Design and Data Collection
The current study was conducted as a cross-sectional study on 200 sterilized women who attended the 8 health care centers in Guilan province, Iran during 2015-2016.
Research Ethics Committees of Tarbiat Modares University of Medical Sciences (IRB # 1056668) was approved this study. After explaining the aims of the study, informed written and verbal consent was obtained from all participants. Subjects were signed that their participation was voluntary, confidential, and anonymous. The women were allocated by the convenience sampling method.
The inclusion criteria were as follows: women underwent TL at least 1 year ago, not being in the postmenopausal period, absence of the history of chronic disease includes diabetes, hypertension, thyroid and cardiovascular diseases, not using psychiatric medications, not having the history of menstrual disorders before sterilization, lake of the history of sexual abuse, no history of gynecologic surgery except caesarean section and TL, not doing breastfeeding.
Hypothesized mediators were assessed using Path analysis. The model included menorrhagia, (dependent variable); SF, anxiety, self-esteem, body image (mediators), and QOL (independent variable). We hypnotized that menorrhagia, SF, anxiety, self-esteem, and body image have direct effects on QOL. Also, menorrhagia, anxiety, self-esteem, and body image are predictors of SF. We considered anxiety as a factor affecting on self-esteem, SF, and body image satisfaction.
Demographic and obstetric data
Socio-demographic and anthropometric characteristics including women’s age, married age, gravid, para, BMI, level of educational, history of smoking, income, job, drug and alcohol abuse, and method of delivery were collected for all subjects.
Quality of life
The Short Form Health Survey (SF-12) containing 12 items was used to assess QOL across eight domains (includes physical function, physical role, social role, emotional role, bodily pain, general health, vitality, and mental health). The total score ranges from 0 to 100 with higher scores referring to the best condition. The psychometric properties of this questionnaire have been verified in the Iranian population (10).
Depression and Anxiety
Hospital Anxiety and Depression Scale (HADS) questionnaire was used to evaluate the severity of anxiety and depression. This survey has 14 questions composed of two subscales that examined anxiety (7 Items) and depression (7 Items). Each item was rated on a 4-point Likert-type scale ranging from 0 to 3 (0=never, 1=seldom, 2=sometimes & 3= always) with a score range of 0–21 for both subscales. Higher scores represent greater anxiety and depression state. The validity and reliability of this questionnaire were approved among Iranian population (11).
Women’s sexual function in the previous 4 weeks was measured using the Female Sexual Function Index (FSFI). This scale consists of 19 items, which assesses six main aspects of sexual functions as follows: sexual desire, arousal, lubrication, orgasm, satisfaction, and pain.
Each question was rated on a scale from 0 or 1 to 5. The sum of each domain’s scores was multiplied in its certain factor. The overall scale score ranged from 2 to 36, which higher scores meaning better sexual function. The overall scale score was obtained by adding the mean scores of all six domains, with ranged from 2 to 36. A higher scores represent better sexual function. In the Iranian population, the psychometric properties of the questionnaire have been verified (12).
Body Image Concern
We used the Body Image Concern Inventory (BICI) for evaluating of the discontent and concern of the women about their appearance. This questionnaire consisted of 19 items about appearance, reassurance seeking, social concerns, and avoidance related to appearance. The answers of each item, based on the Likert spectrum, are graded from 1 (never) to 5 (always). The total score ranged from 19 to 95. Women who had a higher score are considered as a group with high body image concerns. This scale has good validity and reliability among Iranian women (13).
The Rosenberg Self-Esteem Scale was used for evaluation of women's self-esteem. This scale is a 10-items questionnaire about overall feelings of self-worth or self-acceptance.
Participants respond are ranked on 5-point Likert scale ranging from strongly agree to strongly disagree. Higher scores meaning high self-esteem. Validity and reliability of the Persian version of the questionnaire are well documented (14).
The pictorial blood loss assessment chart (PBLAC) was used to determine the average blood loss during menstrual period. Some pads with the same brand were given to all women that participated in this study. The pictorial chart consists of diagrams that describe levels of blood on sanitary pads in three degrees: light, moderate, and heavy saturation. After swapping out the pads, according to the degree of sanitary pad stained with menstrual blood the women make a tally mark in the cell pertaining to that day of the month, and all patients used the same sanitary products. At the end of menstruation, each tick was multiplied by the corresponding coefficient (score of 1for light, 5 for moderate, and 20 for heavy staining). A total score was counted by adding together all of tally marks. PBLAC scores above 100 were defined as heavy menstrual bleeding or menorrhagia. This scale has good validity and reliability (15).
Data analysis was carried out using SPSS (version 21) and LISREL software (version 8.8). Bivariate correlations were used to analyze the degree of association between the QOL, sexual function, menorrhagia, anxiety and depression, body dissatisfaction, self-esteem,
A path model was used to assess the predictive effects of independent variables on the QOL in sterilized women. Also by path analysis, we can test the cause-effect relationship between some variables. Direct, indirect, and total effects of causal relations between variables, and also values of these fit indices were computed by LISREL statistical program. For evaluation of the model fitness, RMSEA (Root mean square error of approximation), AGFI (adjusted goodness of fit index), CFI (Confirmatory Factor Analytic), and Chi-square/df were used. RMSEA values less than 0.07, Chi-square/df lower than 3, AGFI more than 0.9, and CFI more than 0.95 are indicative of a good fitting model. T-value more than +1.96 or less than – 1.96 were considered statistically significant.