Study design and setting

This study employed a qualitative research design using a latent content analysis approach to explore the perceived value of religious ceremonies and the barriers to participation among students of Sirjan School of Medical Sciences in southern Iran. The study was conducted between March 13^th and July 15^th, 2025 and was grounded in the interpretivist paradigm, which is well-suited for examining subjective experiences and social phenomena [11].

The decision to use qualitative methodology was driven by the study’s aim to gain an in-depth understanding of the underlying beliefs, social influences, and institutional factors shaping students’ engagement or disengagement with religious practices within the broader context of their ethical development in academic and clinical settings. In line with the interpretivist stance, the research questions were designed to explore meaning-making processes rather than to test predefined hypotheses, allowing participants to articulate their subjective interpretations in their own terms.

Philosophical paradigm and researcher positioning

This study was grounded in the interpretivist paradigm, which is based on the ontological assumption that reality is multiple, subjective, and socially constructed, and the epistemological view that knowledge is co-created through interaction between the researcher and participants. This paradigm is particularly suitable for exploring complex, meaning-laden phenomena such as students’ perceptions of religious ceremonies and their ethical significance, as it allows for in-depth understanding of lived experiences within their cultural and social contexts. From this perspective, the researchers were not considered detached observers but active participants in the knowledge production process. Their role as instruments of data collection and interpretation required ongoing reflexivity and sensitivity to participants’ narratives. During interviews, efforts were made to create a dialogical and non-judgmental environment that facilitated open sharing of experiences, acknowledging that meanings were co-constructed through these interactions. Furthermore, the interpretivist stance informed the analytical approach by emphasizing inductive coding, contextual interpretation, and the identification of latent meanings rather than merely surface-level descriptions. The researchers continuously reflected on how their own backgrounds and assumptions might influence data interpretation, and took deliberate steps – such as team discussions and reflexive note-taking – to ensure that findings remained grounded in participants’ perspectives.

Importantly, the research team included members with diverse academic backgrounds, including medical education and Islamic studies, which made reflexivity and critical self-awareness essential throughout the research process. Particular attention was paid to managing potential influence of disciplinary perspectives during data interpretation.

Participants

Participants were selected from a wide range of academic programs offered at the school, including medicine, nursing, midwifery, public health, laboratory sciences, and allied health disciplines. The study sought to ensure variation in terms of gender, field of study, academic year, and self-reported levels of religious engagement, thereby enabling the exploration of diverse perspectives. A total of 33 students participated in the study through semi-structured, in-depth interviews.

Inclusion and exclusion criteria

The inclusion criteria required participants to be currently enrolled in one of the academic programs offered by Sirjan School of Medical Sciences across various medical sciences disciplines, to express willingness to participate voluntarily, and to have the ability to articulate their views and experiences related to religious ceremony participation. Individuals who withdrew during the interview process or declined to provide informed consent were excluded from the study.

Sampling and recruitment strategy

A purposive sampling strategy with maximum variation was employed to capture a broad spectrum of perspectives. Participants were initially identified through coordination with faculty members and student representatives across different departments, who facilitated access to students with diverse academic backgrounds and varying levels of religious engagement. In addition, recruitment announcements were disseminated via student social media groups and institutional communication channels, inviting interested students to voluntarily contact the research team. To ensure inclusion of participants with differing degrees of religious involvement, initial screening questions were used to assess self-reported frequency of participation in religious ceremonies (e.g., regular, occasional, or non-participation). Furthermore, a snowball sampling technique was applied, whereby interviewed participants were asked to introduce peers with differing viewpoints or experiences. Potential participants were approached either in person or through direct messaging, provided with detailed information about the study objectives, and invited to participate. Recruitment continued until data saturation was achieved.

Pilot testing of the interview guide

Prior to commencing formal data collection, the interview guide was pilot tested with three medical sciences students to ensure the clarity, cultural appropriateness, and relevance of the questions. Based on their feedback, minor revisions were made to the wording and sequence of questions to enhance comprehension and flow. The finalized interview guide began with a broad, open-ended question inviting participants to reflect on their experiences of attending or not attending congregational prayers during their student life. This was followed by probing questions organized around seven broad sensitizing domains designed to guide exploration of the topic rather than to structure analysis. These domains included: time and academic pressure, relevance to professional goals, cultural and personal beliefs, social dynamics, institutional support, perceived ethical value, and emotional and community benefits. Importantly, these domains were used only to ensure comprehensive coverage of relevant aspects during interviews and did not function as predefined analytical categories. Probing and follow-up questions were employed throughout the interviews to encourage depth and elaboration, such as “Can you explain more?”, “Do you have an example?”, or “How did that affect you?” (see supporting information).

Importantly, the data obtained from pilot interviews were used solely to refine the interview guide and were not included in the final analysis.

Data collection

All interviews were conducted face-to-face in a quiet and private setting within the school premises. The interviews were carried out by two trained and experienced qualitative researchers (ARY and AHMD), both of whom had prior experience in conducting in-depth interviews and qualitative fieldwork. Interviews lasted approximately 30–45 minutes and were conducted in Persian, the participants’ native language, to facilitate a natural and comfortable conversation. Each interview was audio-recorded with the participant’s informed consent. In addition to audio recordings, the researchers also took field notes to capture non-verbal cues and contextual details that could enrich the interpretation of data. Interviews were transcribed verbatim on the same day, and transcripts were cross-checked against the audio recordings to ensure accuracy and completeness. Anonymity and confidentiality were strictly maintained throughout the study, and all transcripts were de-identified using participant codes.

Data collection continued until thematic saturation was reached, defined as the point at which no new codes or categories emerged in three consecutive interviews, as confirmed through regular team discussions and iterative data analysis.

Data analysis

Data analysis was guided by the principles of latent content analysis, following the methodological framework proposed by Graneheim and Lundman [12]. The researchers initially immersed themselves in the data by reading transcripts multiple times to achieve a holistic understanding of participants’ narratives. Meaning units relevant to the research questions were then identified within the text, condensed while preserving their core meaning, and subsequently coded inductively. These codes were continuously compared for similarities and differences and grouped into subcategories, which were then abstracted into broader categories and overarching themes that captured the latent meanings underlying participants’ experiences. Initial coding was conducted independently by two researchers, who coded the transcripts line-by-line. The independently generated codes were then compared in iterative meetings to enhance consistency and interpretive rigor. Disagreements in coding or interpretation were resolved through discussion and, when necessary, consultation with a third senior qualitative researcher to reach consensus. To ensure transparency of the analytic process, the transformation from raw data to final themes was carefully documented. For instance, the participant statement “I barely have time for sleep, let alone attending a religious event. Between lectures, hospital rounds, and assignments, my day is fully packed” (P03) was first identified as a meaning unit reflecting time-related constraints. This was then condensed into the meaning “lack of time due to heavy academic and clinical workload prevents participation in religious ceremonies”, and subsequently coded as academic overload limits participation in non-academic activities. This code was grouped under the subcategory heavy course load, which ultimately contributed to the broader theme time and academic pressure. This analytic progression illustrates how raw narrative data were systematically abstracted into higher-order conceptual categories while preserving contextual meaning. Throughout the analysis, an analytic audit trail was maintained, including coding manuals, category development records, decision logs, and reflexive memos documenting interpretive decisions. These materials enabled continuous tracking of analytical decisions from raw data through to final thematic development. The entire analytical process was facilitated using MAXQDA software (version 2022), which supported systematic organization, retrieval, and comparison of data segments.

Trustworthiness

To ensure the rigor and trustworthiness of the study, the criteria established by Lincoln and Guba – namely credibility, dependability, confirmability, and transferability – were applied [13]. Credibility was strengthened through prolonged engagement with participants across the data collection period, as well as member checking with a subset of participants selected to represent different academic disciplines, academic years, and levels of religious engagement. During member checking, preliminary interpretations and summarized meanings were presented to these participants either immediately at the end of interviews or through follow-up contact. Participants generally confirmed the accuracy of interpretations, and minor clarifications (e.g., rephrasing of motivational statements) were incorporated into the final analysis. In addition, peer debriefing sessions were conducted biweekly with two qualitative research experts outside the immediate research team. These sessions focused on reviewing emerging codes and themes, challenging interpretations, and discussing alternative explanations. Feedback from these discussions contributed to refining category boundaries and improving analytical consistency. Dependability was addressed by documenting the analytical process in detail and maintaining consistency in data handling. An explicit audit trail was maintained, including raw interview transcripts, coding manuals, category development tables, decision logs, and reflexive memos, which documented all major analytical decisions and revisions throughout the research process. These documents allow external researchers to trace the full analytical pathway from raw data to final themes. Confirmability was ensured by maintaining a transparent audit trail of decisions made during coding and theme development, including reflexive notes and analytic memos. This was further strengthened through continuous reflexive engagement by the research team, ensuring that findings were grounded in participants’ narratives rather than researchers’ preconceptions or disciplinary perspectives. Transferability was enhanced by providing thick descriptions of the research context, participant characteristics, and analytical interpretations. Specifically, Sirjan School of Medical Sciences is located in a culturally and religiously embedded region of southern Iran where religious ceremonies are socially visible and integrated into community life. At the same time, the school hosts a diverse student population from various provinces of Iran. Participants represented multiple disciplines (medicine, nursing, midwifery, public health, laboratory sciences, and allied health), different academic years, and varied living conditions (dormitory and non-dormitory students), enhancing the contextual richness and applicability of the findings to similar settings.

Researcher reflexivity

Given the sensitive nature of religious beliefs and ethical development, the research team engaged in reflexive practices throughout the study. The primary researchers had academic backgrounds in medical education and qualitative research and were familiar with the cultural and religious context of the participants. Importantly, one member of the research team had an academic affiliation with the Department of Islamic Studies, which necessitated heightened reflexivity regarding how disciplinary perspectives might influence the research process, particularly in relation to religious meanings and interpretations.

To minimize potential bias, the researchers acknowledged their preconceptions regarding the value of religious practices and actively reflected on these assumptions during data collection and analysis. In practice, this process was framed as reflexive awareness rather than strict bracketing, meaning that the researchers did not attempt to fully suspend their perspectives, but instead continuously examined and documented how these perspectives could shape interpretation. This approach is consistent with the interpretivist paradigm, which recognizes the co-constructed nature of meaning.

The research team also reflected on how their positionality could influence the research process. Specifically, the presence of a researcher with Islamic Studies expertise may have shaped participants’ perceptions during interviews, potentially increasing expectations of religious alignment or influencing the way questions were interpreted. To mitigate this, interviews were conducted in a neutral, non-judgmental manner, emphasizing voluntary participation and academic rather than ideological interest in the topic.

Reflexive notes were maintained throughout the study to document personal reflections, assumptions, and decision-making processes. Regular team discussions were conducted to critically examine interpretations and ensure that findings were grounded in participants’ narratives rather than researchers’ prior beliefs. These discussions explicitly focused on identifying instances where disciplinary perspectives could have influenced coding decisions, and alternative interpretations were actively considered to reduce interpretive bias.

Ethics approval and consent to participate

This study is approved by the Sirjan School of Medical Sciences Ethics Committee under ID number IR.SIRUMS.REC.1403.052. The study protocol was also registered in the school research system (project code: 403000040). All methods were carried out in accordance with relevant guidelines and regulations. All participants provided written informed consent and were assured of their right to withdraw from the study at any point without any consequences.

Variations across participant characteristics

Although the primary aim of this study was not to conduct subgroup comparisons, several notable patterns emerged across participant characteristics. Students in clinical disciplines, particularly medicine and nursing, more frequently emphasized time constraints, academic workload, and burnout as primary barriers, reflecting the demanding nature of clinical training. In contrast, students in earlier academic stages and non-clinical fields (e.g., public health and laboratory sciences) more often highlighted social influences and uncertainty regarding the relevance of religious ceremonies. Additionally, nursing and midwifery students tended to express stronger appreciation for the emotional and ethical value of participation, particularly in relation to compassionate care and patient-centered practice. Regarding gender, while both male and female participants shared similar structural concerns, female students more frequently articulated the emotional and community-related benefits, such as sense of belonging and emotional catharsis. These observations, although exploratory, provide additional depth to the findings and suggest potential directions for future research.

Policy implications and recommendations

The findings of this study call for academic institutions, particularly medical universities, to re-evaluate the integration of spiritual and ethical programming within their educational environments. Rather than offering generic optional ethical sessions, universities could implement structured “ethical reflection modules” embedded within specific clinical rotations (e.g., pediatrics, emergency medicine, palliative care), where students engage in facilitated group reflection on real clinical experiences related to suffering, compassion, and responsibility. These sessions should be designed as 20–30 minute structured debriefings facilitated by trained faculty members, using culturally resonant narratives – including but not limited to religious stories, patient narratives, and ethical dilemmas – to stimulate reflection without imposing any specific worldview. Institutional support in the form of scheduling flexibility, adequate facilities, and visible promotion of such activities can significantly improve engagement. Faculty development programs should train educators in facilitating reflective discussions rather than delivering didactic moral content. In addition, evaluation mechanisms such as reflective journals or structured feedback forms could be used to assess the impact of these interventions on students’ ethical reasoning and professional identity development over time. Promoting inclusivity and respect for diverse beliefs must remain central to any policy reform to ensure participation is empowering rather than alienating.

Limitation

While this qualitative study offers rich insights, it is not without limitations. The sample was limited to students from a single cultural and academic setting, which may restrict the transferability of findings to broader populations. Additionally, participants’ self-selection may have introduced bias, as those with stronger opinions – positive or negative – about religious ceremonies may have been more inclined to participate. The sensitive nature of the topic may also have led some students to withhold or temper their true views during interviews, despite assurances of confidentiality.

Suggestions for future research

Future studies could adopt comparative or longitudinal designs to examine how perceptions and participation in religious or ethical activities evolve over time and across different academic disciplines or cultural contexts. Quantitative studies could help validate the themes identified here and measure the impact of spiritual engagement on specific professional outcomes, such as empathy, ethical reasoning, or burnout resilience. It would also be valuable to explore faculty and institutional perspectives on the role of religion and spirituality in ethical development to create more holistic and responsive educational strategies.