Results of the Search
A total of 14, 536 records are searched from 6 databases. From the stated records, 265 studies were retained after duplicates were excluded. studies did not address dimensions of marital conflict among married couples from the general public and those studies that addressed marital conflict among couples in selected segments of the community are excluded. Studies that examined the effect of the intervention before and after using pretest-posttest without a control group were also excluded. Following a full-text analysis of 148 study articles, 117 that appeared to be not relevant were excluded. The remaining 31 studies were assessed for eligibility and 20 were excluded and 11 (5 for qualitative synthesis(17–21) 6 for quantitative analysis (22–27) included in the final systematic review and meta-analysis. Details of characteristics of included studies and reason for exclusion depicted in tables below.
Study characteristics
Looking at the nature of included studies, almost all of them applied therapies that were of different types and contents, having different follow-up periods, focused on various aspects of marital conflict, and were made on selected individuals and used different scales to measure the outcomes. Although their names and meanings vary, conflicts in marriage induce disagreements, and dissatisfaction, etc. results in problems in health. Since social and economic crises of either marital conflict or marital distress are similar, we combined existing studies for meta-analysis.
As provided above, the current systematic review and meta-analysis included studies from different parts of the world. Specifically, most of the studies were from different corners of the world, including from Region of American two studies (17,20), Eastern Mediterranean Region seven studies (18,19,22–24,26,27), Southeast Asian region (01 studies) (21). The included studies were published between January 1, 2010, December 31, 2020.
Design
Regarding the content and depth of the included studies, most of them were experimental studies with pretest-posttest and follow up with a waiting-list or no-treatment control group. Out of the 11 studies, 5 were Quasi-experimental studies, with Pretest Posttest and control group design(18,19,22,23,25), 4 were Qazi- experimental studies with pretest, post-test, control group and follow-up (20,24,26,27), 1 experimental study, with group A and Group B, compares two different interventions(17) and 1 Experimental study with Pre-Posttests, that compares the intervention before and after without control (21).
Population
There are perhaps various population attributes, sample involved, age, sex distribution, marital duration, and educational level were being described. Accordingly, participants from different socio-demographic characteristics were included in the current systematic review. A total of 911., people were surveyed, with an average number of 31 couples or 66 individuals were included in each study. When we look at the participants in each domain in detail, in Experimental arm Male=total 231, 7-43 and in average 21 individuals included in each study, Women total 231, 7-43 in average 21 individuals included in each study. Similarly, in the control arm, Male=total 225, 8-43, and on average 20 individuals included in each study, Women total 224, 8-42 in average 20 individuals included in each study. The mean age of the samples ranged from 21 to 71 years old and 72 have a minimum of high school diploma and higher (22,24). Since the participants were couples, 50% identified as men and 50 % were women
Intervention
The proposed interventions in the included studies comprised training and or counseling services that were tailored to the stated population using group counseling, verbal or written methods. The stated interventions were provided in a clinic or the community and targeted to men, women, or couples. But few studies did not specify where the intervention would be delivered (Bakhshandeh et al, 2015, Cornelius, Tara L.2007)(17,23).
Concerning the types of interventions, McMaster training model(22), Cognitive-behavioral group counseling and integrated Cognitive-behavioral therapy (ICBT), and Cognitive-behavioral therapy (CBT) intervention(23,25) intimacy training with cognitive-behavioral approach(19), Gottman's couple therapy, Gottman et al. hypothesis that the speaker-listener technique couple discussing an issue about each other(17,24), Prevention and Relationship Education Program (PREP) training,(26), (PREP) or (CARE)(20), the conflict resolution skills training(27), Marital counseling on marital quality(21), and mindfulness training (18) were tested for their effect on different dimensions of marital conflict. Each of the above interventions consisted of three to ten gatherings, each lasting an average of 192.7 minutes. They had an average of two months of follow-up.
Comparison
The comparison can be done between the intervention under the study and another intervention, or usual care, or without any intervention. Seven (58.3%) compared the effect of the interventions with those who did not receive the intervention in the control condition(18,19,22–24,26,27). One study (8.5%) compared CBT and CBT control treatment with a no-treatment control group (25). Two studies (16.7%) (20,21), compared marital counseling and PREP group intervention and its effect in similar population on marital quality before (Pretests) and after (Posttest) intervention. Conversely, one study (8.5%) discussions on the emotionally charged issue within their marriage and outside their marriage(17).
Outcome
Marital conflict refers to an open or latent antagonism between marriage partners due to various reasons including, sexual disagreement, child-rearing differences, temperamental and, religious differences and disagreements over money management that could result in a lot of adverse conditions unless managed properly (1) was the primary outcome of the current study.
The studies described above have been conducted to examine the effectiveness of interventions on marital conflict. In other words, different dimensions of marital quality such as marital conflict, and mindfulness, anxiety marriage, marital satisfaction and communication behaviors, marital violence, marital satisfaction, and communication behaviors were the primary outcome variable of the included studies. Two studies (16.7%)(18,27) examined the effect of an intervention on marital conflict.
Another study focused on marital quality, measured using a marital quality scale which has an internal consistency of 0.91 and test-retest reliability of 0.83. This scale measured the twelve dimensions of marital quality including affection, decision making, despair, dissolution potential, discontent, dominance, rejection, role function, satisfaction, self-disclosure, trust, and understanding each other(21). Similarly, (24) and (23) examined the intervention effect on Marital violence and anxiety marriage respectively. Almost all treatment outcomes were measured by validated scales.
Risk of bias assessment
The risk of bias in individual studies assessed based on the Cochrane Risk of Bias Tool (28). Eight of the eleven studies were determined to have an overall low risk of bias(18–20,22–25,27) Figure 3. The Risk of bias in included studies depicted in table 3 below presents the findings of risk of bias criteria, with green indicating low risk; yellow, unclear risk; and red, high risk of bias.
Because of the nature and techniques of the interventions, blinding of both participants and investigators was found to be cumbersome. Overall, the risk of bias across all studies included in this synthesis is expressed as a percentage provided in figure 2. As noted, we found that most of the included studies had a low risk of bias. In general, except for one, allocation concealment; more than 50% of the items had a low risk of bias. Overall, the graph shows that approximately 100% of studies posed a low risk of bias concerning detailing the method of randomization. In 54.55% of the studies, it was unclear if a method of allocation concealment was used. The 90.9 % of included studies posed a low risk of bias concerning ''selective reporting bias'' and about 63.63% of studies posed a low risk of bias to blinding of outcome assessment bias.
Results of individual studies
Out of 11 studies, seven (63.6%) examined the effect of intervention between the participants who received the intervention (experimental) and control (not received any intervention(18,19,22–24,26,27), 1 (9.1%) tested similar intervention on some population before and after (21), another 2 (18.2%) study tested two different intervention between two groups (Group A, Group B)(17,20), and 1 (9.1%) examined the effect of two treatments between two intervention and control group(25).
Of these studies, 8 (72.7%) showed consistent differences favoring marital couple intervention over usual care (no intervention) (18–20,22–24,26,27). Out of the remaining 3 studies, 1 (9.1%) show no difference between groups(17), whereas 2 (18.2%) showed mixed-effects (21,25)
Concerning the findings of individual studies, couples who received McMaster model training showed a greater increase in mindfulness and decreased marital conflicts than those who did not receive this training(22). The young male and female in marriage who have been chosen to be married in a marital couple intervention reported more improvement in marital distress (anxiety marriage) compared to their control counterparts(23). Similarly, Davoodvandi and his colleagues found that Gottman's couple therapy approach had positive effects on improving marital adjustment and couples' intimacy(24). Distressed marital couples in IBCT and CBT reported more improvement in conflict-related and violence-related marital distress, however, ICBT was found to be more effective than CBT(25).
Another study(26), which examined the effect of PREP training on marital conflict and marital satisfaction reported a significant positive outcome(26). The conflict resolution skills training intervention for distressed couples was more effective and significantly reduce marital conflict(27) but the speaker-listener technique intervention did not show a significant effect(17)
In one study (21), the marital counseling intervention was tested among previously and currently married couples who come for counseling sessions showed significant positive outcome that, those received marital counseling intervention revealed significant differences in most of the dimensions of marital quality, compared with the control group. A small-group intervention designed to teach engaged and newlywed couples in managing conflict and problem resolution (PREP) or skills in acceptance, support, and empathy (CARE) indicated that Couples in the no-treatment condition dissolved their relationships at a higher rate (24%) than couples completing PREP, CARE (18,20), and (18) also tested the effects of mindfulness, emotion regulation, and intimacy training interventions on marital conflict and marital quality. Both of the studies reported a significant positive effect of the intervention on the outcome.
Meta-analytic Findings
Six of the eleven studies selected for this study were considered for meta-analysis. The remaining five(17–21) were not subject to meta-analysis because they did not provide the means, standard deviations, and test statistics for outcome assessments.
Overall, the current Meta-analyses that examine the effectiveness of marital couple intervention versus control were conducted to test three outcome groups including marital conflict, anxiety marriage, and marital distress. The scales used to measure the effect sizes combined in the meta-analyses were validated and the results were presented using the SMDs with 95% CIs. The summary of effect sizes and confidence limit of individual studies depicted in figure 3. The numbers with a minus (-) sign favor the intervention that, marital interventions effectively reduce a variety of aspects of marital conflict among samples of married couples who experienced marital stress. Conversely, the number with a plus (+) sign denotes that the marital interventions benefit the control.
Six studies (Experimental n=182, Control n=194) examined the dimensions of marital distress(22–27). Three of these studies used the marital conflict scale,(decreased cooperation, decreased sexual relation, increased emotional reactions, increased attraction of children’s support, increased individual relation with relatives, decrease in family relations with relatives of spouse and friends, separation of financial affairs, and decrease of effective relation) and additional scales, including ENRICH Questionnaire, a revised Marital Satisfaction Inventory, and Five-Facet Mindfulness Questionnaire scale(22,26,27). Two used the Marital distress scale or Marriage anxiety questionnaire,(23,25) and the other study used Spanier Questionnaire and Walker and Thompson's Questionnaire(24). The stated interventions significantly influence marital conflict. The meta-analysis finding showed a significant overall effect (SMD, 95% CI) of marital couple’s intervention favoring the experimental group (-1.71, [-2.93, -0.49]. The analysis also confirmed that substantial levels of heterogeneity between studies (I2 =96%), thus further analysis was not carried out.