Qadir et al.

BMC Public Health 2013, 13:1150

http://www.biomedcentral.com/1471-2458/13/1150

RESEARCH ARTICLE Open Access

The association of marital relationship and

perceived social support with mental health of
women in Pakistan
Farah Qadir1, Amna Khalid1,3, Sabahat Haqqani1, Zill-e-Huma1 and Girmay Medhin2*

Abstract
Background: Marital circumstances have been indicated to be a salient risk factor for disproportionately high
prevalence of depression and anxiety among Pakistani women. Although social support is a known buffer of
psychological distress, there is no clear evidence as to how different aspects of marital relations interact and
associate with depression and anxiety in the lives of Pakistani married women and the role of social supports in the
context of their marriage.
Methods: Two hundred seventy seven married women were recruited from Rawalpindi district of Pakistan using a
door knocking approach to psychometrically evaluate five scales for use in the Pakistani context. A confirmatory
factor analysis approach was used to investigate the underlying factor structure of Couple satisfaction Index (CSI-4),
Locke-Wallace Marital Adjustment Test (LWMAT), Relationship Dynamic Scale (RDS), Multidimensional Scale for
Perceived Social Support (MSPSS) and the Hospital Anxiety and Depression Scale (HADS). The interplay of the
constructs underlying the three aspects of marital relations, and the role of social support on the mental health of
married Pakistani women were examined using the Structural Equation Model.
Results: The factor structures of MSPSS, CSI-4, LWMAT, RDS and HADS were similar to the findings reported in the
developed and developing countries. Perceived higher social support reduces the likelihood of depression and
anxiety by enhancing positive relationship as reflected by a low score on the relationship dynamics scale which
decreases CMD symptoms. Moreover, perceived higher social support is positively associated with marital adjustment
directly and indirectly through relationship dynamics which is associated with the reduced risk of depression through
the increased level of reported marital satisfaction. Nuclear family structure, low level of education and higher
socio-economic status were significantly associated with increased risk of mental illness among married
women.
Conclusion: Findings of this study support the importance of considering elements of marital relationship:
satisfaction, adjustment and negative interactions which can be prioritized to increase the efficiency of marital
interventions. It also highlights the role of social support in the context of marital relationships among
Pakistani women. Furthermore, the study presents the etiological models of depression and anxiety with
reference to the above.
Keywords: Marriage, Mental health, Social support, Scale validation

* Correspondence: gtmedhin@yahoo.com
2
Aklilu Lemma Institute of Pathobology, Addis Ababa University, P.O. Box
1176, Addis Ababa, Ethiopia
Full list of author information is available at the end of the article

© 2013 Qadir et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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Background approach marital satisfaction is identified as an internal

Depression and anxiety are common and disabling condi- subjective characteristic of a person [24] and marital ad-
tions [1]. Strong research evidence indicates that women justment is considered to have dyadic properties referring
experience depression and anxiety more than men [2]. to the interactions between spouses [12].
There is paucity of research in the field of mental The second approach identifies relationship dynamics
health in Pakistan. However, the few studies that have specific to negative patterns of interactions such as argu-
been conducted have repeatedly reported that women ments that contribute to the quality of marital relations
have disproportionately higher rates of depression and [14]. Combining these two approaches helps to develop
anxiety compared to other developing countries [3,4]. a framework which proposes that being satisfied and/or
Relationship and adjustment problems with husband well-adjusted in a marriage does not mean absence of
and in-laws have been associated with attempted suicide negative interactions [25] and that if these negative in-
[5] as well as common mental disorder (CMD) [6]. One teractions reach a certain threshold they could adversely
study examining marital dissatisfaction and its relation contribute to the interpersonal adjustment within mar-
to mental health reiterated the high rates of CMD riage which may decrease marital satisfaction [26]. The
among married women and attributed it to the women's resultant framework is expatiated below.
perceived dissatisfaction from their marriage [7]. It has been argued that marital satisfaction and adjust-
A systematic review based on 20 studies [4] carried out ment are related although they represent different con-
in both rural and urban parts of Pakistan reported the structs and they should be measured separately [25]. In
average prevalence of depression and anxiety in the com- general, satisfaction is a state of happiness over pain [27]
munity to be 34%. The range for women was 29-66% and and it is a global assessment of the quality of a person’s
for men it was 10–33. Factors perceived by women to circumstances based on their own selected norms. Al-
affect their mental health were absence of a confiding rela- though these norms are determined by cultural influences,
tionship, marital disputes, verbal abuse by in-laws, too satisfaction is internally decided. Thus if marriage is satis-
many children and financial difficulties [4]. fying for one person it may not be automatically satisfying
Marital relation is one of the most frequently studied for another [8]. Marital satisfaction was initially thought
phenomena in the field of family and relationships [8]. to be represented by adjustment to spouse, marriage and
Continued importance is placed upon the quality of mari- marital relationship [28]. However, later marital satisfac-
tal relationship due to its impact on individual and family tion was recognised as a person’s subjective experience of
wellbeing [9]. Over the years the quality of marital rela- the relationship [24,29]. On the other hand, marital adjust-
tionship has been investigated as “satisfaction”, “adjust- ment is “the integration of the couple in a union, in which
ment”, “adaptation” and/or “happiness” [10]. Sometimes the two personalities are not merely merged, or sub-
these terms have been used interchangeably and some- merged but interact to complement each other for mutual
times as complimentary elements of marital relationship satisfaction and the achievement of common objectives”
quality [11-13]. [12]. Furthermore, evidence indicates that marital adjust-
Marital satisfaction and marital adjustment have been ment even when reported by one partner indicates the
used interchangeably in research [14]. Although, there is perceived adjustment of the couple within the institute of
no universally accepted definition of these constructs, marriage whereas marital satisfaction is the individual's
their association with mental health and wellbeing is own personal contentment within the relationship [30]. In
well documented [15-19]. In the absence of universally our study the respondent reported marital adjustment as
agreed upon definition of these concepts researchers are mutual interaction of the spouses, and for marital satisfac-
often motivated to use these terms according to their tion they reported their subjective experiences.
own interpretation of the concept [20]. Therefore, oper- Marital satisfaction may essentially not be composed of
ationalizing variables becomes difficult leading to ambigu- the elements that are simply the opposite of those that
ity in definition and affecting the validity of interpretations lead to dissatisfaction [8]. In fact it has been contended
[21]. Hence, distinct and specific definitions are needed for that where agreement in couples on major issues is im-
accurate measurement which would help to compare and portant for marital adjustment, minor differences and
examine these concepts cross culturally. even trivial anger exchanges if processed appropriately
The present study therefore hinges on a combination may broaden their perspectives within the dyad of the re-
of two theoretical approaches in an attempt to study three lationship and increase satisfaction [8,26]. On the other
distinct constructs of marital relations and to examine hand, studies showed that negative interactions like with-
their interplay within the Pakistani cultural context. The drawal; undermine marital satisfaction by diminishing
first distinguishes between marital satisfaction and adjust- positive factors of the relationship (e.g., trust, and commit-
ment as distinct components of marital relations using ment) in a marriage [31]. It is evident that the inclusion of
intrapersonal and interpersonal distinction [22,23]. In this elements of marital satisfaction and adjustment does not
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automatically imply absence/presence of negative inter- It is also hypothesized that social support will protect
action in the marriage, emphasizing that they must be against mental health problems by enhancing marital
studied separately. satisfaction and adjustment and by helping to reduce
Thus, we propose that different instruments should be negative interactions in marital relation.
used while researching the satisfaction, adjustment and
interaction patterns in marital relationship research. Methods
When taking concepts of marital relations as the ob- Study setting and study design
ject of research, it is essential to contextualize them. A cross-sectional survey was conducted in Rawalpindi
Therefore, in this paper we approach marital relations district of Pakistan. The Islamic Republic of Pakistan is a
from the perspective of the Pakistani Muslim population. developing South Asian country with females accounting
Pakistan is predominantly a Muslim state where mar- for 49.2% of its total population [40] which also reflects
riages are highly influenced by religion. Though the reli- the population distribution of the district of Rawalpindi
gious sanctions require marriage to be based on mutual (48.8% females) [41]. The current study participants
consent of the husband and wife, parental approval of were recruited from urban and rural areas of the Rawal-
both parties is considered necessary in Pakistan for a pindi district.
marriage to be socially and culturally approved. Like
other countries in the region and unlike Western coun- Ethical considerations
tries Pakistanis are less likely to endorse the boundary of This study was approved by Ethics Committee of Fatima
relationships between the couple and their parents [32]. Jinnah Women University Rawalpindi. Informed verbal/
It is therefore not surprising that marital issues are written consent was taken from the study participants.
shared with family members in hope of support [33], To ensure confidentiality interviews were anonymized
giving them a pivotal position in contributing to marital using numerical codes.
satisfaction, adjustment and interaction patterns for cou-
ples. This emphasizes the significant role of social support Recruitment of study participants
among Pakistani married women's marital relationship. Eligibility criteria for the study was being a married
This is supported by both theory and research [18,34]. woman at the time of data collection, within the age range
There is little empirical evidence of the current state of 17 to 65 years and being a resident of the pre-specified
of marital relationships in Pakistan. This is partly due to sites of Rawalpindi (i.e. Kallari, Askari and Jhanda Chichi).
the lack of availability of psychometrically sound instru- Divorced/Separated women or those diagnosed with se-
ments validated in this population. Keeping in view the vere medical or psychiatric conditions were not eligible.
unique background of Pakistani Muslim marriages it is The sampling frame was obtained from official Gov-
important to first investigate the factor structure of rele- ernmental lists which helped identify potential eligible
vant instruments that are to be used to measure martial participants. These were used with discretion only for
circumstances in this population before embarking upon the purpose of carrying out this research. Local contacts
any endeavour to explain the state of marital relations were used to facilitate access to the catchment areas.
and its association with social support and mental health Door knocking technique was used to approach house-
of Pakistani women. holds. In one of the Urban slum areas (Jhanda Chichi)
Our study was carried out on married Pakistani women. the local contact helped with the snowball sampling
The objectives of this study were: (1) to assess the factor technique to cope with the respondents’ reluctance.
structure of Multidimensional scale for perceived social Using this process of recruiting study participants infor-
support (MSPSS) [35] (Zimet et al., 1988), Couple satis- mation was collected from 277 married females (i.e. 67
faction Index (CSI-4) [36], Locke-Wallace Marital Ad- from Kallari area, 96 from Jhanda area and 114 from
justment Test (LWMAT) [37], Relationship Dynamic Askari area). Out of 106 households approached in Kallari,
Scale (RDS) [38] and Hospital anxiety and depression 15 doors were locked from outside and 20 houses refused
scale (HADS) [39] and (2) to apply the structure equa- to participate in the study. In the Askari area 235 families
tion model (SEM) to examine the associations between were approached and 60 households did not respond to
martial circumstances, perceived social support socio- our door knocking, two attempts were made 11 house-
demographic risk factors and mental health of these holds refused to participate and 2 families did not have eli-
married women. gible women.
It is hypothesized that the increased marital satisfac-
tion and adjustment enhances mental health of women Data collection
and high levels of negative interactions can reduce mari- Two trained female research assistants carried out the
tal adjustment, satisfaction and elevate the risk of Com- interviews under the supervision of a senior researcher.
mon Mental Disorder (CMD). On average an interview took 33 minutes to complete.
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The protocol consisted of a structured socio-demographic depression and anxiety which are scored separately. This
questionnaire, the Self-Reporting Questionnaire (SRQ-20) scale is scored on a 4 point likert scale (0 = not at all to
[42] and Hospital Anxiety and Depression Scale (HADS) 3 = most of the time) [39], generating a maximum score
[39] were used to assess mental health, and women’s per- of 21 for each subscale [53]. The HADS scores may be
ceived social support was examined through Multidimen- interpreted as follows 0–7 (Normal), 8–10 (Mild), 11–14
sional Scale of Perceived Social Support (MSPSS) [35]. (Moderate) and 15–21 as Severe [53]. HADS is a well
The three scales used to measure different aspects of validated instrument [54]. According to a review the
marital circumstances were; the Relationship Dynamic sensitivity and specificity for both anxiety and depression
Scale (RDS) [38], Locke-Wallace Marital Adjustment Test sub-scales of HADS is approximately 0.80 [55]. Though
(LWMAT) [37], and the Couple’s Satisfaction Index-4 HADS was not initially developed for community
(CSI-4) [36]. screening for depression and anxiety, however recently it
has been extensively used and proven suitable for use in
Description of the scales: the general population in the developed [56,57] and the
Social support measures developing countries [58]. The present study used the
1) Multidimensional Scale of Perceived Social Support Urdu translation [59] which has been used in a number
(MSPSS) [35] is a 12 item measure of perception of sup- of studies to screen for depression and anxiety [60-62].
port from family, friends and significant others. The re- 6) Self Reporting Questionnaire (SRQ-20) is a 20 item
spondents rate each item on a 7-point scale ranging instrument to screen psychiatric disorders. Every item
from very strongly disagree (1) to very strongly agree (7). has a yes (1) and a no (0) response format with a total
Hence, the total score ranges from 12 to 84. Previous score of twenty. The acceptable cut-off score for case-
studies have reported it to have good validity and reli- ness of CMD is 8 and above [42]. The instrument has
ability estimates [43,44]. The present study used the sound reliability and validity [42]. Its specificity ranged
Urdu version of MSPSS which has strong psychometric from 72-85% and sensitivity from 73-83% [63]. A trans-
properties [45]. lated Urdu version of SRQ-20 [64] was used in the current
study. This scale has been previously used extensively in
Marital relationship measures Pakistan [65,66].
2) Locke-Wallace Marital Adjustment Test (LWMAT)
[37] is a widely used self-report measure of adjustment Data management and analysis
in marriage. It assesses negative pattern of interaction After cleaning the data basic characteristics of the study
between couples such as negative escalation, invalida- participants were summarized using frequencies. All
tion, negative interpretation, winner/loser, withdrawal scales indicated good internal consistency. A structural
and alternative monitoring. The scale scores range from equation model was developed to test the relationship
2–158. A score of less than a100 reflects marital distress between perceived social support, marital relations and
in marital adjustment [46,47]. A wide range of research mental health. Before fitting full structural equation
evidence supports the psychometric properties of this model, measurement models for each construct were in-
measure [48,49]. This scale was translated in Urdu using vestigated. Five measurement models were tested for the
translation back translation method and pilot tested on following unobserved variables (latent constructs): 1)
6 married women before applying it in the current two correlated latent variables, anxiety and depression,
study. in which seven items of HADS were used as indicators
3) Relationship Dynamic Scale (RDS) [38] is an eight of each construct 2) marital adjustment in which eleven
item measure which was developed to predict if a rela- items instead of original 15 items of Locke-Wallace
tionship is vulnerable to marital problems. The scale has Marital Adjustment test (LWMAT) were used as indica-
shown good reliability and excellent validity [50]. In the tor variables (3) perceived social support (second level
current study we used the Urdu version of RDS [51]. construct) for which three first level latent variables
4) Couple’s Satisfaction Index-4 (CSI-4) is a four item (friends, family, significant others) were used as indicator
measure of relationship satisfaction [36]. The possible variables each of which (i.e. friends, family, significant
responses on each item range from 0 (not at all) to 6 others) were constructed using four indicator variables
(absolutely and completely). CSI-4 has robust psycho- of MSPSS (4) relationship dynamics in which eight items
metric properties [36]. The current study used the Urdu of RDS were used as indicator variables and (5) couple
translated version of CSI-4 [52]. satisfaction in which four items of CSI-4 were used as
indicator variables. Each scale was tested for its fit to the
Mental health measures data as it was hypothesized by its authors using con-
5) Hospital Anxiety and Depression Scale (HADS) is a firmatory factor analysis approach. In case of poor
fourteen item scale developed to determine levels of fit, models were modified by excluding insignificant
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loadings of individual items and inclusion of correlated Table 1 Socio-demographic characteristics of study
error terms. After deciding on the best fitting measure- participants (N = 277)
ment model for each of the five scales, full structural Characteristics Response Number
equation model was fitted to evaluate the association of categories (%)
social support and martial circumstances with Depres- Age in years Less than 26 years 46(16.6)
sion and Anxiety of married women mediated through 26–30 years 57(20.6)
various alternative routes. In full structural equation 31–35 years 35(12.6)
model we tested for the following pathways (a) RDS with 36–40 years 46(16.6)
Anxiety and depression through SRQ-20, CSI-4 and 41 and years 93(33.6)
LWMAT, (b) MSPSS with Anxiety and depression through Years of education No formal 16(5.8)
RDS, LWMAT and CSI-4. Further it was tested if CMD education
(SRQ-20 score) associates with depression and anxiety. Grade 1–10 154(55.6)
Moreover, the mediating pathway for increased CMD Above grade 10 107(38.6)
symptom between marital interaction and mental disor- Occupation of respondent Housewife 244(88.1)
ders (anxiety and depression) was assessed. Lastly, the ef-
Working women 30(10.8)
fects of age, husbands education, family system, age at
Students 2(.7)
marriage, number of children and asset based socio-
Husband’s education (n = 272) No formal 13(4.7)
economic index (including ownership of TVs, VCD/DVD, education
computers, ACs, cars, house, servants in the house, and
Grade 1 to 10 244(88.1)
number of bedrooms, bathrooms, and foreign visits by the
Above grade 10 13(4.7)
respondent) were investigated. In the process of develop-
ing measurement models and full structural equation Husband’s monthly income < 10001 55(19.9)
PKR(n = 212)
model non-significant pathways and variables were re-
10001–30000 107(38.6)
moved from the models and the overall model fit indices
30001> 50(18.1)
were examined. Pathway associations for the prediction of
psychological morbidity are expressed as crude and stan- Total earning members in family 0-1 family 173(62.5)
members
dardized regression weights. Correlations are reported for
2 & above 100(36.1)
associations between unobserved variables. Overall model
Total monthly income (n = 197) < 10001 38(13.7)
fit was assessed using the Tucker-Lewis Index (TLI), Root
Mean Square Error of Approximation (RMSEA) and Com- 10001–30000 72(26)
parative Fit Index (CFI). The Tucker-Lewis Index (TLI) 300001> 87(31.4)
[67] indicates the proportion of co-variation among indica- Family system Joint family 113(40.8)
tors explained by the model relative to a null model of in- Nuclear family 164(59.2)
dependence, and is independent of sample size. Values Presence of any physical or mental No 212(76.5)
near 1.0 indicate good fit; those greater than 0.90 are con- illness
sidered satisfactory [68]. Comparative fit index compares Yes 62(22.4)
the samples covariance matrix with the null model and PKR = Pakistani Rupee.
its value ranges between 0.0 and 1.0 with values closer
to 1.0 indicating good fit [69]. The Root Mean Square
Error of Approximation (RMSEA) assesses badness of 4.32 years), 39% had more than 10 years of education,
fit per degree of freedom in the model and is zero if the and 11% were employed outside home. Nuclear living
model fits perfectly; RMSEA values of less than 0.05 in- arrangements were more frequent and family income
dicate close fit and 0.05 to 0.08 reasonable fit of a ranged from Rs. 4000 to Rs. 250000 (M = Rs. 46984.77,
model [70]. SD = Rs. 47223.73). Majority of the respondents were
married through family arrangements, 47% were married
Results within the family and 22% had a history of abortion.
Background characteristics of study participants Examination of asset based socioeconomic status showed
Data was collected from a total of 277 married females that majority of them had moderate standard of living;
within the age range of 17 to 65 years (M = 36.7 years, 81.9% had TV, 63.9% did not have DVD, 39.7% had com-
SD = 9.96 years). Background characteristics of these re- puter, 52.7% did not have ACs, 44.8% did not have their
spondents are summarized in Tables 1 and 2. A large personal car, 66.1% could not afford to have servants in
proportion of the study participants were above the age their house, 84.5% never had a foreign visit, 59.9% lived in
of 40 years, majority were house wives, age at marriage their own home and 50.2% of the participants had a house
ranged from 13 to 43 years (M = 21.8 years, and SD = with three to four bedrooms and attached bathrooms.
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Table 2 Marital circumstances, (N = 277) Psychometric properties and factor structure of the scales
Characteristics related to martial Response Number Multidimensional Scale for Perceived Social Support
circumstances categories (%) (MSPSS)
Age at marriage Below 16 years 16(5.8) The factor structure presented in Figure 1 fits well to
16–20 years 98(35.4) the data (Chi-square = 121.3 with 51 degrees of freedom
21–25 years 115(41.5) and p-values < 0.001; TLI = 0.889, CFI = 0.927; RMSEA =
26 years > 46(16.6) 0.071(90% CI: 0.055, 0.088) and it is in line with the ori-
Duration of marriage Less than 62(22.4) ginal structure of the scale. Indicators of perceived sup-
6 years port from friends and significant others are less strongly
6–10 years 38(13.7) correlated with the underlying construct compared to
11–15 years 45(16.2) perceived support from family.
16–20 years 45(16.2)
Locke Wallace Martial Adjustment Test (LWMAT)
21–25 years 35(12.6)
The model summarized in Figure 2 fits relatively well to
Above to 52(18.8)
25 years the data (Chi-square = 103.3 with 41 degrees of freedom
Decision of marriage Love based 22(7.9)
and p-value < 0.001; TLI = 0.847, CFI = 0.898; RMSEA =
0.071(90% CI: 0.053, 0.088). The scale has uni-dimensional
Arranged by 252(91)
family structure as suggested by the original authors of the scale.
Type of marriage (n = 182) Not within 52(18.8) However, inclusion of items 11, 12 and 13 significantly af-
family fects the overall fit of the model and each of these items
Within family 130(46.9) was not significantly correlated with the underlying con-
Number of children ever born No children 28(10.1) struct. However, after removing these items the factor
1–2 children 92(3.2)
structure was stable and the remaining items had signifi-
cant correlation with the construct although the magni-
More than 2 156(56.3)
tude of correlation between some of the items of the scale
Most recent childbirth (n = 238) Normal 178(64.3)
(item 10, 5 and 6) and the construct is small.
Caesarean 59(21.3)
History of abortion No 156(56.3) Couples Satisfaction Index (CIS-4)
Yes 61(22) The factor structure hypothesized for Couples Satisfac-
tion Index (CIS-4) (Figure 3b) gave excellent fit to the
data with Chi-square value of 0.13 with 1 degree of free-
dom and p-value =0.721; TLI = 1.00, CFI = 1.00; RMSEA =
0.000(90% CI: 0.000, 0.115). The uniqueness factors of
item 1 and item 2 are significantly correlated indicating

Perceived
Social support MSPSS1
MSPSS9
0.46
0.61
0.82 0.66 MSPSS2
MSPSS7 0.82
Friends Others 0.51
0.63
MSPSS5
0.66 Family 0.63
MSPSS6
0.65
0.78
MSPSS10
0.69 0.55 0.88 0.76
MSPSS12

MSPSS11 MSPSS8 MSPSS4 MSPSS3

Figure 1 Factor structure of multidimensional scale of perceived social support (MSPSS) (The numbers attached to each variable name
within each rectangular box indicates item number in the MSPSS scale, circle represents underlying factor for the set of indictor
variables attached to it by an arrow, numbers on the side of each arrow represents standardized regression weights or standardized
factor loading).
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LWMAT
0.52
0.52
LWMAT1 LWMAT15
0.62
0.20
LWMAT2 LWMAT10
0.54
0.34 0.53
LWMAT3 LWMAT9
0.39 0.52
0.67 0.74
LWMAT4
LWMAT8
LWMAT5 LWMAT6 LWMAT7

Figure 2 Factor structure of Locke-Wallace Marital Adjustment Test (LWMAT) (The numbers attached to each variable name within
each rectangular box indicates item number in the LWMAT, circle represents underlying factor for the set of indictor variables
attached to it by an arrow, numbers on the side of each arrow represents standardized regression weights or standardized
factor loading).

that these two items have some degree of commonality be- data with Chi-square value of 25.8 with 20 degrees of free-
yond what they share with the other two items of the scale. dom and p-value =0.171; TLI = 0.977, CFI = 0.987;
RMSEA = 0.033(90% CI: 0.000, 0.065). Item 6 is less im-
Relationship Dynamics Scale (RDS) portant followed by item 8. However, a large proportion of
The factor structure hypothesized for Relationship Dy- variance within each of the remaining items was explained
namics Scale (RDS) (Figure 3A) gave excellent fit to the by the underlying Relationship Dynamics. Similarly, all the

A
RDS4 RDS5 RDS6
RDS3

0.56 0.19
0.76 RDS7
RDS2 0.70
0.68

RDS8
0.61
RDS1
RDS 0.37
0.56

B CSI 0.76
CSI1
0.89

CSI4 0.87 0.79 0.31

CSI2
CSI3

Figure 3 Factor structure of (A) Relationship Dynamics Scale (RDS) and (B) Couples Satisfaction Index (CSI-4) (the numbers attached to
each variable name within each rectangular box indicates item number in their respective scale, circle represents underlying factor for
the set of indictor variables attached to it by an arrow, numbers on the side of each arrow represents standardized regression weights
or standardized factor loading).
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items used as indicators of Couples Satisfaction Index are likelihood of Depression and Anxiety by enhancing posi-
highly correlated with the underlying satisfaction construct. tive relationship as reflected by a low score on the rela-
tionship dynamics scale which decreases CMD symptoms.
Hospital Anxiety and depression scale (HADS) Moreover, perceived higher social support is positively as-
The model described in Figure 4 fits relatively well to sociated with marital adjustment directly and indirectly
the data (Chi-square = 199.3 with 75 degrees of freedom through relationship dynamics which is associated with
and p-value < 0.001; TLI = 0.815, CFI = 0.868; RMSEA = the reduced risk of depression through the increased level
0.078(90% CI: 0.065, 0.091). The scale has two correlated of reported marital satisfaction.
dimensions as it was suggested by the original devel-
opers of the scale. However, unlike the original sugges- Discussion
tion item 8 loads significantly on both dimensions and To the best of our knowledge the construct of marital
item 7 loads on Depression but not on the Anxiety fac- satisfaction (CSI-4), adjustment (LWMAT) and negative
tor. There were also significant correlations between two interaction in marital relations (RDS), perceived social
pairs of items (i.e. uniqueness of item one with that of support (MSPSS) and their relationship with mental health
item 2 and uniqueness of item 11 with that of item 12). of Pakistani married women (HADS) has not been studied
Assessing by the magnitude of standardized factor load- previously. Therefore the present study sought to examine
ings items 8, 12 and 14 were less important indicators of the interplay and associations between them using Struc-
Depression factor and item 11 was a less important indi- tural Equation Modelling.
cator of the Anxiety factor. The results indicated that the three scales used to
examine marital relations did in fact measure three sep-
Results from full structural equitation modelling arate yet interrelated elements of marriage. As hypothe-
Full structural equation model (Figure 5) shows the associ- sized they inversely correlated with psychiatric morbidity
ations of the socio-demographic characteristics, perceived of married women in Pakistan as assessed by HADS and
social support, various aspects of marital relationship SRQ-20. Increased marital satisfaction was protective
circumstances and the effects of these relationships on against depression whereas social support had a buffer-
mental health status of married women. The overall ing as well as a main effect on marital relations which in
model fits to the data reasonably well (TLI = 0.84, CFI = turn influenced the mental health of married women.
0.85, RMSEA = 0.046 (90% CI: 0.042, 0.050)). Residing in Residing in nuclear family system and having lower
nuclear family system and having less education are sig- educational level are significantly associated with an in-
nificantly associated with an increased risk of elevated creased risk of having elevated CMD symptoms which
CMD symptoms which in turn leads to an increased in turn leads to an increased likelihood of Depression
likelihood of Depression and Anxiety. Higher socioeco- and Anxiety.
nomic status does not have a significant direct effect on
the levels of CMD symptoms or the likelihood of having Social support as measured by MSPSS
Depression or Anxiety. However, it is a risk factor for The Urdu version of MSPSS in the present study repli-
Depression through its negative effect on the association cated a three factor structure as proposed in the original
with the level of the respondent's marital satisfaction. Fur- study [35]. Similar structure was reported in a previous
thermore, perceived higher social support reduces the study conducted in Pakistan [71] and other Asian countries

HADS1
HADS2 0.70 0.23 0.57

0.60 Anxiety 0.77 HADS3

HADS4 Depression

0.64 0.73
HADS5
HADS6
0.50 0.64
0.30 0.41 0.59 HADS9
HADS10 0.62
0.30 0.30 0.28
HADS11
HADS12
HADS14 HADS8 HADS7 HADS13

Figure 4 Factor structure of Hospital Anxiety and Depression scale (HADS) (the numbers attached to each variable name within each
rectangular box indicates item number in the HADS, circle represents underlying factor for the set of indictor variables attached to it
by an arrow, numbers on the side of each arrow represents standardized regression weights or standardized factor loading).
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From Wealth index

others
LWMAT
0.23 -0.24
0.73
1.02 Perceive
-0.72
Social
From CSI-4
support -0.56
friends RDS
0.35
-0.24
0.53
0.46
From 0.68 Depression
Family Elevated SRQ-20 score

Anxiety
0.76
0.12 -0.40

Being in nuclear Increased years of

Family system education

Figure 5 Structural equation model evaluating interrelationship of perceived social support, martial satisfaction, socio-economic situation
and mental health status of married women (RDS = Relationship Dynamics factor; CSI = Couples Satisfaction index; LWMAT = Locke-Wallace
Martial Adjustment; the numbers on the sides of the arrows are standardized regression coefficients or standardize factor loadings;
variables within the rectangles are measured variables and variables within circle/oval are underlying constructs or factors expressed
by measured indicator variables).

[72,73]. However, studies have reported one [45] or two previously [75]. Except for item 11 (Do you and your
[73] factor solutions as well. mate engage in outside interests together?), item 12
Pakistani society encourages strong familial culture (What do you/does your mate prefer in leisure time?)
which was reflected in the factor structure of the social and item 13 (Do you ever wish you had not married?) all
support scale. This is consistent with research on Indian other items contributed significantly to measuring the
immigrants in Britain [33] where married persons turn construct of marital adjustment. One previous study [76]
more frequently to family for support. In the current excluded item 12 from the scale on the basis that “ex-
study the weakest correlation was observed between the ploring leisure activities are more characteristic of cou-
latent construct of perceived social support and signifi- ples who are friends”. Friendship and companionship
cant others. This is consistent with a study comparing may not be a desirable characteristic for marital adjust-
Pakistani and Nepalese respondents living in Hong ment in Pakistani culture where most of the marriages
Kong. According to this study the Nepalese version of are arranged by families. A plausible explanation of item
MSPSS demonstrated a three factor structure while the 11 not being a valid indicator of marital adjustment in
Urdu version of MSPSS confirmed a two factor struc- the present study could be that in Pakistani cultural mi-
ture; in which items pertaining to 'significant others' lieu women generally get little freedom to have leisure
subscale were absorbed in the ‘family’ subscale [74]. and social life outside home [77]. This reduces their
Similarly another study among antenatal Pakistani chances of engaging in activities with their partners out-
women [45] showed a single factor structure for MSPSS. side home. Items 13(Do you ever wish you had not mar-
These studies collectively support the strong familial ried?) was perhaps a weak correlate because getting and
support system, however, support from friends and sig- staying married is religiously and culturally endorsed in
nificant others has shown inconsistent results. These dif- Pakistani society for females. Also Pakistani women re-
ferences in factor structure can be explained in terms of port to be committed to their marriage and respect the
difference in characteristics of the target population. solemnity of the relation [7]. Previous research among
Further exploration is suggested to establish the con- Pakistani and Bangladeshi women living in UK [77]
struct of perceived social support from a collective point found that almost all unmarried women in their study
of view. explicitly stated that they will get married and already
married ones had always expected it. It is perhaps im-
Marital adjustment as measured by LWMAT possible to envisage a life without marriage particularly
The current finding supports that LWMAT is a unidi- for women who are informed by the parents and the so-
mentional measure of marital adjustment as proposed ciety almost from birth that they belong to someone else
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and are to settle in another family. This could be one of the theory and interventions by focusing on the specific
the reasons that item 13 was not very relevant to Pakistani relationship elements and processes affecting mental
society. health of married women in Pakistan. In the past re-
searchers have used marital adjustment and marital sat-
Marital satisfaction as measured by CSI-4 isfaction interchangeably with their own interpretation
One dimensional factor structure of CSI-4 in the current of the concepts [14,20,28]. In our study moderate correl-
study is in agreement with the findings of a previous study ation between marital adjustment and satisfaction im-
[36]. The significant co-variation between uniqueness of plies that these are different but related constructs that
two items of CSI-4 (Degree of Happiness in the Relation- should be measured separately, which has been previ-
ship and Do you have a warm and comfortable relation- ously suggested both empirically and theoretically sug-
ship with your partner?) might be a function of the fact gesting that one may be used to predict the other rather
that unlike Western societies in Asian countries happiness than substituting one for the other [36].
is more a product of warmth and comfort in social rela- The absence of significant correlation between CSI-4
tionships from which the individual derives pleasure where and RDS in the present study also confirms previous
the self is perceived as part of the whole relationship [78]. postulation that they are distinct constructs. This con-
tributes to the growing evidence that the elements of
Dynamics of relationship as measured by RDS negative interaction are perhaps not mere opposite of
The current study supports the original one factor struc- happiness or satisfaction in marriage [8,10]. Further-
ture for RDS as previously proposed [38]. Weak loading more, the association of negative interactions and mari-
of item 6 of RDS (i.e. I think seriously about what it tal adjustment confirms the proposition that studying
would be like to date or marry someone else) on its marital satisfaction and adjustment does not automatic-
underlying construct might be explained as both ideas ally imply the absence/presence of negative interaction
suggested as options are not culturally viable particularly in the marriage and that they must be studied separately.
for women in Pakistan. To date and to think about men Hence, these constructs can exist parallel to each other.
other than the husband is considered blasphemous These findings are particularly useful for clinical inter-
therefore to elicit a response to the exploration of alter- pretations where clinicians are interested in the contri-
natives the question should be rephrased to suit the bution of disagreement and satisfaction in marital
Pakistani Muslim society. conflicts. Moreover, different instruments may be used
in research and by practitioners to determine if a marital
Depression and anxiety as measured by HADS relationship is non-distressed or if the couple experi-
In the current study, a two factor structure emerged for ences marital satisfaction.
HADS as proposed by the authors of the scale [39]. The In the current study increased negative interaction pat-
two sub-scales were significantly correlated, this correl- terns and decreased marital satisfaction both independently
ation could be explained by the known comorbidity be- contribute to the development of mental health problems.
tween depression and anxiety [55,79,80]. Psychometric Whereas marital adjustment associates with depression
issues in HADS have been discussed in literature over through its relationship with marital satisfaction. This is
time and several factor structures have been proposed in accordance with marital discord model of depression
[55]. The item analysis showed anomalous loading of [19], suggesting that problems in marriage elevates the
two items of HADS (items 7 and 8) on depression and risk for psychological morbidity which leads to depres-
anxiety which is consistent with other previous studies sion whereas marital satisfaction reduces the chances of
[81]. Item 7 in the present study loaded on depression experiencing depression. In SEM the pathway indicating
sub-scale but not on anxiety sub-scale. Similar results the woman’s experience of increased negative interac-
were reported previously [82] where item 7 (I can sit at tions adversely affects their mental wellbeing which is in
ease and feel relaxed) loaded on the anxiety sub-scale as agreement with recent findings [84].
well as on depression sub-scale. Whereas in another
study [83], this item loaded more strongly on depression
subscale as compared to anxiety. Item 8 (“I feel as if I Role of social support
am slowed down”) loaded significantly on both dimen- The SEM model suggests that social support plays a role
sions in agreement with previous studies [54]. in determining the perceived quality of Pakistani women’s
marital relationship. In keeping with Cohen’s theory [85]
Marital satisfaction, adjustment and negative interactions of mechanisms of social support and other findings [86],
as distinct components of marital relations the role of social support in the current study is twofold;
The model built in the current study using structural firstly it buffers the impact of negative interactions
equation model has important contributions to offer to (RDS) in marital relationship to indirectly increase
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marital adjustment (LWMAT) and it also enhances the and anxiety. Previous studies in Pakistan have reported
adjustment in marriage directly. both living in nuclear and joint family system as being
In Pakistani cultural context where boundaries be- risk factors for CMDs [4,90]. More evidence is required
tween the relationship with parents and spouse are and encouraged in future research to clarify this
blurred [32], family plays a greater role as an influential ambiguity.
source that affects the quality of marital interactions. In Women reporting higher socioeconomic status (SES)
line with Goodwin and Cramer [33] the current study were more likely to score low on marital satisfaction
established a greater role of family members in providing which in turn increased their risk for depression. How-
social support for marital relations. Surra [87] argues ever, a previous study examining the direct effect of SES
that family members serving as a source of social sup- on depression in Pakistan [90] reported a negative cor-
port influence an individual by communicating their relation. Further research is recommended in order to
opinions about an individual’s actions. This process can better understand the role of SES in marital relations
in turn enhance or diminish the quality of marital inter- and mental health.
actions [87]. The support provided by the family can also
enhance the quality of marriage by validating the rela-
tionship through asserting their worth as a couple, Limitations
accepting them socially and assuring that they can work The present study has important implications for marital
through their problems as a pair [88] this perhaps is one relations, perceived social support and mental health of
of the reasons why arranged marriages survived in com- Pakistani married women. However, the results should
munal cultures. Although there is evidence indicating be interpreted in the light of a few limitations. The cross
negative role of families in marriages for women in sectional study design does not allow causal inference
Pakistan, however the present study indicates that when therefore prospective research is recommended to estab-
the family plays a positive role in a woman's married life lish the temporal link between the above mentioned fac-
and it is perceived as such it is likely to reduce risk of tors. Our sample size does not allow representation of
mental health problems for married women. As mentioned regional differences. Furthermore, in our study men are
earlier in the background section that the prevalence for not represented which does not permit a gender com-
psychiatric morbidity for women is disproportionately high parison. It is an essential aspect that needs to be ad-
for Pakistani women and married women are more at risk dressed in future research. Having said this, the study is
because of dissatisfaction from marriage and problems an essential first step in shedding light on important as-
with in laws. Our study is a step forward in encouraging pects to be looked at for improving mental health and
interventions at individual, couple and social level to en- marital satisfaction of Pakistani women.
hance support from the indigenous source of family. Fur-
ther research needs to be conducted to get a perspective
on how the same applies to men in their marriage. Conclusion
In summary the current findings shed light on the mari-
Role of education, family system and socio-economic tal relationship processes and their etiological role in
status models of depression and anxiety by identifying specific
Among the three demographic factors under discussion aspects of marriage that may be addressed collectively or
in the current study educational status has protective ef- independently to improve the mental health of married
fect against mental health problems of married women. Pakistani women. Furthermore, social support may be
In the present study less education of participants was utilized as a resource to enhance marital relations and
associated with increased CMD symptoms leading to de- potentially reduce marital distress as a risk to women's
pression and anxiety. This correlation has been reported mental health.
in various studies [89] including studies in Pakistan This study contributes to the theoretical models and
where young women having higher educational level are intervention efforts. It fits well with theories of marital
found to be at lower risk for CMDs [90]. Secondly, living relations, mental health and social support, by allowing
in nuclear family system was found to be protective to capture the specific role played by individual elements
against mental health problems in the present sample. of marital relations. The findings will help in refining the
Pakistan is a collectivist country where social relation- prevention programs for marital discord by targeting indi-
ships play a greater role in an individuals’ life. In the vidual relationship processes directly to enhance the effi-
current study where family played an important role in cacy of interventions.
providing social support, living with the spouse and/or
children, away from other family members may nega- Competing interests
tively affect mental health which may lead to depression We have no competing interests to declare.
Qadir et al. BMC Public Health 2013, 13:1150 Page 12 of 13
http://www.biomedcentral.com/1471-2458/13/1150

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We are grateful to the study participants for taking out the time to share 22. Burr WR: Satisfaction with various aspects of marriage over the life cycle:
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