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   Table of Contents      
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 104-112

The process of promoting spiritual health in iranian muslim adults: A grounded theory


1 Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
2 Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran

Date of Submission13-May-2019
Date of Decision14-Sep-2019
Date of Acceptance18-Oct-2020
Date of Web Publication05-Mar-2021

Correspondence Address:
Dr. Marzieh Momennasab
Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz - 71936-13119
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.IJNMR_92_19

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  Abstract 


Background: Spiritual health is a complex concept and it is important to review its promotion and evolution from a Muslim point of view in Iran. So, the present study was designed to explore the process of spiritual health promotion among Iranian Muslims. Materials and Methods: This study is a grounded theory in which the continuous comparative analysis method Strauss & Corbin (1998) was used to analyze data. This study's sampling method was purposive in trying to select participants with the maximum variation. Results: The “striving effort to promote spiritual health” was the core category which was the participants' strategy of the participants to confront their main concern, “to achieve transcendence”. The essential spiritual process in this study was “the journey in the transcendence path”. People would find the purpose and meaning of life by interconnecting and relying on their inner forces, and by establishing the moderation between the dimensions of existence. In this way, individuals will become closer to human perfection with the help of these components. They will achieve immersive wellbeing and moral maturity through the consolidation of spiritual health. Such a person lives to serve among the people. Conclusions: Adult promotion of spiritual health is dynamic and complex. The main process in this path is spiritual growth, which begins and continues as a result of the striving to advance spiritual health and refinement. Considering these findings has become a concern for holistic care within the scope of nursing care.

Keywords: Grounded theory, Iran, Islam, nursing, spirituality


How to cite this article:
Jaberi A, Momennasab M. The process of promoting spiritual health in iranian muslim adults: A grounded theory. Iranian J Nursing Midwifery Res 2021;26:104-12

How to cite this URL:
Jaberi A, Momennasab M. The process of promoting spiritual health in iranian muslim adults: A grounded theory. Iranian J Nursing Midwifery Res [serial online] 2021 [cited 2021 Apr 10];26:104-12. Available from: https://www.ijnmrjournal.net/text.asp?2021/26/2/104/310834




  Introduction Top


Many health care practitioners are now searching for theological and spiritual ideas.[1],[2],[3] Nurses, as a part of the healthcare team, do the same as well. Nurses have a unique role to play in sustaining and encouraging health in society and in patients.[4] In view of the physical, psychological and social aspects of health, just as nurses are responsible for the preservation and promotion of physical health, promoting spiritual health is certainly one of the duties of nurses.[5] Despite increasing attention to spiritual health, it should be noted that spirituality is based on beliefs and is shaped in the context of culture and religion.[6] In order to explain this concept, it is therefore necessary to undertake studies in different cultural contexts.

Another important issue is that despite extensive studies on the spiritual health of the elderly, adolescents, children and adults with chronic and end-of-life diseases and palliative care,[5],[7] few studies have examined this concept in healthy adults.[8] It is important to explain the concept of spiritual health at various stages of growth and development because spiritual health develops in phases of growth and through the occurrence of life challenges in various forms, through the ups and downs of life. Based on theories of spiritual development described by Fowler (1981) and Eaude (2008),[9],[10] it can be assumed that spiritual health and spirituality vary from adults (19-60 years) in infants, teenagers and the elderly.[11] On the other hand, Iranian adults account for more than 65 percent of the population[12] and it is important to consider their health dimensions, including spiritual health, given that adults constitute the active and productive population of any society.

In addition, many of the existing studies in athletes, college students, and social workers are related to Christianity[13],[14],[15] and few attempts have been made to define spiritual health from the Islamic point of view.[6],[16],[17] Thus, it is critical for Iranian nurses and other health care providers to recognize and understand spiritual health in the context of Iranian Islamic culture and religion. Despite western nursing literature, few Iranian nursing literature attempted to define the concept of spiritual health. Some studies have explored the meaning of similar concepts such as spirituality and spiritual well-being, but given the Islamic perspective, there is still no clear and consistent understanding of the concept of spiritual health in nursing, which can serve as a basis for research and a guide to practice.[18] Considering the scarcity of the studies on the concept of spiritual health in the Muslim population - despite their vast population in the world (1.3 billion)[19] and in Iran, which make up the majority (more than 90') of the population,[20],[21] it is essential to conduct studies based on the Iranian religious and cultural context.

Given the abstract nature, multidimensionality of this concept, its complexity in different periods of life from childhood to the end of life, and its dependence to social and religious culture, qualitative studies are necessary in order to explain the concept of spiritual health and its dimensions. On the other hand, since the meaning of concepts and social interactions is an expression of feelings, ideas, and attitudes[22] and the process of ascribing meaning to data corresponds to the essential grounded theory methods of coding,[23] this study aimed at explaining the theoretical process of promoting spiritual health from the viewpoint of Iranian Muslim adults with a grounded theory approach. Moreover, since one of the metaparadims of nursing is health and spiritual health is one of the aspects of health,[24],[25] and the difference between modern nursing and Islam's view of the human being,[26] the present study takes into account the philosophical foundations and Islamic worldview.


  Materials and Methods Top


This research has a grounded theory design (Strauss & Corbin 1998).[27] The purpose of this study's sampling method was to select participants with the maximum variation between January and September 2017. The first participant was purposefully recruited on the basis of his spiritual background and willingness and ability to express his thoughts and feelings. After first coding processes, the relationship between concepts and subcategories became clear when new data did not emerge, according to the theory formed in this stage, theoretical sampling was performed. The repetition of this process has emerged the final theory by diversifying the data, consolidating the categories and subcategories and their relations. Therefore, theoretical sampling was used in the development of concepts and the emergence of essential social-spiritual processes from the data. The iterative cycle of data generation continued until data saturation.

The inclusion criteria for this study were: aged 18–60, the ability to provide rich information, the absence of high-risk diseases such as cancer, end stage cardiac and renal and liver diseases and disabling neurological diseases, the ability to speak and understand Persian, and being Muslim. Initially, the interviewer, who had experience in spiritual health and nursing care, personally sought out key informants at these centers. The interviews took place over nine months and were repeated in 4 cases. After providing verbal explanation of the study to the participants and taking their written consents, the interviews were conducted in their offices or in the School of Nursing, Shiraz University of Medical Sciences. [Table 1] outlined the participants' demographics.
Table 1: Demographic characteristics of the participants

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The research setting included two large shopping centers, banks, Shiraz University of Medical Sciences and the retirement center in Shiraz, as these centers could provide maximum variation in age, gender, education, and occupation for the participants. In this study the method of collecting data was a semi-structured face to face interview. Interview questions, emerged from literature review and pilot study, and began with a general question: “What does the health mean to you?” The following questions were raised according to the answers of the participants: “What do you think spiritual health means?” These questions were formulated through literature review. The review of the literature also provided the existing philosophical and theoretical knowledge on the topic and helped the researchers to better analyze the subject, thus increasing the sensitivity of the researchers. The interviews were transcribed and recorded. Interview time averaged 48 minutes. After 14 participants interviewed, no further data had been obtained.

For data analysis, the Strauss & Corbin (1998) (simultaneous data collection and data analysis) included three open, axial, and selective coding steps was used.[27] At the beginning, each interview was read line by line, and the basic concepts were extracted at the open coding stage using theoretical and analytical memos. Memos are the record of the researcher's ideas about the resulting data and questions, and the similarities and differences between the data. For example, one of the first participants mentioned: “We discover spirituality within ourselves, which means that this spiritual dimension will not be discovered as long as I'm in the physical dimension.” The researchers found out, based on this quotation, that this aspect of health is innate and should be discovered through some processes. Hence, the questions were established in the subsequent interviews to probe this quest of discovery.

Primary codes were classified into 15 subcategories and 4 main categories. The coding paradigm has been used in axial coding to discover the relationship between the context and the process. The core category of the study had been revealed in the selective coding step. At this stage, the theory was assessed over internal consistency and gaps after organizing the categories around the main category. These gaps were resolved through literature review. This coding process is presented in [Table 2]. The process of data analysis ultimately led to the creation of a theory. Some diagrams about phenomenon, context, consequence and strategy were drawn to develop and formulate the concepts and categories, one is presented in [Table 3]. In a conceptual model the theory concepts and their relationships were shown. [Figure 1].
Table 2: Examples of open, axial and selective coding

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Table 3: An example of paradigmatic analysis

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Figure 1: The conceptual framework of spiritual health promotion

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The rigor criteria considered in this study were credibility, dependability, transferability, and conformability. Participant data verification (member check), prolonged engagement with the participants, search for contrast evidence, researcher's and team members' credibility, external checking, and triangulation methods were taken into account for credibility. In addition, providing feedback to the participants, data verification by the participants, description of the concepts as opposed to spiritual health, and accurate memo-writing about the process of transforming primary data into categories provided dependability or auditability. Sampling by maximum variation along with purposeful sampling and in-depth and rich data also helped to achieve transferability. Finally, to confirm the data, thick and in-depth descriptions of the study data and trend and audit trials were used. In order to control the researchers' opinion bias, thoughts, beliefs, and feelings about the subject were written from the start and at all stages of the research. This practice is called a “reflective idea” wherein the researcher discovers and articulates personal emotions and experiences that might influence the study process.

Ethical considerations

This study was approved by Shiraz University of Medical Sciences' Ethics Committee code no. IR.SUMS.REC.1393.S7326. Participants who participated in the project were fully aware of the study's goals and method, and were voluntarily present in this study. Other ethical considerations of this study were obtaining informed consent from the participants, maintaining the anonymity and confidentiality of information at all stages of the research and the ability to quit studying at each stage of the research.


  Results Top


Participants were mostly female and single. Other demographic data presented in [Table 1]. In this study, the process of spiritual health promotion expressed in terms of four categories and 15 subcategories presented in [Table 4]. Sub-categories and categories have been developed in terms of their characteristics and dimensions. Multiple smaller concepts falling within a category are the characteristics that help to clarify the categories. On the other hand, dimension represents the spectrum or range of that characteristic. [Table 5] shows one example of that characteristic and dimension.
Table 4: Categories and subcategories of spiritual health promotion process

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Table 5: Characteristics and dimensions of one subcategory

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In this study, the “wise striving to promote spiritual health” was the core category which was the participants' strategy to confront their main concern, “to achieve transcendence”. The outcomes of that striving were spiritual excellence, which included moderation, morality, peace, altruism and becoming an example. Moreover, the backgrounds of the striving for spiritual health promotion were spiritual suffering, philosophical viewpoints, some demographic factors and socio-cultural factors.

1. Wise striving for spiritual health:

The participants believed that all human beings had innate spiritual health. However, the soul and its capabilities should be discovered within the existence and then permanently nurtured so as not to exit from the path of transcendence and reach the highest level of perfection. Spiritual health grows in different stages of life after it is discovered. In other words, spiritual health is a continuous movement going through a progressive course. As a participant also said: “It's a process, it is a progress, (and) it means it has no end”(Participat7).

This category includes 3 subcategories: Multifaceted, glorious relationships, Faithfulness, Spiritual abstinence.

Multifaceted, glorious relationships

Growth and development of the spiritual health are not formed in solitude. It is shaped and developed in communication. The first and most prominent communication to be noted by the participants was relationship with God. “Spiritual health is related to God -… Generally speaking, there is no other way than this -… My soul should not be alone, when I connected to him, I feel everything is all right” (Participant14).

Communication with others was another aspect of spiritual communication. The importance of communicating with others is such that some contributors use interpersonal relationships to define spiritual health. “So, being in a community, living with people -… do not be dissociate, (also) living with family and friends (are parts of spiritual health)” (Participant9).

Participants in this study also referred to nature as a as a sign of God's greatness and beauty, as observing and thinking about it strengthened their relationship with God and encouraged them to thank blessings of God. “A part of this connection is also the relationship with animals and plants or with the environment. A person who harasses animals, trees, forest and the environment does not have spiritual health”(Participant6).

Faithfulness:

One of the other factors necessary for the journey towards spiritual health promotion is the inner and outer beliefs and faith. Contributors, who were Muslim and Shi'a, considered the inner faith related to the spirit, and the outer faith related to religious practices. But at the same time, they did not separate the two parts from each other. Instead, they considered them to be either parallel, or complementary. “Spiritual health, apart from external appearance, also has an internal features. so, one aspect of it is something that everyone have inside them”(Participant10).

In this study, the religious aspect of spiritual health was emphasized by all participants. The outer aspects of faith are presented as behaviors and religious rituals from their point of view. Participants in this study referred to religious beliefs as a source of spiritual support. ”(Spiritual health) is about religion and beliefs. Relationship with God is prayer, fasting and worship -… that is to say, he (human being) is committed to a series of principles and ethics. It means that he has conscience and ethical codes”(Participant1).

Spiritual abstinence:

Spiritual health requires protection and abstinence after spiritual formation and growth, which needs to be practiced in a permanent basis. The surmounting of everyday life neglects the growth of spiritual health. However, spirituality would be back at the center of attention following certain triggers such as hopelessness and death or illness of loved ones.”(Spiritual growth) means being solid, staying in a smooth path, not going to the left and right, it's about his resistance. It's like a battle and how much a person can withstand”(Participant6).

2- Search for spiritual transcendence:

The participants believed that spiritual health promotion is a path in which the attempt to discover and search for meaning would be achieved through capacities and inward contemplation. This category includes 3 subcategories: meaning, discovering, and using capacities and abilities and inward deep contemplation.

Meaning:

One of the main points among the participants in this study was the search for and discovery of meaning. They were trying to find a reason for, and derive meaning from, the bad events and experiences. “For example, I have a serious illness, first I think, God why did I become so. When I think about it, I see that if God gave me such a thing, it should have had a reason. Then,-… I'll live my life. I'm calm”(Participant11).

Discovering and using capacities and abilities

Spiritual health is a dynamic process from being to becoming. This continuous process means the use of maximum abilities in different fields of science, art, and so on. In the sense what is set in human existence can be actualized and move towards the perfection of its existence. “For example, he must feel responsible for those who are younger than himself, to pass on their experiences to them and to work for their welfare -… to be productive for the people of their country and for human beings -… even after they die. His work -… like his words, scientific content -… can be effective”(Participant2).

Inward deep contemplation

In reflection, introspection, and contemplation on behaviors, attitudes and thoughts, the inward deep contemplation which is a part of communication with self is explained. Participants believed that we don't need to find the spiritual health from the outside world. Rather, this dimension exists within all human beings, and in order to find, flourish and grow it, we just need to think deeply through ourselves. In fact, having a positive attitude towards the world and ourselves along with a multidimensional attitude have led to thinking about and reflecting on different aspects of life and understanding our place in the world. One participant stressed the importance of thinking and contemplation for promotion of spiritual health as follows: “Sa'adi says something about flowers. it means that the person who is narrow-minded and has a one-dimensional look at the world is not a successful person. It means that -… I can change when I change my attitude” (Participant13).

3. Spiritual background:

In the path to spiritual growth, certain events and factors are effective. This category included spiritual suffering as a factor for spiritual transformation, value/philosophical system, social/cultural/family background and some demographic factors.

Spiritual suffering as a factor for spiritual transformation (The effect of early and critical life events):

One of the factors contributing for spiritual transformation was specific life events or crises. “For me, these changes were due to a series of events -… that would lead a person to transform. I have always been waiting for it to happen ”(Participant6).

Value/philosophical system

Participants also believed that spiritual health was based on the person's worldview and value. This system nurtures and guides all principles of life and, of course, spiritual health. Thus, any changes to this view leads to changes in spiritual health. This is clearly seen in the statement of this participant: “ On top of the existence, there is a system of value and belief that -… as a filter -… screens everything and determines what is good and bad. Everyone must have a comprehensive worldview that can satisfy the mind and heart -… every guiding principle -… any framework that guides us towards this goodness is the spiritual framework”(Participant13).

Social/Cultural/Family Background:

The spiritual-religious background was the underlying factors that affect the perceptions, thoughts, actions and spiritual responses of the participants. “I think that the most part of spiritual health is the one we have grown with us since we were child. For example, I am from a Muslim family and I raised and grew up with those Islamic ideas. However, my education, consciousness and awareness will complete it later on”(Participant3).

The results of this study indicated that spiritual health is also based on the cultural and social background of the participants. “It seems to me that all religious principles are those that bring you peace of mind and health, and the cultural and social principles are also subordinate to these principles”(Participant4).

Some demographic factors

According to the statements of the participants, education, age and gender of the individual were effective in their spiritual development. “I think women have a higher spiritual health than that of men. Education sometimes is effective -… It's not possible to say that married persons are different from single ones, but they are not alike. It's higher in married persons”(Participant 12).

4. Spiritual Excellence:

The manifestation of spiritual growth in behavior is spiritual excellence, which was characterized by moderation, morality, peace of mind and spiritual vitality, growing up of altruism and becoming an example.

Moderation:

Participants stated that human beings have different dimensions. Therefore, a person with spiritual health could not be one-dimensional and ignore one dimension of his existence. Contributors described one-dimensional behaviors as a caricature growth, some of which were smaller and larger than the rest of the cartography and created a bizarre shape: “whoever has spiritual health should have a balance. It means that he has to be the same in his life and all of his aspects of life should be this way.” Of course, he should be in a moderate way”(Participant6).

Morality:

Some contributors considered moral aspects as part of the definition of spiritual health aside from religious aspects. Inspired by the Islamist doctrine, Muslims believe that human beings, in the light of morality, can throw their carnality away from ugliness and evil. Some of the moral considerations in this study were: mutual trust and confidence, lack of jealousy and hypocrisy, honesty, and good-temperedness. “They have good morals. They are honest. They don't discriminate between people. They have good temper and behavior. They don't torment other people”(Participant8).

Peace

One of the ultimate outcomes of spiritual health from the perspective of the participants was spiritual peace and joy. The foundation of that peace was deism. “(Those who have spiritual health) are satisfied with life -… that is, they have accepted life as it is -… they are peaceful and calm” (Participant2).

Growing up of altruism

Another aspect of spiritual health was the altruistic social efforts. Respecting the rights of others and providing assistance and supporting others was a part of these activities. Contributors have cited spiritual health as a source of willingness to help others and take up pioneering benevolence. ”(Whoever has spiritual health) helps people in any way he can -… you can count on him, even by speaking he helps you”(Participant5).

Becoming an example:

Those who walk in the path of transcendence and reveal their existential capacities will have behaviors that distinguish them from others. The internalization of spiritual health in these people decodes their behavior in a way that is considered as a prominent example of spiritual health. “I am the one who does not follow anyone or accept someone, but I can't ignore these kind of people somehow because they are perfect and a good example”(Participant10).


  Discussion Top


The results of this study aimed at explaining the views of Iranian Muslim adults on the process of spiritual health promotion, suggested that the essential spiritual process in this study was “the journey in the transcendence path” and the “wise striving to promote spiritual health” was the core category which was the participants' strategy to confront their main concern, “to achieve transcendence”. The outcomes of that striving were spiritual excellence which included moderation, morality, peace, altruism and becoming an example. Moreover, the backgrounds of striving for spiritual health promotion were spiritual suffering, philosophical viewpoints, some demographic factors and socio-cultural factors. In this growth path, with the occurrence of certain incidents, a sudden change occurs in the spiritual health of the individual, known as the spiritual development.

Wisdom-thinking and spiritual striving was the main category in this study for attaining transcendence. Individuals seems to achieve spiritual understanding by using reflection and introspection.[28] Allameh Tabatabai also refers to the verse “the [responsibility for] yourselves is upon you “[29] as evidence of self-knowledge as the perquisite for health and transcendence.[30] Although the striving is difficult, mystical, Islamic and Western texts have stated that the attainment of spiritual transcendence only goes through the diligent efforts and spiritual striving. The Holy Qur'an emphasizes the use of intellect, thought and understanding in many verses and addresses inattentive people who are not using their wisdom with a violent tone.[29] On the other hand, faithfulness was one of the other factors contributing to the growth and enhancement of spiritual health in this study. The importance of religious worship as part of the concept of spiritual health has also been emphasized in the views of nursing researchers.[31]

Searching and achieving transcendence was the main strategy or concern of the participant in the journey. In this way, with inward deep contemplation, people ultimately achieve spiritual self-awareness through an inner journey towards transcendence and find meaning accompanied by spiritual striving, eventually leading them to spiritual health. Meaning of life is the core of many belief systems, and religions made explicitly reference to the need to seek meaning in life and to maintain it.[32]

Many authors have noted the importance of previous life events in spiritual growth and transformation. Traumatic and life-threatening diseases can make the spiritual dimension more attentive.[33],[34],[35] Other backgrounds such as demographic factors, family/cultural/social, and value/philosophy have also been considered as factors affecting the promotion of spiritual health. The flourishing of self and soul requires an appropriate social and cultural environment. Researchers also believed that the association between connection, purpose, and meaning with a clear and distinct worldview is so strong that spiritual health could be considered beyond social psychological variables.[36]

The outcome of this spiritual transcendence is excellence including moderation, morality, peace, etc., In fact, spiritual health has a deep connection with human moral virtues like forgiveness, compassion, and kindness.[37] Morality is one of the issues that is considered by many Muslim scholars and in religious spiritual health is so great that the Prophet Mohammad (pbuh) considered his goal as the moral munificence completed.[38] Another manifestation of spiritual health in the present study was joyfulness and spiritual vitality. The result of this quest is also what is perceived in the Islamic Iranian culture of the concept of peace.[2]

The characteristics mentioned are considered both in Western as well as Islamic texts. However, in the present study, the concept of moderation was a characteristic mentioned by participants. Therefore, paying attention to an aspect of existence and ignoring the other dimensions would corrupt balance and peace of humanity, the ultimate result of which will be the deviation from the path of spiritual health. The Holy Qur'an also calls the Islamic people a middle nation, saying: “And so we have made you a just community that you will be witnesses over the people.[29]

Generally, many nurses in clinical settings are faced with a dimension of human experience that goes beyond physical or mental problems. In this dimension, well-being and distress parameters have to do with the spirit and connection to something ultimate. Therefore, maintaining and improving spiritual health as well as physical health is certainly the responsibility of nurses, as a member of the health team.[39] Moreover, in the second half of the twentieth century, the spiritual dimension of care was considered and nursing diagnoses, such as spiritual distress and spiritual despair, along with their nursing interventions were presented.[40] The findings of the present study could also provide a new perspective for such nursing diagnosis and Islamic-specific interventions.

One of the main limitations that should be considered in this study is the overlapping of the concept of spiritual health with concepts like spirituality and spiritual well-being. The close proximity of these concepts to one another could lead to misunderstandings about this concept at various stages of the study. The experience and mentality of the researcher might also affect the findings of this study, which is considered as a limitation of all qualitative studies.


  Conclusion Top


Based on the results of this study, spiritual health promotion in adults is a dynamic, complex, and multifaceted process. The main process in this path is spiritual growth that begins and continues as a result of the striving to advance spiritual health and spiritual refinement. Although during this journey, humans may develop and evolve, there are times when negligence occurs when the stimulants revert the person to this path again.

Within the scope of nursing care, it is important to consider spiritual health as an essential component of the definition of health given that care has become a concern for holistic care. Moreover, one of the main concepts in nursing metaparadigm is health, one of its dimensions is spiritual health. Nurses can use this approach to identify spiritual health aspects and attributes and to try to incorporate them in caring and health promotion. Nursing profession, as a profession aiming at providing health and well-being, could achieve holistic well-being as its greatest professional goal. This spiritual activity through divine connection would ultimately lead to the promotion of spiritual health as a healthy behavior.

Acknowledgements

This manuscript was extracted from PhD dissertation financially supported by the Vice-Chancellor for Research Affairs of Shiraz University of Medical Sciences, Shiraz (Grant No. 93-7326). The authors wish to express their thanks to Ms. A. Keivanshekouh at the Research Improvement Centre of Shiraz University of Medical Sciences for improving the use of English in the manuscript. Thanks also go to the participants who participated in this study.

Financial support and sponsorship

Vice-Chancellor for Research Affairs of Shiraz University of Medical Sciences, Iran

Conflicts of interest

Nothing to declare.



 
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