Abstract
Background
Studies have shown that individuals with fertility problems experience psychosocial problems. The use of various coping strategies seems to have different impacts on women with infertility stress. The aim of this study was to examine the role of coping strategies (active-avoidance, passive-avoidance, active confronting and meaning based) in predicting infertility stress among a group of women seeking infertility treatment in Shiraz.
Methods
One hundred twenty infertile women were recruited from several infertility clinics in Shiraz using convenience sampling method. The participants completed research measures including the Infertility Problem Stress Inventory and the Ways of Coping Scale (passive-avoidance, active-avoidance, active-confronting, meaning-based). Multiple regression analysis was used for data analysis. A p-value less than 0.05 was considered as statistically significant.
Results
The findings showed that participants had the highest scores on passive-avoidance coping strategies followed by meaning-based coping, active-confronting coping and active-avoidance coping. The findings also indicated that women who utilized more active-avoidance coping strategies reported less infertility stress. Furthermore, the results of regression analysis demonstrated that two coping strategies including active-avoidance (β=0.35, p<0.001) and meaning-based coping (β=-0.50, p<0.001) predicted infertility stress significantly. Moreover, meaning-based coping strategy was the strongest predictor of low infertility stress.
Conclusion
The present study showed that the majority of infertile women used passive-avoidance coping strategy. Furthermore, those who perceived their infertility problem as meaningful had a low infertility stress, while those who used active-avoidance coping strategies had high infertility stress.
Keywords: Coping skills, Female, Fertility, Infertility, Psychological, Stress
Introduction
There is no precise information on the incidence of infertility in Iran, but, it is estimated that about 22% of Iranian women experience primary infertility (1). Infertility has been found to yield psychological and social consequences, and the female partner tends to be more adversely affected than her male counterpart (2). The inability to have children is felt by individuals and couples as a stressful experience (3). Research has shown that women with infertility problems experience perceived lack of control in their life (4), social isolation, loneliness, (5), sexual dysfunction (6), low self-esteem (7), and fertility distress (8). The loss of control over one's life has been regarded as the most difficult consequence of infertility (9). Many studies have been conducted on stress and coping within the infertility context. The influence of coping strategies appears to depend on the specific constraints imposed by the stressful situation (10). It is believed that appraisal of controllability is an important factor in adoptions of coping strategies. In a study, Bento and his colleagues (11) found that appraisal of high controllability was related to adopting active coping strategies. The use of more passive and less active coping strategies has also been found to be related to psychological distress in patients with chronic illnesses (12). Although, infertility has an adverse effect on both men and women, females seem to suffer more. Women are under more pressure to conceive than men. According to some studies, in some cultures and societies such as Iran, there is a relatively high pressure on women to have a child (13). In such cultures, children are an important source of social desirability. They represent the creation of family bonds that link individuals, couples and generations to each other (14). Therefore, infertility can have a devastating effect on women's mental health. With regard to the fact that certain coping strategies have different impacts on individuals' mental health, it is important to understand which forms of coping strategies are used more frequently by infertile women. Thus, the aim of this study was to examine the contribution of coping strategies including active-avoidance coping, passiveavoidance coping, active-confronting coping and meaning based-coping in predicting infertile stress among a group of women seeking infertility treatment in Shiraz, Iran.
Methods
Participants were recruited from several infertility clinics in Shiraz using convenience sampling method. The sample consisted of 120 infertile women undergoing infertility treatment. This study was conducted between July and December 2012. The participants who had been trying to conceive for a year or more were included in the study. The informed written consent was obtained from the participants. Patients who agreed to participate in this study were asked to complete the questionnaires. Statistical analyses were performed using SPSS (version 16) software. Simultaneous multiple regression was utilized to analyze the data. A p-value <0.05 was considered significant.
Measures
Fertility Problem Stress Scale
The Fertility Problem Stress Inventory was designed to measure infertility-related stress. This scale was developed by Schmidt (15) and consists of 14 items. The scale is composed of three domains including personal domain (6 items), marital domain (4 items) and social domain (4 items). Responses are rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Research undertaken to determine reliability revealed an internal consistency of 0.74, 0.79 and 0.82 for the subscales, respectively (15). In this study, Cronbach's alpha coefficients were 0.70, 0.76, and 0.85 for personal, social, and marital domains, respectively. The Farsi version of the scale was submitted to a panel of experts to evaluate its content validity. The panel consisted of four infertility experts. All four approved the content validity of the instrument.
Ways of Coping Scale
The Ways of Coping Scale was used to assess strategies coping with infertility stress. This scale was designed by Schmidt (15) and consists of 29 items and four subscales. The subscales include active-avoidance strategies (e.g. avoiding being with pregnant women or children), active-confronting strategies (e.g. showing feelings, asking others for advice), passive-avoidance strategies (e.g. hoping for a miracle) and meaning-based coping strategies (e.g. thinking about the fertility problem in a positive light, finding other goals in life). The authors developed their own scale based on Ways of Coping Questionnaire (16, 17). The responses to this scale are rated based on a 4-point Likert scale ranging from 1 (not used) to 4 (used a great deal). A Cronbach's alpha ranging from 0.62 to 0.77 for the dimensions of the scale has been reported (15). The reliability of this scale was examined in this study and Cronbach's alpha coefficient for the subscales ranged from 0.57 to 0.79. The scale showed good convergent validity with Ways of Coping Questionnaire (r=0.68, p< 0.01).
Results
The mean age of the participants was 29.2 (SD=4.5) years and the ages were ranging from 24 to 52. The education level for the sample was: below high school (38%), high school (27%), undergraduate (32%), and postgraduate (3%). Majority of women were housewives (74%). In addition, the mean duration of infertility was 4.2 years, and the mean length of fertility treatments was 2.8 years. The descriptive data are presented in Table 1. As seen in the table, the highest score of infertility stress is related to personal domain followed by marital and social domains. In terms of coping strategies, the highest score was on passive avoidance coping and the lowest score was on active-avoidance. In order to identify the contribution of various components of coping strategies, an analysis of simultaneous multiple regression was conducted. At first, independent variables such as active-avoidance strategies, active-confronting strategies, passive-avoidance strategies and meaning-based coping were entered into the model, and then, infertility stress score as a dependent variable was entered into the model. The results demonstrated that active-avoidance coping (β=0.35, p<0.001) was a significant predictor of high infertility stress, while meaning-based coping (β=-.50, p<0.001) was the significant predictor of low infertility stress. Findings also indicated that two other coping strategies including passiveavoidance and active-confronting did not predict infertility stress. Moreover, among all variables tested for their influences on stress, the meaningbased coping strategy was the most predictive of women's infertility stress. The model explained 36% of total variance of prediction. The results are shown in Table 2.
Table 1.
Descriptive statistics for components of coping strategies and infertile stress
| Infertile stress domains | Mean± SD |
|---|---|
| Personal | 1.80±0.51 |
| Marital | 1.64±0.68 |
| Social | 1.10±0.79 |
|
| |
| Coping strategies | Mean± SD |
|
| |
| Active-avoidance | 0.83±0.66 |
| Passive-avoidance | 2.36±0.62 |
| Active-confronting | 1.66±0.74 |
| Meaning-based | 1.79±0.64 |
Table 2.
Multiple regression analysis for predicting infertility stress
| Coping strategy | B | β | t | p | R2 |
|---|---|---|---|---|---|
| Active-avoidance coping | 1.06 | 0.35 | 4.13 | 0.001 | 0.36 |
| Active-confronting coping | -0.04 | -0.02 | -0.17 | 0.89 | -- |
| Passive-avoidance coping | -0.05 | -0.01 | -0.10 | 0.92 | -- |
| Meaning-based coping | -1.22 | -0.50 | -5.08 | 0.001 | -- |
Discussion
The present study sought to examine the association between various forms of coping strategies and infertility stress. The findings showed that women with fertility problem used passive avoidance coping more frequently than other forms of coping strategies such as active-avoidance coping or active-confronting coping. In passive avoidance coping, the participants looked for a miracle and wished for positive changes. This finding differs from a number of studies indicating frequent use of active-avoidance coping among infertile women elsewhere (15). A possible explanation for frequent use of passive avoidance coping may be that participants of this study perceived less control over their infertility condition. Furthermore, infertility in Iranian culture is a social stigma and infertile women try to avoid the condition. In Iranian society, where childbearing is highly valued, infertility is against the societal norms and thus may be considered as a stigma (14, 18). Another explanation for the use of passive avoidance coping may be related to low level of education. The finding of this study indicated a significant association between the low level of education and passive-avoidance coping. Previous studies have shown that low educated people were more likely to use passive coping than high educated people (18, 19). The majority of participants in this study had a low level of education which might have made them to use passive avoidance. Furthermore, findings of this study demonstrated that activeavoidance predicted high stress, while meaningbased coping predicted low infertility stress. These results confirmed previous findings concerning the negative effect of coping through escaping (15, 20–22). Findings also support the theories indicating the use of avoidance strategy in situations such as infertility that individuals do not have control on it (11, 22). Although, the use of avoidance coping may be ineffective, in the case of infertility in which controllability is low, it can be an adaptive coping. The result of this study for meaning-based coping was in agreement with previous research demonstrating that personal meaning has an important impact on psychological well-being as a coping mechanism particularly when individuals suffer and face challenging life events such as infertility (23–25). The role of meaning-based coping in reducing infertility stress seems to be more important for Iranians. Religious beliefs are significant in daily life of Iranian people providing a meaningful framework for infertile women. The results of this study suggest that different forms of coping strategies may have different impacts on coping. This study has several limitations. The first one is the small sample of infertile women. With regard to high prevalence of infertility, future studies should survey a large sample of people with diverse characteristics. Furthermore, there may be some other important variables such as religious beliefs which contribute to infertility stress. Therefore, future studies should consider this. Finally, the current study did not include men in the research, therefore, the future research needs to investigate coping strategies among men with infertility problem and compare the results with those of women. Findings of the current study would help health services to promote the health of infertile couples and to provide psycho-education interventions.
Conclusion
The results of this study suggest that infertile women used passive avoidance coping more frequently than other coping types. This study also indicated that the use of meaning-based coping had positive impact on stress reduction, while use of active-avoidance coping increased infertility stress. This study highlights the importance of coping strategies in improving the mental health of women with fertility problem. The clinical interventions for infertile individuals may need to promote awareness about the usefulness of coping strategies.
Acknowledgement
The authors would like to thank the Infertility Clinics in Shiraz for their corporation and also the participants for taking part in this study.
To cite this article: Aflakseir A, Zarei M. Association between Coping Strategies and Infertility Stress among a Group of Women with Fertility Problem in Shiraz, Iran. J Reprod Infertil. 2013;14(4):202-206.
Conflict of Interest
Authors declare no conflict of interest.
References
- 1.Kazem M, Ardelan A. An overview of the epidemiology of primary infertility in Iran. J Reprod Infertil. 2009;10(3):213–6. [PMC free article] [PubMed] [Google Scholar]
- 2.Tarlatzis I, Tarlatzis BC, Diakogiannis I, Bontis J, Lagos S, Gavriilidou D, et al. Psychosocial impacts of infertility on Greek couples. Hum Reprod. 1993;8(3):396–401. doi: 10.1093/oxfordjournals.humrep.a138059. [DOI] [PubMed] [Google Scholar]
- 3.Fido A, Zahid MA. Coping with infertility among Kuwaiti women: cultural perspectives. Int J Soc Psychiatry. 2004;50(4):294–300. doi: 10.1177/0020764004050334. [DOI] [PubMed] [Google Scholar]
- 4.Greil AL, Slauson-Blevins K, McQuillan J. The experience of infertility: a review of recent literature. Sociol Health Illn. 2010;32(1):140–62. doi: 10.1111/j.1467-9566.2009.01213.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kavlak O, Saruhan A. A study on determination the loneliness level in infertile women and to assess the factors that effects of the loneliness level. Ege J Med. 2002;41:229–32. [Google Scholar]
- 6.Fode M, Krogh-Jespersen S, Brackett NL, Ohl DA, Lynne CM, Sonksen J. Male sexual dysfunction and infertility associated with neurological disorders. Asian J Androl. 2012;14(1):61–8. doi: 10.1038/aja.2011.70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Wirtberg I, Moller A, Hogstrom L, Tronstad SE, Lalos A. Life 20 years after unsuccessful infertility treatment. Hum Reprod. 2007;22(2):598–604. doi: 10.1093/humrep/del401. [DOI] [PubMed] [Google Scholar]
- 8.Greil AL, McQuillan J, Lowry M, Shreffler KM. Infertility treatment and fertility-specific distress: A longitudinal analysis of a population-based sample of U.S. women. Soc Sci Med. 2011;73(1):87–94. doi: 10.1016/j.socscimed.2011.04.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Redshaw M, Hockley C, Davidson LL. A qualitative study of the experience of treatment for infertility among women who successfully became pregnant. Hum Reprod. 2007;22(1):295–304. doi: 10.1093/humrep/del344. [DOI] [PubMed] [Google Scholar]
- 10.Karlsen B, Bru E. Coping styles among adults with type 1 and type 2 diabetes. Psychol Health Med. 2002;7:245–259. [Google Scholar]
- 11.Bento SP, Goodin BR, Fabian LA, Page GG, Quinn NB, McGuire L. Perceived control moderates the influence of active coping on salivary cortisol response to acute pain among women but not men. Psychoneuroendocrinology. 2010;35(6):944–8. doi: 10.1016/j.psyneuen.2009.12.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Peterson BD, Newton CR, Rosen KH, Skaggs GE. Gender differences in how men and women who are referred for IVF cope with infertility stress. Hum Reprod. 2006;21(9):2443–9. doi: 10.1093/humrep/del145. [DOI] [PubMed] [Google Scholar]
- 13.Shahnooshi M, Karimi Z. [Sociological impact of infertility upon family in Isfahan province] J Soc Sci. 2010;11(4):171–198. Persian. [Google Scholar]
- 14.O'Donnell E. Paris: Le Monde Diplomatique; 2008. Apr, Infertile in Iran [Internet] [cited 2013 Aug 12]. Available from: http://mondediplo.com/2008/04/15iran. [Google Scholar]
- 15.Schmidt L, Holstein BE, Christensen U, Boivin J. Communication and coping as predictors of fertility problem stress: cohort study of 816 participants who did not achieve a delivery after 12 months of fertility treatment. Hum Reprod. 2005;20(11):3248–56. doi: 10.1093/humrep/dei193. [DOI] [PubMed] [Google Scholar]
- 16.Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer; 1984. p. 256. [Google Scholar]
- 17.Folkman S. Positive psychological states and coping with severe stress. Soc Sci Med. 1997;45(8):1207–21. doi: 10.1016/s0277-9536(97)00040-3. [DOI] [PubMed] [Google Scholar]
- 18.Younesi SJ, Akbari-Zardkhaneh S, Behjati Ardekani Z. [Evaluating stigma among infertile men and women in Iran] J Reprod Infertil. 2006;6(5):531–545. Persian. [Google Scholar]
- 19.Rouchou B. Consequences of infertility in developing countries. Perspect Public Health. 2013;133(3):174–9. doi: 10.1177/1757913912472415. [DOI] [PubMed] [Google Scholar]
- 20.Schmidt L, Christensen U, Holstein BE. The social epidemiology of coping with infertility. Hum Reprod. 2005;20(4):1044–52. doi: 10.1093/humrep/deh687. [DOI] [PubMed] [Google Scholar]
- 21.Lykeridou K, Gourounti K, Sarantaki A, Loutradis D, Vaslamatzis G, Deltsidou A. Occupational social class, coping responses and infertility-related stress of women undergoing infertility treatment. J Clin Nurs. 2011;20(13-14):1971–80. doi: 10.1111/j.1365-2702.2011.03696.x. [DOI] [PubMed] [Google Scholar]
- 22.Peterson BD, Newton CR, Rosen KH, Skaggs GE. The relationship between coping and depression in men and women referred for in vitro fertilization. Fertil Steril. 2006;85(3):802–4. doi: 10.1016/j.fertnstert.2005.09.020. [DOI] [PubMed] [Google Scholar]
- 23.Berghuis JP, Stanton AL. Adjustment to a dyadic stressor: a longitudinal study of coping and depressive symptoms in infertile couples over an insemination attempt. J Consult Clin Psychol. 2002;70(2):433–8. doi: 10.1037//0022-006x.70.2.433. [DOI] [PubMed] [Google Scholar]
- 24.Gibson DM. The relationship of infertility and death: using the relational/cultural model of counseling in making meaning. J Humanist Psychol. 2007;35(3):275–289. [Google Scholar]
- 25.Peterson BD, Pirritano U, Christensen U, Schmidt L. The impact of partner coping in couples experiencing infertility. Hum Reprod. 2008;23(5):1128–1137. doi: 10.1093/humrep/den067. [DOI] [PubMed] [Google Scholar]