Abstract
Objective
Human papillomavirus, a common sexually transmitted infection, may negatively affect psychological health and marital relationships. This study aimed to examine individual and psychological predictors of marital satisfaction among married Iranian women diagnosed with human papillomavirus.
Results
This descriptive-analytical study included 238 married women with a confirmed diagnosis of human papillomavirus. Most participants reported moderate depression and severe to very severe anxiety, while stress levels were predominantly normal to mild. Nearly all participants reported moderate levels of marital satisfaction. Univariate analyses identified significant associations between marital satisfaction and age, women’s education, spouse’s education, employment status, family income, tobacco use, and psychological variables. Multiple linear regression analyses showed that age, women’s education, spouse’s education, and spouse’s tobacco use were significant predictors of overall marital satisfaction. Anxiety, stress, and women’s tobacco use predicted communication, whereas spouse’s employment status and family income predicted conflict resolution. Age and spouse’s education were associated with idealistic distortion. Among the examined variables, spouse’s education and stress demonstrated the strongest effects in their respective models.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13104-026-07691-z.
Keywords: Psychological factors, HPV, Marital satisfaction, Iranian women, Regression analysis
Introduction
HPV is one of the most common sexually transmitted infections worldwide, with significant physical, psychological, and social consequences [1] Its prevalence has risen in recent years [2]. According to the World Health Organization, cervical cancer is projected to cause over 443,000 deaths worldwide by 2030 [3] The prevalence of high-risk HPV infections varies across populations; in Iran, one study reported a rate of 10.3% [4].
In Iran, where sexual health is sensitive and stigmatized, HPV can increase psychological and social burdens. Women with HPV may experience shame, isolation, and fear of judgment [5, 6]. International studies in culturally similar regions also indicate that stigma associated with sexually transmissible infections can exacerbate emotional distress, reduce help-seeking behaviors, and negatively impact intimate relationships [7, 8]. Cultural/social factors highlight the need to study marital satisfaction in Iranian women with HPV, since norms/stigma may affect their sexual function, mental health, and relationships.
High-risk behaviors, such as having multiple sexual partners and smoking, have contributed to a significant increase in HPV infections [9]. HPV-related psychological burdens including shame, stigma, anxiety about transmission, and emotional strain can significantly was associated with intimate relationships [10]. Relationships Theory, stressors such as illness or stigma can disrupt communication, intimacy, and mutual support between partners, thereby lowering marital satisfaction [11]. Moreover, psychological factors like depression, anxiety, and perceived stress are known predictors of reduced marital quality, highlighting the complex interplay between individual health, mental well-being, and relationship functioning [12].
Women with HPV may experience sexual dysfunction (reported in 64–70% of cases), reduced sexual desire, and relational difficulties, which can further exacerbate marital dissatisfaction [13]The combination of physical symptoms (e.g., genital warts, precancerous lesions), emotional distress (shame, guilt, fear of transmission), and social stigma may jointly influence intimate interactions and satisfaction within marriage [9]. Individual characteristics, such as lifestyle factors and partner-related variables, may moderate these effects, suggesting the need for a nuanced understanding of marital outcomes in HPV-positive women [14].
Cognitive processes play a central role in shaping marital satisfaction [15]. Among these, ideal distortion refers to the tendency of individuals to perceive their partner or relationship in a more idealized way than reality, often downplaying negative aspects and emphasizing positive traits [16]. Such distortions can influence how couples interpret interactions, manage conflicts, and maintain satisfaction over time. In addition, broader cognitive factors, including beliefs, expectations, and appraisals of partner behavior, are known to affect relationship quality and adjustment [17]. Introducing these concepts prior to the Discussion provides readers with the necessary theoretical foundation to understand how psychological mechanisms may interact with HPV-related stress to influence marital [18]. This study uses a theoretical framework linking HPV-related psychological stress to marital satisfaction, The Systemic-Transactional Model (STM) of dyadic coping (Bodenmann, 2005; Falconier & Kuhn, 2019) serves as the guiding theoretical framework for this study. The STM views stress as dyadic, where one partner’s stress affects the other, creating tension. Key aspects are stress communication, supportive, delegated, and common dyadic coping. Positive coping reduces stress’s negative impact; negative coping worsens it [11, 19].
In the context of HPV, the STM posits that psychological distress (anxiety, stress) and demographic factors (e.g., education, tobacco use) may impair dyadic coping processes, leading to reduced marital satisfaction, communication, and conflict resolution [20]. This framework informs the study’s exploratory examination of predictors, anticipating that higher psychological distress and certain demographic vulnerabilities will negatively predict marital satisfaction components, while factors like higher spouse education may facilitate better coping and idealization of the relationship [21]. Figure 1 illustrates the conceptual model of the study, showing the hypothesized relationships among demographic factors, psychological distress related to HPV, and marital satisfaction components based on the Systemic-Transactional Model of dyadic coping.
Fig. 1.
Conceptual model illustrating the relationships among demographic factors, psychological distress (depression, anxiety, and stress), and marital satisfaction and its components (communication, conflict resolution, and idealistic distortion) among women with HPV. The model is grounded in the Systemic-Transactional Model (STM) of dyadic coping, conceptualizing HPV as a dyadic stressor that affects marital functioning through both direct and indirect pathways
Present study
This study investigates demographic and psychological factors affecting marital satisfaction in Iranian HPV-positive women, a group understudied in Iran and the Middle East, where prior research has focused on the psychosocial effects of HPV [9], few have focused on marital satisfaction as a key relational outcome [13]. This study explores individual and psychological factors predicting marital satisfaction in a clinical sample.
Guided by the Systemic-Transactional Model (STM) of dyadic coping [11, 19], This study frames HPV stress as a shared issue for couples, impacting coping in relationships. It examines how demographics and distress affect marital dynamics in Iranian couples with HPV, informing culturally relevant interventions. Hypotheses: (1) Higher distress (depression, anxiety, stress) reduces marital satisfaction. (2) Older age, lower education (especially women’s), and tobacco use negatively affect satisfaction, while higher spouse education and SES (employment, income) improve it. These reflect HPV’s relational impact.
Materials and methods
Study design and subject selection
A descriptive-analytical study was conducted on HPV-positive women referred to the Gynecology Clinic in 2025 after Ethics Committee approval. Data was collected from May 20, 2025, for six months. Participants were HPV-positive women in good health with adequate communication skills, without mental illness, able to participate in interviews. Women with acute conditions impairing participation were excluded. The sample size was calculated as 225 (G Power 3.1, α = 0.05, power = 95%, effect size = 0.15, 10% dropout). 238 HPV-positive women were selected via convenience sampling and enrolled after consent.
Data collection instruments
Data were collected using a socio-demographic information form, the DASS-21 questionnaire, and the Enrich Couple Marital Satisfaction Questionnaire. The socio-demographic form included questions about age, education, marital status, occupation, and HPV type.
The DASS-21, developed by Lovibond and Lovibond, is a 21-item self-report instrument designed to assess depression, anxiety, and stress. It has demonstrated sufficient psychometric properties, including reliability and validity, making it a widely used and credible tool for evaluating negative emotional states in both clinical and non-clinical adult populations. Its abbreviated format allows efficient assessment while maintaining comparability with other established scales.
The questionnaire’s 21 items constitute a set of 3 self-reported scales intended to measure DASS. Subscale Questions: Depression: 3,5,10,13,16,17,21, Anxiety: 2,4,7,9,15,19,20 and Stress: 1,6,8,11,12,14,18.
The 7 items on the scales are rated using a Likert scale ranging from 0 to 3 (0: “Did not apply to me at all,” 1: “Applied to me to some degree or some of the time,” 2: “Applied to me to a considerable degree or a good part of the time,” and 3: “Applied to me very much or most of the time”). Depression, anxiety, and stress scores are calculated by summing up the scores of the relevant items. The intensity of each subscale.
| Severity | Depression | Anxiety | stress |
|---|---|---|---|
| Normal | 0–9 | 0–7 | 0–14 |
| Mild | 10–13 | 8–9 | 15–18 |
| Moderate | 14–20 | 10–14 | 19–25 |
| Severe | 21–27 | 15–19 | 26–33 |
| Very severe | + 28 | + 20 | + 33 |
Given that the DASS-21 is a condensed version of the original 42-item DASS, the score for each subscale needs to be doubled to determine the final score.
As per the guidelines, the resulting scores are then categorized as: “normal, mild, moderate, severe, or extremely severe.“ [22, 23]. Lavibond (1995) reported the validity of the DASS-21 questionnaire as 0.77, and its Cronbach’s alpha coefficient in each domain was: Total: 0.83, Anxiety: 0.84, Depression:0.89 and Stress:0.82 [22]. This tool was examined in the Iranian population and the internal consistency of the DASS scales was calculated using Cronbach’s alpha and the following results were obtained: Depression scale 0.77, Anxiety scale 0.79, Stress scale 0.78 [24].
Marital satisfaction was measured using the Persian and validated version of the 35-item Enrich Couple Marital Satisfaction Questionnaire [25, 26]. The scale uses a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with reverse scoring on 19 items. It has four components: marital satisfaction (10 items), communication (10 items), conflict resolution (10 items), and ideal distortion (5 items). Higher total scores indicate greater marital satisfaction. Component raw scores are also reported [27–29]. Marital satisfaction levels are categorized based on percentage scores: high dissatisfaction (< 15%), somewhat dissatisfied (16–35%), somewhat satisfied (36–60%), high satisfaction (61–80%), and high satisfaction in all dimensions (> 80%) [30].
Vahidi et al. (2013) found the scale had good psychometric properties, with acceptable reliability for the total scale (α = 0.81) and components: marital satisfaction, communication, conflict resolution (α = 0.71), and ideal distortion (α = 0.78) [31].
In the current sample, the DASS-21 subscales demonstrated acceptable internal consistency: depression (α = 0.85), anxiety (α = 0.79), and stress (α = 0.81). The ENRICH subscales also showed good reliability: communication (α = 0.88), conflict resolution (α = 0.82), idealistic distortion (α = 0.77), and overall marital satisfaction (α = 0.90).
Selection of predictor variables
Spouse’s education and tobacco use were chosen as predictors based on theory and prior HPV outcome links. Relationship duration, sexual satisfaction, and HPV symptom severity were excluded due to data limitations but warrant future study for a fuller analysis.
Statistical analysis
Quantitative variables were described with means and standard deviations; qualitative with frequencies and percentages. Normality was assessed by Kolmogorov-Smirnov test. Univariate linear relationships were analyzed using Mann-Whitney (two-state quantitative-qualitative), Kruskal-Wallis (multi-state quantitative-qualitative), and Spearman correlation (quantitative-quantitative) tests. A significance level of 0.3 maximized variable inclusion in a backward stepwise multiple regression model (p < 0.05, borderline significance up to p < 0.09) to examine predictors of marital satisfaction. Due to the study’s exploratory nature, multiple comparisons were not adjusted for, increasing Type I error risk, and thus results should be interpreted cautiously.
Results
This study included 238 married women aged 20–44 (mean age 27.47 ± 5.24 years) with HPV. Sample characteristics are shown in Table 1.
Table 1.
Description of participants based on individual factors (Demographic variables and tobacco use)
| Variable | Frequency | Percentage |
|---|---|---|
| Age Group (Years) | ||
| 20 to 35 | 221 | 86.92% |
| Above 35 | 17 | 7.14% |
| Education Level | ||
| Below high school diploma | 109 | 45.80% |
| High school diploma | 93 | 39.07% |
| University degree | 36 | 15.13% |
| Spouse’s Education Level | ||
| Below high school diploma | 117 | 49.16% |
| High school diploma | 100 | 42.02% |
| University degree | 21 | 8.82% |
| Employment Status | ||
| Yes | 171 | 71.85% |
| No | 67 | 28.15% |
| Spouse’s Employment Status | ||
| Worker or employee | 108 | 45.38% |
| Self-employed | 53 | 22.27% |
| Other | 77 | 32.35% |
| Family Income Level | ||
| Insufficient | 30 | 12.60% |
| Relatively sufficient | 175 | 73.53% |
| Sufficient | 33 | 13.87% |
| History of Tobacco Use | ||
| Yes | 103 | 43.28% |
| No | 135 | 56.72% |
| Spouse’s History of Tobacco Use | ||
| Yes | 158 | 66.39% |
| No | 80 | 33.61% |
Participants exhibited the following mean scores: depression (15.55 ± 2.22), anxiety (15.84 ± 2.42), and stress (16.76 ± 1.99). Depression severity: normal/mild (17.23%, n = 41), moderate (81.93%, n = 195), severe/very severe (0.84%, n = 2). Anxiety severity: normal/mild (1.26%, n = 3), moderate (22.69%, n = 54), severe/very severe (76.05%, n = 181). Stress severity: normal/mild (81.51%, n = 194), moderate (18.49%, n = 44). Marital satisfaction subscales (Marital Satisfaction, Communication, Conflict Resolution) had moderate mean scores (44–46% of max). Conflict Resolution had the highest mean (22.48 ± 3.86), Communication the lowest (22.18 ± 3.89). Idealistic Distortion mean was 12.48 ± 3.43 (49.9% of max), indicating moderate-to-high idealization. Total marital satisfaction (112.80) suggests moderate-to-low satisfaction.(Table 2).
Table 2.
Description of total marital satisfaction score and its components
| Variable | Mean ± SD | Minimum | Maximum |
|---|---|---|---|
| Total Marital Satisfaction Score | 112.80 ± 17.38 | 60 | 163 |
| Marital Satisfaction | 22.97 ± 4.18 | 13 | 37 |
| Communication | 22.18 ± 3.89 | 13 | 34 |
| Conflict Resolution | 22.48 ± 3.86 | 13 | 33 |
| Idealistic Distortion | 12.48 ± 3.43 | 6 | 21 |
By measuring the normality of quantitative variables using the Kolmogorov-Smirnov test, it was found that all quantitative variables (age, scores of depression, anxiety, and stress components, and scores of marital satisfaction components) were not normal (P < 0.05).
Table 3 shows significant correlations between: age and marital satisfaction (P = 0.016) & idealistic distortion (P = 0.002); depression and conflict resolution (p = 0.306); anxiety and communication (P = 0.241) & idealistic distortion (P = 0.307); stress and marital satisfaction (P = 0.306), communication (P = 0.034), & idealistic distortion (P = 0.107). Significant associations for dichotomous variables included women’s employment with marital satisfaction (P = 0.203) & idealistic distortion (P = 0.048); women’s tobacco use with communication (P = 0.051) & conflict resolution (P = 0.300); spouse’s tobacco use with marital satisfaction (P = 0.089), communication (P = 0.183), & conflict resolution (P = 0.221). For multi-level variables, women’s education related to marital satisfaction (P = 0.187) & idealistic distortion (p = 0.008); spouse’s education related to marital satisfaction (P = 0.280), conflict resolution (P = 0.310), & idealistic distortion (P = 0.025). Multiple regression models predicted each Enrich component based on variables with significant univariate relationships (Table 4).
Table 3.
Examination of univariate linear relationships between dimensions of marital satisfaction with psychological and individual factors (demographic variables and tobacco use)*
| Marital satisfaction | ||||||||
|---|---|---|---|---|---|---|---|---|
| Variable | Marital satisfaction | Communications | Conflict resolution | Distortion of ideal | ||||
| Index | p-value | Index | p-value | Index | p-value | Index | p-value | |
| Age | −0.155 | 0.016ᵃ | −0.010 | 0.877ᵃ | −0.044 | 0.500ᵃ | −0.196 | 0.002ᵃ |
| Depression | 0.025 | 0.696ᵃ | −0.040 | 0.543ᵃ | 0.058 | 0.306ᵃ | 0.043 | 0.514ᵃ |
| Anxiety | −0.053 | 0.420ᵃ | 0.076 | 0.241ᵃ | 0.027 | 0.677ᵃ | −0.064 | 0.307ᵃ |
| Stress | 0.060 | 0.306ᵃ | −0.137 | 0.034ᵃ | 0.051 | 0.436ᵃ | 0.105 | 0.107ᵃ |
| Qualitative variables - index: (average rank) standard deviation ± mean | ||||||||
| Education Level | ||||||||
| Less than Diploma | 23.36 ± 4.213 (126.76) | 0.187ᵇ | 22.28 ± 3.825 (122.71) | 0.478ᵇ | 22.30 ± 3.790 (117.37) | 0.460ᵇ | 12.67 ± 3.408 (123.71) | 0.008ᵇ |
| Diploma | 22.41 ± 4.087 (109.41) | 22.38 ± 3.850 (120.62) | 22.90 ± 3.736 (125.68) | 11.78 ± 3.329 (104.68) | ||||
| University | 23.28 ± 4.287 (123.57) | 21.33 ± 4.168 (106.90) | 21.94 ± 4.355 (109.97) | 13.72 ± 3.436 (145.03) | ||||
| Spouse’s Education Level | ||||||||
| Less than Diploma | 22.56 ± 4.071 (113.42) | 0.280ᵇ | 22.36 ± 3.836 (122.96) | 0.744ᵇ | 22.84 ± 3.904 (124.55) | 0.310ᵇ | 12.16 ± 3.240 (113.81) | 0.025ᵇ |
| Diploma | 23.20 ± 4.163 (122.92) | 21.97 ± 3.828 (115.94) | 22.24 ± 3.788 (117.02) | 12.48 ± 3.540 (118.14) | ||||
| University | 24.24 ± 4.732 (137.10) | 22.14 ± 4.564 (117.17) | 21.67 ± 3.916 (103.19) | 14.29 ± 3.552 (157.71) | ||||
| Employment Status | ||||||||
| Yes | 22.78 ± 4.377 (115.96) | 0.203ᶜ | 22.29 ± 4.002 (121.32) | 0.514ᶜ | 22.57 ± 3.790 (121.84) | 0.401ᶜ | 12.20 ± 3.312 (113.99) | 0.048ᶜ |
| No | 23.46 ± 3.624 (128.54) | 21.88 ± 3.591 (114.86) | 22.25 ± 4.050 (113.54) | 13.21 ± 3.645 (133.55) | ||||
| Spouse’s Employment Status | ||||||||
| Worker or Employee | 23.23 ± 3.888 (125.88) | 0.234ᵇ | 22.01 ± 3.824 (117.79) | 0.167ᵇ | 23.08 ± 3.958 (128.81) | 0.138ᵇ | 12.30 ± 3.299 (115.91) | 0.009ᵇ |
| Self-employed | 23.34 ± 4.875 (122.15) | 21.57 ± 4.069 (122.15) | 22.08 ± 3.826 (115.93) | 13.72 ± 3.634 (144.19) | ||||
| Other | 22.36 ± 4.055 (108.73) | 22.83 ± 3.806 (108.73) | 21.92 ± 3.705 (108.90) | 11.90 ± 3.303 (107.55) | ||||
| Family Income Level | ||||||||
| Insufficient | 22.60 ± 3.979 (110.32) | 0.474ᵇ | 22.87 ± 4.006 (129.97) | 0.581ᵇ | 21.30 ± 2.628 (97.57) | 0.069ᵇ | 12.73 ± 3.373 (126.85) | 0.182ᵇ |
| Moderately Sufficient | 23.15 ± 4.143 (122.76) | 22.01 ± 3.899 (116.88) | 22.50 ± 4.013 (119.87) | 12.68 ± 3.453 (122.02) | ||||
| Sufficient | 22.36 ± 4.602 (110.56) | 22.45 ± 3.751 (123.86) | 23.48 ± 3.759 (137.47) | 11.48 ± 3.299 (99.47) | ||||
| History of Tobacco Use | ||||||||
| Yes | 22.80 ± 4.324 (116.07) | 0.500ᶜ | 21.62 ± 3.716 (109.56) | 0.051ᶜ | 22.27 ± 3.820 (114.30) | 0.300ᶜ | 12.34 ± 3.446 (116.03) | 0.495ᶜ |
| No | 23.11 ± 4.082 (122.12) | 22.60 ± 3.976 (127.08) | 22.64 ± 3.895 (123.47) | 12.59 ± 3.430 (122.15) | ||||
| Spouse’s History of Tobacco Use | ||||||||
| Yes | 22.64 ± 4.195 (114.12) | 0.089ᶜ | 21.92 ± 3.971 (115.28) | 0.183ᶜ | 22.68 ± 3.738 (123.37) | 0.221ᶜ | 12.42 ± 3.343 (118.93) | 0.856ᶜ |
| No | 23.64 ± 4.104 (130.12) | 22.68 ± 3.693 (127.83) | 22.09 ± 4.082 (111.85) | 12.60 ± 3.620 (120.63) | ||||
Table 4.
Final model of multiple linear regression analysis using the backward method
| Criterion variable | Predictor variable | B (SE) | 95% CI | Standardized β | p-value | f² |
|---|---|---|---|---|---|---|
| Marital Satisfactionᵃ | Intercept | 23.774 (1.716) | (20.392, 27.155) | – | – | – |
| Age | −0.102 (0.051) | (−0.202, −0.002) | −0.128 | 0.045 | 0.015 | |
| Education | −1.187 (0.477) | (−2.127, −0.247) | −0.204 | 0.014 | 0.025 | |
| Spouse’s Education | 1.533 (0.528) | (0.493, 2.573) | 0.237 | 0.004 | 0.034 | |
| Spouse’s Tobacco Use | 1.172 (0.563) | (0.063, 2.280) | 0.133 | 0.038 | 0.016 | |
|
Adjusted R² for initial model (adjusted R² for final model) 0.080 (0.069) | ||||||
| Communicationᵇ | Intercept | 22.045 (2.581) | (16.960, 27.131) | – | – | – |
| Anxiety Component | 0.182 (0.107) | (−0.029, 0.394) | 0.114 | 0.090 | 0.013 | |
| Stress Component | −0.252 (0.131) | (−0.510, −0.005) | −0.129 | 0.050 | 0.016 | |
| Tobacco Use | 0.939 (0.504) | (−0.055, 1.932) | 0.120 | 0.064 | 0.007 | |
|
Adjusted R² for initial model (adjusted R² for final model) 0.046 (0.037) | ||||||
| Conflict Resolutionᶜ | Intercept | 26.002 (1.147) | (23.742, 28.262) | – | – | – |
| Spouse’s Employment | −0.644 (0.283) | (−1.201, −0.088) | −0.146 | 0.023 | 0.019 | |
| Family Income Level | −1.164 (0.479) | (−2.108, −0.221) | −0.156 | 0.016 | 0.026 | |
|
Adjusted R² for initial model (adjusted R² for final model) 0.068 (0.042) | ||||||
| Idealistic Distortionᵈ | Intercept | 14.042 (1.307) | (11.467, 16.617) | – | – | – |
| Age | −0.099 (0.042) | (−0.181, −0.017) | −0.151 | 0.019 | 0.017 | |
| Spouse’s Education | 0.727 (0.339) | (0.060, 1.394) | 0.137 | 0.033 | 0.018 | |
|
Adjusted R² for initial model (adjusted R² for final model) 0.081 (0.043) | ||||||
a: The variables age, stress, education, spouse’s education, employment, spouse’s employment, and spouse’s tobacco use were initially entered into the model
b: The variables anxiety, stress, spouse’s employment, tobacco use, and spouse’s tobacco use were initially entered into the model
c: The variables depression, spouse’s education, spouse’s employment, family income level, tobacco use, and spouse’s tobacco use were initially entered into the model
d: The variables age, anxiety, stress, education, spouse’s education, employment, spouse’s employment, and family income level were initially entered into the model
Backward regression revealed significant predictors: Marital satisfaction (R²adj = 0.069) was predicted by age (β=−0.128), education (β=−0.204), spouse’s education (β = 0.237), and spouse’s tobacco use (β = 0.133), with spouse’s education having the largest effect (f²=0.034). Communication (R²adj = 0.037) was predicted by anxiety (β = 0.114), stress (β=−0.129), and tobacco use (β = 0.120), with stress having the greatest effect (f²=0.016). Conflict resolution (R²adj = 0.042) was predicted by spouse’s employment (β=−0.146) and family income (β=−0.156), with income having the largest effect (f²=0.026). Idealistic distortion (R²adj = 0.043) was predicted by age (β=−0.151) and spouse’s education (β = 0.137), with age having a slightly larger effect (f²=0.017).
Discussion
A study in Babol, Iran, found that demographic factors (age, education, spouse’s education, spouse’s tobacco use) and psychological factors (depression, anxiety, stress) significantly predict marital satisfaction in married women with HPV. These results, measured by the Enrich Marital Satisfaction Scale, support existing literature on psychological health, socio-demographics, and marital dynamics in chronic illness, and can be interpreted using the Systemic-Transactional Model (STM) [11, 19],which views HPV diagnosis as a dyadic stressor spilling over to both partners, potentially disrupting communication and support processes.
Demographic factors and marital satisfaction
Regression showed age, education, spouse’s education, and spouse’s tobacco use predicted marital satisfaction. STM suggests higher spouse education improves dyadic coping and stress communication, buffering HPV-related strain. This aligns with research linking higher partner education to better communication and conflict resolution, enhancing marital satisfaction, as education influences cognitive emotion regulation (Akbari et al.) [32].
Younger women reported higher marital satisfaction, possibly due to shorter marriages or greater adaptability to health challenges. This aligns with Hyun et al. (2021), who found younger individuals handle health stressors better, sustaining relationship satisfaction [33].
Our finding that a spouse’s smoking relates to lower marital satisfaction aligns with research showing health-risk behaviors like smoking harm relationship quality (Homish & Leonard, 2005) [34].
Multivariate analysis showed higher education in women correlated with lower marital satisfaction (β=−0.204, p = 0.014), also seen in idealistic distortion (p = 0.008, univariate). This may result from awareness of gender disparities and expectations for egalitarianism conflicting with Iranian norms (vahidi et al., 2023) [35]. In stigma-sensitive contexts like Iran, where women’s autonomy is frequently curtailed by familial and societal pressures, higher education can amplify perceptions of inequity, leading to reduced satisfaction despite potential economic benefits (Sorokowski et al., 2017) [36]. Similar dynamics have been documented in other traditional cultures; for instance, in India, Vikram (2024) [37] found that more educated women initially report lower marital quality due to tensions between their aspirations for independence and entrenched patriarchal expectations, though long-term equality may mitigate this over time. These findings underscore the need for culturally tailored interventions that address expectation-reality gaps in educated Iranian couples.
Psychological factors and marital communication
Marital satisfaction’s communication dimension was significantly predicted by anxiety, stress (largest effect), and women’s tobacco use. Stress impairs effective marital communication, aligning with Kakman et al. (2022) who found stress correlates with emotional dysregulation hindering interpersonal communication [38]. High anxiety (76%) may worsen communication in couples, causing avoidance or misinterpretation. Anxiety and stress likely impair coping and communication, increasing tension in HPV-affected couples.
Women’s tobacco use also influenced communication, potentially reflecting coping mechanisms for stress or HPV-related stigma, which may disrupt open dialogue with partners. Although not directly addressed in the cited studies, Akbari et al. [32] suggest that health-related behaviors, including substance use, can impact emotional regulation and relational dynamics, providing a plausible link.
Conflict resolution and socioeconomic factors
Spouse’s employment and family income predicted conflict resolution, with income having a slightly stronger effect. Socioeconomic stability aids marital conflict management, especially with chronic illness. Lower income increases stress and limits resources, hindering conflict resolution, as supported by Fowers and Olson [25], who developed the Enrich scale and noted that socioeconomic factors significantly influence marital dynamics [39]. Additionally, the study by Vahidi et al. [35]. Enrich scale reliably measures socioeconomic factors affecting conflict resolution in Iranians. Socioeconomic stability may foster collaborative coping in couples, aiding HPV management, aligning with STM principles.
The spouse’s employment status as a predictor suggests that occupational stability may contribute to a supportive marital environment, reducing conflict. This aligns with broader literature on socioeconomic determinants of marital quality, though specific references to HPV-related contexts are limited.
Ideal distortion and cognitive factors
Age and spouse’s education predicted idealization of marriage. Younger women with more educated spouses showed greater idealization, possibly coping with HPV stress. This aligns with prior research [25], who noted that ideal distortion can serve as a buffer against relational dissatisfaction [39]. The role of spouse’s education further suggests that cognitive resources, such as problem-solving skills, may influence idealized perceptions, as supported by Vahidi et al. [35]. Higher idealistic distortion among younger women and those with educated spouses may reflect a protective common dyadic coping strategy, idealizing the relationship to maintain unity against HPV stigma [11].
STM explains how HPV distress and demographics impair dyadic coping, lowering marital satisfaction. Interventions boosting coping skills (communication, joint coping) could help. Findings show individual, psychological, and socioeconomic factors affect marital satisfaction in women with HPV. Stress/anxiety suggest CBT is needed for women and partners. Education/income indicate public health should address socioeconomic barriers to improve marital outcomes.
Limitations
This study has several limitations that should be considered when interpreting the findings:
Sampling method: Convenience sampling from a single clinic may limit the representativeness of the sample.
Generalizability: Results may not be applicable to other regions, cultural contexts, or unmarried women affected by HPV.
Measurement bias: Data were collected using self-report questionnaires, which could introduce social desirability or reporting bias.
Missing variables: Key relationship- or HPV-related clinical variables, such as time since diagnosis, partner infection status, and symptom severity, were not assessed and may confound observed associations.
By explicitly acknowledging these limitations, the study provides transparency and supports replication efforts, while still offering insights into factors influencing marital satisfaction among women affected by HPV.
Recommendations for future research
Based on our findings, several practical recommendations can be made for healthcare providers, counselors, and marital therapists. Integrating HPV-related counseling into routine healthcare services can provide affected women with accurate information and emotional support. Implementing mental health screening for anxiety and depression allows timely psychological interventions or referrals. Additionally, communication-based interventions for couples may enhance relationship quality, reduce stress, and support marital satisfaction in the context of HPV. These strategies bridge research findings with clinical practice, offering actionable guidance to improve the well-being of women and couples affected by HPV.
Conclusion
This study identified key predictors of marital satisfaction among married women with HPV, including age, education, spouse’s education, tobacco use, anxiety, stress, employment status, and income. The findings highlight the important role of both psychosocial and socioeconomic factors in marital well-being. Addressing these factors through integrated psychological support and counseling can help improve marital satisfaction in this population.
Supplementary Information
Acknowledgements
We thanks to clinical research development unit of rohani hospital.
Author contributions
Conceptualization: NAT and MG, Data curation: MG, NAT, ZF.Formal analysis: MG and ZF, Methodology: MG, NAT, ZF.Project administration NAT and MG.,Resources: MG, NAT.Supervision: MG, NAT, Validation: MG, NAT.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Data availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This survey was carried out in accordance with the guidelines of the Declaration of Helsinki, was approved by the Ethics Committee of Babol University of Medical Sciences (Ethics Code: IR.MUBABOL.HRI.REC.1404.043), and written informed consent was obtained from all individual participants who participated in the study. Also, all methods are carried out in accordance with relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Organization WH. WHO recommendations on self-care interventions: human papillomavirus (HPV) self-sampling as part of cervical cancer screening and treatment. World Health Organization; 2023. [Google Scholar]
- 2.Akbar SN, Nikoozadeh EK, Rafieipour A. Effects of acceptance and commitment Therapy-Based intervention on Biological, Psychological, and social indicators of women aged 35–65 Years with Human Papillomavirus Infection. 2024.
- 3.Joharinia N, Mousavi-Nejad SA, Farhadi A, Safaei A, Hosseini SY, Sarvari J. The frequency of High-Risk and Low-Risk human papillomavirus genotypes in different grades of cervical lesions in Shiraz, South-West of Iran. Iran J Med Microbiol. 2023;17(2):161–6. [Google Scholar]
- 4.Bagherinia M, Dolatian M, Mahmoodi Z, Ozgoli G. Prevalence of genital human papillomavirus in suburban women: a systematic review and meta-analysis. Iran J Obstet Gynecol Infertil. 2023;26(7):80–93. [Google Scholar]
- 5.Qaderi K, Mirmolaei ST, Geranmayeh M, Sheikh Hasani S, Farnam F. Iranian women’s psychological responses to positive HPV test result: a qualitative study. BMC Womens Health. 2021;21(1):128. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Taebi M, Riazi H, Keshavarz Z, Afrakhteh M. Knowledge and attitude toward human papillomavirus and HPV vaccination in Iranian population: a systematic review. Asian Pac J Cancer Prevention: APJCP. 2019;20(7):1945–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Ibrahim IAE. Unveiling the hidden barriers: a review of stigma associated with infectious diseases and its impact on prevention and control. J Pharm Bioallied Sci. 2025;17(Suppl 1):S166-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Dom NC, Dapari R, Harith Mohamad Syahriman MA, Mohd Sukri AA, Azwa Kamarudin NL, Aqilah Ahmad Bakhtiar NS, et al. Mapping the hidden epidemic: a scoping review of sexually transmitted diseases in Southeast Asia. Int J STD AIDS. 2025. 10.1177/09564624251349598. [DOI] [PubMed] [Google Scholar]
- 9.Tehranian A, Dastjerdi MV, Hatamian S, Ghahghaei-Nezamabadi A. Sexual function and quality of life in Iranian women with human papillomavirus infection. J Fam Reprod Health. 2024;18(3):154. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Zhu J, Gao J, Lu R, Yang R, Ma X, Yang Y. The impact of HR-HPV infection on women’s cognition. Psychology, and Behavior: A Qualitative Study; 2025. [Google Scholar]
- 11.Falconier MK, Kuhn R. Dyadic coping in couples: a conceptual integration and a review of the empirical literature. Front Psychol. 2019;10:571. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Jiménez-Picón N, Romero-Martín M, Ramirez-Baena L, Palomo-Lara JC, Gómez-Salgado J. Systematic review of the relationship between couple dyadic adjustment and family health. Children. 2021;8(6):491. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Leite V, Santos BD, Pereira MG. Psychosocial impact of human papillomavirus on women’s sexual dissatisfaction and quality of life. J Psychosom Obstet Gynecol. 2019;40(3):232–8. [DOI] [PubMed] [Google Scholar]
- 14.Bitarafan F, Hekmat MR, Khodaeian M, Razmara E, Ashrafganjoei T, Gilani MM, et al. Prevalence and genotype distribution of human papillomavirus infection among 12 076 Iranian women. Int J Infect Dis. 2021;111:295–302. [DOI] [PubMed] [Google Scholar]
- 15.Amini S, Mardanirad M, Khosravi Babadi AA, Poshaneh K. The structural model of marital satisfaction based on relational beliefs with the mediating role of cognitive emotion regulation in married women. Shenakht J Psychol Psychiatry. 2024;11(3):99–109. [Google Scholar]
- 16.Bradbury TN, Fincham FD. Attributions in marriage: review and critique. Psychol Bull. 1990;107(1):3. [DOI] [PubMed] [Google Scholar]
- 17.Bradbury TN. The longitudinal course of marital quality and stability: a review of theory, methods, and research. Psychol Bull. 1995;118(1):3–34. [DOI] [PubMed] [Google Scholar]
- 18.Donato S, Pagani AF, Rosta-Filep O, Faggiano M, Pajardi D, Martos T, et al. Partners’ internal stress and well-being: the role of dyadic coping and problem resolution. Personal Relationships. 2023;30(1):332–52. [Google Scholar]
- 19.Bodenmann G. Dyadic coping and its significance for marital functioning. 2005.
- 20.Mahdoodizaman M, Razaghi S, Amirsardari L, Hobbi O, Ghaderi D. The relationship between interpersonal cognitive distortions and attribution styles among divorce applicant couples and its impact on sexual satisfaction. Iran J Psychiatry Behav Sci. 2016;10(3):e5644. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.McBride E, Tatar O, Rosberger Z, Rockliffe L, Marlow LA, Moss-Morris R, et al. Emotional response to testing positive for human papillomavirus at cervical cancer screening: a mixed method systematic review with meta-analysis. Health Psychol Rev. 2021;15(3):395–429. [DOI] [PubMed] [Google Scholar]
- 22.Lovibond S, Lovibond P. Manual for the depression anxiety stress scales. Sydney: Psychology Foundation. 101037/t01004-000. 1995.
- 23.Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample. Psychol Assess. 1998;10(2):176. [Google Scholar]
- 24.Sahebi A, Asghari M, Salari R. Validation of depression anxiety and stress scale (DASS-21) for an Iranian population. Full Text in Persian. 2005.
- 25.Fowers BJ, Olson DH. ENRICH marital inventory: a discriminant validity and cross-validation assessment. J Marital Fam Ther. 1989;15(1):65–79. [DOI] [PubMed] [Google Scholar]
- 26.Sanaei B, Zaker B, Alaghband S, Falahati M. Psychometric properties of the short form of the ENRICH marital satisfaction questionnaire. J Fam Res. 2008;4(2):155–70. [Google Scholar]
- 27.Hayati R, Zahrani ST, Ali Akbari SA, Zadeh EF. A Descriptive Comparative Study of Marital Satisfaction among Healthy Women and Women with Breast Cancer. J midwifery reproductive health. 2022;10(4):1. [Google Scholar]
- 28.Nouri M, Kebria MH, Ahmadianfar F, Khosravi A. Marital satisfaction and related factors among married women. Shahroud J Med Sci. 2018. 10.22100/ijhs.v4i4.480. [Google Scholar]
- 29.Karami M, Ahmadi S, Ghobadi S. Prediction of marital satisfaction based on happiness and quality of life in couples in Tehran. Knowl Res Appl Psychol. 2021;22(1):93–102. [Google Scholar]
- 30.Takbiri Boroujeni A, Imeni M, Gilasi HR, Amerian M. Comparison of marital satisfaction in the elderly and non-elderly and related factors in 2012. Prev Care Nurs Midwifery J. 2020;10(1):31–8. [Google Scholar]
- 31.vahidi f, Entezar RK, Hassani f, golshani f. Investigation of psychometric properties of Enrich Couple Inventory of married women residing in Tehran. Psychometry. 2024;12(46):70–82. [Google Scholar]
- 32.Akbari E, Mashhadi A, Azimi Z, Nazhad RA, Pichakolaei AA. Comparing cognitive emotion regulation, stress, depression, anxiety, and stress related to life events in people with and without periodontal disease. J Dent Med. 2018;30(4):230–42. [Google Scholar]
- 33.Hyun J, Quinn B, Madon T, Lustig S. Mental health need, awareness, and use of counseling services among international graduate students. J Am Coll Health: JACH. 2007;56(2):109–18. [DOI] [PubMed] [Google Scholar]
- 34.Homish GG, Leonard KE. Spousal influence on smoking behaviors in a US community sample of newly married couples. Soc Sci Med. 2005;61(12):2557–67. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Vahidi. validated the psychometric properties of the Enrich scale in Iran, noting its sensitivity to socio-demographic influences, supporting the relevance of education in marital satisfaction. J Marital Satisfaction. 2023. 10.1177/02654075221095052. [Google Scholar]
- 36.Sorokowski P, Randall AK, Groyecka A, Frackowiak T, Cantarero K, Hilpert P, et al. Marital satisfaction, sex, age, marriage duration, religion, number of children, economic status, education, and collectivistic values: data from 33 countries. Front Psychol. 2017;8:1199. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Vikram K. Modern marriage in a traditional society: the influence of college education on marriage in India. J Fam Issues. 2024;45(5):1116–41. [Google Scholar]
- 38.Kakemam E, Navvabi E, Albelbeisi AH, Saeedikia F, Rouhi A, Majidi S. Psychometric properties of the Persian version of Depression Anxiety Stress Scale-21 Items (DASS-21) in a sample of health professionals: a cross-sectional study. BMC Health Serv Res. 2022;22(1):111. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Nunes C, Martins C, Leal A, Pechorro P, Ferreira LI, Ayala-Nunes L. The ENRICH marital satisfaction (EMS) scale: a psychometric study in a sample of Portuguese parents. Soc Sci. 2022;11(3):107. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.