Health, Spirituality and Medical Ethics

Introduction
Marital relationships are one of the most critical determinants of healthy family functioning [1]. Despite this, societies incur significant costs annually to address marital problems. Although the divorce rate is the most reliable indicator of marital distress, evidence suggests that marital satisfaction (marital happiness) is not easily attainable, even among couples experiencing difficulties [2]. Marital satisfaction encompasses multiple components, including sexual fulfillment, receiving support from one’s partner, participation in decision-making processes, relationships with in-laws, social support, psychological well-being, and overall life satisfaction [3]. A confluence of intrapersonal, interpersonal, and environmental factors can significantly impact marital health. Intrapersonal factors, such as personality traits, physical and mental health, positive cognitive characteristics, and spiritual-religious beliefs, play a crucial role. Interpersonal factors, including effective communication, constructive relationship dynamics, love, affection, and sexual satisfaction, are also essential. Environmental factors, such as social support, employment status, and economic stability, further influence marital well-being [4]. Researchers have long sought to identify the factors that contribute to marital satisfaction. Studies have demonstrated that individual characteristics and background factors can influence the quality of life (QoL). Among these factors, self-compassion, spiritual well-being, and anxiety have emerged as potential antecedents [5].
Among the influential factors, self-respect and self-compassion have been identified as strong predictors of marital satisfaction [6]. The construct of self-compassion, characterized by kindness, understanding, and mindfulness, encompasses three core components as follows: 1) Self-kindness, involving treating oneself with empathy and care, particularly in times of failure or inadequacy; 2) Common humanity, recognizing that suffering and imperfection are universal human experiences; and 3) Mindfulness, cultivating a balanced awareness of one’s thoughts and feelings without judgment or rumination [7].
Self-compassion fosters a non-judgmental attitude toward oneself, particularly about one’s weaknesses. Individuals with high levels of self-compassion tend to experience increased positive emotions. This shift facilitates cognitive and emotional changes, enabling individuals to perceive life’s challenges as natural occurrences [8]. Research suggests that self-compassion reduces stress levels, enhances hope in relationships, increases empathy in intimate relationships, and promotes intimacy in marital relationships [9]. Consequently, self-compassion likely contributes to the quality of interpersonal relationships by fostering emotional resilience and mental calmness, enabling individuals to respond constructively to interpersonal conflicts and problems [10].
Spirituality, encompassing fundamental beliefs and values, plays a significant role in human growth across cognitive, ethical, and emotional domains. It can also have a profound impact on marital relationships [11]. In the context of potential marital conflicts, religiosity has been identified as a means of restoring marital satisfaction [12].
Research suggests that spiritual well-being positively influences marital satisfaction, serving as a reinforcing factor in establishing and maintaining marital harmony [13]. Spirituality can enhance individual psychological well-being and interpersonal adjustment. Providing a foundation of shared spiritual beliefs and values can contribute to family balance and overall mental health [14].
The lack of marital satisfaction can contribute to the development, maintenance, and exacerbation of anxiety disorders [15]. While the factors contributing to anxiety disorders are diverse and complex, self-compassion and spiritual well-being may play a mitigating role [16]. Anxiety disorders are among the most common mental health disorders, significantly impacting individuals and their close relationships [17]. Studies have shown that anxiety disorders negatively impact social functioning, including marital relationships [18, 19]. Such disorders can be burdensome for both individuals and their families, affecting interpersonal relationships, hindering family members’ adjustment, and disrupting family functioning, particularly marital relationships [20]. In traditional societies, where extended families play a significant role in marriage, anxiety disorders can exacerbate marital discord and decrease marital satisfaction [21]. 
Given the increasing stress levels among university students and the importance of marital satisfaction for overall well-being, this research investigates the connections between self-compassion, spiritual well-being, and marital satisfaction among married university students. While previous studies have highlighted the potential benefits of self-compassion and spiritual well-being, limited studies have explored their interplay, specifically within the context of married university students. This population faces unique stressors, and understanding these relationships can inform interventions aimed at improving marital satisfaction and overall well-being in this vulnerable group. Additionally, the role of anxiety in these relationships has not been adequately explored. By examining anxiety’s mediating influence, this study explains the mechanisms through which self-compassion and spiritual well-being may impact marital satisfaction, providing a more nuanced understanding of these connections.
Methods
This research employed a descriptive-analytical study design to explore the associations between predictor variables (self-compassion and spiritual well-being) and the outcome variable (marital satisfaction), with a particular focus on the mediating role of anxiety. Accordingly, a conceptual model was developed and tested (Figure 1). A sample of 356 married students from Azad University of Ahvaz, Iran, was recruited in 2023 using stratified random sampling. The participants were included based on their willingness to participate and provide informed consent. Individuals who were divorced, unwilling to continue participation, or left more than 10% of the questionnaire items unanswered were excluded from the study.
Research instrument
The marital satisfaction scale (MSS)
The MSS is a 35-item instrument that assesses various aspects of marital satisfaction, including communication and conflict resolution. The MSS provides a broader assessment, encompassing factors such as idealization, personality traits, financial management, and intimacy. Responses to both scales are rated based on a 5-point Likert scale. Scores on the MSS range from 35 to 175, with higher scores indicating greater marital satisfaction [22]. The Persian version of the MSS exhibited satisfactory reliability with a Cronbach α of 0.74 [23].
The spiritual well-being scale (SWBS)
The SWBS is a 20-item self-report measure developed by Paloutzian et al. [24]. Items are rated based on a 6-point Likert scale, and negatively worded items are reverse-scored. The total score reflects overall spiritual well-being, with higher scores indicating greater spiritual health. Scores on the SWBS range from 20 to 120, with higher scores indicating greater spiritual well-being. The SWBS has demonstrated satisfactory reliability, with a Cronbach α of 0.81 [25].
The self-compassion scale-long form (SCS-LF)
The SCS-LF was used to assess self-compassion. This 26-item self-report measure, developed by Neff [26], requires participants to rate items based on a 5-point Likert scale. Higher scores indicate greater self-compassion. Scores on the SCS-LF range from 26 to 130, with higher scores indicating greater self-compassion. The SCS-LF has demonstrated acceptable internal consistency, with a Cronbach α of 0.89 reported by Momeni et al. [27].
The state-trait anxiety inventory (STAI)
The STAI is a 40-item self-report measure that assesses both state and trait anxiety. The participants rate items based on a 4-point Likert scale. Scores on the STAI range from 40 to 160 for each subscale (state and trait anxiety), with higher scores indicating greater anxiety levels [28]. The STAI has demonstrated strong reliability, with Cronbach α coefficients of 0.88 for trait anxiety and 0.84 for state anxiety [29].
Data analysis
The data were analyzed using structural equation modeling (SEM) with SPSS software, version 26 and AMOS SPSS software, version 26. Bootstrapping was employed to assess the mediation effect. A more complete statistical analysis was conducted, including descriptive statistics (Mean±SD, skewness, and kurtosis) for all variables. Pearson correlation coefficients were calculated to examine the relationships between variables. Model fit was assessed using multiple indices, including the chi-square statistic divided by degrees of freedom (χ²/df), the normed fit index (NFI), the comparative fit index (CFI), the incremental fit index (IFI), the Tucker-Lewis index (TLI), and the root mean square error of approximation (RMSEA).
Results
A sample of 356 married undergraduate students (184 women, 172 men) aged 20-40 participated in this study. Table 1 presents descriptive statistics, including skewness and kurtosis values, which fell within acceptable limits, indicating normality. The skewness and kurtosis coefficients of the variables were within the acceptable range of -2 to 2, indicating that the normality assumption for the data distribution is tenable. The results showed a significant negative correlation between self-compassion and anxiety. Additionally, a significant positive correlation was found between self-compassion and spiritual well-being. Furthermore, anxiety was significantly negatively correlated with spiritual well-being and marital satisfaction.
A SEM approach was adopted to test the proposed model, which involved marital satisfaction as the outcome variable, self-compassion and spiritual well-being as the predictor variables, and anxiety as the mediating variable. To assess model fit, a suite of fit indices, including χ²/df, NFI, CFI, IFI, TLI, and RMSEA, was examined. According to Table 2, the model exhibited an adequate fit to the empirical data. A visual representation of the hypothesized model is presented in Figure 2.
The direct and indirect effects among the study variables are reported in Table 3. Self-compassion was negatively associated with anxiety (β=-0.19, P=0.007) and positively associated with marital satisfaction (β=0.21, P=0.001). Similarly, spiritual well-being was negatively associated with anxiety (β=-0.11, P=0.008) and positively associated with marital satisfaction (β=0.10, P=0.020). Additionally, anxiety was negatively associated with marital satisfaction (β=-0.19, P=0.001). Moreover, self-compassion (β=0.04, P=0.013) and spiritual well-being (β=0.02, P=0.049) indirectly improved marital satisfaction through anxiety (Table 3).
Discussion
This study assesses the relationships between self-compassion, spiritual well-being and marital satisfaction among married university students and examines the mediating role of anxiety. The present study determined the causal relationship between marital satisfaction, self-compassion, and spiritual well-being, with a focus on the mediating role of anxiety among married university students in Ahvaz City, Iran. The findings revealed a negative correlation between self-compassion and anxiety among married students, indicating that as self-compassion increased, anxiety decreased. These findings align with previous studies [30, 31]. To explain this finding, self-compassion allows individuals to develop a broader perspective on their problems, view life challenges and personal failures as a normal part of life, and connect with others more during times of pain and suffering rather than feeling isolated. Additionally, self-compassion encourages individuals to become aware of their thoughts, emotions, and feelings rather than suppressing, judging, or avoiding them. These factors help couples cultivate a more open-minded approach, enhancing their ability to modify cognitions and behavioral responses and adopt more effective coping strategies. Consequently, this leads to improvements in negative emotional states, such as anxiety [31]. 
Furthermore, controlling distressing thoughts can reduce the likelihood of engaging with anxiety symptoms. Individuals can achieve this by consciously and consistently controlling negative and anxious thoughts, shifting their focus away from excessive preoccupation with their perceived shortcomings and the negative aspects of the world. When individuals view their flaws and inadequacies as a shared human experience, they consciously accept them as part of life and perceive them without harsh judgment. As a result, they treat themselves with compassion when faced with unpleasant feelings, worries, and disturbances, thereby reducing their anxiety [30].
Another significant finding of this study was the confirmation of a negative relationship between spiritual well-being and anxiety. Previous research [32] has consistently reported a negative correlation between spiritual well-being and anxiety. Individuals with higher levels of spiritual well-being exhibit greater capacity to regulate their anxious feelings compared to those with lower levels. This finding can be attributed to the protective role of religiosity against anxiety. Religiosity can foster healthier lifestyles, greater self-acceptance, and increased resilience, ultimately leading to the alleviation of psychological distress [2]. 
By shaping a purposeful value system and a sense of meaning based on trust and acceptance of divine providence, spiritual well-being seems to facilitate a form of spiritual coping in the face of anxiety, thereby enhancing coping abilities and psychological hardiness in couples [13]. In other words, spiritual well-being acts as a protective factor against threatening events, aiding individuals in overcoming distress and challenges. Furthermore, it can provide a sense of purpose and higher life goals. These goals motivate spiritual endeavors, guiding individuals’ lives and significantly impacting their psychological and physical functioning. Consequently, in the face of psychological adversity such as anxiety, individuals with stronger spiritual well-being have access to a wider range of religious coping mechanisms, including meditation, prayer, and religious appraisals, which can effectively reduce anxiety [14].
The present findings also supported a positive relationship between self-compassion and marital satisfaction among married university students, consistent with previous studies [33]. This finding can be explained as individuals who exhibit self-compassion tend to foster deeper connections with their partners and establish more intimate relationships with others. Consequently, higher levels of acceptance towards their partners and greater experiences of autonomy and independence contribute to a more authentic and fulfilling marital life. Individuals who practice self-compassion are more likely to be kind to themselves and others, openly expressing their feelings [8]. This process breaks the cycle of isolation, leading to increased connection and greater satisfaction with their partners. Moreover, due to their recognition of shared human experiences, individuals with self-compassion not only uphold their cultural values but also respect their partners’ cultural values, fostering acceptance of both self and others. Self-compassion enables individuals to respond more constructively to interpersonal challenges and conflicts, thereby promoting psychological well-being within interpersonal relationships [33].
Another significant finding of this study was the positive influence of spiritual well-being on marital satisfaction. This finding aligns with previous research [34]. To elucidate this finding, it can be argued that spirituality is an intrinsic human need essential for cognitive, moral, and emotional growth, as well as for individuals’ ongoing quest to find meaning in life. Interpersonal relationships, particularly marital relationships, can be profoundly influenced by spirituality. Religiosity, both internally and interpersonally, can enable individuals to regulate their anger physiologically, cognitively, and emotionally while also fostering a sense of accountability for their actions during conflicts. Interpersonally, religious practices can provide a space for individuals to seek divine guidance during times of anger, offering couples a supportive framework to avoid conflict [34]. Consequently, spiritual well-being likely exerts a positive influence on couples and their marital relationships, contributing to increased marital satisfaction. Therefore, the presence of spiritual well-being as a crucial aspect of understanding the psychological dynamics of marriage appears to be vital, especially in contemporary society, where individuals often prioritize material and worldly needs over marital satisfaction. With the incorporation of spiritual elements, couples, in addition to relying on each other, seem to experience hope, support, and guidance within their marriages, fostering a conducive environment for a successful and fulfilling partnership [13].
Another significant finding of this study was the negative impact of anxiety on marital satisfaction. This finding is consistent with the results of previous studies [15, 16]. To elucidate the relationship between anxiety and marital satisfaction, anxiety, due to its nature and symptoms, exerts a negative influence on marital life. A strong negative correlation typically exists between anxiety disorders and marital distress [16]. Given the bidirectional nature of the relationship between anxiety and marital satisfaction, it is plausible that an anxious spouse may, on the one hand, disrupt the marital relationship through their anxiety and, on the other hand, experience increased anxiety due to marital turmoil. This cyclical pattern of distress is likely to be accompanied by a decrease in marital satisfaction, particularly when a decline in one partner’s satisfaction negatively impacts the other partner’s satisfaction.
Mediation analysis further revealed an indirect effect of self-compassion on marital satisfaction through anxiety. Similarly, the indirect effect of spiritual well-being on marital satisfaction through anxiety was confirmed. To elaborate on these findings, self-compassion offers a powerful framework for achieving a state of happiness and life satisfaction. By cultivating unconditional self-compassion, individuals can distance themselves from fear-based beliefs, negativity and isolation, promoting positive mental states such as joy and optimism [8]. The reduction of anxiety through self-compassion, on the one hand, helps couples avoid excessive focus on negative aspects of themselves and the world, and on the other hand, by decreasing turmoil and hostility in marital relationships, it likely contributes to improved relationship quality and marital satisfaction. Couples with high levels of spiritual well-being can experience less anxiety when faced with challenging circumstances by relying on their spiritual beliefs and finding purpose in life [34]. This perspective fosters hope and enables individuals to view conflicts and life’s unpleasantries as opportunities for growth. Consequently, they experience less fear and anxiety when confronted with unpredictable threats. Spiritual well-being, through its connection to a higher power, fosters a sense of inner support and peace, free from anxiety, which can contribute to maintaining marital harmony and satisfaction.
Conclusion
The findings of this study provide significant insights into the intricate relationship between self-compassion, spiritual well-being, anxiety, and marital satisfaction among married university students. The results demonstrated that higher levels of self-compassion and spiritual well-being were associated with lower levels of anxiety, which, in turn, positively influenced marital satisfaction. These findings underscore the importance of fostering self-compassion and spiritual well-being as potential avenues for enhancing marital quality. The mediating role of anxiety in the relationship between self-compassion, spiritual well-being, and marital satisfaction was confirmed. This suggests that anxiety may serve as a crucial psychological mechanism through which self-compassion and spiritual well-being exert their influence on marital satisfaction. The implications of these findings are far-reaching. By targeting self-compassion and spiritual well-being, interventions can be developed to reduce anxiety levels and ultimately enhance marital satisfaction among married university students. Future research could explore the longitudinal effects of these variables on marital outcomes and examine the potential moderating role of other factors, such as stress and social support.
Study limitations
This research was focused on a specific group of married students at Azad University of Ahvaz, Iran. This limitation may restrict the applicability of the findings to other groups, such as married individuals from diverse cultural or socioeconomic backgrounds. Additionally, the use of self-reported measures could be influenced by social desirability bias, where participants might provide responses aligned with social norms rather than their true experiences.
Ethical Considerations
Compliance with ethical guidelines
The Ethics Review Board of Ahvaz Branch, Islamic Azad University, Ahvaz, Iran approved the present study (Code: IR.IAU.AHVAZ.REC.1402.055).
Funding
This research received no funding from public, commercial, or not-for-profit sources.
Authors' contributions
All authors equally contributed to preparing all parts of the research.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors express their gratitude to all individuals who contributed to this research, particularly the students.