Relationship between Premarital Mental Health Status (GHQ-12) and Marital Satisfaction after the First Year of Marriage: A Prospective Study

Special Article - Community Medicine

J Fam Med. 2019; 6(5): 1176.

Relationship between Premarital Mental Health Status (GHQ-12) and Marital Satisfaction after the First Year of Marriage: A Prospective Study

Muhammad Samari¹, Mahdieh Yazdanpanah¹ and Nouzar Nakhaee³*

¹Research Center for Health Services Management, Institute of Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

²Department of Population and Family Health, Ministry of Health and Medical Education, Tehran, Iran

³Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran

*Corresponding author: Nouzar Nakhaee, Professor of Community Medicine Neuroscience Research Center, Kerman University of Medical Sciences, Kerman Neuroscience Research Center, Somayeh Cross-In Front of Besat Clinic Kerman, Kerman, Iran

Received: April 04, 2019; Accepted: May 10, 2019; Published: May 17, 2019


Background: Macrosocial changes and modernization have forced researchers to reexamine factors associated with marital satisfaction. Although correlation of mental health problems and marital health has been examined in several studies, almost all of them were retrospective or cross-sectional in nature.

Objectives: The aim of this research was to assess the relationship between premarital mental health and marital satisfaction one year after marriage, controlling for sexual satisfaction and demographic factors.

Methods: This prospective study was carried out on a consecutive sample of 386 women attending premarital education classes in Kerman (southeastern Iran). At first, they were asked to complete the General Health Questionnaire-12 (GHQ-12); one year later, their marital satisfaction (using ENRICH Marital Satisfaction scale) and sexual satisfaction (using sexual satisfaction index) were examined.

Results: The average (±SD) age of women was 23.6±5.1. Based on the GHQ-12 score, 51.0% of them were mentally healthy before marriage. Nearly 12% of them were dissatisfied with sex. In the multivariate linear regression, a significant relationship was observed between marital satisfaction and both sexual satisfaction (P <0.001) and mental health (P <0.001).

Conclusion: To identify those at risk of marital dissatisfaction, GHQ-12 test may be conducted on women before marriage. To generalize the results of the study it would be replicated in diverse settings.

Keywords: Marital satisfaction; Mental health; Women; Iran


Marriage is still regarded as a life priority by collectivist societies [1]. Researchers have shown that people will be happier and healthier if they have a successful marriage [2]. People marry with different motives; no matter what their motives are, they wish to have a more satisfied life after marriage [3]. Marital satisfaction is a crucial source to achieve a healthier life from different physical, social and psychological aspects [4].

Global statistics and figures have represented the increasing trend of divorce in recent decades. Assessing its causes in different cultures and countries (whether developed or developing) has suggested that social changes, modernization and increased individualism have played undeniable roles in this regard [5]. Iran is no exception; in Iran as one of high divorce countries, one in three marriages ends in divorce in some large cities [6].

Both experts and lay people try to predict people’s marital life before they marry so as to prevent divorce using premarital interventions. Marital satisfaction has been shown to be related to various factors including sexual satisfaction [7,8], personality traits [9] and some demographic factors [10]. Although the relationship between marital satisfaction and mental health has been evaluated in several studies and has been significant in most of them [11,12], almost all of them have been retrospective [11] or cross-sectional [12] studies. Uncertainty of temporal relationship between these two issues has made it difficult to judge them. Although in few studies mental health has been measured after marriage [13,14], they are either devoted to a specific subsample [13] or the main objective of the study is not prediction of marital satisfaction [14].

According to World Health Organization (WHO), mental health is an integral part of health; indeed, there is no health without mental health [15]. According to the WHO, nearly half of the world's population suffers from mental illness which affects their work and relationships in their everyday life [15]. Concerning the significant impact of mental health on different aspects of life, this study tried to answer this question: “Does mental health of people who want to marry have any contribution to their marital satisfaction one year after marriage?” The reason why only women participated in this study was that men, in Iran’s culture, are not willing to answer private questions especially sexual ones related to their marriage [8] and that women are more vulnerable to marital problems, seek help more and their dissatisfaction is more likely to trigger the cascade of divorce [16].

Based on our knowledge, this is the first study which examined and evaluated the relationship between mental health before marriage and marital satisfaction one year after the marriage in the presence of some correlates including demographic factors and sexual satisfaction.


Settings and participants

This follow up study was conducted in Kerman a city located in southeastern Iran on women attending premarital education classes. Participating in premarital education classes became compulsory in 1993 in Iran [8]. These compact course is mainly about sexual education.

Three hundred eighty six subjects were studied by enrolling 20 consecutive classes over a one month period in 2015. One exlusion criteria were defined; unwilling to participate in the study and the only inclusion criteria was “entering marriage for the first time”. About 20 people participated in each class, and questionnaires (except for marital satisfaction questionnaire) were distributed and collected before the classes started. Participants were told that they would be interviewed one year after their marriage to check their marital satisfaction. One year later, the participants were telephoned to remind them, and then two female interviewers interviewed them on their doorstep using the Enrich questionnaire. Each participant was given $15 for their time and participation at follow-up survey completion.

Ethical considerations

After explaining the purpose and nature of the study and after obtaining the informed consent, they participated in this study. This plan was approved by the university ethics committee (approval code: K/226).

Measurement tools

The GHQ-12 questionnaire contained 12 questions to assess mental health based on a four-point Likert scale; lower scores represented better mental health [17]. Scores above the median score (score 4) were considered the cut-off of the mental health questionnaire [17]. Its validity and reliability were confirmed in Persian [17]. The GHQ-12 was completed collectively before the classes started. The reliability coefficient of the questionnaire was 0.74 in our study. The GHQ-12 is the most widely-used screening tool to assess the mental health status in non-clinical setting [17].

One year after the marriage, the ENRICH Marital Satisfaction (EMS) scale consisting of 10 questions was completed at the participants’ houses using the 5-scale Likert method [18]. Validity and reliability of 10-question questionnaires have been confirmed in Iranian research [19]. To investigate the sexual satisfaction four questions of the sexual satisfaction index (SSI) questionnaire [8] which was about the experience of satisfaction with sex were also completed. In both questionnaires, higher scores represented higher satisfaction. The maximum acceptable score for both questionnaires was five. Cronbach's alpha for two questionnaires mentioned above was 0.84 and 0.79, respectively.

Concerning the possible relationship between demographic variables and marital satisfaction [10], participants were asked about their age and education, spouse`s age, friendship period before marriage, income and the family relationship.

To examine the relationship between marital satisfaction (as dependent variable) and demographic variables, scores of mental health and sexual satisfaction, the multivariate linear regression was used.


Of 386 women who completed the questionnaire before marriage, 351 ones completed marital satisfaction and sexual satisfaction questionnaires one year after the marriage (response rate = 90.9%). Demographic variables in drop outs showed no significant difference with others. The mean (±SD) age of participants and their spouses was 23.6±5.1 and 27.0±5.3 respectively, although in nearly 23% of cases women were older than men. In about a third of cases, they were friends for more than one year, before getting married (Table 1). Furthermore 71% of participants were pregnant or had children.