Predictors of Marital Burnout in Pregnant Women Based on Social Cognitive Theory Components

Women's health conditions in all dimensions are considered the most important foundation of community health (1). The women's roles as mothers and wives greatly affect the health of other family members (2). Pregnancy is one of the most important and sensitive periods of a woman's life (3) that causes various physical, psychological, and social changes in pregnant women and their husbands (4). These changes can also affect the couples' emotional relationship and marital satisfaction (5). The results of studies indicate a decrease in marital satisfaction during pregnancy (6). The change in the roles of husband and wife due to pregnancy is also considered one of the causes of marital burnout (7). The literature review in this field has shown that women are significantly more likely to suffer from marital burnout than men (7, 8). Based on the results of a study conducted by Soares, approximately 21% of women had high levels of burnout (9).

Burnout begins with a mismatch between people's expectations and the realities of their lives (10), and then gradually the conflicts, challenges, and stresses of life lead to marital burnout (11). In addition, psychological pressures and small resentments contribute to the development of burnout (12). Pines has identified the components of couples' burnout in three dimensions, namely physical, emotional, and psychological (13). Accordingly, physical burnout occurs with feelings of tiredness, boredom, and lethargy that cannot be relieved by sleep.

The emotional dimension includes lack of desire and satisfaction, development of emotional erosion, and reduction of motivation (11). Individuals with emotional exhaustion suppose that they are emotionally devastated and are constantly annoyed and discouraged (14). Mental exhaustion usually manifests itself in the form of decreased self-esteem, negativity towards the relationship with the spouse, and feelings of despair and frustration towards the spouse (11, 14). Holstean defines burnout as a form of depression since they have some common symptoms (8). Marital satisfaction has also been expressed as a factor influencing women's mental health (15). Regarding this, marital burnout is an important issue that is associated with numerous negative variables, such as depression, tension, despair, and sadness, and negative thoughts are among the factors that can cause burnout in couples. Several factors lead to marital burnout among couples, including social communication problems, loneliness, and decreased life satisfaction (16).

The issue of marital burnout in society can negatively affect the mental health of both couples and children (17). In case that affecting factors on marital burnout are being addressed, it can be expected various psychological, emotional, and social problems of families, and in general of the society, are reduced (10). It has been revealed that the rate of marital burnout has a two-way relationship with environmental and social factors and the quality of life (11). Nowadays, the patterns and theories of healthcare education identify several factors affecting behavior and determine the relationships among these factors and the conditions under which these relationships occur (18). One of the most effective theories in this field is the social cognitive theory developed by Bandura (19). The social cognitive theory emphasizes that individual and environmental characteristics impact behavior. This theory determines the predictors and effective principles in behavior formation and offers solutions to change behavior (20).

Social cognitive theory is a causal model that according to the principle of reciprocal determinism presents three sets of factors that affect each other (21), namely the individual (e.g., beliefs and expectations), individual's behavior, and environment (22). This theory strongly emphasizes the importance of the environment (23) and provides a theoretical framework for understanding the social-psychological mechanisms influencing an individual's beliefs and behavior change (24). To the best of our knowledge, no research has been conducted to examine the predictors of marital burnout among pregnant women based on social cognitive theory. The related studies have been conducted mainly in the field of recognizing predictors of mental health and life satisfaction based on social cognitive theory in different groups, such as women and students.

In a study conducted by Jamali, students' mental health predictors have been investigated based on social cognitive theory (18), and in a study performed by Shamshirgaran, the correlation between communication skills and marital burnout has been examined (25). In another study, Abusalehi determined the predictors of mental health among the elderly based on social cognitive theory (26). Moreover, Ghasemi has evaluated the relationship of social support and self-efficacy with mental health and life satisfaction (27). Therefore, considering the importance of pregnant women in the healthcare system of each country, the probability of marital burnout in this group, the lack of studies in the field of theoretical frameworks affecting marital burnout, and the need of recognizing these factors to design effective educational interventions, this study aimed to determine the predictors of marital burnout among pregnant women based on social cognitive theory.

Materials and Methods

This descriptive-analytical cross-sectional study was conducted on 261 pregnant women referring to comprehensive healthcare services centers for prenatal care in Gonabad, Razavi Khorasan Province, Iran, 2017. The sample size was determined at 265 people according to a similar article (28) with a mean of 20.76±20.76, interval confidence of 95%, and a power test of 2.5 using the formula for comparing the mean with a constant number.

The instruments used in the study included two questionnaires, namely the Standard Couple Burnout Measure (CBM; designed by Pines) and a two-part researcher-made questionnaire. The first part of this questionnaire consisted of the demographic information of pregnant mothers, including age, spouse age, year of marriage, week of pregnancy, history of abortion, planned pregnancy, employment status, education, and physical or mental illness. In the second part, questions related to the components of the social cognitive theory were investigated in 11 sections, namely awareness, outcome expectation, outcome value, self-efficacy, self-efficacy of overcoming obstacles, access, social support, observational learning, skills, understanding of situation perception, and self-regulation. The items in each section were as follows:

-  Awareness: 7 items (e.g., "Why is a satisfying relationship with a spouse important in pregnancy?"

- Outcome expectation: 6 items (e.g., "Having an emotional, verbal, and sexual relationship with a spouse makes me spend a good pregnancy."

- Outcome value: 5 items (e.g., "A proper and emotional relationship with my spouse is very important to me because of the baby's physical and mental health."

- Self-efficacy: 4 items (e.g., "I can have a good relationship with my spouse even when I feel depressed."

- Self-efficacy of overcoming obstacles: 5 items (e.g., "I can treat my spouse well even when my spouse does not treat me well."

- Understanding of the situation: 5 items "I understand my spouse even if he cannot pay attention and treat me well due to work fatigue."

- Access: 4 items (e.g., "My spouse and I have access to the information needed to have a proper and emotional relationship with each other."

- Social support: 5 items (e.g., "Healthcare staffs encourage me to have a proper relationship with my spouse."

- Observational learning: 4 items (e.g., "Observing people with an emotional and intimate relationship with their spouse encourages me to do the same."

- Skills: 6 items (e.g., "I have the ability and skill to build emotional and friendly relationships with my spouse."

- Self-regulation: 6 items (e.g., "I have a goal and regular plan to have a better relationship with my spouse."

The researcher-made questionnaire, which was on the basis of the social cognitive theory, was prepared based on the Marital Satisfaction Scale (developed by Enrich with a high correlation with couples' burnout) and similar studies in this field. To check the content validity of the researcher-made questionnaire, the opinions of 11 experienced professors of health education, health promotion, and reproductive health were applied in the preparation, edition, and modification of the questionnaire.

 Finally, the content validity indices of awareness, outcome expectation, outcome value, self-efficacy, self-efficacy of overcoming obstacles, understanding of the situation, access, social support, observational learning, skills, and self-regulation were obtained at 0.88, 0.91, 0.94, 0.91, 0.94, 0.89, 0.99, 0.98, 0.94, 0.93, and 0.94 in this study, respectively. Since the obtained index for each of these components was higher than 0.79, it can be concluded that this questionnaire had a high content validity index. Furthermore, according to the opinions of the experts evaluating the items, those with a relative validity ratio of less than 0.62 were removed from the questionnaire.

To determine the internal and external reliability of the instrument, after obtaining the necessary permissions, 29 pregnant mothers were randomly selected by referring to the comprehensive healthcare services centers. The participants completed the informed consent and responded to the Pines CBM and the researcher-made questionnaires in two stages with a one-month interval. The collected data were analyzed in SPSS software (version 25). The internal reliability of the instrument was obtained using Cronbach's alpha test; afterward, its external reliability was calculated using the intraclass correlation coefficient (ICC) and the correlation of the values obtained in the first and second stages.

Cronbach's alpha and correlation coefficients were obtained respectively for the components of awareness at 0.72 and 0.77, outcome expectation at 0.81 and 0.81, outcome value at 0.72 and 0.70, self-efficacy at 0.92 and 0.88, self-efficacy of overcoming obstacles at 0.71 and 0.97, understanding the situation at 0.73 and 0.75, access at 0.76 and 0.71, social support at 0.87 and 0.94, observational learning at 0.82 and 0.85, skills at 0.71 and 0.88, and self-regulation at 0.70 and 0.89. Additionally, Cronbach's alpha coefficient and ICC of the whole researcher-made questionnaire of marital burnout based on social cognitive theory were estimated at 0.88 and 0.95, respectively, which indicated the good reliability of the questionnaire.

The 21-item CBM is rated on a 7-point Likert scale (from 1 to 7), rendering for the total range score of 21-147, in which higher scores indicate higher burnout levels. To achieve better interpretation, the scores obtained from the questionnaire were divided by 21 (i.e., the total number of items), and then, the resulted scores were converted into degrees. Accordingly, the grades higher than 5, between 4 and 5, between 3 and 4, between 2 and 3, and 2 and less showed the need for immediate help, crisis, burnout, the risk of burnout, and a good relationship, respectively.

It should be noted that the test-retest reliability scores of this questionnaire were obtained at 0.89, 0.76, and 0.66 in the one-month, two-month, and three-month periods, respectively. Moreover, its alpha coefficient was measured at 0.91-0.93. In Iran, Navidi administered this questionnaire on a sample of 240 cases (120 nurses and 120 teachers) and calculated its reliability at 0.86 using Cronbach's alpha coefficient (29). In our study, the external and internal reliability scores of this questionnaire were estimated at 0.77 and 0.81 using Cronbach's alpha coefficient and ICC, respectively.

The samples were collected from all comprehensive healthcare services centers in Gonabad (7 centers). The list of pregnant mothers of each center was prepared and according to the population of pregnant mothers covered by each center and the inclusion criteria, sampling was performed from each center separately using the random sampling method. To this end, the lists of pregnant mothers were prepared from each center separately and all centers (i.e., the total population of pregnant women in the city). Afterward, sampling was conducted by calculating the proportion of the population covered by each center.

The inclusion criteria were being at the age range of 15-45 years old, having at least primary school education, and being willing to participate in the study. On the other hand, the participants who were dissatisfied to take part in the study and had an acute physical or mental illness were excluded. The subjects were assured of the confidentiality of the information and the possibility of voluntary participation in this study. After obtaining informed consent from the participants, the questionnaires were distributed among them to fill out.

The questionnaires were given to 276 pregnant mothers referring to the comprehensive healthcare services centers; however, finally, 261 questionnaires were analyzed due to the incomplete completion of some questionnaires. The data were then analyzed in SPSS software (version 25) using the Kolmogorov-Smirnov test to evaluate the presence or absence of normal distribution in the variables.

Due to the non-normal distribution of the studied variables, Spearman's correlation test and linear regression were used to investigate the correlation of the components of social cognitive theory with couple burnout score and its dimensions and examine the correlation between the predictors of couple burnout based on the components of social cognitive theory, respectively. It is noteworthy that this study was derived from a master's thesis conducted on health education and promotion and was approved by the Ethics Committee of the Mashhad University of Medical Sciences, Mashhad, Iran (IR.MUMS.REC.1395.407).

Results

The mean age of pregnant women was obtained at 28.69±5.47, and the subjects were at 23.67±9.91 weeks of pregnancy. The mean scores of marital burnout, physical burnout, emotional exhaustion, and mental exhaustion were calculated at 2.64±0.78, 2.28±0.70, 2.43±0.86, and 2.52±0.83, respectively. Other demographic variables and their relationship and correlation coefficient with marital burnout are presented in Table 1.

It was revealed that among the studied demographic variables, only the year of marriage had a positive and significant relationship with marital burnout (P=0.046), while the other components showed no significant relationship (P<0.05).

Table 2 tabulates the relationship of the components of social cognitive theory with marital burnout and its dimensions. According to the results of Spearman's correlation, all components of social cognitive theory, except the outcome expectation, had a significant

relationship with marital burnout (P

Multiple linear regression was performed to investigate the importance of each component, and therefore, prepare the educational content for the pregnancy period. Stepwise linear regression was also used, and all the components of social cognitive theory and the year of marriage that were significant were regressed.

The Durbin-Watson test was applied to detect the lack of autocorrelation, the statistic of which was 1.56, and there was no correlation between the variables. Most of the variance inflation factors were related to the self-efficacy of overcoming obstacles calculated at 1.49. The coefficient of determination of the model was obtained at R²=0.15, and the residues had a normal distribution (P=0.256). The final model is given in Table 3.

Discussion

Based on the research and considering the limitations of studies conducted in this field, the present study used the social cognitive theory to predict the factors that have a direct and indirect effect on marital burnout among pregnant women. Since the mean score of marital burnout in pregnant women was obtained at 2.64±0.78, the identification of the factors affecting marital burnout in pregnant women could play a special role in improving couples' relationships and reducing psychological, emotional, and social problems during pregnancy.

The results of our study showed the existence of a relationship between the years of marriage and marital burnout, which was consistent with the findings of a study conducted by Khodadai indicating a significant relationship between marital burnout and the duration of marriage among nurses (30). This result was in line with those of a study performed by Zareh (31). The decrease in marital satisfaction in couples can be due to the increased responsibility of couples, the birth of children, and the financial problems associated with raising children (32).

In the present study, all components of social cognitive theory, except outcome expectation, had a significant relationship with marital burnout. Along with these results, the aesthetic study showed that expectation of outcome has nothing to do with mental health (18). However, in some studies, such as research carried out by Micaeili, this structure was able to predict life satisfaction (33). Outcome expectation is the prediction of possible consequences of behavioral conflict, which can be physical or psychological (34). This discrepancy can be attributed to the overlap of variables, in other words, the effects of other components are so high that they hide the effect of the outcome expectation; therefore, further studies are needed to be performed in this field.

It should be noted that the studied components of this theory included awareness, outcome expectation, outcome value, self-efficacy, self-efficacy of overcoming obstacles, access, understanding of the situation, social support, skills, self-regulation, and observational learning. All these components and the years of marriage were examined using stepwise multiple linear regression. Accordingly, it was found that two components, namely skills and understanding of the situation, were predictors of marital burnout among pregnant mothers, and these components can be used as a reference framework for designing interventions in the field of marital burnout.

In line with our results, Shamshirgaran reported a significant inverse relationship between communication skills and marital burnout (35). In another study conducted by Alipour, the training of communication skills increased marital satisfaction and decreased depression and anxiety among pregnant women (36). Behavioral skills lead to the exchange of positive behaviors, reduction of negative behaviors, and changes in people's feelings, behaviors, and attitudes. Finally, these changes reduce the emotional burnout of couples and increase marital satisfaction (13). The social cognitive theory also emphasizes skills (21), based on which, Bandura highlights the roles of knowledge and skills to perform the behavior as crucial factors for health promotion programs to be successful (37).

In a study carried out by Aliakbari, skills and self-efficacy were reported to be among the most important predictors of health literacy. Self-Efficacy, not only helps to master a behavior but also influences the use of skills and whether they are utilized well and emphasizes the learning and developing skills (21). Self-efficacy refers to a person's belief in his/her ability to successfully accomplish a task or goal (21), while self-efficacy of overcoming obstacles is defined as an individual's confidence in overcoming obstacles while performing the behavior (34).

The results of a study conducted by Martin suggested that the best predictor of behavior was self-efficacy of overcoming obstacles (38), which was consistent with our findings. Furthermore, Jamali predicted the positive and significant correlation between self-efficacy and mental health in this study (18). The findings of another study indicated that self-efficacy played a mediating role in the relationship of social support with life satisfaction and mental health. The mentioned study also emphasized the relationship between this component and stress (39), since when people's tasks are within their perceived self-efficacy scope, they will have less anxiety and stress. However, doubts about the ability to deal with problems cause mental distress and physiological arousal (40).

Understanding the situation refers to how one perceives and interprets his/her environment (34). In a study performed by Sadeghi et al., the component of understanding the situation and perceived obstacles (i.e., self-efficacy of overcoming obstacles) had a positive and significant correlation with general belief (41), which was partly in agreement with the results of our research. In the studies conducted on social cognitive theory, especially those in the field of mental health, this component has rarely been investigated. The component of understanding the situation refers to an individual's perception of living conditions and environment. Consequently, according to the findings of this study, it will be possible to modify and improve the component of understanding the situation in mothers' educational programs with an emphasis on the need of having a positive attitude towards living conditions and provision of more personal and environmental support. Additionally, educational interventions aimed to improve communication and marital skills can help reduce marital burnout.

According to the findings of the present study, the social cognitive theory was able to describe and predict 15% of marital burnout among pregnant women. In line with the findings of the current study, in a study performed by Abusalehi, the social cognitive theory was able to predict 42.1% of the mental health among the elderly (26). Davis Mogel showed that the use of social cognitive theory could be effective in promoting safe sexual behaviors (42).

It might be that the difference between the predictive power of social cognitive theory components in the present study and other studies is attributed to the fact that some studies only examined the predictive power of significant components, whereas, in the present study, the interactive effect of all components on marital burnout was examined. Furthermore, the number of components studied in our study was different, and even more, from those in the mentioned studies.

Discrepancies in results can have various causes, among which is probably the difference in the study population and the other is the difference in the domain of the mentioned studies from that of the present study, which due to the lack of studies in the field of factors affecting marital burnout among pregnant mothers, our citations were mostly to related articles in this field.

One of the limitations of our study was the findings obtained through self-report, meaning that the participating pregnant mothers might have been influenced by temporal, environmental, or a large number of questions and might have expressed appropriate responses for that particular time or situation or avoided expressing their feelings and behaviors correctly. On the other hand, one of the strengths of this study was the investigation of environmental and psychological factors collectively and the application of all components of social cognitive theory, as well as the use of random sampling method that provides the possibility of generalizing the results to the whole society.

Conclusion

According to the findings of the present study, the social cognitive theory was able to predict marital burnout well and the components of skills and understanding the situation were the most important factors affecting marital burnout in pregnant mothers. It is suggested to use this theory, and especially focus more on these variables, in designing educational programs to reduce physical, emotional, and psychological problems caused by marital burnout in pregnant women.

Acknowledgements

The present article was derived from a master's thesis with the design code 950205 and was conducted with the financial support of Mashhad University of Medical Sciences. The authors would like to express their gratitude to the esteemed Vice-Chancellor for Education and Research of Mashhad University of Medical Sciences, pregnant women in Gonabad city, staff of healthcare services centers in Gonabad, and all those who cooperated in this study.

Conflicts of interest

Authors declared no conflicts of interest.