Caspian Journal of

1. Introduction
Spirituality or Spiritual Well-Being (SWB) is one of the fundamental concepts among humans and has been considered remarkably by psychologists and mental health professionals in recent decades as a global phenomenon [1, 2]. In fact, SWB is the newest recognized health dimension that has been placed alongside other dimensions of health [3] and most health education models focus on spiritual health [4]. Spiritual health is characterized by features such as stability in life, feelings of association with “self”, God, society, and other creatures and being purposeful in life [5, 6, 7, 8]. Spiritual health involves three dimensions including cognition, emotions, and action. Spirituality indicators are not just the part of psychological behaviors or emotions, such as internal satisfaction or internal peace, but also spiritual well-being focuses on all human life aspects [8, 9, 10, 11] and can affect the quality of life [12].
One of the factors associated with spiritual health is the happiness that results from personal judgement about how to live. This judgment is not imposed from the outside, but rather a personal and internal affair that is affected by the positive excitement. Happiness is one of the most important ways of prevention and treatment of mental disorders [13, 14, 15]. It is a condition of the cheerfulness or joy as positive emotions, being satisfied with life, and lack of depression and anxiety as negative factors emotions [16, 17, 18, 19, 20, 21]. 
An extraordinary force existing in spiritual health gives the person a spiritual power and distracts him/her from anxiety and worries [22, 23] and play a major role in the mental and physical health of individuals as a useful way to deal with psychological problems, including depression [24, 25]. Depression is a common disorder that is one of the most serious physical and mental illnesses and its prevalence rate in the world is 10-20% per year. Approximately, 15% of the total population experiences a period of major depression in an episode of their lives [26, 27]. Students’ populations are prone to be depressed and depressed students face more problems in their curriculum, and their grades are lower than other their counterparts [28]. The results of published studies in Iran indicate that prevalence of depression among university students is between 36% and 66%. Around 2 to 5% of them suffering from severe type of disorder [29, 30]. Also, in some studies, happiness and its role in satisfying students’ lives are investigated [31, 32]. Promoting spiritual well-being in universities is often recommended. Therefore, in addition to the skills required for students, it is also necessary to gain spiritual skills [33, 34]. Determining the predictors of spiritual health can be the basis of planning for promotion of happiness among students, because investing in universities to improve the spiritual health of students can lead to a reduction in depression, increasing happiness, and, ultimately, academic achievement among them. Therefore, the purpose of this study was to determine the spiritual health and its relation with happiness among the students of health sciences of Guilan University of Medical Science.

2. Materials and Methods
Study design and study population
This was a descriptive, cross-sectional study. The statistical population included all students of Health Sciences studying in Guilan University of Medical Sciences in the first semester of the academic year 2016-2017. Exclusion criterion was the unwillingness to participate in the study. The number of investigated students was 323. 

Study instrument
The data collection tool was a questionnaire. The Spirituality Well-Being Scale (SWBS) designed by Pulotsin and Ellison in 1982 were used to measure the spiritual health [31]. It consisted of 20 questions categorized based on 5-choice Likert scale (totally agree, agree, no opinion, disagree, totally disagree). The score for each item was scaled from 1 to 5. The spiritual health score was defined as the sum of the scores of three dimensions of cognition, action, and emotion ranging from 20-100. The Persian version of SWBS was validated in previous study [35]. The Oxfords Happiness Inventory (OHI) developed by Argil in 2001 [36] was used to measure happiness. The questionnaire consisted of 29 items ranked using a 4-point Likert scale ranging from 1 to 4. The response options were; always, sometimes, rarely, and not at all. The happiness score range is between 29 and 116. The validity and reliability of this questionnaire in Iranian society were assessed by Alipour and Harris Agah [22]. According to Mozafari Nia and his colleagues’ findings, validity and reliability of the two questionnaires were higher than 0.90 [37]. 

Statistical analysis
Frequency distribution and Mean±SD were used to describe variables. Normality assumption was assessed using skewness indices. Spearman correlation coefficient, t-test, and analysis of variance were used to investigate association between variables. Multivariate linear regression model was applied to determine independent predictors of spiritual health. All data analysis was performed in SPSS version 19. 

3. Results
In this study, 93% of students were females and the Mean±SD age of participants was 24.61±7.62. Seventy percent of students were single and 42% had more than high interest in their field of study. Table 1 shows the scores of SWB in terms of demographic variables of the study participants.

Age and marital status were significantly associated with SWB. Younger than 20 years old students had higher score compared to 20-30 years old and more than 30 years old students (P=0.049). the score of single students was significantly higher than married ones (P=0.04). 
Table 2 shows dimension scores of SWB and happiness.

The Mean±SD of SWB and happiness were 55.82±4.71 and 60.88±12.9, respectively. Table 3 illustrate correlation coefficient of the dimensions of SWB and happiness.

The strongest significant direct correlation was between cognitive dimension of SWB and dimension of welfare (r=0.92, P=0.005) and positive mood (r=0.90, P=0.007). In multivariate linear regression model adjusted for age categories, marital status, and domain of happiness, there was significant relationship between satisfaction and spiritual health (β=0.66, P=0.02). 

4. Discussion
This study found a lower than mean values of SWB and happiness among students of health science. This finding is in contrast of previous studies which found higher than mean values of SWB and happiness [19, 37, 38]. The finding revealed a weak correlation between SWB and total score of happiness. In the study by Feizi et al. on a sample of Iranian healthcare students, happiness had a moderate correlation with SWBS [19]. In the study by Hatami and Shekarchizadeh for estimating the relationship between spiritual health, resilience and happiness on 150 volunteer dental students from Islamic Azad University of Isfahan, spiritual health had a significant positive correlation with happiness [39]. In the study of Dadfar et al. on students of nursing and midwifery in Ardabil, there was a significant positive correlation between spiritual health of students with their happiness. Also, All dimensions of spiritual health had significant relationship with happiness [40]. The controversial result on the strength of correlation between SWB and happiness might be due to different instrument for assessing the SWB. In our study we used spirituality well-being Scale designed by Pulotsin and Ellison in three dimensions of cognitive, emotional, and action. While, some previous studies used the Islamic-based questionnaire which was developed for Iranian population [19]. 
In current study, age and marital status was an important confounder for the relationship between SWB and total score of happiness. In the adjusted model, dimension of satisfaction was the only significant predictor of SWB. 
In this investigation, there was a significant relationship between spiritual well-being and marital status, in which, the Mean±SD of spiritual health in single students (56.10±4.74) was more than married ones (55.20±4.61). This finding is consistent with the studies of Mozafarinia et al., Abadi et al., and Tavan et al. [37, 41, 42]. 
In this study, there was no relationship between gender and spiritual well-being, which is consistent with the studies of Chiang and Allah Bakhshian [43, 44]. There was no relationship between educational level and housing situation with spiritual health, which was in agree with Mozafarinia et al’s [37].

5. Conclusion
The finding revealed a lower than mean value of happiness and SWB among students of health sciences. There was a weak correlation between SWB and happiness and dimension of satisfaction was the most important independent predictor of SWB.
This study suffered from some limitation including cross-sectional nature of study design which obscure assessing temporal association between variables. The SWB questionnaire used in this study was not adapted for Islamic culture of Iranian society. 

Ethical Considerations
Compliance with ethical guidelines
The study protocol was approved by Ethical Review Board of Guilan University of Medical Science (Code: IR.GUMS.REC.1395.384).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgements
Our grateful thanks go to all participants in the present study.


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