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Research article
The relationship between spiritual well-being and happiness among
healthcare students: Application of the spiritual health questionnaire for the
Iranian population
Shahoo Feizi
a
, Morteza Nasiri
b
,
c
, Hanieh Bahadori
d
, Meysam Hosseini Amiri
e
,
f
,
*
,
Hamid Mirhosseini
g
a
Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
b
Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
c
Department of Operating Room Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
d
Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
e
Spiritual Health Research Center, Qom University of Medical Sciences, Qom, Iran
f
Department of Anesthesiology, School of Paramedicine, Qom University of Medical Sciences, Qom, Iran
g
Research Center of Addiction and Behavioral Sciences, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
ARTICLE INFO
Keywords:
Happiness
Iran
Islam
Spirituality
Students
Well-being
Behavioral medicine
Health promotion
Clinical psychology
ABSTRACT
Objectives: To investigate the relationship between spiritual well-being (SWB) and happiness in a sample of Iranian
healthcare students, considering a culturally-adapted and a context-based measure of SWB.
Methods: In this descriptive-correlational study, 343 Muslim students of Qom University of Medical Science are
studied from October 2017 to March 2018. Data collection tools were the culturally-adapted spiritual well-being
scale (SWBS), the spiritual health questionnaire for the Iranian population (SHQ), and the Persian version of
Oxford happiness inventory (OHI).
Results: Total scores of SWBS, SHQ, and OHI were in moderate (68.42 12.76), high (193.74 24.26), and
moderate (37.95 14.56) levels, respectively. Happiness had a significant positive correlation with all domains of
SWBS and SHQ. Moreover, a significant proportion of happiness was determined by SWBS and SHQ. Also, some
domains of SWBS and SHQ showed a significant correlation with age, gender, marital status, and academic major.
Conclusion: There was a significant correlation between happiness and SWB, measured by SWBS and SHQ. Hence,
it seems that both SWBS and SHQ are sufficiently sensitive to assess the relationship between happiness and SWB.
1. Introduction
As the essence of human beings, spiritual well-being (SWB) and
spirituality affect many aspects of our health, including mental health [1,
2]. Several studies reported that SWB is associated with both positive
(i.e., happiness, hope, kindness, compassion, purpose in life, optimism,
self-esteem, and gratefulness) and negative (i.e., depression, suicide,
anxiety, psychosis, substance abuse, cigarette smoking, extra-marital
sexual behaviors, delinquency/crime, and marital instability) mental
health outcomes [3,4,5]. However, some studies reported that SWB can
negatively affect mental health [6,7].
According to the literature, SWB is a major contributor to happiness in
many cultures [8,9,10]. In Iran, as the host to the largest population of
Shia Muslims, there is an increasing interest to assess the relationship
between SWB and happiness [11,12,13], particularly in university stu-
dents [14,15,16,17]. However, few researchers have addressed this
relationship in Iranian healthcare students. Recently, Jalilian et al. reported
asignificant positive correlation between SWB and happiness using the
spiritualwell-being scale (SWBS) and Oxford happiness inventory (OHI) in
students of Kermanshah University of Medical Sciences, West of Iran [14].
The higher the number of measures in SWB, the better is the assess-
ment of various domains [18]. In the past decade, the culturally-adapted
SWBS has been considered as a common measure of SWB in Iran [1,19,
20]. Although culture has a significant influence on the results obtained
from SWB [22], according to the best knowledge of the authors, no study
has investigated the relationship between SWB and happiness using an
Iranian context-based SWB questionnaire yet. Recently several studies
have used the spiritual health questionnaire (SHQ) for the Iranian
* Corresponding author.
E-mail address: Hoseini_amiri@yahoo.com (M. Hosseini Amiri).
Contents lists available at ScienceDirect
Heliyon
journal homepage: www.cell.com/heliyon
https://doi.org/10.1016/j.heliyon.2020.e05448
Received 27 April 2020; Received in revised form 16 June 2020; Accepted 3 November 2020
2405-8440/©2020 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Heliyon 6 (2020) e05448
population, an Islamic- and Iranian-based questionnaire for SWB
assessment, especially among university students [21,22,23,24].
To broaden the current knowledge of SHQ and also to better under-
stand the relationship between SWB and happiness among Iranian
healthcare students, we used SHQ in addition to SWBS and OHI to
describe students' SWB and happiness and to evaluate the bivariate and
multivariate relationship between SWB and happiness. Moreover, the
SWB is analyzed based on the students' demographic characteristics.
2. Methods
2.1. Participants
This descriptive-correlational study was conducted on students of the
Nursing &Midwifery and Paramedical schools of the Qom University of
Medical Sciences, Qom, Iran, from October 2017 to March 2018. The
exclusion criteria were as follows: 1) having a non-Muslim religion
(Bah
a'í faith and Christianity); 2) having a history of using psychoactive
drugs; 3) confirmed diagnosis of chronic disorders; 4) having a family
member with disability; and 5) experiencing a mental disorder during the
past six months. Partially completed questionnaires were also excluded.
Students were selected using the stratified random sampling tech-
nique. So that students with similar majors (nursing, midwifery, oper-
ating room technology, anesthesiology, laboratory sciences, and
emergency medical services) were allocated to a similar group, then
simple random sampling was used to select students from each group,
consistent with the size of the target population. Using the Eq. (1), the
sample size was calculated as 330:
α
¼0.01, β¼0.1, and r ¼0.210 [15].
n¼ðZ1∝
=
2
þZ1βÞ2
ð1
2Ln1þr
1rÞ2þ3⇒n¼ð2:58 þ1:65Þ2
ð1
2Ln1þ0:210
10:210Þ2þ3¼330 (1)
To consider the sample attrition and to increase the validity of the
results, the sample size was increased to 360. In total 343 questionnaires
were eligible for statistical analyses, 27 were excluded due to
incompleteness.
2.2. Ethical considerations
The study is approved by the Research Ethics Committee of the Qom
University of Medical Sciences (ethic No. IR.MUQ.REC.1396.42). All
procedures were performed following the ethical standards of the local
Ethics Committee and Helsinki declaration. First, the objectives of the
study were explained to eligible students, then, if they were agreeing,
written informed consent was obtained. Also, all students were assured
about the confidentiality of their information. Besides, they were free to
withdraw from the study at any time. Likewise, all students were assured
that their participation would not affect their academic grades and/or
evaluation.
2.3. Measures
2.3.1. Demographic questionnaire
A researcher-made questionnaire was used to collect demographic
information, including age, gender, marital status, academic major, and
academic degree.
2.3.2. SWBS
The SWBS, developed by Paloutzian and Ellison (1982) at the Uni-
versity of Idaho, is a general index of the subjective condition of well-
being and perceived spiritual quality of life and contains 20 positive
and negative items [25]. Each positive item should be answered on a
six-point Likert scale, ranging from “strongly disagree”(score 1) to
“strongly agree”(score 6). Conversely, each negative item is
reverse-scored, ranging from “strongly agree”(score 1) to “strongly
disagree”(score 6). Higher scores represent greater well-being. The
SWBS includes two subscales of “religious well-being (RWB)”and
“existential well-being (EWB)”[26,27].
- RWB subscale: This subscale consists of 10 odd-numbered items,
which measure the individual's relationship with God. It consists of
both negative (i.e., item No. 1: I don't find much satisfaction in private
prayer with God) and positive items (i.e., item No. 3: I believe that
God loves me and cares about me). The total score of RWB ranges
from 10-60 and is categorized as low (a score of 10–20, which in-
dicates a sense of unsatisfactory individual's relationship with God),
moderate (a score of 21–49 which reflects moderate and positive
views of the individual's relationship with God), and high (a score of
50–60 which indicates high and positive views of the individual's
relationship with God) [26,27].
- EWB subscale: This subscale consists of 10 even-numbered items,
which refers to the horizontal dimension of well-being about the
world about us. It includes components such as having a life purpose,
having life satisfaction, being related to others, and the environment
surrounding the person, with no specific religious word or concept.
This subscale also has a combination of negative (i.e., item No. 2: I
don't know who I am, where I came from, or where I'm going) and
positive items (i.e., item No. 4: I feel that life is a positive experience).
The total score of EWB ranges from 10-60 and is categorized as low (a
score of 10–20, which indicates a low satisfaction with life), moderate
(a score of 21–49, which indicates a relative lack of clarity about
purpose in life), and high (a score of 50–60, which indicates a mod-
erate and high level of satisfaction and purpose in life) [26,27].
The total SWBS score is computed by summing up RWB and EWB
scores, ranging from 20-120. The total score is categorized as low (score:
20–40), moderate (score: 41–99), and high (score: 100–120) [26,27].
The validity and reliability of the Persian version of SWBS are previously
approved [1,28]. Biglari Abhari et al. measured the reliability and val-
idity of the scale in students of the Iran University of Medical Sciences
and reported adequate validity and a Cronbach's alpha coefficient of
0.81, 0.84, and 0.89 for the RWB, EWB, and SWBS, respectively [1]. In
the present study, the Cronbach's alpha coefficient of RWB, EWB, and
SWBS was 0.76, 0.74, and 0.77, respectively.
2.3.3. SHQ
This Islamic-based questionnaire was developed for the Iranian
Muslim population by Amiri et al. (2015) at the Spiritual Health
Department of the Academy of Medical Sciences of Iran [29]. It consists
of 48 items on a five-point Likert scale with two subscales of “insight/-
tendency”(cognitive/emotional component) and “performance”
(behavioral component).
-“Insight/tendency”subscale: It consists of 28 items, which evaluate
the individual's insights/trends (attitude) over the last year about
“relationship with God”,“relationship with self”, and “relationship
with the surrounding”(i.e., item No. 1: The purpose of man's creation
is to reach perfection). This subscale is scored using a five-point Likert
scale, ranging from “strongly disagree”(score 1) to “strongly agree”
(score 5). The total score of this subscale ranges from 28-140 and is
categorized as low (score: 28–83) and high (score: 84–140) [21].
-“Performance”subscale: It consists of 20 items, which evaluate the
individual's behavior over the last year about “relationship with
God”,“relationship with self”, and “relationship with the surround-
ing”(i.e., item No. 30: For the sake of Allah, I avoid bribery, usury,
gambling, and drinking alcohol). The scoring of this subscale is also
based on a five-point Likert scale, ranging from “never”(score 1) to
“always”(score 5). The total score ranges from 20-100 and is cate-
gorized as low (score: 20–59) and high (score: 60–100) [21].
The total score of SHQ is calculated by summing up the scores of each
subscale, ranging from 48- 240. Higher scores indicate greater SWB and
S. Feizi et al. Heliyon 6 (2020) e05448
2
the categorization of scores is as follow: 48–115 as low and 116–240 as
high [21]. The content validity index (CVI) and the content validity ratio
(CVR) of SHQ for the urban Iranian population are estimated as 0.85 and
0.80, respectively, and the Cronbach's alpha coefficients of “insight/-
tendency”and “performance”subscales and SHQ were 0.95, 0.96, and
0.98, respectively [29]. In two recent investigations on Iranian health-
care students, the Cronbach's alpha coefficients of SHQ were reported as
0.83 [22] and 0.95 [23], respectively. In the present study, the Cronba-
ch's alpha coefficients of SHQ, “insight/tendency”, and “performance”
were 0.89, 0.83, and 0.84, respectively.
2.3.4. OHI
The OHI developed by Argyle et al. (1989) to measure personal
happiness with five dimensions of “satisfaction with life”,“self-esteem”,
“self-efficacy”,“subjective well-being”, and “positive mood”. It includes
29 items that are answered on a four-point Likert scale ranging from
“never”(score 0) to “always”(score 3) [30]. The total score ranges from
0-87, and the higher scores indicate greater happiness [31]. Based on the
total score, happiness is categorized into three categories: low (score:
0–28), moderate (score: 29–57), and high (score: 58–87) [32]. In a study
on undergraduate students, Alipoor and Noorbala (1999) approved the
reliability and validity of the Persian version of OHI [33]. Liaghatdar
et al. and Bayani reported adequate validity of the scale and a Cronbach's
alpha coefficient of 0.93 and 0.92 among university students [34,35]. In
the present study, Cronbach's alpha coefficient was 0.91.
2.4. Data collection procedure
Before filling questionnaires, first, a brief explanation was provided to
participants to make sure that they understood the questions. The
questionnaires were filled using the self-reported method in an appro-
priate time either in the classroom or at home. Those who were willing to
complete the questionnaires at home were asked to return the ques-
tionnaire at least two days before the deadline.
2.5. Statistical analysis
Data were analyzed using SPSS version 22 (SPSS, IBM©Corp.,
Armonk, NY, USA). A p-value <0.05 was considered statistically sig-
nificant. Descriptive statistics (i.e., mean, standard deviation, numbers,
and percentage) were used to report demographic characteristics, SWB,
and happiness. The Pearson correlation test was used to investigate the
bivariate correlation between SWB and happiness. Moreover, the mul-
tiple linear regression was applied to evaluate the predictive role of SWB
toward happiness. The Spearman and Pearson tests were applied to
evaluate the correlation of demographic data with SWB. Also, SWB was
compared in terms of demographic variables using the one-way analysis
of variance or independent t-test.
3. Results
3.1. Demographic data
The mean age of the students was 23.89 5.36 years and 254
(74.1%) of them were female. Most students (69.1%) were single and
mostly (96.2%) were in the B.Sc. degree program. Most of them were
studying operating room technology (38.8%), followed by anesthesi-
ology (23.6%), nursing (18.4%), laboratory sciences (9.9%), and
midwifery (5.5%). Also, 13 students were in the associate degree pro-
gram of emergency medical services (3.2%) and the M.Sc. degree pro-
gram of nursing (0.6%).
3.2. SWB and happiness status
The scores of SWBS, SHQ, and OHI are presented in Table 1. The total
score of happiness was 37.95 14.56, and 213 students (62.1%) had a
moderate level of happiness. The total scores of SWBS and SHQ were
68.42 12.76 and 193.74 24.26, and 339 students (98.8%) obtained a
moderate score in SWBS, but 342 of them (99.7%) had a high score in
SHQ.
3.3. Bivariate and multivariate relationship of SWB and happiness
Bivariate correlation of SWBS, SHQ, and OHI is shown in Table 2.
Total score of OHI was significantly correlated with the total score of
SWBS (r ¼0.497, p <0.001) and also subscales of EWB (r ¼0.690, p <
0.001) and RWB (r ¼0.245, p <0.001). Moreover, the total score of OHI
had a significant positive correlation with the total score of SHQ (r ¼
0.205, p <0.001) and subscales of “insight/tendency”(r ¼0.208, p <
0.001) and “performance”(r ¼0.149, p ¼0.007).
Based on the results of the multiple linear regression, SWBS (adjusted
R
2
¼0.524, F
2, 340
¼190.07, p <0.001) and the SHQ (R
2
¼0.044, F
2,
340
¼7.879, p <0.001) predicted a significant proportion of happiness.
As shown in Table 3, the EWB subscale significantly and positively pre-
dicted happiness (p <0.001), whereas this prediction was negatively
significant for the RWB subscale (p <0.001). Moreover, “insight/ten-
dency”subscale significantly and positively predicted happiness (p ¼
0.005), whereas the “performance”subscale did not predict it signifi-
cantly (p ¼0.523).
3.4. SWB and demographic variables
The bivariate correlation of SWBS and SHQ with demographic vari-
ables is shown in Table 4. All domains of SWBS and SHQ showed a sig-
nificant and positive correlation with age (p <0.001), whereas marital
status and academic degree had a significant and negative correlation
with SWBS and also SHQ in all domains (p <0.05). Moreover, a signif-
icant and negative correlation was found between academic major and
all domains of SWBS (p <0.001), but this variable was significantly
positive only for the “performance”subscale of SHQ (p ¼0.035). Gender
was correlated significantly and positively with all domains of SHQ (p <
0.001), whereas the relationship between this variable and SWBS was
negative and significant in the RWB subscale (p ¼0.077).
Students' SWB scores separated by demographic variables are shown
in Table 5. Students with an associate degree, emergency medical ser-
vices, and married status had significantly higher scores in all domains of
SWB. The SWB was higher in male students compared to females; how-
ever, the difference was not statistically significant.
4. Discussion
The present study had two main objectives. Firstly, to describe the
students' SWB using SWBS and SHQ and their happiness using OHI. Based
on the findings, students had a moderate level of happiness. While, based
on the SHQ and SWBS, SWB was high and moderate, respectively. These
findings are somehow consistent with the results of previous students
[14,23,28]. In line with our findings, Hezomi and Nadrian reported a
moderate level of happiness and also the religious belief among a sample
of Iranian female students [36].
Regarding the SWBS subscales, the RWB was higher than EWB, which
is in line with the findings of previous studies on the Iranian healthcare
students [14,28]. Contrary to our findings, a study in Brazil reported
higher scores for EWB than RWB [37]. A probable assumption for this
difference is that Iranians pay more attention to the relationship with
God, as expected in Muslim communities, therefore religious issues and
spirituality are more valued in Iran [38]. However, more comparative
studies are required to shed light on this assumption. Also, a significant
and positive correlation was found between the total score of SWBS with
its subscales, and a significant and positive relationship between RWB
and EWB subscales. In other words, it was found that higher RWB scores
indicate higher scores for EWB, which is consistent with a previous study
conducted in Iran [28].
S. Feizi et al. Heliyon 6 (2020) e05448
3
Comparing the SHQ subscales revealed that the “insight/tendency”
subscale was higher than the “performance”subscale. In addition, a
significant and positive correlation was revealed between the total score
of SHQ and its subscales, and the subscales were found to be significantly
and positively correlated. In other words, higher scores in insights/trends
(attitude) toward spirituality led to greater performance in this regard.
Consistent with our findings, a previously conducted study in Iran re-
ported higher scores for the “insight/tendency”subscale, compared to
other subscales, and a significant and positive relationship between the
two subscales of SHQ [23]. Moreover, in a study conducted on Iranian
nurses, the “insight/tendency”subscale obtained higher scores, and the
“performance”score was positively associated with “insight/tendency”
[24]. However, in a nationwide study on Iranian Muslim patients, a
negative linear correlation was observed between “insight/tendency”
and “performance”subscales of SHQ [21]. The discrepancy could be
attributed to the differences of participants and cultural issues.
As the second objective, the present study aimed to evaluate the
correlation between SWB and happiness. A direct and significant
Table 1. Mean and standard deviation of the students' spiritual well-being and happiness.
Status Total
Low Moderate High
Mean SD Mean SD Mean SD Mean SD
Oxford happiness inventory (OHI)
1
19.72 5.64 41.75 7.32 63.08 5.83 37.95 14.56
Spiritual well-being scale (SWBS)
Religious well-being subscale
2
0.0 0.0 37.67 5.52 52.25 1.89 39.67 7.21
Existential well-being subscale
2
18.11 2.44 30.23 6.06 0.0 0.0 28.75 6.98
Total spiritual well-being
3
0.0 0.0 68.03 12.30 101.75 2.87 68.42 12.76
Spiritual health questionnaire (SHQ)
Insight/tendency subscale
4
103.01 10.89 - 126.76 10.45 114.51 15.97
Performance subscale
5
72.52 7.44 - 89.33 7.68 79.23 11.16
Total spiritual well-being
6
110.0 0.0 - 193.99 23.86 193.74 24.26
The higher scores indicate greater spiritual well-being or happiness.
1
The total score ranges from 0-87 and is categorized as low (0–28), moderate (29–57), and high (58–87).
2
Total score ranges from 10-60 and is categorized as low (10–20), moderate (21–49), and high (50–60).
3
The score ranges from 20-120 and is categorized as low (20–40), moderate (41–99), and high (100–120).
4
Total score ranges from 28-140, and is categorized as low (28–83) and high (84–140).
5
Total score ranges from 20-100 and is categorized as low (20–59) and high (60–100).
6
The score ranges from 48-240 and is categorized as low (48–115) and high (116–240).
Table 2. Correlation between the scores of the spiritual well-being scale, spiritual health questionnaire, and Oxford happiness inventory.
(1) (2) (3) (4) (5) (6) (7)
(1) Oxford happiness inventory (OHI) 1
Spiritual well-being scale (SWBS)
(2) Religious well-being subscale 0.245* 1
(3) Existential well-being subscale 0.690* 0.616* 1
(4) Total spiritual well-being 0.497* 0.902* 0.895* 1
Spiritual health questionnaire (SHQ)
(5) Insight/tendency subscale 0.208* 0.692* 0.293* 0.552* 1
(6) Performance subscale 0.149** 0.355* 0.100*** 0.255* 0.585* 1
(7) Total spiritual well-being 0.205* 0.619* 0.239* 0.481* 0.928* 0.846* 1
*p <0.001 obtained by the Pearson correlation test.
**p ¼0.007 obtained by the Pearson correlation test.
***p ¼0.063 obtained by the Pearson correlation test.
Table 3. Estimation of the students' spiritual well-being for happiness
y
.
Statistical indices
B SE Beta t p*Collinearity statistics
Tolerance VIF
Spiritual well-being scale (SWBS)
Religious well-being subscale - 0.585 0.096 - 0.290 - 6.121 <0.001 0.620 1.612
Existential well-being subscale 1.811 0.099 0.868 18.352 <0.001
Spiritual health questionnaire (SHQ)
Insight/tendency subscale 0.167 0.060 0.183 2.801 0.005 0.657 1.521
Performance subscale 0.055 0.085 0.042 0.640 0.523
y
Obtained by the Persian version of Oxford happiness inventory (OHI).
*
Obtained by the multiple linear regression.
S. Feizi et al. Heliyon 6 (2020) e05448
4
correlation was found between happiness and SWB, measured by SWBS
and SHQ. In other words, the higher the students' SWB, the greater their
happiness. These findings suggest good sensitivity of the SWBS and SHQ
for assessing the relationship between happiness and SWB.
To the best of our knowledge, the present study is the first to
investigate the correlation between SHQ and OHI. Based on the litera-
ture, we could not find any similar study in design to compare with our
results. However, the findings support previous studies on the role of
SWB in the happiness of students. In a similar study, a significant and
positive relationship is reported between all domains of SWBS and OHI
in a sample of Iranian healthcare students [14]. In another study, a
positive and significant correlation was found between the scores of
spiritual intelligence (King's spiritual quotient scale) and OHI among
Iranian non-healthcare students [16]. Similarly, a positive correlation
was reported between happiness (satisfaction with life scale) and
spirituality (daily spiritual experiences scale [DSES]) using a sample of
medical students in the United States [39]. Accordingly, university au-
thorities are recommended to inform the students about spirituality and
SWB and their importance in happiness. Moreover, they should estab-
lish some strategies to promote the students' SWB to subsequently in-
crease their happiness.
In contrast with our findings, some studies reported no relationship
between SWB and happiness or reported a relationship only in some
dimensions of SWB. In a study conducted on students, teachers, and
administrative staff and managers of Iran University of Medical Sciences,
it was indicated that the respondents who had a higher score in EWB,
RWB, and SWBS reported significantly higher happiness assessed by OHI.
However, OHI had no significant correlation with SWBS and its subscales
[1]. This discrepancy can be attributed to the characteristics of the par-
ticipants and using various definitions of SWB.
Table 4. Correlation of the students' spiritual well-being with demographic variables.
Domains
Variables
Spiritual well-being scale (SWBS) Spiritual health questionnaire (SHQ)
Religious well-being subscale Existential well-being subscale Total spiritual well-being Insight/tendency subscale Performance subscale Total spiritual well-being
rp r p rp rp rprp
Age 0.400 <0.001*0.310 <0.001*0.396 <0.001*0.268 <0.001*0.205 <0.001*0.271 <0.001*
Gender -0.096 0.077** 0.574 <0.001** 0.882 <0.001** 0.698 <0.001** 0.309 <0.001** 0.590 <0.001**
Marital status -0.294 <0.001** -0.250 <0.001** -0.281 <0.001** -0.263 <0.001** -0.237 <0.001** -0.283 <0.001**
Academic degree -0.268 <0.001** -0.244 <0.001** -0.267 <0.001** -0.168 0.002** -0.138 0.010** -0.157 0.004**
Academic major -0.217 <0.001** -0.243 <0.001** -0.276 <0.001** 0.011 0.842** 0.114 0.035** 0.057 0.292**
*
Obtained by the Pearson correlation test.
**
Obtained by the Spearman correlation test.
Table 5. Students' spiritual well-being separated by demographic variables.
Dimensions
Variables
Spiritual well-being scale (SWBS) Spiritual health questionnaire (SHQ)
Religious well-being subscale Existential well-being subscale Total spiritual well-being Insight/tendency subscale Performance subscale Total spiritual well-being
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Gender
Male 40.91 7.15 29.14 7.52 70.05 13.24 116.71 14.22 78.77 10.00 195.49 21.05
Female 39.24 7.19 28.61 6.79 67.85 12.56 113.73 16.49 79.40 11.56 193.13 25.30
p*0.060 0.540 0.162 0.130 0.650 0.431
Marital status
Single 38.21 6.58 27.55 6.19 65.77 11.10 111.84 15.34 77.67 11.48 189.52 14.13
Married 42.92 7.52 31.44 7.88 74.36 14.21 120.47 15.80 82.72 9.58 203.19 21.86
p*<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Academic degree
Associate's degree 50.38 2.18 38.84 8.22 89.23 9.46 126.76 12.72 86.69 9.75 213.46 20.51
Bachelor's degree 39.31 7.01 28.43 6.61 67.74 12.13 114.00 15.94 78.95 11.16 192.95 24.15
Master's degree 32.66 3.05 20.00 4.35 52.66 7.23 117.00 13.07 78.00 7.93 195.00 20.78
p*<0.001 <0.001 <0.001 0.005 0.014 0.003
Academic major
Anesthesiology 37.01 4.93 27.61 5.00 64.62 7.60 107.97 14.28 75.88 9.89 183.86 21.33
Operating room
technology
45.08 6.30 32.39 6.88 77.48 11.93 121.82 15.57 80.87 12.53 202.6 24.74
Laboratory sciences 33.85 3.18 25.76 4.61 59.61 5.64 104.00 14.33 74.85 9.35 178.85 22.12
Nursing 34.81 3.90 24.21 4.49 59.03 6.43 113.60 11.96 82.04 9.40 195.64 18.47
Midwifery 34.05 3.76 23.73 6.69 57.78 7.00 106.78 15.74 77.10 9.79 183.89 14.61
Emergency medical
services
50.27 2.24 37.81 8.47 88.09 9.18 125.36 12.93 84.81 9.80 210.18 20.08
p*<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
**Obtained by the one-way analysis of variance.
*
Obtained by the independent t-test.
S. Feizi et al. Heliyon 6 (2020) e05448
5
According to the results of the multiple linear regression, the EWB
was most important for happiness and the RWB was negatively associ-
ated with happiness. A study conducted on German students reported
that personal SWB evaluated by the German version of the spiritual well-
being questionnaire could predict the levels of subsequent happiness
obtained by OHI [40]. In another study on Latina/o students enrolled in
the United States, it was shown that daily spiritual experiences evaluated
by DSES were significant predictors of subjective happiness assessed by
the subjective happiness scale [41]. Moreover, a study conducted on
Iranian students reported that spiritual intelligence was a positive pre-
dictor of happiness [16]. In the current study, EWB was found to be a
potential co-founder in the relationship of RWB and happiness. When we
adjusted the confounding effect of EWB, the positive correlation of RWB
and happiness, which was found by bivariate correlation, was reversed,
so that each unit increase in the RWB was associated with a 0.585
decrease in OHI score. Moreover, the significant and negative association
between happiness and RWB may be justified by the innate condition of
spirituality and the origin of SWBS. It worth noting that this scale is not
specifically designed for Muslims, and RWB evaluates only the individ-
ual's relationship with God with 10 items, which most items are a com-
mon fact among Iranians. To better understand the relationship of SWB
and happiness, we used the SHQ, as an Islamic native questionnaire for
the Iranian community, and a positive relationship was found between
happiness and two subscales of “insight/tendency”and “performance”in
the linear regression model and also when running bivariate correlation.
Although the exact mechanisms of the correlation between SWB and
happiness are not well explained, several studies suggested that spiritu-
ality and religiosity are correlated through behavioral, psychological,
physiological, and social factors. From a behavioral perspective, in-
dividuals with higher spirituality and religiosity are often committed to a
healthier physical and mental lifestyle such as moderation in eating,
commitment to hard work, marital fidelity, altruism, and forgiveness; all
of which are directly associated with subjective happiness through con-
trolling their minds [16,42]. Concerning the psychological view, in-
dividuals in religious cultural contexts remain happy and hopeful to a
heavenly life with no more sufferings; because subjective spirituality and
religiosity help them to give meaning to adversities and tensions that
occur during lifecycle [16]. Based on a physiological perspective,
participating in religious practices (i.e., prayer) is a means of relaxation,
which can promote mental health outcomes such as happiness [21]. It
was proposed that happier individuals may be more likely to regularly
attend religious services, than those who are less happy [43]. From the
social perspective, frequent attendance in religious institutions such as
churches, temples, and mosques is shown to positively influence the
happiness; because it can lead to more social support by increased in-
timacy and connection with others [42,44]. A moderated mediation
analysis indicated that higher levels of happiness in religious individuals
could be explained by social sanctions and rewards that religious and
non-religious individuals receive in their societies [45]. Besides, it's
proved that religious individuals enjoy the health benefits of religiosity,
if they receive a social valuation from their cultural context [46]. Ulti-
mately, further studies are needed to better understand the mechanisms
and pathways of action that correlate religiosity and spirituality with
happiness.
4.1. Limitations
Using an Islamic- and Iranian-based questionnaire of SWB for the first
time to evaluate the relationship between SWB and happiness are the
main strengths of the present study. However, we are aware that the
current study may have some limitations. First, the study was conducted
on healthcare students in a Muslim population, therefore the results
might not be generalizable to other groups, because there are other
contributing factors (i.e., cross cultural differences and social contexts)
that affect this relationship [45]. Second, the study had a
descriptive-correlational design; hence, no cause-effect relationship
could be established between SWB and happiness. Third, the
self-reporting method of data collection, with students may potentially
under/over report the issues.
5. Conclusion
A significant direct correlation was found between students' happi-
ness and SWB, obtained by SWBS and SHQ. Accordingly, it seems that
spirituality-based interventions could be helpful to promote the students'
happiness; thus, future interventional studies are recommended to fully
understand the role of SWB in the students' happiness. Moreover, it was
revealed that both SWBS and SHQ are sufficiently sensitive to assess the
relationship between happiness and SWB; however, because of its
context-based nature, SHQ is a more appropriate measure for Iranian
populations. Likewise, it seems that behavioral, psychological, physio-
logical, and social mechanisms have a significant influence on the rela-
tionship between spirituality and happiness. However, further studies are
needed to better understand the specific mechanisms and pathways of
action that mediate SWB in happiness.
Declarations
Author contribution statement
Shahoo Feizi, Hamid Mirhosseini: Analyzed and interpreted the data;
Wrote the paper.
Morteza Nasiri: Conceived and designed the experiments; Analyzed
and interpreted the data; Wrote the paper.
Hanieh Bahadori: Performed the experiments; Analyzed and inter-
preted the data; Wrote the paper.
Meysam Hosseini Amiri: Conceived and designed the experiments;
Performed the experiments; Analyzed and interpreted the data;
Contributed reagents, materials, analysis tools or data; Wrote the paper.
Funding statement
This work was supported by the Spiritual Health Research Center of
Qom University of Medical Sciences, Qom, Iran (Grant No. 96826).
Data availability statement
Data included in article.
Declaration of interests statement
The authors declare no conflict of interest.
Additional information
No additional information is available for this paper.
Acknowledgements
Authors appreciate the valuable assistance of all students and schools'
managers. Also, the authors would like to thank Shiraz University of
Medical Sciences, Shiraz, Iran and also Center for Development of Clin-
ical Research of Nemazee Hospital and Dr. Nasrin Shokrpour for editorial
assistance.
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