Prediction of Mental Health by Religious Orientation and the Mediating Role of Death Anxiety Among Nurses in the Covid-19 Pandemic

Background: The COVID-19 pandemic has been around for more than a year as a global problem, with nurses being among the rst groups involved in treating epidemics. In addition to becoming infected and dying from the disease, nurses also suffer from death anxiety, affecting their mental health. It is necessary to investigate the modulating factors of this anxiety. The purpose of this study was to predict mental health by religious orientation and the mediating role of death anxiety among nurses in the COVID-19 pandemic. Methods: The present descriptive-analytical and cross-sectional study was conducted on 208 nurses working in the Central Hospital for the Treatment of COVID-19 patients in the Persian Gulf Martyrs Hospital in Bushehr, who were enrolled in the census. Data collection tools were the General Health Questionnaire-28 (GHQ-28), the Templer’s Death Anxiety Scale (DAS), and the Revised Religious Orientation Scale (ROS). Data were analyzed by SPSS version 22 software using the Pearson correlation test and multiple regression analysis. Results: Among the subjects, 53.5% of nurses experienced high death anxiety. According to the ndings, death anxiety had a signicant negative effect on mental health (P<0.001, β=-0.54). Intrinsic religious orientation led to a reduction in death anxiety (P=0.01, β=-0.16) and improved mental health (P<0.001, β=0.40), while extrinsic socially-oriented religiousness resulted in increased death anxiety (P<0.001, β=0.19) and decreased mental health (P<0.001, β=-0.20). Conclusion: The prevalence of death anxiety in the COVID-19 pandemic was high in nurses, which led to a decrease in their mental health. The results of this study revealed that the intrinsic religious orientation had a positive effect on reducing death anxiety and promoting mental health.

The Religious Orientation Scale (ROS; Gorsuch and McPherson; 1989) measures three factors, including intrinsic religious orientation, extrinsic sociallyoriented religiousness, and extrinsic personally oriented religiousness. The rating of this 14-item scale is based on a 5-point Likert scale (zero: strongly disagree to four: strongly agree). This scale can be used for people with different levels of education. The reliability of the Persian version has been checked by the internal consistency method. The reliability of its subscales was obtained from Cronbach's alpha method in Iran from 0.61 to 0.85. The construct validity of this scale also con rmed the existence of three factors [21].
The validity and reliability of this questionnaire have been con rmed in Iran [22]. In the test-retest reliability method, the reliability coe cient was 0.72 for the whole questionnaire and signi cant for the subtests of physical symptoms, anxiety, and insomnia, social dysfunction, and depression (P < 0.001). The reliability coe cient with split-half analysis was 0.93 for the whole scale and 0.86, 0.84, 0.68, and 0.77 for the subscales, respectively. All these coe cients were signi cant at a signi cance level of P < 0.001 [23].
Templer's Death Anxiety Scale (DAS) was designed by Templer in 1970 to measure death anxiety, which has been the most used of its kind. This scale includes 15 questions and 5 dimensions (fear of death, fear of pain and illness, death-related thoughts, time passing and short life, and fear of future).
The participants mark their answers to each question with "Yes" or "No" options. The answer "Yes" indicates the presence of anxiety in the person.

Data analysis
Descriptive ndings were reported using mean, standard deviation, frequency, and percentage. First, the Pearson correlation test was performed to examine the relationships between variables. Then, the "Enter Method" of multiple regression analysis was carried out to evaluate the predictive power of religious orientation and death anxiety for mental health. An independent t-test was performed to examine the mean differences between the two sexes, and an ANOVA test was used to calculate the mean differences between different marital statuses, levels of education, and wards. Data were analyzed using SPSS version 22 software (α = 0.01).
Data were analyzed via V.23 software and descriptive ndings were reported using mean, standard deviation, frequency, and percentage.
An independent t-test was performed to examine the mean differences between the two sexes, and an ANOVA test was used to calculate the mean differences between different marital statuses, levels of education, and wards.
The Pearson correlation test was performed to examine the relationships between variables.
The "Enter Method" of multiple regression analysis was carried out to evaluate the predictive power of religious orientation and death anxiety for mental health.

Results
The study participants were 208 nurses, 106 (51%) were male. The mean age of participants was 32.45 ± 6.45 years. The mean work experience was 9.88 ± 7.98 years for men and 8.57 ± 7.08 years for women, and the mean working hours of the participants were 45.99 ± 16.37 hours per week. Other demographic variables are shown in Table 1. 53.50% of nurses scored 7 or higher on the DAS. The mean total score of death anxiety of nurses was 6.84 ± 4.35 and the mean total score of mental health was 62.07 ± 12.76. The difference in the mean death anxiety between the two sexes was signi cant (males: 5.83 ± 4.70 and females: 7.90 ± 3.69, P = 0.001).
There was no signi cant difference between death anxiety score and different marital status, education levels, and wards. No signi cant correlation was found between death anxiety and age, work experience, and working hours per week.
As shown in Table 2, all dimensions of death anxiety and mental health are inversely correlated, but the intrinsic religious orientation had a positive and signi cant correlation with all dimensions of death anxiety. The extrinsic personally oriented religiousness had a positive and direct correlation with the dimension of depression, and the extrinsic socially-oriented religiousness had a negative and signi cant correlation with the dimensions of physical symptoms, anxiety symptoms, and sleep disorders.  The intrinsic religious orientation can predict all aspects of mental health. The extrinsic personally oriented religiousness can only explain the symptoms of anxiety and sleep disorders, and the extrinsic socially-oriented religiousness can predict physical symptoms, anxiety symptoms and sleep disorder, and social functioning (full information is shown in Table 3 and Fig. 1).

Discussion
The purpose of this study was to predict mental health by religious orientation and the mediating role of death anxiety among nurses in the COVID-19 pandemic. The ndings showed that more than half of nurses experience high death anxiety. Women had higher death anxiety than men. Intrinsic religious orientation had a direct and signi cant correlation with all dimensions of mental health. Extrinsic socially-oriented religiousness was inversely and signi cantly correlated with the dimensions of physical symptoms, anxiety symptoms, and sleep disorders, but extrinsic personally oriented religiousness was Death anxiety scores were signi cantly different in different marital statuses, education levels, and wards. These results were not found in demographic variables and death anxiety in a study by Moudi et al [26]. However, some studies had different results and showed that nurses with younger ages and working in intensive care units experience more death anxiety [27,28]. This difference could be related to the type of disease and the epidemic, because the COVID-19 pandemic affected all age groups, all departments of the hospital, and caused a great deal of fear among healthcare professionals.
The ndings of this study showed that the dimensions of death anxiety can predict changes in the dimensions of mental health in nurses during the COVID-19 pandemic. These ndings were also observed in other studies [26,29]. Anxiety can endanger health by affecting physical and mental functions [30]. Constant exposure to the patients, responsibility for human health, clinical procedures, and dealing with dying patients and emergencies can reduce the optimal performance of nurses [31]. Death anxiety is one of the stresses experienced by nurses in the workplace [32]. This problem is exacerbated during the COVID-19 epidemic because of problems such as the absence of effective prevention and treatment, along with high infection rates, but all healthcare professionals at risk. According to reports, healthcare workers experience 56% of work stress and anxiety during the COVID-19 pandemic [33].
In this study, the intrinsic religious orientation had a negative effect on death anxiety but the extrinsic socially-oriented religiousness increased death anxiety and the extrinsic personally oriented religiousness had no effect on death anxiety. The religious orientation sometimes reduces death anxiety, but this should change one's attitude toward change, and only intrinsic religious orientation can change attitudes [34]. Explaining this nding, it can be said that one of the results of panic management theory is related to fear of death. A common feature in the worldview of people who believe in heavenly religions is the assurance of the existence of a kind of life after death; one of the most important functions of religion is to reduce the panic associated with one's mortality.
Given that all the nurses participating in this study were Muslims and believed in eternal life after death, this belief could lead to a reduction in their death anxiety.
The results of this study showed that the intrinsic religious orientation had a positive effect on mental health but the extrinsic socially-oriented religiousness had a negative effect on mental health and the extrinsic personally oriented religiousness had no effect on mental health. In another study, the effect of both intrinsic and extrinsic dimensions of religious orientation was positive on reducing symptoms of anxiety and depression [35]. In general, the relationship between religiosity and psychological well-being can be complex. Contradictory ndings illustrate this complexity; as for the intrinsic religious orientation, having meaning and purpose in life, feeling of belonging to a high source, hoping for God's help in di cult life situations and consequently being optimistic in these situations and so on are resources for religious people to suffer less psychological damage in the face of stressful life events. This difference may be because the majority of people believe in Islam in Iran, the effects of extrinsic socially-oriented religiousness on individuals have decreased and only the effects of extrinsic personally oriented religiousness can lead to mental health. The intrinsic religious orientation can lead to a sense of comfort and mental health by creating a worldview of life after death and establishing a positive relationship with God [36], but the extrinsic religious orientation is mostly aimed at gaining group support and has little effect on a person's attitude and feelings.
The study limitations were the cross-sectional design, the small sample size, and the study area only in one city, which reduces the generalizability of the ndings but can be a basis for knowledge and comparison for healthcare decision-makers and other studies.

Conclusion
According to the ndings of this study, more than half of the nurses experienced high death anxiety. "Intrinsic religious orientation" and "Extrinsic sociallyoriented religiousness" were the most important dimensions capable of predicting death anxiety and mental health of nurses working during the COVID-19 pandemic. Given the high prevalence of death anxiety and its impact on the mental health of nurses, by the end of the COVID-19 pandemic, it is better to plan and implement programs related to the religious and Islamic beliefs of nurses to improve the mental state to provide the basis for promoting the mental health of those in the front line of the COVID-19 infection control. In the meantime, it is recommended to pay more attention to and prioritize women in these programs. Declarations