Introduction
Spiritual health has obtained significant attention from scholars and researchers as a fundamental component of overall well-being. Given the challenges faced by students in the academic domain, as well as the emergence of detrimental behaviors, such as substance abuse, recklessness, and psychological problems, addressing spiritual health has become increasingly important. These issues are often associated with feelings of emptiness and a lack of spiritual well-being. However, despite recognizing the importance of spiritual health, there is currently a lack of a universally accepted, comprehensive, and standardized definition for this concept [1]. Numerous studies have been conducted to explore various dimensions and factors that influence spiritual health. Empirical evidence has demonstrated a strong correlation between spiritual health and life satisfaction, as well as academic performance [2-5]. Psychosocial structures have been identified as significant in understanding health literacy within the context of spiritual health [6], while interpersonal relationships have been found to play a crucial role in determining levels of spiritual health. Additionally, factors, such as religious beliefs, marital status, fatigue, and social support have been identified as influencers of spiritual needs [7]. In addition, studies have shown the predictive role of spiritual intelligence in students’ spiritual health [8]. Additionally, there is a positive correlation between daily spiritual experiences and spiritual health [9]. Spiritual leadership has also been highlighted as influential in promoting spiritual health [10]. Additionally, the significance of practical training in spiritual health within the medical field has been underscored [11]. However, challenges persist in conceptualizing, understanding, and evaluating spiritual health primarily due to its definition being shaped by the cultural context of each society [12]. While there are various tools available for assessing spiritual health, many of them lack the necessary scientific rigor to facilitate accurate investigations. It is crucial to construct these tools based on a theoretical foundation that clarifies the conceptual structures. This requirement is often overlooked during tool development. Experts in the field of tool development emphasize the importance of deriving the content of a specific tool directly from the individuals who serve as the reference for that tool [13]. By incorporating the perspectives of participants in the development process, the resulting tool can comprehensively cover all relevant aspects of spiritual health literacy. Furthermore, the cultural context plays a significant role in tool development, as values and meanings can vary across cultures. Involving the study population in content extraction ensures scientific validity and reliability, as it aligns the tool with the cultural context and maximizes its effectiveness [14]. Additionally, the formulation of questionnaires should consider individuals’ subjective experiences, which are influenced by their cultural background. This is a factor that is often disregarded in studies focused on tool development [15]. Aligning emic and etic concepts and extracting content from the reference population can improve the efficiency and validity of scales. Scale development is recognized as a crucial scientific foundation for conducting research. Researchers who do not have a suitable and scientifically sound tool face challenges in conducting rigorous and valid investigations, which can result in questionable findings [16]. Therefore, the adequacy of a research study is now assessed by prioritizing the examination of the measurement tool’s validity, as the credibility of research findings relies on the scale’s validity. Meanwhile, no tool has been developed thus far to measure students’ spiritual health literacy. Consequently, this study designs a comprehensive tool that addresses the significant gap in the existing literature. This tool will consider various aspects, such as validity, reliability, and construction to ensure its effectiveness.

Methods 

Study design
This exploratory qualitative study focused on the conceptualization of spiritual health literacy among students at Gonabad University. The data were analyzed using the framework analysis. This study was conducted from December 2022 to November 2023 in Gonabad City, Iran.
Participants characteristics
The participants were 13 faculty members and experts from Gonabad universities. They were Iranian, Persian native speakers, and had at least 5 years of expertise. The participants’ ages ranged from 30 to 60 years old. The characteristics of the participants are summarized in Table 1.



Data collection
Purposive sampling was conducted to select the participants. The participants were from Gonabad University of Medical Sciences and Gonabad Seminary. A total of 13 in-depth face-to-face interviews were conducted for data collection. The interviews were conducted in the most comfortable location for the participants, following an interview guide. Interviews started with indirect questions, and participants were asked to explain their perceptions about spiritual health literacy. After icebreaking they were asked more questions, such as “How do you define spiritual health?”.
Probing questions were used to further explore the responses. Each interview lasted between 35 and 90 min, with an average duration of 60 min. The interviews were continued until data saturation was achieved. All interviews were digitally recorded, carefully listened to, and then transcribed verbatim by the first author. All transcripts were read thoroughly, which allowed for a deep understanding and complete grasp of the entire content of each interview.

Data analysis
MAXQDA software, version 20 was applied to data analysis. Data analysis was conducted using a thematic analysis approach. The data analysis process consisted of the following 5 main stages: Familiarization with the interviews, development of a thematic framework, indexing, charting, mapping, and interpretation. These stages were presented in a textual table to provide clarity on the framework analysis process (Table 2). In summary, meaningful phrases from the interviews were categorized into 148 open codes, which were then summarized into 24 subthemes, and finally extracted into six main themes. The process of analysis is presented in Table 2.



Research rigor
Guba and Lincoln’s components of research rigor, including credibility, confirmability, and transferability, were considered to ensure trustworthiness [18]. Audio recordings of the interviews were used, and participants’ quotes were included in the reporting of results to enhance credibility. Dependability was ensured through peer reviewing, as well as reflexivity during data collection and analysis. Detailed descriptions of research settings, participants, and methods ensured transferability. Conformability was ensured by maintaining an audit trail of all documents and decisions [19].

Results
Data analysis revealed main themes, including culture, family status, education, justice, social characteristics, and modeling (Table 3). 



Culture
Spiritual health literacy is defined within the cultural framework specific to each society. Therefore, considering culture is essential in defining and examining spiritual health within a cultural context. It was conceptual that major cultural factors are interconnected.
“I believe that health literacy encompasses behaviors that contribute to a healthy lifestyle.”
“Certain behaviors, such as wearing seat belts, serve the purpose of aiding others and can become habits as a result of societal pressure. On the other hand, driving under the influence is always considered a crime, highlighting individual responsibility within society. However, individuals with mental disorders may face legal consequences for engaging in such behavior (Participant (P)1, academic member, 34 years old).” 

Family factors
Family factors play a significant role as the primary influential factor in shaping spiritual health literacy. Spiritual health literacy has the potential to be nurtured and developed.
‘’It is my idea that literacy, as well as families being the primary influence, together with personal literacy, can educate students. However, the concepts of good and bad vary across different societies and can be nurtured (P2, academic member, 42 years old).”

Education
To promote the expansion of spiritual health literacy, it is essential to enhance practical education. Students should be exposed to practical examples of spiritual health literacy behaviors, and this should be demonstrated by the instructor’s performance.
“‘It is my idea that to promote spiritual health literacy, practical education should be strengthened. Students need to be exposed to practical examples of spiritual health literacy behavior, and this should be reflected in the instructor’s performance (P3, academic member, 50 years old).”

Justice
If seeking to create an ideal society, in addition to education, infrastructure should also be reformed. The consequence of such a society would be the convergence and movement of the community toward justice and fairness, as well as experiencing peace and spiritual, mental, and physical well-being.
“It is my idea that addressing the physiological needs and socioeconomic issues is crucial for promoting spiritual health literacy. Imam Ali’s statement highlights the impact of poverty on faith. To create a virtuous society, both education and infrastructure must be improved. This would lead to unity, justice, and the experience of peace and well-being in all aspects of life (P4, academic member, 55 years old).”

Societal characteristics
An important factor in spirituality is the society in which one lives. Each individual has inherent qualities that naturally incline them towards spirituality, but external factors, such as the education system also play a significant role.
“It is my idea that the important factor involved in spirituality is that it is tested by society.” “There are inherent qualities in every individual that naturally lean toward spirituality, but external factors, such as the educational system act as secondary influential factors” (P5, academic member, 48 years old).”

Modeling
Modeling leadership and management responsibilities is crucial. In the context of education, we prioritize efficiency by implementing effective methods and enhancing models that have a positive impact on young people.
“It is my idea that pattern-making is the duty of leadership and management.” In our training, we aim to reduce the duration while enhancing effective methods and impactful patterns for young people” (P6, academic member, 49 years old).”

Discussion 
The issue of spiritual health literacy holds paramount importance concerning life conditions and quality. Drawing from the obtained findings, the antecedents related to spiritual health literacy encompass the six following main themes: Culture, family factors, education, justice, societal characteristics, and modeling. The findings of this study are in line with prior research conducted by Lotfian et al. (2020) titled “the correlation of daily spiritual experience with the level of spiritual health in military university professors (spiritual experience and spiritual health)” [6]. This study establishes a positive correlation between professors’ spiritual experiences and their health. It sheds light on the multifaceted nature of spiritual health literacy among students and its underlying factors [6]. In studies conducted in Iran, the authors identified the following 5 main themes related to effective teaching: Attention to educational philosophy, communication, religious values, and curriculum revision. These themes highlight the significance of spiritual health literacy [20]. Moreover, it was emphasized that spiritual literacy is a concept that can be nurtured and developed [21-23]. It involves reflecting on and developing one’s skills, aligning behavior with social norms, fostering relationships, and experiencing environmental sensitivity and connectedness with nature [24]. Spiritual needs are considered profound and play a crucial role in enhancing health and addressing illness. Spiritual health literacy is considered universally applicable and can be acquired and enhanced by all individuals [25]. The promotion of spirituality, especially within the family, is crucial for nurturing spiritual growth and well-being. Ethical considerations, such as justice and adherence to principles, also contribute to enhancing and broadening spiritual health literacy [26].Aligning cultural values and principles with the concepts of spiritual health literacy ensures its preservation and institutionalization within individuals [27]. In the investigation of spiritual health literacy, 15 primary themes and 53 sub-themes were identified, including meaning in life, self-awareness, optimism, and relationship enhancement. These findings align with previous research on spiritual health in Iranian elders and the relationship between spiritual health, general health, and health literacy [28]. Neglecting foundational aspects, such as identifying spiritual needs, may hinder the achievement of spiritual well-being. Spirituality and spiritual needs are influenced by cultural customs and beliefs. Religious and spiritual beliefs significantly impact individuals’ approach to life’s joys and hardships [26]. Faith can provide individuals with purpose and guiding principles, especially during challenging circumstances such as health issues. Religious beliefs and practices can help individuals confront feelings of helplessness, restore meaning and order, and regain a sense of control. Spirituality serves as an empowering source for some families, and medical investigations have shown the profound impact of spirituality on mental well-being. Therefore, spiritual health literacy is closely linked to an individual’s spirituality, search for meaning, and the framework that guides their life [27]. Self-awareness, perception of meaning, and appreciation of relational and ethical concepts contribute to the promotion and expansion of spiritual health literacy. Studies have identified eight main themes related to spiritual health, including ethical behavior, inner peace, self-control, progress, reduced violence, improved quality of life, mental health management, and increased emotional intelligence. These findings align with the research conducted by Farhadyan and Moradi, which demonstrated a significant predictive relationship between spiritual health and psychological well-being among university students [28]. The study conducted by Brokhi Milan et al. explored the role of social support, spiritual health, and health literacy in predicting risk behaviors among adolescents. The findings of this study are in line with previous research, emphasizing the importance of utilizing coping mechanisms, cognitive abilities, and behavioral strategies to effectively manage stress and demands that surpass personal resources [29]. Religious and spiritual coping, which involves utilizing religious resources and seeking assistance from a higher power, has been identified as a strategy for confronting adversities. Recent findings suggest that these coping mechanisms provide emotional support and a positive interpretation of life events, facilitating the adoption of subsequent coping strategies and benefiting individuals. Individuals with high levels of spirituality can rely on resources, such as a sense of meaning and purpose in life, connection to a higher power, and seeking divine assistance during difficult times. These resources, along with social support, help reduce psychological distress when individuals encounter stressful life events. Engaging in these patterns and behaviors leads to improved psychological skills and well-being while reducing negative patterns that contribute to psychological harm.

Conclusion
Based on the obtained findings and the significant impact of beliefs and their prevalence within families on the level of spiritual health literacy, it is proposed to promote increased spirituality within families and advocate for its enhancement through television programs and advertising campaigns. These initiatives can effectively contribute to the development of spirituality and the fostering of related values within family units. Moreover, considering the influence of family relationships on the extent of spiritual health literacy, it is recommended to provide specific indicators related to this issue and emphasize the importance of spiritual health literacy in children’s decision-making processes. By introducing and promoting these concepts, families can be educated on behavior guided by spirituality and the corresponding values, thus facilitating their development within familial contexts. Accordingly, this study developed content and workshops that educate families on the importance of spirituality and its role in decision-making processes, ultimately fostering spiritual health literacy. It was suggested to promote spirituality within families through television programs and advertising campaigns to enhance spiritual health literacy.

Study limitations
The translation of participants’ perceptions from Persian to English was a limitation as well, which was mitigated by the help of a native English editor.

Ethical Considerations

Compliance with ethical guidelines
The study was approved by the Research Ethics Committee of Gonabad University of Medical Sciences (Code: IR.GMU.REC.1402.122). Informed written consent was obtained from all participants after an explanation of the research project’s purpose.

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

Authors' contributions
All authors contributed equally to preparing this article

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank Islamic Azad University, Qaenat Branch for supporting the study.




References