The protective factor of depression and anxiety in the general population in the post-coronavirus era: coping, spiritual well-being & resilience

Background: Considering the crisis of the coronavirus in the world and the confusion and mental distress that arose for people in different societies, it seems necessary to find protective factors against depression and anxiety caused by this epidemic. This study aims to find the relationship between resilience, spiritual well-being, and coping with depression and anxiety. Methods: Using the available sampling method, a descriptive survey design was employed to select 900 adults from the general population of Tehran. They received questions to answer the questions of the hospital anxiety scale, 9-question patient health questionnaire, brief resilience scale, Holahan and Moss coping scale, and Grech and Hamby spiritual well-being scale. The data were analyzed using Pearson correlation and multiple linear regression methods. Results: The results indicated the prediction of anxiety and depression through resilience (sig = 0.000) and spiritual well-being (sig = 0.002), as well as a strong negative correlation between depression and spiritual well-being (-0.492). Conclusion: Study findings suggest empowering individuals regarding spiritual well-being, raising religious awareness, and fostering a connection with a higher power can enhance resilience. This empowerment can help individuals withstand critical situations such as the coronavirus pandemic and mental injuries and disorders. Furthermore, increased resilience is associated with reduced anxiety and depression, promoting overall well-being and self-fulfillment.


INTRODUCTION
Since December 2019, several cases of the 2019 virus disease have been reported in Hubei Province's Wuhan, and the disease has spread rapidly in The capacity for resilience, defined as the capacity to face traumatic experiences based on the interplay between individuals and their coping mechanisms, is another aspect that influences people's mental health during the challenging Coronavirus era (Cai et al., 2020).A study considers the idea of resilience as a person's ability to battle hypothetical emotional distress caused by a problematic and damaging atmosphere (Bjelland et al., 2002).Hence, it arises from an inherent motivation to heal, stemming from the human inclination to resist adverse circumstances and refuse to accept suffering or the current state of reality.Therefore, it represents an individual's capacity to achieve a state of tranquility by effectively dealing with traumatic experiences (Hamadeh-Kerbage et al.,

2021).
Having efficient coping strategies to deal with Tense circumstances is essential because it may prevent experiences that lead to stress-related mental disorders (Sameer et al., 2020).However, when a person has trouble with stress and specific conditions, having the ability to adapt can help them.Various studies have shown that people use different coping methods in stressful situations and crises (Health, 2011).The Mariani et al., (2020) study indicated a connection between anxiety and emotion-focused and avoidant coping mechanisms.However, regression analysis only supported the emotional strategy's function in predicting anxious symptoms.Analysis failed to show a connection between anxiety and felt social support (Mariani et al., 2020).The results also showed that avoiding thinking about the current stressful condition, ignoring coping strategies, and not knowing the correct coping methods have a significant relationship with anxiety and depression (Mariani et al., 2020).
Similarly, humor as a coping strategy was significantly less associated with stress (Budimir et al., 2021).It proves challenging to consider which coping mechanisms are most effective because none were linked to probable PTSD or a lack of it.However, as the study's findings indicate, it might be helpful to share information about efficient coping strategies and ways of coping (Bailey, 2008).Utilizing religious and spiritual practices as coping mechanisms during this trying period in Corona is one of the most effective approaches since many people turn to their religion, spirituality, or sense of faith to help them cope with stress and the unfavorable effects of life's problems (Sanne et al., 2003).The COVID-19 pandemic can be considered an ongoing traumatic event related to other disasters that can seriously affect a person's psychological state in private and public settings (Hamby et al., 2013;Smith et al., 2008;Vanistendael and Lecomte, 2002).
Due to the connection between faith, spirituality, and mental health, religious acts may be considered a resilient plan during the pandemic (Leys et al., 2021).Recent research results, which analyzed daily data on Google searches in 95 countries, show that during the COVID-19 crisis, Google searches for prayer increased by 50% and reached an all-time high.This could indicate that in times of hardship, many seek to draw closer to God as has ever been recorded (Ran et al., 2020).In March 2020, one of the most checked prayers was the "Corona Prayer," which asked God to protect against the coronavirus, stay strong, and thank nurses for their efforts (Hiyoshi et al., 2015).Therefore, this study examines the protective factors of anxiety and depression in the general population during the post-coronavirus stress era with the role of mediating coping, spiritual well-being, and resilience.

Study procedure
This study is a cross-sectional survey conducted in the Tehran area from January 2023 to September 2023.The method of this study was descriptive and prediction type and regression statistical way.Statistical Society, the general population was Tehran residents who answered the questionnaire's questions online.The method of collecting information was accessible; In this way, the general public was asked to answer the questionnaires online.The study is a cross-sectional study conducted on the general public after the plan was approved and the code of ethics was received.Data collection includes demographic and quantitative information that was done online with the help of a questionnaire.
The full description of each questionnaire is given at the end.The sampling method is available.The sample size was calculated using the Free Statistics Calculators software, taking into account the effect size of 0.3, the power of 0.8, latent variables of 4 obvious variables of 34, and alpha of 0.5, suggesting a sample of 888 people.Finally, 900 people were selected participants in the research, taking into account the potential of dropping out of the subjects.To analyze the tests of the structural equation model, regression and correlation were done with the help of SPSS-26 software.The criteria for entering this research included informed consent, minimum ability to read and write, and proper literacy.The criteria for exiting the study were lack of satisfaction and not answering all the questionnaires.

Patient Health Questionnaire (PHQ-9)
The Patient Health Questionnaire (PHQ) was the first self-report questionnaire created for use in medical focus on finding specific disorders using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) (Löwe et al., 2004).It assigns scores to each of the nine criteria outlined in DSM-V, ranging from zero to three, representing the frequency of occurrence from "never" to "almost every day" (Löwe et al., 2004).PHQ-9 questionnaire measures the diagnosis of depression disorder based on criteria and is a valid and reliable tool in clinical work and research actions (Milstein et al., 2020).In a recent study by Arellano-Vilela and Tume-Zapata, (2021) the PHQ-9 was found to have high internal consistency (α = .91).The Persian version of the PHQ-9 indicated an acceptable internal consistency (α = .84)in a sample of Iranian psychiatric outpatients (Dadfar et al., 2018).

Hospital Anxiety Scale
A self-report scale has been designed and demonstrated to be an accurate tool for identifying symptoms of depression and anxiety among patients attending a medical outpatient clinic in a hospital setting (Norton et al., 2013).This scale consists of 7 questions that are designed with four options for each question.The scoring is such that the option "often" gets a score of 3, and the option "never" gets a score of 0. The range of scores is from 0 to 21, and the larger the score, the greater the extent of the disorder (Stern, 2014).Only anxiety-related questions were used in this research (Snaith, 2003).It has been validated in many languages, countries, and cultures, including general practice and the general population (Bjelland et al., 2002;Herrmann, 1997;Snaith, 2003).Several studies have reported acceptable reliability and validity of HADS (Stern, 2014).The Persian version of the HADS showed good reliability (Montazeri et al., 2003).

Spiritual well-being scale
This questionnaire was created by Banyard, Grech, and Hamby in 2013; it has 5 items with 4 options (Genia, 2001).It assesses the degree to which individuals believe in a satisfying connection with God (Genia, 2001).Each question has a value from 4 to 1, and the total score is the sum of the scores of all the items.The results show that validity in non-clinical samples strongly correlated with other outcome measures, such as post-traumatic growth (r = 0.58), subjective well-being (r = 0.59), as well as religious meaningmaking (r = 0.71) (Imam et al., 2009).The Persian version of the SWBS showed an acceptable internal consistency (α = .78)in a sample of Iranian patients with cancer (Nia et al., 2022).

Coping scale
The coping scale evaluates cognitive, emotional, and behavioral methods to address problems (Kato, 2015).This study used a combination of items from different sources to assess mental and emotional factors.Specifically, items 2, 3, and 4 were selected from the widely used scale developed by Holahan and Moss in 1987 (Kuo et al., 2006) Hospital patients includes (0.88 and 0.91) (Sinclair and Wallston, 2004).Cronbach's alpha of this scale for a group of Iranian patients was 82, and its item-total correlation coefficient was reported to be (.56 to .91)(Rohani et al., 2010).

Brief Resilience Scale
The Brief Resilience Scale (BRS) specifically targets recovery by assessing an individual's ability to return from stress and adversity (Smith et al., 2008).It measures the person's capacity to quickly and effectively retrieve their psychological well-being after facing difficulties (Smith et al., 2008).The study employed a self-report scale of six questions, each offering six options.Participants were required to select one answer ranging from 1 (strongly disagree) to 5 (completely agree) for each of the six questions.The total score on the scale ranged from 6 to 30, with broader scores indicating a greater degree of resilience, according to Balter's scoring system (Rodríguez-Rey et al., 2016).The English version of the scale showed good internal consistency (Cronbach's alpha: 0.80-0.91)and was loaded onto a single factor, indicating that the items are measuring the same construct effectively.The Persian version of the BRS showed excellent internal consistency (α = .85)in a sample of students (Gheisari et al., 2023).

Ethical considerations
This study was approved by the Medical Ethics Committee of the Shahid Beheshti University of Medical Sciences (IR.SBMU.MSP.REC.1401.249).Before the commencement of the study, the participants were informed of the study objectives and assured of data confidentiality.All participants signed the informed written consent.

RESULTS
Nine hundred people aged 20 to 60 with a mean age of 31.74 and a standard deviation of 9.44 participated in this study.Table 1 shows the demographic characteristics of the research samples.The Compared gender groups had a similar percentage of reported participants (Figure 1).The results of Table 2 report the mean and standard deviation of the research questionnaires, and Figure 2 shows the mean selfreport score for both males and females.Table 3 shows the correlation coefficient of the variables together.As we can see, a strong negative correlation (-.492) exists between depression and spiritual well-being.Also, the Pearson correlation coefficient shows that there is a negative correlation between depression and resilience (-.164), and there is a positive correlation between spiritual wellbeing and coping (.272), and a negative correlation between anxiety and resilience (-.124).As the results of Table 5 show, the significance level of 0.000 shows that the regression result and significant prediction between the variables of this study are established.As the results of Table 6 show, the significance level of 0.000 shows that the regression result and significant prediction between the variables of this research are established.As Tables 7 and 8 performances, the relationship between the variables is essential if the two variables of spiritual well-being and resilience are entered in both cases when they are the criteria (dependent) variable of anxiety and depression.In other words, the two variables of resilience and spiritual well-being can predict anxiety and depression.Still, no relationship between coping and anxiety and depression was found in this study.

DISCUSSION
The purpose of the present study was to apply multiple regression statistics to predict how resilience, coping skills, and spiritual well-being will affect people's feelings of anxiety and depression across the post-Corona Crisis period.Our research shows that people's resilience can predict their anxiety and depression.These results agree with previous studies This study observed that psychological resilience is essential for psychological intervention in public health emergencies; adolescents with low resilience to stress were at increased risk of persistent use of antidepressants and anti-anxiety medications (Hiyoshi et al., 2015).Therefore, resilience can help people against psychological distress and is a protective shield against stress or a traumatic event; assessing individual psychological resilience can also predict people's mental health status (Ran et al., 2020) ).During the coronavirus crisis, the self-reported strengthening of religious faith has been revealed more among some entirely religious people at the beginning.So, most religious Americans who attend religious services regularly and frequently see religion as very important to them are much more likely than others to say their faith has become more substantial due to the coronavirus outbreak (Gecewicz, 2020).Also, spirituality as a psychosocial resource supplies better mental and physical health conditions after recovery from depression.Based on previous research findings, it can be concluded that spirituality protects against depression by providing positive coping, flexibility, high frustration tolerance, and meaning or purpose in life (Akbari et al., 2020).
Also, this study found no relationship between coping and anxiety and depression, contrary to previous studies (Chen et al., 2019;Mariani et al., 2020;Yang, 2021).The difference between these results and results from past studies regarding anxiety symptoms may be because coping involves a variety of approaches, each of which can produce outcomes that are distinct from those of the others.As was found in a previous study, anxiety is associated with avoidant and emotion-oriented coping methods.
These findings suggest that depression and anxiety are distinct symptoms of an out-of-control emotional state, which might sometimes result in emotional problems and indifference (Ogueji et al., 2021).Even in the case of anxiety, the emotional disturbance must first be identified and regulated, and experiencing powerful emotions cannot be effectively used to manage stress (Mariani et al., 2020).The result of this study has also shown that coping cannot predict a person's level of anxiety and depression.

CONCLUSION
According to the findings of this study, it can be determined that by empowering people in terms of spiritual well-being and by raising religious awareness and communication with a supernatural force more potent than themselves, people can be saved in critical situations such as the coronavirus and front of mental injuries and mental disorders are resistant and also, in this way, the level of resilience of people can be increased.With the ability of resilience, people experience less disturbing anxiety and depression, and in life, the well-being and well-being of the subject The need for self-fulfillment.The research limitations include the use of an available sample and the cross-sectional nature of the research method, as well as the non-experimental nature and the inability to investigate the cause and coronavirus research results.
. These items have been extensively validated and are recognized in the field.Additionally, items 1, 5, 6, and 8 were developed specifically for this study to capture other cognitive and emotional aspects not covered by the Holahan and Moss scale (Kuo et al., 2006).The test-retest reliability for the sample of ANALYSIS ARTICLE | OPEN ACCESS Medical Science 27, e351ms3220 (2023)

(
Leys et al., 2021; Moret-Tatay and Murphy, 2022;Vanistendael and Lecomte, 2002).The results of studies in China show an excessive incidence of psychological disorders such as depression and anxiety among the general public at the height of the outbreak of COVID-19 in China, which had a negative correlation with the level of resilience in people.

Table 1
Comparison of demographic characteristics of research samples Figure 1 A clustered bar chart comparing the age percentage of the gender groups Medical Science 27, e351ms3220 (2023) 5 of 10

Table 2
Mean and standard deviation of research questionnaires Figure 2 Mean participant self-report scores by gender group

Table 3
Regression correlation coefficient between research variables

Table 4
The results of the follow-up test of the Durbin-Watson and Model Summary a. Predictors: (constant), spirituality b.Predictors: (constant), Spirituality, Resilience

Table 5
ANOVA, The significance level of the test, Dependent variable: Depression

Table 6
ANOVA, The significance level of the test, Dependent variable: Anxiety

Table 7
Specific regression correlation coefficients when the dependent variable is depression

Table 8
Specific regression correlation coefficients when the dependent variable is anxiety . This helpful findinBraam and Koenig, 2019;Chehrazi et al., 2021;Milstein et al., 2020;ways to improve people's resilience in critical situations and life fluctuations.People with better patience and internal resistance through coping strategies are less anxious and depressed and can use proper social and functional performance in critical situations.Also, results demonstrated that Spiritual well-being can predict anxiety and depression in the general population, according to the results of several previous studies(Akbari et al., 2020;Braam and Koenig, 2019;Chehrazi et al., 2021;Milstein et al., 2020;