Health, Spirituality and Medical Ethics

Introduction
Marriage is the most vital and basic human relationship [1] because it provides a basic structure for establishing a family relationship and educating the future generation [2]. The quality of marital life is considered crucial in marriage, as it is one of the vital aspects of a marital system and one of the most essential structures that determine the health of families [3]. Marital quality is a concept consisting of positive dimensions, including happiness and positive marital interactions, and negative dimensions, including conflicts and negative attitudes) that exist in relationships between couples [4]. Therefore, marital quality is a multidimensional concept and includes various dimensions of couples’ relationships, such as compatibility, satisfaction, happiness, cohesion, and commitment, and is considered one of the factors affecting successful marriage [5]. Marital quality is considered the main factor that plays a significant role in the success or failure of marriage [6]; consequently, it has attracted increased attention from researchers in the last decade [7].
Considering the role of the quality of marital life, many influential indicators and factors have attracted the attention of researchers. One of the most vital factors is mindfulness [8]. Mindfulness refers to awareness of internal and external experiences without judgment, characterized by frankness and acceptance [9]. It is a multifaceted trait that includes attention and awareness focused on the present, as well as purposefulness related to the motivational components of attention and behavior. This attitude reflects a person’s state of attention, encompassing interest, curiosity, non-judgment, acceptance, and responsiveness [10]. It is also an inherent feature that reflects a person’s tendency to be mindful in everyday life [11].
The purpose of mindfulness is to maintain moment-to-moment awareness, separating a person from extreme attachment to beliefs, thoughts, and emotions, separating [12]. Mindfulness can increase constructive responses and positive psychological outcomes, and reduce confusion [13]. Studies have confirmed the direct and significant effect of mindfulness on the quality of marital relationships among married female nurses [14], the moderating role of mindfulness in the relationship between romantic attachment styles and marital quality [15] and the role of mindfulness in predicting the quality of marital relationships among married students.
On the other hand, spiritual experiences hold special importance among the factors affecting the quality of life (QoL) [17]. The daily experience of spirituality includes finding meaning in life, which includes understanding the meaning of life, having positive experiences, and feeling happy and satisfied [18]. Spiritual experiences are a type of individual psychological event indicating a feeling of unity and harmony with the holy forces, an awareness of the universe, and the hidden wisdom and goodness in life events. These experiences can lead to effects such as religiousness, the ability to explain phenomena, and emotional changes driven by love and passion for God and the creatures of the world [19].
Spiritual experiences include hope, finding meaning in life, forgiving others’ mistakes, moral beliefs and values, having a good relationship with others, believing in God, being moral, and creativity and self-expression [20]. Spiritual experiences, regardless of people’s religious orientation, include their inner understanding of the presence of God and their relationship with Him, as well as their sense of responsibility toward others, serving as sources of belonging and reliance on a higher source [21].
Spiritual experiences are vital for humans, fostering attention and understanding of others. These experiences usually strengthen family relationships and connections around them, as well as increase commitment to environmental sustainability to provide a better world for future generations [22]. In this regard, studies indicate the relationship between daily spiritual experiences and the QoL of single university students [17], the role of spiritual orientation in predicting the quality of marital life [23] and the relationship between spiritual intelligence and the dimensions of marital relationship quality [24].
The quality of marital life is considered one of the vital family issues because the success and happiness of life depend on the proper quality of marital life. In other words, it will be impossible to achieve a satisfactory and successful life without paying attention to the issue of marital quality and making efforts to improve and promote it [25]. Therefore, improving the quality of marital life has attracted the attention of researchers and is one of the factors that is effective in the overall assessment of family communications [6].
On the one hand, due to the emphasis of the World Health Organization on the importance of the quality of marital life throughout a person’s life, as well as the significance of variables such as mindfulness and spiritual experiences, and the existing research gap in the relationship between these variables in the target society, the present study was conducted to examine the role of mindfulness and spiritual experiences in predicting the quality of married life among individuals visiting cultural and community centers in District Five of Tehran City in 2022. This study seeks to answer the question of whether mindfulness and spiritual experiences can predict the quality of marital life of people attending culture and community centers of District 5 of Tehran City in 2022.
Methods
The present study was descriptive-correlational. The statistical population included all married men and women visiting the cultural and community centers of District 5 of Tehran City during the second half of 2022. Cultural and community centers are civil and urban institutions managed under the supervision of the neighborhood management headquarters, and provide cultural, artistic, recreational, sports, and religious education and activities for a wide range of urban residents.
The sample size was estimated at 100 people using G*power software, considering an error level of 0.05, a power of 0.95, and an effect size of 0.15 (based on the average from previous studies [16-17]) in a regression design with two predictor variables. The samples were selected by convenience sampling.
The inclusion criteria were being married, the desire to complete the questionnaire, an education level of at least a diploma, being between the ages of 30 and 50, not taking psychiatric drugs in the last six months, living together with a spouse in the last six months and providing informed consent. The exclusion criterion was the violation of the questionnaire. The participants were asked about the inclusion and exclusion criteria during a preliminary interview, and those who did not meet the criteria were not included in the study.
The research data collection tools were as follows:
Spiritual experiences scale: Underwood and Tersi designed this 16-question scale, which measures three factors of feeling the presence of God (questions 1, 2, 4, 5, 6, 8, 9, 10, and 11) and communication with God (questions 3, 7, 8, 12 and 15) and the feeling of responsibility toward others (questions 13 and 14). The scale uses a six-point Likert scoring method, where a score of six indicates “most times” and a score of one indicates “never or rarely.” Therefore, the range of scores is between 16 and 96, and higher scores indicate more spiritual experiences. Underwood and Tersey, while confirming the concurrent validity, reported the internal consistency of the scale using Cronbach’s α, with values of 0.94 and 0.95 in two separate instances [26]. In Iran, Taghavi and Asadi reported the validity of the scale using concurrent validity methods and factor analysis, confirming the validity of the scale. They found reliability coefficients of 0.96 for re-test reliability, 0.88 for Spearman-Brown classification, and 0.91 for Cronbach’s α [27]. In the present study, the overall reliability was obtained at 0.81 using the Cronbach’s α method.
Mindfulness questionnaire: Chadwick et al. prepared this 15-question questionnaire that measures three factors, including conflict with thoughts (questions 8, 13, 3, 6, 2 and 15), acceptance (questions 12, 4, 11, 7, 10), and awareness of thought (questions 1, 14, 9 and 5). It uses a seven-point Likert scale ranging from zero (strongly agree) to six (strongly disagree). The range of scores is between 0 and 96, where higher scores indicate higher mindfulness and vice versa. In Chadwick et al.’s study, the content validity and reliability were confirmed, with a Cronbach’s α coefficient of 0.89 in the normal population and 0.82 in the clinical group [28]. In Foroughi et al.’s study, validity was confirmed through exploratory factor analysis and convergent validity, while reliability, assessed using the Cronbach’s α coefficient method, yielded scores of 0.78 for engagement with thoughts, 0.69 for acceptance, 0.62 for awareness of thought, and 0.76 for total reliability [29]. In the present study, total reliability was obtained at 0.78 using the Cronbach’s α method.
Marital life quality questionnaire: Busby et al. prepared this 14-question questionnaire, which measures three subscales: Agreement, satisfaction and cohesion, on a six-point Likert scale from zero (we always disagree) to five (we always agree). The range of scores is between 0 and 70, and high scores indicate higher marital quality. Busby et al. confirmed its content validity and reported reliability using Cronbach’s α method, which yielded a coefficient of 0.83 [30]. In Yoosefi’s study, the validity of the factor analysis was confirmed using the inclined rotation method of the direct Oblimin type, while reliability, assessed using the Cronbach’s α coefficient method, resulted in values of 0.92 for the entire questionnaire and 0.89 for its components [31]. In the present study, total reliability was obtained at 0.88 using the Cronbach’s α method.
After obtaining the necessary permits, cultural and community centers in District 5 of Tehran City were visited. People who met the inclusion and exclusion criteria for participating in the research were asked to participate in the study. At first, the objectives of the research were explained to them and they were assured that the information would remain confidential and the results would be used only for research purposes. After obtaining the consent of the individuals, the questionnaires were given to them individually and the necessary explanations were presented to complete them. It took 20 to 30 minutes to complete the questionnaires. All the questionnaires were completed in the winter of 2022. Data analysis was conducted using SPSS software, version 22, employing Mean±SD, Pearson correlation, and multiple regression.
Results
Based on the results obtained, 57 participants (57%) had a diploma, 29 participants (29%) had a bachelor’s degree, and 14 cases (14%) had a postgraduate education or higher. Additionally, 65 cases (65%) were women and 35 cases (35%) were men. Table 1 presents the descriptive results of the research variables.
Based on the results obtained from Table 2, all the correlation coefficients calculated between spiritual experiences and mindfulness with the quality of marital life were positive and significant, the positivity of the obtained coefficients showed a direct relationship between spiritual experiences and mindfulness with the quality of marital life (P<0.01). Based on the results presented in Table 2, all the correlation coefficients calculated between spiritual experiences and mindfulness with the quality of marital life were positive and significant. The positivity of the obtained coefficients indicates a direct relationship between spiritual experiences and mindfulness with the quality of marital life (P<0.01).
To predict the quality of marital life of married people through mindfulness, multiple regression analysis was used. Durbin-Watson statistic was used to check the independence of the residuals. Given that its value (1.914) falls between 1.5 and 2.5, it can be concluded that the assumption of independence of the residuals was met. Tolerance indices and variance inflation factor (VIF) were used to check the presence of multicollinearity between the predictive variables. According to the obtained results, no deviations from the multicollinearity assumption were observed.
In Table 3, the F value obtained for the regression analysis was equal to 10.17, which was significant at <0.01, and showed that mindfulness can effectively explain the changes related to the quality of marital life and indicates the appropriateness of the regression model. The value of the R square indicates that the components of mindfulness explain 23% of the variance in the quality of marital life. The standardized regression coefficients (Beta) for the components were as follows: Conflict with thoughts (P=0.193, β=0.16), acceptance (P=0.089, β=0.19), and awareness of thought (P=0.011, β=0.24). Therefore, it was concluded that the component of awareness of thought positively and significantly predicted the quality of marital life of married people.
In Table 4, the F value obtained for checking the regression model was equal to 19.13, which was significant at <0.01 and showed that spiritual experiences could effectively explain the changes related to the quality of marital life and demonstrated the appropriateness of the regression model. The adjusted R2 value showed that the components of spiritual experiences explained 35% of the variance in the quality of marital life. The standardized regression coefficients (Beta) for the components were as follows: Feeling God’s presence (P<0.001, β=0.31), communication with God (P=0.024, β=0.20), and feeling God’s presence (P<0.001, β=0.36). Therefore, it was concluded that the components of spiritual experiences positively and significantly predicted the quality of marital life of married people.
Discussion
The present study aimed to investigate the role of mindfulness and spiritual experiences in predicting the quality of marital life of people visiting cultural and community centers in District 5 of Tehran City in 2022. The research results showed that the correlation between mindfulness and the quality of marital life was positive and significant, and the components of mindfulness, including conflict with thoughts, acceptance, and awareness of thoughts, predicted the quality of marital life positively and significantly. In other words, it can be said that the quality of married life increases by increasing mindfulness.
Although no study has directly examined this specific relationship, the findings are consistent with the results of similar studies in the field. For example, the results of Zarei and Biglari showed that mindfulness has a direct and significant effect on body image and the quality of the marital relationship among working married female nurses in the gynecology and obstetrics department [14]. Mindfulness moderates the relationship between secure, disturbed, and discrete attachment styles and marital quality [15]. SedaghatKhah and BehzadiPoor showed a significant relationship between communication beliefs, mindfulness, psychological flexibility and marital relationship quality of married students of Islamic Azad University [16]. Yang et al.’s study showed a significant correlation between mindfulness, marital quality, and postpartum depression in primiparous women [32].
In the above explanation, it can be said that mindfulness is a quality of alertness and means paying attention to the present moment. It encompasses purposeful and non-judgmental attention, without making judgments about what is happening; in other words, it is the experience of pure reality without explanation. Therefore, mindfulness helps us to understand that although negative emotions may arise in life, they are not a constant part of one’s personality or life process. This understanding enables individuals to respond to these events thoughtfully, rather than reacting involuntarily.
Therefore, mindfulness represents a new style for more efficient communication in life, which relieves or mitigates human pain and suffering while enriching life with enjoyable meaning [32]. Therefore, it is logical that mindfulness serves as a significant predictor of the quality of marital relationships.

In another explanation, it can be said that mindfulness causes people to have more successful stress management in their daily lives. Mindfulness can free the mind from mental preoccupation and threatening thoughts about functions by encouraging people to repeatedly practice attention focused on neutral stimuli and intentional awareness of the body and mind. This practice reduces anxiety and physiological tension by increasing awareness of current experiences and redirecting attention to the cognitive system, allowing for more efficient information processing.
The mindfulness approach, due to its underlying mechanisms, such as acceptance, increasing awareness, desensitization to the present moment, and observation without judgment, makes a person look at senses, thoughts, and emotions as reality, and consider them as aspects of reality. By recognizing these elements as transient experiences that pass through awareness, individuals can manage them more effectively. Therefore, they can improve the quality of their marital life through the skillful management of thoughts and emotions.
Another research showed that the correlation between spiritual experiences and the quality of marital life was positive and significant, and the components of spiritual experiences, including the feeling of God’s presence, communication with God, and the feeling of God’s presence, positively and significantly predicted the quality of marital life of married people. It can be concluded that the quality of marital life increases with the increase of spiritual experiences in life.
Our results are consistent with the results of previous related studies in this field. For example, the results of the regression analysis by Khodadadi Sangdeh showed that hope and daily spiritual experiences can predict the QoL in students [17]. Another research showed that spiritual orientation and its components are one of the main indicators of improved marital quality and stability, playing a decisive role in the marital quality of couples [23]. Sadeghi showed a significant relationship between spiritual intelligence and the quality of marital relationship dimensions (intimacy and sexual passion) among married women [24]. Daaleman and Frey showed that spiritual experiences play an effective role in health-related QoL [33].
In explaining the obtained result, it can be said that spiritual experience includes religious values ​​and attitudes, behavioral dimensions, supernatural beliefs, and religious practices. It is closely related to an individual’s values and worldview, such that it can be viewed as a product of the individual’s attitudes and as a motivating force guiding them toward a broader understanding of personal knowledge [34].
Therefore, spiritual experiences serve as a source of relief, providing individuals with peace, fostering hope about life and its events, increasing empathy and mutual understanding, and significantly reducing negative emotions such as disappointment, anger, and feelings of emptiness. On the other hand, these people have a positive and pleasant expectation of the events of their lives and a positive attitude and more effective performance when facing challenging life situations; as a result, they have a higher quality of marital life [17].
In another explanation, it can be said that religious beliefs and spiritual experiences manifest as reduced nervous tension and more flexible behaviors in family conflicts. Therefore, trust in God increases when facing problems, and as a result, it affects the perception of a person’s ability to face the environmental situation and promotes personal growth. Therefore, by feeling a sense of control and acceptance from God, individuals realize they are not alone; they perceive God’s presence and assistance in their lives. In other words, God does not play a passive role but is actively involved in determining the fate of life, which increases trust in God and aids in confronting life’s issues, which in turn affects an individual’s level of exploration, competence, and ability. Ultimately, this leads to increased social interactions and actions, resulting in an improvement in the quality of marital relationships.
Conclusion
The results showed a direct and significant relationship between mindfulness and spiritual experiences with the quality of marital life. The components of mindfulness and spiritual experiences could predict the quality of marital life. Therefore, according to the results, it is essential to implement necessary planning to strengthen spiritual experiences and mindfulness, as well as to organize educational workshops at the community level to improve the quality of marital relationships among couples.
Limitations
This study had some limitations. The study was conducted on people referring to cultural and community centers in District 5 of Tehran City. The cross-sectional nature of the research and the convenience sampling method were the limitations of the study. Therefore, caution should be observed in generalizing the results to other populations. Additionally, using the questionnaire as the sole research tool and source of data collection represents another limitation. There was also a lack of motivation from the sample, and t it was somewhat challenging to attract their cooperation. Also, the possibility of bias among respondents, which could lead to inaccurate answers based on their characteristics, is another limitation of this research.
It is suggested to study in different clinical and non-clinical populations at different times along with random sampling methods to better understand the relationship between the variables. Also, preventive measures should be taken in the field of strengthening the spiritual experiences and mindfulness of couples. Related governmental and non-governmental centers and organizations should develop necessary plans in this field and help improve the quality of couples’ marital relations by holding educational workshops at the community level.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Islamic Azad University, Bojnourd Branch (Code: IR.IAU.BOJNOURD.REC.1401.014).
Funding
This study was extracted from the PhD dissertation of Abdolreza Afzood, approved by Islamic Azad University, Bojnord Branch.
Authors' contributions
Writing the original  draft: Abdolreza Afzoud; Conceptualization and Supervision: Abolfazl Bakhshipour; Data  analysis: Meysam Sadeghi.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors express their sincere gratitude to all the married men and women referring to cultural and community centers in District 5 of Tehran City and assisted us in completing the questionnaires.