Relationship between Marital Satisfaction and Mental Health of Married Women Referring to Health Centers in Sanandaj , Iran in 2014

Background: As the most splendid social custom to attain security and emotional needs of adults, marriage has always won the approval of the community as a whole. In this regard, the endeavors of couples to preserve their relationships and achieve higher levels of marital satisfaction have been of great significance. As a component of personal characteristics, mental health has always been associated with marital satisfaction. This study investigated the relationship between marital satisfaction and mental health of married women referred to health centers in Sanandaj, Iran in 2014. Methods: This was a cross-sectional study conducted on 393 women referring to the health centers in Sanandaj, Iran who were selected randomly in 2014. Data collection tool were ENRICH Marital Satisfaction Questionnaire and General Health Questionnaire (GHQ-28), which was completed by the participants in the study. Data were analyzed using SPSS version 16, descriptive, and analytical statistics. Results: The results indicated that most of the patients were between 35-26 years, did not complete secondary school, were housewives, had only one child, and were married for 10 years. Most of the participants enjoyed marital satisfaction and had good mental health. There was a significant relationship between mental health and marital satisfaction (p<0.001). In terms of mental health, depression and marital satisfaction had the most significant negative correlation (p<0.001). However, there were no statistically significant relationship between female’s education and their employment with marital satisfaction and mental health. Conclusion: According to the findings of our study, in terms of the relationship between mental health and marital satisfaction, solving marital problems and increasing couples’ satisfaction can lead to the promotion of their mental health, leading to the increase in the health status of families and society a whole; hence, the significant role of family counseling centers.


Introduction
The family is the oldest social organization that existed from the beginning of mankind.The family has been located at the core of the extended social communities and play a key role in the mental health of the population (Kaakinen, Coehlo, Steele, Tabacco, & Hanson, 2014).Family acts as a cellular tissue to social organs and has an important effect on the education and training.Psychologists believe that the health of the family is provided under the protection of parents with a strong and permanent relationship between the woman and the man, which known as marriage.Among various effects of marriage, emotional relationships between men and women provide comfort between them (Bott & Spillius, 2014).Marital satisfaction is a key factor in a marriage.Marital satisfaction is a situation in which husband and wife are feeling happy and satisfied most of the times (Kalhor, Penjvini, & Olyaie, 2014).This factor may range from high satisfaction to low dissatisfaction.According to the previous studies on marital relations, different variables are associated with the trend of marital satisfaction over time.Some variables are related to mental health.World Health Organization (WHO), described mental health as the ability to: create peaceful connections with others, change personal and social environment, successfully resolve conflict, and manage personal interests by a logical, fair, and appropriate approach (Piccinelli & Gomez Homen, 2012).Therefore, mental health is people's compatibility with the world around, which leads to happiness and effective wellbeing.Marital satisfaction is one of the most important aspects of compatibility.
Marriage and marital life require a stable level of compatibility between husband and wife.Satisfaction plays an important role in the normal functions of the family.Marital relationship as a critical factor affects the mental health of family members.Parents with higher marital satisfaction have compliant children.Successful marriages are associated with caring parents and loving relationships between parent and children (Rostami, Ghazinour, Nygren, & Richter, 2014).Children feel safe when their parents are satisfied with their lives.Disputes and disagreements between husband and wife can cause more anxiety, aggression and other behavioral problems among children.Due to the different situations and different point of views of husband and wife, sometimes conflict occurs in the family (Rasolabadi, Rasouli-Ghahfarkhi, et al., 2015).Deviation from the norms of society are associated with a wide range of emotional problems such as low self-esteem in childhood and mental disorders in adulthood.Therefore, it is necessary to highlight the mental health status of women and men during their marital life.Moreover, the effect of mental disorders on the incidence of marital conflicts should be determined.Bearing in mind, the importance effect of the family health on community mental health, and the important role of husband and wife indicating their marital satisfaction (Oliaee, Emami, & Kalhor, 2014;Rasolabadi, Khaledi, Ardalan, et al., 2015;Rasolabadi, Khaledi, Khayati, et al., 2015), this study aimed to investigate the relationship between mental health and marital satisfaction in women referring to health centers in Sanandaj, Iran.The main objective of the present study was to propose a framework for further actions to solve marital problems and their conflicts.According to the above points, the specific objectives of this study are listed as follows: (a) The demographic characteristics of women referred to health centers in Sanandaj, (b) the level of marital satisfaction in women referred to health centers in Sanandaj, (c) the mental health of women referred to health centers in Sanandaj, and (d) the relationship between the marital satisfaction and mental health of women referred to health centers in Sanandaj.

Materials and Methods
In this descriptive-analytical study, the study population consisted of all married women referring to health centers in Sanandaj using simple random sampling.Considering the level of satisfaction of 50%, coefficient interval of 95%, and accuracy of 5%; 388 patients were calculated as the sample size.To achieve the objectives of the present study, two questionnaires were used as a data collection tool.The first part in relation to marital satisfaction was investigated using ENRICH Marital Satisfaction Questionnaire.This questionnaire as a valid research tool is used in the investigations and clinical works.This scale was revised by Elson in 2006; the new scale includes 35 words that are expressed in 4 subscales such as satisfaction, communication, conflict resolution, and idealistic distortion.Each question is on a 5 point Likert scale.ENRICH Test Questionnaire was implemented by David Elson and Amir Elson in 2000 on 25,501 married couples.The Alpha coefficient for the subscales of marital satisfaction, communication, conflict resolution and idealistic distortion were 0.86, 0.80, 0.84 and 0.83, respectively.Moreover, alpha coefficient of the questionnaire in the Assode study (2010) with a sample size of 365 coupled, were 0.78, 0.78, 0.62 and 0.77; respectively.
In the second part to determine the mental health of the participants, a General Health Questionnaire (GHQ-28) was used.It contained 28 questions and was provided for all age groups.The questionnaire has four sub-scale and includes somatic symptoms, anxiety, insomnia, social dysfunction and depression.This questionnaire was scored using the Likert method (0-1-2-3) and 84 was the maximum obtained score in this method.The cut-off point of this questionnaire was 23.So, people with mental health problems had scores higher than 23.The test was evaluated in 1996, by Palahang et al, and its validity was calculated as 91%.In addition to the two mentioned questionnaires, demographic data such as age, education, and duration of marriage were collected using an extra questionnaire (Palahang & Shah Mohammadi, 1996).Data were analyzed by SPSS software (Version 16); using descriptive and inferential statistic tests such as frequency, mean, Spearman correlation analysis, and chi-square.
According to the statistics of the Department of Health; there are 18 health centers in the Sanandaj.20 cases were selected from each health center, and 40 cases were selected from two health centers, considering diverse population distributions and social classes.After referring to the clinic and explain the aim of the study to the patients, the questionnaires were provided to those who were willing to participate in the study.The questionnaires were filled out by interviewer for the illiterate women.The inclusion criteria were married women who experienced an acute stress during their last 6 months (such as the death of a close one, etc.).

Results
In this study the age ranges of the participants were 16 to 65 years, and most of them (51.4%) were in the age range of 26-35 years.45% of the participants had secondary school education and lower; and the rest had a high school diploma and higher.The average duration of their marriage was 11.21±7.4.Most of their husbands were self-employment.Most of the participants (43.5%) had one child.Most of them lived only with their husband and children at home.The results showed that 1.46% of participants had mental health problems and their scores were higher than the cut-off point (Table 1).Most of the subjects (60.1%) were satisfied with their marital life (Table 2).While, most of the dissatisfaction were in the area of communication and conflict resolution.Feelings and beliefs in relation to marital relationships and conflict resolution approach to end the conflicts were not sufficient, causing dissatisfaction in their relationship.There was no significant difference between the demographic variables and mental health status in the studied cases.In general, a statistically negative correlation was observed between mental health and marital satisfaction.Consequently, people with higher marital satisfaction had fewer mental health problems.There was a significant relationship between mental health and various aspects of marital satisfaction (p<0.00).The most significant correlation was observed between depression and marital satisfaction (Table 3).There was a statistically negative correlation between mental health and marital satisfaction, including communication, conflict resolution, idealistic distortion, and satisfaction.The results reflected that persons with poorer mental health in the above areas were less satisfied (Table 4).

Discussion
Results showed that most of the participants (60.1%) were relatively satisfied with their marital life.In addition, 46.1% of them had mental health problems, and the social functioning was the most common problem among the four aspects of mental health.Most problems of marital satisfaction are associated with the couple's communication.Results indicated that there was a significant relationship between mental health and marital satisfaction in various aspects, and the most correlation was observed between depression and martial satisfaction (Montesi et al., 2013).These results are consistent with findings of an Iranian study, in which the authors reported that the marital satisfaction was closely attributed to the relationship between husband and wife (Monjezi & Iravani, 2013).
Results of another study on the problems of couples revealed that due to a lack of communication skills, people may live unsatisfactorily with the belief that their main problem is related to sexual, financial, and spouse's relative (Askari, Noah, Hassan, & Baba, 2013).While the root cause of their problems was due to communication problems and lack of ability in communication and leadership.
Progressive families, have learned how to communicate and send messages as well.Therefore, they can form healthy patterns.While in challenging families improper circumstances was observed, such as cold and negative relationships, physical and mental problems, grim and sad faces, and indirect and ambiguous relationships (Steinmetz & Sussman, 2013).Our findings are consistent with Shahi and Ghafari study; in which people with anxiety and depression may have a negative outlook on the world.This negative outlook includes their view about spouse and the marital relationship (Shahi, Ghaffari, & Ghasemi, 2011).On the other hand, depression was correlated with further defects in marital functioning (such as problem resolution and martial relationship).Depressed mood lead to reduction of energy and dissatisfaction with the life activities, resulting in a decline in personal and social efficiency.The above mentioned points is associated with communication problems.In another study on the relationship between marital satisfaction and depression concluded that marital dissatisfaction in depressed couples was three times higher than that of the non-depressed couples; hence, the relationship between depression and dissatisfaction (Fink & Shapiro, 2013).In the present study there was no significant relationship between the women's education, marital satisfaction, and mental health in the studied cases.This result is not in line with finding of Banaian and Parvin study (Banaian & Parvin, 2006).
Since, high education has an effective role in improving the social functioning and communication, it became evident that higher education could improve the communication skills.As a result, with increasing the level of education we may find lesser problems with marital satisfaction.In this study, 50% of participants had a high school education and higher, resulted in a higher marital satisfaction.

Conclusion
Concerning the aspects of marital satisfaction, the greatest problem is related to the lack of communication; so, proper and effective communication plays an important role in solving the marriage problems.Marital satisfaction is one of the strongest predictors of mental health.Accordingly, the more intimate the couples are, their marital satisfaction increased and their mental problems decreased.In this regard, conflict resolution in marital life and enhancing their satisfaction could lead to the increase in the mental health, resulting in an improvement in the family and community health.The current study highlights the need for family counseling centers in the health centers.

Table 1 .
Frequency of mental health status in the studied cases

Table 2 .
Frequency of mental satisfaction status in the studied cases

Table 3 .
Correlation of marital satisfaction with mental health

Table 4 .
Correlation of mental health with the dimensions of marital satisfaction