Journal of Preventive Medicine

Introduction
The coronavirus disease 2019 (COVID-19) was started in Wuhan, China and, after a short period of time, it spread throughout China and many other countries [1, 2]. One of the variables that can help in difficult situations is spirituality and religious beliefs [10]. Regular remote religious activities can somehow reduce psychological pressure of COVID-19 [10]. Cho et al. [19] investigated the effect of religious activities on depression and anxiety during the COVID-19 pandemic and showed that people who used positive religious coping style had less depression and anxiety. Among other variables that can lead to the reduction of anxiety is resilience [21]. Resilience is the process of adaptation in facing stressful, tragic and threatening events [3]. The results of recent studies have indicated the important role of resilience in coping with the psychological consequences of COVID-19 [25, 26]. In a study, Ferreira et al. [27] showed significant relationships between demographic characteristics and the level of resilience during the outbreak of COVID-19. Older people and those with lower education had lower levels of resilience. Considering that the pandemic has created a lot of psychological pressure on many people, the present study was conducted to investigate the role of spirituality and resilience in predicting COVID-19-related anxiety.
Methods
The is a descriptive correlational study. The study population consists of the students of Tarbiat Modares University in Tehran, Iran in the academic year of 2020-2021. The sample size was estimated to be 260 [29] who sampling was done by a convenience sampling method. The criteria for entering the study were consent to participate and access to the Internet. The exclusion criteria were: Not being a student of the university and returning the questionnaires incomplete. Data collection tools were: 
• Corona Anxiety Scale which was developed by Alipour et al. in Persian [30] and has 18 items and 2 subscales. Items 1-9 measure physical symptoms and items 10-18 measure psychological symptoms. The items are rated on a 4-point Likert scale.
• Spirituality Questionnaire which was developed by Parsian and Dunning. It has 29 items and four subscales of self-awareness (10 items), importance of spiritual beliefs in life (4 items), spiritual practices (6 items) and spiritual needs (9 items). The items scored on a Likert scale from 1=completely disagree to 4=completely agree. The total score ranges from 29 to 116, where higher scores indicate higher level of spirituality
• Connor-Davidson Resilience Scale which was developed by Connor and Davidson [24]. It has 25 items that are scored based on a 5-point Likert scale (from 0 to 4). The total score ranges from 0 to 100, where higher scores indicate higher level of resilience.
Results
Participants were 260 male and female college students with a mean age of 25.78 years; 148 were female and 112 were male; 87 were married and 173 were single. The results showed that the variables of self-awareness, the importance of spiritual beliefs in life, spiritual practices, spiritual needs, total spirituality, and resilience had a significant negative correlation with the COVID-19-related anxiety (P<0.01) such that with the increase of the mentioned variables, the level of anxiety decreases. In Table 1, the results of examining the role of spirituality and resilience in predicting the COVID-19-related anxiety are presented.


As can be seen, the coefficient of correlation between the above-mentioned variables and COVID-19-related anxiety was 0.68 and these five variables could significantly predict 45% of changes in anxiety (P<0.001). According to the beta values, the predictors were ranked as: Resilience (β=-0.378), self-awareness (β=-0.313), total spirituality (β=-0.293), spiritual needs (β=-0.270), spiritual practices (β=-0.228), and the importance of spiritual beliefs in life (β=-0.164) (P<0.05).
Discussion
Every human being needs a source of comfort during hard and difficult situations [13]. During the COVID-19 pandemic, people have suffered from many psychological problems, which are directly related to the aggravation of the disease in them [9]. Performing religious activities during the pandemic can increases the meaning and purpose in life. The present study was conducted with the aim of investigating the role of spirituality and resilience in predicting anxiety caused by COVID-19. The results showed that people who had a low level of spirituality and resilience had high anxiety. Considering the role of spiritual practices in strengthening the body’s immune system, it can be expected to have an effect on people’s moods. A study showed that people who were at high levels of resilience during the pandemic had more psychological flexibility and could better adapt to the conditions [4]. Having resilience helps the person to make the best decisions during stressful and anxiety-triggering events. In fact, resilience helps people to look for solutions and solve problems according to their abilities and experiences in facing the problems in the past, instead of giving up and regretting [7]. The participants in this were the students of one university in Tehran. Therefore, caution should be observed in generalizing the results to all students and cities of Iran. The use of self-report questionnaires online were other limitations of the study.

Ethical Considerations
Compliance with ethical guidelines
Ethical approval was received for this study from the Ethics Committee of Baqiyatallah University of Medical Sciences (Ethical Code: IR.BMSU.REC.1399.139).

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conception, revision and approval of the original version: Farzin Bagheri-Shikhangfeshe; Data collection: Farishte Rezaeinasab; Collected and written by: Alireza Al-Saadi Thani; Collecting and writing the results: Vahid Swabiniri; Editing and approval of the original version: Ali Fathi Ashtiani.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors of this study appreciate and thank all the educated students who answered the questions of this study very carefully and provided the link of the questionnaires to their friends and other dear students.


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