Influential factors on quality of life in married Iranian women during the COVID-19 pandemic in 2020: a path analysis

Coronaviruses are enveloped RNA viruses that are transmissible among humans, other mammals, and birds [1]. A novel contagious primary atypical (viral) pneumonia was reported in Wuhan, China, in December 2019. Then it was classified as a zoonotic coronavirus, similar to the SARS coronavirus and MERS coronavirus, and was named COVID-19 [2]. The World Health Organization (WHO) has recently announced COVID-19 has become a pandemic, with more than 180,000 reported cases to date [3]. The pandemic announcement raised major concerns universally with transmission prevention being comprehensively upgraded.

The uncertainty and low predictability of COVID-19 not only threaten people’s physical health but also affect people’s mental health, especially in the field of emotions and cognition. According to the Behavioral Immune System (BIS) theory, people are likely to develop negative emotions (e.g., aversion, anxiety, etc.), and negative cognitive assessment to protect themselves when faced with potential illness. Long-term negative emotions may reduce the immune function of people and disturb the balance of their normal physiological mechanisms [4]. As an outcome of the increasing number of confirmed cases and deaths caused by the COVID-19 virus, both the medical staff and members of the community have experienced psychological problems such as anxiety, depression, and stress [5].

Anxiety about COVID-19 infection is common. Coronavirus has also spread in Iran and quickly endangered mental and physical health [6]. Depression is a common mental health condition that affects many aspects of daily life and is associated with many mental health conditions, especially anxiety [7].Existing studies show that dysfunction in daily routine life and psychological problems can negatively affect the quality of life (QoL) [8]. QoL is defined by WHO as “the perception of the individual about his position in life, in the context of culture and value systems in which he lives, and about his goals, expectations, standards, and concerns [9]. Also, Sexual Function (SF) is an important element of QoL [10]. Diseases can lead to reduced QoL in various psychological and physical dimensions [11].

Considering the prevalence of the COVID-19, its various effects (physical, psychological, social, and economic effects) on people's lives, and the little information about this field, it is necessary to identify influential factors on QoL in married Iranian women during the pandemic of COVID-19.This study aimed to test a conceptual model considering the interrelated role of anxiety, depression, marital satisfaction (MS), mental health, SF, and corona disease anxiety on the QoL of married women. Based on the above aims, this study proposes the following hypotheses (Hypotheses 1–5):

Table 1 describes the socio-demographic characteristics of participants. The mean age of participants and the 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. 82.43% of the samples had academic level education and about 40.88% of them were unemployed. The overall mean score of QoL was 62 ± 7.

Table 2 shows the Correlation (bivariate analysis) between all variables included in the path model. Results showed that QoL was correlated with SF (r = 0.53, P < 0.001), anxiety (r = − 0.22, P < 0.001), 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).

The overall goodness-of-fit statistics demonstrated that the conceptual model of the study was excellent (P-value = 0.01; chi2 = 37.82; DF = 21; chi2/df = 1.81; RMSEA = 0.05; CFI = 0.97; GFI = 0.98) (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.

The pandemic of COVID-19 severely affects the lives of individuals around the world. Social distances have been integrated into human lives. Disruption to the social norms could therefore drive stress because of loneliness, anxiety, depression, mental disorders, health risks, and many other things that affect a person's life [20].

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 identified as a factor influencing on QoL in individuals, and in fact, the 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 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 identified as an influential factor on QoL and the results of a study by Keramat et al. confirmed this finding. In the study of Keramat, a significant 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 influencing the QoL associated with health and even its impact on QoL have 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 scientific 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 this study, there was a significant 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 difficult 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 specific understanding of satisfaction in life, physical health, social and family health, hope, social etiquette, and mental health [30]. It is believed that various factors might influence the QoL that mental health is one of the important and influential factors in QoL [31].

Anxiety and depression are two important aspects of mental health [32]. In the 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. confirmed our findings. In Alizadeh's study, corona disease anxiety was negatively correlated with mental health. Anxiety is the most fundamental feature of a crisis. The critical condition of the COVID-19 pandemic by increasing negative factors such as anxiety affects mental health [33]. Women are the most vulnerable group in society to mental health problems during the outbreak of Covid-19. One of the main concerns of women in this period is receiving reproductive-sexual, pregnancy, childbirth, and postpartum care which has involved a large number of them. Women in pregnancy and during postpartum may represent a vulnerable population who might be severely psychologically affected [34]. Social distancing and quarantine restrictions can increase anxiety in most pregnant mothers during the spread of COVID-19 and on the other hand, they are worried about their children after birth for vaccinations and necessary screenings in pandemic conditions. Therefore, the protocols and guidelines for the management of COVID- 19 in the field of obstetrics and gynecology should be improved.

Epidemics of the diseases affect people physically as well as society at different levels which leads 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 [35]. The results of the study by Wu et al. showed that awareness of COVID-19 significantly increased the prevalence of perinatal depression [36]. Also, in the study of Zheng et al., they concluded that the prevalence of COVID-19 may be higher than the incidence of depression in cancer patients [37]. 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 the study of Khazei et al. In this study, there was a significant relationship between sexual dysfunction and low MS. MS is related to the level and quality of general health and life satisfaction [38]. MS is impressed by many factors. A Safe and enjoyable sexual relationship is one of the most important factors considered in many studies [39]. Sexual dysfunction probably affects MS through its impact on QoL and mental health.

In this study, more duration of quarantine will be associated with a 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, financial loss, and stigma [40].

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 [41].

The results of this study showed that SF, MS, anxiety, general health, and corona-related anxiety are factors influencing 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.