In uential Factors on quality of life in married Iranian women during the Covid-19 pandemic in 2020: A Path Analysis


 Background

The aim of this study was to investigate the relationship between quality of life (QoL) with anxiety, depression, corona disease anxiety, sexual function (SF), and marital satisfaction (MS) in married women during the Covid-19 pandemic.
Methods

We performed a cross-sectional study involving n = 296 married women. We used the Short Form Health Survey (SF-12), Marital Satisfaction Scale (MSS), Female Sexual Function Index (FSFI), Hospital Anxiety and Depression Scale, and coronary disease anxiety questionnaire, as determinants of QoL for data collection. Data were analyzed using Pearson correlation coefficient and path analysis.
Results

There was a relationship between the components of QoL with SF, anxiety, depression, MS, general health and contamination obsessions. The results of path analysis also showed that that SF, MS, anxiety, general health and corona-related anxiety have a direct effect on women’s QoL. General health has a more direct effect on QoL.
Conclusion

The results of this study could help to planning to improve the QoL of women during the coronavirus epidemic.


Hypothesis 3
contamination obsession will be associated with higher level of anxiety, depression, and also have a worse effect on SF, MS, general health, and QoL.

Hypothesis 4
Longer quarantine will be associated with higher level of anxiety, depression, and also have a worse effect on SF, MS, and QoL.
Hypothesis 5 SF, MS, anxiety, depression, general health, duration of quarantine, contamination obsession will be associated with QoL.

Methods:
Design and Data Collection: Of the 325 women who completed the questionnaires, 29 women excluded of study due to lack of entry criteria or incomplete lling of questionnaires. Finally, the current cross-sectional study was conducted on 296 married women. Data collection was performed using an online questionnaire. Due to home quarantine to prevent coronavirus disease, rst, the existing valid questionnaires link was designed and the designed link via social media with the help of members of the research team was sent to all social groups that were only women. On the rst page of the survey, information about the study objectives, methods and potential outcomes were provided. Research Ethics Committees of Tarbiat Modares University of Medical Sciences approved the study protocol (IR.MODARES.REC.1399.004). Sampling method was convenience sampling.
Inclusion criteria were age range of 18-45 years, absence of the history of chronic diseases or condition resulting in sexual dysfunction (such as cardiovascular disease, diabetes, hysterectomy, premature ovarian failure, psychiatric illnesses, infertility), not using any medications affecting sexual response cycle (such as: antihypertensive drugs, antipsychotic drugs, antidepressants, hormonal drugs) and lack of addiction to narcotics and alcohol, married and living with husband, and having sexual intercourse in the past 4 weeks.

Measures:
Socio-demographic and obstetric characteristics including: women's age, age at marriage, body mass index, province and city of residence, income amount, educational level, duration of marriage, menstrual status, occupational status, gravid, para, abortion, intrauterine fetal death, history of infertility, and number of children.

Quality of Life
Short Form Health Survey (SF-12) includes 12 questions related to 8 dimensions (sexual performance, physical role, physical pain, general health, energy and vitality, social performance, emotional role and mental health) which are divided into two subscales of physical and mental health. The maximum score obtained for each section or subscale is 100 and the minimum score is zero with a higher score indicating a better health status. The validity and reliability of this questionnaire was previously con rmed in Iran [12].

Sexual Function
The Female Sexual Function Index (FSFI) is multidimensional self-report tool for evaluating the key dimensions of SF in women (sexual desire, arousal, lubrication, orgasm, satisfaction and pain)with 19 items [13]. Its validity and reliability in Iran were previously con rmed [14].

Depression and Anxiety
Hospital Anxiety and Depression Scale (HADS) designed by Zigmond and his colleagues in 1983 has seven questions on symptoms of anxiety and seven questions on symptoms of depression. This questionnaire is based on a four-point Likert scale. Finally, out of a total of 21-points score, scores above 8 were considered as being anxious and depressed in each subscale. This scale has been validated as a good tool for screening mental health disorders in Iran [15].

Marital Satisfaction
Marital Satisfaction Scale-shortened version (MSS) contains 10 items measuring the satisfaction of marital relationships. Using the 5-point Likert scale, the answers range from "5 = I totally agree with" to "1 = I totally disagree with". Questions number Q1, Q3, Q5, Q8, and Q9 were negative items and need reversing. Total scoring of this questionnaire ranges from 10 to 50. A higher score indicates higher MS. A valid and reliable version of the MSS scale was translated into Persian by Arab Alidousti et al. The Persian version showed the desired validity and reliability [16].

Mental Health
General Health Questionnaire (GHQ) was developed by Goldberg in 1978. The GHQ-28 is a screening tool to detect those likely to have or to be at risk of developing psychiatric disorders. The GHQ-28 has been divided into four subscales. These are: somatic symptoms (items 1-7); anxiety/insomnia (items 8-14); social dysfunction (items 15-21), and severe depression (items 22-28) [17]. Psychometric form 28 item of this questionnaire (GHQ) was conducted in Iran, the results of which approved validity and reliability [18].

Corona Disease Anxiety
Corona disease anxiety scale has been prepared and validated by Alipour et al to measure anxiety caused by the prevalence of corona virus in Iran. To prepare Corona Anxiety Scale, different questionnaire questions, including the AIDS anxiety questionnaire and questionnaires related to fear of health risks were surveyed and 23 items selected. The nal version of this tool has 18 items and 2 components. Items 1 to 9 are for measuring psychological symptoms and items 10 to 18 are for physical symptoms. This tool is in the 4-degree Likert range (never =, 0 sometimes = 1 most of the time = 2 and Always = 3). Therefore, the highest and lowest scores obtained by the respondents in this questionnaire are between 0 and 54. The high scores in this questionnaire indicate a higher level of anxiety in individuals [6].

Statistical analysis
Software SPSS (version 20) was used for descriptive statistics and to determine the effects of variables on each other, the method of path analysis with Lisrel software was used. Correlations between the variables were investigated using Pearson's correlation coe cients.
The path analysis method is a generalized general regression that is able to express in addition to the direct effects of indirect effects and the general effect of each of the variables for the dependent variables, and interpret the observed relationships and correlations between them with logical expression.
In the present study, the Root Mean Square Error of Approximation (RMSEA), goodness t comparative Fit Index (CFI) used to determine the t of the model. These indicators are similar to the correlation coe cient. In other words, their value varies between zero and one. Chi-Square value evaluates the overall model t [19]. Table 1 describes the demographic characteristics of participants. The mean age of participants and duration of their marriage were 33.68 ± 6.47 and 10 ± 7 years, respectively. The majority of participants (63.17%) were in home quarantine for 6-7 days per week. In terms of educational level, 82.43% of subjects had academic level education and about 40.88% of them were unemployed. The overall mean score of QoL was 62 ± 7.  (3) 28 (9) 68 (22) 187 (62) 5 (1) Income (Toman) ** Less than 1 million  depression (r=-0.17, P < 0.01), MS (r = 0.28, p < 0.001), general health (r=-0.52, P < 0.001), and contamination obsessions (r=-0.14, P < 0.05).   Table 3).  Table 4 and Fig. 1 show the direct, indirect, and total effects of variables on women's QoL. Results show that SF (β = 0.31), MS (β = 0.21), anxiety (β =-0.09), general health (β=-0.33), and corona-related Anxiety (β=-0.14) have a direct effect on women's QoL. Among variables, general health has a more direct effect on QoL. Anxiety, depression, and corona related anxiety are the main predictors of general health. On the other hand, general health with indirect effects through SF can change women's QoL. Women with a higher level of SF had better MS and QoL. We also observed a lower level of QoL and longer duration of quarantine in women with a higher level of corona related anxiety. Contamination obsessions were related to more duration of quarantine, and a higher level of corona related anxiety.  [20].

Results
In this study, the effect of factors: SF, MS, mental health, anxiety, depression, corona disease anxiety on the QoL of married women during the epidemic of Covid virus 19 was studied using path analysis. Our results showed the SF, MS, anxiety, general health and corona-related anxiety have a direct effect on women's QoL. In some studies, sexual dysfunction has been identi ed as a factor in uencing on QoL in individuals, and in fact, the investigate of SF plays an important role in studies related to QoL [21]. In the study of Zhang and his colleague, 52.1% of participants felt horror and apprehensive due to the pandemic of COVID-19 and the pandemic was associated with mild stressful impact in participants [22]. SF may be negatively affected by any type of stress or emotional distress [23]. Therefore, it can be said that stress caused by COVID-19 can affect SF and SF is also one of the factors affecting the QoL.
In our study, MS was identi ed as an in uential factor on QoL and the results of a study by Keramat et al, con rmed this nding. In this study (Keramat), a signi cant relationship was found between QoL and MS.
The study was performed on infertile women [24]. Infertility and its treatments, like Corona's pandemic, is a crisis that can affect the MS and then the QoL changes. In studies, MS and SF have been associated with QoL [25]. One of the indicators of mental health is MS [26], so it can affect the QoL.
Anxiety and depression are the most important factors in uencing on the QoL associated with health and even its impact on QoL has been reported to be stronger than physical conditions such as angina and other chronic diseases [27]. Anxiety about COVID-19 is common and seems to be mostly due to uncertainties. Low scienti c knowledge about the Covid-19 also exacerbates this anxiety [6]. In this study, corona disease anxiety and anxiety had a direct impact on QoL that was in line with the results of a study by Parsamehr et al. In Parsamehr et al.'s study, there was a signi cant negative relationship between depression and anxiety with patients' QoL who had been undergone coronary artery bypass graft. The researchers said anxiety and depression can reduce the QoL of patients by causing physical and psychological consequences [28].Anxiety is a natural reaction to di cult and threatening situations, but if it is severe and prolonged and causes suffering, it disrupts life and reduces the QoL.
In addition to causing physical harm, Covid-19 also has a serious effect on people's mental health [29]. In our study, among the variables affecting QoL, general health has a strong direct impact. QoL has a multidimensional and complex meaning and often as a speci c understanding of satisfaction in life, physical health, social and family health, hope, social etiquette, and mental health [30]. It is believed that various number of factors might in uence the QoL that mental health is one of the important and in uential factors in QoL [31].
Anxiety and depression are two important aspects of mental health [32]. In present study, anxiety, depression, and corona related anxiety are the main predictors of general health. The results of a study conducted by Alizadeh Fard et al, con rmed our ndings. In Alizadeh's study, corona disease anxiety was negatively correlated with mental health. Anxiety is the most fundamental feature of a crisis situation.
The critical condition of the coronavirus pandemic by increasing negative factors such as anxiety affect mental health [33].
Epidemics of the diseases affect people physically as well as society at different levels which lead to mental disorders such as anxiety and stress.
In our study, depression was also a predictor of general health. In a study conducted by Steger et al, depression is considered to be the strongest predictor of mental health [34].
The results of the study by Wu et al showed that that awareness of COVID-19 signi cantly increased the prevalence of perinatal depression [35]. Also, in the study of Zheng et al, they concluded that prevalence of COVID-19 was presumably to excess the incidence of depression in cancer patients [36]. It seems that excessive stress and anxiety in the current situation increase the risk of depressive disorder.
In our study, women with a higher level of SF had better MS. This result is congruent with study of Khazei et al. In this study, there was a signi cant relationship between sexual dysfunction and low MS. MS is related to the level and quality of general health and life satisfaction [37]. MS is impressed by many factors. Safe and enjoyable sexual relationship is one of the most important factors considered in many studies [38]. Sexual dysfunction probably affects MS through its impact on QoL and mental health.
In this study, more duration of quarantine, will be associated with higher level of anxiety, depression and QoL. A review of Brooks et al, showed that quarantine has negative psychological effects containing post-traumatic stress symptoms, anger, and confusion. During quarantine days, separation from loved ones, loss of liberty, uncertainty about the condition of the disease, and boredom can have impressive effects. Stressors included longer quarantine duration, infection fears, disappointment, fatigue, incomplete supplies, inadequate information, nancial loss, and stigma [39].
The result of the present study showed that contamination obsessions were related to more duration of quarantine, and a higher level of corona related anxiety. Among the many psychosocial consequences that have occurred due to the pandemic of COVID-19, the prominence of obsessive-compulsive symptoms has been largely neglected. Uncontrolled obsessions and compulsions can lead to dermatological conditions, chronic stress, insomnia and high risk for suicide [40].
The strengths of the present study include it is the rst study conducted in the eld in Iran and in the world; and the participants were from a wide range of socioeconomic and geographic backgrounds.

Conclusion:
The results of this study showed that SF, MS, anxiety, general health and corona-related anxiety are factors in uencing the QoL during the pandemic of covid-19. Stress and anxiety disturb the immune system and make individuals vulnerable to contagious diseases such as corona. This warrants research on strategies to improve people's mental health.

Availability of data and materials
The data sets used and analyzed during the current study are available from the corresponding author on reasonable request Path diagram (T-value) for the predictors of QoL