Marital Satisfaction, Coping, and Social Support in Female Medical Staff Members in Tehran University Hospitals

Stress significantly influences marital satisfaction. Women tend to be more emotionally involved in problems than men. Furthermore, employed women encounter more stressors especially when their job is stressful which it is often the case in medical professionals. In the present cross-sectional study, relationships were analyzed between marital satisfaction (ENRICH Marital Satisfaction Inventory), ways of coping (Ways of Coping questionnaire) with marital stress and social support (Social Support Questionnaire) in 100 female medical staff members in Tehran university hospitals. The results revealed a significant negative relationship between subscales of marital satisfaction and using “seeking social support”, “confrontive coping”, “escape avoidance”, “distancing”, and “self-controlling” as ways of coping related to marriage related problems. Furthermore, the analyses showed that job satisfaction, social support, and ways of coping explain between 24% and 38% of the variance in subscales of marital satisfaction. Therefore focusing on these factors could be an effective approach to promote marital satisfaction in female medical staff members.


Introduction
Stress is an important and unavoidable concern in everyday life which people have to deal with.Women and men appraise and respond to stressors in different ways.It is assumed that women are more often exposed to stressful situations than men (Almeida & Kessler, 1998;McDonough & Walters, 2001); and women seem to appraise stressors more stressful than men do (Kessler, McLeod, & Wethington, 1985;Ptacek, Smith, & Zanas, 1992).For example, women are more likely than men to appraise family life and interpersonal events, such as marital relationship as stressful (McLaughlin, Cormier, & Cormier, 1988;Oman & King, 2000).Furthermore, women are more intensely affected by the stress of those around them, and they tend to be more emotionally involved in social and family networks than men (Kessler & McLeod, 1984;Turner, Wheaton, & Lloyd, 1995).
In traditional Iranian families, the main duties of a woman are being a wife and a mother, and the man is the head and breadwinner of the family.By the societal change to modernization in Iran, this family pattern is changing, and this includes changes in women's roles in family and society.Today, Iranian women are more educated and active in the society, and they work alongside men outside their homes.But, Iran is still in a transitional stage of Interpersona | An International Journal on Personal Relationships interpersona.psychopen.eu | 1981-6472 this movement.Work and family are two important issues in individuals' life that can interfere with each other.Iranian people, especially Iranian women, encounter conflicts between modern and traditional values, and they are still considered as the responsible person for home duties.They have different roles, as wife, mother, homemaker, and employee that are somehow incompatible.Expectations from employed women related to their family role are similar high compared to those who are unemployed or house wives (Rafatjah, 2011).This inter-role conflict is an important source of stress, and employed women have to find a balance between their different roles.They experience multiple-roles stress that can affect their marital, parental, and occupational situation (Kandel, Davies, & Raveis, 1985).
Social relationships, and marital or partner relationships can be a major source of stress.Stress in couples has a mutual influence; stress of one partner can affect the other one if he/she can't handle the stress by adequate coping.Bodenmann (2005) classified close relationship-stress in three categories: 1) the way that the stressful event affects each one (direct or indirect); 2) the origin of stress (within or outside of a couple); 3) the time sequence (the stress involves the spouses simultaneously or subsequently).Stress significantly determines marital satisfaction and the development of close relationships (Neff & Karney, 2004;Story & Bradbury, 2004).Daily stress negatively affects marital satisfaction in three ways; by effects on couple's communication, by reducing the time the spouses spend together, and by increasing health problems.
Based on the transactional theory of stress and coping, stress is defined as a process between a person and his or her environment."Cognitive appraisal" and "coping" are two mediator processes between person and environment.Cognitive appraisal has been defined as the process of evaluating an event and its significance for the person's well-being.There is a basic distinction between "primary appraisal" and "secondary appraisal".The primary appraisal constitutes the evaluation of a situation or event as being benign/positive, irrelevant or stressful, and the secondary appraisal relates to the evaluation what might and can be done, and which coping options are available to the individual and can be applied to manage the situation best (Lazarus & Folkman, 1984).
Coping is defined as "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands appraised as taxing or exceeding the resources of a person" (Lazarus & Folkman, 1984, p.141).
Coping efforts serve two main functions; the management or change of the source of stress (problem-focused coping) and the regulation of the individual's emotional responses to the problem or stressful situation (emotionfocused coping) (Lazarus & Folkman, 1984).Applying particular coping strategies can decrease or increase the stress effects (Bodenmann, 2000;Revenson, Kayser, & Bodenmann, 2005).A significant relationship between quality of individual coping and marital satisfaction could be demonstrated.Bodenmann and Cina (2000) found that couples that used avoidance or self-blaming, and lacking active problem solving at the first assessment, were significantly more likely to have a problematic marital relationship or divorce at five-year follow-up.Ways of coping, such as denial, avoidance, self-blaming, negative self-verbalization, withdrawal, drug abuse, and violence often are negatively associated with marital quality, whereas active engagement, constructive problem solving, optimism, positive self-verbalization, and reframing of the situation are more likely to represent functional coping in marital relationships (Bodenmann & Cina, 2000;Ptacek & Dodge, 1995).Women scored significantly higher than men on emotional and avoidance coping, and lower on problem focused coping and detachment (Matud, 2004).Furthermore, a study of the role of coping in marital satisfaction in Iran showed a positive association between problemfocused as well as positive emotional strategies and marital satisfaction.Emotional negative coping also led to psychological stress and impacted negatively on the quality of marital relationships (Besharat, Tashk, & Rezazadeh, 2006;Bouchard & Thériault, 2003;Markman, 1991).Social support theories have been closely associated with concepts of stress and coping.For example, the cognitive appraisal of stress somehow depends on the perceived availability of social resources (Schwarzer, Knoll, & Rieckmann, 2004).DeLongis and Holtzman (2005) mentioned three important contextual factors of impact on the process of selecting certain coping: the nature of the stressful event, the personality of those involved, and the social context in which coping occurs.The main aspect of social context is satisfaction with social support, especially support from emotionally close persons.Social support can cause improved psychological strength and provides with other resources that needed to cope with stress (Cohen, 2004), and, by that, buffers negative effects of life stress on marital satisfaction (Chi et al., 2011;Mueller, 2006).Furthermore, in female employees, social support from family, relatives, friends, and colleagues at the workplace can provide with emotional and instrumental support for dealing with work-family conflicts (Namayandeh, Yaacob, & Juhari, 2010).Medical staff are confronted with many stressors in their job environment, such as death and suffering of patients, emergency situations, and time pressure at work (Adeb-Saeedi, 2002;Mosadeghrad, Ferlie, & Rosenberg, 2011).Although many Iranian women work out of the home, for example in medical professions, the traditional believe about domestic duties has not changed much yet, and the working women are supposed to fulfill their additional duties according to the traditional role as housewives and mothers.This causes further responsibilities as an employee out of the home (Rastegarkhaled, 2004), especially when their job is demanding and stressful, such as in medical professions.Job stress can reduce the time that partners spend together and the time that they are emotionally available, it can negatively affect sexual interests, activities, and satisfaction, it can reduce the frequency of shared experiences, and the amount and intensity of shared emotions, and it can reduce the feeling of we-ness (Bodenmann, 2000).Based on the family stress theory, critical work events, such as overloaded job, job dissatisfaction, and shift work can negatively affect the family.
The objectives of the present study were to assess 1) the major problem areas of marital stress in female medical staff members; 2) the ways of coping with marital conflicts in female medical staff members; and 3) associations between ways of coping and marital satisfaction in relation to marriage problems in female medical staff members.
The following questions should be answered: What types of encounters within intimate relationships are perceived as stressful by female Iranian medical staff members?How do female Iranian medical care staff members cope with marital stress?

Participants
In a cross-sectional study on ways of coping with marital problems and marital satisfaction 653 medical staff members in hospitals that are affiliated to Tehran Medical University in Tehran were investigated.The sample consisted of married (for at least one year) medical staff members, who currently live with their spouse, without any addiction problems or severe physical and psychological disorders which could affect their life.One hundred and sixteen of the 653 participating individuals reported a marriage-related problem as reference event for completing the WOC.Hundred of these were females.Because of the very small number of men (n = 16) reporting a marriage-related problem as reference event for completing the WOC, we decided to focus this analysis exclusively on these women.The women, on average, were 33.21±6.43years old (ranging from 23 to 53 years, whereas their husbands, on average, were 36.40±7.83years old (ranging from 23 to 60 years).They were married for 6.81±5.26years (ranging from 1 to 30 years).Forty four % of them did not have any child, 39% had one child, 14% had two children, and only three per cent had more than two children.Thirteen % had gained a masters degree or PhD, 67% reported having a Bachelor's degree, and only 20% gained an education at Diploma or HND i level.
The study was approved by the scientific and Ethics committee of Tehran Medical University in Tehran, Iran.After receiving permission to perform the investigation from the Tehran Medical University and hospital managers, the principle researcher explained the aims of study to the staff members of every hospital ward, and they were asked to complete a set of questionnaires.Participation in the study was voluntary, and the participants could withdraw from the investigation at any time of the investigation.The willingness to participate and delivering completed questionnaires was evaluated as informed consent.

Instruments
Data collection was performed by a questionnaire-booklet which consisted of three parts; a socio-demographic form, the ENRICH marital satisfaction inventory, ways of coping checklist (WOC), and the Social Support Questionnaire (SSQ).
A Socio-demographic questionnaire was designed by the first author to collect socio-demographic backgroundinformation such as participant's age, gender, education, length of marriage, number of children, spouse's age and education, and some other socio-demographic variables.(Fowers & Olson, 1989).In the present study, the short form of this questionnaire that was standardized in Iran by Soleimanian (1994) was applied.This version consists of 47 items in 9 scales: personality issues, marital communication, conflict resolution, financial management, pleasure activities, sexual activities, marriage and children, family, and friends, religious orientation.The domain scores are calculated as the sum of item scores divided by the number of items in the domain.Furthermore, for providing a standardized total score after calculating the average score of all items, the T-score of the average score was obtained from a standardized score-table.Construct validity by comparison with a Family Satisfaction Scale showed an acceptable amount of shared variance (0.41-0.60) among the scales.Internal consistence for the measure was calculated as Cronbach's alpha of 0.95 for men and women.Furthermore, test-retest reliability was investigated with a reliability coefficient of 0.92 (Rasooli, 2001).
The Ways Of Coping Questionnaire (WOC) (Folkman & Lazarus, 1988) is a 66-item self-report questionnaire to assess coping related to a particular event to be answered on a 4-point Likert scale (0 = does not apply/or not used, 1 = used somewhat, 2 = used quite a bit, 3 = used a great deal) with eight subscales: Confrontive Coping, Distancing, Self-Controlling, Seeking Social Support Accepting, Responsibility, Escape-Avoidance, Planful Problem Solving, and Positive Reappraisal.The Validity and reliability of the Persian version of the Ways of Coping were studied by Padyab, Ghazinour, and Richter (2012).They reported a good face and content validity.The factor structure of the WOC was analyzed both with explanatory and confirmatory factor analyses.A 7-factor structure model with some important similarities and differences to the original version was confirmed.Modifications were performed in a stepwise procedure.In total, 20 of the original WOC items were dropped from the calculation of scale-scores in the Farsi version.The Farsi version of the WOC was found to have good construct reliability and model fit, and has considerable potential to be used in future coping research among Iranian populations.The Cronbach's alpha for the total score as indicator for its internal consistency was 0.88.
The Social Support Questionnaire (SSQ) is a 27-item self-report questionnaire that measures perceived social support and satisfaction with social support (Sarason, Levine, Basham, & Sarason, 1983).The SSQ yields scores for satisfaction with social support (SSQS) and perceived number of social supports (SSQN) that are avaiable based on a 6-point scale from "very dissatisfied" to "very satisfied".The overall SSQN and SSQS scores are obtained by dividing the sum of satisfaction scores and the number of social supporters for all items by 27 (the number of items in terms of scenarios/situations).The validity and reliability of the Farsi version of this questionnaire were investigated by Nasseh, Ghazinour, Joghataei, Nojomi, and Richter (2011).An exploratory factor analysis, principle component analysis with varimax rotation, was calculated in order to investigate the structure in the data.In order to test the fit of the structure in the data to the theoretical model, a confirmatory factor analysis was performed.They reported differences relating to gender, education, and marital status, supporting the SSQ's concurrent validity.The internal consistence of the Farsi version in terms of Cronbach's alpha was 0.95 for the SSQN scale and 0.96 for the SSQS scale.

Statistical Analysis
None of the dependent variables (the marital satisfaction subscales) were normally distributed (tested by Kolmogorov-Smirnov-test).Therefore, non-parametric tests were applied for testing for mean score differences (Kendall's τ) or correlations (Spearman rank correlation) of marital satisfaction and socio-demographic variables.
Multivariate analyses of variance (MANOVA) were calculated on a multivariate level of analysis with all nine marital satisfaction subscales as dependent variables, age, and spouse's age as continuous variables as covariates, and various categorical socio-demographic variables as fixed factors.Interaction terms were included in the model when theoretically and statistically indicated.Hierarchical multiple regression analyses were calculated to evaluate the predictive power of the WoC factors for marital satisfaction factors.
The situations that were reported as a stressful event for the WOC by these women could be grouped into four categories: conflict because of problem between the spouses (50%), conflict because of husband's family or friends (25%), conflict about a child's upbringing (17%), and conflict because of economic problems (8%).There was no association between the type of stressful event and the women's educational level (Kendall's τ = .012;exact p = .897),the occupational situation of the spouse (Kendall's τ = .063;exact p = .342),or the age difference between the spouses (Kendall's τ = .088;exact p = .158).But, there was a significant association between the reported stressful event and the husband's educational level (Kendall's τ = .182;exact p = .042).When husbands having gained a Diploma or HND only, conflicts between the spouses were most often reported (68.8%).When the husband had a Bachelor degree, conflicts between spouses were reported to 43.1% and 27.5% referred to conflicts about child's upbringing representing the highest relative frequency for this category.When the husband had a master degree or a PhD, the women used to 35.3% a conflict between the spouses and 52.9% used a conflict with their husband's family or friends as a reference in answering the WOC items, the highest relative frequency in this category.Furthermore, there was a significant association between the difference on education level between the spouses and the type of applied difficult-to-cope-with situation (Kendall's τ = -.201;exact p = .025).When both spouses had gained a degree of the same level, 39.1% reported a conflict between the spouses, 26.6% a conflict with the husband's family or friends and 12.5% mentioned an economic problem as a reference for the WOC (the only group who mentioned economic problem for that), but, when the husband had a higher degree than the wife, 50.0% reported a conflict between the spouses and 35.7% a conflict with the husband's family or friends, and finally, when the women had gained the higher degree, 81.8% described a conflict between the spouses and 13.6% a conflict with the husband's family or friends.
The women had more children in case that they reported a conflict about child's upbringing compared to those reported a conflict between the spouses or with the husband's family of friends (F(3, 96) = 7.12; p < .001)indicated by significant post-hoc tests (Tukey-B).
In case that the women mentioned the conflict about child's upbringing as a stressful situation for the WOC, their job satisfaction was significantly higher than for those women who used a conflict between the spouses (F(3, 96) = 3.13; p = .029).Job satisfaction was lowest among those women who used economic problems as reference for the WOC responses (F(3, 96) = 4.22; p = .029).
The totally perceived social support was significantly lower in those women who used economic problems as reference then in those who used a situation from one of the other three categories (F(3, 96) = 4.22; p = .008).
Marital satisfaction score for 'family & friends' was higher when a conflict with the husband was applied in the WOC (F(3, 96) = 3.14; p = .029).None of the other measured socio-demographic variables or questionnaire factors of the SSQ, the ENRICH or the WOC were significantly associated with the used situation categories.
Fifty five per cent of the 100 women were moderately satisfied, and 20% were very unsatisfied, 23% unsatisfied with their marital situation based on the overall score on the ENRICH questionnaire, whereas only 2% reported to be satisfied.However, none of them were very satisfied.Those women, who were satisfied in their marriage, reported to apply escape avoidance (post-hoc tests between p < .001and p = .021;F(3, 96) = 1.48; p = .225)and support seeking (post-hoc tests all with p < .001;F(3, 96) = 2.40; p = .073)less often than the other women, and, they reported a significantly higher satisfaction with social support (post-hoc tests all with p < .001;F(3, 96) = 2.86; p = .012)than the less satisfied women.
The total score of the ENRICH questionnaire as well as factors 'Financial management', 'Sexual Activities', and 'Religious orientation' were significantly negative correlated with confrontive coping, whereas 'Marital Communication' was significantly negative associated with distancing, escape avoidance, and support seeking, and 'Marriage & Children' was significantly negative correlated with self-control and distancing as ways of coping (see Table 1).In MANOVA (Table 2) with the marital satisfaction factors of the ENRICH as dependent variables a model with a main effect for WOC situations (based on significant differences for "Conflict Resolution", "Sexual Activities", and "Family and Friends") and the co-variate effect of the women's age (based on significant differences for "Religious orientation") could be evaluated.In a model with the SSQ factors as dependent variables the WOC reported situation categories was the only fixed factor of substantial main effect (based on significant differences for "SSQ satisfaction").When using the WOC factors as dependent variables, no corresponding significant model could be developed.In hierarchical regression analyses with the various ENRICH factor scores as dependent variables and job satisfaction as the independent variable in the first block, the two SSQ factors in the second block, and the WOC factors in the third block, between 24 and 38% of the variance in seven of the nine ENRICH factors (not significant model for "Family & Friends" and "Marriage & Children") could be explained by the variation in all the independent variables with varying weight of the several independent variables (Table 3).

Discussion
The aims of our investigation were a) to explore the types of encounters within intimate relationships that are perceived as stressful by female Iranian medical staff members; and b) to analyze their ways of coping with marital conflicts.The women reported a "conflict because of problem between the spouses" most often as a marital stressor especially those with higher education than their husbands.Shift work, time pressure at work, high workload, and high responsibility in medical staff possibly affect the time that spouses spend together, what, in turn, negatively affects their relationship and can additionally increase the number of conflicts between spouses.
Other types of conflicts might occur already shortly after marriage, especially in Iranian couples, since legal, social, and religious restrictions highly limit the possibilities of the potential partners for developing relationships or becoming familiar with each other before marriage.On the one hand, based on masculine-dominated and patriarchal culture in Iran, men are the head and main decision-makers at home.On the other hand, women's increasing higher education represents an important factor promoting women's power in Iranian families.Education and social presence of women influence women's perceived identity, awareness of women's rights; and their attitudes toward gender roles in general and in family life, in particular (Tohidi, 1994).Therefore, in a family where the wife has a higher education than her husband, dividing and sharing power and authority might become a background factor for more frequent conflicts between spouses.
The analysis of the frequency of coping behaviors in female medical staff members revealed that "planful problem solving", "positive reappraisal", and "self-controlling" were more often used for encounter with marital stressful situations.As Folkman and her colleagues mentioned, an individual's cognitive appraisal of the stressful situation is important in the selection of the applied ways of coping.For example, if a person appraises the situation for herself as changeable, problem-focused coping is more often used, whereas emotion-focused coping is applied more often in situations that are evaluated as unchangeable (Folkman, Lazarus, Gruen, & DeLongis, 1986).Our results revealed a significant negative relationship between subscales of marital satisfaction and using "seeking social support," "confrontive coping," "escape avoidance," "distancing", and "self-controlling".This result confirms the findings of several investigations on negative relationship between using confrontive coping, seeking social support, avoidance, and distancing and marital satisfaction (Bodenmann & Cina, 2000;Bouchard, Sabourin, Lussier, Wright, & Richer, 1998).Applying protective buffering coping strategies such as distancing, avoidance, and confrontive coping can reduce effective communication or increase conflicts within couples and consequently increase spouses' stress (Coyne & Smith, 1991) which can negatively influence the marital relationship.Furthermore, our results showed a positive association between social support and marital satisfaction, but, seeking social support had a negative relationship with marital satisfaction subscale "marital communication".Social support as a moderator has an important role as a buffer against negative consequences of daily life stressors related to marital conflicts and other social conflicts which can affect marital satisfaction (Chi et al., 2011;Mueller, 2006).
Additionally, our results showed that women, who mentioned their husbands as supporter more often, used "seeking social support" less often than women with less husband support (p = .027).These findings indicate that couples that have better communication and are more satisfied with perceived support, don't need to seek much social support outside the marriage.When perceived spousal support is not sufficient, seeking support from extended family and friends become more important (Namayandeh et al., 2010).
As hierarchical regression analyses revealed, job satisfaction, SSQ and WOC factors can explain between 24% and 38% of the variance in six of the eight ENRICH factors.Social support satisfaction and planful problem solving can explain a substantial amount of variance in many subscales of martial satisfaction.Furthermore, "escape avoidance" negatively explains the variance of "communication", and "conflict resolution" in a marriage.It reveals that talking about and finding solutions for stressful marital events can improve the communication and conflict resolution between partners.These results are in accordance with the findings of several other studies that showed "escape avoidance", and "planful problem solving" as the important predictors of marital satisfaction (for example, Bouchard & Thériault, 2003;Markman, 1991).
The high percentage of women who were very unsatisfied or unsatisfied (43%) with their marital satisfaction needs more in-depth clarification of marital life in this group, in particular, but, also in comparison with women of other professions and from the general population.This study assessed individual coping in female medical staff members only.Investigating dyadic coping within the framework of a longitudinal study would help to gain more knowledge and more detailed findings about partnership processes, particularly in situations when individuals must cope with stressors that affect both spouses.
Our findings should be considered by health policy decision makers, family counselors, psychologists, and social workers to improve marital satisfaction in women by empowering the spouses more frequently to apply "planful problem solving" ways of coping instead of "distancing," "escape avoidance" or "confrontive coping" in stressful marital situations.Furthermore, considering the important role of social support in marital satisfaction, establishing Richter, Rostami, & Ghazinour

Table 2
Multiple Analysis of Variance Results With ENRICH Factors or Social Support Questionnaire Factors as Dependent Variable

Table 3
Hierarchical Multiple Regression Findings With ENRICH Factors as Dependent Variables