Discussion

The purpose of this study was to identify and explain the indicators and dimensions of spiritual health for medical students. Based on the results of the research, the dimensions of spiritual health can be expressed in three cognitive, emotional, and behavioral dimensions. The cognitive dimension of spiritual health refers to the knowledge of one's self toward God, himself, others, and the peripheral environment. The emotional dimension of spiritual health refers to the feelings, emotions, and attitudes of the individual toward God, himself, others, and the peripheral environment. In fact, in the emotional sphere, interests, motivation and attitudes, appreciation, or values are desired, and spiritual health involves one's behaviors in relation to God, himself, others, and the peripheral environment. Spirituality is often defined in dictionaries as an immaterial, supernatural, and soul-related phenomenon related to the original human nature.[11]

Several studies and research on the definition and indicators of spiritual health have been made by scholars and researchers, and so far, there is a difference of opinion and one-dimensional attitude in them. Dimensions and indicators that have been presented by the researchers and those who have been present in the field of spiritual health are in line with the aspects and dimensions of the present study, Baljani et al.,[12] Rahimi et al.,[13] and Yasminejad et al.[14] categorize spiritual health dimensions into existential health and religious health. In addition, Fisher categorizes the dimensions of spiritual health into individual, social, environmental, and transcendental dimensions.[15]

Abbasi et al. form the components of spiritual well-being after spiritual understanding, spiritual affections, spiritual action, and spiritual production.[1] According to the available sources and literature, spiritual health is the relationship with God, oneself, others, and nature.[16] Similarly, the responses of our participants showed four types of communication in spiritual health, relationship with God, himself, others, and nature. Spirituality is a dynamic dimension of human life that relates to how individuals (individuals and communities) experience, express, and/or seek meaning, Purposeful and transcendent and how to link them to the moment, to yourself, to others, it is with environment, to remarkable and/or sacred.[17]

In confirmation of the findings of this study, in the studies of Abulghasemi et al.[18] and Mesbah et al.,[19] spiritual health indicators are classified into the following four categories: cognitive, emotional, behavioral, and consequential. Mozafarinnia et al. have also categorized the dimensions of spiritual well-being to the cognitive dimension, then emotions and the dimension of action.[20] Marzband and Zakwey[21] and Amiri et al.[22] also referred to the components of spiritual well-being for cognitive indices, behavioral, emotions, and spiritual states and outcome indicators. Tawan et al. also categorize spiritual health dimensions into belief system, intellectual system, ethical system, and lifestyle.[23] According to the evidence, people with better mental health usually choose a lifestyle that can improve their health. Numerous systematic reviews have shown that mental health can contribute to positive health outcomes.[24] From decades ago, European governments signed the Copenhagen Declaration on Social Growth and committed them to the spiritual needs of their peoples (individuals, families, and communities), and their policies toward political, economic, moral, and spiritual insights for social development.[25] In the scientific education of the world's medical universities, the discussion of spirituality has become a hot topic in scientific circles and clique. Studies show that 59% of UK medical faculties and 90% of American medical faculties have courses with spiritual health content in their curriculum, but little information on the integration of spirituality in the curriculum of Latin America, Asia, Australia, and Africa is available.[26] This is while our mystical heritage is so rich and the spiritual capital of Islam is so rich that it has the ability to make a great social revolution. The importance of spirituality and spiritual health in humans over the past few decades has increasingly attracted the attention of psychologists and mental health professionals, as the WHO has addressed the existing definitions of human and human nature. For example, the World Health Organization refers to the physical, psychological, social, and spiritual dimensions in the definition of human existential dimensions, and also implies spiritual implications for human development and evolution.

Spiritual health is influenced by the knowledge and worldview of society and is also influenced by different religions and cultural conditions because each culture defines spiritual health from its own point of view.[27] Therefore, it is very important to pay attention to the culture and religion of individuals in evaluating spiritual health.

It is suggested that in future studies, the conceptual and operational model of spiritual health be developed in the curricula of medical students. Furthermore, the effects and interventions of such training programs on the spiritual health and professional practice of physicians and medical professions should be examined. It is suggested that in future studies, the factors affecting spiritual health be examined and strategies for promoting and increasing the level of spiritual health among the medical sciences community can be studied.

Limitation

One of the limitations of this research is that the results were collected based on the opinion of experts and scholars, and if the results were collected through the analysis of documents and other methods, it would be more reliable and generalizable. One of the strengths of this research is the identification of spiritual health indicators of research based on the cultural and religious context of the society.

Conclusion

If we want to teach spiritual health and spirituality for medical students, it is essential that in educational policy and in designing and developing curricula, attention is increasingly paid to spirituality and spirituality should be included in the curriculum and education of medical disciplines. The spiritual curriculum that is appropriate to Islamic culture can provide scientific and explicit solutions for gaining professional capabilities and competencies. The results of this study represent the indicators and dimensions of spiritual health. Therefore, it is suggested that policymakers and curriculum planners provide educational opportunities and design effective strategies for the understanding, recognition, and development of these indicators in medical science students.

Financial support and sponsorship

Aja University of Medical Sciences, Tehran, Iran (research code: 8097) supported the study.

Conflicts of interest

There are no conflicts of interest.