Design and Data Collection:
This descriptive-analytical study was conducted between March to April 2020. The project used a non-probability, convenience sample of 279 eligible breastfeeding women. The protocol was approved by the Institutional Review Board and Research Ethics Committee of Tarbiat Modares University (code: R.MODARES.REC.1399.004)). The consent was obtained from participants in the study and they all made sure that their information will be kept private and confidential.
An electronic questionnaire (https://survey.porsline.ir/s/qahAeAY) was used to gather the data in order to maintain physical distance to prevent coronavirus disease. The designed questionnaires on the web were sent to breastfeeding women. The aim of the study, inclusion criteria and the way of responding to questions were mentioned on the first page.
Eligibility criteria required individuals to have infant under 6 month old; to be healthy, with no identifiable mental disorder or medical disease; have BMI< 40; and to be sufficiently literate to be able to understand and answer all questions; have no corticosteroid therapy, a history of chemotherapy, malignancies, organ transplants, HIV infection, cardiovascular disease, high blood pressure, diabetes, and respiratory illness.
Socio-demographic and obstetric check list
At first, a checklist of socio-demographic and obstetric variables including women’s age, gravidity, parity, number of live children, age at marriage, duration of marriage, previous mode of delivery, body mass index, residency, monthly income, level of educational, occupational status, type of pregnancy (planed or implanted pregnancy), contraception method, and type and number of breastfeeding per day (exclusive breastfeeding, bottle feeding, or combination of two methods).
The General Health Questionnaire (GHQ)
The General Health Questionnaire (GHQ) evaluate four dimensions of physical symptoms (1-7), anxiety and insomnia (8-14), social function (15-21), and depression (28-22) (12). Higher scores represent worse general health. The validity and reliability of this questionnaire which was first developed by Goldberg (1978) have been also confirmed in Iran (13, 14).
Hospital Anxiety and Depression Scale (HADS)
Hospital Anxiety and Depression Scale (HADS) is a widely used instrument to measure the severity of depression and anxiety consisting of 14 questions composed of two subscales of anxiety (HADS-A) and depression (HADS-D). Each question is ranked on a four point Likert scale, into three levels of normal range (total score < 8), slight changes (score of 8-10) and high levels of anxiety and depression (total score > 11). In Iran, the validity and reliability of this questionnaire were investigated by Montazeri et al. (15).
Corona Disease Anxiety Scale (CDAS) Preliminary validation of the Corona Disease Anxiety Scale (CDAS) in Iran has been prepared by Alipour et al. to measure anxiety caused by coronavirus outbreaks. This questionnaire has 18 items to measure psychological symptoms (Items 1 to 9) and physical symptoms (items 10 to 18). This tool is rated on a 4-point Likert scale ranging from a score of 0 to 54 as the lowest and highest scores are given by the respondents. High scores on this questionnaire is a sign of higher level of anxiety in individuals. The validity and reliability of this questionnaire are well documented (16).
Quality of life
Quality of life assessment was performed using the short form 12 questionnaire (SF12) which is composed of eight subscales of physical performance, physical role, social role, emotional role, body pain, general health, vitality, and mental health. Questions 1, 8, 9, and 10 were negative, so their scoring was reversed. Each item scored from 1 to 6, and total scores computed from 0 to 100. A higher score indicates the best situations. The questions were in the form of a Likert ranges from score 1 to 6. In Iran, the psychometric properties of this questionnaire was confirmed (17).
Data were analyzed using a software package used for statistical analysis (SPSS version 22, SPSS, Inc.) and linear structural relations (LISREL; version 8.8). Multiple correlation coefficients as a test which assesses the effects of independent variables on the dependent variable, were used to determine the relationship between QoL variables, anxiety and depression, general health, education, income, breastfeeding and corona disease anxiety.
Path analysis has been applied to generate the specified pattern of causal relationships between variables. Path analysis determines the type of relationship between predicted variables and responsible variables. In this study, a conceptual model of path analysis to determine the simultaneous relationship Between QoL, anxiety and depression, general health, breastfeeding, and corona disease anxiety was a good fit to the data.
After analyzing the fit of the data and finding the best fit, the acceptable model was determined. For evaluation of the model fitness, Root means a square error of approximation (RMSEA), Adjusted Goodness of Fit Index (AGFI), Confirmatory Factor Analytic (CFI), and Chi-square/df were applied. RMSEA values less than 0.08, Chi-square/df lower than 3, AGFI more than 0.9, and CFI more than 0.95 are the characteristics of a good fitting model.