Introduction 
ealth is an outcome, a resource for life, and a valuable condition in society and between people as it allows people to be active and participate in life [1]; however, its definition is different in societies and even in individual opinions [2]. In 1971, health experts included the spiritual dimension of health in the general concept of health, and in 1984, the World Health Organization (WHO) introduced the spiritual dimension as an integral part of health [3].
Today, despite the importance of spiritual health and its effect on other dimensions of health [4], a common understanding of spiritual health has not yet been formed and there are several definitions of the concept of spiritual health and its dimensions and characteristics [5]. Accordingly, the views of religious scholars differ from those of secular scholars on the concept and dimensions of spiritual health. Religious scholars in their studies consider spiritual health as believing in the existence of God and performing religious practices [6]; they define spirituality in the context of religion. Therefore, having the right faith and belief, taking a step in the path of divine guidance, and avoiding moral pollution are considered the definition of spiritual health [4]. According to Allameh Tabatabai’s view, the dimensions of spiritual health include spiritual insight, spiritual tendencies, and God-centered behaviors [3].
On the other hand, some secular views generally separate religion from spiritual health [7-9]. In this view, love, wonder, and amazement of the greatness of the world, pleasure, ambition, beauty, music, art, and science constitute the spiritual dimensions [10]. Some studies also stated that children’s spiritual health is similar to that of adults in the four dimensions of relationships with self, others, nature, and higher power [11, 12]. However, some experts consider spiritual health as a vertical and horizontal dimensional concept [13]. In the horizontal dimension, a relationship with oneself is an important discovery of life, curiosity, finding meaning in life, self-awareness, being purposeful, and experiencing pleasure in life relationship with others includes kindness, forgiveness, and helping others. In the vertical dimension, there is a relationship with God, belief in God, talking about God and religious books, as well as the desire to read religious books and stories [11, 12].
A study by Leitao et al. showed that the concept of spirituality in children is different from that of adults, and in addition to the vagueness of this concept in children and overlapping with the concept of religion, there is a prominent role of parents and family and the relationship with the environment, especially peers [14]. Findings of studies show that a child’s spiritual health is focused on all aspects of his existence [15] and it means an increase in awareness, inner experience of surprises, curiosity, belief in a strong force, and transcendence in life.
The limited understanding of the concept of spiritual health in children has a role in the performance of specialists and their readiness to deal with children’s issues in this field [14]. During this period, the personality, spiritual, and even physical foundations are formed and from then, they are effective throughout human life. Understanding children’s spirituality is an emerging field of research [9]. Considering that spiritual health in children from birth to 18 years of age plays an important role in children’s well-being, improving their relationships with themselves and others, increasing their self-esteem and resilience, and reducing their stress and depression [16-18], conducting numerous studies on understanding the concept of spiritual health in children and its dimensions is necessary.
Many studies have been conducted on the spiritual health of children [11, 12, 19], but one of the most important criticisms of such studies is their inability to distinguish different dimensions of spirituality [20]. Children’s spiritual development is influenced by cultural context, religious and spiritual identity, social identity (age, gender, and race), and experiences, such as oppression, power, and privilege. On the other hand, due to the wide concept of spiritual health and the effect of awareness and perception of spirituality, religion, and various cultural conditions on the concept of spiritual health [21], it is necessary to study the dimensions of this concept in children in the cultural context of Iranian society. Based on the opinions of experts in the field of spiritual health in Iran and the review of the studies conducted, no study has been done to explain the dimensions of spiritual health of children in Iran. Additionally, the range of other studies regarding children’s spiritual health is limited. Therefore, the necessity of examining children’s spiritual health was also revealed through interviews. On the other hand, by examining the dimensions of children’s spiritual health, it becomes possible to measure and use the capacity and potential of this dimension of health to influence other dimensions of health and to improve the general dimension of children’s health, and it becomes a foundation for other studies. Considering that qualitative methods have a high power in achieving a deep understanding of the concept of health and based on our current knowledge, a qualitative study has not been conducted with the participation of children in Iran; therefore, this study explains the dimensions of children’s spiritual health in Iranian society.

Methods
This is a qualitative study to find the dimensions of children’s spiritual health. This subject was broached by the conventional content analysis approach from March 2020 to February 2021 in Tehran City, Iran. Given the COVID-19 pandemic and due to the willingness of the participants, most of the interviews were conducted through WhatsApp. In other interviews, place and time were agreed mutually. A total of 26 interviews were conducted with an average duration of 30 min. The participants included 17 children and 9 researchers and specialists in the field of children’s mental health who were selected by the purposeful sampling method. To select the sample, first, the research team held a face-to-face meeting to choose people for the interview. The selected children were from different families in terms of cultural, religious, educational, and economic levels. They were also selected from different cities in Iran. The experts were selected purposefully at the beginning, and the sampling continued through the introduction of other people in the form of a snowball. The 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 the interviews. Meanwhile, the inclusion criteria for professionals were to have a history of activity in the field of spiritual health and the growth and development of children. Data collection was performed using semi-structured interviews with open-ended questions. The interviews began with a few general questions. The main questions in the interviews with children included “What do you think health means?” and “When do you feel good?”. In addition, the researchers were asked questions, such as “What is your definition of spiritual health?” and “What are the spiritual features of a healthy child?”. During the interview, more specific questions were asked based on the answers of the interviewees (such as “Can you give a clearer example?”).
Granheim and Landmann’s content analysis approach was used to analyze the data. First, the text of the interviews was transcribed on paper, and after studying the text of the interview several times, it was divided into semantic units, and the initial codes were determined. The codes were then divided into categories and subcategories based on similarities and differences. Eventually, themes were created that represented the hidden content of the interviews [22]. After analyzing 23 interviews, no new categories were formed, but to ensure, three more interviews were conducted. Lincoln and Goba’s four criteria, including validity, reliability, authentication, and transferability were used to increase data quality [23]. To increase the validity and reliability of the data, in addition to allocating enough time to collect data and long-term engagement with the data and immersion in them from member check (two 11-year-old boys and a 9-year-old girl; an active psychologist in the field of the child 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 authentication by discarding thoughts and assumptions in the process of data collection and analysis.
In this research, all the necessary points related to ethical considerations were observed, and for conducting the research, the code of ethics with the number was acquired from the university. The researcher assured the participants that all information would remain confidential. The participants were reassured about leaving at any stage of the study they wished without any adverse consequences.

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 176 main codes, 33 subcategories, 6 main categories, and two themes. The dimensions of spiritual health were explained with two themes including balanced relationship and relationship transcendence (Table 1).




Discussion
In the present study, the participants’ experiences of the dimensions of children’s spiritual health were explained with two themes of balanced relationship and relationship transcendence. The theme of balanced relationship was formed by the juxtaposition of categories of relationship with God, relationship with self, relationship with others, and relationship with the environment. In balanced relationships in the age range of children who participated in this study, all dimensions of relationship have clear characteristics in the field of spiritual health concerning God, self, and others; this balanced spiritual development in three simultaneous dimensions in the age group, which according to psychologists has not yet developed the moral development and cognitive development of the child, is significant. Relationship is an important issue in the field of psychological health and social health, and the child must achieve balance in these four dimensions to achieve spiritual health. Findings from the study also show that children who feel a high level of belonging to their communities, families, and schools report higher mental life satisfaction, better emotional health, and well-being [24]; therefore, some child education professionals built their educational model on the premise that children’s search for meaning can only be identified and nurtured through their connection to other people, nature, and the world [25].
The theme of balanced relationship in the dimension of relationship with God refers to children’s research on the nature of God, attention to divine pleasure, and acknowledgment of the full power and generosity of God (religious knowledge), so that the child’s attention to God is not a one-axis or self-centered relationship, and God in the minds of children is not merely as a source of power that meets the needs and prayers. Having a variety of questions about God, designing, and asking these questions show the child’s innate tendency to know God. Given the cultural-religious context of Iran, the search and tendency to understand God, worship, as well as performing religious practices, prayer, and worship to highlight this connection and an answer to their curiosities were the views of the participating children. The experience of living with children sometimes brings to mind that children have a material and instrumental understanding of the concept of God in their minds, and based on this, their relationship with God is formed at lower levels of relationship. However, the present study with the method of purposeful interviews with children showed that God in the world of children’s relationships has a concept beyond meeting personal needs or rescuing them from problems. Concerning the relationship with God mentally and behaviorally, they think and comprehend more correctly and completely than their intellectual age. This suggests that the potential of divinity in the children’s id has a developmental process incomparable to their cognitive, behavioral, or social dimensions. Children in the field of spirituality have not only grown in the dimension of behavioral balance according to our initial perception and assumption but also in the dimension of behavioral transcendence and have incredible cognitive-spiritual growth and development.
In the issue of balanced relationship in the dimension of relationship with God, referring to the areas of trust shows that for the child, parents are not the only ones who provide security and peace of her/his mind. In addition to relying on the factors of power and security that s/he understands, s/he also relies on the factor of eternal power that s/he cannot imagine, trusts it, and feels secure by relying on Him.
In the issue of balanced relationship in the dimension of relationship with God, referring to the good feeling resulting from praying and worshiping God or performing actions, such as reading the Qur’an, performing ablutions, and fasting (worship) shows that the deed of relationship with God is central to the child. Believing and acting on behaviors that are not normally perceived and known to the child is the peak of the capacity and potential of the divine nature in the child, which shows itself in every educational and environmental context with various components with a high benefit of spiritual health. According to Fowler’s study, children can think about and ask questions about people and things that do not exist. As a result of such curiosities about identity and what happens daily, their spirituality is formed. Prayer and worship and the emergence of religious behaviors help the children operationalize the concepts [26]. In his study of Canadian children, Michaelson states that the children who participated in the study stated that the feeling of belonging to something greater than oneself, even if one does not believe in God, gives human beings a sense of connection to the whole world [12]. 
Balance relationship in the dimension of self-relationship was abstracted from the combination of characteristics, such as self-respect, self-awareness, self-belief, self-care, resilience, self-control, and self-expression. In the study of Hekmatipour et al., spiritual experiences in adolescents have been expressed in the form of self-care and self-control [27]. 
Self-belief is a value that is formed within a person starting from childhood, and slowly develops and strengthens over time; it is an inner force that prepares a person to face the basic challenges of life. Self-control is a type of inner care and skill that helps the child control their thoughts, actions, and emotions to do the right thing. This skill is important especially when interacting with others. Controlling one’s actions and reactions helps children be flexible concerning other people; therefore, it is effective in improving the child’s performance in society and increasing self-esteem. Such a child performs their duties well without being supervised by anyone and avoids unconventional activities [28]. Self-management is a set of behaviors, such as adherence to medication, nutrition, physical activity, problem-solving, stress reduction, and so on, that people do to prevent problems and improve injuries. Although children need their parents to achieve self-management, it is possible to lead them toward independent self-care activities by taking advantage of the logical thinking ability of children’s development at different ages [29].
Benson and Spilka reported a positive relationship between self-image and especially self-esteem and God’s image. The more positive the self-esteem and self-image, the more positive, supportive, kind, and powerful God was imagined [30].
Resilience is the process of coping with stress and recovery from physical, mental, and hardship problems. Such a person can maintain their performance in unusual circumstances and even grow after that [31]. In their study, Schwalm et al. showed a moderate positive relationship between resilience and religious and spiritual beliefs [32].
The theme of balance relationship in the relationship with others and the child’s environment regarding respect for parents and others, service to them, not judging others, appreciation, attention, and preservation of the environment and animals. Accordingly, the child is not focused on those around them as providers who try to fulfill their peace and desire. Rather, they considered themselves as a healthy spiritual person who looked at themselves from a higher perspective. Such a person’s mission is to pay attention to and meet the needs and satisfaction of the people and the environment, as well as to pay attention to their dignity and personality. Children did not mention the duties and roles of others and the environment about themselves, or did not mention their two-way relationship with others and the environment, and referred to the nature of their spiritual action and behavior toward others and the environment per se. This shows the intactness of spiritual thoughts in children. Hence, we can assume that perhaps the one-sidedness of children’s spiritual thoughts in their relationship with God and with others indicates their greater spiritual health compared to adults. In other words, with increasing age, spiritual thoughts and behaviors derived from the spiritual health of individuals become more ambivalent.
In the components of a relationship with the environment, understanding and paying attention to the environment while enjoying it and also preserving the environment were the characteristics of children’s spiritual health. Children have an innate desire to explore and connect with the natural world. The core of all theories of growth is the interaction of the individual with the environment. Psychologists believe that interaction between humans and the environment plays an important role in meaning-making and organizing human life [33]. Kahn and Kellert believe that children experience nature in three direct, indirect, and symbolic ways. Relationship with nature affects a child’s physiological, psychological, social, and emotional functioning. Feeling peace, learning, strengthening memory, increasing accuracy, adventuring, developing physical skills, etc. are developed in the child as a result of relationships and interaction with the environment. In addition, it leads to the establishment of an emotional link between the child and nature and the development of a sense of responsibility for the preservation of nature [34].
The theme of relationship transcendence was determined as the two categories of love of God and transcendent behaviors. If we consider that in terms of balanced relationships, children outside the designated growth chart go through the path of spiritual growth towards spiritual health faster than other dimensions, considering the relationship transcendence for this age group is out of our scientific-probable assumptions. However, the results of this study showed that children in this age group, in addition to having a balanced relationship based on spiritual health, also enjoy a significant amount of relationship transcendence based on spiritual health. As scientific citations in the field of psychology show, those who are in the age group of children are incapable of understanding abstract concepts, and gradually they achieve the ability to understand abstract transcendent concepts in the course of development in adolescence and youth. Despite this scientific evidence, the present study showed that children in this age group fully infer and understand transcendent characteristics about others and consider and emphasize their behavioral assumptions with others. In other words, the abstraction of the characteristics of relationship transcendence, which usually occurs in the post-childhood ages, can be abstracted in childhood; it is evoked in the mind and thought and is produced in behavior. Therefore, apart from other pillars of development that follow the rule of maturity, balanced relationship and relationship transcendence in children do not follow the rule of maturity, and due to the innate foundations of balanced relationship and relationship transcendence of spiritual health, these characteristics have been present in children since childhood, regardless of any religious-spiritual measures within the family, and the children activate the potential of their spiritual health from the early childhood of the second stage and are highly prepared to establish the factor of spiritual health in themselves. Considering the socio-educational institutions and the educational context of the family, this important issue can accelerate growth and stabilization.
Altruism, good temper, empowering others without expecting them to accept others as they are, and creating common sense with each other make a servant and hard worker from the child who never neglects to serve others [35].
Positive emotions and love of God and prophets express relationship transcendence. Having characteristics, such as seeking God, a sense of worship, servitude to God, and love of Him, and choosing God is a sign of the transcendence of the human soul. Given that human beings love beauty in their nature, while admiring these beauties, they love the creator of them and also love other creatures [36].

Conclusion
The findings of the present study explained the dimensions of children’s spiritual health with two themes balanced relationship and relationship transcendence. Interacting in life and communicating with God, self, others, and the environment helps humans achieve balanced relationships and success in life stages. The child’s perception of God, self, others, and nature (environment) is involved in the development of spiritual emotions and behaviors. Love and affection for the creator of the universe and the manifestation of human behaviors also indicate the spiritual health of the child. Therefore, the child’s awareness of the self and the universe and curiosity in this field, as well as connection with other people, creatures, and nature provide the basis for a balanced relationship. Supporting and strengthening the balance with the right plan and timely guidance contributes to spiritual health by creating relationship transcendence.

Study strengths and limitations
The generalizability of the study findings is limited based on the qualitative method. Another limitation of this study was limited access to children from other religions. One of the strengths of the present study is its sampling diversity and deep interviews with a variety of children in different regions and cities of Iran.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by AL Zahra University (Code: IR.ALZAHRA.REC.1399.011).

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

Authors' contributions
Conceptualization: Soolmaz Moosavi and Maryam Safara; Methodology, data collection, analysis and writing the original draft: Soolmaz Moosavi and Hanieh Gholamnejad; Review, editing and supervision: Maryam Safara.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank all the participants.




References