Iranian Journal of Military Medicine Vol. 14, No. 3, Autumn 2012; 186-191
The Relationship between Spiritual Health and
Social Anxiety in Chemical Veterans
Mahboobi M.1PhD, Etemadi M. 2MSc, Khorasani E.3MSc, Qiyasi M.4PhD, Afkar A. 5PhD
Kermanshah University of Medical Sciences, Kermanshah, Iran
Tehran University of Medical Sciences, Tehran, Iran
3
Isfahan University of Medical Sciences, Isfahan, Iran
4
Shaid Beheshti University of Medical Sciences, Tehran, Iran
5
Guilan University of Medical Sciences, Guilan, Iran
1
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2
Abstract
Aims: Spiritual well-being is an essential force in making for the physical, mental and social dimensions of
man’s life. Social anxiety can have an adverse effect on spiritual well-being. For this reason, the aim of this
study was to investigate the relationship between spiritual well-being and social anxiety in the veterans who
are the victims of chemical weapons.
Methods: This descriptive correlational study uses a questionnaire that included demographic and spiritual
well-being features as well as a Liebowitz social anxiety scale test. 109 veteran victims of chemical weapons
were selected using convenience sampling in the province of Kermanshah. Data analysis was performed by
descriptive statistics and Spearman and Mann-Whitney tests.
Results: In this study, there was an inverse relationship between spiritual well-being and social anxiety (p =
0/01, r = -0/363), but there was no statistically significant relationship between spiritual well-being or social
anxiety and demographic characteristics.
Conclusion: Several studies have confirmed the existence of anxiety in war disabled veterans of affected by
chemical weapons. Improving spiritual well-being, as a strong force affecting physical, mental and social
health, can help control the social anxiety of such veterans, and they doubly need such improvement in order
to be able to carry out their main personal activities. Therefore, there is a greater need for measure to boost the
spiritual well-being of such victims in the new social conditions.
Keywords: Spiritual Well-being, Social Anxiety, Veterans, Kermanshah
Introduction
Health condition is an effective factor in the life
quality of war disabled people. Health, according
to the definition provided by the WHO, has different aspects: physical, mental, social and spiritual [1]. Of these, spiritual well-being has a special
value. Some scholars believe that paying attention to spiritual well-being is especially necessary
because it is the most important aspect of human
existence for one third of the people and acts as
a strong force in the center of their life and is connected to their health, feeling good and recovery
[1, 2]. Thus spiritual well-being can be defined as a
sense of connection to others, having a meaningful
life with a goal, and believing in and connecting to
a transcendent power [3].
Researches show that without spiritual well-being,
other aspects of human life, such as mental and
social aspects, cannot function well and, as a result, achieving the highest quality of life will not
be possible [1]. Recent studies reveal that spiritual
well-being strongly affects mental and physical
health and is reckoned to be a common solution
to problems [4, 5]. Spirituality can enhance a patient’s ability to tackle diseases and speed up recovery [2, 6].
Various studies confirm the hypothesis that spiritual well-being can improve mental functions and
adaptability. There are significant correlations between spiritual well-being and other variables such
as depression, self-esteem, life satisfaction, temper, and anxiety [3, 7, 9].
Social anxiety is an important psychiatric disorder.
Social anxiety is an expressive persistent fear of
social or performance situations rooted in a person’s belief that he or she will act in an embarrassing or humiliating way [10]. The anxiety disorder
is the third most common mental disorder after
major depression and alcoholism. Epidemiological studies reveal that the prevalence rate of social
anxiety during life is 13.3% [11, 12]. Experiencing
anxiety may not only upset us but also negatively
Corresponding author: Elahe Khorasani. Please, direct all correspondence to [email protected]
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Mahboobi M. et al
affect out daily performance and jobs [12]. People
who suffer from social anxiety disorder usually
avoid embarrassing situations and scarcely undergo performance or social situations, and when they
do, they suffer severe anxiety [13].
A person who suffers from social phobia (i.e., anxiety) does not like to start a relationship with others and, avoids with an unusual fear any situation
where he or she may be judged by others [14]. In
fact, the main fear in this type of anxiety is the fear
of others’ negative judgment in social situations
and of behavior which may provoke such judgment
[15]. Studies show that negative self-assessment,
avoiding assessment situations and expecting others’ negative judgment are among the most typical
features of social anxiety [12].
This disorder usually leads to a long-term disability and affects people’s daily activities and social
and career relationships. This disorder is also connected with anxiety disorder, depression and other
personality disorders [16]. It also results in safety
behavior which has destructive effects on their life
[17]. For these reasons, social anxiety or phobia
has been considered in recent years as an important disorder in public health [16].
Some researchers have shown that spirituality has
much to do with a person’s general health and is
thus an important source to rely on for coping with
events which create tension [1]. They have also
revealed that spirituality not only affects people’s
manners and their mental health but also enhances
their physical conditions. Improvement in spirituality makes for a decrease in the death rate of cardiac disease patients and reduction of blood pressure in patients suffering from high-blood pressure
and helps faster recovery from depression. Spirituality similarly helps cope with severe diseases
such as cancer and reduces pain in patients who
complain of severe skeletal and muscle pains [18].
Other researches point to the relationship between
spiritual well-being and higher immunity against
certain diseases [1].
Spirituality has a special role in critical situations,
creates meaning in life and inspires the person in
facing problems. People who enjoy higher spiritual well-being are strong and capable people with
a higher controlling power and social support [19].
Nowadays mental health problems are increasing
and have become an important issue, on the one
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Vol. 14, No. 3, Autumn 2012
hand, and an increasing number of people take
spiritual health to be an effective approach in dealing with psychological disorders. Thus, some therapists of mental health have recently paid special
attention to the role of spiritual well-being [20].
Fahring et al. argue that there is positive correlation
between inner faith, spiritual well-being and other
good manners. They also point out that spiritual
well-being is an important help in gaining higher
self-confidence and reducing social anxiety [21].
War disabled people are especially affected by tension-creating factors, which make for disorders in
the social, mental, physical and familial realms of
such people. Psychological changes, such as excitability, anxiety, tension, nervousness and inability
to control oneself make for disorders in social and
family relationship [22]. According to The Foundation for War Disabled People, there are 43913
war disabled veterans in Iran. In view of this large
number of victims and due to the importance of
the psychological aspects of disability, the study of
war disabled people in terms of their spiritual wellbeing and social anxiety seems important [23]. Besides, the relationship between spiritual well-being
and social anxiety is not quite clear in such veterans. The aim of this study, then, is to determine this
relationship in war disabled veterans.
Methodology
This study was carried out using a descriptive correlation method on all veteran victims of chemical weapons who visited public places, such as
parks, local public ceremonies and elections offices in late 2011 and early 2012 in the cities of
Guilanegharb, Sarepolezahab and Kermanshah, all
located in the province of Kermanshah. The public locations were chosen because of easier access
to the subjects. The sample size was determined
using the KREJCIE and Morgan method. 109 victims, 25% disability or higher, were studied using
the convenience sampling method, and data were
gathered using questionnaires. Before filling out
the questionnaires, the subject and aim of the research project were explained to the subjects and
it was made sure that they were happy with filling
out the questionnaires. The confidentiality condition of the subjects’ identities was also observed.
The questionnaire was made up of three parts:
1) demographic features,
2) the spiritual well-being scale (SWBS) question-
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Spiritual Health and Social Anxiety
naire created by Palouzian and Ellison consisted
of 10 items relating to religious well-being and 10
items concerned with existential well-being. The
religious well-being which includes people’s understanding of their own spiritual well-being in
connection to a “higher being.” And existential
well-being concerns the way people adjust to life,
living and community. The ranges of the scores for
existential and spiritual well-beings were each 1060., and the scores were the basis of judging the
scales of these two types of well-being, so that a
higher score meant higher existential or religious
well-being. The score of spiritual well-being was
produced by combining the scores of the two subscales, ranging 20-120 on the whole. The items
were scored on a 6-point Likert scale, ranging from
“strongly disagree,” to “strongly disagree.” At the
end, spiritual well-being was classified into three
levels of low (for the scores of 20-40), average (4199) and high (100-120). The validity and reliability
of the Persian version of the questionnaire had been
examined in various studies [2, 4, 18, 19, 25]. The
reliability of this tool was confirmed by Rezaie in
Tehran with a Cronbach’s alpha of 0.82 [18] and
with 0.87 in a more recent study. Future studies
may use a Chronbach’s alpha of more than 0.9.
3) “The Liebowitz Social Anxiety Scale (1987) was
the first clinician-administered scale to evaluate the
wide range of social situations that are difficult for
individuals with social phobia. The scale contains
24 items, 13 concerning performance anxiety and
11 concerning social situations. Each item is rated
separately for fear (0 to 3 = none, mild, moderate,
severe) and avoidance behavior (0 to 3 = never,
occasionally, often, usually). Thus, the LSAS provides an overall social anxiety severity rating, and
scores on 4 subscales: 1) performance fear, 2) performance avoidance, 3) social fear, and 4) social
avoidance” [26].
The validity and reliability of this questionnaire
was confirmed by Azmoon Yar Pooya company,
which has ascribed a general alpha coefficient of
0.95, an alpha coefficient of 0.82 for the subscale
of performance anxiety and an alpha coefficient
of 0.91 for the subscale of social anxiety. Various
other studies have also given the Cronbach’s alpha
of this questionnaire. The validity of this scale has
been reported to be 0.95, its reliability using questionnaire 1 to be 0.87 and the validity of the minor
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Vol. 14, No. 3, Autumn 2012
scales was confirmed as acceptable. The internal
consistency of the social anxiety scale was 0.82 in
Anari’s study [17]. The relationship between the
demographic variables’ values and those of spiritual well-being and social anxiety was examined
using the Spearman correlation coefficient. The
marital status, visiting public places (i.e., places established and controlled by the city councils), previous experience of anxiety (the number of acute
anxiety fits per week), financial status (based on
public or private sector employment), relationship
with the family (the number of family gatherings
per week), the percentage of disability (based on
valid ID cards) and age were criteria for entering
the study, visiting public places and the subjects’ inclination to participate in the research project. The
criteria for exclusion were incomplete filling out of
the questionnaires, a history of anxiety or taking
anti-anxiety medication, which led to the exclusion
of three subjects. The data were analyzed using the
SPSS version 16. The Spearman and Mann-Whitney tests to examine the relationship between the
demographic variables and the factors considered
in this study.
Results
In this study, 109 war disabled veterans of
Guilanegharb, Sarepolezahab and Kermanshah (all
located in the province of Kermanshah) with 25%
or higher level of disability filled out the questionnaire during late 2011 and early 2012 (the second
half of 1390 in Persian calendar). Due to special
conditions of visiting the subjects, all those who
participated in the study were male and aged 4249 with the mean age of 41.3±1.12. Of these, 80.8
were married, 76.3% had an average financial status, and 68.4% had social anxiety.
85% of the subjects described their family relationship as good and 82.1% frequently visited public places. The average of disability of the subjects
was 30%. Using descriptive statistics and calculating the mean and standard deviation of the scores,
it was revealed that the mean score of the veterans’ social anxiety was 32.3±10.8 (Table 1) and the
mean spiritual well-being score was 92.5±14.86
(Table 2).
The Spearman correlation test showed that there
was a significant inverse relationship between
spiritual well-being and social anxiety (r=0.363,
p=0.01). Using the Spearman and Mann-Whitney
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Mahboobi M. et al
tests, no significant relation was found between the
demographic features and spiritual well-being or
social anxiety (Table 3).
Discussion
The findings of this study showed the following
points. Most of the veteran victims of chemical
weapons enjoyed high spiritual well-being (with
scores ranging 100-120).There was an inverse relationship between the veterans’ spiritual well-being
and their social anxiety, that is, veterans with high
spiritual well-being had lower social anxiety and
vice versa.
Other similar studies have also shown the effect of
praying lowering the anxiety and depression scores
[27, 28]. Spiritual well-being has proven to be effective in lowering different types of anxiety. Moghimian has shown that spiritual well-being can reduce
exam anxiety [29]. There was no significant statistical
Table 1) Subjects Social Anxiety Scores
Level of social anxiety
Low social anxiety
Average social anxiety
Severe social anxiety
Acute social anxiety
Mean social anxiety score
veterans and their demographic features of age,
marital status, visiting public places, previous
history of anxiety, financial status, family relationships and percentage of disability. This finding was in agreement with those of Aghhosseini
[25] and Moghimian [29].
Many of the subjects (35.2%) had experienced
severe social anxiety (with scores ranging 81-95).
This finding agrees with those similar studies regarding veterans’ social anxiety (PSTD) [30, 33].
This finding is also true of social anxiety in the
children of such veterans [23]. In this study, there
was no significant cor
relation between the demographic variables and
social anxiety, which agrees with the findings of
Kashdan [31], while Mokhtaripoor et al. show
that there is a significant correlation between
these two sets of
Range of social anxiety score
55-65
66-80
81-95
Above 95
32.3±10.8
Score percentage
15%
28%
35.2%
21.8%
Table 2) Subjects’ Spiritual Well-being Scores
Level of spiritual well-being
Low
Average
High
Mean spiritual well-being score
Range of spiritual well-bring
score
20-40
41-99
100-120
92.5±14.86
Percentage score
0%
35.5%
65.5%
Table 3) Correlation of Subjects’ Demographic Features with Their Spiritual Well-being and Social Anxiety
Demographic features
Spiritual well-being (P value)
Social anxiety (P value)
Marital status
0.068
0.547
Visiting public places
0.106
History of anxiety
0.749
Financial status
0.195 (-0.152)
Family relationship
0.822 (-0.022)
0.541 (0.87)
Disability percentage
0.080 (0.388)
Age
0.152 (0.134)
relationship between the spiritual well-being of the
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Spiritual Health and Social Anxiety
variables in the students of medical sciences universities (F=2.584, P=0.0086), with the highest
negative correlation between the subjects’ socioeconomic status and their anxiety [34].
High social anxiety can result in lower social performance (feeling that one is less accepted and supported by others), lower intimacy [35], social fear,
shyness and substance abuse disorder [17]. Based
on the findings of this study, it is possible to reduce
veterans’ social anxiety by enhancing their spiritual well-being using such tools as prayers. Also,
there is a correlation between increase in veterans’
social activity and reduction in their physical pain
complaints, depression, anxiety, integration, social
dysfunction [22]. Therefore, it is also possible to
reduce veterans’ social anxiety by increasing their
social activity. A research limitation of this study
was considering the relationship between the veterans’ spiritual well-being and psychological problems.
Conclusion
Various researches have confirmed anxiety in the
veteran victims of chemical weapons. It is possible
to reduce social anxiety in such people by improving their spiritual well-being as a strong factor
influencing physical, mental and social health because such veterans doubly need to improve their
mental and physical health. The need to improve
the veterans’ spiritual well-being is essential in the
new social conditions.
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