Health, Spirituality and Medical Ethics

Introduction
One of the basic components of a happy and successful society, whether at the family, tribe, village, or city level, is good interpersonal relations, and when these interpersonal relations are less in the society, such a society cannot realize its full potential. Interpersonal relationships are vital in governance, politics, and economic, and social development because humans are social beings [1] and it seems that some background variables are effective to form these desirable interpersonal relationships [2]. Studies show that attachment style can have a significant effect on interpersonal relationships [3]. Bowlby (1969) defines attachment as a stable psychological bond between two people. According to this theory, many forms of mental irritation and disorders in personal and social fields are the result of the child's deprivation of maternal care or the instability of the child's relationship with the attachment style [4]. Hazan and Shaver identified three adult attachment styles, secure, anxious/ambivalent, and avoidant [5].
Securely attached people can declare their helplessness and ask for support [6], the anxious/ambivalent style is characterized by being dependent, needy and ambivalent feelings in relationships and people with avoidant attachment style in establishing intimate relationships with others have problems and do not want to share their thoughts and feelings with others [7]. Research has shown a strong correlation between secure attachment and positive interpersonal relationships. It can be concluded that without secure attachment, challenges may be existed in interpersonal relationships [1]. To build healthy relationships in personal life, secure attachment is an essential prerequisite at the basic level [8]. From a neurological point of view, the release of neurotransmitters is stimulated through attachment and prosocial behavior [9]. On the other hand, insecurely attached people are usually preoccupied (anxious-ambivalent) adults who show high anxiety, low avoidance, exaggerated desire for closeness and affiliation, and intense worry about rejection [10].
It also seems that a significant relationship is observed between attachment styles with moral identity [11] and moral identity with interpersonal relationships [12]. Moral identity is an integrated concept of self and ethics [13]. Moral identity is affected by individual and contextual factors, at the individual level, variables, such as personality and cognitive development can affect the evolution of moral identity [14] and attachment styles are one of these factors [15]. Moral emotions may be rooted in early emotional experiences with attachment figures [15, 16]. A secure attachment style creates a mutual response orientation for parent and child, causing the formation of moral cognition and moral emotions [11]. A relationship exists between moral emotions, especially empathy, sympathy, guilt, and desirable social behaviors, in other words, moral emotions can be considered one of the foundations of desirable social behaviors and necessary for their occurrence [17, 18].
In a meta-analysis study, Costa Martins and colleagues [19] also showed a significant positive correlation between secure attachment and feelings of guilt, shame, and forgiveness, and in these models, the mediating role of empathy between attachment and evolving desirable social behavior can be seen [20]. Also, in another study, the mediating role of moral maturity in the relationship between attachment styles and moral behaviors has been confirmed [21]. In today’s modern world, it is essential to investigate the factors that can affect interpersonal relationships, and the background investigation shows that the developmental factors of the individual are among the possible influencing variables [1], and since some mental disorders are affected by the problem is in interpersonal relationships, and interpersonal relationships affect many person’s occupational, academic, and social relationships [22, 23], examining the variables affecting it adds to the necessity of related studies. Some numerous studies and the review of the research background show that individual and contextual variables are effective in the formation of interpersonal relationships and the role of attachment styles and moral identity in the formation of interpersonal relationships are separately investigated and confirmed, but the present study intends to examine the question that attachment styles play a role in the formation of interpersonal relationships via moral identity?
Methods
According to the method of data collection, the present study is correlational research, and due to the analysis of the structural relationships of the variables, it is considered part of the causal research [24]. The statistical population in the present study included all the residents in West Azarbaijan Province between March 2021 and April 2022, who were selected by convenience method. To determine the sample size, Lohin (1992) suggests that to examine the structural model in which 2-4 agents participate, the researcher should plan on collecting at least 100 to 200 cases [25], in the present study, 200 people participated in the study. The inclusion criteria included interest in participating in the study, age over 16, and education level over secondary school, and the exclusion criterion included incomplete completion of the questionnaire. To conduct the research, a questionnaire was designed after the link and placed on social networks through a public call. Also, the principle of secrecy and confidentiality of information was emphasized, then the obtained data were analyzed using SPSS software, version 24 and Amos software, version 24 using correlation and path analysis method at the level (P<0.05).
Research tools
Ethical Identity Questionnaire
This questionnaire was designed by Black, and Reynolds [26] and has 20 items and is scored on a 6-point Likert scale from 1=completely disagree to 6=completely agree. Also, they reported the criterion, convergent and divergent validity of the questionnaire desirable. The results of their research in the field of internal consistency by Cronbach’s alpha method were 0.90. The retest coefficient of this statement was 0.87. In the study conducted by Abbasi Asal et al. [27], 5 items of this questionnaire were removed and the scoring of questions 8 to 15 was reversed, and Cronbach’s alpha coefficient was reported as 0.85. In the present study, internal consistency was obtained to be 0.70 using Cronbach’s alpha coefficient.
Attachment styles questionnaire
The attachment scale of Collins and Read [28] consists of 18 items, it is measured on a 5-point Likert scale. In this questionnaire, three subscales of dependence, closeness, and anxiety are measured. The anxiety subscale (A) corresponds to anxious-ambivalent insecure attachment, the closeness subscale (C) is related to secure attachment, and the dependence subscale (D) is related to avoidant attachment. They reported Cronbach’s alpha for each subscale of A, C, and D as 0.81, 0.78, and 0.85, respectively. In Pakdaman’s study [29], Cronbach’s alpha for the subscales was 0.74, 0.28, and 0.52, respectively. In the present study, the internal consistency of Cronbach’s alpha coefficient for the secure attachment style was 0.59, for the avoidant attachment style, it was 0.54 and for the anxious attachment style, it was 0.81.
Interpersonal skills questionnaire
This questionnaire was designed by Manjemizadeh [30] and has 19 questions and its response range is Likert type (very low=1 to very good=5), a score below 45 indicates acute communication problems, score of 65-46 indicates a communication problem and a score of 95-66 indicates a capable person. Manjemizadeh [30] reported concurrent validity with the effective communication skill questionnaire r=0.69. Cronbach’s alpha for the interpersonal communication skills questionnaire was 0.73, which indicates the good reliability of this questionnaire. In the present study, internal consistency was obtained to be 0.87 using Cronbach’s alpha coefficient.
Results
The results of the demographic findings showed the Meam±SD age of people (25.07±7.87) and the frequency of gender (20.5% male and 79.5% female), 37% of people had a diploma and under diploma education, 49.5% had bachelor’s degree, 11.5% had master’s degree and 2% had doctoral education, also 13% of people were self-employed, 9.5% were employees, 50% were students and 27.5% were unemployed. Table 1 presents the descriptive findings of the study variables.
According to the results obtained from Table 1, the amount of skewness and kurtosis of the research variables in the sample group is in the range of -2 to 2, and this shows that the variables have a normal distribution, and the shape of the curve is bell-shaped and the skewness is left-right and kurtosis did not have high or low. In the following, the correlation coefficients of the study variables are presented.
As Table 2 shows, a significant relationship is observed between secure attachment style and interpersonal communication skills. A significant and negative relationship is observed between anxious attachment style and moral identity and interpersonal communication skills. A significant and negative relationship is observed between avoidant attachment style and interpersonal communication skills. However, no significant relationship is observed between avoidant attachment style and secure attachment style and moral identity.
To test the research model, path analysis via the maximum likelihood method using Amos software was used. Before using path analysis, univariate outlier data were checked using a box plot and multivariate outlier data were checked using Mahalanobis statistics and excluded from the data set. The skewness and kurtosis of the distribution of variable scores were calculated using SPSS software, version 24 and the results showed that none of the values of skewness and kurtosis were ≥± 2. Accordingly, the data follows a normal distribution. The assumption of independence of errors was investigated with Durbin-Watson’s statistic to calculate the regression equations of the research model, and the obtained value is 1.89, which is in the range of 1.5 to 2.5 and indicates the establishment of this assumption. Tolerance statistic and variance inflation factors were calculated to investigate multicollinearity. The results showed that none of the values of tolerance statistics are smaller than the permissible limit of 0.1 and none of the values of the variance inflation factor are larger than the permissible limit of 10. Therefore, based on the two mentioned indicators, the existence of multicollinearity was not observed in the data. After examining the assumptions and ensuring their establishment, path analysis was used to evaluate the studied model. Figure 1 shows the results.
Figure 1 shows the standard coefficients of the proposed model to investigate the mediating role of moral identity in the relationship between different attachment styles and interpersonal communication skills. The indices related to the fit of the model are presented in the Table below.
Table 3 presents the fit indices of the model. The chi-square ratio index on the degree of freedom (χ²/df) is a number in the range between 1 and 3 and confirms the fit of the model. The root mean square error of approximation (RMSEA) equals 0.08, thus confirming the fit of the model. Incremental fit index (IFI), comparative fit index (CFI) and normed fit index (NFI) indices are also larger than the desired criterion (0.9). The obtained coefficients indicate the optimal fit of the model.
Table 4 presents the direct, indirect, and total effects of the model variables. Based on the obtained results, the secure attachment style (P<0.05, β=0.19) has a direct and positive effect on moral identity. Anxious attachment style (P<0.05, β=-0.11) has a direct and negative effect on moral identity.
Secure attachment style has a positive effect on interpersonal skills both directly (P<0.01, β=0.70) and indirectly and with the mediation of moral identity (P<0.05, β=0.047). Anxious attachment style has a negative effect on interpersonal communication skills both directly (P<0.05, β=-0.60) and indirectly with the mediation of moral identity (P<0.05, β=-0.028). Avoidant attachment style has a negative effect on interpersonal communication skills both directly (P<0.05, β=-0.24) and indirectly with the mediation of moral identity (P<0.05, β=-0.016). Ethical identity has a direct (P<0.01, β=0.22) positive and significant effect on interpersonal communication skills.
Discussion
The results of this study showed a positive relationship between secure attachment style, moral identity and interpersonal relationships. Also, a negative relationship was observed between anxious attachment style and moral identity, and negative relationship was observed between anxious and avoidant attachment style with interpersonal relationship, and a positive relationship was observed between moral identity and interpersonal relationships. The results of this study are consistent with the studies conducted by Hojjati et al, Zeng et al. and Narvaez et al. [11, 31-33]. People who have a secure attachment can establish desirable relationships with others even in adulthood [34] because these people had a good relationship with their parents in childhood and have a positive internal model of their parents, and because they have grown in an environment full of responsiveness, they have planted schemas of moral concepts in their minds and made it part of their identity and personality [11]. Securely attached people have an exploratory feature, which makes them understand others [35], according to Kochanska’s two-stage model, moral identity is created in a mutual relationship. In other words, children who have emotional, intimate, and secure relationships with their parents, accept their parents’ values and rules, and moral self is a regulator of moral behavior [36]. Also, in avoidantly attached people, the ideal of being good and moral is not formed in their self-concept [37], so they do not understand the harmful effect of unethical behaviors on themselves and others, and for this reason, they do not consider the failure to perform ethical behaviors worthy of blame [7]. Also, ambivalent people, due to the fear of being rejected by others, do not have a safe base to gain internal control, free exploration, and the power of reasoning to defend their ideas, therefore to gain the approval of others [38], ethical behaviors should not be their priority because getting the approval of others is the first mental priority of these people.
The attachment style in which attachment is ignored, and is associated with low anxiety and high avoidance, is associated with problems such as hostility, interpersonal coldness, and emotional detachment [39]. In other words, a secure attachment contributes to a life of positive interpersonal relationships, whether at home, at work, or in society [1].
Also, the results of the model showed that moral identity has a mediating role in the relationship between attachment styles and interpersonal relationships, in other words, secure attachment style through moral identity has a positive effect on interpersonal relationships, and anxious and avoidant attachment style through moral identity has a negative effect on interpersonal relationships. The results of this study are consistent with the research of Hasan-Nia and Sheikhul-Islami, Zhang et al., and Wang et al. [21, 40, 41].
Ju [42] in his study showed a relationship between attachment styles and interpersonal relationships, and attachment styles play a mediating role in the relationship between hidden narcissism and interpersonal relationships. People who have a secure attachment style have high social acceptability and emotional independence and can show moral traits objectively and practically [7]. Zhang et al. [40] in their study showed that parents› emotional warmth can predict altruistic Internet behaviors through ethical behaviors. Also, Zeng et al. [32] showed in their study that moral identity plays a mediating role in the relationship between moral perfectionism and desirable online social behaviors. According to the social learning model, people acquire some behavioral norms by observing similar patterns [43]. Therefore, people who grow up with the emotional warmth of their parents form a positive moral personality trait in themselves, on the other hand, people who have this personality trait are interested in creating good interpersonal relationships [40].
In another explanation of the findings of the present study, securely attached people are sensitive to establishing desirable relationships with others, and in the context of these interpersonal relationships, they pay attention to some behavioral principles for interpersonal relationships to be continued and desirable moral identity as a mediating variable has a significant effect. On the one hand, avoidantly attached people do not have a special trust in interpersonal relationships and do not use positive moral principles in this regard, on the other hand, insecure attached, ambivalent people pay extreme attention to establishing relationships with others, therefore they only look at the goal and in this way, they may use any kind of cognitive or behavioral tools. Among the new findings of the present study is the investigation of the relationship between the three variables of attachment styles, moral identity and interpersonal relationships in the context of the model because previous studies have mainly measured the correlations between these variables and fewer have investigated their relationships in the form of a model. In other words, the present study shows that attachment styles, in addition to the direct effect they can have on interpersonal relationships, which have been examined and confirmed before, can also affect interpersonal relationships through the development of moral identity. The present study, like similar studies, faced some limitations. Electronic execution and lack of observation of people while responding and failure to respond to faults and problems were among the limitations of the present study. The present study was a correlational type and causality cannot be assumed, due to the electronic call and non-cooperation of people, a diverse range of people participated to answer and the statistical sample was not homogeneous. In future studies, it is suggested to carry out face-to-face implementation on a homogeneous spectrum, and longitudinal developmental studies are also suggested.
Conclusion
The results of the present study showed a relationship between attachment styles and interpersonal relationships with the mediating role of moral identity. In other words, the results of the present study showed that the secure attachment style through moral identity has a positive effect on interpersonal relationships, and the insecure, avoidant and anxious attachment styles through moral identity have a negative effect on interpersonal relationships.
Considering that this study has identified the effective factors on interpersonal relationships and moral identity, the obtained results can be used to improve interpersonal relationships and moral identity of people at the community level to foster a healthy society in ethics and relationships by identifying the effective factors on these variables.
Ethical Considerations
Compliance with ethical guidelines
Scientific ethical principles, such as confidentiality and informed consent have been observed in this research.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors
Authors' contributions
Data collection: Elaha Zunuzi and Shaghayegh Sadeghi; Statistical analysis, supervision: Shirin Zeinali; Writing: Shirin Zeinali and Hossein Rostami.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
 The authors of this article are extremely grateful to all the dignitaries who completed the research questionnaires.