Quality of Life of Kurdish Women from Martyrs’ Families in Kurdistan Region of Iraq as a Middle East Conflict Area

Quality of life (QOL) research develops data and insight into issues that pertain not only to the individual but also can apply to the population as a whole. This study aimed to analyze the QOL of Kurdish women from martyr families of Kurdistan region of Iraq.Methods A cross sectional study was conducted on 380 women from martyrs’ families who were patients at the Medical Center of Martyr Families in Erbil City during the period of January 2018 to April 2019. Through direct interviews data were collected and the WHOQOL-BREF scale was used for measuring the QOL. The samples were divided into four categories (quartiles) according their QOL score: 1st, 2nd, 3rd and 4th quartile. Kruskal-Wallis and Chi-Square tests were used for data Analysis.Results The QOL domains of the study sample were set in following quartiles: Overall QOL and General Health Domain (66.6%) and Physical and Psychological Health Domain (56.9%) in 1st and 2nd quartiles, Social Relationships (47.9%) in 3rd quartile, Environment Domain (85.6%) in 2nd and 3rd quartile. The total QOL of more than half (52.1%) of the studied women were in 1st and 2nd quartiles.Conclusion Women of martyr families were not satisfied with their QOL especially in Physical and Psychological Domains. International political and humanitarian actions are needed to reduce the destructive consequences of war and conflicts on these suffering women.


Abstract Background
Quality of life (QOL) research develops data and insight into issues that pertain not only to the individual but also can apply to the population as a whole. This study aimed to analyze the QOL of Kurdish women from martyr families of Kurdistan region of Iraq.Methods A cross sectional study was conducted on 380 women from martyrs' families who were patients at the Medical Center of Martyr Families in Erbil City during the period of January 2018 to April 2019.
Through direct interviews data were collected and the WHOQOL-BREF scale was used for measuring the QOL. The samples were divided into four categories (quartiles) according their QOL score: 1st, 2nd, 3rd and 4th quartile. Kruskal-Wallis and Chi-Square tests were used for data Analysis.Results The QOL domains of the study sample were set in following quartiles: Overall QOL and General Health Domain (66.6%) and Physical and Psychological Health Domain (56.9%) in 1st and 2nd quartiles, Social Relationships (47.9%) in 3rd quartile, Environment Domain (85.6%) in 2nd and 3rd quartile. The total QOL of more than half (52.1%) of the studied women were in 1st and 2nd quartiles.Conclusion Women suffer more severely from the damage to the health and other infrastructure and the wider economic damage as well as from displacement and dislocation during and after conflict [2].
Quality of life research increase knowledge related to the individual for clinical management, develop an epidemiological perspective to the problems, provide data to evaluate the cost-effectiveness of various permutations in the balance between the three levels of prevention, and the 'human effectiveness' of health care system restructuring. Therefore QOL data have significant implications for social and public policy [3].
During the last 100 years ago, Iraq generally, and Kurdistan region particularly underwent wars and conflicts which led to massive loss of men from families. Those people died for the principal slogans of The general purpose of the present study is to provide evidence on need assessment of Kurdish women, specifically from martyr families because of their challenges in health needs and their role in supporting family members. Therefore this study aimed to find out the QOL of Kurdish women from martyr families and find out its association with their sociodemographic characteristics.

Methods
A cross sectional study was conducted in Medical Center of Martyr Families in Erbil city during the period of January 2018 to April 2019. This center is under the direction of the Ministry of Martyrs and Anfal (Genocide), Kurdistan region, Iraq. In the entire Erbil Governorate this is the only medical center available to provide health care specifically for this group and it is only accessible to families living within the city limits. Surgeon, internist, rheumatologist, urologist, dentist, ENT and dermatologist are available in this center. Basic laboratory tests, x-ray and sonography are available; for more advanced intervention, treatment and care, the cases are referred to government hospitals. Three hundred eighty women from martyrs' families attending the center through non probability sampling were recruited for participation in the study. For calculation the sample size the Epiinfo 7 Computer Program was used. The following information had been entered in the program: population size 50,000, expected proportion of women of quality 50% (it was set as 50% because of unavailability of data, knowing that 50% will give the highest sample size), precision 5%, and confidence level 95%.
Accordingly the estimated sample size was 381, so 380 were considered for convenience. Prior to data collection, permission to conduct this study was secured from Directorate of Martyrs in Erbil city and proposal of the study was approved by Scientific and Ethical Committee of College of Nursing, Hawler Medical University.
A questionnaire form was developed for the purpose of data collection which includes demographic characteristics of women. For measuring the QOL the WHOQOL-BREF scale was used. It assesses the individual's perceptions in the context of their culture and value systems, and their personal goals, standards and concerns. The WHOQOL instruments were developed collaboratively in a number of centers worldwide, and have been widely field-tested. The WHOQOL-BREF instrument comprises 26 items, which measure the following broad domains: physical health, psychological health, social relationships, and environment. The WHOQOL-BREF is a shorter version of the original instrument (WHOQOL-100) that may be more convenient for use in large research studies or clinical trials [5].
All martyr family members can attend this center. By carefully chosen sampling methods wives, mothers, sisters and daughters of martyrs who attended the center during data collection were included in the study. Informed consent was taken from those who accepted to participate in the study after explaining the purpose and answering any questions they had. Forms were coded without asking their names or writing on the form of the questionnaire. Data were entered into and analyzed by Statistical Package for Social Silences (version 23). Kolmogorov-Smirnov test was used to determine the normality distributions of the quantitative variables. The sample was divided into four categories (quartiles) according their QOL score: 1) the lowest 25%, the next lowest 25% of numbers (up to the median), 3) the second highest 25% of numbers (above the median), 4) the highest 25% of numbers. Frequency, percentage, Kruskal-Wallis, Mann-Whitney, and chi-square tests were used for data Analysis.

Results
Thirty hundred and eighty women from martyrs' families engaged in this study with mean age 48.6±13.5 and mean years of education 3.5±4.7. More than half of the study sample (51.6%) were aged between 41-60 years old and were illiterate (53.7%). The majority were housewives (92.9%) and were married (90.5%). Most of the study sample were either a wife, sister or daughter of the martyr (Table 1). The highest percentage (66.6%, 56.9%, and 69.2%) of the study samples of overall QOL and general health, physical and psychological health, were in first and second quartiles, respectively. Nearly half (47.9%) of the women -quality of social relationships -were in third quartile. The majority (85.6%) of them -quality of environment domain -were in second and third quartile. The total QOL of more than half (52.1%) of studied women were in first and second quartiles ( Table 2).  Table 3).
The response of the majority (99.2%) of the study sample to the question " Do these questions show your quality of life?" was "Yes". The median of social relationship domain of the quality of life was higher than the median of other domains. Psychological domain and overall QOL and general health had the lowest median (Figure 1).

Discussion
The  [6,7]. The results show that the quality of life of these women is not desirable and even poor depending on age, educational level, occupation, marital status and relationship to the martyr. The quality of physical health and psychological domain of the study sample were low, which may be due to lack of governmental health organization support and the provision of health care to this group of women as well as proper financial support. In addition role of socio-demographic factors especially educational level and occupation were manifest, as the majority of women were illiterate and housewives. Results of the other studies shows that QOL deficits in both veterans and refugees have been consistently linked with war-related posttraumatic stress symptoms [8,9].
In a study done in Western Europe on Balkan residents and refugees, results show that employment and financial situation were among strong factors of dissatisfaction by participants and Social QOL (SQOL) had affected strongly by posttraumatic stress symptoms. lower SCOL were directly depended with traumatic war events and post-war environment [10]. society [13].

Results
Kurdistan Region Government (KRG) has supported those families who lost their family members (specially the breadwinner of the family in defense of the Kurdistan) including a monthly salary and support for health care, education, and housing [14]. Despite this, it seems those families struggle with their life needs, as the results of the present study shows that only 10.5% of the study sample situated in 4 th quartile of total QOL according WHOQOL-BREF. It is worth mentioning that the poorest martyr families attend the medical center (setting mentioned in method) for seeking health care.
Results of a qualitative study in same center indicated that women of martyr families were not satisfied with the health services of the center; they had expected that more assistance would be provided from the government to respect them and provide their emotional, social, economic and physical needs [15]. all study participants as generally this approach is preferred by people and the written consent is not mellow in our community which approved by Ethics and scientific committees.

Consent for publication: not applicable.
Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Figure 1
Box plot indicating median, quartiles and extreme values for domains of QOL