Outcomes of Spiritual Health in Children: A Qualitative Content Analysis

Background: The socio-cultural status of any society depends on the health of children. Enjoying spiritual health, as one of the important dimensions of health, plays an essential role in ensuring the comprehensive health of the child. This qualitative study was done to explore the consequences of spiritual health in Iranian children. Methods: This qualitative study was conducted using semi-structured interviews. Participants included 17 children and 9 researchers and specialists in the field of children’s mental health. Data analysis was carried out using the qualitative content analysis approach developed by Graneheim and Lundman. Results: During the analysis of the text of the interviews, three themes of “psychological consequences” with three categories (mental vitality, mental growth, and cognitive growth), “socio-moral consequences” with two categories (ethical growth and social growth), and “religious-spiritual consequences” with two categories (religious behavior, religious transcendence) were obtained. Conclusion: The spiritual health in children helps them grow in all aspects, which indicates the capacity of spiritual health in children. It seems that focusing on moral-spiritual development in order to ensure the spiritual health of the child helps to prevent moral-behavioral disorders and provides the ground for excellence and meaningful growth. Therefore, considering the importance of having spiritual health in children, it is necessary for those in charge of education to implement and evaluate written and practical programs based on the consequences of spiritual health and in accordance with the family system, community, and school.

of positive outcomes such as calmness, self-control, happiness, hope, better adaptation to the situation, easier confrontation with the problems ahead, and lack of stress were reported. Besides, creativity has been mentioned as a consequence of spiritual health in children (6). According to researchers, an increase in spiritual health can give children the power to cope with psychological stresses and life crises, conceptualize faith, worship of God, trust in God, and honesty, and prevent early behavioral disorders in adolescence (15).
In 2019, Nauli and Mulyono conducted a correlational study in Indonesia to examine the relationship between spirituality level and the degree of resilience in schoolaged children. They found that children's happiness, lack of stress and depression, easier control of emotions, and comfortable adaptation to circumstances are the consequences of spirituality in children (16). A study investigating the foundation of spiritual education of children and the role of parents in promoting it showed that the consequences of spiritual health include vitality, hope, satisfaction, intimate confidence, peace, a healthy heart, a dynamic relationship based on moral virtues, love, and affection for oneself, others, and the world around (17).
According to experts in various scientific fields, childhood is one of the most important periods of human life (18). In this period, personality, as well as spiritual and even physical foundations are formed, and from then on, they are effective throughout the whole period of human life. Therefore, the method of training, education, and health in childhood is much more important for the rest of life and in society (3,4). Childhood is the first opportunity to provide conditions that affect the child's spiritual growth and development (12). Considering that spiritual health is a universal concept and that many of its components and indicators are the same in different cultural contexts, it can be said that its consequences such as mental vitality, mental development, cognitive development, and so on are the same in all societies and cultures and only the behaviors that include these components and indicators have different definitions in different cultures. Accordingly, it can be argued that the basic foundation of spiritual health outcomes in children is transcultural and trans-religious and can be generalized to other nations and ethnicities. Since no study has comprehensively examined the consequences of spiritual health in Iranian children, researchers decided to acquire rich and complete information in this field by conducting a qualitative study.

Materials and Methods
This qualitative research was conducted from March 2020 to February 2021 in Tehran with the participation of 26 people. A total of 17 interviews were conducted through WhatsApp due to the participants' desire to maintain social distance due to the COVID-19 pandemic. Participants included 17 children and 9 researchers and specialists in the field of children's mental health that were selected by purposive sampling in order to obtain an in-depth understanding of the concept. Before starting the sampling, the research team selected people based on the purpose of the study in a meeting. The research team selected the people who helped in better understanding the concept based on their experiences. In order to achieve the maximum variation of participants, people from different age ranges, genders, geographical regions, and religious backgrounds were selected. Inclusion criteria for children aged 6-12 years were the ability to communicate meaningfully and conduct conversations, willingness to participate in research, and parental consent to conduct interviews. The inclusion criterion for professionals was having a history of activity in the field of spiritual health and growth and development of children. Data collection was performed using semi-structured interviews through open-ended questions. The interviews began with a few general questions. The main questions in the interview with the children included "What does health mean to you?" and "How has health benefited you?". Researchers were asked questions such as "What is your definition of spiritual health?" and "What effect does spiritual health have on children?". During the interview, more specific questions were asked based on the interviewees' answers (e.g., can you give a clearer example?). The interviews lasted for an average of 30 minutes.
Data analysis was performed using the content analysis approach developed by Graneheim and Lundman. After writing down the text of the interviews and studying them several times, the text of the interview was divided into semantic units, and initial codes were assigned. The codes were then divided into categories and sub-categories based on similarities and differences. Eventually, themes were created that represented the hidden content of the interviews (19). After analyzing 22 interviews, no new categories were formed, but for more certainty, four more interviews were conducted. To increase the quality of data, the four criteria of Lincoln and Guba including validity, reliability, authentication, and transferability were used (20). To increase the validity and reliability of the data, in addition to allocating enough time to collect the data, long-term engagement with the data, and immersion in them, member check (two 11-year-old boys, a 9-year-old girl, an active child psychologist participating in the study) and peer check (two faculty members) were also used. Maximum diversity in sampling methods was observed to ensure the reliability of the data. The researcher tried to increase the reliability by discarding thoughts and assumptions in the process of data collection and analysis.

Results
In this qualitative study, 26 participants including 17 children (9 boys and 8 girls) and 9 researchers and specialists in the field of children (6 women and 3 men) participated. The age range of children was 6-12 years and the age range of researchers was 35-56 years. The results of the analysis of the text of the interviews included 908 primary codes which after reducing the data and merging the overlapping expressions were reduced to 187 main codes, 28 subcategories, 7 main categories, and 3 themes. The outcomes of spiritual health were classified into three themes including "psychological consequences", "socio-moral consequences", and "religious-spiritual consequences" (Table 1).

Discussion
The outcomes of children's spiritual health were explained based on the experiences of the participants in this study with three themes: psychological consequences, sociomoral consequences, and religious-spiritual consequences. Raising a child and her/his all-round development are important goals of educational systems, because childhood plays a crucial role in life and shapes human behavior in adulthood, and on the other hand, children get ready to accept and learn concepts and values. Spiritual education provides the foundation for the growth of personality and self-exaltation.
The theme of psychological consequences was formed by the juxtaposition of the categories of mental vitality, psychological growth, and cognitive development. Mental vitality is the result of loving the universe and beings, joy, and happiness. Psychological growth in the child is the result of having satisfaction and calmness and controlling fear when faced with problems, as well as having resilience, emotion control, a purpose in life, motivation to achieve goals, and positive thinking in this direction. Hope and cognitive development were the results of problemsolving ability, self-awareness and recognition of the feelings, strengths and weaknesses of the self, which can finally result in the emergence of appropriate behavior in different situations, based on the participants' experiences.
Maaref and Asadi reported in their study that human relationship with the Creator is the source of peace and relief from stress, anxiety, and preoccupation. Lack of spiritual health and lack of purpose and meaning in life cause a feeling of emptiness and mental and physical problems (21). Azizi reported in their study that believing in and relying on superior power and the resulting peace of heart create vitality and satisfaction in the individual (12). Creationism and the desire to maintain a relationship with God and belief in His kindness lead to curiosity and understanding of the greatness of the Creator. In such a situation, man sees the Creator as the overseer of life, and he not only avoids some sins but also seeks the approval of his Lord and actually gives meaning and purpose to his/ her life.
In a study, Bożek et al reported that people with a sense of mental well-being have a positive attitude toward themselves and their past. Such people believe in meaningful life and are purposeful. They also have high-quality interpersonal relationships and are therefore constantly growing and developing individually (22). Evidence shows that spiritual health affects physical health, mental health, as well as quality of life, coping skills, and the reduction of high-risk behaviors (23,24). In their study, Rossato et al reported that praying, going to religious places, and reading holy books promoted adjustment and coping behaviors in children with cancer (25). Based on the findings of studies, it seems that spiritual health by promoting mindfulness and emotion control can promote mental health and a sense of wellbeing (26,27).
Children instinctively seek to understand the meaning of life and the events of their lives through religious and spiritual experiences, or other sources, regardless of whether they are religious or non-religious. Spirituality and spiritual health in traumatic situations such as illness, death, and abuse help the child adapt and maintain relationships (28).
The theme of socio-moral consequences was formed by the juxtaposition of the categories of social development and moral growth. Achieving moral growth is the result of not having pride and arrogance and humility towards human beings and good morals in social relations. Paying attention to other people, considering the wants and needs of other human beings, and trying to help and meet the needs of others are the bases for social growth, which can result in the achievement of spiritual health based on the experiences of participants. Having good morals paves the way for the growth and development of human personality and goodness and blessings in life. On the other hand, having virtues such as kindness, sobriety, and humility helps the child establish proper relationships with parents, friends, and classmates, thereby improving the child's social interactions. In their study, Khorashadizadeh et al reported that people with spiritual health are conscientious. Therefore, these people act responsibly according to the situation and take into account the interests of individuals and communities. Therefore, they not only have moral virtues such as patience, tolerance for people, altruism, humility, and so on but also try to get rid of moral vices (29). People with spiritual health have the awareness, attitude, and ability to excel and become closer to God commensurate with their abilities. Such people, while coordinating with the world around them, display behaviors appropriate to different situations to achieve the ultimate goal (5,30).
The theme of religious consequences was formed by the juxtaposition of the categories of religious behavior and religious transcendence. The emergence of religious behavior, which is achieved by strengthening faith and beliefs, the ability to control the self and reducing moral deviations, as well as performing religious acts and religious duties voluntarily, and religious transcendence, is the result of piety, trust, and closeness. These children call God in the heart and with the tongue in all matters appropriate to their age. According to the religious view, spirituality is rooted in human nature and finds meaning through faith in God and righteous deeds. Trust means trusting in the Almighty God in all matters of life and considering God as the observer for deeds (21,31). Faithful  Problem-solving ability • Children who are spiritually healthy have good problem-solving abilities. • These kids know how to solve their problems.

Social-moral consequences
Ethical growth Humility • They recognize the position of slavery, so they are no longer arrogant and immoral.
Good manner • They do not get angry easily, and they are not immoral. • They make others happy. • They are vital, they laugh and make others laugh.

Social growth
Other-oriented • Despite their own inner desires and hedonism, they sacrifice for others.
Giving service to others • They see that this world is passing, they do not perform bad things and try to do good things, so they try to love and serve others. • They help satisfy the needs and wants of others, even those not mentioned. They consider and observe the needs of others. people depend on only one source of power and believe in this superior power. It seems that children are acquainted with this concept both instinctively and through telling different stories in this field, and as a result, they rely on God for spiritual health in their work and issues according to their capacities and needs. Therefore, in all behaviors and actions, considering God, they seek help from Him to achieve their goals and leave the result to God (31). Another consequence of spiritual health in children is piety. Piety is defined as being protected from something that hurts human beings (22,32). Therefore, the pious person tries not to do bad deeds, avoids deviations and has the ability to distinguish between good and bad. Consequently, with piety and trust in God, human is on the path of divine training, and by strengthening self-esteem, courage, patience, and so on, she/he can reduce the psychological pressures of life. On the other hand, such a person stays safe from mental illnesses by avoiding moral vices such as polytheism, hypocrisy, jealousy, arrogance, lies, backbiting, and so on (33). Worshiping God and praying are other consequences of spiritual health in children.
Maaref and Asadi stated that daily prayers, which are performed regularly, are a kind of coherent program in a person's life that empowers human beings with a sense of connection and communication with the Creator (21). The results of a study by Zahed Babelan et al showed that attachment to God and the power and sense created by it play a role in creating an optimistic outlook on stressful and threatening life events (34). Spirituality plays an important role in illness, situation evaluation, and selfknowledge. Therefore, trying to reach and benefit from support resources reduces the feeling of vulnerability. Harmful and threatening experiences, such as contracting a disease, lead to mental and spiritual distress, and trying to find meaning makes people think and search for sources of adaptation. Such a person considers each movement and stillness as dependence on the pure essence of God and never feels grief. This is the submission and trust in the religion of Islam that makes a person feel successful in life-threatening situations, such as illness, through the relationship with God, hope, and motivation.

Conclusion
The findings of the present study showed the consequences of children's spiritual health in psychological, sociomoral, and religious-spiritual dimensions. In fact, the results obtained from the analysis of the interviews have pointed to the psychological consequences of spiritual health in children with three main categories including mental vitality, psychological development, and cognitive development. In the category of mental vitality, peace, happiness, and the power to love were identified. In the category of psychological development, flexibility, independence, emotion management, dynamism, purposefulness, motivation, identification, resilience, hope, and positive thinking were identified. In the category of cognitive development, tactfulness, self-awareness, and problem-solving ability were identified. Therefore, it can be said that a child with such characteristics resulting from spiritual health shows a low level of tension and better confrontation with the environment and society. Moral-social consequences of spiritual health in children were also determined by two main categories of moral growth and social growth. In the category of moral development, humility and good manners were identified. In the category of social development, appreciation, othercenteredness, serving others, and good communication with others were identified. Children with spiritual health face less communication challenges and have greater popularity in the social context, and due to the presented characteristics, they are able to solve problems in communication.
Additionally, religious-spiritual consequences of children's spiritual health can be classified into two categories of religious behavior and religious excellence. In the category of religious behaviors, staying away from sin, believing in God and prophets, and performing religious duties were identified. In the category of religious excellence, piety, trust, and seeking closeness were identified. Therefore, based on the spiritual strength of such children, it is predicted that this kind of connection with oneness protects them from suffering from psychological and social damages.
Therefore, it can be said that considering the establishment of this level of mental, spiritual, and social health in children and their significant immunity from personal and social damages, it is very necessary for education authorities to design, implement, and evaluate upbringing programs in order to achieve spiritual health outcomes.