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. 2020 Oct 25;8(5):2007–2017. doi: 10.1002/nop2.657

A systematic review of social determinants of healthy lifestyle among Iranian women

Sakineh Ghasemi Yngyknd 1, Mohammad Asghari Jafarabadi 2,3, Solmaz Ghanbari‐Homayi 4, Delara Laghousi 5, Mojgan Mirghafourvand 6,✉
PMCID: PMC8363399  PMID: 34388863

Abstract

Aim

This review aimed to determine the social determinants of healthy lifestyle among Iranian women.

Design

A systematic review and meta‐analysis.

Method

A comprehensive electronic search was carried out with no time limit until 6 September 2019. Newcastle–Ottawa Quality Assessment Scale (adapted for evaluating cross‐sectional survey/studies) was used to evaluate the quality of the articles. The metap code was used in SATATA16 to combine the p‐values using Edgington's additive method.

Results

Twelve studies entered the systematic review. The meta‐analysis results showed that social determinants of healthy lifestyle among Iranian women included income, job, education, spouse's education and occupation, housing and social support.

Conclusions

Given the relationship between modifiable factors and women's lifestyles, it seems that it is necessary to set policies to improve the status of factors related to women's lifestyle including reducing poverty, promoting education and providing social support to eliminate.

Keywords: health behaviour, Iran, lifestyle, social determinants of health, women

1. INTRODUCTION

The World Health Organization (WHO) defines social determinants of health as the environment where people are born, grow, work and age (Marmot et al., 2008). This environment is shaped by the distribution of money, power and resources at the national, regional and global levels that are by themselves influenced by political choices. Social determinants account for a bulk of the inequities (unjust and avoidable differences in health status seen within countries) (WHO, 2020). Key social determinants of health include socio‐economic status, education, income, early childhood, social isolation (caused by discrimination, unemployment and defamation), social capital (intragroup and intergroup relationships), occupation, housing and the environment surrounding the place of residence (Welfare, 2016). Social determinants of health can identify individuals by adjustable behavioural and medical risk factors (Raphael, 2011). Social inequalities in health are associated with social differences in lifestyle and behaviour (WHO, 2010).

Healthy lifestyles range from appropriate behaviours, activities and performances such as adequate levels of physical activity, healthy sleep patterns, for example adequate rest, the ability to adapt to stress, the ability to enjoy family and community support, working in a favourite job, recreational activities and devoting sufficient time for spiritual and mental development, health and well‐being (Stanhope & Lancaster, 2016). Individuals themselves choose their own lifestyles, but their choices are influenced by their social circumstances. Thus, peoples’ behaviours are a result of their choices within the existing opportunities (Cockerham et al., 1997). In fact, structural determinants of inequality in health affect health through a set of mediating factors which include material conditions such as the quality of neighbourhood and housing, consumption potential (e.g. affording the purchase of healthy food, warm clothing) and workplace conditions, psychosocial conditions (e.g. psychological stressors, living conditions and stressful relationships, social support and coping styles), as well as behavioural and biological factors (e.g. nutrition, physical activity, tobacco and alcohol use), which are heterogeneously distributed across different social groups. Biological factors include genetic factors, and healthcare system itself is recognized as a social determinant (WHO, 2010).

Women experience various issues (puberty, fertility, menopause, etc.) during their life, and in addition to biological and fertility issues, lifestyle issues and socio‐economic status also affect their health (WHO, 2009). Women with low socio‐economic status become menopausal sooner than the ones with higher socio‐economic status. In addition to genetic factors, cumulative effects in life stages such as childhood nutrition, stress, nulliparity, obesity, sedentary lifestyle and smoking are associated with premature menopause (Dratva et al., 2009). Also, poor educational level and economic status are related to different health dimensions in women of reproductive age (Baheiraei et al., 2015).

In line with the sustainable development, progresses in maternal and child health depend on several key determinants and a wide range of interventions are required in both the health care and social determinants of health (Bishai et al., 2016). Removing economic and social inequalities needs an understanding of the variables, mechanisms and cause–effect relationships (Bayati et al., 2012). Many of the health differences are directly related to social inequalities and their impacts on lifestyle (White et al., 2009). Given the importance of a healthy lifestyle in promoting women's health (WHO, 2009) and that we did not find studies that collected evidence about social factors related to Iranian women's lifestyle, we conducted this systematic review. The question of this review was as follows: What are the social determinants of a healthy lifestyle among Iranian women?

2. METHODS

2.1. Literature selection

The present review study was performed based on the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) guidelines. A comprehensive electronic search of English (PubMed, Cochrane Library, Embase, ProQuest, Scopus, Web of science) and Persian (SID, Magiran, IranMedex) databases and the Google search engine with equivalent keywords (Women [Mesh], Life Style [Mesh], Reproductive [Mesh], Social Determinants of Health) and a combination of words with AND and OR functions were carried out with no time limit until 6 September 2019. All published observational studies on lifestyle of Iranian women of reproductive age were reviewed. Two authors independently reviewed the titles and abstracts of the extracted articles to exclude irrelevant ones. If the abstract of an article did not have sufficient information for decision‐making, the full text of the article was checked. The disagreements between the two authors about the eligibility of the articles were resolved through discussion, and a third person (MM) was consulted if they disagreed. The search was updated on 22 October 2019, but no more studies were found to be eligible.

Cohort, case–control, nested case–control or cross‐sectional studies concerning the lifestyles of women of reproductive age in Iran were included in the study, and all qualitative studies, interventional studies and editorial letters were excluded. Both authors independently collected the following information from each study: study design, the number of participants, research setting, inclusion and exclusion criteria and data collection tools.

2.2. Assessment of methodological quality

Newcastle–Ottawa Quality Assessment Scale (adapted for evaluating cross‐sectional survey/studies) was used to evaluate the quality of the articles, and the articles were categorized into three categories of poor, moderate and good in terms of methods (cut‐off scores: high methodological quality 12 stars [achieved score > 75%], moderate methodological quality 9–11 stars [50% < achieved score < 75%], low methodological quality 0–8 stars [achieved score ≤ 50%]). Both researchers independently scored each part of the checklist (Aim [one item], maximum 2 stars, subject selection [four items] and outcome [two items] maximum 2 stars can be given in each item for selection and outcome items [maximum 8 stars for selection and 4 stars in outcome], comparability [one item] maximum one star can be given in each item for Comparability [Maximum 2 stars]). Different scores were discussed in one item until an agreement was reached. If a study achieved > 75% of the score, it was categorized as high quality methodologically (Hillen et al., 2017)].

2.3. Data collection

Each study was tabulated using a validated data collection form. This form enabled that data were extracted systematically, including an assessment of eligibility and quality. It was also used to justify why some studies were excluded. The extracted data for each study were as follows: study design and duration (years), participant (inclusion (I)/exclusion (E), number (N)), sampling method, scale, outcome definition, measure of determinant, summary of results and adjustments. Data were extracted by two authors (SGY AND SGH) separately.

The process of selecting studies is presented in Figure 1. Our search resulted in 6,109 studies from related databases, and one study was retrieved from the references of a study. Once the titles and abstracts were examined, 3,945 studies were excluded. Forty articles were selected for a full‐text review, and 28 were excluded because they did not meet the eligibility criteria or did not analyse the relationship between health‐promoting behaviours and social determinants. Finally, 12 studies entered the systematic review.

FIGURE 1.

FIGURE 1

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Study flow diagram

2.4. Statistical analysis

The metap code was used in SATATA16 to combine the p‐values using Edgington's additive method. Edgington's additive method based on the sum of probabilities (Edgington, 1972) method is suggested to combine a small number of studies, producing similar results as Fisher's method.

3. RESULTS

3.1. Description of studies

The general features of the existing articles in this systematic review are summarized in Table 1. No study was found to have directly examined the relationship between social determinants of health and women's lifestyle in Iran. The included studies comprised 11 cross‐sectional studies and one case–control study from 2012 to 2018. In all studies, health‐promoting behaviours and their related factors were analysed. In most studies (Abedi et al., 2015; Ahmadi et al., 2015; Ahmadipour & Kiarash, 2016; Amirabadizadeh et al., 2016; Anbari et al., 2015; Bakouei et al., 2017; Enjezab et al., 2012; Mirghafourvand et al., 2014; Tol et al., 2018), Walker's health‐promoting lifestyle Profile (HPLP 2) (Walker et al., 1987) was used to investigate health‐promoting behaviours. Two studies used a researcher‐made questionnaire (Mahdipour et al., 2013; Rafiee et al., 2014), and one study applied the Lifestyle Questionnaire (LSQ) designed by La'li et al. in Iran (Zare & Khaluee, 2016). Studies that subjectively examined the determinants by self‐report through one variable such as social class were excluded (Ahmadi et al., 2015).

Table 1.

Overview of study characteristics and quality assessment score

First Authors, Year Study design Sample Scale Outcome definition Measure of determinant Summary of results Adjustments Quality score Quality rating
Abedi et al. (2015) Cross‐Sectional

(N = 1,200)

I: 15 to −45‐year‐old married women referred to health centres, minimum education in reading and writing, no drug addiction. E: Menopause, pregnancy, infertility, sleep disorders, lactating women <2 months after delivery, a history of diseases such as high blood pressure, diabetes and mental health problems

Socio‐demographic characteristics,

Walker's health‐promoting lifestyle

Profile (HPLP2)

Health‐promoting behaviours,

Woman Education, Woman Occupation, Husband Education, Husband Occupation

 Logistic regression The number of children, job situation and educational level of woman, also job situation of the spouses were affected health‐promoting lifestyles (p < .05) Yes 10 62.5
Ahmadi et al. (2015) Cross‐Sectional

(N = 392) Reproductive age women (15–49 years old)

The eligibility criteria have not been reported

Socio‐demographic characteristics,

Walker's Health‐Promoting lifestyle Profile (HPLP), Health knowledge

Health‐promoting behaviours,

Woman Education, Husband Education

 Multiple regression was used for predictive factors for health‐promoting behaviours; study in health matters, Health knowledge, women's education, husbands’ education and socio‐economic class The age, education and health education, affected health knowledge (β = 0.168, 0.239 and 0.150 for age, education and health education, respectively). Health knowledge and health education affected HPLS with Beta values of 0.168 and 0.330, respectively NO 11 68.75
Ahmadipour and Kiarash (2016) Cross‐Sectional (Brief Report) (N = 400) 15‐ to 64‐year‐old women Walker's Health‐Promoting lifestyle Profile (HPLP) Persian version of the 34‐item form, demographic questionnaire

Health‐promoting behaviours,

Income, Woman Education, Woman Occupation

 Independent t test and one‐way ANOVA were used for comparing the health‐promoting lifestyle scores between two groups and between more than two groups, respectively. Linear regression was used for the analysis of variables in predicting health‐promoting lifestyle scores Employment status was a significant predictor of health‐promoting lifestyle scores (p = .04) No 10 62.5
Amirabadizadeh et al. (2016) Cross‐Sectional (N = 290) Women Age of 30 – 59 years, residence in Birjand, Iran, No communication problems, written consent for participation and no chronic and refractory disease such as cancer, cardiovascular diseases, diabetes mellitus, renal and mental disorders, hypertension and pulmonary diseases Walker's Health‐Promoting lifestyle Profile (HPLP), (SF−36) QOL questionnaire, demographic questionnaire

Health‐promoting behaviours,

Income, Woman Education, Woman Occupation, Husband Education, Husband Occupation, Housing, Quality of Life

 One‐way ANOVA and independent t test The study found the significant correlation of women's HPL with their husbands’ job No 9 56.25
Anbari et al. (2015) Cross‐Sectional (N−500) Women aged from 15 to 49 years; referring to the health centres Walker's Health‐Promoting lifestyle Profile (HPLP), demographic questionnaire

Health‐promoting behaviours,

Income, Woman Education, Woman Occupation

 Multivariate linear Regression Education level (p = .004, β = 0.15), marital status (p = .021, β = −0.1) had positive effects on health‐promoting behaviours. No 7 43.75
Bakouei et al. (2017) Cross‐Sectional (N = 330) Reproductive age women (between 15 and 49 years) without any known diseases such as severe mental retardation and mental disorders Walker's Health‐Promoting lifestyle Profile (HPLP), demographic questionnaire

Health‐promoting behaviours,

Income, Woman Education, Woman Occupation, Ethnicity, Crowding Index

 One‐way ANOVA Regarding ANOVA with a Tukey post hoc test, there was a significant difference in health‐promoting behaviours with respect to women's educational level just in illiterate/primary level in comparison with other levels (intermediate, high school and university) Yes 9 56.25
Enjezab et al. (2012) Cross‐Sectional N = 483, Middle‐aged women 40–60 years, no mental disorder and speaking problem Walker's Health‐Promoting lifestyle Profile (HPLP), demographic questionnaire

Health‐promoting behaviours,

Woman Education, Woman Occupation

 Pearson, Spearman correlation test, one‐way ANOVA and covariance analysis Positive significant correlation of HPBs with education level (p < .016, p < .001) and women's job (HPBs in retired women were significantly higher than others even after adjusting for age) Yes 10 62.5
Rafiee et al. (2014) Cross‐Sectional (N = 384), 15‐ to 45‐year‐old married women referring to health centres Researcher designed two‐section question naire includes two sections: individual profile and lifestyle (a total of 73 item) Healthy lifestyle includes: nutrition, physical activity and exercise, sleep, leisure time, fertility behaviour, personal hygiene and smoking Income, Woman Education, Woman Occupation, Ethnicity, Housing Qui‐square test Significant association between lifestyle and ethnic (p < .001), marital status (p < .004), occupation (p < .002) and income (p < .001) NO 7 43.75
Tol et al. (2018) Cross‐Sectional (N = 461), 15‐ to 49‐year‐old married women referring to health centres, No diagnosed severe mental disorders require taking medication

The second version (49 item)

Walker's Health‐Promoting lifestyle Profile (HPLP), demographic questionnaire, Oxford Happiness Inventory (OHI)

Health‐promoting behaviours,

Income, Woman Education, Woman Occupation

 Multivariate variance analysis (MANOVA)

High economic level (p < .0001), Education level (p < .0001),

Employment status (p = .004) had relationship with health‐promoting behaviours’ score

 Yes 9 56.25
Zare and Khaluee (2016) Case‐Control (N = 240) 120 Employed women working at training centres and 120 sisters of women that was not employed

La'li et al.

LSQ = life Style Questionnaire

 Health‐oriented lifestyle includes physical and psychological health, social health, spiritual health, environmental health, disease prevention, drugs and alcohol avoidance, exercise and health, weight control and nutrition, Woman Education, Woman Occupation, Housing Multivariate regression, t test and analysis of variance There was a significant relation between healthy lifestyle of employed and non‐employed women. Multiple regression analyses shows that respectively education and age explain 10% of health and lifestyle changes Yes 11 68.75
Mahdipour et al. (2013) Cross‐Sectional (N = 138) Middle‐aged women in the age of 40–50 years, exclusion criteria: having specific diet or women who had problem to do exercise or had mental disorder were excluded Researcher‐made questionnaire 40 questions in four aspects of lifestyle (nutrition, physical activity, psychological health, interpersonal relationships), Income, Woman Education Descriptive statistics, Spearman correlation test significant relationship between educational level of the samples and lifestyle No 7 43.75
Mirghafourvand et al. (2014) Cross‐Sectional (N = 1,359) Women aged 15–49 years, Eligibility criteria: Iranian, Able to speak, Residing in, Neither pregnant nor in the puerperium period, No diagnosed severe mental disorders that make her unable to respond to the questions Health‐Promoting Lifestyle Profile‐II (HPLP‐II), Personal Resource Questionnaire 85‐Part 2 (PRQ85‐Part 2), perceived social support Health‐promoting behaviours, Income, Woman Education, Woman Occupation, Husband Education, Husband Occupation, social support, Ethnicity, Crowding Index, Health Insurance, Housing, perceived social support Pearson correlation test was used to assess the association between health‐promoting behaviours and perceived social support, one‐way ANOVA for relationship between socio‐demographic characteristics and health‐promoting behaviours. Backward multivariable linear regression model was used to determine the predictive factors for health‐promoting behaviours Social support, education and crowding index predicted 29.8% of the variance of health‐promoting behaviours Yes 11 68.75
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A significant relationship has been reported between income and healthy lifestyle in three studies (Mirghafourvand et al., 2014; Rafiee et al., 2014; Tol et al., 2018). There was a significant relationship between job and healthy lifestyle in four studies (Abedi et al., 2015; Enjezab et al., 2012; Rafiee et al., 2014; Tol et al., 2018). In all included studies except of one study (Ahmadipour & Kiarash, 2016), a significant relationship has been reported between education and healthy lifestyle. For determinant of spouse's education, there was a significant relationship in three studies (Abedi et al., 2015; Ahmadi et al., 2015; Mirghafourvand et al., 2014). There was a significant relationship between spouse's job and healthy lifestyle in two studies (Abedi et al., 2015; Amirabadizadeh et al., 2016). For determinant of housing, there was a significant relationship in two studies (Rafiee et al., 2014; Zare & Khaluee, 2016). The association between health knowledge and social support with healthy lifestyle has been assessed only in one study, and a significant relationship has been reported (Ahmadi et al., 2015; Mirghafourvand et al., 2014).

3.2. Meta‐analysis results

The meta‐analysis results showed that effective predictors of healthy lifestyles among healthy Iranian women included the income variable (p = .00066) by entering 8 studies, the job variable (p = .0027242) by entering 10 studies, the education level variable (p < .001) by entering 12 studies, the spouse's occupation variable (p = .0000953) by entering 3 studies, the spouse's education level variable (p = .00137223) by entering 4 studies, the housing variable (p = .00006484) by entering 3 studies and the social support variable (p = .02) and health knowledge (p = .000) by entering 1 studies. Also, the meta‐analysis results showed that the ethnicity variable (p = .10527145) by entering 3 studies and the crowding index variable (p = .324818) by entering 2 studies were not effective predictors of healthy lifestyles among healthy Iranian women (Figure 2; Table 2).

FIGURE 2.

FIGURE 2

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Social determinants of lifestyle in Iranian women (It was drawn by second authors of this study (MAG) based on the results of included studies)

Table 2.

Number of studies included in the analysis of social determinants components and their results

Variable Number of study p
Income 8 .00066
Women Education 12 .000
Women occupation 10 .0027242
Spouse education 4 .00137223
Spouse occupation 3 .0000953
Housing 3 .00006484
Social support 1 .02
Crowding index 2 .324818
Heath knowledge 1 .000
Ethnicity 3 .10527145
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4. DISCUSSION

Our findings showed that social determinants of healthy lifestyle among healthy Iranian women included income, job, education, spouse's education and occupation, housing and social support. Health behaviours are considered a mediator for social class and health outcomes (Petrovic et al., 2018).

Income was one of the social determinants of lifestyle in the present study. High costs and financial pressures prevent women from addressing health‐promoting lifestyle (Baheiraei et al., 2013). Material resources can also affect health‐related behaviours by providing appropriate environmental conditions, including walking facilities, recreational areas and access to healthy food. Material factors may also serve as a psychosocial stress source, which may influence health‐related behaviours (WHO, 2010).

Education was another determinant of a healthy lifestyle in Iranian women. Education promotes peoples’ awareness and skills and can facilitate healthy behaviours. In addition, higher education leads to finding better jobs and higher income and can lead to health‐promoting lifestyle in a variety of ways, such as job‐related benefits, environmental opportunities and stress reduction (Panagiotakos et al., 2016; Telfair & Shelton, 2012; Virtanen et al., 2008). Education also influences health through psycho‐biological processes such as belief control, social status and affairs related to one's thinking and social relations (Egerter et al., 2009). Behavioural factors account for about half of the difference in mortality rates in cardiovascular diseases observed between the lowest and highest levels of education (Soskolne & Manor, 2010).

Another social component related to a healthy lifestyle in the present study was spouse's level of education and occupation. Spouse's occupation and education are among the components of social class (Vallot, 2019) which affect health through mediating effect of behaviours along with other structural determinants (WHO, 2010). Meanwhile, family income and one's education were found to be key determinants of a healthy lifestyle in Canada (Qi et al., 2006). According to the Iranian Statistics Center data, only 11.8% of Iranian women over 10 years of age are economically active (Portal, 2016‐2017), which reveals they are dependent on the family in terms of the income component. In the present review study, most participants were married women of childbearing age, so the husbands’ income was as effective as the women's income. In the Kave Firouz et al.’s (2017) study, employed women had a healthier lifestyle than non‐employed women and women with higher education and college degree had a healthier lifestyle.

Another social component related to a healthy lifestyle in the present review was social support. A study by Adams et al. (2017) has shown the association between social support and health‐promoting lifestyle in rural women. A qualitative study also reported the lack of social support to be a barrier to women's adopting health‐promoting behaviours during reproductive age (Baheiraei et al., 2013). In Ahmadi's review study (2016), there was a relationship between social support and health‐promoting lifestyle in both sexes. Another study conducted on 3,124 patients with coronary heart diseases in Iran also showed that social support is the most important variable of healthy lifestyle in them (Keyvan & Ahmadzadeh, 2016). The results of two above mentioned studies are consistent with the results of the present systematic review. Therefore, it is important to improve social support to change unhealthy lifestyles and to adopt health‐promoting behaviours. Social support is a multidimensional concept defined as feeling being attended to by others and belonging to a social network. Social support is divided into four domains: emotional, instrumental, informational and appraisal (Vaux, 1988). When an individual enjoys social support, their response to stress reduces and they are less exposed to various diseases such as cardiovascular diseases, cancer and rheumatoid arthritis (Goodenow et al., 1990; Holahan et al., 1997; Penninx et al., 1998).

Housing was another component of the women's healthy lifestyle in this study. Housing is one of the social determinants of health (Wilkinson & Marmot, 2003) related to health behaviours including physical activity. Dimensions of housing that are effective in promoting health include its affordability, quality, stability and context (Neighbourhood opportunity) (Swope & Hernández, 2019). The included studies examined residential stability, cost of rental houses and ownership status (organizational accommodation, owning the home). The economic component is the most important factor in selecting household's housing, which is also influenced by cultural, social and geographical factors (Wong, 2002). Strategies needed to achieve equality in healthy housing include appropriate housing conditions, suitable prices and stable housing (Hernandez & Suglia, 2016).

4.1. Nursing implications

To address the social determinants of healthy lifestyle, training nurses and other health providers including midwives should be considered as one of the main principles for promoting more equitable health outcomes for women and their families as well as communities. In this systematic review, we determined the social determinants of healthy lifestyle that nurses can use from its results in their clinical practice for improving of women's lifestyle. For example, nurses can improve healthy lifestyle among women through social support, especially emotional and informational support.

4.2. Strengths and limitation

Limited sample size and not disclosing the method for estimating the sample size in half of the included studies are among the limitations of this study. Also, the low number of studies included in the analysis of some of the social determinants is another limitation. The methodological quality of most studies was categorized as moderate. Another limitation of this study is the heterogeneity in the analysis methods and differences in confounding factors. All the included studies, except one, were conducted in the provincial centres, which hold a higher level of economic and social status than other provincial cities. Finally, the nature of cross‐sectional studies is such that they are not able to detect the cause–effect relationship. One of the strengths of this study is the use of standard tools in most studies.

5. CONCLUSION

Healthy lifestyle determinant among healthy Iranian women includes adjustable components of income, job, education, spouse's education and occupation, housing and social support. It is necessary to set policies to improve the status of factors related to women's lifestyle including reducing poverty, promoting education and providing social support to eliminate inequality in women's health.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

AUTHOR CONTRIBUTION

SGY, SGH, MAJ, DL and MM participated in the study designing. SGY and SGH searched the literature and selected studies, extracted data, assessed quality and drafted the manuscript. MAJ analysed data. DL and MM revised the draft and all authors read and approved the final version of the manuscript.

ETHICAL APPROVAL

This study was approved by the ethics committee of Tabriz University of Medical Sciences (Ethics code: IR.TBZMED.REC.1397.700).

PATIENT CONSENT

Not applicable.

ACKNOWLEDGEMENTS

No acknowledgements.

Ghasemi Yngyknd S, Asghari Jafarabadi M, Ghanbari‐Homayi S, Laghousi D, Mirghafourvand M. A systematic review of social determinants of healthy lifestyle among Iranian women. Nurs Open.2021;8:2007–2017. 10.1002/nop2.657

Funding informationThis study was financed by Tabriz University of Medical Sciences.

DATA AVAILABILITY STATEMENT

Not applicable.

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