Relationship of Sexual Satisfaction with Spiritual Health and Demographic Characteristics in Women Referring to Health Centers in Qom

Introduction exual satisfaction is based on one’s assessment of their sexuality, which includes their understanding of the satisfaction of their needs, realization of their expectations from the intercourse, and their positive assessment of it. Sexual satisfaction is one of the important indicators of a successful marriage and family health and plays a significant role as one of the fundamental factors of relationship satisfaction. Sexual S Please Cite This Article As: Dehghani F, Zargham Hajebi M, Gharlipour Z. Relationship of Sexual Satisfaction with Spiritual Health and Demographic Characteristics in Women Referring to Health Centers in Qom. Health Spiritual Med Ethics. 2020;7(4):1-7. Abstract


Introduction
exual satisfaction is based on one's assessment of their sexuality, which includes their understanding of the satisfaction of their needs, realization of their expectations from the intercourse, and their positive assessment of it. Sexual satisfaction is one of the important indicators of a successful marriage and family health and plays a significant role as one of the fundamental factors of relationship satisfaction. Sexual intercourse does not necessarily refer to copulation; moreover, its purpose is not merely the experience or non-experience of orgasm (1). The increasing rate of family conflicts, divorce, and issues, such as marital infidelity, in society has attracted more attention to the factors that affect the stability and satisfaction of marital relationships.
Sexual satisfaction is one of the important components and key variables of marital satisfaction that plays an undeniable role in strengthening and stabilizing the family. It is one of the natural and original functions of the institution of marriage and affects the reduction or increase of marital satisfaction. Accordingly, adjustment, balance, and compatibility in sexual intercourse are the most important components of happiness in marital relationships (2). Based on the results of several previous studies, spiritual health is one of the basic components that have a great impact on the improvement of marital commitment and its quality (3).
Spirituality and spiritual growth of human beings have increasingly attracted the attention of psychologists and mental health professionals in the past few decades. Advancement of psychology, on the one hand, and the dynamic and complex nature of modern societies, on the other, have made the spiritual needs of human beings more important than their material desires and needs. Spiritual health refers to a state of being that results in positive knowledge of and behavior towards oneself, others, God, and nature. It makes the individual full of a sense of identity, satisfaction, happiness, contentment, beauty, love, respect, inner peace, harmony, and purposefulness (4). Spirituality creates peace, mental security, liberation from feelings of emptiness and loneliness, meaning in life, hope, life satisfaction, and social support. Therefore, it leads to an improvement in psychological capacities, the ability to cope with stress and problems, mental health, physical health, and greater longevity (5) According to previous studies, health has physical, mental, social, and spiritual aspects. Spiritual health is related to other aspects of health and affects them; moreover, it provides a coordinated and integrated relationship between internal forces (6). Spirituality leads to peace, mental security, liberation from feelings of emptiness and loneliness, a meaningful life, hope, life satisfaction, and social support. Consequently, one's psychological capacity and the ability to cope with stress and problems improve which results in the enhancement of mental and physical health and greater longevity (7).
Based on the findings of another study, spiritual health has a positive relationship with the quality of life and marital satisfaction in married people. Spirituality consists of a set of resources and capacities which help to increase the quality of life of individuals, especially regarding marital relationships (5).
According to the results of previous research, couples who have higher levels of spiritual health experience fewer marital conflicts and are more capable of resolving interpersonal conflicts. The above-mentioned study also revealed that spiritual health has a positive relationship with the quality of life and marital satisfaction. Spirituality consists of a set of resources and capacities which help to increase the quality of life of individuals, especially regarding marital relationships (7).
Sexual satisfaction is one of the most important and fundamental issues in a marital relationship and sexual adjustment is one of the causes of happiness, success, vitality, and health of couples. Moreover, sexual satisfaction prevents tension and conflict to a large extent. However, only few studies have been conducted about this issue; therefore, this study aimed to determine the relationship between spiritual health and sexual satisfaction of women referring to health centers in Qom, Iran in 2020.

Methods
This correlational cross-sectional study used a descriptive-analytical design and was performed on women who referred to health centers in Qom. The sample size was calculated based on a study carried out by Shawani et al. in which the correlation between spiritual health and sexual satisfaction was 0.4 while the type I error was 0.05. Finally, the sample size was calculated at 320 subjects (8).
Subsequently, four out of the eight existing regions (one, two, four, and eight) were selected using the multi-stage sampling method by lottery method. Thereafter, two health centers were selected from each region using the simple random method. Finally, the subjects were selected using the random sampling method.
The inclusion criteria were 1) lack of pregnancy, breastfeeding, or menopause, 2) marriage duration of more than one year (9), 3) literacy, and 4) lack of disability or a chronic physical or mental illness (all clients have a record in the Sib system and their medical history can be traced). The written informed consent of the patients was obtained before they participated in the study. The research tools were the Sexual Satisfaction Scale for Women developed by Metson and Trapnell and Spiritual Well-Being Scale by Paloutzian and Ellison. The questionnaires were distributed among the participants and the necessary explanations were provided for them regarding how to answer the questions. Moreover, they were ensured that the data obtained from the questionnaires will only be published as general and not individual results. Furthermore, there was no need for them to include their first and last names in the questionnaire.

Data Collection tools Sexual Satisfaction Scale for Women by Matson and Trapnell
This scale includes 30 items consisting of five aspects, namely contentment (items 1-6), communication (items 7-12), compatibility (items 13-19), relational concern (items 19-24), and personal concern (items 25-30). The overall score of sexual satisfaction can be calculated through this scale. Each item is scored based on a five-point Likert scale ranging from strongly agree to strongly disagree and higher scores indicate more satisfaction. The Cronbach's alpha coefficient of the total score of the questionnaire and its aspects were calculated at 0.96 and 0.82-0.91, respectively (10).

Spiritual Well-Being Scale by Paloutzian and Ellison (1982)
This questionnaire is used to assess the vertical and horizontal aspects of spiritual health (11). It includes 40 items that measure spiritual health (n=20), religious health (n=10), and existential health (n=10). Items 2,4,6,8,10,12,12,14,16,18, and 20 are related to existential health while the rest are related to religious health (8). Scores of each of the religious and existential health subgroups range from 10 to 60. Higher obtained scores in this questionnaire indicate higher religious and existential health. The spiritual health score is the sum of these two subgroups and is within the range of 20-120. The items were scored based on a six-point Likert scale ranging from strongly disagree to strongly agree. Spiritual health level is divided into three levels of low (20-40), moderate (41-99), and high (120-100). Allahbakhshian et al. translated this questionnaire to Persian and examined and confirmed its content validity. They reported its Cronbach's alpha coefficient at 0.82 (12).
The collected data were analyzed in SPSS software (version 23) using Pearson correlation, Spearman correlation, and multiple regression analysis methods. Moreover, if it was necessary, descriptive statistical methods, such as mean, were used as well. It should be noted that all ethical considerations were respected in all stages of the research, including the principles of voluntariness and confidentiality of information. This article was extracted from a research proposal with the ethics code of IR.MUQ.REC.1399.107.

Result
Based on the results obtained from Table 1, sexual satisfaction had a negative significant correlation with age, marriage duration, and age of the husband. Accordingly, with the increase     Table 2, sexual satisfaction has a significant correlation with health components (i.e., religious and existential health) (P<0.01). Accordingly, people with more existential and religious health have higher sexual satisfaction. Table 3 tabulates the results of multiple regression analysis for the prediction of sexual satisfaction through the components of spiritual health. The standardized regression coefficient (Beta) for the religious and existential health components were 0.264 and 0.357, respectively. According to the obtained t-value, which is significant at the alpha level of 0.01, it can be concluded that the components of spiritual health positively and significantly predict the sexual satisfaction of women referring to health centers in Qom.

Discussion
Based on the results, there is a significant direct relationship between spiritual health and sexual satisfaction; accordingly, people with more spiritual health have higher sexual satisfaction. It should be mentioned that no previous research has directly examined the relationship between spiritual health and sexual satisfaction; therefore, we will discuss the other related literature that could be found in this regard.
Salehi et al. conducted a study on married students titled "The Relationship Between Spiritual Health and Marital Satisfaction". They found that spiritual health had a direct and significant relationship with marital satisfaction which is in line with the results of this study (13).
Shawani et al. carried out a research in 2014 titled "The Role of Sexual Satisfaction, Spiritual Health, Psychological Distress, and Self-Esteem in the Marital Commitment of Women with a Veteran Spouse". They found that marital commitment had a positive and significant relationship with spiritual health and sexual satisfaction which was consistent with the findings of the present study (8).
Moreover, Taheriha et al. performed a study titled "Role of Spiritual and Mental Health in the Prediction of Marital Satisfaction" and found that marital satisfaction had a significant relationship with spiritual and mental health. They also observed that spiritual and mental health can predict marital satisfaction which is consistent with the results of the present study (11).
Findings of another research have indicated that higher levels of spiritual health lead to fewer marital conflicts and a greater ability to resolve interpersonal conflicts which are consistent with those of the present study (14). Moreover, in a study conducted by Peplau, it was found that spiritual health plays an important role in the improvement of marital commitment and quality of marital relationship which is consistent with the results of this study (3).
These findings are justifiable since religious beliefs can affect all physical, psychological, and social aspects of life. People with high levels of spiritual health consider diseases or problems as the signs of divine wisdom and God's special attention to them. Moreover, spirituality increases their trust in God, enhances their patience over problems, and gives them hope for receiving spiritual rewards in the afterlife and obtaining the satisfaction and attention of God.
According to the results of the present study, sexual satisfaction had a negative significant relationship with age and marriage duration. Accordingly, with the increase of age and marriage duration, the rate of sexual satisfaction will decrease. Moreover, there was a direct and significant relationship between education level and sexual satisfaction.
Findings of this study were not directly consistent with those of any other study; however, other studies can be used to explain these findings. In a study conducted by Esther Castellano, it was found that variables, such as gender, age, social class, share in household chores, self-care, financial cooperation, child care, and self-perceived health status can lead to an increase or decrease in sexual satisfaction. Gender and class inequalities reduced sexual satisfaction; in addition, decreased sexual satisfaction was observed in women over the age of 45. Nevertheless, women who cared for themselves were 1.7 times more sexually satisfied, compared to women who could not feel good about themselves. These findings are in line with those of the present study (15).
According to the findings of a previous study, demographic characteristics affect marital satisfaction and can explain the changes in marital satisfaction which is consistent with those of this study (16). Furthermore, the results of another study also indicated that demographic characteristics affect marital satisfaction and explain the changes in marital satisfaction which is also in line with those of this study (17).
These results can be justified since the more open and trained view of educated people contributes effectively to how they judge physiological processes, such as sleep and sexual behavior. Sexual behavior can be affected by psychological disorders and seriously influence the quality of life of a person. Moreover, aging reduces the ability and desire for sexual relationships. In addition, the partners might lose their attraction for each other after some years which can also be an important and influential factor in the reduction of sexual satisfaction.

Research limitations
Limitations of the study include the lack of generalizability of the data, self-report nature of the study, as well as the impossibility of investigation of the causal relationships. Another limitation of this research was the sensitivity of sexual issues which caused the participants to be less interested in answering questions about this topic.

Conclusion
Based on the results of this study, spiritual health had a direct and significant relationship with sexual satisfaction. Moreover, among the demographic components, there was a negative significant relationship between marriage duration and sexual satisfaction, while there was a direct and significant relationship between education level and sexual satisfaction. Therefore, it is suggested to create a suitable platform for education to enhance spiritual health in families through the national media and virtual or in-person training workshops. Besides, it is recommended to provide the required environment for research on this topic in different regions of the country.

Conflict of interest
The authors declare that there was no conflict of interest in this study.