Health, Spirituality and Medical Ethics

Introduction
Marriage is the beginning of family formation and has been recognized as the highest social norm for achieving the emotional and security needs of adults. While a healthy marriage is an important factor in society’s mental well-being, when marriage and family life fail to meet the psychological needs of the couple, it can harm mental health, sometimes causing serious and even irreversible consequences [1]. Life satisfaction means feeling that things are going as they should and it is a mindset or state of mind [2]. Therefore, the fulfillment of needs leads to satisfaction in individuals, which is an abstract concept. Needs are traditionally related to life satisfaction in the sense that when human needs are met, life satisfaction increases [3, 4]. Life satisfaction and the fulfillment of needs are connected to a deeper aspect called spirituality [3]. Most experts believe that to solve many existing problems, we need individuals who possess intellectual abilities and have a variety of skills, such as socio-cultural, emotional, and spiritual skills. Recognition of the importance of these skills and the ability to interact effectively with others has led to a growing interest in the concept of multiple intelligences, including spiritual intelligence [2].
Spiritual intelligence includes inner guidance and knowledge, maintaining mental balance, inner and outer peace, and acting with insight, gentleness, and kindness, as well as the ability to gain the power that helps people achieve their dreams [5]. Piedmont introduces the term spirituality as the inner core that can provide peace to a person, especially in stressful situations, and connect them to a higher power in the universe [6]. Noorzad also examined the relationship between spiritual intelligence and students’ religious coping methods and showed a positive relationship between spiritual intelligence and religious coping, specifically noting that students with high spiritual intelligence utilize religious coping, particularly trust in God, more when faced with unfortunate events in life. In other words, these individuals rely on God to cope with life’s unfortunate events while simultaneously striving for well-being and stress reduction [7]. Therefore, in addition to behavioral and mental characteristics, other factors that can affect the lives of married individuals are emotional stability and the quality of their attachment to God [8].
Kirkpatrick is one of the first theorists in the field of attachment to God. He believes that attachment to the primary caregiver in childhood continues over time and within the framework of other systems, much like attachment to God and homeland. He posits that attachment theory can also be used to study and identify religious behaviors and to understand the quality of religious beliefs. He lists four criteria for the support of attachment, two of which apply to God [8]. One criterion is that God serves as the source and basis of security for individuals when they are stressed and mentally disturbed, while the other is that God is a supportive and reliable source for exploration and inquiry in the surrounding environment. Therefore, God can be considered and accepted as the support of attachment. Accordingly, God can be viewed as the object of attachment that provides people with peace and security and allows them to take control of uncontrollable situations [9]. Regarding the role of attachment to God (theism) in family issues, research also shows that membership in religious groups both reflects and reinforces the value and worth of family life [10]. The results of studies conducted in recent years indicate that attendance at religious ceremonies and worship of God are positively associated with many indicators of physical, mental, family and social health [11]. Based on the available evidence, the elements of critical existential thinking, creating personal meaning, transcendental awareness and expanding the state of consciousness are important components of spiritual intelligence that can relate to an individual’s life satisfaction. However, each of these components can play a role in guiding the individual both specifically and collectively. Hence, the present study establishes both direct and indirect relationships between these components with the mediating role of attachment to God.
Methods 
The present study is descriptive, applied in terms of purpose and correlational in terms of methodology. The statistical population of the study consisted of all married female students in Qom City, Iran, in 2021, who were selected through simple random sampling. To determine the sample size, the Barbara sampling method was used, which considered 15 samples for each variable (a total of 105 people) and for reliability, this number was increased to 20 samples for each variable. 
At first, the participants completed questionnaires on life satisfaction, attachment to God and spiritual intelligence. After the questionnaires were completed, data were collected and statistically analyzed. Following the removal of corrupted questionnaires, 120 questionnaires were examined. 
The bootstrap test was used to analyze the effect of the mediating and indirect variables. The normality of the data was initially tested using the Kolmogorov-Smirnov statistical test to determine the appropriate statistical method (parametric or non-parametric) to be used. If the data were normal, one of the most important assumptions of parametric tests was met. In this study, descriptive statistical methods, including Mean±SD, as well as inferential statistics, including correlation coefficient and path analysis, were employed. A confidence level of 0.05 was also considered for testing the hypotheses. 
Meanwhile, ethical considerations, including the voluntary participation of married female students in this project and the confidentiality of completed questionnaire information, were observed. Accordingly, information related to individuals was analyzed without names and only with identification codes. Group members were asked to express their consent to participate in the research. The participants were also assured that the information in the questionnaires would be used for research purposes only. They were encouraged to ask the researcher for further clarification if they encountered any ambiguity while completing the questionnaire.
Research tools
God attachment scale
The God attachment scale was developed by Rowatt and Kirkpatrick in 2002, consisting of 9 items and two dimensions: Avoidant attachment and anxious attachment. Six items measure avoidant attachment to God, characterized by viewing God as distant and unfriendly, while the other three items measure anxious attachment, defined as perceiving God as responsive to needs in some situations and unresponsive in others (Figure 1). The participants respond to each of these items on a 7-point based on Likert scale ranging from 1 (not at all a part of my personality) to 7 (very much a part of my personality). Rowatt and Kirkpatrick identified two latent factors in the factor structure of this test using confirmatory factor analysis. The Cronbach α coefficient was estimated to be 0.92 for the avoidance dimension and 0.80 for the anxiety dimension. Additionally, the scale of devotion to God has demonstrated evidence of construct validity. Discriminant and convergent validity have been used to confirm the construct validity of this test. The anxiety dimension of this scale predicted neuroticism and both positive and negative emotions in individuals. In Iran, the Cronbach α coefficients for the avoidant, anxious, and secure attachment dimensions have been reported to be 0.88, 0.77 and 0.90, respectively [12]. In the present study, the reliability coefficient analysis showed that the secure attachment style had an α coefficient of 0.78, the anxious attachment style had an α coefficient of 0.79, and the avoidant attachment style had an α coefficient of 0.83.
Spiritual intelligence self-report inventory (SISRI)
The SISRI is a 24-item scale designed by King in 2007. It measures spiritual intelligence with four subscales as follows: Critical existential thinking, creating personal meaning, transcendental awareness and expanding the state of consciousness, each of which contains 7, 5, 7 and 5 items, respectively. The subjects rated their responses to each item on a four-point scale (0=completely false, 1=not true, 2=somewhat true, 3=very true, 4=completely true). Accordingly, the score on this scale can range from 0 to 96, with a higher score indicating a greater level of spiritual intelligence in individuals. King (2007) reported an α coefficient of 0.95 for this scale in a study of 619 students. The α coefficients for its subscales were as follows: Critical existential thinking=0.88; creating personal meaning=0.87; transcendental awareness=0.89 and expanding the state of consciousness=0.94. In 2009, the validity and reliability of the questionnaire were assessed by Raghib et al. and the reliability of this scale was estimated to be 0.88 using the Cronbach α coefficient. The face and content validity of the scale were confirmed by psychological experts, and the convergent validity was assessed simultaneously with the Ghobari-Bonab spiritual experience questionnaire, with a correlation coefficient of 0.66 between the two questionnaires. To examine the validity of this scale, it was compared with several valid questionnaires, including the transpersonal self-interpretation scale, the mysticism scale and the internal and external religiosity scale, with their correlation coefficients being 0.67, 0.63 and 0.78, respectively [13, 14].
Satisfaction with life scale (SWLS)
SWLS is a 5-item questionnaire designed by Bayani et al. [15] in 1989 to measure an individual’s cognitive and overall judgment of life. Scoring is conducted based on a 7-point Likert scale, with a score of 1 indicating strongly disagree, a score of 2 indicating disagree, a score of 3 indicating somewhat disagree, a score of 4 indicating neither disagree nor agree, a score of 5 indicating somewhat agree, a score of 6 indicating agree, and a score of 7 indicating strongly agree. The total score of this scale is calculated by summing the responses, and its range is between 5 and 35. A higher score indicates a higher level of satisfaction with life. Psychometric evaluation of the life satisfaction scale was conducted on a sample of 176 undergraduate students. Bayani et al. reported a relatively high internal consistency of 0.87. The test re-test correlation coefficient at a two-month interval was 0.82. Construct validity is demonstrated by the consistent differences between the results of individuals who were expected to have different levels of life satisfaction; for example, prisoners, patients, and abused women consistently scored lower. In a concurrent validity study through correlation with 10 other scales that measured psychological well-being, each of these scales had a correlation coefficient of 0.5 or higher with the SWLS. Various studies have shown a low correlation between the SWLS and the negative and positive affectivity scales. Bayani et al. in examining the validity and reliability of the SWLS, found that the validity of the SWLS was 0.83 using the Cronbachα method and 0.69 using the test-retest method [15].

Results
The age range of most participants was between 20 and 25 years (58.33%), the duration of their marriage was between 1 and 5 years (76.66%) and most of them did not have children (56.66%) (Table 1).
According to Table 2, the distribution of the scores of the variables was normal, as determined by the Kolmogorov-Smirnov test. 
There was a significant positive correlation between attachment to God and life satisfaction (P=0.01) and there was also a significant positive correlation between attachment to God and spiritual intelligence (P=0.01) (Table 3).
In Table 4, the results for the paths indicate the significance of the mediation paths.

Given that zero falls outside the upper and lower bounds of the confidence interval, this mediating role is significant, thus confirming the hypotheses related to the indirect paths (Table 5).
According to Table 6, the size of the indices resulting from the examination of the structural model fit was good, indicating a satisfactory fit of the model.

Discussion 
The main objective of the present study was to investigate the mediating role of attachment to God in the relationship between spiritual intelligence and life satisfaction in married students. The results of the Pearson correlation showed a significant positive correlation between attachment to God, spiritual intelligence and life satisfaction. In addition, attachment to God played a significant mediating role in the relationship between spiritual intelligence and life satisfaction among married students. Thus, the hypotheses related to the indirect (mediated) paths were confirmed.
The results of the present study are consistent with the findings of the research conducted by Starks and Hughey [16], Fabricator et al. [17], Bagheri et al. [18], Nasr Esfahani and Etemadi [19] and Yonker et al. [20]. Starks and Hughey, as well as Fabricator et al. showed a significant positive relationship between life satisfaction and spiritual intelligence [16, 17]. Bagheri et al. also demonstrated a significant positive relationship between spiritual intelligence and happiness in life [18]. Nasr Esfahani and Etemadi. showed a significant positive relationship between spiritual intelligence and personality traits, as well as life adjustment [19]. Yonker et al. also found a significant positive relationship between religiosity towards God, spirituality, and psychological outcomes [20]. Attachment to God minimizes anxiety and acts as a vital factor against feelings of existential despair; thus, with an increasing belief in God and internal acceptance of religion, anxiety levels decrease and mental health improves [21]. On the other hand, religious commitment is associated with forgiveness (both forgiveness from God and others) and increased life satisfaction [22]. Most of the characteristics of spiritual intelligence are evident in a person’s relationship with God, which is referred to as attachment to God. Therefore, individuals with lower spiritual intelligence toward God are more likely to be anxious, ambivalent, or confused about God’s willingness to respond in threatening situations and do not perceive God as responsive and available [19].
People with low spiritual intelligence are hesitant to accept God as a foundation of safety and a reliable source of support in times of hardship. They may not feel God’s presence in their lives and are often anxious about God’s absence in difficult and significant issues and problems they face. These individuals consistently experience a type of anxiety that signifies a distance from God and are generally dissatisfied with their lives due to their low attachment to God [16]. High spiritual intelligence leads to a positive perception of God and a strong attachment to God, which allows individuals to address higher levels of needs, namely spiritual needs, in the light of the faith and peace they achieve [18]. Therefore, these individuals make more efforts to draw closer to God, and this closeness and attachment to God lead to increased life satisfaction. This occurs because people with high spiritual intelligence have a more positive mental image of God, viewing Him as accepting, close and accessible [23] and because a positive perception of God is related to attachment style and life satisfaction [24].
Accordingly, since attachment to God and spiritual intelligence have a positive relationship with life satisfaction, increasing attachment to God leads to greater life satisfaction. Conversely, individuals who have less attachment to God or lower spiritual intelligence experience decreased life satisfaction and patience [7]. People with higher spiritual intelligence tend to be more patient in the face of stressful events and life’s challenges, and with hope and trust in God, they believe that God will not abandon those who remain patient during times of trouble and hardship; God is always with them [18]. This strengthens their connection with God and their attachment to Him [21]. They value themselves more and recognize that God loves them, even if His will aligns with their prayers. In contrast, those with lower attachment may perceive themselves as incapable due to their lack of preparation to face problems, feel helpless in the face of challenges, complain to God and experience dissatisfaction with life [10].
Conclusion 
People can become resilient to the hardships of life by utilizing spiritual intelligence and devotion to God, living purposefully, and viewing life’s problems as a divine test that can be endured. Such a belief can help individuals overcome critical situations and achieve greater satisfaction with life. Therefore, to increase life satisfaction, attention should be given to strengthening the subsystems of spiritual intelligence to enhance devotion to God.
Ethical Considerations
Compliance with ethical guidelines
All ethical issues were 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
Conceptualization and Study design: Mena Danaei Kosha; Data collection: Maryam Eslami Sarsheke; Data analysis and interpretation: Mena Danaei Kosha; Drafting of the manuscript: Monireh Masoumian; Critical review: Sara Torabian; Statistical analysis: Mena Danaei Kosha.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgments
The authors are grateful to all those who assisted us in conducting this research.