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Volume 9, Issue 3 (2021)
Health Educ Health Promot 2021, 9(3): 193-199 |
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Received: 2021/04/14 | Accepted: 2021/05/23 | Published: 2021/09/5
Received: 2021/04/14 | Accepted: 2021/05/23 | Published: 2021/09/5
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Yousefi Afrashteh M, Bitarafan L. Relationship between Spiritual Well-Being and Resilience with Health Anxiety in Pregnant Women: The Mediating Role of self-Compassion. Health Educ Health Promot 2021; 9 (3) :193-199
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1- Department of Psychology, Faculty of Humanities, University of Zanjan, Zanjan, Iran
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Introduction
Pregnancy is a unique event for every woman's life, accompanied by psychological, social, and physiological changes [1]. Pregnancy is very important because the mother's behaviors affect the outcome of labor as well as the quality of life of mother and child [2]. A woman's ability to cope with stress and difficulties of pregnancy affects her physical and mental health. It also plays a vital role in the health of the developing child [3].
Mental health problems such as depression and anxiety are common among pregnant women, with high rates of up to 30% [4]. One common type of anxiety in pregnant women is health anxiety [5]. Health anxiety manifests itself in two forms: illness anxiety disorder and physical symptom disorder. The symptoms may vary from mild to severe with different clinical symptoms. Pregnancy-specific anxiety is a form of anxiety disorder that a woman experiences during pregnancy due to the rapid physical change or illness anxiety disorder [6].
According to the studies on maternal health during pregnancy, spirituality has a preventive effect on stress during pregnancy [7-9]. Foruzandeh et al. confirmed that one mechanism for coping with stress during pregnancy is the women's spiritual beliefs and values [8]. Belgic et al. also showed in 2021 that spiritual well-being and psychological well-being effectively reduce the fear of giving birth [9]. Religion as a set of dos and don'ts and a collection of specific and generalized values is one of the most effective psychological supports that adds meaning to one's life in different stages in life. It also works as explanatory support in special circumstances, guarding the individual against absurdity and meaninglessness of life [10].
As one of the deepest human drives, spirituality is among the needs that its identification and provision have a special place in promoting health and proper response to diseases. Spiritual well-being is one of the defining cornerstones of human health, reflecting the three dimensions of emotion, behavior, and proper knowledge of the relationship with oneself, others, nature, and a superior being. It encompasses the two dimensions of religious spirituality and existential spirituality. In the context of religious and existential spirituality, one understands the meaning, purpose, and transcendent values of life. Interaction of these two dimensions leads to spiritual health, satisfaction and purposefulness, joy, respect, positive attitude, inner peace, and an integrated identity in the individual [11].
People with higher spiritual intelligence enjoy a higher level of resilience, hence are more likely to develop a more comprehensive attitude in the face of difficulties. Spirituality helps people build up resistance to pain. Mental health resilience plays an important role in today's world, examined in prenatal health research for more than two decades [12].
In recent years, approaches focusing on human capacities and abilities rather than abnormalities and disorders have received considerable attention. One of the most fundamental building blocks of these approaches is resilience [13].
Resilience is a contributing factor in reducing the tendency to anxiety [14]. Resilience is defined as a dynamic process in which a person exhibits positive adaptive skills in the presence of unpleasant traumatic experiences. Resilience is a multidimensional structure the extent to which the individual benefits is determined by the interaction of both personal and environmental factors. Resiliency is the outcome of facing challenging situations and threats rather than escaping them [15]. Suzodo et al. showed that resilient people reported higher levels of family cohesion, better communication, and fewer problems with family functioning. However, people with less resiliency reported a greater number of conflicts in family communication [16].
Intervention measures and support programs are needed to promote resilience and increase the mental health of pregnant women. One of the modern methods that can help in this field is self-compassion training. The emergence of the third wave of cognitive-behavioral therapies, on the one hand, and the expansion of interest and focus of the positive psychology research on emotions and positive personality traits, on the other, provided a platform for concepts such as self-compassion [17].
Self-compassion is also a skillful response that allows us to deal with uncontrollable adversity - not by challenging our perception of adversity or facilitating fruitless efforts to overcome it - but by avoiding self-blame and self-criticism through self-acceptance and acceptance of the truth [18].
Self-compassion is how a person opens himself to the suffering that he experiences, cares about himself, understands himself, does not judge his inadequacies and failures, and realizes that the experience is also a common experience for everyone [19].
From the above, it is clear that in addition to the fact that spiritual well-being and resilience separately and directly affect the health anxiety of pregnant women, they can also indirectly reduce health anxiety in pregnant women by affecting and strengthening self-esteem. Although the spiritual factor, resilience, and self-sufficiency leave their impact on pregnant women's health anxiety in different ways, researchers have not yet comprehensively concluded that spiritual well-being and resilience are placed next to self-compassion and its effect on health anxiety in pregnant women. For this reason, in the present study, the mediating role of self-compassion in the relationship between spiritual well-being and resilience in health anxiety of pregnant women was investigated.
Instrument and Methods
The present descriptive study was conducted in 2020 on 390 pregnant women referring to health centers in Hamadan, Iran. To select the sample, 9 centers were randomly selected from among the health centers of Hamadan. After referring to the centers by available sampling method, pregnant women who were eligible to enter the study were asked to complete the questionnaires. According to Cochran's formula, 365 people were selected for the sample. Three hundred ninety questionnaires were administered due to the possibility of non-return.
![src=./files/hehp/images/HTML_Publish/51660/51660-Formool_1.png]()
Inclusion criteria were duration of pregnancy over three months, no stressful personal event such as illness or death of loved ones or severe marital conflicts in the last three months, no use of psychiatric drugs, no history of acute psychiatric disorders, at least eight classes of education according to the test guide and consent to participate in the study. Failure to complete the questionnaires was the exclusion criterion.
Several questionnaires were used to collect data, which are introduced below:
Demographics: Participants provided data on age, gender, education, job status, and number of pregnancies, number of children, and history of infertility.
Spiritual Well-Being Scale (SWB): The SWB [20] has two subscales, Religious Well-Being (RWB) and Existential Well-Being (EWB), each of which has ten items. The scales are rated from 1 (strongly disagree) to 6 (strongly agree). The RWB and EWB subscale scores can range from 0 to 60. The RWB subscale assesses the relationship with good, whereas the EWB subscale assesses meaning and purpose. The Cronbach’s alphas, calculated for the subscales and total scale: RWB alpha=0.91 and EWB alpha=0.91 and SWB=0.93 [21]. Test-retest reliability reported by Ellison [20] was 0.93 for SWB; 0.96 for RWB; and 0.86 for EWB. In addition, Ellison [20] reports face validity and SWB scale theoretical correlation with other scales purported to measure spirituality. In the present study, reliability with Cronbach's alpha for this questionnaire was 0.75 that is a desirable amount.
Self-Compassion (SCS-Tot): The 26-item SCS [22]. assessed Total Self-Compassion (SCS-Tot), as well as six-factor analytically derived facets of self-compassion: Self-Kindness (SCS-SK), Self-Judgment (SCS-SJ), Common Humanity (SCS-CH), Isolation (SCS-IS), Mindfulness (SCS-MI), and Over identification (SCS-OI). Participants indicated agreement with statements describing responses to difficult experiences (e.g., When times are really difficult, I tend to be tough on myself) on a scale from rarely (1 point) to almost always (5 points). Subscale scores were created by averaging across subscale items. SCS-Tot was calculated by averaging all items after reverse-scoring SCS-SJ, SCS-IS, and SCS-OI items. The SCS has previously demonstrated construct validity and test-retest reliability [23]. In this study, SCS-Tot exhibited high internal consistency (α=.88) and all subscales demonstrated good reliability: SCS-SK, α=0.81; SCS-SJ, α=0.76; SCS-CH, α=0.70; SCS-IS, α=0.79; SCS-MI, α=0.75; SCS-OI, α=0.74. In the present study, reliability with Cronbach's alpha for this questionnaire was 0.79 that is a desirable amount.
Health anxiety inventory: HAI is a self-report scale developed by Salkovskis et al. [24] and contains 18 questions. The first 14 questions consist of four options from which individuals select the one that best describes their mental state. The last four questions are intended to measure mental state in the event of severe disease. All questions are scored 0-3, with higher scores indicating greater health anxiety. The total score ranges from 0 to 54. The validity and reliability were studied by Aydemir et al. [25]. In the present study, reliability with Cronbach's alpha for this questionnaire was 0.83 that is a desirable amount.
Connor-Davidson Resilience Scale: This questionnaire was developed by Connor & Davidson by studying the general population, patients referred to primary care, outpatient and a psychiatric ward, patients with generalized anxiety disorder, and two groups of patients with post-traumatic stress disorder. This scale has 25 statements and is scored on a Likert scale between 0 (completely false) and 5 (always true) [26]. The reliability coefficient of this scale has been reported 78% by Cronbach's alpha coefficient in this research. In the present study, reliability with Cronbach's alpha for this questionnaire was 0.72 that is a desirable amount.
The approval of the Department of Psychology of Zanjan and the necessary permits obtained. Written and informed consent was obtained from all individuals to participate in the study, and they were assured that the information in the questionnaire would remain confidential.
After taking the sample, statistical analysis was performed using SPSS 26 software. Mean, and standard deviation indices were reported for descriptive statistics. The mediating role of self-compassion in the relationship between spiritual well-being and health anxiety in pregnant women was also evaluated using path analysis with LISREL 10.2 software. The Pearson correlation coefficient was used to analyze the data.
Findings
Out of 371 women, 10% were in the age group of 16-20 years old. 10% of participants in the current pregnancy were treated for infertility (Table 1).
Table 1) Demographic statistics of the 371 participants
![src=./files/hehp/images/HTML_Publish/51660/51660-T_1.png]()
The skewness index for all variables was between 1 and -1, confirming the normal distribution for them (Table 2).
Table 2) Mean±SD of descriptive statistics for research variables
![src=./files/hehp/images/HTML_Publish/51660/51660-T_2.png]()
According to the results of Table 3, there was an opposite correlation in health anxiety with spiritual well-being, resilience, and self-compassion variables (p<0.01). Also, the correlation between spiritual well-being and resilience with self-compassion was positive and significant (p<0.01).
Table 3) Correlation coefficient between variables (p<0.01)
![src=./files/hehp/images/HTML_Publish/51660/51660-T_3.png]()
All multiple relationships analyses had t-values higher than two and were significant (p=0.01;
Figure 1).
In order to evaluate the overall quality of the model, general goodness-of-fit indices, e.g., RMSEA (Root Mean Square Error of Approximation), GFI (Goodness of Fit Index), AGFI (Adjusted Goodness of Fit Index), TLI (Tucker–Lewis Index), NFI (Normed Fit Index), and CFI (Comparative Fit Index) were used (Table 4).
![src=./files/hehp/images/HTML_Publish/51660/51660-F_1.png]()
Figure 1) Standard parameter and value t (in parentheses) for paths related to relationships between variables
Table 4) goodness-of-fit indices
![src=./files/hehp/images/HTML_Publish/51660/51660-T_4.png]()
Discussion
The present study investigates the mediating role of self-compassion in the relationship between spiritual well-being and resilience and health anxiety of pregnant women. According to the results, there is a significant relationship between spiritual well-being and resilience and health anxiety of pregnant women. The findings of the present study are consistent with the previous research conducted by Dolatian et al. [7], Tajvidi et al. [27], Piccinini et al. [28], Mutmainnah et al. [29], Garssen et al. [30], and Dunn et al. [31]. In explaining these findings, it can be argued that having a sense of belonging to a superior power and belief in God helps religious people to improve their mental health and suffer less from the hurdles of life [32]. Spiritual well-being is a factor influencing life satisfaction. It seems that spirituality creates a sense of meaning and purpose, which improves satisfaction [33]. Faith in God is the source of piety that provides the women a very positive lens of their pregnancy and motivates them to nurture their babies, and themselves and awareness of God is the best method of self-control. The faith and close relationship with God help women overcome the challenges in pregnancy and childbirth. The power of the relationship with God can be deduced from the participants' expression of their beliefs and worship activities, such as God will provide help to his pious servants [29].
Spirituality can lead to greater psychological adjustment by providing supportive resources for the individual and indirectly promoting hope. Many interventions and spiritual skills, such as chanting, act as calming techniques and alter mental states, which can be considered self-regulating ways to deal with stress and anxiety, which affect psychological and physical processes and distract the individual from thoughts and disturbances.
The results showed that the relationship between resilience and health anxiety in pregnant women was significant. In other words, resilience training was effective in reducing anxiety in pregnant women. These findings were consistent with the research conducted by Ghopani et al. [34], Ma X et al. [35], Cheadle et al. [36], García-León et al. [37]. People with low levels of resilience are more vulnerable in various life situations and lack the motivation and courage to fix stressful situations. Their minds are constantly preoccupied with problems.
Moreover, they tend to exaggerate these problems and consider themselves victims of these events [38]. Explaining these findings, we can say that resilient people in the face of adverse conditions are more likely to seek meaning. Having faith increases people's endurance in the face of adversity and helps those overcome challenges and life changes. Trans-spiritual communication (i.e., believing in a greater power) has also been mentioned as an individual supportive factor to create and facilitate resilience, and spirituality has been considered a key factor in fostering resilience. Resilient people can adapt successfully despite threats and adverse environmental conditions. Resilient people evaluate negative events from a different perspective. As a result, they experience less discomfort and stress and better cope with events [39]. One of the reasons for the effectiveness of resilience training in reducing anxiety can be teaching coping strategies and better defense mechanisms to individuals. Highly resilient people react to stressful situations with optimism, assertiveness, and self-confidence, thus finding events controllable. Optimistic attitudes lead to more effective information processing and more active coping strategies while increasing the ability to cope with difficult situations. Resilience, through increasing a person's flexibility, develops an individual's ability to cope with different situations, and by reducing negative emotions, increases mental health and reduces anxiety [40].
The people with high resiliency confront the stressful incidents with more optimism, self-expression, and self-confidence. Therefore, they consider these incidents to be manageable. The optimistic attitude makes the information procedure more effective, and the person applies a more active coping strategy, and the ability to deal with the unpleasant conditions will be empowered. Resilient people are flexible and resourceful, they adapt themselves to the environmental changes, and they can recover so fast after the obviation of the stressful factors [41].
Based on the present study's findings, in the relationship between spiritual well-being and resilience with pregnant women's health anxiety, self-compassion serves and a mediating role. This shows that self-compassion is an effective mediator for the relationship between spiritual well-being and resilience in reducing health anxiety in pregnant women. Self-compassion was effective in reducing health anxiety in pregnant women. These findings are consistent with Xavier et al. [42], Felder et al. [43], Abdollahi Boughrabadi [44]. In explaining these findings, it can be argued that self-compassion has a significant relationship with positive emotion, happiness, high self-esteem, life satisfaction, and lower levels of negative emotion, anxiety, and depression. Thus, teaching self-empowerment techniques enables individuals to use learning experiences to become more adaptive in the face of stressful life events [45]. By teaching empathy, sympathy, forgiveness, the development of valuable and transcendent feelings, acceptance, and taking responsibility, it is possible to reduce anxiety, stress, and depression among pregnant women and lay the foundation for improving the quality of their lives and increasing their mental well-being.
Spiritual well-being provides such conditions for one's growth that go beyond the material world. In other words, there is a fundamental difference between psychological and spiritual well-being that in spiritual well-being, an individual has the potential to unite with the whole universe. This can help the individual to find a purpose in life. Give meaning to one's life and ultimately lead to self-awareness and compassion. In other words, such a person values his life and existence and takes care of himself. He considers oppression to be incompatible with the reasons for his existence and considers it important to pay attention to himself to achieve greater goals.
On the other hand, such a person can express himself because the source of this trust is greater than the material world. Therefore, psychological well-being lays the ground for self-development and self-expression. On the other hand, adopting a compassionate attitude towards oneself and the self-care strategies that have been taught will shield these people against the problems of life. Another component that plays an important role in the effectiveness of self-compassion training for the development of resilience is love and affection meditation.
One of the most important limitations of this research is the city of study. Different results may be obtained in other cultural contexts. Failure to receive interview information limits our knowledge of women's mental status.
Conclusion
Spiritual well-being and higher resilience have a direct impact on reducing the health anxiety of pregnant women. On the other hand, self-compassion, directly and indirectly, reduces health anxiety in pregnant women. So, by teaching self-compassion to pregnant women, they could reduce their health anxiety.
Acknowledgments: The authors appreciate all the women who participated in this study.
Ethical Permissions: This study was approved with code 58278 by the psychology department at the University of Zanjan.
Conflicts of Interests: The authors declared no conflict of interest.
Authors' Contribution: Yousefi Afrashteh M. (First Author), Introduction Writer/Methodologist/Assistant Researcher/Statistical Analyst/Discussion Writer (50%); Bitarafan L. (Second Author), Methodologist/Main Researcher/Statistical Analyst/Discussion Writer (50%)
Funding/Support: There was no financial support.
Pregnancy is a unique event for every woman's life, accompanied by psychological, social, and physiological changes [1]. Pregnancy is very important because the mother's behaviors affect the outcome of labor as well as the quality of life of mother and child [2]. A woman's ability to cope with stress and difficulties of pregnancy affects her physical and mental health. It also plays a vital role in the health of the developing child [3].
Mental health problems such as depression and anxiety are common among pregnant women, with high rates of up to 30% [4]. One common type of anxiety in pregnant women is health anxiety [5]. Health anxiety manifests itself in two forms: illness anxiety disorder and physical symptom disorder. The symptoms may vary from mild to severe with different clinical symptoms. Pregnancy-specific anxiety is a form of anxiety disorder that a woman experiences during pregnancy due to the rapid physical change or illness anxiety disorder [6].
According to the studies on maternal health during pregnancy, spirituality has a preventive effect on stress during pregnancy [7-9]. Foruzandeh et al. confirmed that one mechanism for coping with stress during pregnancy is the women's spiritual beliefs and values [8]. Belgic et al. also showed in 2021 that spiritual well-being and psychological well-being effectively reduce the fear of giving birth [9]. Religion as a set of dos and don'ts and a collection of specific and generalized values is one of the most effective psychological supports that adds meaning to one's life in different stages in life. It also works as explanatory support in special circumstances, guarding the individual against absurdity and meaninglessness of life [10].
As one of the deepest human drives, spirituality is among the needs that its identification and provision have a special place in promoting health and proper response to diseases. Spiritual well-being is one of the defining cornerstones of human health, reflecting the three dimensions of emotion, behavior, and proper knowledge of the relationship with oneself, others, nature, and a superior being. It encompasses the two dimensions of religious spirituality and existential spirituality. In the context of religious and existential spirituality, one understands the meaning, purpose, and transcendent values of life. Interaction of these two dimensions leads to spiritual health, satisfaction and purposefulness, joy, respect, positive attitude, inner peace, and an integrated identity in the individual [11].
People with higher spiritual intelligence enjoy a higher level of resilience, hence are more likely to develop a more comprehensive attitude in the face of difficulties. Spirituality helps people build up resistance to pain. Mental health resilience plays an important role in today's world, examined in prenatal health research for more than two decades [12].
In recent years, approaches focusing on human capacities and abilities rather than abnormalities and disorders have received considerable attention. One of the most fundamental building blocks of these approaches is resilience [13].
Resilience is a contributing factor in reducing the tendency to anxiety [14]. Resilience is defined as a dynamic process in which a person exhibits positive adaptive skills in the presence of unpleasant traumatic experiences. Resilience is a multidimensional structure the extent to which the individual benefits is determined by the interaction of both personal and environmental factors. Resiliency is the outcome of facing challenging situations and threats rather than escaping them [15]. Suzodo et al. showed that resilient people reported higher levels of family cohesion, better communication, and fewer problems with family functioning. However, people with less resiliency reported a greater number of conflicts in family communication [16].
Intervention measures and support programs are needed to promote resilience and increase the mental health of pregnant women. One of the modern methods that can help in this field is self-compassion training. The emergence of the third wave of cognitive-behavioral therapies, on the one hand, and the expansion of interest and focus of the positive psychology research on emotions and positive personality traits, on the other, provided a platform for concepts such as self-compassion [17].
Self-compassion is also a skillful response that allows us to deal with uncontrollable adversity - not by challenging our perception of adversity or facilitating fruitless efforts to overcome it - but by avoiding self-blame and self-criticism through self-acceptance and acceptance of the truth [18].
Self-compassion is how a person opens himself to the suffering that he experiences, cares about himself, understands himself, does not judge his inadequacies and failures, and realizes that the experience is also a common experience for everyone [19].
From the above, it is clear that in addition to the fact that spiritual well-being and resilience separately and directly affect the health anxiety of pregnant women, they can also indirectly reduce health anxiety in pregnant women by affecting and strengthening self-esteem. Although the spiritual factor, resilience, and self-sufficiency leave their impact on pregnant women's health anxiety in different ways, researchers have not yet comprehensively concluded that spiritual well-being and resilience are placed next to self-compassion and its effect on health anxiety in pregnant women. For this reason, in the present study, the mediating role of self-compassion in the relationship between spiritual well-being and resilience in health anxiety of pregnant women was investigated.
Instrument and Methods
The present descriptive study was conducted in 2020 on 390 pregnant women referring to health centers in Hamadan, Iran. To select the sample, 9 centers were randomly selected from among the health centers of Hamadan. After referring to the centers by available sampling method, pregnant women who were eligible to enter the study were asked to complete the questionnaires. According to Cochran's formula, 365 people were selected for the sample. Three hundred ninety questionnaires were administered due to the possibility of non-return.
Inclusion criteria were duration of pregnancy over three months, no stressful personal event such as illness or death of loved ones or severe marital conflicts in the last three months, no use of psychiatric drugs, no history of acute psychiatric disorders, at least eight classes of education according to the test guide and consent to participate in the study. Failure to complete the questionnaires was the exclusion criterion.
Several questionnaires were used to collect data, which are introduced below:
Demographics: Participants provided data on age, gender, education, job status, and number of pregnancies, number of children, and history of infertility.
Spiritual Well-Being Scale (SWB): The SWB [20] has two subscales, Religious Well-Being (RWB) and Existential Well-Being (EWB), each of which has ten items. The scales are rated from 1 (strongly disagree) to 6 (strongly agree). The RWB and EWB subscale scores can range from 0 to 60. The RWB subscale assesses the relationship with good, whereas the EWB subscale assesses meaning and purpose. The Cronbach’s alphas, calculated for the subscales and total scale: RWB alpha=0.91 and EWB alpha=0.91 and SWB=0.93 [21]. Test-retest reliability reported by Ellison [20] was 0.93 for SWB; 0.96 for RWB; and 0.86 for EWB. In addition, Ellison [20] reports face validity and SWB scale theoretical correlation with other scales purported to measure spirituality. In the present study, reliability with Cronbach's alpha for this questionnaire was 0.75 that is a desirable amount.
Self-Compassion (SCS-Tot): The 26-item SCS [22]. assessed Total Self-Compassion (SCS-Tot), as well as six-factor analytically derived facets of self-compassion: Self-Kindness (SCS-SK), Self-Judgment (SCS-SJ), Common Humanity (SCS-CH), Isolation (SCS-IS), Mindfulness (SCS-MI), and Over identification (SCS-OI). Participants indicated agreement with statements describing responses to difficult experiences (e.g., When times are really difficult, I tend to be tough on myself) on a scale from rarely (1 point) to almost always (5 points). Subscale scores were created by averaging across subscale items. SCS-Tot was calculated by averaging all items after reverse-scoring SCS-SJ, SCS-IS, and SCS-OI items. The SCS has previously demonstrated construct validity and test-retest reliability [23]. In this study, SCS-Tot exhibited high internal consistency (α=.88) and all subscales demonstrated good reliability: SCS-SK, α=0.81; SCS-SJ, α=0.76; SCS-CH, α=0.70; SCS-IS, α=0.79; SCS-MI, α=0.75; SCS-OI, α=0.74. In the present study, reliability with Cronbach's alpha for this questionnaire was 0.79 that is a desirable amount.
Health anxiety inventory: HAI is a self-report scale developed by Salkovskis et al. [24] and contains 18 questions. The first 14 questions consist of four options from which individuals select the one that best describes their mental state. The last four questions are intended to measure mental state in the event of severe disease. All questions are scored 0-3, with higher scores indicating greater health anxiety. The total score ranges from 0 to 54. The validity and reliability were studied by Aydemir et al. [25]. In the present study, reliability with Cronbach's alpha for this questionnaire was 0.83 that is a desirable amount.
Connor-Davidson Resilience Scale: This questionnaire was developed by Connor & Davidson by studying the general population, patients referred to primary care, outpatient and a psychiatric ward, patients with generalized anxiety disorder, and two groups of patients with post-traumatic stress disorder. This scale has 25 statements and is scored on a Likert scale between 0 (completely false) and 5 (always true) [26]. The reliability coefficient of this scale has been reported 78% by Cronbach's alpha coefficient in this research. In the present study, reliability with Cronbach's alpha for this questionnaire was 0.72 that is a desirable amount.
The approval of the Department of Psychology of Zanjan and the necessary permits obtained. Written and informed consent was obtained from all individuals to participate in the study, and they were assured that the information in the questionnaire would remain confidential.
After taking the sample, statistical analysis was performed using SPSS 26 software. Mean, and standard deviation indices were reported for descriptive statistics. The mediating role of self-compassion in the relationship between spiritual well-being and health anxiety in pregnant women was also evaluated using path analysis with LISREL 10.2 software. The Pearson correlation coefficient was used to analyze the data.
Findings
Out of 371 women, 10% were in the age group of 16-20 years old. 10% of participants in the current pregnancy were treated for infertility (Table 1).
Table 1) Demographic statistics of the 371 participants
The skewness index for all variables was between 1 and -1, confirming the normal distribution for them (Table 2).
Table 2) Mean±SD of descriptive statistics for research variables
According to the results of Table 3, there was an opposite correlation in health anxiety with spiritual well-being, resilience, and self-compassion variables (p<0.01). Also, the correlation between spiritual well-being and resilience with self-compassion was positive and significant (p<0.01).
Table 3) Correlation coefficient between variables (p<0.01)
All multiple relationships analyses had t-values higher than two and were significant (p=0.01;
Figure 1).
In order to evaluate the overall quality of the model, general goodness-of-fit indices, e.g., RMSEA (Root Mean Square Error of Approximation), GFI (Goodness of Fit Index), AGFI (Adjusted Goodness of Fit Index), TLI (Tucker–Lewis Index), NFI (Normed Fit Index), and CFI (Comparative Fit Index) were used (Table 4).
Figure 1) Standard parameter and value t (in parentheses) for paths related to relationships between variables
Table 4) goodness-of-fit indices
Discussion
The present study investigates the mediating role of self-compassion in the relationship between spiritual well-being and resilience and health anxiety of pregnant women. According to the results, there is a significant relationship between spiritual well-being and resilience and health anxiety of pregnant women. The findings of the present study are consistent with the previous research conducted by Dolatian et al. [7], Tajvidi et al. [27], Piccinini et al. [28], Mutmainnah et al. [29], Garssen et al. [30], and Dunn et al. [31]. In explaining these findings, it can be argued that having a sense of belonging to a superior power and belief in God helps religious people to improve their mental health and suffer less from the hurdles of life [32]. Spiritual well-being is a factor influencing life satisfaction. It seems that spirituality creates a sense of meaning and purpose, which improves satisfaction [33]. Faith in God is the source of piety that provides the women a very positive lens of their pregnancy and motivates them to nurture their babies, and themselves and awareness of God is the best method of self-control. The faith and close relationship with God help women overcome the challenges in pregnancy and childbirth. The power of the relationship with God can be deduced from the participants' expression of their beliefs and worship activities, such as God will provide help to his pious servants [29].
Spirituality can lead to greater psychological adjustment by providing supportive resources for the individual and indirectly promoting hope. Many interventions and spiritual skills, such as chanting, act as calming techniques and alter mental states, which can be considered self-regulating ways to deal with stress and anxiety, which affect psychological and physical processes and distract the individual from thoughts and disturbances.
The results showed that the relationship between resilience and health anxiety in pregnant women was significant. In other words, resilience training was effective in reducing anxiety in pregnant women. These findings were consistent with the research conducted by Ghopani et al. [34], Ma X et al. [35], Cheadle et al. [36], García-León et al. [37]. People with low levels of resilience are more vulnerable in various life situations and lack the motivation and courage to fix stressful situations. Their minds are constantly preoccupied with problems.
Moreover, they tend to exaggerate these problems and consider themselves victims of these events [38]. Explaining these findings, we can say that resilient people in the face of adverse conditions are more likely to seek meaning. Having faith increases people's endurance in the face of adversity and helps those overcome challenges and life changes. Trans-spiritual communication (i.e., believing in a greater power) has also been mentioned as an individual supportive factor to create and facilitate resilience, and spirituality has been considered a key factor in fostering resilience. Resilient people can adapt successfully despite threats and adverse environmental conditions. Resilient people evaluate negative events from a different perspective. As a result, they experience less discomfort and stress and better cope with events [39]. One of the reasons for the effectiveness of resilience training in reducing anxiety can be teaching coping strategies and better defense mechanisms to individuals. Highly resilient people react to stressful situations with optimism, assertiveness, and self-confidence, thus finding events controllable. Optimistic attitudes lead to more effective information processing and more active coping strategies while increasing the ability to cope with difficult situations. Resilience, through increasing a person's flexibility, develops an individual's ability to cope with different situations, and by reducing negative emotions, increases mental health and reduces anxiety [40].
The people with high resiliency confront the stressful incidents with more optimism, self-expression, and self-confidence. Therefore, they consider these incidents to be manageable. The optimistic attitude makes the information procedure more effective, and the person applies a more active coping strategy, and the ability to deal with the unpleasant conditions will be empowered. Resilient people are flexible and resourceful, they adapt themselves to the environmental changes, and they can recover so fast after the obviation of the stressful factors [41].
Based on the present study's findings, in the relationship between spiritual well-being and resilience with pregnant women's health anxiety, self-compassion serves and a mediating role. This shows that self-compassion is an effective mediator for the relationship between spiritual well-being and resilience in reducing health anxiety in pregnant women. Self-compassion was effective in reducing health anxiety in pregnant women. These findings are consistent with Xavier et al. [42], Felder et al. [43], Abdollahi Boughrabadi [44]. In explaining these findings, it can be argued that self-compassion has a significant relationship with positive emotion, happiness, high self-esteem, life satisfaction, and lower levels of negative emotion, anxiety, and depression. Thus, teaching self-empowerment techniques enables individuals to use learning experiences to become more adaptive in the face of stressful life events [45]. By teaching empathy, sympathy, forgiveness, the development of valuable and transcendent feelings, acceptance, and taking responsibility, it is possible to reduce anxiety, stress, and depression among pregnant women and lay the foundation for improving the quality of their lives and increasing their mental well-being.
Spiritual well-being provides such conditions for one's growth that go beyond the material world. In other words, there is a fundamental difference between psychological and spiritual well-being that in spiritual well-being, an individual has the potential to unite with the whole universe. This can help the individual to find a purpose in life. Give meaning to one's life and ultimately lead to self-awareness and compassion. In other words, such a person values his life and existence and takes care of himself. He considers oppression to be incompatible with the reasons for his existence and considers it important to pay attention to himself to achieve greater goals.
On the other hand, such a person can express himself because the source of this trust is greater than the material world. Therefore, psychological well-being lays the ground for self-development and self-expression. On the other hand, adopting a compassionate attitude towards oneself and the self-care strategies that have been taught will shield these people against the problems of life. Another component that plays an important role in the effectiveness of self-compassion training for the development of resilience is love and affection meditation.
One of the most important limitations of this research is the city of study. Different results may be obtained in other cultural contexts. Failure to receive interview information limits our knowledge of women's mental status.
Conclusion
Spiritual well-being and higher resilience have a direct impact on reducing the health anxiety of pregnant women. On the other hand, self-compassion, directly and indirectly, reduces health anxiety in pregnant women. So, by teaching self-compassion to pregnant women, they could reduce their health anxiety.
Acknowledgments: The authors appreciate all the women who participated in this study.
Ethical Permissions: This study was approved with code 58278 by the psychology department at the University of Zanjan.
Conflicts of Interests: The authors declared no conflict of interest.
Authors' Contribution: Yousefi Afrashteh M. (First Author), Introduction Writer/Methodologist/Assistant Researcher/Statistical Analyst/Discussion Writer (50%); Bitarafan L. (Second Author), Methodologist/Main Researcher/Statistical Analyst/Discussion Writer (50%)
Funding/Support: There was no financial support.
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