The Mediating Effect of Depression on the Relationship between Marital Satisfaction and Quality of Life in Women

Abstract

Purpose: Depression experienced during marriage affects the dynamics of marriage and life. This study aimed to examine the mediating effect of depression on the relationship between marital satisfaction and quality of life in women. Methods: The data were collected by the researchers using a Participant Information Form, the Marriage Satisfaction Scale, the Beck Depression Scale, and the World Health Organization Quality of Life Scale Short Form. In the evaluation of the data, analyses were made by establishing a Structural Equation Model with the AMOS 24 package program. Results: There was a statistically significant negative correlation between the dependent variable of depression and the independent variable of marital satisfaction (β1=-0.636; p=.001 < .05). There was a statistically significant negative correlation between the dependent variable of quality of life and the independent variable of depression (β1=0.250; p=.001 < .05). There was a statistically significant positive correlation between the independent variable of marital satisfaction and the independent variable of quality of life (β1=0.620; p=.001 < .05). Conclusions: According to the results of the mediation effect analysis based on the bootstrap method, it was found that the depression score has a mediator effect between marital satisfaction and quality of life.

Headnote

Abstract

Purpose: Depression experienced during marriage affects the dynamics of marriage and life. This study aimed to examine the mediating effect of depression on the relationship between marital satisfaction and quality of life in women

Methods: The data were collected by the researchers using a Participant Information Form, the Marriage Satisfaction Scale, the Beck Depression Scale, and the World Health Organization Quality of Life Scale Short Form. In the evaluation of the data, analyses were made by establishing a Structural Equation Model with the AMOS 24 package program.

Results: There was a statistically significant negative correlation between the dependent variable of depression and the independent variable of marital satisfaction (β1=-0.636; p=.001 < .05). There was a statistically significant negative correlation between the dependent variable of quality of life and the independent variable of depression (β1=0.250; p=.001 < .05). There was a statistically significant positive correlation between the independent variable of marital satisfaction and the independent variable of quality of life (β1=0.620; p=.001 < .05).

Conclusions: According to the results of the mediation effect analysis based on the bootstrap method, it was found that the depression score has a mediator effect between marital satisfaction and quality of life.

Keywords: Marriage satisfaction; depression; quality of life; structural equation modeling; mediator role

Introduction

Marriage is one of the most important decisions in human life. For the continuation of society, the transfer of values to the next generation begins with marriage. For this reason, a quality marriage is important for the health of society. The most important indicator of marital quality is marital satisfaction (Taghani et al., 2019; Tekin Catal & Kalkan, 2019).

Marriage satisfaction is one of the concepts used to evaluate happiness and stability in marriage. Marriage satisfaction is expressed as a real sense of pleasure, satisfaction, joy, and contentment experienced by spouses when they consider their marriage from all aspects (Taghani et al., 2019; Tavakol et al., 2017). The harmony between the expected situation in the marital relationship and the existing situation increases the marital satisfaction needed for the continuity of the marriage. The love of the spouses for each other, the closeness of the spouses, their contentment, happiness, sexual satisfaction, and positive attitudes toward marriage indicate marital satisfaction (Taghani et al., 2019). In the literature, it is stated that marital satisfaction is affected by many variables such as socio-economic status, marital conflict, religious beliefs, intelligence, personal values and attitudes, marital communication, marriage age, harmony between couples, supportive approach, ability to share feelings and thoughts, time spent together, and mental state (Frye et al., 2020; Hajihasani & Sim, 2019; Ikican et al., 2020; Sayehmiri et al., 2020). When the marriage is stable and satisfying, the spouses are healthier and happier. Low marital satisfaction leads to less happiness, less social support of spouses towards each other, worsened mental health, and therefore, a decrease in overall quality of life (Karney & Bradbury, 2020; Mehrara et al., 2019). Quality of life includes people's psychological states and social and environmental relations. Many individual and social factors affect the quality of life (Zeren & Gursoy, 2019). Therefore, depression in individuals with low marital satisfaction may cause negative behaviors in the marital relationship, leading to worsen marital satisfaction and lower quality of life (Aggarwal et al., 2017; Mehrara et al., 2019; Salinger et al., 2021; Wang et al., 2014). When the literature is examined, it is stated that low marital satisfaction negatively affects the quality of life and increases mental symptoms (Salinger et al., 2021; Seyed Mousavi et al., 2021). It is seen that women are the most affected party by the negative consequences of marriage. Reasons for this are stated as follows: women are more sensitive to marital difficulties; they put their spouses more at the center of their lives; they pay greater effort to maintain the marriage despite adversities; and, their upbringing with traditional gender roles causes them to feel prone to self-blame. In addition, it is thought that women act more with their emotions when faced with marital problems, and also that women are more affected by the negativities in marital satisfaction due to their susceptibility to depression (Salinger et al., 2021; Wang et al., 2014). These reasons reveal that more research on marital satisfaction in women is needed. In addition, there was no study in which marital satisfaction, depression and quality of life were examined by structural equation modeling. Therefore, the aim of the study was to examine the mediating effect of depression in the relationship between marital satisfaction and quality of life in married women

Study Hypotheses

H1: There is a significant positive relationship between marital satisfaction and quality of life.

H2: There is a significant negative relationship between marital satisfaction and depression.

H3: There is a significant negative relationship between quality of life and depression.

H4: Depression plays a mediating role in the relationship between marital satisfaction and a quality of life

Methods

Type of research: The research was conducted as a correlational survey model. Study population and sampling: The research was carried out between May 2018 and January 2019 in 5 Family Health Centers (FHCs), which were determined by drawing lots among 65 Family Health Centers located in a province in eastern XXX. The population of the study consisted of married women aged 18-65 years and registered in those 5 FHCs. The sample size of the study was determined as 402 women with a power analysis based on 0.4 effect size, 0.05 error level, and 0.95 power to represent the population (Kabasakal and Soylu, 2016). The improbable random sampling method was used for sampling. The study was completed with 540 women presented to the FHCs and met the inclusion criteria. Inclusion criteria for the study: Being in an age range of 18-65 years; being married for at least one year; living with husband; and, volunteering to participate in the research. Exclusion criteria were: being pregnant and having a psychiatric diagnosis.

Data collection procedure and data collection tools: The data were collected by the researchers through face-to-face interviews, 5 weekdays a week in the FHCs. Research data were collected using a Participant Information Form, the Marital Satisfaction Scale (MSS), the Beck Depression Inventory (BDI), the World Health Organization Quality of Life ScaleShort Form (WHOQOL-BREF).

Participant information form: This form, developed by the researchers in line with the literature, consists of 9 items: sociodemographic characteristics of married women (age, spouse's age, education level, employment status, income level) and marital characteristics (marriage age, duration of marriage, type of marriage, conflict with spouse).

Marital satisfaction scale (MSS): It was developed by Celik and Yazgan Inanc in 2009 to evaluate the marital satisfaction of married individuals. The MSS is a 5-point Likert-type scale consisting of 13 items. The score range of the scale is 65-13. Higher scores indicate higher marital satisfaction. The scale has three sub dimensions: family, sexuality, and self. In the original study of the scale, Cronbach's Alpha coefficient was .79 for the total scale, .83 for the family sub-dimension, .81 for the sexuality sub-dimension, and .75 for the self-sub-dimension (Celik & Yazgan Inanc, 2009). In this study, the total Cronbach's Alpha coefficient of the scale was .83, .89 for the family subdimension, .85 for the sexuality subdimension, and .61 for the self-sub dimension

Beck depression inventory (BDI): It is a self-assessment inventory developed by Beck in 1961 (Beck et al., 1961). Its validity and reliability study in Turkey was performed by Hisli in 1988 (Hisli, 1988). The inventory consists of 21 items. It is a 4-point Likert scale. Each item is scored between 0 and 3 and a total score is obtained by summing these scores. The score range of the scale is 0-63. A higher total score on the BDI indicates more severe depression (Hisli, 1988). In the Turkish validity and reliability study of the BDI, Cronbach's Alpha coefficient for the total scale was .80 (Hisli, 1988). In this study, Cronbach's Alpha coefficient of the scale was .83.

World health organization quality of life scale-short form (WHOQOL-BREF): The Turkish adaptation of the form, which was developed by the World Health Organization Quality of Life Group, was carried out by Eser et al. in 1999. The original version of the scale includes twenty-six 5-point Likert-type items. Each item is scored between 1 and 5. The scale consists of 4 dimensions, namely physical, psychological, social, and environmental. Since each dimension indicates the quality of life in its own dimension independent of the other, dimension scores are calculated separately. Each dimension score range is 0-20. The higher the score, the higher the quality of life. The Cronbach's Alpha coefficient of the scale was found .83 in the physical dimension, .66 in the psychological dimension, .53 in the social relations dimension, and .73 in the environmental dimension (Eser et al., 1999). In this study, Cronbach's Alpha coefficient was obtained as .74 in the physical dimension, .72 in the psychological dimension, .68 in the social relations dimension, and .82 in the environmental dimension.

Ethical aspect of research: Ethical approval was obtained from the XXX Health Sciences Non-Interventional Clinical Research Ethics Committee on 08.05.2018 (Decision No: 2018/10-10). Permission was obtained from the FHCs where the research was conducted. The women participating in the study were included in the study after they were informed about the study and their informed consent was obtained. Research and publication ethics complied with the study.

Statistical analysis: Data analysis was carried out with the SPSS (Statistical Package for Social Sciences) 25 program. The Kolmogorov Smirnov Test was used to check whether the research data conformed to the normal distribution (Alpar, 2020). Descriptive statistics such as number, percentage, mean, and standard deviation were used to evaluate their descriptive characteristics. The significance level was taken as p<0.05 for comparison tests. Since the variables were normally distributed (p>0.05), the analysis was made with parametric tests. The cronbach &agr; coefficient was used to determine the reliability analysis of the scales. A Structural Equation Model (SEM) was established and analyzed with the AMOS 24 package program. In order to perform multivariate analysis, first, a multiple normal distribution control was performed on the data. The multivariate normal distribution control of the data was checked with the "Observations farthest from the centroid (Mahalanobis Distance) Menu" in the AMOS program. According to Mahalanobis Distance, 45 questionnaires were excluded from the study. The skewness value of the model was calculated to be 3.045, and because it was less than 8, a multivariate normal distribution was provided (Inceoglu et al., 2021). To ensure that there is no relationship between the independent variables (scales), multicollinearity control was performed in the data and it was observed that the calculated Variance Inflation Factor (VIF) values did not exceed 10 (VIF; 1.000). (Albayrak, 2005). The Mediation Effect Structural Equation Model (SEM) analysis based on the bootstrap method was applied to the data using the AMOS 24 program. It has been argued that the results obtained with the Bootstrap method are more reliable than the classical method of Baran and Kenny and the results obtained with the Sobel test. To implement the bootstrap method, 5000 samples were reloaded. If the lower and upper limits of the 95% confidence interval (CI) found as a result of the bootstrap method do not contain zero (0), there is a mediating effect between the variables (Batmaz et al., 2020).

Results

In the study, the mean age of the women was 36.05 ± 9.46 years, the mean age of the spouse was 39.79 ± 10.55 years, the mean age at marriage was 21.84 ± 4.02 years, and the mean duration of marriage was 14.01 ± 10.98 years. It was determined that 37.5% of the women had primary education, 65.7% did not work, 68.7% of them had income equal to their expenses, 47.6% had love marriage, and 64.9% of them were the ones who started conflict with their spouse.

SEM was established to examine the mediating effect of depression in the relationship between marital satisfaction and quality of life. The diagram of the first model established for SEM analysis is given below:

In the model, the sub-dimensions of the scales and the depression score represent the observed variables; marital satisfaction and quality of life scale total scores represent unobservable variables; and, e1, e2, e3, e4, e5, e6, e7, e8, e9, and e10 represent error terms.

To interpret the relationships as a result of the analysis, it is first checked whether the regression coefficients on the arrows drawn between the variables are significant. The regression coefficients and significance values are given in Table 1:

In the model, the goodness of fit index values obtained as a result of the analysis were found as follows: χ2 191.640, df 18, χ2/df 10.647, CFI and IFI 0.900, GFI 0.903, NFI 0.891, and RMSEA 0.140 (Table 1).

The regression coefficients of the model established between the variables were found to be statistically significant (p < .05)

However, the goodness of fit values of the model were not in the desired range. For this reason, the model was modified by drawing the covariances between the error terms in the model. For the purpose of modification, covariances were drawn between e1-e2, e1-e3, e4-e5, and e6-e7 and the analysis was repeated. The diagram of the second model obtained is given below:

To interpret the relationships as a result of the analysis of the newly established model, the regression coefficients and significance values are given in Table 2.

There was a statistically significant negative correlation between the dependent variable of depression and the independent variable of marital satisfaction (β1=-0.636 p=.001 < .05). If marital satisfaction increases by 1 point, depression score decreases by 3.283 points (β2= 3.283; p=.001 < .05). It was found that 40.5% of the depression score is explained by the marital satisfaction score (R2 = 0.405) (Table 2).

There was a statistically significant negative correlation between the dependent variable of quality of life and the independent variable of depression (β1=0.250; p=.001 < .05). If depression increases by 1 point, the quality of life score decreases by 0.073 points (β2=0.073; p=.001 < .05)

There was a statistically significant positive correlation between the independent variable of marital satisfaction and the dependent variable of quality of life (β1=0.620; p=.001 < .05). If marital satisfaction increases by 1 point, the quality of life score increases by 0.933 points (β2=0.933; p=.001 < .05).

It was found that 64.4% of the quality of life score was explained by depression and marital satisfaction scores (R2 = 0.64.4) (Table 2).

When the bootstrap results were evaluated, it was found that the indirect mediating effect of depression score on marital satisfaction and quality of life was statistically significant (β= 0.159. CI [0.051. 0.230]).

It was observed that the bootstrap lower confidence interval (0.051) and upper confidence interval (0.230) obtained using the percentile method did not include the zero (0) value (Table 2).

In the structural equation modeling, which shows whether the model established with the factors obtained as a result of the research is confirmed with more than one fit index, all indices are evaluated together instead of a single fit index (Ozdamar, 2016). In the newly established model, the goodness of fit index values obtained as a result of the analysis were calculated as follows: χ2 68.057. df 14, χ2/df 4.861. The decrease in the χ2 value and the χ2/df value below 5 indicate that the model has a good fit (Table 3). The fact that the RMSEA value, which is the index showing the adequacy of the sample number, is 0.079 (RMSEA<0.80), shows that the sample size is at a very good level for the model used. Model fit is very good in terms of fit indexes of the model, with the GFI value being 0.967, the CFI value and IFI value increasing to 0.969, and the NFI value to 0.961 (IFI>0.90, NFI>0.90, CFI>0.90, GFI>0.90) (Table 3) (Gurbuz, 2019).

Discussion

Marriage is a universal institution that affects the psychological, social, and economic domains of individuals, and therefore, has a significant impact on their quality of life. Marriage satisfaction covers a wide spectrum ranging from an intimate environment to a cold environment in the marital relationship. Many factors are effective in the formation of this wide spectrum.

One of these factors is the mental state of the person. Mental conditions such as depression can negatively affect individuals' marital satisfaction. For this reason, negative changes in marital satisfaction can also affect the quality of life of individuals (Aggarwal et al., 2017; Frye et al., 2020; Hajihasani and Sim, 2019; Karney & Bradbury, 2020; Mehrara et al., 2019; Zeren & Gursoy, 2019).

Although there are studies on marital satisfaction in the literature (Salinger et al., 2021; Seyed Mousavi et al., 2021), there exists no study examining the mediating effect of depression on the relationship between marital satisfaction and quality of life. For this reason, the findings of our study are discussed with similar literature.

There was a statistically significant positive correlation between the independent variable of marital satisfaction and the dependent variable of quality of life (β1=0.620; p=.001 < .05) (Table 2)

In line with this result, this hypothesis was accepted: "H1: There is a significant positive relationship between marital satisfaction and quality of life." Similarly, in the study of Kasapoglu (2018) it was found that when marital satisfaction levels increase, life satisfaction also increases, and there is a significant relationship between positive life satisfaction and quality of life.

In the study of Kayabası and Sozbir (2022) on assisted reproductive technologies and their effects on women who became pregnant with the help of these technologies, it was determined that marital satisfaction positively affected their quality of life.

Again, in the study of Mehrara et al. (2019) in Iran, it was determined that there was a direct relationship between marital satisfaction and quality of life. Our findings are compatible with the literature.

There was a statistically significant negative correlation between the depression dependent variable and the marital satisfaction independent variable (β1=-0.636; p=.001 < .05) (Table 2). In line with this result, this hypothesis was accepted: "H2: There is a significant negative relationship between marital satisfaction and depression". Psychosocial factors, which cause psychiatric disorders to be seen more frequently in women, are also important for the marital relationship.

Marriage satisfaction acts as a buffer in stress conditions and its consequences (Ikican et al., 2020; Li et al., 2020). In a study conducted with 189 mothers in Iran, it was determined that mothers with low marital satisfaction experienced more psychological distress (Seyed Mousavi et al., 2021).

A study of 3163 women in China found that a satisfying marital relationship helps a woman's maintain a physical and mental health by increasing positive emotions (e.g., happiness); and at the same time, it was determined that marital satisfaction acts as a support for improving the mental health of the individual under stress conditions (Li et al., 2019).

In another study, it was determined that the risk of developing depression is low in women with good marital satisfaction (Ikican et al., 2020). Our findings are compatible with the literature.

There was a statistically significant negative correlation between the dependent variable of quality of life and the independent variable of depression (β1=0.250; p=.001 < .05) (Table 2). In line with these results, this hypothesis was accepted: "H3: There is a significant negative relationship between quality of life and depression". When the literature is examined, it has been observed that stress or depression experienced by women negatively affects their quality of life (Huang et al., 2018; Kim et al., 2018; Schnettler et al., 2019).

In a study conducted in 121 couples in Seoul, it was determined that depression negatively affected their quality of life (Kim et al., 2018). Our findings are compatible with the literature.

When the bootstrap results were evaluated, it was found that the indirect mediating effect of depression score on marital satisfaction and quality of life was statistically significant (β= 0.159. CI [0.051. 0.230]) (Table 2).

Therefore, it was determined that marital satisfaction and depression affect the quality of life. In line with this result, this hypothesis was accepted: "H4: Depression plays a mediating role in the relationship between marital satisfaction and quality of life."

When the literature is examined, it is seen that the quality of life of individuals with low marital satisfaction is low and depression worsens the quality of life of individuals (Kasapoglu, 2018; Kim et al., 2018; Li et al., 2019; Mehrara et al., 2019; Schnettler et al., 2019; Seyed Mousavi et al., 2021).

In a study conducted in India, it was determined that depressed women had a lower quality of life compared to non-depressed women. It was also determined that the quality of life of depressed women who had marital difficulties was low (Aggarwal et al., 2017).

Our findings are compatible with the literature. In line with our results, it can be said that depression is an important component of the relationship between marital satisfaction and quality of life.

Conclusion and Recommendation: As a result of the study, it was found that depression score had a mediator effect between marital satisfaction and quality of life. In line with these results, one should be aware of the effects of marital satisfaction and depression on quality of life. While evaluating the life quality of married individuals, health professionals should not ignore the marital satisfaction levels and the presence of depression, and they should display a holistic approach. In order to improve their quality of life, women with low marital satisfaction should receive professional support. At the same time, to increase the marital satisfaction of women, depression levels should be examined and improvement should be attained by providing appropriate interventions.

Sidebar

Correspondence: Fatma Keskin Tore, PhD, Assistant Professor, Kahramanmaras Sutcu Imam, Faculty of Health Sciences, Department of Obstetrics and Gynecology Nursing, Kahramanmaras, Turkiye E-mail: [email protected]

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