Journal of Medical Ethics and History of Medicine

Original Article

Explanatory definition of the concept of spiritual health: a qualitative study

in Iran
Ahmad Ghaderi1, Seyed Mahmoud Tabatabaei2, Saharnaz Nedjat3, Mohsen Javadi4,
Bagher Larijani5*

1
PhD Candidate in Medical Ethics, Medical Ethics and History of Medicine Research Center, Tehran University of Medical
Sciences, Tehran, Iran; Department of Medical Ethics, School of Medicine, Tehran University of Medical Sciences, Tehran,
Iran.
2Professor, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
3 Professor, Epidemiology & Biostatistics Department, School of Public Health, Tehran University of Medical Sciences, Tehran,

Iran.
4
Professor, Department of Ethics, Qom University, Qom, Iran.
5
Professor, Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran
University of Medical Sciences, Tehran, Iran.

Corresponding Author: Bagher Larijani

Address: No. 10, Jalal Al-Ahmad St., next to Shariati Hospital, Chamran Hwy, Tehran, Iran.
Email: [email protected]
Tel: :( +98) 21 88631296

Received: 30 July 2017

Accepted: 10 March 2018
Published: 9 April 2018

J Med Ethics Hist Med, 2018, 11:3

© 2018 Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences. All rights reserved.

Abstract
Scientists and researchers have examined spiritual health from different angles and proposed various definitions, but a
comprehensive definition does not exist for the term as of now. The present study aimed to offer the definition, components and
indicators of spiritual health from experts’ perspective.
This qualitative study utilized conventional content analysis and individual in-depth interviews with 22 experts in the area of
spiritual health in various fields selected through purposeful sampling. Member check, credibility, reliability, transferability and
allocation of adequate time for data collection were measured to increase the validity and reliability of the results. Conventional
content analysis was performed in three main phases: preparation, organization and reporting, and the categories, subcategories
and codes emerged accordingly.
Participants defined spiritual health in three dimensions: religious, individualistic, and material world-oriented. The study
revealed four types of connection in spiritual health: human connection with God, himself, others and the nature. The majority
of participants stated that spiritual health and spirituality were different, and pointed out the following characteristics for
spiritual health: it affects physical, mental, and social health; it dominates other aspects of health; there are religious and
existential approaches to spiritual health; it is perceptible in people’s behavior; and it can be enhanced and improved. Most
experts recognized human connection with God as the most important part of the definition of spiritual health. In conclusion, the
connection between humans and themselves, others and the nature was not seen as a component specific to spiritual health.

Keywords: Spiritual health, Spirituality, Health-care ethics

J Med Ethics Hist Med 11: 3, March, 2018 jmehm.tums.ac.ir Ahmad Ghaderi et al.

Introduction Spiritual Health Department in the Academy of

The word “spirit” is derived from the Latin words Medical Sciences of Iran. The selected experts had
“spiritus” (meaning breath, courage, vigor, or soul) articles, books or lectures in the field of spiritual
and the word “spirare” (meaning to breathe) (1). Five health. It should be noted that other qualified people
characteristics of spirituality include: meaning, in the field of spiritual health were also consulted
value, transcendence, connecting (with oneself, who were contributed by selected experts. After
others, God/supreme power and the environment), explaining the objectives of the study, observing
and becoming (the growth and progress in life) (2). confidentiality and obtaining informed consent from
Five decades have passed since the introduction of participants, individual semi-structured in-depth
spiritual health and its various definitions. Spiritual interviews were conducted until data saturation. A
health is about the connection with self (personal total of twenty-two interviews were conducted, each
dimension), others (social dimension), the nature lasting between 40 to 50 minutes. The time and
(the environment) and God (transcendental location of interviews were determined by the
dimension) (3). The basic characteristics of spiritual experts. Interview questions included: “What is your
health are as follows: proper lifestyle, connection definition of spiritual health?” “What are the
with others, asking about the meaning and purpose components of spiritual health?” “What are the
of life, and transcendence (4). Spiritual health is indicators of spiritual health?” “Do you think
extremely important for many researchers, to the spiritual health and spirituality are different or not?”
extent that it is seen as one of the key aspects of and “Please mention other points, if any”. A voice
health (5). According to numerous studies conducted recorder was used to record the interviews, and notes
on various patients, spiritual health leads to were taken of the experts’ talks. The experts were
improved mental health (6), and is positively related informed that they could ask the researcher to pause
to physical health, for instance, it may help patients the recording anytime during the interview, or
experience lesser pain (7). withdraw from the study at any stage. The experts’
Scientists and researchers have studied spiritual responses were returned to them to check in order to
health from different angles and offered various increase the validity and reliability of the study
definitions for it, but have failed to propose a (member check). Other measures that were used to
comprehensive definition for the term. Major increase the validity of the results included
challenges for addressing issues related to spiritual credibility, reliability, transferability and allocation
health include: providing a comprehensive definition of adequate time for data collection. Data analysis
for it; identifying the components and indicators of was performed through conventional content
spiritual health; and its effect on other aspects of analysis in three main phases: preparation (selecting
health. Even though a number of studies have been the unit of analysis, immersion in the data);
conducted on the subject of spiritual health in Iran organizing (coding, creating categories and
(5, 7), there are not enough studies on the definition abstraction); and reporting. The contents of the
of the term according to experts. Given the interview audio files were transcribed and the
importance of the issue, the shortage of literature, transcripts were carefully and repeatedly read to
and the need to consider different views about extract meaning units, which could be either words
spiritual health, this study was conducted in Iran to or sentences. Thus open codes were extracted,
explore the definition, components and indicators of redundant codes were eliminated, and the codes that
spiritual health from experts’ perspective. propounded a single subject were placed in one
category. Next, key and abstract concepts were
Method extracted, and categories, subcategories and codes
This was a qualitative study in which we arranged emerged.
individual in-depth interviews with experts and
analyzed the contents. Experts in the area of spiritual Results
The results of the study showed five clusters of
health in various fields such as ethics, philosophy, information about spiritual health including its
theology, medicine, psychiatry, psychology, health definition, components, indicators, characteristics
and medical ethics were selected by purposeful and the differences between spiritual health and
sampling. The experts were academicians, spirituality. Each cluster was characterized by
authorities on health-care system in the Ministry of specifications as presented in Table 1.
Health, researchers and authors in the field of
spiritual health and spirituality, and members of the

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Table 1- The results in the form of categories and subcategories

Category Subcategory
Religious dimension
Definition of spiritual health Individualistic dimension
Material world-oriented dimension
Religious (Human connection with God)
Components of spiritual health Individualistic (Human connection with himself)
Material world-oriented (Human connection with others and the nature)
Human connection with God
Human connection with himself
Indicators of spiritual health
Human connection with others
Human connection with the nature
Differences between spiritual health
Relative coincidence between spiritual health and spirituality
and spirituality
Different definitions for spiritual health
The effect of spiritual health on the other three dimensions of heath
The dominance of spiritual health over other aspects of health
Characteristics of spiritual health
The religious and existential approaches to spiritual health
The manifestation of spiritual health in behavior
Spiritual health as a dynamic process

Definition of Spiritual Health spiritual health as follows:

Participants believed that spiritual health has three “Those components of health that are not physical,
dimensions: religious, individualistic, and material psychological or social can be placed in the context
world-oriented. of spiritual health”.
Religious Dimension: “Spiritual health promotes human capacity”.
According to the participants, this dimension of “Spiritual health means a purposeful life”.
spiritual health entails knowledge, attitude and “Spiritual health causes a balance between internal
practice based on divine unity so that one has a human possibilities”.
dynamic and active relationship with oneself, others 4) Individuals’ feelings about a supreme power,
and the nature because one considers God in all themselves and others; having positive feelings;
connections. In this regard, one of the participants balance; peace; feeling vitality and empowerment,
said, “Spiritual health means to move toward God”. hope and satisfaction; and reduced unpleasant
Individualistic Dimension: feelings such as sadness, anxiety and anger. One of
The study participants indicated that this dimension the interviewees stated, “I think an important
may be defined as: parameter of spiritual health is to have positive
feelings about spiritual matters”.
1) Believing in the meaning and spirituality, and
Material World-Oriented Dimension:
absence of spiritual ailments such as hopelessness
This dimension is defined as well-wishing, helping
and lack of love, happiness, forgiveness and
others without expecting them to return favors,
common sense experiences in one’s interactions with
feeling of closeness and harmony with the universe,
others. One participant said, “The minimum level of
and human connection with himself, others and the
spiritual health means that an individual does not
nature based on moral virtues. With respect to the
suffer from spiritual ailments and has embraced
individualistic dimension, one interviewee said,
spirituality”.
“Spiritual health is helping others without expecting
2) Having good moral character and decent beliefs.
something in return”.
This specification can be noted in one participant’s
Additionally, participants stated that spiritual health
words: “A person who enjoys spiritual health does
has different definitions based on individuals’ beliefs
not have negative moral characteristics and wrong
and opinions. According to one participant:
beliefs”.
“Spiritual health is as varied as people’s
3) Parts of health or human existence that cannot be
perspectives, and therefore it is impossible to offer a
explained from physical, mental or social
single definition for spiritual health”.
perspectives. Spiritual health includes a purposeful
Components of Spiritual Health
life, transcendence and actualization of different
According to the results of our study, the three
dimensions and capacities of human beings. Spiritual
components of spiritual health are: religious,
health creates a balance between physical,
individualistic, and material world-oriented.
psychological and social aspects of human life.
Religious Component
Some participants presented their perception of

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According to our findings, the religious components benevolence, helping others unconditionally,
may be the result of human connection with God, humility, and lack of jealousy and grudge.
including a sense of connection with God, love of One participant stated, “The indicators of spiritual
God, prayer, the feeling that God is effective, and health are human behaviors, for instance the sense
God-oriented knowledge, attitude, and behavior. As of responsibility toward others”.
one of the participants mentioned, “The most Human connection with the nature:
important and essential component of spiritual The study participants presumed certain behaviors to
health is communication with God”. be the result of human connection with the nature.
Individualistic Component Instances included recognizing one’s duties in
The individualistic component comes from human dealing with the nature, acknowledging the
connection with himself. Instances include: self- importance of interest in the nature, and showing
scrutiny, examining the meaning of life, hope, self- respect for it.
actualization, moral virtues, peace, responsibility for Differences between Spiritual Health and
oneself, balance, transcendence, values, mysticism, Spirituality
culture, and knowledge, attitude, and behavior in The participants’ views on the differences between
relation with oneself. spiritual health and spirituality can be divided into
In this regard a participant stated, “The second two categories:
component of spiritual health is the humans’ 1) The majority of our participants believed that
connection with themselves”. spiritual health and spirituality are different because:
Material World-Oriented Component: a) spirituality is a state of being, but spiritual health
This refers to human connection with others and the is a state of having; b) spirituality is a general
nature. Connection with others creates a sense of concept, while spiritual health is a particular
responsibility toward them, unconditional love, concept; c) spirituality is a subjective issue, but
forgiveness, pacifism, harmony with others, and spiritual health is objective; d) spirituality is a
knowledge, attitude, and behavior in relation with comprehensive issue, and spiritual health is the
others. subset of spirituality; e) spirituality is potential, but
Human connection with the nature develops spiritual health is actual.
responsibility, love, and knowledge, attitude and Accordingly, one participant said, “If you want to
behavior in relation with the nature. define spiritual health in medical literature, it is
To quote a participant: “One component of spiritual quite different from spirituality in the sense of value-
health is that man should form his relationship with judgment”.
others and with the nature”. 2) Some were of the opinion that there is a relative
Indicators of Spiritual Health coincidence between spiritual health and spirituality,
According to our participants, the indicators of and that the former is the manifestation (product) of
spiritual health entail four domains of the connection the latter.
between humans and God, themselves, others, and One of the participants remarked, “If we define
the nature. spirituality as whatever leads humans to perfection
Human connection with God: and happiness, then people who are more spiritual
The connection with God is characterized by will be healthier”.
knowing God, feeling affection and love toward Characteristics of Spiritual Health
God, laying one’s hopes on God, being thankful for According to our participants, spiritual health has 6
divine blessings, and prayer. These specifications different characteristics:
were reflected in one of the participants’ perception 1) It has different definitions.
of God as follows: “The first and most important 2) It affects physical, mental, and social health.
indicator of spiritual health is obeying God’s 3) It is preferred over the other aspects of health.
commands”. 4) There are religious and existential approaches to
Human connection with himself: it.
This type of connection is a source of self-esteem, 5) It is presented in individuals’ behavior.
reasoning and thinking, calmness, responsibility for 6) It is a dynamic state and can be promoted.
oneself, satisfaction, vitality, empowerment, hope, a The following statements also reflect the
sense of purpose, self-worth, and self-awareness. characteristics of spiritual health according to some
One of the interviewees stated, “The second participants:
indicator of spiritual health is rationality in personal “The definition of spiritual health varies based on
and social behaviors”. the views of individuals”.
Human connection with others: “Spiritual health can affect other aspects of health,
The participants believed that connection with others meaning physical, mental, and social health”.
could positively affect an individual’s behavior and “Spiritual health encompasses physical and mental
result in acceptance of social responsibility, respect health”.
for the rights of others, honesty, compassion, “There are different approaches to spiritual health:
altruism, generosity, optimism, empathy, one is the religious approach and another is the

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existential approach”. and a sense of control are among the aspects of

“Spiritual health is manifested in the behavior of spirituality (14).
people”. It seems that spiritual health and spirituality are
“Spiritual health can be improved”. different, although there is a relative coincidence
between the two and they overlap.
Discussion Characteristics of Spiritual Health:
Our study revealed that in order to approach spiritual Several definitions and characteristics were
health, we need to consider five clusters of identified for spiritual health (15). In any given
information: its definition, components, indicators, culture, spirituality has different meanings (16),
characteristics and the differences between spiritual which is in agreement with our findings that
health and spirituality. Each cluster is discussed produced various definitions and characteristics for
separately as follows: spiritual health based on individuals’ beliefs and
Definition of Spiritual Health: worldviews.
According to the existing literature, spiritual health A large number of systematic reviews showed that
is the connection with God (a superior existence), spiritual health can contribute to positive health
oneself, others and the nature (3, 8). Likewise, our outcomes (17). Heidari et al. revealed that spiritual
participants’ responses indicated four types of health improves physical well-being and quality of
connection in spiritual health, that is, human life (18). Research conducted on patients with
connection with God, himself, others and the nature. asymptomatic heart failure in 2009 indicated that
The participants believed that spiritual health spiritual health is positively related to better mental
encompasses those features of health or human health (19). Rahnama et al. also showed that spiritual
existence that cannot be explained from physical, health prevents the emergence of depression and
mental and social aspects. Absence of spiritual anxiety in patients with spinal cord injury (20). This
ailments is embedded in the definition of spiritual is in agreement with the results of the present study
health. that illustrated the positive effect of spiritual health
Based on our participants’ opinions, a suitable on physical, mental and social health.
human connection with oneself, others and the Literature review showed that spiritual health unites
environment reflects mental and social health, and is the physical, mental and social dimensions of people
therefore not specific to spiritual health. In response (21). Moreover, some health models consider
to the claim that spiritual health means absence of spiritual health the focus or the most significant of
spiritual ailments, it should be mentioned that these all other aspects of health, which emphasizes the
ailments need to be precisely defined. Moreover, we importance of spiritual health (1).
need to develop tools to determine spiritual ailments, Based on our participants’ responses, it can be stated
and then ascertain the absence of which ailments and that spiritual health encompasses other dimensions
to what degree would indicate spiritual health, which of health and is more important than its other
is a rather difficult thing to do. aspects.
Components of Spiritual Health: However, in interpreting the results we should
In agreement with the literature, our results show consider the type of the studies, because cross-
that spiritual health is determined by the components sectional studies cannot determine the casual
of connection with oneself, God (transcendent relationship, but measure the correlation between
reality), society (others), and the nature (9, 10). two variables.
Indicators of Spiritual Health: Spiritual health has two dimensions: religious and
Studies show that spirituality is a way through which existential. Religious health is related to individuals’
one communicates with oneself, others, the nature perception of their health in relation to a supreme
and everything that is sacred (holy entities) (11, 12). power, while existential health is related to their
It seems that the indicators of spiritual health can be socio-mental preoccupations and their way of
investigated in four domains, that is, human interacting with themselves, the society and the
connection with God, himself, others, and the nature. nature (5). Spiritual well-being has two components:
As previously explained, human connection with religious well-being, which refers to the connection
himself others and the environment are not specific with God or a higher being, and existential well-
to spiritual health; therefore, it can be stated that the being, which pertains to the meaning and purpose in
above-mentioned components and indicators also life (22).
exist in the domain of mental and social health. Accordingly, it can be assumed that spiritual health
Differences between Spiritual Health and has two dimensions: religious health, which is
Spirituality: shaped in connection with God or a supreme power
There is a consensus among researchers that spiritual (a transcendent and holy existence), and existential
health be treated as a sub-concept of spirituality (13). health in human connection with himself, others and
After reviewing the literature, Selman et al. the nature, the meaning and purpose in life.
concluded in 2007 that spirituality has six aspects People with better spiritual health are more likely to
and indicators of spiritual health, for instance peace select a lifestyle that enhances their health (17). An

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appropriate lifestyle is a fundamental characteristic superiority of one component over the others.
of spiritual health (4). Likewise, it can be concluded Human connection with himself, others and the
that spiritual health presents itself in the individual’s nature is not specific to spiritual health because these
behavior. components of spiritual health are present in mental
Spirituality is a dynamic state; it can be promoted, its and social health as well. Although we found
identities and patterns may change, and it can be different definitions for spiritual health, we believe
hidden or invisible (23). Our study participants that these may differ based on individuals’ beliefs
believed that spiritual health has a dynamic nature, and opinions. It is suggested that further longitudinal
i.e., it can be increased or decreased. studies be conducted to provide more accurate
In conclusion, the present study confirmed four types explanations for spiritual health by interdisciplinary
of connection in the definition of spiritual health: collaboration between mental health specialists,
human connection with God, himself, others and the social health specialists and religious scholars. Such
nature. Most of the experts who participated in the studies would result in more accurate research on
current study recognized human connection with spiritual health and its causal relationship with
God as the most important part of the definition of physical health, mental health and social health.
spiritual health and also stated that human
connection with God is the most important Conflict of Interests:
component and indicator of spiritual health. Other None declared.
studies, on the other hand, could not show the

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