Relationship between Quality of Life of Women-Headed Households and Some Related Factors in Iran

Background & Aim: Women heading their households are the ones who lead their life alone. Burden of life probably decreases the quality of life of women-headed households. The aim of this study is to determine the relationship between quality of life of women-headed households and some related factors in Iran. Methods: The study was a cross-sectional study and 180 women-head households were selected from Welfare Organization, Tehran Province, using stratified random sampling method in 2015(January up to April). Social World Health Organization's quality of life questionnaire was used to gather information. The data were analyzed using SPSS statistical software (15) and suitable descriptive and analytical methods were applied. Results: Quality of life was moderate in the studied women. The highest mean score (50.35) was related to the physical aspect and the lowest mean (37.82) was about the environmental aspect. Conclusion: Quality of life of the studied women is not desirable; so, it is necessary to design appropriate interventions to improve their quality of life.


Background
Women-headed households are women without regular attendance or support of an adult male, the householder, and in charge of the economic, social, and cultural family responsibilities as well as major and vital decision-making for their life (President Center for Women and Family, 2013;Salehi, 2012). Women-headed households are among the vulnerable groups of the society (Morasae, Forouzan, Asadi-Lari, & Majdzadeh, 2012;Nazoktabar &Veicy, 2008;Rimaz et al., 2014). The role of families headed by single mothers, especially in developing countries, is among important issues and family management by single parents is hard, because women are faced with material and spiritual issues (Khosravan, Salehi, Ahmadi, & Mansoorian, 2013;Schatz, Madhavan, & Williams, 2011). Factors such as divorce, death, addicted spouse, and disability cause this large group of society to be vulnerable and lead to some problems, especially in financial terms ( President Center for Women and Family, 2013;Presidential, Control, Iran, 2011;Salehi, 2012). The conducted studies have shown that today 60% of women in the world are breadwinners and 37% of the world families are women-headed households (Moti, 1999;Tatina Boldaji, Foruzan, & Rafiey, 2011). In developing countries, at least 10% of the households are female-headed; however, there is no accurate estimation of the occurrence and type of female-headed families. Statistics and Informatics Unit of Women Participation Affairs Office announced 1'037'112 household-head women (9.1%) in 2004 in Iran. This number was increased to 2'548'072 (12.5%) in 2011 (Hossein & Aliabadi, 2011;President Center for Women and Family, 2013;Presidential, Control, Iran 2011). On the other hand, according to Social Welfare Organization during the past years (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006), 60300 individuals have been annually added to the population of women-headed households (Hossein & Aliabadi, 2011;Rimaz et al., 2014). Of course, these figures may be underestimated, because the families in which men as heads of households are unemployed, imprisoned, escaped from home, and addicted to drugs are still announced as male-headed households, so at least 3 or 4 million could be added to the number of women-headed households (Aghajanian & Thompson, 2013;Shaditalab & Geraei, 2004). Women in women-headed households, beside the duty of house-holding and earning money, are charged with the task of motherhood; by definition is the women's role even in a man headed household. Number of additional roles, concerns about economic issues, and future stress increase health, social, and psychological problems that effects on their quality of life (Hernández, Aranda, & Ramírez, 2009;Presidential Control, Iran, 2011). Quality of life is a collection of complete well-being and physical, mental, and social health that is understood by the individual or group of individuals and influenced by several factors. Thus, quality of life not only is the standard level of living and achieving the minimum level of comfort and facilities, but also includes the quality of interpersonal and social relationships (GHaffary, Karimi, & Nowzeri, 2012;Group, 1998). A qualitative life usually occurs in the form of pleasure, satisfaction, joy, happiness, and ability to overcome problems. In fact, quality of life is reported and evaluated by individuals (Frisch, 2005;Phillips, 2006;Hamedan & Aliha, 2014).
Studies in the field of women-headed households have suggested that these groups of people are suffering from difficulties and obstacles both at individual and social levels (Arias & Palloni, 1999;Rimaz et al., 2014).
In one study, Hrmandazvi et al. concluded that women without husbands were more likely to experience psychological and physical symptoms of depression, which could indicate their low quality of life (Hernández et al., 2009). Moreover, in the research conducted by Tahmasebi, the results showed that women-headed households, due to the higher frequency of roles they took than other women, experienced more stress and, consequently, had lower quality of life (Tahmasebi, 2006).
The aim of the present study is to determine the quality of life of women-headed households in Social Welfare Organization of Tehran Province in 2014 in terms of physical, psychological, social, and environmental aspects as well as public health and assess the relationship between quality of life of women-headed household and some of its related factors.

Materials and Methods
This study was a cross-sectional study and the sample size with the confidence level of 95% and first error of α= 0.05 was 180 people (Boldaji et al., 2011). Stratified random sampling method was done and 5 welfare centers were randomly selected from 22 welfare centers covered by Social Welfare Organization in Tehran Province, Iran in 2015(January up to April). After the necessary coordination with these centers, the women profiles in the welfare centers were used to prepare a list of women-headed households. The inclusion criteria were being working women, acting as heads of family, and being under the cover of Social Welfare Organization in Tehran. The exclusion criterion was body disability, mental disorder and unwillingness to participate in the study. Then, the women were briefed on the importance of design, inclusion and exclusion criteria of the study, and way of filling the questionnaire in a session. The researcher filled the questionnaire according to the interviews; probably in 10-15 min. Data collection instrument included the quality of life questionnaire (WHOQOL-BREF). In this study, the Iranian version of WHOQOL-BREF was used, Validity and reliability were approved using Cronbach's alpha, intra-class correlation of >0.7, and highly acceptable test-retest (Nejat, Montazeri, Holakouie Naieni, Mohammad, & Majdzadeh, 2006). It had four areas of physical (7 items), mental (6 questions), public (3 questions), and environmental (8 questions) health. Two other questions were also included in the questionnaire that did not belong to any of these areas and assessed health status and quality of life in a general way. The questionnaire included the total of 26 questions. The 5-point Likert scale (1 to 5) was used to respond to the queries of this tool. After obtaining the raw scores, each subscale should be converted into a standard score. Each area receives the score of 0 to 100, where 0 indicates the worst and 100 the best states of the respective domain; i.e. the higher score indicates the best quality of life. The data were analyzed using SPSS (15) statistical software and using descriptive methods (mean, standard deviation, absolute frequency, and relative frequency) and analytical analysis (Chi-square test and Spearman). The researcher began the study after obtaining the permit of Ethical Committee of Iran University of Medical Sciences. The researcher provided full explanation of the research goals for the participants and emphasized the confidentiality of their data while obtaining the written consent.

Results
Women-headed households in Social Welfare Organization of Tehran Province aged between 23 and 64 years old and mean age of the participants was 43.39 years old (SD=8.83). Also, 39.4% of the investigated individuals held high school degrees and 65.6% were divorced. Moreover, 48.3% of them had headed their families for less than five years, 69.4% had headed households with less than 3 people, 42.2% had worked for less than five years, 91.7% were Day Laborers, and 56.7% were paid more than 150 $USD.
The obtained mean score and standard deviation related to the quality of life of the investigated women-headed households of in Social Welfare Organization in Tehran were 44.49 (SD=11.51). Among the quality of life aspects of the studied women, the highest mean was related to the physical aspect and the lowest mean was associated with the environmental aspect (Table 1).  (Table 2).
In the present study, significant correlation was found between quality of life and marital status using Chi-square test (p=0.019). Also, significant correlation was observed between quality of life and heading time (p=0.039) and also between quality of life and employment time (p=0.02). Quality of life and income were also significantly correlated (p=0.002) ( Table 3).
According to the type of variables were used Spearman's correlations, Kruskal-Wallis and ANOVA tests.
For assessing significant correlation between below variables with quality of life areas was used Spearman's correlation test: -Physical health area with income (p=0.02, r=0.169). -

Discussion
According to the results, quality of life in women headed house hold is not desirable. Therefore, the need for effective intervention programs to enhance the quality of life for this group of women is one of the priorities of the society. In the current study, most the participated women as heads of households were middle-aged with high school education and the results were similar with those obtained in the studies by Rimaz et al., Morasae et al., Akinsola et al., and Klasen et al. (Akinsola & Popovich, 2002;Klasen, Lechtenfeld, & Povel, 2011;Morasae et al., 2012;Rimaz et al., 2014).
In the present study, significant correlation was found between quality of life and marital status, i.e. married www.ccsenet.org/gjhs Global Journal of Health Science Vol. 8, No. 10;2016 women had lower quality of life score. In other studies, marital status has been among the related factors for the quality of life (Hafarian, Aghaei, Kajbaf, & Kamkar, 2009;Rimaz et al., 2014).
Also, significant and positive correlation was founded between quality of life and heading duration, i.e. the women with more heading duration had better quality of life. In the study by Tahmasebi, the heading duration was also among the related factors for the quality of life (Tahmasebi, 2006).
In the current study, there was significant and positive correlation between quality of life and employment duration so that better quality of life was observed among the women heads of households with more employment duration. In the study by Boldaji et al., employment duration was included but there was no correlation between quality of life and the duration of employment (Tatina Boldaji et al., 2011); the differences in the results seem to be due to the difference in time, conditions, and sample size of each work.
Furthermore, this study indicated a significant and positive correlation between physical health area and income so that women-headed households with higher income had better physical health. In the study by Zanjani and Bayat, income was among the related factors to physical health (Zanjani & bayat, 2010). In the current study, significant correlation was found between physical health, education, and marital status so that women with higher education had better physical health and married women had worse physical health. In other studies, marital status and education (Tatina Boldaji et al., 2011) have had an impact on quality of life and physical health (Al-Arabi, 2003;Rimaz et al., 2014).
According to the results of this study, significant and positive correlation was found between the area of mental health and income so that women heading households with higher income had better mental health. In the study by Zanjani and Bayat, income was not among the related factors to psychological health (Zanjani & bayat, 2010).
In the present study, significant correlation was found among the psychological, environmental, social and public health as wel as income. In the study by Lee, it was shown that income had significant correlation with all aspects of quality of life (Lee, 2008). In the present study, significant correlation was found among mental health, general health, and education. In the study by Hafarian et al. and Lee, education has been demonstrated to have significant correlation with all aspects of quality of life (Hafarian et al., 2009;Lee, 2008).
Moreover, in the present research, significant correlation was found among the psychological, environmental, social, and public health as well as duration of heading and employment. The results obtained by Tahmasebi indicated significant correlation between quality of life and duration of heading (Tahmasebi, 2006). In the study by Hafarian et al., divorce time was not among the related factors to quality of life (Hafarian et al., 2009). It seems that the difference in the results could be due to the difference in time, place, and circumstances related to the different research. In the present investigation, significant correlation was found between environmental health and Family size. Tahmasebi found no significant correlation observed between quality of life and Family size (Tahmasebi, 2006). It seems that the difference in the results could be ascribed to the difference in time, place, and circumstances related to the research. In the present study, significant correlation was found between public health and heading cause. In the study by Tahmasebi, no significant correlation was observed between aspects of quality of life and heading cause (Tahmasebi, 2006).
In the present study, significant correlation was found between the public health and employment type. In the study by Jawaheri, significant correlation was observed between quality of life and employment type (Javaheri, Serajzadeh, & Rahmani, 2010).
According to the results of the present study, quality of life of women-headed households was moderate and there were relationship between various social and individual factors with quality of life of these households, so it is suggested that Social Welfare Organization with the help of charities and Ministry of Labor and Social Affairs can design programs to promote the group's attitude.

Limitations
Like other cross sectional studies, we could not claim causality. Thus, longitudinal cross-sectional studies with in-depth qualitative study may help clarify the direction of causality.

Implications for Health Policy
The most important health policies are psychological and economic implications, because low psychological health in women-headed households leads to increased treatment cost, directly affects children, and increases economic problems. Education can be effective for decreasing psychological and economic problems.

Conclusion
Quality of life of women-headed households is moderate and it is essential to design appropriate interventions to improve their quality of life. The items that can be offered to improve the quality of life for these women are emotional and psychological support during this period, establishing social support networks to improve the quality of life of women-headed households, designing training programs on the importance of healthy and inexpensive eating and physical activity, skills of coping with single-parenting problems, designing interventions in the direction of heading women's life quality improvement, and providing advisory services with the approach of women health promotion to improve their health status. Also it is important to financial support of female-headed by welfare organization and charitable people.