Hajar Hospital Research Articles

A Rare Case of Pericarditis following DKA in Hajar Hospital of Shahrekord, Iran

Background and purpose: DKA is a serious complication of relative insulin deficiency that can occur in type 1 and type 2 diabetes mellitus. One of the most common complications in autoimmune disorders is pericarditis but it is very rare in DKA. Case Report: The patient is an 8-year-old girl who was admitted with weakness, lethargy, dizziness and fever. Blood sugar of 490 mg/dl and acidosis with ketoneuria demonstrated DKA. During hospitalization, due to abdominal and chest pain echocardiography were done, and moderate to severe pericarditis and pericardial effusion were reported. Conclusion: DKA is a serious complication of relative insulin deficiency that occurs during diabetes and epidemiological data showing a steady increase in its incidence in children. Immunodeficiency effect of diabetes and hyperglycemia can cause complications in DKA patients. Understanding mechanisms of complications such as pericarditis is important in decreasing morbidity and mortality and also appropriate treatments.

RELATIONSHIP SOCIAL SUPPORT AND RESILIENCE WITH STRESS LEVELS OF FAMILY CAREGIVERS HEMODIALYSIS PATIENTS SURABAYA

Introduction: Hemodialysis is a life-long treatment for end-stage renal disease (ESRD). ESRD has physical and psychosocial challenges to experience stress which not only affects but patients but also family members who care for them or also called family caregivers. Analyzing the relationship of social support and resilience to the level of stress in the family caregiver of hemodialysis patients at Haji Hospital Surabaya.Methods: A cross-sectional study with a population of family caregiver members of hemodialysis patients at RSU Haji Surabaya. The sample size was 92 respondents with criteria, namely families who treat hemodialysis patients at RSU Haji Surabaya, live in one house with patients, aged > 18 years, and can read and write. The variables of this study are social support, resilience, and stress levels. Data collection was performed using a questionnaire and analyzed using Spearman’s Rho test. Results : There was a significant negative relationship between social support and stress levels (p = 0.004 and r = -0.296) and resiliency with stress levels (p = 0.003 and r = -0.311).Discussion: The level of stress in a family caregiver hemodialysis patient can be influenced by the social support received and the level of resilience they have. The social support has an important role for family caregivers obtained from the family and significant other.

Deteksi Dini Penyakit Arteri Perifer pada Pasien Diabetes Melitus di Kota Mataram

Diabetes mellitus is currently becoming a major public health problem in the world. The prevalence of diabetes mellitus globally in 2019 is estimated at 9.3% and will increase to 10.9% in 2040. Peripheral artery disease is one of the important complications of diabetes mellitus. Patients with diabetes mellitus accompanied by peripheral artery disease have high morbidity and. Therefore, early detection of peripheral artery disease in diabetic patients is important. This event is carried out with the aim of early detection of peripheral artery disease in diabetes mellitus sufferers in Mataram. A total of 183 diabetes mellitus patients at the Siti Hajar Hospital, Mataram, were participated in this event, with an average age of 57 years and 67.8% of them were women. Most of the patients (75.4%) had poor blood glucose control. Of these, 26.8% of patients had peripheral artery disease. Patients and/or caregivers showed high enthusiasm during the education regarding the detection results of the peripheral artery disease. This event was very useful in increasing the knowledge of diabetic patients, especially in terms of blood sugar control, prevention, and management of peripheral artery disease.

EFEKTIVITAS TERAPI LATIHAN TERHADAP PENURUNAN DEPRESI PADA PASIEN STROKE

Exercise therapy is a systematic, planned physical exercise in posture or body training that aims to restore decreased body function, prevent or increase physical activity in order to carry out daily functional activities. Depression is a condition of feeling sad that has a negative impact on a person's thoughts, actions, feelings and mental health, in stroke sufferers this often occurs because of the inability to carry out functional activities. The purpose of this study was to determine the effectiveness of exercise therapy in reducing depression in stroke patients. The population used was all stroke patients who came to the Physiotherapy clinic at Siti Hajar Hospital Medan. Respondents used were stroke patients with depressive disorders as many as 24 respondents with purposive sampling technique, quasi-experimental design with the form of one group pre-test-post test. The results of the test analysis with the Paired T test obtained a correlation value of 0.915 which means that it has a strong and positive relationship between before exercise therapy and after it is given. The result of t count with a value of 7,218 and exceed the value of t table which means significant. At the p value of the Paired T test, the results were 0.000 (<0.05) with 95% confidence, which means that there is an effectiveness difference between before and after the treatment is given.

Hubungan Tingkat Pengetahuan dan Perilaku Perawat terhadap Risiko Kegiatan Pembuangan Limbah Medis Padat Di Ruang Syifa Dan UGD RS Haji Jakarta Tahun 2015

Hospital is one of the health care facilities that have complex characteristics especially concerning the interaction between the various processes, scientific devices and various types of health workers who are related to each other. In addition to a positive impact, the Hospital had negative impacts that generate waste during its activities; one of waste is solid medical waste. Solid medical waste is one of the sources of pollution, so it is necessary to conduct an integrated management starting from segregation to the disposal of solid medical waste. Researcher raised this issue because there were incident afflicting health workers and cleaning services at Haji Hospital Jakarta, they were punctured used needles. In a period of 2 years from 2014 to 2015, there had been 5 cases of used needles should not happen. This research use quantitative and qualitative methods. Quantitative research conducted by distributing a questionnaire to measure the level of knowledge (age, length of work, education, training), facilities and behavior of nurses and cleaning services to the risk of solid medical waste disposal activities. The qualitative research conducted with in-depth interviews. Result of the relation between nurse knowledge against the risk of solid medical waste disposal based on the result of the t-test 1.661 < t-table 2000. Result of the relation between nurse behavior with the risk of medical waste disposal activities based on the result of the t-test 1.975 < t-table 2000. Result of the relation between of the level nurse knowledge and nurse behavior with the risk of solid medical waste disposal based on the result f-count 3.036 < f-table 3.35. So there is no relation between nurse knowledge and nurse behavior with the risk of medical waste disposal activities at Haji Hospital Jakarta.

Analisis Kegiatan Penyediaan Berkas Rekam Medis Rawat Inap di RSU Haji Surabaya

One indicator in measuring the quality of medical records is the punctuality. The punctuality means managing the medical record file from the patient registering until the medical record file with the time limit specified in the standard operating procedure. At Haji Hospital Surabaya, the delay in providing the inpatient medical records is still a problem. It can cause obstruction of the patient care process so that it will also affect service satisfaction. This research was aimed to analyze the activities of providing inpatient medical records at the Hajj General Hospital in Surabaya with the type of qualitative research. Data collection techniques used are observation, interviews, and documentation based on the variables Ability, Motivation, and Opportunities. The results of this study indicate that there are no SOPs related to the time the provision of inpatient medical records is the main factor being addressed. The Efforts can be made by rearranging SPOs related to providing inpatient medical record time.

Characteristics of Mothers Before and During Pregnancy Causing Postpartum Hemorrhage in Surabaya, Indonesia

Postpartum hemorrhage (PPH) is one of the direct causes of maternal mortality with the highest percentage. Postpartum hemorrhage is the bleeding that occurs due to the blood loss of 500 ml or more from the reproductive organs after labor. The objective of this present research was to understand the characteristics of mothers before and during pregnancy that induce postpartum hemorrhage in Surabaya. The research method employed was a control case design consisting of 180 postpartum mothers, being analyzed using a multinomial logistic regression. The research was conducted in Soewandi Hospital and Haji Hospital Surabaya. The research results revealed that characteristics of mothers before pregnancy causing the incidence of postpartum hemorrhage were as follows: a) Age < 20 and > 35 (66.7%), b) multi-parity (61.14%), pregnancy spacing ≤ 24 months (70.4%), d) possessing postpartum hemorrhage history (93.3%) and e) suffering from anemia (80.8%). Characteristics of mothers during pregnancy were among others : Double pregnancy (71.4%), preeclampsia (79.5%) and obesity (70.6%). It is expected that the cadres of health staffs recognize the characteristics of these mothers and are able to detect earlier any postpartum hemorrhage that occurs to pregnant women so that earlier prevention actions may be taken. 
 
 Keywords: causing factor; before and during pregnant; postpartum hemorrhage

A retrospective cross-sectional study of urinary tract infections and prevalence of antibiotic resistant pathogens in patients with diabetes mellitus from a public hospital in Surabaya, Indonesia

Diabetes mellitus (DM) is a metabolic disease that can cause many complications. The occurrence of urinary tract infection is also considered to be the cause of complications in patients with DM. This study aimed to evaluate the prevalence of urinary tract infection (UTI) and antibiotic-resistant bacteria found in urine culture from patients with DM in Surabaya, Indonesia. This study was conducted with a retrospective cross-sectional study design, using a database of 1551 patients with DM admitted to Haji Hospital, Surabaya, Indonesia, from January 2017 to December 2018. Data regarding the bacteria isolated from urine and antimicrobial sensitivity were analyzed. The prevalence of UTI was 3.93% - 61 patients were confirmed with urine culture for UTI diagnosis. The predominant isolates found were Escherichia coli (24.5%) and Enterococcus faecalis (8%). This study also showed multidrug-resistant organisms (MDRO) found in UTI such as Escherichia coli MDRO (3.3 %), Klebsiella pneumoniae MDRO (3.3%), Acinetobacter baumannii MDRO (1.6%), extended-spectrum beta-lactamase (ESBL) Escherichia coli (3.3%). The E. coli were sensitive to fosfomycin (93%), meropenem (93%) and nitrofurantoin (67%). No significant difference in the prevalence of UTI was found among ages, sex, and duration of disease in all patients with DM. The cases of UTI seen in patients with DM show the importance of monitoring UTI occurrence in this patient category to ensure better treatment for these patients.

Explaining Consequences of Parents Having Child with Thalassemia: Qualitative Study

Background: Thalassemia can affect different aspects of life the same as any other chronic disease. Despite therapeutic measures of thalassemia, the patient and families encounter several physical and psychological problems. Having a child with thalassemia can disrupts the family mental balance. Objectives: The purpose of this study is to explain the consequences of parents who have children with thalassemia. Methods: Inductive qualitative approach was applied in 2017 - 2018 in Hajar Hospital. Semi-structured interviews were conducted for data collection. Qualitative conventional content analysis was employed for data analysis. 10 five mothers, one grandmother, and two fathers and nurses participated in this study. Results: The three specified categories were as follows: (1) Non-acceptance of disease: disbelief, not following up treatment, and interest for abortion, (2) parent psychological reactions: unhappiness, anxiety, and mental confusion, (3) Isolation: dissociation and stigma. Conclusions: Parents who had children with thalassemia experienced several psychological problems. The consultative and supportive services of the health system were necessary for these parents. Also, it was urgent that the health authorities establish consulting clinics for chronic diseases to provide them the required consulting services.

Proportion of Peptic Ulcer Patients Based on Esophagogastroduodenoscopy (EGD) Examination at Jakarta Haji Hospital 2015-2018

Objectives: The morbidity and mortality rate of peptic ulcer disease (PUD) is quite high. For example proportion of PUD in China was 17.2%. There is a lack of epidemiological data available for this disease in Indonesia. This study aims to determine the proportion of PUD in Haji Hospital Jakarta and to describe the risk factors of age, sex, and patient history of NSAIDs medication.Materials and Methods: This was a cross sectional study. Samples were patients who undergo esophagogastroduodenoscopy (EGD) examinations at the Hajj Hospital Jakarta from 2015 until 2018. Samples who met the inclusion dan exclusion criteria were selected randomly as needed. Data of chief complaints, diagnosis, age, sex, and history of NSAIDs medication were taken from the medical record.Result and Discussions: 112 samples were selected in this study. Major chief complaint was dyspepsia (42.9%). The proportion of PUD was 16 (14.3%) and predominantly male (75%). Most of the samples with PUD were >46 years old (68.8%). History of NSAIDs medications were 81.3% and most commonly used was mefenamic acid (41.2%). There was no significant association between PUD with sex (p>0.005), but there was a significant association between PUD and age (p < 0.005). Furthermore, older people more than 46 years were 11.5 times more likely to develop peptic ulceration than below 46 years (PR= 11.556).Conclusion: Elderly people should be more aware of the risk of getting PUD, especially those who had a history of NSAIDs medication.International Journal of Human and Health Sciences Vol. 05 No. 01 January’21 Page: 27-30

The superior service based on the highest number of visits and income of Hajj Hospital Surabaya in The National Health Insurance era.

Background: A hospitals’ superior service is expected to be of higher value than other available provisions, which consequently differentiates the facility from others, as the branding easily attracts the community attention. The purpose of this study, therefore, is to identify the most needed and profitable health services from existing hospitals.Design and methods: This was a descriptive research performed with a cross sectional study approach. The variables studied include the number of visits, and revenue based on National Health Insurance (JKN).Results: Findings show that the polyclinics were the highest number of visits between 2016 and 2017 include Cardiac, Internal Medicine, Medical Rehabilitation, Nerve, General Surgery, and also Dental & Mouth. Conversely, those with the most significant income include Heart, Polyclinics, Dental & Mouth, as well as General Surgery Polyclinics. Moreover, the Medical Rehabilitation and Internal Medicine outpatient installations demonstrated negative INA income, while the already running featured Services in high demand were Heart, Nerve, Dental & Oral, and also General Surgery polyclinics.Conclusions: In can be concluded that not all polyclinics with high traffic generate positive income, hence it is necessary to monitor and analyze National Health Insurance (JKN) monthly income.Significance for public healthA hospitals’ superior service is expected to be of higher value than other available provisions, which consequently differentiates the facility from others, as the branding easily attracts the community attention. This study identifies the most needed and profitable health services from existing hospitals.

Analysis of Patient Safety and Occupational Health Safety in Surabaya Haji Hospital

Introduction: Safety standards are one of the important indicators of hospital services. But so far there
 have been no studies that discuss safety efforts in the Surabaya Haji Hospital. This study aims to study
 and understand the management in the Intensive Care, Central Surgery and Inpatient Installation of the
 Surabaya Hajj Hospital, especially the standards of patient safety and occupational health safety in the
 hospital. Method: The study used primary data from observation, in-depth interviews, and secondary
 data from each unit. Study location were in Intensive Care Unit, Central Surgery Installation and Inpatient
 Installation. Results: This study shows the efforts of the Surabaya Haji Hospital in ensuring patient safety
 and work safety in the hospital environment. In general, the steps of hospital management were right. Patient
 safety procedures referred to service quality standards at JCI hospitals. While work safety efforts in hospitals
 have also received attention because a special team has been formed that regulates hospital health and
 safety. Conclusion: To ensure patient safety and occupational health safety in the hospital runs according to
 established procedures, hospital management needs to conduct regular supervision.

The Mantel-Haenszel Analysis to Control Confounding Variable between Birth-Weight Andearly-Onset Neonatal Sepsis at Hajj Hospital, Surabaya, Indonesia

The association of birth-weight and early-onset neonatal sepsis has not been consistent for decades. Classifying birth-weight as high risk group without clear evidence of a consistent association can lead to economic burdens to the health systems. Its evidence namely confounding variables. The Mantel-Haenszel test represents a simple and useful tool to obtain estimates of association adjusted for the effect of one or more confounders. This study explored the association of confounding variable between birth-weight and early-onset neonatal sepsis (EONS) using the Mantel-Haenszel Test. A cross-sectional study was undertaken at Hajj Hospital. Surabaya City. Indonesia and using retrospective documents review in NICUs. The sample size of this study was 1.461 neonates were born from January 2018 to December 2018. The confounder of this study was amniotic fluid. Bivariate analysis showed that there was a correlation between amniotic fluid and EONS (p<0.001); and there was a correlation between amniotic fluid and birth-weight (p=0.006). It means that amniotic fluid was proven as a confounding variable. Without considering amniotic fluid condition the result of binary logistic-regression shows that early-onset neonatal sepsis was influenced by birth-weight (p<0.001; cRR: 20.498; CI: 13.464-31.208). With considering amniotic fluid the result of mantel-haenszel test shows that early-onset neonatal sepsis was influenced by birth-weight (p<0.001; aRR: 24.632). It could be concluded that amniotic fluid condition can increase the chance of neonatal sepsis among neonates who had low birth-weight

Comparison of the Effect of Instrumental Music and Holy Quran Recitation on the Anxiety of Patients with Acute Coronary Syndrome: Semi-Experimental Study

Background: Anxiety is one of the most common psychological problems after myocardial infarction and can lead to many problems in acute coronary syndrome (ACS). Two possible ways to reduce anxiety are to listen to music and to recite the Holy Quran, the effects of which have never been compared to date. Objectives: The aim of this study was to compare the effect of listening to instrumental music and listening to Quran recitation on the anxiety level of patients with acute coronary syndrome. Methods: This semi-experimental study was conducted among 96 patients with ACS referred to Hajar Hospital, Shahrekord, Iran, from 3/10/2019 to 4/30/2019. The patients were entered into the study using the convenience sampling method and then randomly assigned to the three groups of Quran recitation, instrumental music, and control. In this study, the patients’ anxiety level was measured using Spielberger’s state-trait anxiety inventory (STAI) before and after listening to Quran recitation and instrumental music. Data were analyzed by SPSS version 16 using descriptive and analytical tests, including paired samples t-test, Chi-square, and one-way ANOVA. Results: Anxiety level decreased from 43.1 ± 6.15 to 38.5 ± 3.82 in Quran recitation group (P < 0.001) and from 44.2 ± 1.21 to 39.1 ± 4.17 in the instrumental music group (P = 0.035), and from 46.3 ± 3.84 to 44.7 ± 6.21 in the control group (P < 0.001). There was no significant difference between the three groups before the program. However, the mean score of anxiety level showed a significant difference, indicating that listening to Quran recitation had a greater effect than listening to instrumental music in reducing the patients’ anxiety (P = 0.02). Conclusions: Both interventions can be useful in decreasing the anxiety level of patients with ACS; however, the Holy Quran recitation had a greater effect in this regard.

SENSITIVITY AND SPESIFICITY VALUE OF PLATELETS, MALIGNANCY RATIO INDEX AND BOTH COMBINED IN DIAGNOSING OVARIAN CANCER AT GENERAL HOSPITAL HAJI ADAM MALIK MEDAN FROM 2016-2018

Objective: This research aimed to analyze sensitivity and specificity values of platelets, RMI and both combined as ovarian cancer diagnostic modality in Haji Adam Malik Hospital in 2016-2018.
 Methods: This is analytic research with a diagnostic test design on 204 patients who had been diagnosed with ovarian cancer and patients with ovary benign tumors which have been examined the value of full blood and the malignancy ratio index and ovarian mass that has been proven by the results of anatomic pathology at General Hospital Haji Adam Malik Medan in 2016-2018. The data is tabulated into 2x2 table and then calculated for each sensitivity, specificity, positive predictive value and negative predictive value. 
 Result: By using platelet cut-off value>450000 per mm3 in diagnosing ovarian cancer with sensitivity 55.44% and specificity 83.65% were obtained. IRK has a sensitivity 83.16% and specificity 76.92%. Platelet and IRK values ​​provided the highest diagnostic value (specificity) compared to when they were each single which was 97.11% while the combination of platelet and IRK values ​​had a sensitivity of 49.50%.
 Conclusion: Platelet and IRK values ​​gives the highest diagnostic value (specificity) compared to when both are used, namely 97.11%.

The Patient Safety Model within Decubitus Ulcer Patients in Hospital: Based on the Organizational Citizenship Behavior and Knowledge Management

Decubitus ulcer event is an indicator of patient safety in nursing care at the clinic, so a method is needed to reduce the incidence of decubitus ulcer in the patient in hospital. The research aims to create a model for increasing patient safety based on Organizational Citizenship Behavior (OCB) and knowledge management on unexpected events (decubitus ulcer) in achieving the target of patient safety program in Hospital, using cross-sectional design. The subjects were 100 nurses who work in the inpatient room of Surabaya Haji Hospital, selected by purposive sampling. Data collection was done by questionnaire, then analyzed using Partial Least Square (PLS). The model of increasing patient safety based on OCB and knowledge management has proven effective in reducing the incidence of decubitus ulcer in the patient ward. This model is recommended to implement in the hospital to enhance the quality of nursing care.

The Influence of the NHT Assisted Media Model and Learning Motivation on Learning Outcomes of Citizenship Education

The aim of this research is to know the influence of NHT assisted media model and learning motivation on learning outcomes of citizenship education. This research will be implemented in 5th grade of Primary School at SD IT Tahfizhil Quran YIC SU, which is located at Jalan Haji Hospital. This school has an "A" accreditation. The research activities were carried out in the first semester of the 2018-2019 Academic Year, setting the research schedule according to the schedule set by the school principal. The subject matter selected in this study is "Diversity" which is the material in the class IV syllabus that is being studied in the semester.

Serum Homocysteine Level and Ankle-Brachial Index in Peripheral Arterial Disease

Patients with peripheral arterial disease have a higher risk of death compared to normal populations. There are several relatively new risk factors significantly increase the vulnerability to suffering from peripheral arterial disease, one of which is homocysteine. Studies investigating the role of serum homocysteine level as a biomarker of the severity of peripheral arterial disease based on an ankle-brachial index (ABI) in the different populations were still limited and it was never been studied in Mataram. This was a cross-sectional study aimed to investigate the correlation between serum homocysteine level and ABI in 77 peripheral artery disease (PAD) outpatients in Siti Hajar Hospital, Mataram. The diagnosis of PAD was based on ABI<0.9. Fasting serum homocysteine level was examined using the ELISA technique. Characteristic data collected were gender, age, hypertension, diabetes mellitus, and body mass index (BMI) category. There was a significant correlation between the increase of serum homocysteine levels and the decrease of ABI. The main risk factors for peripheral arterial disease in the subjects are hypertension, diabetes mellitus, and overweight/obesity. Serum homocysteine level is a predictor of peripheral arterial disease severity measured using ABI.

The effect of zinc supplementation in delayed preterm delivery and biometric of neonates suspected with preterm delivery in mothers suspected of having a preterm delivery

Background and aims: Micronutrient deficiency in women of reproductive age is considered as a major health problem in many developing countries. Therefore, it is important to prevent micronutrient shortage before pregnancy. This study aimed to evaluate the effect of zinc (Zn) supplementation on delaying preterm delivery and biometric neonates with suspected preterm birth. Methods: In this semi-experimental study, 140 women with preterm delivery were selected by a gynecologist in the Hajar hospital of Shahrekord University of Medical Sciences in 2016. The women were divided into four groups. Then, the serum Zn level of the mother’s blood and the umbilical cord was measured First group had a normal level; Zn level in the second group was between 50-70 mg/dL; in the third group between 20-50 mg/dL; and in the fourth group fewer than 20 mg/dL. Three groups received <20-70 mg/dL oral Zn and the normal group was given a placebo. Next, the serum Zn levels of mothers were measured and recorded at the end of the eighth month and delivery time. Infant anthropometric parameters at birth, 1 month to 3 months were measured as well. Overall, 71 (50%) and 69 (49.3%) infants were males and females, respectively. The data were analyzed using descriptive statistics and analytical statistics tests. Results: The average age of 140 pregnant women was 30.39±5.33 years old and their age range was between 18 and 41 years. In addition, the maternal Zn serum level was 56.52±33.38 mg/dL on admission and the serum level on the cord blood at birth was 53.22 ± 66.94 μg/ dL. A significant relationship was reported between the level of serum Zn on cord blood and the maternal serum Zn level on admission with growth in babies at birth and the first, second, and third month (P<0.05). Conclusion: In general, Zn is effective in children’s growth and the use of Zn supplementation can be suggested during pregnancy.

Postpartum depression and its correlation with spiritual health

Background and aims: Postpartum depression has a high prevalence in communities and needs great financial resources. On the other hand, the world views the spiritual health as a new and complementary dimension of health. The aim of this study was to investigate the correlation between postpartum depression and spiritual health.Materials and Methods: This correlational-analytic study was conducted on 152 women who gave birth 8 months ago, referred to Hajar Hospital, Imam Ali hospital, Molavi clinic, or other health centers of Shahrekord, and were also satisfied with participating in the study. They were selected by the simple sampling method and completed the Palutzian and Ellison Spiritual Health Questionnaire. Finally, the collected data were entered in SPSS software and descriptive statistics in addition to the Pearson correlation coefficient and K2 test were used to analyze the data.Results: In the present study, the mean age of the subjects was 29.15 (SD=5.45) with the range of 16-45 years. The mean scores of spiritual health and depression were obtained 96.3 and 8.94, respectively. The results of this study showed that the Pearson correlation coefficient was -75.5% (P˂ 0.001), demonstrating an inverse correlation between the scores of postpartum depression and spiritual health.Conclusion: In general, the correlation between postpartum depression and spiritual health was an inverse correlation and the level of depression decreased by an increase in spiritual health. It can be concluded that without the need for specific treatments, the level of postpartum depression can be reduced by increasing the level of spiritual health.