Quality-of-life index and its related factors during COVID-19 pandemic: A community-based study in Rashtian women/Iran

Abstract

BACKGROUND:

The changes in everyday life, caused by the COVID-19 pandemic, were rapid and unprecedented. This pandemic affected not only physical health but also well-being and life satisfaction. This study was designed to assess the status of a quality-of-life index and some related factors during the coronavirus pandemic in the public population of Rashtian women.

MATERIALS AND METHODS:

This cross-sectional study was performed on 784 Rashtian women who were selected by cluster random sampling between 2020 and 2021. The data collection tool was the Ferrans and Powers Quality of Life questionnaire, which has two parts: satisfaction and importance of life. Each section consists of four subscales: health and performance, social and economic, psychological/spiritual, and family. Data analysis was done using descriptive and analytic statistics.

RESULTS:

The mean score of the quality-of-life index in this study was 21.39 (of 30), which is higher than the mean level. The scores obtained from the satisfaction section were inferior to the similar questions in the important section. The findings showed that there was no statistically significant difference between the quality-of-life scores of women living in different urban areas (P > 0.05).

CONCLUSION:

The feeling of satisfaction increases the ability to cope with problems and mental pressures and improves the level of mental and physical health of couples and ultimately of all members of society. So although the overall quality of life was above average, appropriate interventions should be designed to maintain and improve their satisfaction.

Introduction

All humans desire to have a life of great quality. The concept of quality of life is considered an interdisciplinary and dynamic concept that changes over time and different definitions have been proposed for this.[1,2,3,4] Following the World Health Organization definition, “Quality of life is determined by a person’s perception of their position in life, in the cultural context and value systems that they live and concerning their goals, expectations, relationships and needs.”[5] Some scholars suggest the association between this concept and life satisfaction. There is increasing recognition that life satisfaction is one of the most important aspects of an individual’s quality of life. This meaning is a subjective and dynamic concept resulting from an interplay between the importance and satisfaction of different aspects of life.[6] Even some experts have defined quality of life as satisfaction with life, others consider it as the level of satisfaction with the possibilities of life.[7]

Ferrans (1992) defines the quality of life as “The person’s sense of well-being that originates in their satisfaction or dissatisfaction of life aspects that are important to him/her.”[8] In other words, quality of life reflects the living conditions and well-being of individuals and shows a person’s satisfaction with health, education, employment, living and social environment, relationships, and security.[9,10] Some scholars believe that happiness and satisfaction are the two main characteristics of quality of life. For the quality of life index (QLI), Ferrans considers four components: “health and functioning,” “socio-economic,” “psychological/spiritual,” and “family,” including child, husband, and family health.[11]

Some factors affect the quality of life state, such as income, which affects people’s living conditions and is a major determinant of socioeconomic health.[12] Other studies have found that housing conditions, health, and social support in poor urban areas have a significant relationship to quality of life.[13] On the other way, 2 years ago, the global pandemic of the coronavirus (COVID-19), as a severe acute respiratory syndrome, which emerged in December 2019, has become a serious threat to the health and lives of millions of people.[14] The instant measures taken in response to this pandemic caused many new challenges adversely; it is expected that the quality of life of the public had been affected mainly during the COVID-19 pandemic with widespread panic, anxiety, and stigmatization of patients with the disease.[15] Even if most people are not infected and remain physically well, they often suffer from the negative psychological effects of the epidemic.[16]

As all human efforts are focused on improving the quality of life and achieving complete satisfaction, this is considered to be the most fundamental topic in the development of societies, and it is, therefore, necessary to identify problems that may affect the quality of life. Among these, women are considered not only as one of the objectives of any development of society but also as an effective lever to achieve the objectives of economic and social development.[17]

Several instruments can be used for the measurement of quality of life. The experts in quality-of-life research say that since quality of life is a subjective thing, the most appropriate way to research quality of life is to ask people directly about their perception of their life. Besides that, some experts suggest that the measure of the quality of life in the domain of satisfaction and general happiness, which is only definable by the individual, can only be measured by the use of surveys of individuals.[18] It is pointed out that several studies have been conducted in Iran to assess this concept, and most of them have used the health-related quality-of-life scale or the world health organization quality-of-life questionnaire, which only examines the physical and mental health dimensions. Many social elements, however, influence the quality of life of individuals that are not measured in these studies.[19,20,21] The real state of the satisfaction status of Iranian women during the coronavirus pandemic can be reflected by the quality-of-life indicators. In this study, we, therefore, used the Ferrans and Powers’ QLI, which measures the quality of life in terms of life satisfaction in healthy people and considers the social aspects.[22] This index determines and evaluates the quality of life in terms of value and weighted satisfaction.[23] The advantages of this questionnaire are in having subjects related to satisfaction with the important aspects of life, fluency and family focus, which seem not to be considered in the previous quality-of-life research in Iran. On this basis, the present study was carried out to answer the question “What is the state of the quality-of-life index in the public female population of Rasht, during the coronavirus pandemic?”

In addition, the following hypotheses are proposed:

• There is a difference in the QLI among the women surveyed depending on their age group.

• There is a difference in the QLI among the women interviewed according to their educational level.

• There is a difference in the average QLI of the women interviewed depending on their employment situation and the type of occupation (public or private).

Materials and Methods

Study design and setting

This study was a population-based survey that adopted a cross-sectional design to determine the state of the quality of life among Rashtian women and its relationship with some sociodemographic variables during the COVID pandemic, which was conducted between 2020 and 2021. The population of the study included middle-aged women living in the metropolis of Rasht (aged 30–65 years). The inclusion criteria were as follows:

At least having lived in Rasht city for 2 years at the time of the survey. Married women who agreed to take part in the study and who could communicate verbally to answer questions. Those who had a good physical and mental health history and were not using medication for a specific disease at the time of the research.

In addition, the exclusion criteria included women who had a family member who suffered from a chronic debilitating disease, an incurable disease or congenital anomalies, those who have recently lost their family head for various reasons (death, divorce, etc.), women with a history of domestic violence in recent months, or who are currently exposed to domestic violence.

Study participants and sampling

Considering that no previous study has been conducted to measure the quality-of-life index in the general population of Iranian women, the sample size was estimated at 384 by using the Krejcie and Morgan Table. In this study, the design efficiency to determine the optimal size of each cluster was considered to be equal to 2. The sample size should be determined based on the relationship Ncs = Nsrs×Deffcs. In this context, Nsrs is the calculated sample size for simple random sampling and Ncs is the actual sample size for cluster sampling with a design effect equal to Deffcs, which means that the cluster sampling method requires twice the initial sample size. Therefore, the total required sample count is 768 people. In total, 800 respondents were included in this study. Respondents who did not answer the satisfaction or importance questions (n = 16) were excluded. After applying these exclusion criteria, 784 respondents were analyzed in the present study.

The cluster random sampling method was used due to the dispersion of the statistical population, and the sample was selected corresponding to the population size from each area. Rasht city, in terms of division, is divided into five urban areas. This includes two developed and developing regions and one less developed area. Each of these areas was considered a cluster. In each cluster, the sampling was initiated by randomly selecting several alleys in the desired urban area and referring to the residential location within that area. After selecting a woman matched to the study inclusion criteria, the trained interviewer provided a description of the study and the requirements for participation and then administered the study protocol.

Data collection tool and technique

The data collection tool consisted of demographic characteristics. The instrument used to measure the status of quality of life was the QLI questionnaire which is developed by Ferrans and Powers.[24] This scale is built on a conceptual psychometric model and proven in numerous international studies, based on precise methodological methods, and includes a representation of the constructs it aims to measure. In addition, it is designed in a simple way that prevents participants from getting bored, especially when people are disabled for reasons such as old age or a low level of education.[25]

It has its origins in English but it has been translated into 20 languages around the world. In the study conducted by Rafiei et al.,[22] in order to translate and validate the Persian version of the QLI questionnaire, the reliability of the questionnaire was estimated using internal consistency. The internal consistency for the global score was 0.934 indicating that all domains met the minimum reliability standard; Cronbach’s alpha ranged from 0.74 to 0.90. As a result, the Persian version of the QLI is a reliable and valid tool. Considering the diversity of the studied population in the present study, the internal consistency of the questions was reexamined, and the results obtained of Cronbach’s alpha were from 0.71 to 0.90.

The current general version of the Ferrans and Powers’ QLI consists of 33 items for each of the two sections of satisfaction and importance. The subjects assign scores in both sections with values ranging from 1 to 6. In the first part, the scale varies from very dissatisfied (1) to very satisfied (6). In the second part, the range of points differs from the lowest score of (1) for the option “It does not matter” up to a score of 6 for “it is very important.”

Each of the two sections above includes four dimensions (subscales): health/functioning (13 items), psychological/spiritual (7 items), social and economic (8 items), and family (5 items). It should be noted that points 21 (employed) and 22 (unemployed) of the socio-economic dimensions are mutually exclusive; this means that only one of them should be considered. To determine scores, each satisfaction factor is compared with its equivalent in importance. The values are the combined raw scores of the two parts obtained after standardization. It should be noted that there are no reverse points and cutoff points in this structure. Scores for this questionnaire are calculated both in terms of quality of life as a whole and separately in each of the four domains, and the post-standardization score range is between 0 and 30. The higher the calculated score for a woman, the better the quality of life she has.[22]

This study was performed in line with the principles of the Declaration of Helsinki and all participants expressed their verbal consent. Approval was granted by the Research Ethics Committee of Tehran University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1398.200).

Statistical analyses

Statistical Package for Social Science (SPSS) version 21.0 was used in data analysis and descriptive statistical methods (frequency distribution table, mean, standard deviation) to describe the population studied. The Kolmogorov–Smirnov test was used for investigated the hypothesis of normality of the distribution of continuous data. The total score of the quality of life and its four domains assessed in the study were considered dependent variables. Independent t-tests and ANOVA tests were employed to determine the correlation of sociodemographic factors with the quality-of-life index. Pearson’s correlation (two-tailed) was used for the relation between quality-of-life domains and quantitative variables, and linear regression was used for multiple associations between sociodemographic factors and QLI score. P values <0.05 were considered statistically significant.

Results

Participant’s characteristics

The mean age (SD) of women was 42.01 (9.27) years. The most common age range was 30–39 years (47.4%). In terms of education level, most of them (60.3%) were in the bachelor’s degree or higher group. The mean (SD) age of marriage was 24.30 (5.40) years, and the mean duration of marriage (SD) was 17.33 (11.12) years. The majority of the women (73.5%) had been born in urban areas. The mean (SD) of the number of children was 1.59 (1.09) (median = 2). Most of the women were employed, and 32.7% of them were housewives. The majority of the participants’ husbands had education in a bachelor’s degree (55.7%). Also, the majority of respondents had a monthly income at an average level (34.4%). Moreover, 8.4% of the respondents in this study were heads of households [Table 1].

Table 1.

Characteristics of 784 women participated in the study

Variable	Study population
	n	%
Age category (years)
30–39	372	47.4
40–49	233	29.7
50–59	132	16.8
≤60	47	6
Education level
Nonformal education	0	0
Under diploma	48	6.1
Diploma and associate degree	263	33.5
Bachelor’s degree and higher	473	60.3
Husband’s education level
Nonformal education	3	0.4
Under diploma	59	7.6
Diploma and associate degree	285	36.4
Bachelor’s degree and higher	437	55.7
Residence of birth
Rural	208	26.5
Urban	576	73.5
Employment
Employed	528	67.3
Housewife	256	32.7
Type of employment
Public	235	44.5
Private	293	55.5
Job satisfaction
Yes	450	85.2
No	78	14.8
Head of household
Woman	66	8.4
Man	718	91.6
Monthly income (Rial)*
Low (<20,000,000)	69	8.8
Moderate (<50,000,000)	270	34.4
High (>50,000,000)	445	56.8
Urban areas
Zone 1	154	19.6
Zone 2	153	19.5
Zone 3	158	20.2
Zone 4	162	20.7
Zone 5	157	20

*30,000 Rial (1 United States dollars)

Women’s quality of life index and domain scores

The mean (SD) score for the standard quality of life was 21.39 (4.10) of 30, indicating a relatively good status. The scores obtained from the subscales scores of this index are presented separately in Table 2. As shown in the results of this table, the highest average score was given to the “family subscale” 23.47 (4.95) and the lowest to the “socio/economic subscale” 19.94 (3.99) [Table 2]. In general, the average overall score obtained in the satisfaction part was much lower than the importance part (36.93 vs. 64.57).

Table 2.

The mean scores of quality-of-life indexes and its domains in Rasht women (n=784)

Dimensions of quality-of-life index	Mean (SD)	Min-score	Max-score	95% Confidence interval
Health and function	21.28 (4.53)	7	30	20.96–21.59
Psychology/Spirituality	21.81 (5.51)	0	30	21.43–22.20
Social/Economic	19.94 (3.99)	4	28	19.70–20.34
Family	23.47 (4.95)	5	30	23.12–23.82
Total quality of life index	21.39 (4.10)	7	30	21.12–21.71

Factors related to quality of life

There was a significant difference between the mean score of the quality of life among the education level groups (F = 2.51, P = 0.01). Therefore, this hypothesis that “there is a statistical difference between the mean quality of life index among the surveyed women based on their education level” was confirmed. But there was no statistically significant difference between the average QLI obtained and the age groups (F = 0.79, P = 0.49). As a result, the other hypothesis of the study, “that there is a significance difference between the mean quality of life index of the women surveyed according to their age groups,” was rejected.

In our study, the scores obtained in the quality-of-life index of individuals based on the urban area of their lives were also evaluated. The results of the one-way ANOVA test showed that there was no statistically significant difference between the average score of women’s QLI in various areas of Rasht (F = 1.53, P = 0.19), although the lowest score was among women living in less developed areas [Table 3].

Table 3.

Mean (SD) of QLI according to the independent variables of women (n=784)

Variable	Study population		Quality of life index scores		P
	n	%	Mean	Standard deviation
Age category					0.49
30–39	372	47.4	21.60	0.47
40–49	233	29.7	21.26	3.94
50–59	132	16.8	21.06	4.18
≤60	47	6	21.80	3.50
Education level					0.01*
Nonformal education	2	0.3	16	2.57
Under diploma	46	5.9	19.72	4.52
Diploma and associate degree	263	33.5	21.85	4.13
Bachelor’s degree and higher	473	60.3	21.99	4.17
Husband’s education level					0.03*
Nonformal education	3	0.4	18.95	1.34
Under diploma	59	7.6	19.67	5.21
Diploma and associate degree	285	36.4	21.7	4
Bachelor’s degree and higher	437	55.7	21.88	4.35
Residence of birth					0.34
Rural	208	26.5	21.65	4.05
Urban	576	73.5	21.33	4.27
Occupation status					0.87
Employed	528	67.3	21.40	4.10
Housewife	256	32.7	21.45	4.43
Type of employment					0.96
Public	235	44.5	21.07	3.99
Private	293	55.5	21.67	4.18
Job satisfaction					0.000**
Yes	450	85.2	22.15	3.63
No	78	14.8	17. 06	3.98
Head of household					0.70
Woman	66	8.4	21.27	3.27
Man	718	91.6	21.43	4.29
Monthly income (Rial)					0.39
Low (<2000,000)	69	8.8	20.77	4.97
Moderate (<5000,000)	270	34.4	21.41	4.37
High (>5000,000)	445	56.8	21.51	3.98
Urban areas
Zone 1	154	19.6	21.21	4.12	0.19
Zone 2	153	19.5	21.70	4.01
Zone 3	158	20.2	21.71	3.85
Zone 4	162	20.7	21.67	4.56
Zone 5	157	20	20.77	4.43

*Significant difference at P<0.05; **Significant difference at P<0.01

Results showed that there was no statistically significant difference between the average score of quality of life of employed women (M = 21.40) compared with women who were housewives (M = 21.45) (T = 0.15, df = 782, P = 0.87). The quality of life of the employees and also a function of their types of jobs were evaluated (public or private). The results of the independent t-tests showed that there was no statistically significant difference between the two groups in terms of the mean QLI (T = −1.67, df = 526, P = 0.09). Therefore, the third hypothesis of the study also was rejected. The results also showed that the total quality of life score was higher in participants with higher monthly income but the statistical analysis did not show a significant mean difference between different income groups (F = 0.93, P = 0.39). It is worth mentioning that the results of the Pearson correlation were shown a significant and positive correlation between job satisfaction of employed persons and the index of their quality of life (T = −11.24, P = 0.001) [Table 3].

Other results showed that there was no statistical significance between the average quality of life for those where women were heads of household compared to those where men were heads (T = −0.37, df = 782, P = 0.70). However, the average score in female-headed households was slightly lower.

Further results obtained from Pearson’s correlation test indicate no statistically significant correlation between the variables such as age of marriage (r = 0.04, P = 0.20), duration of marriage (r = −0.05, P = 0.14), husband’s age (r = −0.03, P = 0.35), and number of offspring (r = −0.03, P = 0.32) with the women’s QLI. The results of regression analysis in the present study showed that none of the predictor variables explained the QLI [Table 4].

Table 4.

Linear regression analysis by considering QOLI as a dependent variable

Factors	B	SE	B	t	P
Constant	21.811	1.495	−	14.589	0.000
Age	−0.102	0.067	−0.224	−1.515	0.130
Age of marriage	0.100	0.069	0.128	1.448	0.148
Birthplace	−0.438	0.346	−0.046	−1.267	0.205
Number of children	0.065	0.186	0.017	0.347	0.729
Duration of marriage	0.073	0.065	0.194	1.121	0.263
Family income	0.228	0.163	0.052	1.396	0.163
Residential area	−0.081	0.112	−0.027	−0.727	0.467

Discussion

The construct of quality of life is considered an analytical structure and a key element in policy-making and review of public policies which is an important element of individuals’ well-being and is referred to as an indicator of social development. It is very important to identify the QLI and its related factors as a measure of life satisfaction, particularly among women, who are responsible for the management of family health. As mentioned previously, rarely in Iranian studies has the quality-of-life status of healthy women been studied using the general version of the QLI questionnaire which examines the importance and satisfaction in various aspects of life. Previous questionnaires used both inside or outside the country are more from a health perspective and focus on the quality of life of people, whereas Ferrans and Powers’ questionnaire can show us a profound and more comprehensive situation of people in terms of quality of life.

To the best of our knowledge, this cross-sectional study is one of the first studies to assess the QLI, by this instrument, in the general population of married women on a sample of Iranian adults especially during COVID-19 pandemic.

The results of this study showed that the mean women’s quality of life in Rasht was above average. In general, there are different findings about the results of women’s quality of life in different areas of Iran. The results of the present study should be compared with the findings of studies that have used similar tools, although as only one evaluation case was done with this tool (to perform the validity of this questionnaire in Persian); for this reason, we will discuss the results of quality-of-life studies conducted with other tools in women in other parts of Iran. The results of Mirzaei et al.’s[26] study on married women in Tabriz showed that the average total quality-of-life score in a range of (0–100) was 56%. In another study conducted in Karaj city, the results showed that the quality of life of women was at a moderate level.[27] Moreover, in the Golami study, quality of life was significantly worse in women in the physical domain.[28] The result of another study showed that the quality of life of Iranians is lower than that of other countries, especially on environmental issues.[29] A study conducted in Slovakia revealed statistically significant differences between quality of life and regions in terms of economic, social, and environmental factors.[30] It may therefore be said that the quality of life is determined by the various conditions in which people live.[31]

In brief, the quality of life from the perspective of people in different situations is different and goes back to the individual’s satisfaction with her life and with factors such as age, culture, gender, education, class status, and social environment,[20] which can be an explanation for the differences in the results of different studies. Contrary to our expectations in this study, there was no meaningful relationship between age and the QLI. Based on the results of Rimaz et al. there was a statistical relationship between age and the total quality index in women.[32] In Golmakani’s study, it was demonstrated that the older people got the lower their quality of life.[33] Aging greatly increases the likelihood of developing chronic mental and physical diseases.[3] Loss of spouse, or family and social isolation, especially for older people, leads to loneliness. Living alone reduces the quality of life, because loneliness can sometimes result in anxiety and depression.[34] The results of the aforementioned studies do not match those of the present study. Perhaps one of the reasons for this disagreement is that our sample was not perfectly balanced in terms of age. A smaller number of older women participated in the current study and the sampling was skewed in the direction of younger adults.

In our study, highly educated participants had more quality-of-life scores often than less-educated participants. Educational attainment can have a positive and constructive impact on everyone’s life. Knowledge learning through scientific learning in various fields and the acquisition of more knowledge has the property that prevents a person from committing inappropriate behaviors and determines the position of the woman in their society. Moreover, improvements in women’s educational attainment have affected their skills and increased their employment opportunities.[26]

We found that there is no statistically significant relationship between people being employed or their type of job and their quality of life. Today, women are interested in employment in order to demonstrate their capacities and increase their self-esteem and fulfillment. Women’s employment status is another factor related to increasing the quality of life of women and the comparison of the mean scores in some studies showed that working women have a better quality of life compared to housewives.[20,26,35] A study in China found that subjective well-being was affected by socio-economic status, and the most influential variables in this regard were education, employment, and income.[36] The results of a study conducted in Iran showed that there was no significant difference between the quality of life in employed women and housewives.[30] Moreover, the results of the research of Kermansaravi et al.[19] in southeast Iran showed that there was no statistically significant difference between the quality of life of employed compared with that of housewives, but the housewives reported better physical functioning compared to the employed women, that is, consistent with the results obtained in our study. In explaining the reason, it should be said that a set of factors affects the quality of life of these two groups, which sometimes has a positive effect and sometimes a negative effect. On the other hand, housewives have fewer problems and worries than women who work and experience less stress and more satisfied with their free time.

The current study implied that job satisfaction plays a major role in women’s higher quality of life. Actuality, the respondents holding a higher quality job enjoy a higher quality of life. This result is similar to the finding of other studies which showed a significant relationship between employed women’s quality of life and their job satisfaction,[37,38] that is, consistent with the results obtained in our study.

In investigation by Solhi et al.,[39] the quality of life of women-headed households was moderate, and the lowest average score is related to the environmental dimension. Also, a review study conducted in Iran indicated a low overall score for the quality of life of women head-of-household women,[40] is in line with the results of the present study.

There are some limitations to our study that need to be borne in mind. First, because of its cross-sectional design, our results should not be interpreted as having cause and effect. Future research is expected to examine these patterns over time using longitudinal data. Also, it is an observational study and all study subjects volunteered to participate in the questionnaire, though the study sample was of substantial size, and it was spread out in many geographical areas of the city; this does not necessarily reflect the characteristics of all Iranian women. In this study, we only studied married women and suggest that future studies should also consider the lives of single women. Another limitation of the study was the presence of a COVID-19 pandemic at the time of the study, which caused individuals to respond quickly to questions to shorten the response time and increased the likelihood of unrealistic answers.

Conclusion

This study adds new insights to understanding the relationships between quality of life, life satisfaction, and demographic variables in Iranian women. An overview of the results of studies in various disciplines shows that the social sciences examine the quality of life from a broader perspective than the health sciences. Since most quality-of-life studies are related to health currently, we suggest that for studies carrying on this matter, more attention be paid to the holistic approach, which requires the use of similar scales in this study that address the social components concept. In conclusion, the participants in our study had good quality-of-life levels during the coronavirus pandemic. Still, their satisfaction with life was low, which could show the possible effects of the pandemic. Education in women and their husbands, and job satisfaction had a relationship with QOL. Also, life quality was more with higher income. These results facilitate a further understanding of the association of QOL with welfare.

Limitation

There are some limitations to our study that need to be borne in mind. First, because of its cross-sectional design, our results should not be interpreted as having cause and effect. Future research is expected to examine these patterns over time using longitudinal data. Also, it is an observational study and all study subjects volunteered to participate in the questionnaire, though the study sample was of substantial size, and it was spread out in many geographical areas of the city; this does not necessarily reflect the characteristics of all Iranian women. In this study, we only studied married women and suggest that future studies should also consider the lives of single women. Another limitation of the study was the presence of a COVID-19 pandemic at the time of the study, which caused individuals to respond quickly to questions to shorten the response time and increased the likelihood of unrealistic answers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.