Introduction
Aging is accompanied by physical, psychological, and social changes [2]. By 2046, it is predicted that the proportion of the elderly population in Iran will reach 15% [3]. Therefore, their health is important, especially their spiritual health. An essential factor in adapting to the consequences of aging and having mental health is spiritual health [4]. Spiritual health is one of the main elements of the health of the elderly [1].
Religion and religious activities can increase communication between people, and be effective in satisfaction with family [12]. Spiritual health as a consequence of religious activities can improve health and family satisfaction [13]. However, this issue is unclear. There is a question on whether there is a relationship between the spiritual health of the elderly and their satisfaction with the family. Meanwhile, spiritual ceremonies cause cohesion between people and create social bonds [12]. However, the relationship between spiritual health and family cohesion is unclear. Accordingly, this study determines the relationship between spiritual health and satisfaction with family, and family cohesion among the elderly in Gonabad City, Iran.

Methods
This descriptive-analytical cross-sectional study was conducted in 2023. The sample size was calculated at 165 people based on a similar study [15] with a confidence factor of 99%, test power of 90%, and the correlation coefficient between spiritual health and life satisfaction (r=0.42). The sample size increased to 200 people with 20% dropping out.
The elderly were selected by stratified sampling method. Three community health centers in Gonabad City, Iran, were considered as classes. Then systematic random sampling was done in each of the classes. Based on the elderly population and the sample size, the sampling interval was determined. Then the subjects were selected based on the list of elderly people of each center according to the inclusion criteria.
The inclusion criteria were being 60 years old, having awareness, having the ability to communicate, having no history of losing a family member in the past year, not being addicted, not taking psychiatric drugs, and not having an incurable disease. Meanwhile, the exclusion criterion was a failure to answer more than 20% of the questions in the questionnaires. The data was collected using questionnaires of family adaptability and cohesion evaluation scales, family satisfaction scale, and spiritual health questionnaire of Ajam et al [16, 17]. To this purpose, after explaining the objectives of the research to the elderly, the questionnaires were completed by the interview method. The data were analyzed using the SPSS software, version 20. Spiritual health, satisfaction with family, and family cohesion did not have a normal distribution (P<0.05). As a result, the Spearman test was used to determine the relationship between the study variables. The confidence interval in this study was considered 95% and the data were analyzed at the significant level of 0.05.

Results
The participants included 200 older adults with a mean age of 68.65 ± 6.05 years. Most of the participants were female (50.5%) and married (80.5%), had higher education (35%), sufficient income for family expenses (73.5%), and lived with their wives (59.5%). Mean±SD of spiritual health, family cohesion, and satisfaction with family were 92.48±6.89, 31.57±3.35, and 40.38±7.29 respectively. The results showed that there was a positive and significant relationship between spiritual health and family cohesion and satisfaction with family (P<0.001).

Conclusion
The present study investigated the relationship between spiritual health and satisfaction with family and family cohesion in the elderly of Gonabad City, Iran. The results of the present study a significant relationship between spiritual health and satisfaction with family in the elderly of Gonabad City, Iran. The results of studies by Rabbani and Beheshti [32], Momeni and Rafiee [34], Singh et al. [35], Wu and Koo [36], and Munawar and Tariq [38] are consistent with the results of the present study.
Based on the results of the present study, there was a significant relationship between spiritual health and family cohesion in the elderly of Gonabad City, Iran. In this regard, the results of the studies of Babaei et al [30], Yadegari et al [38], and Çetin [39] are in line with the results of the present study.

Study Limitations
One of the limitations of this research is the generalization of the results to other communities and age groups because the research community was the elderly of Gonabad City. Another limitation of the research is the type of study that is correlational, so the results do not indicate cause and effect. Therefore, it is suggested to conduct interventional studies in this regard.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Gonabad University of Medical Sciences, Gonabad, Iran (Code: IR.GMU.REC.1401.107). The objectives of the study and the method of conducting the research were explained to the participants in the research. Informed consent was obtained from people to participate in the research.

Funding
This paper was taken from the master’s thesis of Elahe Hesami, approved by the Department of Aging Health, Faculty of Nursing, Gonabad University of Medical Sciences, Gonabad, Iran. 

Authors' contributions
Conceptualization, methodology, investigation, review, editing, and final approval: All authors; Data analysis: Habib Shareiniya; Writing the initial draft: Elahe Hesamiand Hosein Ajamzibad; Supervision: Hosein Ajamzibad and Habib Shareiniya; Project management: Hosein Ajamzibad.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors express their gratitude to the Vice Chancellors for Education and Research, the officials and staff of community health centers in Gonabad, and the elderly participants who contributed to their research.


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