Document Type : Original Article
Authors
1 School of Nursing and Midwifery, Chronic Diseases (Home Care) Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
2 School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
3 Fatemieh Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
4 4Department of Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
Abstract
Keywords
Marital quality has been studied in positive psychology
and its role in interpersonal relationships, especially in
marital relationships, is remarkable. According to Marx,
“quality of marital relations is the result of methods
through which married individuals systematically organize
this triangle”. The quality of marital relations and the
level of happiness depend on how wife and husband interact
with each other and cope with stressful situations
of life (
Marital quality reflects the individual’s total evaluation
of the marital relation (
The first angel is the inner angel that includes the individual’s
personality with his efforts, motivations, and different
energies which is formed based on his experience
during life. The second angle is the relationship with the
spouse. The third angle is any outside concentration point
except for the spouse. Generally, Marx believes that marital
quality is the result of the methods by which married
individuals systematically organize themselves within
this triangle (
Sex education is one of the factors that improves the
relationship between couples and enhances marital quality.
Lack of enough information about sex and improper
attitudes towards this issue in families and couples are
among the major problems that today’s Iranian society is
facing, and leads to collapse of the family. In this regard,
marital counseling as a specialized consultation can convey
the information necessary to create a favorable sexual
life to the couples, so that they can utilize this information
to evolve and complete their marriage. In this regard,
as midwives are in constant contact with the community
and due to their awareness about sexual issues , they play
a significant role in making sure about the couples’ satisfaction
with their marital life, whereby a step towards
creating a healthy society, will be taken (
By providing sex education and consultation, sexual problems could be diminished gradually, and unawareness will be replaced with complete awareness. Marital counseling for prevention of marital difficulties is one of the most effective methods of development of individuals and couples health education.
Sexual counseling plays a significant role in family
health, as it can decrease sexual violence in the family,
prevent sexually transmitted diseases, result in a positive
attitude towards sexual relations and sexual pleasure, decrease
conflicts within the family, and gain pleasurable
sexual experience and sexual satisfaction. Consultation is
a process that helps to improve sexual health, interpersonal
relationships, affection, intimacy, body image, and
gender roles. Sexual counseling is related to a cognitive
domain (information and knowledge), affection domain
(feelings, values, and attitudes), and behavioral domain
(communication skills and decision making) (
Cognitive behavioral therapy is today’s most popular
and widely-used model of psychotherapy, and clinical
studies have proven its efficiency in different populations
and for treatment of various problems. This approach is
characterized by short-term and problem-focused cognitive
behavioral intervention strategies that are retrieved
from science and cognitive and learning theories (
Cognitive behavioral consultation approach is one of
the most common methods of treating sexual dysfunctions
(
This approach was created by combining behavior therapy
approach and cognitive approach either in the form of
cognitive therapy or the framework of cognitive psychology
and basic cognitive science. In cognitive behavioral
therapy, strengths of behavior therapy and cognitive therapy,
i.e. objectivism, evaluation, and assessment on one
hand and the role of memory in reconstructing and interpreting
data, on the other hand, are collected and become
one entity. Nowadays, this approach involves relatively
different theories and attitudes. Unlike other forms of behavior
therapies, cognitive behavioral methods directly
deal with thoughts and feelings that are obviously significant
in all psychological disorders. Cognitive behavioral
therapy fills the gap felt by most merely-behavioral methods
and dynamic psychotherapy (
One of the main components of this therapy is presenting
sexual knowledge and information related to sexual
response cycle, anatomy, and sexual techniques (
Therefore, due to the importance of sexual relationships and their effect on family and society health, significance of presentation of educational and counseling programs in healthcare centers, and limited studies conducted to confirm the effectiveness of this consultation on marital quality of individuals, the present study was done to examine the effect of cognitive behavioral consultation on marital quality among women referring to healthcare centers in Hamadan, Iran.
The experimental study was carried out as a randomized
clinical trial including an intervention group (n=99) and a
control group (n=99) with a pretest and a posttest on qualified
women referring to selected health care centers of
Hamadan. The sample size was calculated using formula,
This research plan with codes of ethics was accepted by the Chronic Diseases Research Center, Hamadan University of Medical Sciences, Hamadan, Iran (IR.UMSHA.REC.1394.573) and (IRCT201610209014N125).
Married women of 15-45 years old (reproductive age), Literacy, Having >6 months of married life, Hamadan residency, No background of remarkable physical and psychological diseases such as psychotic disorders like schizophrenia and severe depression that need special medicine or diet and filling out the questionnaires, age difference of 10 years between the couples.
Becoming pregnant during the study, Unwillingness to continue the trial, addiction to drugs and/or alcoholic drinks.
Subjects in control and intervention groups were randomly assigned to six health centers. Therefore, the relationship between the two groups was completely omitted. For this purpose, three pairs of health centers (each pair consisted of 2 centers that were similar in terms of social, economic, cultural, and geographical characteristics) were randomly selected (one pair of centers was located in a city region with higher socioeconomic class, one in the middle socioeconomic class, and one in the higher socioeconomic class).
In each pair of centers, one was assigned to the intervention group and one to the control group. In other words, 3 centers were selected for the control group and 3 for the intervention group. The sample size in each center was chosen to be 28 individuals, and due to the probable loss of 20%, 33 individuals were selected in each center, and the total sample size became 33×6=198. It should be noted that the participants of each center were invited through a public invitation of participating in the research (the inclusion criteria were included in the invitation) which could be found on the clinics’ bulletin.
The participants were selected using a table of random numbers from women who referred to the clinic. After approval of the Ethics Committee and obtaining informed consent from the participants, all participants were emphatically informed that participation in the study was completely voluntary and they were able to quit at any stage without any restrictions. At the beginning of the study, all of the participants took a pretest.
In the pretest, the participants of both groups filled out the
informed consent form, the demographic information questionnaire,
and the marital quality scale. The demographic
information questionnaire included age, education level,
job, spouse age, spouse education level, spouse job, family
income level, marriage duration, number of pregnancies,
number of children, and addiction background of the couple.
Marital quality was measured using the marital quality
standard questionnaire. This questionnaire includes 14
questions and aims to evaluate marital quality from different
aspects (agreement, satisfaction, and solidarity). It was
devised by Busby, Crane, Larson, and Christensen (
This 14-question scale is scored through a 6-point Likert scale ranging from 0 to 5 in a way that score 5 represents completely agree and score 0 indicates completely disagree. The tool consists of three subscales of agreement, satisfaction, and solidarity and a high score indicates higher marital quality indicator. The subscale of agreement consists of 6 items as follows: v. I always agree, iv. I almost always agree, iii. I sometimes agree, ii. I often disagree, i. I almost always disagree, and 0. I always disagree. The subscale of satisfaction includes items 7 to 11 as follows: 0. Always, i. Most of the time, ii. Most often, iii. Sometimes, iv. Hardly ever, and v. Never. The subscale of solidarity consists of items 12 to 14. Item 12 was scored using the following scale: v. Every day, iv. Almost every day, iii. Sometimes, ii. Almost sometimes, i. Hardly ever, and 0. Never, and the items 13 and 14 were scored using scales 0. Never, i. Less than once a month, ii. Once or twice a month, iii. Once or twice a week, iv. Once a day, and v. More.
In order to obtain the scores related to each dimension,
the total scores of questions relevant to that dimension
were added up, and to calculate the total score of the questionnaire,
the total scores of all questions were added up.
Higher scores indicated higher marital quality and vice
versa. The tool used in the present study was a standard
questionnaire of which validity and reliability were evaluated
in previous studies (
After the primary assessments, the intervention group
was provided with consultation while the control group
received no intervention. The target consultation was provided
in the form of 8 cognitive behavioral counseling
sessions of 90 minutes for 8 weeks (
Session 1 and 2 was identifying inefficient beliefs and explaining negative thoughts regarding sexual satisfaction and marital quality, and psychological training was examining the cognitive behavioral model and introducing cognitive distortion regarding sexual dissatisfaction and unfavorable marital quality, homework was revising cognitive distortion.
Session 3 and 4 was examining the homework, and psychological training was examining the methods to fight against cognitive distortion, Homework was practicing identification of cognitive distortion using thoughts recording sheets.
Session 5 and 6 was examining the homework, and psychological training was introducing coping and preventing methods of behaviors and thoughts leading to sexual dissatisfaction, Homework was cognitive reconstructing, completing the sheets of recording thoughts, practicing coping and preventing inappropriate behaviors and thoughts.
Session 7 and 8 was examining the homework, and psychological training was discussing and examining the factors, preventing approaches, returning from sexual dissatisfaction, increasing sexual satisfaction, and improving marital quality, Homework was practicing preventing approaches to deal with return.
The sessions were held in a training class, and the intervention group participants were informed about the date of attending the sessions by phone calls. Moreover, one day before the sessions, the individuals were reminded about the sessions in order to prevent sample loss as much as possible. Consultation was provided by a clinical psychologist. Moreover, the trainers agreed to perform a uniform teaching method.
After the 8th session, both groups took the posttest in which marital quality was evaluated again. It should be noted that after the study, a session about sexual issues was held for the control group, and they were provided with booklets. In order to analyze the collected data, independent samples t test and covariance analysis or change analysis were utilized. All of the tests were carried out at a confidence level of 95%.
According to the results of the present study, the average
age in the control group was 32.58 ± 7.54 years old and in
the intervention group 35.04 ± 7.91 years old; so, the two
groups were not homogenous in this regard. However, the
two groups were homogenous in terms of husbands’ age
in the intervention group (37.23 ± 8.01 years old), and
in the control group (39.13 ± 7.18 years old), marriage
duration in the intervention group (8.95 ± 7.67 years) and
control group (8.49 ± 6.99 years), and number of children
in the intervention group (1.53 ± 0.96) and control group
(1.74 ± 0.86). Moreover, other demographic characteristics
such as the level of education in wives and husbands,
and drug addiction in wives and husbands, were homogeneous
in the two groups (P<0.05) (
Covariance analysis was used in order to examine marital
quality scores. In this analysis, after modification of the
variables of age, marital quality score of agreement and
satisfaction before the intervention, as well as income status,
marital quality scores were compared between the two
groups. Variance analysis and regression coefficients are
presented in Table 2. The value of determination coefficient
was calculated as 0.85. After the intervention, significant
difference was observed between the two groups in all dimensions
and total marital quality (P<0.05) and the mean
scores of the dimensions increased remarkably (
Here, t test was used to compare the two groups before intervention in order to verify if the two groups are different before the intervention, the effect of this difference should be adjusted when comparing them after intervention.
According to the determined cut-off points based on
marital quality scale, all dimensions and total marital
quality, a limited number of women had a suitable level of
marital quality before the intervention. After the intervention,
however, marital quality scores increased, and a significant
difference was observed between the two groups
regarding all dimensions (P<0.05,
A comparison of demographic characteristics in the two groups
Variable | Control group | Intervention group | P value (%) | |
---|---|---|---|---|
n (%) | n (%) | |||
Education level | Primary | 11 (11.1) | 8 (8.1) | 0.060 |
Secondary | 16 (16.2) | 10 (10.1) | ||
Under diploma | 28 (28.3) | 26 (26.3) | ||
Diploma | 35 (35.4) | 33 (33.3) | ||
University | 9 (9.1) | 22 (22.2) | ||
Spouse education level | Primary | 10 (10.1) | 3 (7.1) | 0.050 |
Secondary | 17 (17.2) | 14 (14.1) | ||
Under diploma | 27 (27.3) | 19 (19.2) | ||
Diploma | 37 (37.4) | 36 (36.4) | ||
University | 8 (8.1) | 23 (23.2) | ||
Spouse addiction | Yes | 21 (21.2) | 26 (26.3) | 0.404 |
No | 78 (78.8) | 73 (73.7) | ||
Addiction | Yes | 1 (1) | 1 (1) | 1 |
No | 98 (99) | 98 (98) | ||
Income status | <1,000,000 | 46 (55.4) | 40 (40.4) | <0.001 |
>1,000,000 | 53 (11.1) | 59 (59.6) | ||
A comparison of the mean scores of different dimensions of marital quality of women before and after the intervention in the two groups
Different dimensions of marital life | Group | Before intervention | After intervention | P value | ||
---|---|---|---|---|---|---|
Mean + SD | Min-Max | Mean + SD | Min-Max | |||
Agreement | Control | 11.18 + 3.41 | 3 (19) | 11.09 (2.94) | 4 (19) | 0.603 |
Intervention | 15.56 + 4.94 | 3 (28) | 25.11 (3.32) | 9 (30) | <0.001 | |
Covariance analysis with adjustment the effect of age, income, agreement score before intervention | ||||||
P (Independent t test) | <0.001 | <0.001 | ||||
Satisfaction | Control | 7.60 (1) | 2.57 (7.46) | 17 (1) | 3.04 (7.60) | 0.489 |
Intervention | 9.89 (8) | 2.13 (16.53) | 18 (1) | 4.35 (9.89) | <0.001 | |
Covariance analysis with adjustment the effect of age, income, satisfaction score before intervention | ||||||
P (Independent t test) | <0.001 | <0.001 | ||||
Solidarity | Control | 7.64 (2.73) | 1 (14) | 7.49 (2.96) | 1 (14) | 0.382 |
Intervention | 8.1 (2.89) | 1 (16) | 15.90 (2.54) | 9 (20) | <0.001 | |
Covariance analysis with adjustment the effect of age, income | ||||||
P (Independent t test) | <0.001 | 0.199 | ||||
Total | Control | 26.41 (6.37) | 9 (45) | 26.05 (5.99) | 9 (64) | 0.261 |
Intervention | 33.60 (9.93) | 6 (67) | 57.54 (5.94) | 34 (69) | <0.001 | |
Covariance analysis with adjustment the effect of age, income, total score before intervention | ||||||
P (Independent t test) | <0.001 | <0.001 | ||||
Frequency distribution of suitable marital quality based on cut-off point before and after the intervention in both groups
Dimensions of married life | Before intervention n (%) | Comparison beforeintervention* (P value) | After intervention n (%) | Comparison afterintervention** (P value) | ||
---|---|---|---|---|---|---|
Control group | Intervention group | Control group | Intervention group | |||
Agreement | 0 (0) | 14 (100) | <0.001 | 0 (0) | 88 (100) | <0.001 |
Satisfaction | 1 (4.8) | 20 (95.2) | <0.001 | 2 (2.2) | 91 (97.8) | <0.001 |
Solidarity | 16 (42.1) | 22 (57.9) | 0.279 | 15 (13.4) | 97 (86.6) | <0.001 |
Total | 0 (0) | 7 (14.3) | 0.014 | 0 (0) | 94 (98) | <0.001 |
*; For comparing agreements, satisfaction and solidarity between the two groups before the intervention, chi-square test was used and to compare total marital quality, Fisher’s exact test was used and **; For comparing solidarity between the two groups after the intervention, Chi square test was used of and to compare other cases (because the two groups at baseline were not similar), Wald test resulting from logistic regression with adjustment for the effect of the intervention, was used.
The present study was conducted in order to examine the effect of cognitive behavioral consultation on marital quality among women. The results indicated that cognitive behavioral consultation led to an increase in total marital quality and all its dimensions (solidarity, satisfaction, and agreement). The individuals had a low marital quality before the intervention; however, after the intervention, the scores rose remarkably showing the efficacy of consultation in improving marital relationships.
This means that cognitive behavioral consultation concerning
sexual issues, led to an increase in the total score
and dimensions of marital quality in the intervention
group. Previously, Young and Carlson (
In the present study, during the sessions, the wives were taught to solve their sexual and marital problems with the help of their husbands. When the problem is regarded as a joint issue, a single individual is not considered as the cause, and the couples become aware of their roles in the emergence of the problem, so, they stop blaming one another, and there will be less argument between them.
Numerous indices are used to show marital quality.
Perry (
Satisfaction with sexual relationships is an important
factor in marital relationships. Individuals who are highly
satisfied with the sexual relationship they have with their
spouses, have a remarkably higher quality of life, express
higher love and interest to their spouse, and have
higher levels of agreement, solidarity, and satisfaction in
their marital relationships (
Regarding marital satisfaction and improvement of
marital quality in dimensions of solidarity and agreement,
the wife’s and husband’s understanding of one another’s
behavior is significantly important. Cognitive behavioral
therapy tries to fix the incorrect attitude toward spouse
and wrong myths about marital relationships and create
skills to establish more effective communication and
problem solving (
In a study, Akbarzadeh (
In the study of Khanjani Veshki et al. (
Moreover, Salimi and Fatehizadeh (
With regard to the significance of our results, it can be stated that the cognitive behavioral sex consultation used in the present study could improve all dimensions of marital relationships by emphasizing on cognitive dimensions of sex consultation such as pinpointing and challenging the common sexual wrong beliefs through group discussion, determination and improvement of individuals attitude toward sexual activity, presentation of realities and importance of satisfying sexual desires, the role of sexual relation in general relationships and quality dimensions of marital relationships.
In the cultural context of Iranian society, women and
men have poor and inaccurate sexual knowledge, and
do not have access to reliable sources in this regard.
Moreover, they have a lot of incompatible and illogical
thoughts, beliefs, attitudes, and understanding of sexual
issues which affect the couples’ sexual relation. In cognitive
behavioral approach, attention is paid to sex education
as Iranian couples had not obtained this knowledge
by a reliable method (
Cognitive behavioral family therapy training equip the couples with skills which are necessary for marital life, and can be generalized to other levels of marital and social levels of life. According to the Iranian culture and since an extensive range of treatment techniques and methods is used, cognitive behavioral method can be effectively employed as an extensive method to treat behavioral problems and positively change couples. Using a large population size from various clinics of the city was the strength of the present study, and failure to follow them after the study was one of its limitations.
Due to the effectiveness of the method used in the present study, it is suggested that techniques of this approach could be utilized by family and marriage counselors to increase sexual satisfaction, solve marital conflicts and improve marital quality of the couples’ life. Moreover, the applicable drills and skills of this method in the form of educational sessions, workshop, videos, and pamphlets should be employed to prevent marital problems.
Due to the role of sexual relations in consolidating marital life, cognitive behavioral consultation as an effective method for improving marital quality, especially after an agreement, can be employed in health care centers to improve the couples’ relationship and reduce divorce rates.