Hrev_master Healthcare in Low-resource Settings 2023; volume 11:11747 The influence of religious well-being on the resilience of family spirituality during the COVID-19 pandemic Yoyok Bekti Prasetyo,1 Faridi Faridi,2 Nur Lailatul Masruroh,1 Nur Melizza,1 Sita Afkarina Mutmainnah3 1Department of Community Health Nursing, Faculty of Health Science, Universitas Muhammadiyah Malang, Malang; 2Department of Islamic Religion, Faculty of Islamic Religion, Universitas Muhammadiyah Malang, Malang; 3Student of Nursing Science, Faculty of Health Science, Universitas Muhammadiyah Malang, Malang, Indonesia Abstract Religious or spiritual well-being has a significant influence on family resilience, particularly in the spiritual aspect when dealing with changes or crises. The COVID-19 pandemic represents a sig- nificant change and crisis that can potentially impact religiosity and affect family resilience in spirituality. This study aimed to ana- lyze the impact of religious well-being on family resilience in terms of family spirituality during the COVID-19 pandemic. This was a descriptive study, utilizing a cross-sectional survey approach. A total of 243 respondents were recruited for this research using accidental sampling technique. Data collection was conducted through questionnaires. Data analysis involved binary logistic regression and multivariate logistic regression, with a 95% degree of freedom and a standard error of 0.05. The main finding of this study indicates that religious well-being (p=0.000) signifi- cantly influences family resilience in family spirituality. Families with sufficient religious well-being are four times more likely to exhibit resilience in family spirituality compared to families with inadequate religious well-being (OR: 3.807; 95% CI: 2.230- 6.498). The family resilience in family spirituality is strongly influ- enced by the factor of religious well-being. Strengthening the com- munity with a religious approach is essential to bolster the family’s ability to cope with the challenges posed by the pandemic. Introduction The high transmission and rapid spread of the COVID-19 dis- ease pose a significant threat to communities, affecting people’s health indiscriminately.1–3 In September 2021, there were 230,326,827 new cases reported worldwide, resulting in 4,722,924 deaths due to COVID-19. Unsurprisingly, the fear of COVID-19 has a profound impact on people’s well-being.4 This fear can significantly affect mental health and overall well- being.5–8 Previous research has revealed alarming statistics, indi- cating that during the pandemic, the prevalence of depression was at 26.1%, anxiety at 33.2%, and stress at 5.8%.9–12 Furthermore, the implementation of social distancing and self-isolation regula- tions in many countries worldwide has led to significant societal changes and has given rise to various mental health issues, includ- ing anxiety, fear, sadness, feelings of worry, impulsive behavior, and difficulty in concentration. However, a previous study has suggested that spiritual beliefs can help reduce fear and anxiety, providing individuals with a sense of security.13 Religious well-being represents a spiritual expression through which an individual connects with themselves, God, society, and the environment. It is typically measured within the dimensions of existential and religious well-being.14–16 This form of well-being has a notable impact on family resilience, particularly in the spir- Correspondence: Nur Melizza, Department of Community Health Nursing, Faculty of Health Science, Universitas Muhammadiyah Malang, Malang, Indonesia. E-mail: melizza@umm.ac.id Key words: COVID-19; family spirituality; resilience; religious well- being. Contributions: YBP, Conceptual, study design, analysis, data interpreta- tion, and overall guidance; FF, Consultant in the field of religious and con- ceptual research frameworks; NLM, Supervision from research concep- tion to final approval of the proposed version; NM, Compilation of arti- cles, overall guidance, and facilitation in article revision for content accu- racy, SAM, Data collection, article writing under the supervision of all authors. Conflict of interest: no potential conflict of interest was reported by the authors. Ethics approval and consent to participate: this study received ethical approval from the Health Research Ethics Commission of the University of Muhammadiyah Malang with protocol number E.5.a/007/KEPK- UMM/I/2022. Participants provided written consent for participation before data collection. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research was supported by a research grant from Productive Innovative Research Funding/Riset Inovatif Produktif (RISPRO) from the Ministry of Finance's Education Fund Management Institute with con- tract number 166/E4.1/ AK.04.RA/2021. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgment: the authors would like to thank the Indonesian Ministry of Education, Culture, Research and Technology which has pro- vided funding for this research. The researcher also thanks the Directorate of Research and Community Service, the Universitas Muhammadiyah Malang, which has provided administrative and policy assistance in this study. Received: 11 September 2023. Accepted: 18 October 2023. Early access: 9 November 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11747 doi:10.4081/hls.2023.11747 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2023; 11:11747] [page 77] Non -co mmerc ial us e o nly itual aspect, enabling families to cope with changes and crises effectively.17 The advent of the COVID-19 pandemic presented a significant crisis, potentially challenging religiosity and influenc- ing family resilience in the spiritual domain.18 Family resilience, in essence, signifies the strength to endure and recover from adversi- ty, necessitating constructive adaptation.19 The COVID-19 pan- demic, marked by elevated levels of fear and anxiety, has prompted significant lifestyle changes, including alterations in religious beliefs and behaviors.20 Resilience during a pandemic can reduce anxiety levels.21 The results of a study conducted in Italy indicated that participants perceived lower levels of spiritual well-being and mental health than in pre-pandemic situations with significant gen- der differences.22 A low level of spirituality will result in psycho- logical impacts such as mental disorders (adjustment disorder or stress reactions that result in depression) (80.2%) and the remain- ing 19.8% only have a low impact.22 Besides that, World Health Organization (WHO) also explains Practical considerations and recommendations for religious leaders that increase spirituality and apply it in daily life during the co-19 pandemic to provide greater resilience to families and society in general.23 Furthermore, a low level of spiritual well-being is related to a decreased life satisfaction level and a disturbing sense of meaning and purpose in life experienced by the community due to the COVID-19 pandemic.24,25 This can be overcome by strengthening spiritual resilience.26–28 Spiritual resilience is different from other forms of resilience, spiritual resilience can strengthen and empow- er resilience that is manifested in other bio-psychosocial emotional forms.26 Spirituality is an effective factor for dealing with stress and anxiety related to COVID-19.19,20,29 Spirituality is a source of social support that creates a sense of meaning to overcome confu- sion and increases a sense of indirect control over an event.30–32 In addition, previous research shows that according to indicators of family resilience, 95% of participants believe that this pandemic is a test from God Almighty and makes participants aware of the importance of family, this shows that spiritual values can be a good coping in the family.33 Spiritual health is created when a person voluntarily strengthens his spiritual strength through prayer, relax- ation, and associating with like-minded people, as well as learning from spiritual guides and reading books on religion.34 Prior research regarding the impact of spirituality on the resilience of patients with chronic illnesses has indicated that spir- ituality plays a significant role in enhancing an individual’s ability to withstand adversity, resulting in increased resilience35. Furthermore, spirituality fosters cognitive flexibility and resilience by encouraging individuals to accept and reconcile with challeng- ing circumstances. Patients with higher levels of spiritual well- being demonstrate more effective coping and adaptation to chal- lenging conditions, leading to heightened levels of resilience and improved stress management. Positive religious coping and regu- lar spiritual experiences have been linked to positive influences and higher life satisfaction. Conversely, religious coping is nega- tively associated with negative affect and psychological distress. Nevertheless, it’s noteworthy that there has been no previous research specifically investigating the influence of religious well- being on the resilience of family spirituality. In overcoming the impact of declining spiritual resilience, religious well-being or spiritual well-being can be used as a protector in psychological and mental health as well as physical health.22 The purpose of the cur- rent study was to analyze the influence of religious well-being on family spirituality resilience during the COVID-19 pandemic. This study also stated that addressing psychosocial and spiritual needs can improve the quality of life and individual well-being, especial- ly in the current pandemic conditions. Materials and Methods Design and participants The study was descriptive study, utilizing a cross-sectional sur- vey approach. The study was conducted in 2022 with data collection carried out in January-February 2022. The study’s population con- sisted of all Indonesian citizens residing in Malang, East Java Province. For eligibility, the sample was defined as adults capable of reading and completing the questionnaire. The sample size, deter- mined using G Power version 3.1, with a z-test, logistic regression, odds ratio of 1.5, a power of 80%, and a probability error of 0.05, resulted in a sample size of 243 respondents. Sampling was conduct- ed through accidental sampling technique. In this study, the inclu- sion criteria encompassed village residents aged 17 years and older who were literate and willing to participate in the research, while the exclusion criteria included individuals who met the inclusion criteria but were ill and unable to complete the distributed questionnaire. Procedure The data obtained by an online survey using Google Forms. Before the research begins, respondents were recruited based on written criteria. After finding suitable respondents, the respondents join the WhatsApp group that has been created. Then the researcher gathered the respondents in the hall, the researcher explained filling in the link, gave informed consent, and then asked the respondent to access the questionnaire link that the researcher distributed via the WhatsApp application. Overall, it took 30 minutes to complete the questionnaire. Meanwhile, for respondents who had not yet come to the hall, data collection was carried out by gathering respondents at one of the respondents’ houses closest to them. To increase and maintain research contribution provisions, incentives are given to respondents after completing the questionnaire. Instruments The main independent variable was religious well-being, which was assessed through a questionnaire consisting of 10 items with a score range of 1-6 (1=often used, 6=never used). Sample questions from this questionnaire include: “I don’t feel satisfaction when I pray to God personally” and “I don’t know who I am, where I am from, or where I am going.” The total scores for this questionnaire can range from 10 to 60. Subsequently, these scores were categorized into two groups: poor (above the median) and good (below the median). Additionally, there were several other independent variables under consideration, such as age, education, family type, income, and occupation. Age is classified into six cat- egories: 17-25 years (late adolescence); 26-35 years (early adult- hood); 36-45 years (late adulthood); 46-55 years (early elderly); 56-65 years (late old age); and over 65 years (old age). Education levels include no schooling, elementary school, junior high school, senior high school, or college. Family types are categorized as nuclear family, extended family, or single-parent. Income is divid- ed into two groups: less than 3 million and more than 3 million. Occupation is categorized as having a job or being jobless. The dependent variable was family resilience in the context of family spirituality, which was assessed through four question items related to worshiping in places of worship, seeking advice from religious figures, belief in God, and participating in worship activ- ities. Respondents provide their answers on a Likert scale ranging from 1 (disagree) to 4 (strongly agree). The composite scores for this variable fall within the range of 4 to 108 and are subsequently categorized as either adequate (above the median) or inadequate (below the median). [page 78] [Healthcare in Low-resource Settings 2023; 11:11747] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly Data analysis All data were analyzed using Statistical Package for Social Science (SPSS) version 21 software (IBM USA). Descriptive analysis was used to identify religious coping, age, education, fam- ily type, income, occupation, and family resilience with frequency and percentage. Logistic binary analysis was used to select candi- date variables. Variables with p<0.25) were included in the model- ing. Multivariate analysis was used to analyze the effect of candi- date variables on family resilience in communicating and solving problems during the COVID-19 pandemic. The degree of freedom used is 95% with a standard error of 0.05. Ethical considerations This study received ethical approval from the Health Research Ethics Commission of the University of Muhammadiyah Malang with protocol number E.5.a/007/KEPK-UMM/I/2022. Participants provided written consent for participation before data collection. Results Univariate analysis among all demographic data was presented in Table 1. Most of the ages ranged from 46 to 55 years as much as 30.9%, with a high school education level (47.7%). The most com- mon type of family was the nuclear family (66.7%). Most of the residents’ income was less than 3 million rupiahs (90.5%). Moreover, the data was also dominated by 162 residents, or 66,7% of people who lost a job during the pandemic, nevertheless, there were 51% of respondents have Good religious well-being and ade- quate family resilience in family spirituality 53.5% (Table 1). From Figure 1, it can be seen that the practice and faith of fam- ily resilience in family spirituality are indicated by activities in the form of maintaining their belief in the power of the Almighty (God) is 91.4%, there were 61,7% of respondents who participate in religious activities and 56 % who worshiping in places of wor- ship, and consulting with religious leaders as much as 53.1%. One factor that influences family resilience in family spiritual- ity is religious well-being. Families with adequate religious well- being were 4 times more likely to have resilience in family spiritu- ality than families with inadequate religious well-being (OR: 3,807; 95% CI: 2,230 - 6,498) (Table 2). The selection of candidates who entered the model was reli- gious well-being, while the variables were not included in the model because they had a p>0.25 value, namely age (p= 0.288), family type (p=0.268), occupation (p=0.552), income (p=0.321). Discussion The study’s findings indicated that religious well-being or spir- itual well-being significantly impacts family resilience in the con- text of family spirituality. Religious well-being encompasses the sense of satisfaction and inner peace experienced by individuals in the practice of their religion or spirituality. On the other hand, spir- itual resilience within a family can be understood as the family’s capacity to uphold their faith and spiritual values in the face of pressure and challenging circumstances. This resilience can also Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 2. The final multivariate logistic regression model of family resilience in family spirituality. Variable B SE Wald p OR 95% CI for Exp (B) Lower Upper Religious well-being 1.337 .273 24.016 0.000 3.807 2.230 6.498 Constant -1.822 .419 18,936 0.000 0.162 Figure 1. Family resilience questionnaire item scores in family spirituality during the COVID-19 pandemic. Table 1. Demographic characteristics of respondents (n=243). Characteristics n Percentage Age 17-25 19 7.8% 26-35 57 23.5% 36-45 56 23.0% 46-55 75 30.9% 56-65 27 11.1% >65 9 3.7% Education No formal education 1 0.4% Elementary school 46 19% Junior high school 55 22.6% Senior High School 116 47.7% College 25 10.3% Family type Nuclear family 162 66.7% Extended family 60 24.7% Single parent 21 8.6% Income <3 million 220 90.5% >3 million 23 9.5% Occupation (during the pandemic) Have a job 81 33.3% Jobless 162 66.7% Religious well-being Poor 119 49% Good 124 51% Family spirituality resilience Inadequate 113 46.5% Adequate 130 53.5% Total 243 100% [Healthcare in Low-resource Settings 2023; 11:11747] [page 79] Non -co mmerc ial us e o nly assist individuals in coping with stress, anxiety, and life’s trials. As a result, an increase in the family’s religious well-being is likely to contribute to the enhancement of their spiritual resilience. This is in line with previous research that mentions that the relationship with God contributes to the welfare of life.36 Families affected by COVID-19 sometimes experience loneliness, religious well-being or spiritual well-being can reduce the loneliness they feel.37 Spiritual well-being also has a role in overcoming stress that occurs, this is because there is a relationship between spiritual well-being, peace, faith, and psychological adjustment to the stress that occurs.38,39 Spiritual well-being along with hope and resilience can be good predictors of stress.40 The ongoing pandemic has brought about significant changes in family routines, which, in turn, can serve as triggers for family problems and health issues.41 In response, families are increasingly relying on mutual support, including spiritual support, as spiritual- ity can be a valuable source of strength42. It has become increas- ingly recognized as a significant contributor to overall health and well-being, and its benefits should not be underestimated.43 A sys- tematic review has demonstrated that various aspects of spirituality and religiosity, such as attendance at places of worship and the sig- nificance of religious beliefs, possess a modest yet consistent abil- ity to predict levels of mental health problems over time.44 Religious well-being or spiritual well-being is widely regarded as a stabilizing factor in life, fostering a sense of spiritual peace.45 Several studies have demonstrated that enhancing the spiritual dimension in one’s life can enhance adaptability to changing cir- cumstances,46 promote the maintenance of mental health,47 and improve social functioning.48 Additionally, spirituality contributes to increased cognitive flexibility and individual resilience when faced with challenging situations.49 The increasing family resilience is associated with higher degrees of spiritual well-being religious well-being and existential well-being.50 The results of this study also found that age, family type, fam- ily income, and education level did not affect family spirituality resilience. The age factor is a direct factor related to a person’s maturity to perceive something. So age does not affect spiritual resilience.51 This is also in line with previous research that age has a significant impact on a person’s perception of spiritual well- being. Family type and family income do not affect spiritual resilience. High family income does not guarantee good spiritual resilience, and low family income does not rule out the possibility of the family having good spiritual resilience.52 This depends on how grateful the family is for everything that happens, revealing the importance of creating gratitude practices every day to build family welfare and family resilience.53 The high and low level of education does not guarantee the strength of spiritual resilience in the family. Since spiritual resilience arises from self-belief and awareness of the existence of a Supreme Being (God), it is in line with research which states that spirituality refers to experiences and deep inner feelings and beliefs that arise from awareness of the existence of the Holy One which can increase the meaning of life’s purpose and inner peace.54 The level of education does not find a significant relationship with the level of spiritual resilience.51 This study shows that work does not affect family spirituality resilience. During this pandemic, the unemployment rate has increased, as well as changes to working regulations to reduce exposure to COVID-19. This is in line with the statement which mentions the development of a global pan- demic causing mass unemployment, and an increase in remote work.55 There is a positive impact from working remotely, where families will have more time to be closer to other family members. Previous research stated that apart from the negative impact of the pandemic that can disrupt family relationships, the pandemic also has a positive impact on families, where families have a lot of quality time and can be spent together.56 This research was con- ducted on respondents who are Muslim, so it has not been able to generalize to other religions. Questionnaires can be developed for other religions. This study has several limitations. This research was only con- ducted on Muslim populations, so the spiritual level data focused on only one religion. Recommendations for further research are that similar research can be carried out with various types of reli- gions so that the data obtained is more diverse. By making diverse religions, it is hoped that future research can represent the entire population without distinguishing between religions. Conclusions Family resilience in spirituality is heavily influenced by factors of religious well-being. 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