This was a quasi-experimental study conducted using pretest-posttest design with control group. Statistical population was all married Afghan women living in Taft. Based on the study by Pourmovahed et al. (19) and a preliminary study by the author, standard deviation was 4, significance level was 5% and power of test was 80%. Using purposive sampling, 60 women were selected and randomly allocated to case (n=30) and control (n=30) groups. Inclusion criteria were being married, consent to participate in the study, having self-care ability, absence of speech problems, good fluency and hearing, and having low scores of mental health or quality of life. Exclusion criterion was failing to participate training sessions. After primary evaluations and specifying case and control groups, pretest was conducted for both groups. Life skills training program was provided to the case group in eight 90-minute sessions once a week. The control group received no trainings. At the end of the training program, posttest was conducted on Afghan women. In addition, to observe research ethics, trainings were also provided to the control group in four compressed sessions at the end of the study. Data were analyzed in SPSS 24 using descriptive statistics such as mean and standard deviation and MANCOVA was used to test the research hypothesis. All methods were carried out in accordance with relevant guidelines and regulations. The following questionnaires were used in this study to collect data.
General Health Questionnaire (GHQ)
The General Health Questionnaire (GHQ) was first developed by Goldberg (1972). This questionnaire aims not to obtain a specific diagnosis of mental illness, rather, it aims to differentiate mental illness and health. In this study, the 28-item questionnaire was used which assesses psychological status of the individual in the last month and includes symptoms such as abnormal thoughts and feelings and aspects of observable behavior here and now. The questionnaire has 4 subscales including physical symptoms, anxiety, insomnia, social dysfunction and depression each of which includes 7 questions. Questions of each subscale are presented in a row, items 1-7 on physical symptoms, 8-14 on anxiety and insomnia, 15-21 on social dysfunction and 22-28 on depression subscale. Likert scale was used for scoring and items are scored as 1, 2, 3 and 4. The total score ranged between 0 and 84. A score of 17 and higher in each subscale and a total score of 41 and higher show deterioration of the participant's condition. Validity of the questionnaire was 0.72 and it was 0.60, 0.68, 0.57 and 0.58 for physical symptoms, anxiety and insomnia, social dysfunction and depression respectively. A P-value of <0.0001 was considered significant (20).
Quality of Life of the World Health Organization Questionnaire (WHOQ- BREF)
In order to measure quality of life in this study, the Quality of Life of the World Health Organization Questionnaire (WHOQ- BREF) was used. It consists of 26 items and 4 subscales (physical health, mental health, social relations, and environmental health). The questions were scored on a 5-point Likert scale (Very Negative, Negative, Neutral, Positive, and Very Positive) from 0 to 4.
Reliability of the questionnaire was greater than 0.70 in all domains using Cronbach's alpha. However, in the social relations, Cronbach's alpha was 0.55 which could be due to a small number of questions in this field or its sensitive questions. Validity of the questionnaire was assessed using linear regression with the capability to differentiate between normal and unhealthy groups where there was a significant difference between various fields. Reliability of the above questionnaire was 0.92 using Cronbach's alpha (21). In this study, the Cronbach's alpha for physical health, mental health, social relations and environmental health was 0.743, 0.798, 0.762 and 0.715 respectively.
Intervention
The 90-minute group training was provided to participants every week. It is worth mentioning that participants' adherence to the rules of sessions was also considered. A summary of training sessions is provided in Table 1.
Table 1- Content of Sessions
Session
|
Training content
|
One
|
Introduction: Familiarity with life skills and self-care, quality of life and mental health behaviors.
|
Two
|
Self-awareness skills training For self-care, we need to be clear about who we are, what we want to be, and our reasons for such change.
|
Three
|
Communication skills training Applying communication skills plays a prominent role in precise diagnosis of the disease in order to prevent it.
|
Four
|
Problem solving and decision making training In this process, women learn to deal with self-care barriers as a problem and then choose one of the possible solutions to change the behavior or adopt a preventive method.
|
Five
|
Stress coping training The higher the individuals' stress coping capabilities, the lower the rate of diseases in them.
|
Six
|
Physical self-care training: Physical activities and exercises, adequate sleep and rest, attention to the surrounding environment, developing a calm and quiet environment
|
Seven
|
Spiritual self-care training: Familiarity with the creator and understanding the meaning of life. The individuals use their beliefs and spiritual teachings as a source of control to protect their health.
|
Eight
|
Summing up the previous sessions, submission of comments and suggestions by group members and conducting post-test
|
Findings
The mean age of participants was 34, the majority of them were illiterate or had education under middle school. In Table 2, the mean and standard deviation of quality of life and mental health scores in the pretest and posttest are presented for case and control groups.
Table 2- Mean and standard deviation of quality of life and mental health scores for case and control groups
Variable
|
Stage
|
Group
|
Mean
|
Standard deviation
|
Quality of life
|
pretest
|
case
control
|
82.50
74.40
|
6.99
7.4
|
posttest
|
case
control
|
89.33
83.80
|
6.46
7.09
|
Mental health
|
pretest
|
case
control
|
30.36
29.46
|
9.01
11.23
|
posttest
|
case
control
|
35.06
30.20
|
9.24
10.16
|
Results of Table 2 suggested that the mean scores of quality of life in the case group following the intervention increased in the posttest (89.33) relative to the pretest (82.50), and the mean scores of mental health also increased in the posttest (35.06) compared to the pretest (30.20).
Results of the Kolmogorov–Smirnov test demonstrated a normal distribution of variables and their dimensions in both groups (p>0.05) and the Levene's test showed that variances were equal (p>0.05). Results of the assuming the equality of the covariance matrix were also approved for quality of life (MBox= 27.848, F=1.377) and mental health (MBox= 52.604, F=1.68).
To measure the effect of independent variable on dependent ones, results of multivariate analysis were used which are shown in Table 3.
Table 3- Results of multivariate analysis for effectiveness of training program
Independent variable
|
Tests
|
Value
|
F statistic
|
Significance
|
Eta squared
|
Training program
|
Pillai's trace
|
0.211
|
3.617
|
0.001
|
0.242
|
Wilks' Lambda
|
0.789
|
3.617
|
0.001
|
0.242
|
Hotelling's trace
|
0.268
|
3.617
|
0.001
|
0.242
|
Results of Table 3 suggest a significant difference between groups in at least one variable. Results of Lambda's test suggest that the difference between groups is significant at least in one variable (f=0.789, p<0.001). Given the significant results of multivariate test, results of MANCOVA were used by controlling the effect of pretest to investigate on what variables the training program has had a significant effect. Results are shown in Table 4.
Table 4- Results of MANCOVA for the effectiveness of training program in quality of life and mental health
Dependent variable
|
Source
|
Total sum of squares
|
Degree of freedom
|
Mean squares
|
F
|
Significance
|
Eta squared
|
Quality of life
|
Pretest
|
388.81
|
1
|
388.81
|
9.718
|
0.003
|
0.27
|
Group
|
848.8
|
2
|
424.4
|
10.598
|
0.0001
|
Mental health
|
Pretest
|
301.465
|
1
|
301.46
|
3.677
|
0.043
|
0.130
|
Group
|
696.732
|
2
|
348.366
|
4.24
|
0.019
|
As shown in Table 4, by controlling the pretest effect, the training program had a significant effect on Afghan women's quality of life (p<0.0001) and mental health (p<0.019).