**3. Biological well-being**

### **3.1 Inflammatory bowel disease**

A study conducted by Cotton et al. [22] reviewed how children with inflammatory bowel disease compared to those without this disorder with regard to their spiritual well-being and mental state. A total of 155 inflammatory bowel disease patients completed the SWBS, Children's Depression Inventory, and Pediatric Quality of Life Inventory. They found that pediatric patients with IBD had similar levels of religious and existential well-being to those without IBD. However, children with IBD considered spiritual well-being to be more influential on their mental health than healthy individuals did.

### **3.2 Immunosuppressive treatment**

This cross-sectional and descriptive study conducted by Gunes et al. [23] looked at the relationship between SWB and patient's self-reported adherence to immunosuppressive therapy following a liver transplant. Following their surgery, 131 patients completed the SWBS, patient information form, and Immunosuppressive Therapy Adherence Scale (ITAS). They found that individuals who had college degrees had lower SWBS scores, while those 65 years of age or older reported higher SWBS scores and lower treatment adherence. However, a regression analysis found a substantial positive relationship between total SWBS scores and adherence to immunosuppressive therapy. In conclusion, SWB predicted better treatment adherence.

### **3.3 Breast cancer**

In a descriptive study of women with breast cancer, Nakane and Koch [24] examined the role of faith in coping with their diagnosis, enduring their treatment, and improving their overall experience. Participants completed the SWBS and an interview. The data showed that 67% of participants considered their faith to be an important component of their medical treatment. Participants scored an average of 92% (M = 111.5) on the SWBS. The data were analyzed according to the RWB which resulted in a 100% (M = 60) score among all participants. The participants scored care 85% (M = 51) on the EWB. The study concluded that incorporating faith in cancer care can be beneficial. Particularly, these patients reported that their faith played the most important role in their treatment and positively affected their experience.

### **3.4 Multiple sclerosis**

A cross-sectional and correlational study conducted by Shaygannejad [25] looked at the relationship between SWBS and social support in patients with multiple sclerosis. The Perceived Social Support Inventory and the SWBS were completed by 120 patients. The average score on the SWBS was 87% (M = 104.4) while the perceived social support was 61%. They reported a correlation between the SWBS and perception of social support, particularly for the emotional dimension, which proved to have a greater connection with spiritual well-being than the other two dimensions of social support.

### **3.5 Coronary artery disease**

De Eston Armond et al. [26] conducted a case-control study involving 88 adults; 42 of these individuals were cases and 46 were controls. They gathered demographic information from participants and administered the SWBS. Data analyses did not show a significant difference between the two groups when comparing levels of SWBS and there was no correlation between coronary artery disease and SWB, RWB, and EWB. Both groups demonstrated high scores on RWB, but there was a significant difference in variability between the "case" and "control" groups on EWB. This may be due to lack of clear differentiation between the two groups. This outcome could be related to study design or an SWBS limitation rather than an actual indicator that SWB is not related to coping with coronary artery disease.

Ramesh et al. [27] examined SWBS, worry and anger among 327 patients with coronary artery disease (CAD). SWBS was negatively related to CAD severity, while worry and angry rumination were positively related. They concluded that worry and anger moderated the relationship of spiritual well-being to CAD.

Mashhadimalek et al. [28] examined the association of heart rate variability (HRV), considered a barometer of health, and SWBS among a sample of 31 of Farsispeaking Muslims. They used cluster analysis to form to groups that differed in SWBS scores. No differences were found in selected HRV indices during the resting phase, but the group with higher SWBS scores differed significantly on selected HRV indices while reading the Quran, indicating increased parasympathetic arousal. Other measures showed the increase in parasympathetic arousal was associated with pleasure and joy. They concluded these findings are consistent with other findings that support a link between R/S and happiness; the HRV findings suggest health gains.

### **3.6 Traumatic brain injury**

Sekely et al. [29] explored how spiritual well-being influenced recovery in individuals who sustained a traumatic brain injury (TBI). Specifically, the study looked at *The Spiritual Well-Being Scale (SWBS) as an Indicator of General Well-Being DOI: http://dx.doi.org/10.5772/intechopen.106776*

how SWB influenced depressive and anxious symptoms following a TBI. After a neuropsychological evaluation to confirm their functioning, 83 participants completed the SWBS, Beck Depression Inventory II, and The Beck Anxiety Inventory. They found that there was a negative correlation between the BDI-II score and the EWB score as well as the BAI score and the EWB score [28]. They concluded that EWB may protect TBI patients from anxious and depressive symptoms.

### **4. Psychological well-being**

Through the Triangle of Well-being and Resilience model, Dr. Dan Siegel [30] demonstrates how our mind, brain, and relationships are part of a flowing system, and are consistently and continuously responding to new experiences. We as humans, function holistically, so anything that affects us, affects our whole self. Our psychological well-being is linked to all other facets of our whole self, including physical health, social endeavors, and spirituality. Dr. Carol Ryff was a pioneer in psychological well-being, focusing on well-being beyond medical or biological descriptions. Ryff [31] developed the Six-factor Model of Psychological Well-Being.

The Six-factors of Dr. Ryff's model include self-acceptance, personal growth, purpose in life, positive relations with others, environmental mastery, and autonomy. Lindfors et al. found that Ryff's model was relevant cross-culturally, and data supports the use of a six-factor model [32]. The six relevant factors of psychological well-being described by Ryff [31] give context to parts of a person's life that could also impact or overlap other areas of well-being, such as spirituality. Ryff's multidimensional construct of well-being builds on such concepts such as

*"basic life tendencies of Buhler, psychosocial stages of Erikson, personality changes in Neugarten, positive criteria of mental health of Jahoda, account of individuation of Jung, formulation of maturity of Allport, depiction of the fully-functioning person of Rogers, and notion of self-actualization of Maslow" ([33] para. 5).*

As explained below, spirituality and religiosity are often primary sources of a person's well-being, and the factors of spirituality tie into all other aspects of wellbeing, including biopsychosocial well-being and what that means from a religious or spiritual perspective.

Wnuk and Marcinkowski [34] proposed that well-being is multidimensional, echoing Ryff [31]. They found that the meaning of life and hope were directly related to psychological well-being in terms of cognitive and emotional measures, however, only in positive directions. They hypothesized that religiosity, including finding the meaning of life and improving hope, might show a positive influence on psychological well-being [33]. They also found that psychological well-being and its relationship with meaning of life, an aspect of religiosity, played a major role in their participants' quality of life.

As previously discussed, spirituality, health-related behaviors, and psychological well-being all intersect. Bożek et al. [33] found that these three particular aspects of life were significantly related in the realm of acquired education. Acquired education in this instance means the subconscious process of retaining knowledge. They found that spirituality and health-related behaviors were linked to psychological well-being and spirituality associations with psychological well-being were stronger in the students who were studying aspects of the human mind and spirit. High levels of

psychological well-being are associated with a "lower risk of depression, a lower possibility of displaying risk behavior, a decreased immune cell expression of a conserved transcriptional response to adversity" ([32], para. 7).

Kamitsis and Francis [35] completed a study to determine how engaging with nature influences psychological health, as well as the role that spirituality plays in the relationship between nature and psychological health. Through surveys, the authors found that "nature exposure and connectedness to nature were positively associated with psychological wellbeing and greater reported spirituality," which supports previous research ([35], p. 139). The results of this study show how people experience nature, and the impact that connecting with nature can have on spiritual and psychological well-being. It is important to study treatment options involving engagement with nature to determine their effectiveness in increasing spiritual and psychological well-being.

When thinking about psychological health and well-being, trauma and traumatic experiences can play a major role in how someone processes or moves towards a more psychologically healthy state of mind. Park [36] completed a study among 436 college students to determine predictors of three aspects of spirituality, including faith, meaning and peace, and relationships among those spiritual well-being aspects and psychological adjustment after experiencing a traumatic event. The results of their study showed that different patterns of coping with a person's trauma predict different components of spiritual well-being. Park [36] also found that each of the three aspects of spiritual well-being, faith, meaning, and peace, particularly the latter two, were correlated with psychological adjustment.

The current research puts a rather large emphasis on the relationship between spiritual well-being and psychological well-being. Implications for future research include studying the intersecting relationships among physical, psychological, social well-being and spiritual well-being.
