Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):13025 Spiritual coping “tri hita karana” and depression prevention behavior among the elderly during the COVID-19 pandemic I Wayan Suardana,1 Ah Yusuf,2 Rachmat Hargono,3 I Gede Juanamasta,4 Ketut Sudiantara,1 I Ketut Gama,1 I Wayan Mustika1 1Polytechnic of Health Denpasar, Bali; 2Faculty of Nursing, Universitas Airlangga, Surabaya, East Java; 3Faculty of Public Health, Universitas Airlangga, Surabaya, East Java; 4Nursing Program, STIKes Wira Medika Bali, Bali, Indonesia Abstract The elderly commonly struggle with mental health issues, especially depression. Spiritual coping is one of the factors that might prevent depression. The aim of this study is to investigate cultural involvement in spiritual coping to depression prevention among the Balinese elderly. From January to March 2021, this study was carried out on 273 elderly members of the Integrated Primary Public Health service in seven districts in Gianyar, Bali. The study used a cluster random sampling method to collect data and focused on quantitative measurements related to participant characteristics, depression prevention, and spiritual coping. The investigation into spiritual coping was based on the tri hita karana, a concept from Balinese philosophy. Bivariate analysis was used to assess the relationship between spiritual coping and depression prevention behaviour. The study comprised 146 male and 127 female participants aged between 65 and 79 years old. Among all participants, 190 (69.6%) were diagnosed with mild to moderate depression, while 83 (30.4%) with moderate to severe depression. However, for the majority, depression prevention was good 163 (59.7%), the rest was moderate 103 (37.7%), and poor 7 (2.6%). Tri hita karana spiritual coping for the majority was good 17 (53.8%). Spiritual coping has a strong correlation with depres- sion prevention (r=0.230). Thus, spiritual coping has a strong cor- relation with depression prevention among the Balinese elderly. It can be concluded that the implementation of tri hita karana becomes a potent spiritual coping enhance depression prevention. Indigenous philosophy embedded in daily life supports social cap- ital in dealing with stress. Introduction Nowadays aging population become an urgent issue globally. The phenomena shifted from high income country into low and middle income countries.1 United Nation projected in 2050 1 in 6 people in the world will be 65 or over. The trend of rising elderly prevalence is fasten in South East Asia and Latin America.2 However the impact of this issue into public health system should be highlighted to encourage active aging where elderly will be empowered to responsible maintenance their physical and mental wellness.3 Strengthen the future health system driven into elderly wellbe- ing which emphasized two integral aspects4. Various studies had been declared both aspects in physical and mental or physcologi- cal.4 The outcome of physical aspects of elderly such as the fitness to move during 3-6 month dependently.5 While the mental health outcome aspects mostly studied were quality of sleep, depression, and anxiety. Elderly as vulnerable population has higher risk of isolation away from family due to immobility and other physical disability. Since 2019, Covid 19 pandemic in makes this reality surging among old population. Elderly feel alone, insecure, helpless, and lack of social support make higher risk of relapse depression and anxiety.5,6 However, depression declared as pathological mental development of getting old. Unlike the younger population, the risk of depression is higher 80% among older alduts.7 This exac- erbated and relapsed classified as major depressive disorder, per- sistent depressive disorder, substance induced depressive disorder and depressive disorder due to a medical condition.8 Management of depression in elderly is essential because it significantly related to family burden, decreased quality of life, and induced idea of suicide.8 Comprehensive clinical guideline has been established.9 First is comprehensive assessment related depression symptom and severity. The symptom listed based on the etiology such as number of medication trigger depression and other underlaying disease. Depression severity mostly measured by GDS, HAM-D, BDI,PHQ-9. For a short relive anti depressant was widely used as pharmacological treatment. Another choice were recommended such as psychotherapy CBT, problem solving, therapy could involved family and caregiver. For the worst case electroconvulsive therapy might be chosen. However concept of healing recently moved into seeking inner peace that authorized the elderly him/herself together creat- ing harmony with social belongings also go beyond with the Supreme Being/God. This approach determined as spiritual cop- ing. The core of spirituality is transcendence with 4 dimensions personal, social, environmental, and religious ones.10 Coping is a form of resilience that is individual in nature as a challenge to suc- cessfully pass every event in old age.11 In its development, the concept of coping that exists and develops so far is still very little Significance for public health Promoting active ageing is crucial, emphasizing the need to address physical and mental health. Older people are at significant risk of depression, exacerbated by factors such as social isolation and the challenges posed by the COVID-19 pandemic. It is essential to implement effective management strategies, including comprehensive assessment and treatment options, to alleviate the burden of depression in this demographic. Furthermore, spiritual coping mechanisms, such as the Balinese philosophy of tri hita karana, have demonstrated the potential to promote well-being and resilience among older individuals. This study sought to explore the correlation between spiritual coping, specifically tri hita karana, and depression prevention behavior among older people during the pandemic. [page 10] [Healthcare in Low-resource Settings 2024;12(s1):13025] discussing culture. Even if the concept of culture already exists, most of the literature still focuses on changes in the mental outlook of cultures that adopt western values and behavior (Divale, 2001). Novelty of this study is accentuated Balinese philosophy of harmo- ny known as Tri Hita Karana.12 Conceptually, Tri Hita Karana is defined three causes of hap- piness.13 Three elements of Tri Hita Karana were relation human to God (theocentric) known as Parahyangan; relation human to human (anthropocentric) known as Pawongan; and relation human to nature (cosmocentric) known as Palemahan.14 One study found that the imbalance of these three things causes disease.15 In looking at the etiology of mental illness, it is more than fully looking at the type of abstract (non-physical) disease.13,15 Thus, Tri Hita Karana might have important part in wellness and health. Despite many studies used Tri Hita Karana concept specifically related to eco- nomic, politic, social and anthropology research,16 lack number of study employ this concept in the health research. Therefore, the study aimed to examine the relationship between spiritual coping “Tri Hita Karana” and depression prevention behaviour among elderly during pandemic Covid-19. Materials and Methods Study design Design of this study is an observational and cross-sectional. Study was conducted during January- Marc 2021 with elderly pop- ulation in Gianyar Distric area Bali Province. Gianyar was chosen as the research site because this area is a pilot for elderly-friendly implementation based on Bali local regulations. This site also well- known as the heart of Balinese culture. This study involved 7 dis- trict primary care provider in rural and urban area Payangan, Ubud, Sukawati, Tegalalang, Blahbatuh, Tampaksiring and Gianyar. Participants of this study was the elderly who joined regular health promotion program for primary care in Indonesia. Inclusion criteria of the participants is fluent to communicate in Bahasa. Exclusion criteria of the sample were severe mental disorder, hearing disorder, refuse to continue join the research. We used estimated proportion formula to count the total sample.17 Based on that formula the assumption probability 0.05 and elderly population in Ginyar Distric 2019 39,637 people, elderly depression prevalence in Indonesia 23,4 % (Riskesdas, 2018). According the calculation total sample involved 273 people. Data collection was performed by enumerator interviewed the elderly using structured questionaries. Instruments In this study, 2 variables were measured, namely depression prevention behavior and religious coping. Depression prevention behavior is measured by giving 12 questionnaires with a Likert scale of 0-2 developed from Llopis & Ggabilondo.18,19 The validity and reliability have been tested . The items-total score of Pearson’s correlation was significant at .05 level and with Content Validity Index for Items (I-CVI) computation was 1.00, with Cronbach’s alpha was .80. Depression prevention behavior classified in three level: good (score 17-24), moderate (score 8-16), less (score 0-7). Spiritual coping was self created questionnaire constructed based one Balinese philosophy Tri Hita Karana. Tri Hita karana spiritual coping complied 3 items element. First prahyangan ele- ment (relation with the supreme god/transcends): 5 items sradha (activity creating offering and praying) and 5 items bhakti (activity to do self reflection to be surrender). Second pawongan element (relation and interaction with human being): 5 items nyama (sup- port system among family) and 5 items (braya support system by neighborhood). Third palemahan element: 3 item utama mandala (space to do praying activity), 4 items madya mandala (space to do human interaction), and 3 items palemahan (green space for plants and pets).20 Self-created questions were tested using Pearson’s Correlation Product Moment for validity with the returned values varying between .412 and .572 in the commonality analysis, and for reliability through Cronbach’s alpha, with all of the questions demonstrating reliability with the value of .583 (higher than 0.5). Another characteristic variables also measured such as gender, age, family type, personality, stress and quality of geriatric health provider. Data analysis The data was managed using the Statistical Package for Social Sciences - SPSS version 23.0. We performed the descriptive statis- tics for the socio-demographic and mental health characteristics, the depression prevention and spiritual coping. In the bivariate analysis, Pearson’s correlation coefficient was used between char- acteristic variables and depression prevention. The relationship magnitude and strength were determined by the following criteria: r= 0.10 -0.29 (small or low relationship), 0.30 –0.49 = medium relationship, and 0.50 –1.0 = strong or high relationship.21,22 The value of significance (2-tailed) is less than 0.05 significant at a 95% confidence interval. Ethical considerations This study was reviewed by The Health Research Ethics Committee Faculty of Nursing Universitas Airlangga, with the ethi- cal approval number 2303-KEPK. Informed consent was distributed to the participants before completing the main questionnaires. The informed consent has been applied approaching the principle of ben- eficial, no harm, confidential, justice, as well as voluntary partici- pants. The provided information should be agreed to by participants before data collection. The participant could stop the survey anytime during the data completion. The informed consent had been reported during the Ethics Approval and Consent prior the study. Results and Discussion Table 1 shows that majority of respondents were 70-79 years old and more than half were male. Primary education was the high- est number compare than another level of education. More than 70% was married with unstable income. Extended family type was the majority of the respondent, followed by nuclear family and liv- ing alone. For depression prevention, 59.7% participants had a good category, 37.7% moderate and the rest was poor. Almost half of them had poor spiritual coping (46.2%). Based on the analysis, depression behavior prevention had a significant correlation with age (r=0.592), gender (r=0.492), income (r=0.468) and spiritual coping (r=0.230; Table 2). Surprisingly, the majority category was good during pandemic situation. This elaborate our correlational finding Tri Hita Karana Spiritual Coping has significant correla- tion with depression prevention behavior. The majority of participants age on range 60-69 years old (83,15%).The rest (16,85%) is 70 years old and over. The cut point 70 years old in this study decided based on the prior study of eld- erly definition according physical and mental health independency among Balinese population.23 This study congruence with elderly classification visited emergency department defined in three group 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13025] [page 11] : youngest-old, ages 65 to 74 years; middle-old, 75 to 84 years; and oldest-old, ≥85 years.24 Based on gender, the proportion of male population is 53,5% and female 46,5%. A study elaborated this finding based on correlational study in Chine related Asian Ethnic measured by life expectancy at age 60 years (LE60) and quality- adjusted life expectancy at age 60 years (QALE60).25 This study found that men have as shorter life expectancy but seems less suf- fering rather than women. Recently depression on of the most common mental health issue among elderly especially since pandemic Covid 19 until 2022.25,26 Study among 457 Indonesian participants found 53,57% experienced depression.27,28 Another study explained predictors of depression in South Asia (India, Pakistan, Bangladesh, Nepal, Sri Lanka) such as : gender, chronic illness, financial and physical dependent with other, not able to work or unemployment, experi- enced stress full event, lack of social support, marital status and living arrangement, substance or elderly abuse, inadequate spiritu- al needs, tension in home, not engage in leisure activities or hob- bies.29 Especially Bali Province as setting of this researched suf- fered a poignant effect of plunged tourism aspect as main income. Another study in Denpasar as part of Bali in first semester of 2020 among 100 respondents experienced anxiety (53,1%); depression (51,2%); and stress (46,1%) since decreasing monthly income and termination of employment.30 Coherent with this research findings all participants experienced depression: mild to moderate 69,59% and moderate to severe 30,41%. Compared with previous study related depression in Bali Old population, the trend is about increasing. Study involved 774 female and 719 male participants aged 60 to 100 using CES-D score of ≥10 as depression as assign- ment declared the prevalence of depression among older adults in Bali was high (42.3%).31 However, old population have been faced many life stress exposure and experienced make the survived and well adapted known as coping.32 The main coping strategies main coping strate- gies were: anticipatory mourning, the desire to die, isolation, sub- mission, negotiation, acceptance, accommodation, seeking social support, seeking spiritual comfort and living in the moment.33 Even during pandemic COVID-19, old population showed their natural resilient dealing with unexpected condition and isolation by positive motioned coping mechanism by generate good mind- set, stay busy, and look for social support. Compared with young population, old population less likely used avoidant coping strate- gy which sign of depressive symtom.34 Explaining the former shape of coping was seed of transaction- al theory developed by Lazarus and Folkman in 1984.35 Transactional explanations emphasizing dynamic relation of indi- vidual ability to responds stress of environment by cognitive phe- nomenological processes. Theory of Coping by Lazarus triggered by stress which interaction environment and person. Later stress stimulate perception named appraisal.36 Appraisal conduct adapta- tion known coping mechanism classified in two: problem focused coping and emotional focused coping.37 Problem focused coping described by using several strategy to remove the stressor by solv- ing the problem.38 While emotional focused coping described by using emotional responds to deal with the stressor.39 Recently, holistic health orientation involved spirituality aspect as coping mechanism.40 Philosophical anaylsis of spiritual coping in nursing science enhanced physical, psychological, and social well-being, resilience, and self-transcendence.4142 Research suggests that spiritual coping strategies, involving relationship with self, others, Ultimate other/God or nature were found to help individuals to cope with their ailments.43 Congruence with Balinese culture the definition of spirituality known as Tri Hita Karana. embodies universal values and represents harmonious and balanced human relationships with the spiritual, social and natural environment to achieve spiritual and physical wellbeing.44 4th International Nursing and Health Sciences Symposium Table 1. Characteristic of participants. Variable (N=273) n % Age 65-69 years old 96 35.2 70-79 years old 177 64.8 Gender Male 146 53.5 Female 127 46.5 Highest level of education None 68 24.9 Primary 84 30.8 Secondary 45 16.5 Tertiary 44 16.1 University 32 11.7 Marital status Married 200 73.3 Divorced 64 23.4 Unmarried 9 3.3 Income status Stable 67 24.5 Unstable 206 75.5 Family type Nuclear family 116 42.5 Living alone 8 2.9 Extended family 149 54.6 Depression Prevention Good 163 59.7 Moderate 103 37.7 Poor 7 2.6 Spiritual coping Good 147 53.8 Poor 126 46.2 Table 2. Correlation characteristic and depression prevention behavior. Variables Category Poor Moderate Good Correlation Age High risk 3 46 47 0.592** Lower risk 4 57 116 Gender Male 3 52 91 0.492** Female 4 51 72 Education level None 1 33 34 0.082 Primary 4 32 48 Secondary 2 10 33 Tertiary 0 19 25 University 0 9 23 Income Status Stable 4 68 108 0.468** Non-stable 3 35 38 Marital Status Married 7 64 129 0.008 Unmarried 0 36 28 Divorced 0 3 6 Family Type Nuclear family 6 51 59 0.010 Living alone 0 5 3 Extended family 1 47 101 Spiritual coping Good 5 40 102 0.230** Poor 2 63 61 **p<0.01. [page 12] [Healthcare in Low-resource Settings 2024;12(s1):13025] Implementation of Tri Hita Karana embedded in Balinese peo- ple daily life. Everyday people in Bali create handmade offering to show gratitude of The Supreme God Blessing. That activity became indigenous culture infused by Hinduism belief (Sradha) and compassion to serve (Bhakti).45 Another implementation of Tri Hita Karana as Spiritual Coping strategy during Covid 19 was implemented by reading Bhagawad Githa involved 100 partici- pants in Bali.46 As part of harmony woth the Supreme God Balinese people tend to be more surrender and more likely do self- control and reflection known as Mulat sarira. Harmony among human as human being in Bali conceptualized Menyama Braya. Menyama, its semantic meaning refers to family ties by marriage and blood; while Braya refers to neighborhood. This concept dur- ing pandemic became social capital build coping and resilience during pandemic.47 Many people give free food supplies to others, giving social loan, and personal protective equipment’s such as mask, face shield, desinfectant. Creating harmony in nature physi- cally reflected on Balinese concept house always provide green space for palemahan. Balinese house divided into 3 elements as Tri Mandala: sacred place or temple for praying, home for human inte- gration, and space for garden / pets.47 Even in dynamic in rural area such as Denpasar as Bali Capital is still maintained.47 Gardening and connect with animal or pets became habitual activity among Balinese people which available in their green space during isola- tion period in pandemic. Gardening engage can facilitate stress reduction through interactions with natural elements, which bolster human health.48 The implementation of Tri Hita Karana in Bali as spiritual coping facilitates coping goal in this contacts of research related depression prevention. Old population in Bali more likely implement spiritual coping rather than problem or emotional focused coping. Based on this observation, the majority of partici- pants did not have role as decision maker and lack of their cogni- tive capability to solve their life problem. Participants also try to hide their emotional feeling to prevent their family burden. Balinese elderly selected other activity to keep them busy and calm down their mind and feeling. Implementation of Tri Hita Karana not only for coping strategy but also outcome itself as depression prevention. Implementation Tri Hita Karana among old people in Bali occupied their physical, social, natural bonding activity to regulate mental health. Conclusions Age, gender, income, and spiritual coping were positively cor- related with depression behavior prevention. This study results can give input to the nurse to understand depression behavior preven- tion. Besides, the results can use to develop intervention through Tri Hita Karana to manage depression behavior prevention. Community nursing or public health nurse could use this concept to promote positive mental health to community. Besides, it might be related to health seeking behavior. Nurse needs to explore more about mental health, which can be an issue to explore for future studies. This study’s findings might not represent Indonesia because data were gathered only in the one district. Therefore, further research is needed with a larger, multiethnic sample to understand spiritual coping “Tri Hita Karana” and depression behavior pre- vention in Indonesia. This finding might be limited to during pan- demic situation, further studies with longitudinal methodology is highly recommended. In addition, the study findings did not present cause effects; thus, a causal model to confirm spiritual coping and depression prevention behavior is needed for future studies. References 1. WHO. Ageing and health [Internet]. 2022 [cited 2024 June 19]. Available from: https://www.who.int/news-room/fact- sheets/detail/ageing-and-health. 2. United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2019: Highlights (ST/ESA/SER.A/430). New York: WHO; 2019. 3. WHO. Decade of Healthy Ageing. World Heal Organ. New York: WHO;2020. 4. Paralikas T, Maria M, Dimitrios T, et al. Physical and Mental Health Level of the Elderly Living in Central Greece. Mater Socio Medica 2021;33:16. 5. Kadariya S, Gautam R, Aro AR. Physical Activity, Mental Health, and Wellbeing among Older Adults in South and Southeast Asia: A Scoping Review. Biomed Res Int 2019;2019:6752182. 6. Mehra A, Rani S, Sahoo S, Parveen S, Singh AP, Chakrabarti S, Grover S. A crisis for elderly with mental disorders: Relapse of symptoms due to heightened anxiety due to COVID-19. Asian J Psychiatr 2020;51:102114. 7. Centers of Disease Control and Prevention. Depression is Not a Normal Part of Growing Older. Washington: CDC;2014. 8. National Institute on Aging. National Institute on Aging. 2021 [cited 2024 Jun 19]. Depression and Older Adults. Available from: https://www.nia.nih.gov/health/mental-and-emotional- health/depression-and-older-adults 9. . Avasthi A GS. Clinical Practice Guidelines for Management of Depression in Elderly. Indian J Psychiatry 2018;60:S341-62. 10. Charzyńska E. Multidimensional approach toward spiritual coping: construction and validation of the Spiritual Coping Questionnaire (SCQ). J Relig Health 2015;54:1629–46. 11. Stanhope M, Lancaster J. Public health nursing: Population- centered health care in the community. Philadelphia, USA: Elsevier Mosby; 2019. 12. Widhiastini W, Permatasari NPI. The Indonesian Journal of Social Studies Social Construction & Tri Hita Karana Concept : Wellbeing. 2020;3:100–8. 13. Satya PANIP, Lase FJ. The Peaceful means of Tri Hita Karana in Balinese culture. 2018 [cited 2024 Jun 19]; Available from: https://repository.unpar.ac.id/handle/123456789/repository.un par.ac.id/handle/123456789/7299 14. Sukarma IW. Tri Hita Karana: Theoretical Basic of Moral Hindu. Int J Linguist Lit Cult 2016;2:84. 15. Putro BD. Mental disorders (Buduh) in Bali as a cultural phe- nomenon: A study of perceptions and behavior of Balinese mental disorder treatment choices. Yogyakarta: Universitas Gadjah Mada; 2004. 16. Kusuma IGAT, Landra N, Widnyana W. Construction of Balinese local wisdom based on social model in the tourism sector in creating happiness to enhance community satisfac- tion. Asia Pacific Manag Bus Appl 2019;8:53–64. 17. Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian J Psychol Med 2013;35:121–6. 18. Jané-Llopis E, Gabilondo A. Mental Health in Older People. Luxembourg: European Communities; 2008. (Consensus paper). 19. Koenig HG. Research on Religion, Spirituality, and Mental Health: A Review. Can J Psychiatry 2009;54:283–91. 20. Wiana IK. Tri Hita Karana According to Hindu Concepts. Surabaya: Paramita; 2007. 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13025] [page 13] 21. Cohen J. Statistical power analysis for the behavioral sciences. New York: Routledge; 1988. 22. Kang K, Gholizadeh L, Inglis SC, Han HR. Validation of the Korean Version of the MacNew Heart Disease Health-Related Quality of Life Questionnaire. J Nurs Res 2019;27:e11. 23. Ouchi Y, Rakugi H, Arai H, et al. Redefining the elderly as aged 75 years and older: Proposal from the Joint Committee of Japan Gerontological Society and the Japan Geriatrics Society. Geriatr Gerontol Int 2017;17:1045–7. 24. Lee SB, Oh JH, Park JH, et al. Differences in youngest-old, middle-old, and oldest-old patients who visit the emergency department. Clin Exp Emerg Med 2018;5:249–55. 25. Hao L, Xu X, Dupre ME, et al. Adequate access to healthcare and added life expectancy among older adults in China. BMC Geriatr 2020;20:1–15. 26. Juanamasta IG, Wati NMN, Widana AAGO. Covid-19: A bali- nese viewpoint. Belitung Nurs J 2020;6:143–4. 27. Kurniawidjaja M, Susilowati IH, Erwandi D, et al. Identification of Depression Among Elderly During COVID- 19. J Prim Care Community Health 2022;13:2150131 9221085380. 28. Aungsuroch Y, Juanamasta IG, Gunawan J. Experiences of Patients with Coronavirus in the COVID-19 Pandemic Era in Indonesia. Asian J Public Opin Res 2020;8:377–92. 29. Assariparambil AR, Noronha JA, Kamath A, et al. Depression among older adults: a systematic review of South Asian coun- tries. Psychogeriatrics 2021;21:201–19. 30. Hartawan IGNBRM, Sastrawan IGG, Parastan RH, Ani LS. Depression, anxiety, and stress levels in Denpasar community during the pandemic of Corona Virus Disease 2019 (COVID- 19). Qanun Medika 2021;5:103. 31. Suriastini NW, Suryani LK, Sikoki B, et al. Depression among older people in bali. Asian J Gerontol Geriatr 2021;16:22–9. 32. Meeks S, Carstensen LL, Tamsky BF, et al. Age differences in coping: Does less mean worse? Int J Aging Hum Dev 1989;28:127–40. 33. Ribeiro M dos S. Coping strategies used by the elderly regard- ing aging and death: an integrative review. Rev Bras Geriatr Gerontol 2017;20:869–77. 34. Nieto M, Romero D, Ros L, et al. Differences in Coping Strategies Between Young and Older Adults: The Role of Executive Functions. Int J Aging Hum Dev 2020;90:28–49. 35. Odato JM. This Brain Had a Mouth. Amherst, MA: University of Massachusetts Press; 2021. 36. Stanisławski K. The coping circumplex model: An integrative model of the structure of coping with stress. Front Psychol 2019;10:1–23. 37. Lestari RF. Coping Strategies for Students Seen from the Big Five Personalities. Acta Psychol 2021;3:29–37. 38. Galiana L, Tomás JM, Fernández I, Oliver A. Predicting Well- Being Among the Elderly: The Role of Coping Strategies. Front Psychol 2020;11:1–8. 39. Hoyt MA. Emotional Approach Coping in Older Adults as Predictor of Physical and Mental Health. Psychol Aging 2020;35(4). 40. Southard ME. Spirituality: The Missing Link for Holistic Health Care. J Holist Nurs 2020;38:4–7. 41. Juanamasta IG, Aungsuroch Y, Gunawan J, Fisher ML. Postgraduate and undergraduate student nurses’ well-being: A scoping review. J Prof Nurs 2022;40:57–65. 42. Dunn KS, Robinson-Lane SG. A Philosophical Analysis of Spiritual Coping. Adv Nurs Sci 2020;43:239–50. 43. Baldacchino D, Draper P. Spiritual coping strategies: A review of the nursing research literature. J Adv Nurs 2001;34:833–41. 44. Huang H, Rockwell J. Nature and the Spirit: Tri Hita Karana, Sacred Artistic Practices, and Musical Ecology in Bali. EnviroLab Asia 2019;3:1–27. 45. Nerawati NGAA, Sudarsana IK. The Role of Pasraman Kilat in Raising Sradha and Bhakti of Teenagers. J Penelit Agama Hindu 2020;4:74. 46. Surpi NK, Istriyanti NLA, Avalokitesvari NNAN. Resilience and Coping Strategy of Bhagavad-Gῑtā Readers on the COVID- 19 Pandemic in Bali. Kurukshetra Univ Res J 2021;55:26–33. 47. Arisanti NMD, Suderana IW. Handling The Covid-19 Pandemic: Collaboration Of District Government With Knpi Gianyar In Gianyar District, Bali. SP 2020;15:87. 48. Egerer M, Lin B, Kingsley J, et al. Gardening can relieve human stress and boost nature connection during the COVID- 19 pandemic. Urban For Urban Green 2022;68:127483. 4th International Nursing and Health Sciences Symposium Correspondence: I Wayan Suardana, Nursing Department, Polytechnic of Health Denpasar, Bali, Indonesia, Jl. Sanitasi, No 1 Denpasar, Bali, Indonesia. Tel.: +62361710447 E-mail: suardanawayan@yahoo.com Key words: depression; elderly; spiritual coping; tri hita karana Contributions: IWS, AY, and RH, made significant contributions to the study through their involvement in study design, data collection and analysis, manuscript writing, and data analysis; KS, IKG, and IWM, also played vital roles by contributing to study design, manuscript writing, and conducting reference searches. Conflict of interest: the authors declare no potential conflict of interest. Funding: this study was financially supported by Polytechnic of Health Denpasar, Bali, Indonesia Clinical trials: not applicable. Ethics approval and consent to participate: this study was reviewed by The Health Research Ethics Committee Faculty of Nuring Universitas Airlangga, with the ethical approval number 2303-KEPK. Informed con- sent was distributed to the participants before completing the main ques- tionnaires. The informed consent has been applied approaching the prin- ciple of beneficial, no harm, confidential, justice, as well as voluntary participants. The provided information should be agreed to by partici- pants before data collection. The participant could stop the survey any- time during the data completion. The informed consent had been reported during the Ethics Approval and Consent prior the study. Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 27th-28th of October 2023, Universitas Brawijaya, Malang, East Java, Indonesia. Acknowledgment: the authors acknowledge the Director of Polytechnic of Health Denpasar, Bali, Indonesia for generously funding this study. Received: 3 November 2023. Accepted: 8 June 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12(s1):13025 doi:10.4081/hls.2024.13025 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 product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. 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