Prediction of war veteran's mental health based on spiritual well-being, social support and self-efficacy variables: The mediating role of life satisfaction.

INTRODUCTION: The present study aims to provide a model for explaining the mental health of war veterans based on the variables of spiritual well-being, social support, and self-efficacy, with the mediating role of life satisfaction.
MATERIALS AND METHODS: The research method was descriptive a correlational. The study samples included 210 veterans, who had records in the Veterans Foundation in Tehran's number one district, Sarallah and Imam Khomeini shelters and Essaar Sports Center in Tehran. They were selected randomly and were asked to respond to questionnaires on mental health, spiritual well-being, life satisfaction, social support, and self-efficacy. The data was analyzed by LISREL software version 8.5, using the path analysis.
RESULTS: The results showed that the designed model fitted the data (AGFI = 1.00, RMSEA = 0.00 and NFI = 1.00). In the fitted model, life satisfaction and spiritual well-being directly, and social support indirectly, had a significant relationship with the mediator variable of life satisfaction of the war veterans' mental health.
CONCLUSIONS: Veterans with better social support, life satisfaction, and spiritual well-being have better mental health.

INTRODUCTION

The imposed war of Iraq against Iran inflicted irreparable damage to our country, including the martyrdom and injuring of many of our fellow citizens. One of the injuries, which left lasting effects, are still evident in many veterans, in the form of their mental health, as also their families’. In the meantime, positive psychology, which can promote their mental health, has been given to provide solutions, from 2000 onwards. Identification and promotion of psychological structures are the most important objectives that the country's psychologists attempt to improve and empower in veterans. The World Health Organization (WHO)[1] has defined the mental health as, “a state of well-being, in which a person knows his capabilities and can cope with normal life stresses, can work efficiently and productively, and can be useful for the community”. Despite the passing of more than 50 years from the establishment of the Mental Health Committee, knowledge about the problem and its dimensions is still poor.[2] In other words, despite the focus of the above definition on positive issues, most of the health professionals often focus on the problems of patients, and the needs and abilities of the healthy people are neglected. Mental Health Centers, rather than paying attention to the positive aspects of their health and education, are more involved in harnessing and treatment. In fact, what exists in the minds about mental health is the psychiatry concept, which considers the individual to be a ‘patient’ or ‘healthy’ psychologically. Such a concept is based on the assumption that a mental disorder and being healthy are two final poles of a continuum.[3] The prevalence of a mental disorder, recurrence of it throughout life, heavy costs of treatment, and the major consequences resulting from it, are serious enough to have the full attention of planners and specialists on the mental illness. Thus, mental health has not received the adequate attention it deserves in practice.[4] However, it is important to note that despite the seriousness of the problem of mental illness, many experimental evidences dispute too much emphasis on the view.[5] What has been neglected is the fact that about 50% of the adult population, during their life, do not suffer from serious mental illness and about 90% of the population, are annually protected from the risk of acute depression.[6] However, relying too much on disease patterns has led to improvements in the methods of drug therapy and psychotherapy but these treatments are often less durable and have limited efficacy, and individuals, families, and communities are still susceptible to damage caused by mental illness. In other words, the allocation of large funds to investigate the etiology and treatment of mental disorders has not decreased the incidence of the disease and is not conducive to alleviating human suffering.[4] Finally, the health and fertility rate in the life of patients with no mental disorders is not similar, and essentially, these people do not have a more healthy life compared to the mentally ill patients. In this regard, it is proposed that positive psychology be studied in a scientific manner, with optimal human functioning, and be focused on the discovery and promotion of agents that will allow individuals and communities to move forward toward prosperity and change. This movement has created a new task in the research field of psychology, where the psychologists focus their attention on mental health resources that lie beyond the study of diseases and disorders.[7] Positive psychologists seek “to find and nurture genius and talent” and “to make normal life more fulfilling”, rather than merely treating mental illness.[8] Increasing the tendency of psychological studies to new researches in the health field, predictions of psychological health and psychological well-being have led to the development and deepening of its boundaries. One of the concepts related to mental health is psychological well-being.

Proponents of spirituality for the improvement of mental health and interpersonal compatibility have made numerous attempts to establish a connection between the two concepts of health and spirituality, as being the structure of spiritual well-being. Spiritual well-being can be defined as a sensory communication with others, having a meaning and purpose to life, and believing and communicating with a superior power.[9] Ellison stated that spiritual well-being is included as a psychosocial element and a religious element, which indicates that there is a connection with a superior power-God. The existing well-being is a psychological element. It is an odd feeling about an individual's feelings, as to who is he, why and what is he doing, and where he belongs.[10] There are several studies in the support of this hypothesis, stating that spiritual well-being will enhance psychological functioning and adaptation. There are significant correlations between the spiritual well-being scale scores and variables such as religious practices,[11] depression, self-esteem, and intrinsic religious orientation.[12] In the research by Beigi et al., it is seen that social support 0.30 present and subscales of religious and social activities with social support explain 0.41 percent of the mental health variance.[13] Among the other variables, with great interest oriented in positive psychology, is life satisfaction. Pavot and Diener[14] state that life satisfaction is an arbitration process, in which the quality of life is assessed based on its unique criteria. People who are satisfied with their lives experience many positive emotions, such as, happiness, pleasure, and joy, and have lower levels of negative emotions such as, sadness, grief, loneliness, and depression. Mayer and Diener[15] show that life satisfaction is correlated with high mental health. Whenever the life satisfaction is higher, a person is more susceptible to experience positive emotions. Maltaby and colleagues have found that individuals with higher life satisfaction use more effective coping styles. They experience positive emotions more deeply and have a greater mental health.[16] Dissatisfaction in life is associated with poorer health status, symptoms of depression, personality problems, poor health behavior, and low social status. Among other variables related to mental health is social support. Social support is defined as the welfare, caring, and respect that the individual receives from others. Perceived social support, in fact, refers to the perception of the individual to love and support family, friends, and relatives against stress and events, which are the sources of support. A person has feelings of caring, being loved, self-esteem, and being valuable. A feeling of belonging to an extensive network of interconnections will be made.[17] In a study by Vang and colleagues[18] it is seen that there is a positive correlation between self-care behavior, hope, and social support.

Among Taiwanese patients who are awaiting heart transplantation, social support is the best predictor for self-care behavior, hope, and perceived self-efficacy. Perceived self-efficacy can be considered as one of the predictors of mental health. Self-efficacy is defined as, ‘people's judgment about their abilities to organize and perform a series of tasks, to achieve a certain types of performances’.[19] Self-efficacy is a constructive ability to organize and adjust planning skills to deal with the needs and conditions.[20] People with low self-efficacy for performing a job, may refrain from doing it, but those who have confidence about their abilities and believe they can do it, will probably participate in those activities.

According to what is described earlier, the aim of the present study is to check the connection among the variables of spiritual well-being, life satisfaction, social support, self-efficacy, and mental health of the war veterans. Given the importance of each of listed predictor variables in mental health and as no research has been done in this area, with the focus to provide a model or pattern to determine the contribution, mediated and non-mediated, these effective variables have been investigated in the veterans’ mental health. Therefore, the aim of the current study is to develop a model to determine the impact of these factors on the veterans’ mental health.

MATERIALS AND METHODS

The present study with regard to the target was among the basic researches and with regard to the method of data collection was a correlational study. The participants in this study were 210 war veterans with records in the Veterans Foundation in Tehran, Sara Allah, and Imam Khomeini shelters, and Esaar Sports Center in Tehran, who were selected randomly. To begin with, the needed explanation was provided about the research goals, its advantages, and completion of the questionnaires by the respondents. They were aware of the confidentiality and gave their approval to participate in the study. Then, in coordination with officials of the Veterans Foundation, with them permission and giving the necessary explanations, the questionnaires were provided to them to be completed. Subsequently, all of the individual scales were given to subjects for responding. It was also requested that none of the questions be left blank and careful attention had to be provided to the answers. In the end, some gifts were given to each subject in order to appreciate their cooperation.

The used tools in this study were as follows:

General Health Questionnaire (GHQ): This questionnaire was a tool for determining the general psychological health in particular, which had been developed by Goldberg and Hiller in 1972, in order to screen the non-psychotic mental disorders in health centers. This questionnaire had the needed ability to assess the severity of mental disorders. Noor Balaa and colleagues examined the validity and reliability of the questionnaire among the women and men. They expressed that the results, after assessing the questionnaire and its concurrent validity, demonstrated that there was a significant correlation (P < 0.001) between the two scales of SCL-90 and GHQ, among all the sub-components. The reliability coefficients and test-retest of the questionnaire was equal to r = 0.85.[21]

Spiritual Well-Being Scale (WBS): This test was developed by Palovtzian and Ellison, in 1982. It had 20 questions and two subscales. The questions were related to the sub-scales of religious well-being and the individual's experience, which was measured by whether or not they had a satisfying relationship with God. The odd questions were related to the existential well-being subscale to measure the sense of purpose and life satisfaction. The scale used for answering the questions was a Likert six-degree scale from, ‘completely-agree’ to ‘completely-disagree’. Method of grading the questions was from one to six and by using this grading scale, the religious welfare, spiritual well-being, and total scores were obtained. In the study of Palovtzian and Ellison,[22] religious welfare, existential coefficients, and the total scale were equal to 0.96, 0.86, and 0.93, respectively. The Cronbach's alpha coefficients were reported to be equal to 0.91 < 0.90 and 0.93, respectively. Dehshiri, Sohrabi, Jafari, Najafi[23] study on male and female students, evaluated the psychometric properties on this scale, in Iran. Cronbach's alpha reliability of this test for the total scale and subscales of religious well-being and existential have been reported as 0.90, 0.82 and 0.87, respectively. The reliability coefficients by the retest method were reported to be 0.85, 0.78 and 0.81, respectively.

Multidimensional scaling of perceived social support (MSPSS): MSPSS, which consists of 12 items, was developed by Zimet, Dahlem, Zimet, and Farley[24] to identify the social support factors perceived by the individuals. The scale is comprised of 3 groups depending on the source of support, each group consisting of 4 items. These are family (3, 4, 8, and 11), friends (6, 7, 9, and 12) and a special person (1, 2, 5, and 10). Each item is rated using a 7 range scale varying between “definitely no” and “definitely yes”. The sum of 4 items under each sub-scale gives the sub-scale score, while the sum of all sub-scale scores gives the overall scale score. The lowest score in sub-scales is 4, and the highest is 28. The lowest overall scale score is 12, and the highest is 84.

General self-efficacy (GSE): The GSE (25) is a Likert format 17-itemscale. The response format is a 5-point scale (1 = strongly disagree, 5 = strongly agree). Sum of item scores reflects general selfnefficacy. The higher the total score is, the more self efficacious the respondent. Sherer et al. developed the GSE scale to measure “a general set of expectations that the individual carries into new situations”. The GSE has been the most widely used GSE measure. The SGSES was primarily developed for clinical and personality research. Later it has also been used in organizational settings.

Reviewing various organizational studies, Chen et al. (26) found internal consistency reliabilities of SGSES to be moderate to high (α = 0.76 to. 89).

Life satisfaction scale: This scale was designed by Diener and others[27] to measure the level of overall life satisfaction. It contained five questions with a seven-degree Likert response scale (‘totally agree’ to ‘totally disagree’). Internal consistency reliability coefficients and retest scale among students were reported to be 0.87 and 0.82, respectively.[27] The followings were used for data analysis: Mean value, standard deviation, Pearson correlation, and path analysis, which assisted the LISREL software version 8.5.

RESULTS

Frequency Distribution of the subjects participating in the study is presented in Table 1. The mean age and SD of the participants were 41.90 ± 11.42. The minimum age of the participants was 22 years and the maximum age was 75 years. In terms of education, 40 participants (19%) had not finished high school, 76 participants (36%) had a high school diploma, 15 cases (7.1%) had a college degree, 61 participants (28.9%) had a bachelor's degree, and 18 cases (8.5%) had a higher education. The criteria for entry into the study included Physical disability over 25%, age, marital status, education, gender, social class, family status, no history of mania, and other psychiatric disorders. The exclusion criteria included history of addiction or taking drugs, being engaged in other non-drug therapies during the study simultaneously with the implementation of this research, and other concurrent psychological disorders.

Table 1

Frequency distribution of the subjects in terms of marital status

There was a significant negative relationship between all predictor variables and mental health. The highest correlation coefficient was related to life satisfaction (r = −0.52, P < 0.01). The lowest correlation coefficient was related to self-efficacy (r = −0.30, P < 0.01) and mental health [Table 2]. It was intended to investigate the relationship between the predictor variables and mental health [Figure 1], and it was presented as the model that best-fitted the obtained data [Figure 2].

Table 2

Mean value, standard deviation, and the correlation matrix of the study variables

Figure 1

Conceptual model of structural relations between spiritual well-being, self-social support, and life satisfaction of veterans’ mental health

Figure 2

Path analysis relationship between social support, spiritual well-being, and life satisfaction in mental health

There is a little difference between the fitted model and the conceptual one [Figures 1 and 2]. The best-fitted model is the model in which self-efficacy has no significant effect, on life satisfaction and spiritual well-being as a mediator variables, and the dependent variable, that is, mental health. It was removed from the model. The investigation of the standardized path coefficient analysis and its corresponding t values show that social support was directly related to life satisfaction (t = 5.98, B = 0.34) and spiritual well-being (t = 5.59, B = 0.36) [Figure 2]. Furthermore, spiritual well-being is also affected directly (t = 3.18, B = 0.22) and indirectly by life satisfaction in the veterans’ mental health. The effect of life satisfaction on mental health is also significant (t = 5.86, B = 0.41). On the other hand, due to the standardized path coefficients, more effect of life satisfaction is obviously on mental health. The ratio of the Chi-square to the degree of freedom in adequate models is less than two. This ratio is much closer to zero, which is better. This value is less than two here. The root mean square error of approximation (RMSEA) in the present model is equal to 0.00 [Table 3]. The criteria for good models is less than 0.05 and for weak models is greater than 0.10.[28] Thus, it is acceptable for the present model. The adjusted goodness of fit index in good models is well above 0.90. As it can be seen in the related Table, all of these parameters show the fitting of the model (AGFI = 0.98). All other parameters (RFI, CFI, NFI, and NNFI) of the model are estimated which is presented in Table 3.

Table 3

Model goodness of fitted indices

DISCUSSION

The aim of the present study was to establish a path analysis in order to predict the mental health of the war veterans based on self-efficacy, social support, and spiritual well-being, with regard to the mediating role of life satisfaction. The Pearson correlation test results demonstrated that there was a significant correlation between all predictor variables and mental health. The highest correlation was related to life satisfaction and the lowest correlation was related to self-efficacy. To determine the precise contribution of the predictor variables on mental health, the path analysis model was used. Overall, the indicators of the model goodness of fitted parameters demonstrated that, in general; the model was fitted to the data and the theoretical model matched to the actual data, with slight modifications. In other words, researcher assumptions, which were based on previous research results were presented in the form of a theoretical model, totally matched to the obtained data from the samples. Therefore, it should be considered that there could be another approved model or models, which would be even better matched with the data from the present model. Investigating the exogenous variables of the model (independent latent) specified that among these variables, the life satisfaction index had the highest factor in the veterans’ mental health. The researchers have shown that life satisfaction is one of the predictors of mental health.[29] Life satisfaction is different from other psychological constructs, such as, positive and negative affect, self-esteem, and optimism.[30]

Koiumaa-Honkanen and colleagues[31] conducted a meta-analysis on life satisfaction. They found that less satisfaction with life was associated with an increased risk of suicide, even with controlling the variables such as age, gender, baseline health status, and alcohol consumption. Dissatisfied men had a greater risk (25 times more) for suicide compared to women who were dissatisfied. Mayer and Dienier[15] showed that life satisfaction is correlated to high mental health. Whenever life satisfaction is higher, the individual is more likely to experience emotions and positive feelings. Maltabay and colleagues found that people with high life satisfaction make use of more effective and suitable coping styles. They experience deeper, positive emotions and have a higher sense of public health.[16] Dissatisfaction in life is associated with poorer health status, symptoms of depression, personality problems, poor health behavior, and low social status. Adler and Fagley[32] showed that life satisfaction was affected by the consciousness of optimism and a spiritually oriented person. In other words, whoever was more self-conscious and more optimistic, with the integration of higher spirituality, was faced with a higher amount of life satisfaction. On the other hand, in the proposed model, it was seen that the coefficient of spiritual well-being on mental health was significant. These findings corresponded with the findings of Nilsson,[33] Wentis,[34] Koeing,[35] Kim,[36] and Bahrami and Tashak.[37] The above findings are indicative of the fact that spiritual well-being affects aspects of the mental and physical health of individuals and in addition produces a significant experience in life and this purposeful sense is essentially associated with the acceptance of life, responsibility, socializing, communication, targeting, hope, and optimism (Pargament, 1990, quoted in 38). In sum, by reviewing the conducted researches of the last decades, it will be possible to reach this point that spirituality is effective in the promotion of mental and physical health and in reducing its related disorders. Spiritual well-being will improve people's mental and physical health by increasing self-awareness, communicating and connecting with others, receiving social support from others, increasing the sense of confidence and the meaning and purpose in life, effective coping, and adaptation of mental and physical health problems, in addition to other factors associated with mental health. It increases the levels of coping with life events. Other findings from the present study are about the fact that social support is associated with life satisfaction and spiritual well-being. Researchers have proposed two models to explain the impact of social support on health. The first model is the main effect model and the other one is the buffering hypothesis against stress. On the basis of the first model, social support, regardless of the affection of stress, shields the individual from negative experiences. This has a beneficial effect on his/her mental health.[1] Based on the second model, social support is useful only for people under stress and acts like a shield to prevent stress on the individual. Studies have shown that there is a significant association between social support and health. People with higher social support have better health status.[39] Social support reduces the likelihood of becoming ill and it will accelerate recovery and reduce mortality.[40] Another finding from the research, according to the fitted model, is that spiritual well-being directly impresses upon life satisfaction.

The researches (Andrews and Withey, 1976; Fordyce, 1997; Pavot, Dinner and Suh, 1998; quoted in 41) showed that a positive religious attitude could lead to life satisfaction and life satisfaction was one of the predictors of mental health. In another research by Kim and colleagues,[36] there was a significant association between spiritual well-being, emotional well-being, and life satisfaction. In the study of Helliwell,[42] it was found that attendance at religious and spiritual places, one or more times per week is associated with higher life satisfaction. In the study of Hayo,[43] attendance at religious and spiritual sites, including the church, was associated with high satisfaction in many aspects of life and the absence was related low satisfaction. Religious people are usually happier compared to secular subjects, regardless of their religious affiliation. Helliwell[42] in a literature review in the previous researches has found that belief in God and a superior force is associated with high levels of mental health, psychological well-being, and life satisfaction. In summary, it appears that war veterans, after facing the mental and physical harm received from the war, understand the necessary social support of the family and community. In order to strengthen spirituality, they have started relying on a superior power to seek support, and thus have taken successful steps, especially in terms of the social dimensions of religion, to strengthen themselves. They are very satisfied with their lives and have lower anxiety and depression. Thus, they have better mental health.

Among the limitations of this study, to some extent, it could be noted that it was a heterogeneous sample, which was associated with the nature of the sample, and was beyond the control of the researchers. However, it was attempted to have a random selection among the depressed veterans and they were replaced randomly to solve the problem.