|Year : 2015 | Volume
| Issue : 3 | Page : 196-203
Spiritual health of students in government medical colleges of Kolkata and their coping skills in a crisis situation
Shibotosh Sen1, Dipak Pal2, Suprakas Hazra3, Girish Kumar Pandey4
1 Medical Officer, West Bengal Public Health and Administrative Service, Government of West Bengal, Kolkata, West Bengal, India
2 Professor, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
3 Demonstrator, Department of Epidemiology, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
4 Director, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
|Date of Web Publication||7-Sep-2015|
4A, Nasiruddin Road, Flat No. 10, Kolkata - 700 017, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The status of spiritual health of the population of India at large including that of young medical undergraduates who are the caregivers of the future and its association, if any, with coping skills in crisis situations is yet to be explored. Objectives: To measure the spiritual health status of the study population, describe the coping skills used by them in crisis situations, identify the sociodemographic factors associated with their spiritual health, and to determine the association of spiritual health status of the study population and their coping skills. Materials and Methods: An institution-based cross-sectional study was performed among the third semester medical students in government medical colleges of Kolkata, West Bengal, India. The study was conducted among 362 medical students by the survey questionnaire method. The Spiritual Health Scale 2011 (SHS 2011) and the Brief COPE Scale were used to measure the spiritual health and coping status, respectively. Results: Of all the respondents, 75.7% had refined spiritual health. The mean spiritual health score of the female students was significantly higher than that of the males. Of all the students, 66.1% showed good coping scores. Of all the respondents, 86.2% and 24.5% had higher adaptive and maladaptive coping scores, respectively. Refined spiritual categories were seen more among those students whose fathers had higher education and whose families arranged rituals at their homes. The spiritual health, self-evolution, and self-actualization scores of the respondents were significantly related to the adaptive coping scores and the fathers' education. Conclusion: The coping skills and hence, the spiritual health of the medical students were greatly influenced by the education of the father and cultural factor(s) like arranging annual rituals at home.
Keywords: Adaptive coping, health balance, spiritual health
|How to cite this article:|
Sen S, Pal D, Hazra S, Pandey GK. Spiritual health of students in government medical colleges of Kolkata and their coping skills in a crisis situation. Indian J Public Health 2015;59:196-203
|How to cite this URL:|
Sen S, Pal D, Hazra S, Pandey GK. Spiritual health of students in government medical colleges of Kolkata and their coping skills in a crisis situation. Indian J Public Health [serial online] 2015 [cited 2017 Dec 11];59:196-203. Available from: http://www.ijph.in/text.asp?2015/59/3/196/164657
| Introduction|| |
Spiritual Health is the youngest element of health as approved by the World Health Organization (WHO). In the words of Derek Yach  (World Health Assembly, May 1998), "From the inception, it was felt that the 4 th Dimension of health was missing from its definition. The special group of the WHO Executive Board (1998) proposed that the Preamble of the Constitution should be amended as follows:" "Health is a dynamic state of complete physical, mental, spiritual and social well being and not merely the absence of disease or infirmity."
Beyond the health triangle, WHO's quest to integrate spiritual health in the development agenda of the United Nations and in the core value system of people's lives can be easily discerned in the words of Stuckelberger:  "Addressing the scientific link between religion, spirituality and health has too often been a 'forgotten subject' or avoided for irrational, emotional or 'political' reasons. It is time for the scientific community to integrate religious and spiritual factors, which have guided human behaviour over centuries, into health and human sciences."
Now, what does this spiritual health consists of? Is it seeking the help of the Almighty or it is the will power of all human beings that often gives the strength to combat crisis situations. The soul of a human being always guides him/her through the difficulties of life. The brain decides what to do but the soul selects the most suitable judgment in a crisis situation.
Spiritual health has been defined as "a state of being where an individual is able to deal with day-to-day life in a manner which leads to the realization of one's full potential; meaning and purpose of life; and happiness from within." 
Spiritual health status of the population at large is still unknown in India. Whether spiritual health has any relation with the coping skills of an individual is yet to be explored. This may help to overcome crisis situations better. Even doctors, the caregivers of the society, need to overcome crises time and again. Bansal et al. in their cross-sectional study on "Spirituality and health: A knowledge, attitude and practice study among doctors of North India"  found that 86.05% respondents felt that a spiritual caregiver can provide better patient care. Of all the respondents, 60.47% also believed that it was important for caregivers to have a spiritual orientation. This aspect can be explored among young medical undergraduates and the lessons learnt from this study may help to improve the quality of care provided by caregivers in the future.
With this background, a study was conducted among the third semester Bachelor of Medicine, Bachelor of Surgery (MBBS) students of government medical colleges of Kolkata, West Bengal, India with the objectives to measure the spiritual health status, describe the coping skills used in crisis situations, identify the sociodemographic factors associated with their spiritual health, and to determine the association of spiritual health with the coping skills.
| Materials and Methods|| |
An institution-based cross-sectional observational study was conducted from October 2012 to March 2013 in three out of the five government medical colleges of Kolkata, West Bengal, India selected by the simple random sampling method. A pretesting of questionnaire was done with 25 medical students (third semester) where the refined status of spiritual health was found among 48% students. Thus, assuming a prevalence of 48%, α as 5%, and 10% absolute allowable error, a sample size of 96 was calculated by the formula Z0(1-α/2)2 .p(1-p)]/d2 . For operational feasibility, the students who attended community medicine class on the day of this survey were asked to take part in it. It was a purposive recruitment. For this reason, a design effect of 3 was assumed and the minimum sample size of 288 was calculated. A total of 362 respondents [among the total 650 students of three medical Colleges, namely, Medical College, Kolkata (250), Nil Ratan Sirkar Medical College & Hospital (NRS) (250), and R.G. Kar Medical College & Hospital (150)], i.e., all those who were present on the day of survey, were administered a pretested, predesigned, semi-structured questionnaire prepared as per the Spiritual Health Scale 2011  (SHS 2011) designed by the National Institute of Health and Family Welfare (NIHFW), New Delhi, Delhi, India and the Brief COPE Scale of the University of Miami, Coral Gables, Fl, USA. , The SHS 2011 was the first of its kind to measure the spiritual health of individuals, which is devoid of religious and cultural biases and can have universal applicability.  NIHFW categorized spiritual health in three domains (Self-Evolution, Self-Actualization, and Transcendence) that were further classified into six constructs ("Wider Perspective" and "Nurturance-Art" under Self-Evolution; "Engineering from Within" and "Deeper Meaning- Purpose of Life" under Self-Actualization; "Universal Love- Sublimating Jealousy" and "Considering oneself as a part of the Supreme" under Transcendence).
The trait version of the Brief COPE  asks respondents about the coping strategies they use during periods of stress. Twenty eight items assess 14 conceptually different forms of coping. It included adaptive coping (active coping, seeking instrumental support, seeking emotional support, planning, and positive reframing), maladaptive coping, or withdrawing from the problem (denial, behavioral disengagement, alcohol and drug use, self-distraction, and self-blame), and other common strategies that do not clearly fall into either of the three categories (acceptance, turning to religion, humor, and focus on venting emotions). Each of the subscales has good internal validity.  The adaptive coping  techniques are positive constructive techniques that improve functioning, whereas the maladaptive coping techniques  are actually noncoping or negative techniques that though reduce symptoms but maintain and strengthen the disorder therein. Anonymous respondents were considered and consent from all the participants was obtained in a specified format. Confidentiality was maintained and clearance from ethics committee of the institutes was obtained.
Although SHS and Brief COPE Scales were scored using 5-point and 4-point scales, respectively, according to the answer key, the scoring was actually numerical using the standard formula given by the SHS scale and the formula planned by us for coping skills, respectively.
SHS scores, being a continuous (dimensional) variable, have a range of 0-5.48 with ≤1.9 being unrefined, 2-2.9 slightly refined, 3-3.9 moderately refined, 4-4.9 refined, and ≥5 a much refined spiritual health status. However, for dichotomous assessment, the score of ≥4 was considered "spiritually refined" and <4 as "less refined" in this study.
In the Brief COPE Scale, there were 28 assertions, each with a minimum 1 mark and maximum 4 marks. The range of scores of adaptive coping, maladaptive coping, and 14 different attributes of coping were determined. Adaptive coping consisted of five attributes assessed by two assertions (4 marks), each totaling to 40 (4 × 2 × 5 = 40). The total adaptive coping scores were divided by 40 that enabled the scores to lie between 0 and 1. Similarly, maladaptive coping was also scored. Since no specific guideline was stated in the Brief COPE Scale, it was decided to fix a cutoff value of 50% of the scores obtained in the survey. The subjects having scores more than the cutoff were considered to use the specific coping skill attributes or strategies more. Similar preconditions were also applied for the SHS, its domains, and constructs. Only the overall spiritual health cutoff value of 4 was retained as per the SHS 2011, as the calculated value was 3.972 that was very close to it. Since the cutoff values of the other variables were not mentioned in the answer keys of SHS 2011, they were calculated from the survey results.
Spiritual health status and coping skills were assessed with respect to sociodemographic indicators like gender, age, religion, family type (nuclear/joint), head of the family, occupation, and education of the parents, per capita income (in Rs.) of the family, Prasad's socioeconomic classification 2013,  relation between the parents, performance in examinations by the subjects, bereavement in the family in the last 1 year, family support (physical and mental) provided to the subjects when they need it most, frequency of religious rituals arranged at home, possession of siblings, and substance and sexual abuse. The data were analyzed using Microsoft Excel 2007 (Microsoft Corporation, US), SPSS version 18 (SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc.), and Epi Info version 7 (Manufactured by Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA).
| Results|| |
Among the medical students aged between 18.59 years and 25.07 years (median 20.2 years), only 35.36% of the respondents were females. Of all the students, 84.25% were Hindus, 13.81% Muslims, and only 1.94% belonged to other religions. Of all the respondents, 98.3% were unmarried. Of all the students, 32.87% hailed from joint families. The father was considered to be the head of the family in 94.5% of the families. Fathers of 43.94% of the students were engaged in service, followed by those who were businessmen (17.46%), teachers (12.11%), doctors (12.39%), etc., whereas 77.01% of the mothers were homemakers followed by teachers (9.97%), those engaged in service (7.76%), doctors (4.71%), etc. In case of all the respondents, fathers of 52.68% and mothers of 48.75% were graduates while fathers of 31.55% and mothers of 19.94% were postgraduates. The monthly per capita income ranged from the minimum of Rs. 312.50 to the maximum of Rs. 83,333.33, with the median monthly per capita income being Rs. 9,000. Of all the students, 87.8% felt that their overall academic performance was good. Of all the students, 56.6% thought that the relations between their parents were excellent, which indirectly states that the internal conflicts between those families were less. Of all the students, 7.46% felt that they were not getting physical and mental support from their families at the time when they need it the most. Of all the students' families, 13.5% did not arrange any ritual or gathering at their home, whereas 22.1% arranged two rituals and 20.4% arranged three rituals/annual gatherings at their home. Of all the students, 10.2% used tobacco products when the study was conducted, 25.7% students had at some point consumed alcoholic drink, and 4.7% had extramarital sexual contact.
The SHS scores of the respondents ranged 2.74-5.34 according to the SHS 2011, which has the lowest value of 0 and the highest value of 5.48. The results obtained in this study are shown in [Table 1] and the results of coping scores are shown in [Table 2].
|Table 1: Spiritual health status of the medical students and the range of scores obtained in the survey (n = 362)|
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|Table 2: Coping status of the medical students and the range of scores obtained in the survey (n = 362)|
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The coping skills significantly differ with the SHS scores and even individually with the domains of spiritual health at various levels, which is subsequently described in the correlation matrix. Bivariate Pearson's correlation coefficients [Table 3] were calculated among the scores of spiritual health, the three domains, adaptive coping, maladaptive coping, and four other attributes. Karl Pearson's correlation coefficients were obtained between the variables. It was found that adaptive coping had a significant positive correlation and maladaptive coping had a negative correlation (although not significant) with not only the overall spiritual health score but also individually with all the three domains of spiritual health. The "turning to religion" attribute was significantly correlated with the Transcendence domain of spiritual health (domain 3).
|Table 3: Correlation matrix between the scores of spiritual health, domains 1-3, coping strategies, and few attributes (n = 362)|
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Multiple ordinal regressions were done separately with categories of spiritual health, the domains, and the constructs as dependent variables (considering the less refined category as the threshold), adaptive coping scores as covariate, and factors being all the 19 socioeconomic variables to identify whether any combined effect of the latter aspect influences spiritual health. The statistically significant findings are presented in the [Table 4]. It was observed that gender, education of the parents, occupation of the mother, arranging annual rituals at home, and consumption of alcohol at some point played important roles to determine the refined criteria of spiritual health.
|Table 4: Multiple ordinal logistic regression analyses of spiritual health of the respondents according to the adaptive coping scores and socioeconomic variables (n = 362)|
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The gender criterion showed that the female students were having better spiritual health compared to their male counterparts. The odds ratio (OR) varies from 2.19 to 3.67 throughout the constructs, domains, and spiritual health categories. The highest OR was in the Self-Actualization domain.
The father's education criterion showed that the respondents who had more educated fathers had better spiritual health. The OR varies from 3.07 to 5.20 throughout the constructs, domains, and spiritual health categories. The highest OR was in the overall spiritual health category. The students having better spiritual health had more educated fathers 5.2 times more than those with less educated fathers. Compared between the domains, Self-Actualization was more than Self-Evolution. The respondents who had more educated fathers had better control of the internal locus ("Engineering from Within" construct) and more holistic approach toward life ("Wider Perspective" construct).
The mother's education criterion surprisingly showed a reverse nature. The students who had less educated mothers had better spiritual health. The OR was 2.93 in favor of the undergraduate mothers. This apparently reverse association probably cropped up from one construct (Universal Love- Sublimating Jealousy) of the Transcendence domain that suggests that the respondents with better scores under the said construct had undergraduate mothers 3.39 times more than those with graduate mothers. The situation seems self-contradictory if the occupations of the mothers are considered where in the same construct it was seen that the respondents having better score were having working mothers 1.99 times more than those having mothers who were homemakers as we generally assume that working mothers possess better qualification. The highly significant distribution of students according to the education and occupation of their mothers with Pearson's chi-square value of 20.979 showed that 89.16% of graduate mothers were working, whereas 62.59% of the graduate mothers were homemakers.
The annual rituals criterion showed that the students whose families arranged annual rituals at home had better spiritual health. The number of students with better spiritual health whose families arranged annual rituals at home were 2.16 times more than those who did not. These rituals were mainly social gatherings, religious offerings, or ceremonies done at a fixed time and in the same way each year. It was also observed that the OR was 2.86 in favor of the ritual performers under the Self-Actualization domain.
It is usually assumed that consumption of alcohol and tobacco contributes to maladaptive coping in a crisis situation. Among the students who were having better scores of the construct "Universal Love-Sublimating Jealousy" that contributes to the "Transcendence" domain, those who never consumed alcohol were 1.96 times more than those who consumed it.
| Discussion|| |
Social determinants like education of the father and the practice of annual rituals at home were influencing the development of spiritual health and augmenting the Self-Actualization domain. Respondents with only the former criterion specifically focus on a holistic approach to life and internal locus of control. These important aspects build the personality of medical students that may help in the nurture of ailing patients.
Maslow noticed that self-actualized individuals had a better insight of reality; deeply accepted oneself, others, and the world; had also faced many problems; and were known to be impulsive people. These self-actualized individuals were very independent and private when it came to their environment and culture, especially their very own individual development on "potentialities and inner resources."  In this study, it was found that the self-actualized students had higher scores of adaptive coping strategies and they were trying to develop their potential inner resources. But there will be error if we mix up both the Self-Actualization categories. Maslow refers to such category as a certain mental state that is achieved at a certain stage of life according to the hierarchy of need.  But here, the said attribute appears as a spectrum that is present throughout life though the characteristics of the self-actualized person suggested by Maslow remains the same.
The apparent contradiction between the education and occupation of the mothers of the respondents may be explained with respect to the sociocultural aspect of West Bengal. Conflicts in the workplace are usually better managed by more educated individuals. But the lesser educated people use the entire existing potential per se to make up for the deficit of education. They work out on their inner resources that further modifies their spiritual health, maintaining equilibrium with their mental health. This, again, changes the overall health status.
Comparison with other studies may not be precise as the definition and interpretation of spiritual health used in this study are different from other published studies. However, Bansal et al. showed that spiritual practices have a positive correlation with survival, low blood pressure, less remission time from depression, less number of cigarettes smoked, less severe medical illness, better quality of life, cooperativeness, etc.  They suggest a positive relation between spiritual practices and positive health outcomes like greater self-confidence, assertiveness, and fewer symptoms of anxiety and depression. Evidence shows that spiritual well-being is positively related with self-ratings of physical health and vitality. In this study, it was seen that the students who did not consume alcohol focused on unconditional love and used it to manage jealousy.
Brougham et al. found that college students of both genders who employ problem-solving strategies have better health and increased self-esteem.  In this study, it was obvious that more students with higher adaptive coping scores not only had a refined spiritual health but also had higher scores for all the domains and constructs.
Thus, the so-called triad of health may be improved by a new concept of health balance [Figure 1]. Here, it is emphasized that balance between the coping skills influences health in which the spiritual component plays a central role. Further, this spiritual component continuously equilibrates with other components like physical, mental, and social well-being. The balance is continuously maintained between adaptive coping and maladaptive coping. The additional weightage of "other coping attributes" can be distributed to either side, partially or entirely, according to the psychological backup of the individual. The coping skills and hence, the spiritual health of the medical students were greatly influenced by the education of their fathers. Higher the education status of the head of the families, better may be the personality of an individual that might further promote spiritual health. Healthy spiritual practices like meditation relax the mind and improve concentration in work. At the same time, annual rituals or social gatherings help to exchange ideas and broaden the mind. Moreover, a spiritually healthy person justifies his/her ideas and works well when he/she compares his/her ideas with others. This activity may further gain social support and relax the mind. It is not that spiritual awakening emerges in a later stage of life; rather spiritual health is everlasting throughout life and somehow influences us to cope with adversities. Along with the life skill education program, development of spiritual health and augmentation of adaptive coping skills in adolescents may act as a primordial prevention for depression and general anxiety disorder. Further research may necessitate its inclusion in the National Mental Health Program.
The authors deeply acknowledge the support of Dr. Neera Dhar, Professor; Dr. S. K. Chaturvedi, Consultant; Prof. Deoki Nandan, former Director; and NIHFW.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]