COVID-19 as an infectious disease, and deadly biological crisis, threatens the bio-psycho-social- spiritual health of the people. Spiritual health from the perspective of Islam, means having a sound heart, living in the present time with sense of peace, security, patience and gratitude, safe from the fear and anxiety of future, grief and regret for the past events. It affects other dimension of health. This study was conducted to investigate the spiritual health services in the face of the COVID-19 pandemic in a Muslim society.
This qualitative study was conducted from March 1, 2020 to the end of May 2020 in Tehran by using the Schwartz and Kim's hybrid model concept analysis with a deductive / inductive analysis approach, in three stages: 1- Theoretical review of religious and scientific evidence, 2- Field research 3- Final analysis. Data collection was done in hospitals and hospices by semi-structured interviews, taking notes, websites and social networks search. Data were analyzed by "Contractual Content Analysis Method".
Despite the fact that spiritual health services (spiritual care and counseling) are not taught in Iranian universities, but in this biological crisis, spiritual health services, based on religious beliefs of health system employees were implemented. The Muslims’ belief in divine test, healing power of God, helping the people as highest worship, aroused spiritual awakening and enthusiasm in the health care team. Spiritual health services at prevention levels were provided with the aim of helping the patient, family and clients, in an inter-professional model based on the jurisprudential rules derived from the religious evidences (Verses and Hadiths), in line with holistic approach, community-based care, spiritual self-care, home-care, family participation. The involvement of non-specialists in the provision of medical services was prevented. According to, preserving the human dignity in Islam, Islamic rituals were performed by the treatment team and volunteer clerics for dying and dead people.
Considering the impact of religious spirituality on Muslims’ lifestyle and health behaviors, it seems that the use of Islamic health guidelines can improve the quality of health care services and help improve the spiritual health of people in biological crises.
Academic Editor: Sasho Stoleski, Institute of Occupational Health of R. Macedonia, WHO CC and Ga2len CC , Macedonia.
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2021 Minoo Asadzandi, et al.
The authors have declared that no competing interests exist.
Coronaviruses can infect animals and humans and cause respiratory distress. These discomforts may be as mild as common cold, or as severe as pneumonia. In some cases, coronaviruses can be transmitted from animals to humans, and infected healthy people such as SARS (Acute Respiratory Symptoms) in 2002 to 2003 or MERS (Respiratory Symptoms of the Middle East) in 2012, which was transmitted from camels to humans. The new coronavirus (COVID-19) with symptoms of fever, cough, and dyspnea can lead to acute respiratory failure and death. It usually spread through coughing and sneezing, contaminated hands, contact with an infected person or touching contaminated surfaces. Due to the contagious power and high mortality of the disease, this biological crisis, in addition to socio-economic consequences, has caused psycho- spiritual problems for people around the world 1, 2, 3, 4, 5, 6 because in acute life-threatening illnesses, the perceived threat of the disease increases due to the severity of the patient's situation 7. In COVID-19 disease, some of the patients should be admitted to the intensive care unit (ICU) due to the respiratory failure and multi- failure organs (MFO) 8. Severe physical symptoms and rapid spread of the disease among family members, causes psychological problems such as (fear, panic attacks, death anxiety, depression, etc.) and spiritual distress (disappointment with God's Mercy, dissatisfaction with fate, resentment, and revenge...) 9. These problems threaten the people’s spiritual health and requires spiritual care 10.
Due to the effectiveness of religious spirituality, on reducing stress 11, 12 the World Health Organization (WHO) introduces a health-promoting lifestyle combined with six dimensions of: -Spiritually and believing in God for mental health,-Sense of responsibility for health promotion,- Maintaining interpersonal relationships to promote the social health,-Stress management for prevention of physical and mental illness,- Physical activity and healthy diet 13. The encouraging healthy behavior and creating a healthy environment were the two goals of the WHO in 2020 for Healthy People Program 14. Health promotion as an important pillar of society's progress has been considered in WHO policy 15. Today, health services and treatment team, are focusing on promoting health, preventing disease, and eliminating factors that have a negative impact on the health of societies. 16. Considering the bio- psycho-socio-spiritual health problems caused by COVID-19 pandemic, the importance of surveying health services in countries around the world is important. Due to the fact that in Iran, health system personnel and health science students do not learn the method of spiritual care or spiritual counseling in the academic course this research was conducted to answer these two questions: 1- Were spiritual health services provided in Pandemic COVID-19 in Iran? 2- What was the basis of providing spiritual health services in this biological crisis? This study aims to investigate the spiritual health services in the face of the COVID-19 pandemic in Iran.
Materials and Methods
This qualitative study was conducted from March 1, 2020 to the end of May 2020 in Tehran, by using the concept analysis method of Schwartz and Kim hybrid model, which is a strong methodology for concept development with deductive / inductive analysis approach. Research was implemented in three stages: 1- Theoretical review, 2- Work in the field (field research) 3- Final analysis 17. The main emphasis in the theoretical review was to identify the essential components of the concept definition, how to measure it, which were included the following steps: concept selection, text search, discussion of the meaning and method of measurement, and finally, the selection of the working definition. Inclusion criteria were: - Religious evidence related to sound heart, Islamic health instructions in infectious diseases, from the books of Shiite Hadith. Scientific evidence related to COVID-19 disease, physical, psychosocial and spiritual consequences of the disease. - access to the full text of the article, -during the outbreak of the disease 2019-2021, -available in reputable databases (PubMed, Web of Science, SID, Scopus, and Magi ran). Exclusion criteria: - Lack of full text or lack of valid sources.
In the field research phase, after obtaining informed written consent, semi-structured individual interviews were conducted by target-based sampling. Samples were selected from the medical staff of Baqiyatallah Hospital. Interviews continued until data saturation. In order to get acquainted with possible and unforeseen issues and to form a combination of questions, a few initial interviews were conducted. The questions were based on the interview process and included the following: 1- Do your patients, their family or your colleagues face spiritual problems? 2- What do you do to help alleviate their spiritual suffering? In order to increase the accuracy and robustness of the research as well as the accuracy and comprehensiveness of the collected information, notes were taken on the people's behaviors in the face of biological crisis in social networks (national media, WhatsApp, Instagram). Work in the field, with the aim of confirming and consolidating the concept through the analysis of collected data, to examine the components of the concept at a practical level, coincided with the first stage of research. In the final analysis stage, the findings of the initial theoretical analysis were compared with the data in the field 18.
Data Analysis Method
Data analysis was performed based on conventional content analysis method, which is a continuous comparative analysis method. This method was used as a method to determine the reliability and validity of data. 19. Usually, the contractual content analysis approach uses for data derived from participants in the research method inductively and without imposing an opinion. In studies that aim to describe a phenomenon, the contractual method is used. This method is used especially when the theory or research literature on a phenomenon is limited. The researcher was completely immersed in the data to gain a new understanding. First, data analysis began with repeated reading of the text to immerse the researcher in it. Then, the texts were read word for word to extract the code. That was a continuous process from code extraction to naming. The codes were then categorized into classes based on the differences, and the relationship between them were determined. These classifications were for organizing and grouping code into "meaning clusters". Also, based on the relationships between subclasses, some of them could be combined and organized within newer classes, and the relationships between them could be shown to reorganize into a schematic tree based on a hierarchical structure. Then for each subcategory, category, code, definition were provided. For the content analysis approach followed these seven steps: 1. Formulate a research question, 2. Select a sample for study, 3. Definition of classes, 4. the process of coding 5. Execute the coding process, 6. Determining validity, 7. Analysis of the results of the coding process 20.
Findings of Scientific and Religious Evidences
From the Qur'an point of view, spiritual health means having a sound heart 21 a calm and confident spirit, with sense of security, hope, optimism, happiness, contentment 22. Spiritual health is achieved by the "truth worship"23. Servants of God, with sense of non-ownership, charity and forgiveness for God's sake, can achieve social health. They achieve mental health by avoiding selfishness, surrendering, trusting, entrusting everything to God and enduring hardships. By fulfilling God's commands and improving lifestyle in nutrition, sleep patterns, activities, avoiding drug addiction, stress management, they can achieve physical health 24.
Loving God and lack of dependence on position, fame, money, social status, lead them to spiritual health 25. The sound heart owners live in the present time with patience and gratitude, safe from the fear and anxiety of future events, grief and regret for the past events 26. They are wise, chaste, brave, righteous, merciful, kind and compassionate. By following the commands of religion and good deeds, they attain faith. Then they find piety, certainty and sincerity in faith 27. They set the Ibrahim (AS) and Prophet Mohammad (PBUH), as their role model and follow them in their personal and social behaviors 28. They trust in God and consider the unpleasant events as a divine test that can be a spiritual experience 29. The sound heart owners, with faith and righteous deeds, attain “Hayat Taybeh” which is the highest level of the quality of life 30. The belief in life after death, makes them patient and resilient in the face of crisis 31. They sincerely strive for God's sake so death is martyrdom for them 32.
Related Spiritual Health Services Table 1.
Despite the fact that spiritual health services (spiritual care and counseling) are not taught in Iranian universities, but in this biological crisis, spiritual health services, based on religious beliefs of health system employees were implemented. The Muslims’ belief in divine test, healing power of God, helping the people as highest worship, aroused spiritual awakening and enthusiasm in the health care team. Spiritual health services at prevention levels were provided with the aim of helping the patient, family and clients, in an inter-professional model based on the jurisprudential rules derived from the religious evidences (Verses and Hadiths). It was in line with holistic approach, community-based care, spiritual self-care, home-care, family participation. (Table 1)Table 1. Spiritual Health Services and their Jurisprudential rules:
|Jurisprudential rule||Related verse and narration||Proceedings|
|Rule of Obligation: The need to prevent possible harm to life. Respect for individuals 34||Do not destroy yourself with your own hands, do well, God loves the doers of good (verse 195 of Surah Al-Baqarah). You are all in charge and responsible, you will be asked "about your subordinates" 35 If you hear about a plague in a land, never enter it. But if the plague spreads in your living space, don't leave it at all.36.||Implementation of the isolation plan: - closing schools and universities and conducting virtual education, -closing mosques and shrines, -closing Friday prayers, -closing passages, parks and busy areas, high-risk jobs, stadiums, -legal bans on trips between cities, "Stay at Home" campaign. Paying attention to the issue of self-care, implementing home care program in cases of non-emergency diseases, participation of family members in care, taking responsibility for maintaining personal and family health,|
|The rule of not harming: In Islam, no harm is allowed to oneself or others37||Whoever persecutes a believer has certainly persecuted me, so whoever persecutes me has persecuted God, and whoever persecutes God, then he is cursed in the Torah, the Bible, the Psalms, and the Qur'an 38. A Muslim is one who, people are safe from his hands and tongue.38As the leader of the society and the Islamic ruler, keep the people from harming others 39.||Permission for "non- presence” of one-third of employees with underlying heart-respiratory diseases - immunodeficiency - undergoing immunosuppressive drugs - over 60 years of age at work. -Disinfection of roads and streets. - People education about the symptoms of the disease, _Encouraging people for going to medical centers only in urgency situation, - Preparing diagnostic kits for the disease, -Presenting the number of infected people, hospitalized and the number of daily deaths in the whole country, -Screening people with the software of the Ministry of Health, -Preparing a software program indicating the level of pollution in each region|
|Rule of announcement: It is obligatory to inform uninformed people 34.||"Use medical treatment, because God did not create the disease without prescribing a medicine for it, except for age.40"||Doing home isolation, -Hospitalizing patients, -Free treatment of poor patients. -Public education about that the disease has not a specific drug for the treatment of the virus. The vaccine has not yet been "prepared." Treatments are symptomatic and life-sustaining.|
|Rule of Obligation: Prevent possible harm to life and property and respect for individuals 34||The sanctity of the believer is higher than the sanctity of the Ka’bah ” 41.||-Recovery services for patients with the disease in the two weeks after treatment, - Voluntary presence of professors and medical students to take care of Corona patients in hospitals and convalescent homes, - spiritual care for "dying people," bathe and bury the dead with respect and human dignity, and bury the dead in a special place in cemeteries by volunteer clerics .|
|Rule of Guidance: Guiding the ignorant person is an obligation||Do not follow what you are unaware of it. The ear, the eye, and the heart are all responsible. (Surah Al- Isra ', verse 36||Informing and answering people’s questions over the phone about COVID-19, its signs and symptoms, at risk people, by Ministry of Health Staff.|
|Guarantee rule: According to Islam, the entry of non-specialists in the field of medicine is strictly prohibited 34.||Anyone who practices medicine without knowledge is a guarantor. Non-physician is guarantor for causing death or less damage. It is necessary for the ruler of the Islamic society to imprison criminal scholars and ignorant doctors.||Legal action taken: -Those who sought medical advice in cyberspace without medical knowledge or who were present at patients' beds and injured patients were prosecuted. - False talks about disease was corrected by specialized doctors.|
The Shiite religion has been the official religion in Iran since the 16th century. After the Islamic Revolution of Iran (1978), the government was established according to the rules of jurisprudence 42, 43 as a divine law that expresses the duty that God expects from His servants in every verbal and non-verbal behavior 44. Imams’ jurisprudence is one of the most important sources of law in Iran 45. The various social laws are inferred from the Qur'an and hadiths 46. Religious orders have shaped the normative beliefs and cultural norms of the Muslims people 34. The Islamic spirituality as a valuable resource for reducing health problems, promoting health, adapting to stressful events and improving the quality of life 47 is in harmony with the World Health Organization perspective about health promotion as empowerment programs for increasing people control over their health 48 and responsibility for their own health and adopt a healthy lifestyle 49. On the other hand the religious spirituality of Islam and the "rule of no harm" governs all aspects of the relationship between individuals in society (such as Articles 11 and 12 of the Civil Liability Law and Articles 140 to 145 of the Islamic Penal Code]34. These laws also govern the provision of health services 50. According to these laws, people who cause harm to themselves or others will be dealt with legally and criminally if they violate the relevant regulations. So all people have a responsibility to repel potential harm from themselves and others 51.
The participation of the people in the face of national crises, are blessings that can be seen among the followers of the Abrahamic religions and Muslims 52. Given that the crisis of manpower shortages, rising treatment costs, disease beyond geographical boundaries, bioterrorism, has affected the health systems of countries 53, this partnership and empathy reinforces the self-care and home care approach, family members' participation in the treatment and care process 54. The religious beliefs, also facilitates the interdisciplinary collaboration of health science graduates with unique cultural contexts and educational approaches and provides inter-professional services to address the health needs of society 55. It provides the holistic care, community-based health services according to the beliefs and cultural values of the community and respecting the opinions of patients / clients / families in crisis situations 56.The inter-professional spiritual health services based on the Islamic culture 57, led the provision of health services at various levels of prevention, for healthy people /clients / patients 58 by a team work approach to combat the disease 59.
All ethical considerations were carefully observed by the authors, including: avoiding plagiarism, obtaining informed written consent, avoiding any manipulation or alteration of data, duplication.
There was no Financial Support.
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