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Differences in Quality of Life Between Infertile Women and Men in Turkey
JOGNN
RESEARCH
Differences in Quality of Life Between Infertile Women and Men in Turkey Nursen Bolsoy, Ayten Taspinar, Oya Kavlak, and Ahsen Sirin
Correspondence Nursen Bolsoy, RN, PhD, Ege University School of Nursing, 35100 Bornova/ Izmir, Turkey. [email protected]
ABSTRACT
Keywords infertile women infertile men quality of life
Participants: The research sample comprised 248 infertile individuals (141 women and 107 men) admitted to the clinic for the first time for diagnosis and treatment between January 1 and June 30, 2007, and who voluntarily agreed to participate.
Objective: To examine potential differences in quality of life between infertile women and men. Design: A descriptive, cross-sectional design. Method: A questionnaire was used to collect individuals’ sociodemographic data; the World Health Organization Quality of Life–BREF (WHOQOL-BREF) tool was used to collect information about quality of life.
Setting: The research was conducted at the Ege University Family Planning and Infertility Research and Training Center Infertility Clinic in Izmir, Turkey. Results: Physical health, psychological health, and social relations domain score means did not show significant differences between infertile women and infertile men (p4.05). However, score means for the environment domain were significantly higher (po.05) for infertile women than for infertile men. Unemployed infertile men had significantly lower score means in the physical health and social relation domains (po.01). No such significant differences were found for the other quality of life domain scores for infertile women or infertile men (p4.05). Conclusion: In the environmental domain, the quality of life of infertile women was greater than that of infertile men. Variables affecting quality of life of infertile individuals were seen to affect women and men in similar ways. Nurses and health care professionals caring for infertile individuals should be aware of the factors that affect quality of life and should plan to meet their care needs accordingly.
JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x Accepted October 2009
Nursen Bolsoy, RN, PhD, is a research assistant and instructor in the Department of Gynecology and Obstetrics, Ege University School of Nursing, Izmir, Turkey. Ayten Taspinar, RN, PhD, is a research assistant and instructor in the Department of Gynecology and Obstetrics in Nursing, Adnan Menderes University, Aydın School of Health, Aydin, Turkey. Oya Kavlak, RN, PhD, is an assistant professor, in the Department of Gynecology and Obstetrics, Ege University School of Nursing, Izmir, Turkey. (Continued)
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nfertility is generally de¢ned as the inability to conceive after 1 year of unprotected and appropriately timed intercourse, and/or the failure to carry a pregnancy to term. Some studies estimate that infertility a¡ects approximately 10% to 15% of couples (Chachamovich, Chachamovich, Zachia, Knauth, & Passos, 2007; Monga, Alexandrescu, Katz, Stein, & Ganiats, 2004; S,irin, 2001), whereas the World Health Organization estimates the prevalence of infertility among couples around the world as between 8% and 12%, thus a¡ecting 50 to 80 million people (Daar & Meralı, 2002). The Turkish Demographic and Health Survey (2003) found the percentage of married women who have not had children and are unable to carry a pregnancy to term to be 9.4%.
I
Infertility in couples creates serious biological, psychosocial, economic, ethical, and cultural problems and reduces quality of life (QOL). As a sudden and unexpected life crisis, the diagnosis and treatment
of infertility is spread over a long time, causing stress and great di⁄culties in terms of adaptation (Akyˇz & I˙nanc, 1999; Brucker & McKenry, 2004; Gˇcsavas,, 1992; Karlıdere et al., 2007; Rashidi et al., 2008; Van den Akker, 2005). For this reason, the lives of many couples change with the diagnosis of infertility (Lee, Sun, & Chao, 2001; Ramezanzadeh et al., 2004; S,irin, 2001). In Turkish society, as elsewhere, infertility is considered a crisis, but the excessive pressure exerted by a traditional societal structure increases the seriousness of the problem. Infertile couples see infertility as a serious handicap as the ability to conceive is considered one of the fundamental elements of the marriage contract (Gˇrhan, Akyˇz, O£az, Atıcı, & Vural, 2007; Khayata, Rizk, Hasan, Ghazal-Aswad, & Asaad, 2003; Ozkan & Baysal, 2006; Saydam, 2003). Infertility may also have a negative e¡ect on marital relations because it can cause feelings of disappointment and guilt, as well
& 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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RESEARCH
Quality of Life of Infertile Women and Men in Turkey
Similar factors affect the quality of life of infertile women and men.
as groundless mutual accusations among couples (Tas,cı, Bolsoy, Kavlak, & Yˇcesoy, 2008). Tas,cı et al. showed that the environmental pressure experienced by infertile individuals reduces marital harmony and happiness. Furthermore, infertility treatment and related procedures increase the stress experienced by couples because their sexual life becomes part of the treatment procedure (Akyˇz, I˙nanc, & Pabuccu,1999; Gˇrhan et al.; Monga et al., 2004). Research data indicate clear di¡erences in the responses of women and men to infertility. Women take the diagnosis of infertility more personally, consider that it might devalue their role as women, and experience reduced emotional stability and a decrease in self-esteem (Gˇrhan et al., 2007; Kavlak, 1999). Although men experience disappointment, they are less vulnerable to feelings of worthlessness (Kavlak). Moreover, women are more likely to experience feelings of loneliness (Jirka, Schuatt, & Foxal, 1996; Kavlak; Lukse & Vacc, 1999). Studies have shown that women experience more stress, anxiety, depression, and animosity than men when faced with the diagnosis of infertility (Akyˇz et al., 1999; Ashkani, Akbari, & Heydari, 2006; Brucker & McKenry, 2004; Gˇrhan et al.; Halman, Andrews, & Abbey, 1994; Karlıdere et al., 2007). Infertile women grieve for the fact that they cannot have children or experience pregnancy, whereas infertile men mourn their loss of power and their inability to become a biological father (Akyˇz et al.).
Ahsen Sirin, RN, PhD, is a professor of Gynecology and Obstetrics in the Nursing Department, Ege University School of Nursing, Izmir,Turkey.
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There are also di¡erences between women and men in strategies to cope with the stress. In stressful situations, women are more likely to feel the need for social support, and for this reason they ¢nd it easier to seek this kind of help (Brucker & McKenry, 2004; Karlıdere et al., 2007). However, the social environment in which women live may also have negative e¡ects (Guz, Ozkan, Sarisoy, Yanik, & Yanik, 2003). Women receiving low levels of support from their spouse and social environment feel greater anxiety and depression (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Gulseren et al., 2006; Guz et al., 2003; Karlıdere et al.; Lee et al., 2001). In contrast, as men are expected to solve their own problems, they do not make use of sources of social support as frequently as women. Therefore, they do not discuss the issues with their relatives and do not try to use coping mechanisms (Brucker & McKenry; Karlıdere et al.). Men’s inclination to disguise
their emotional disturbance may be due to their reluctance to change their behavior or a desire to improve their social standing (Karlıdere et al.). Health-related QOL is de¢ned as an individual’s perception of his or her own health in the social and cultural environment in which he or she lives (Fidaner, 2004). Although infertility has an impact on both sexes, the QOL of women and men may be a¡ected in di¡erent ways and to di¡erent extents. Some studies have shown that women’s QOL is more strongly a¡ected by infertility than men’s (Cattoli et al., 2004; Khayata et al., 2003; Monga et al., 2004; Ragni et al., 2005; Tur-Kapsa, Maor, Meltzer, & Segal, 2001). However, there is a need for more research in this area.
Purpose This descriptive study was designed to examine di¡erences in QOL between infertile women and men. It attempts to address the following research question: Is there a di¡erence between the QOL of infertile women and men?
Methods Setting and Sample The current study was conducted at the Ege University Family Planning and Infertility Research and Training Center at the Infertility Clinic in Izmir, western Turkey. Izmir, which is on the Aegean coast, is the third largest city inTurkey, and the infertility clinic was the ¢rst infertility center in the country. Although there are ¢ve clinics o¡ering infertility treatment in Izmir, this is the only state clinic; the others are private and patient numbers are too low for relevant comparison. In this clinic, treatment costs are met by the social security unit. The clinic receives applications from all over the country, but mainly from people in the Aegean region. The study population was composed of infertile women and men who came to the clinic for diagnosis and treatment between January 1 and June 30, 2007. During this period, 290 new couples were admitted to the clinic. The research sample included 265 infertile individuals (149 female and 116 male) who voluntarily agreed to participate in the study. Among those who agreed to participate, eight women and nine men who did not complete the forms were excluded from the study. Therefore, the data from a total of 141 female and 107 male infertile individuals were included in the analysis population. Prior to beginning the research, human subject approval was obtained from the Ege University School
JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x
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RESEARCH
Bolsoy, N., Taspinar, A., Kavlak, O. and Sirin, A.
of Nursing Ethics Committee and from the clinic where the research was conducted; verbal consent was obtained from all participants before beginning data collection.
The quality of life of infertile women and men, in terms of physical health, psychological health, and social relationships, is affected to a similar extent.
Measurements Basic demographic and clinical data concerning the patients, including age, gender, education, family information, social security status, income level, employment status, duration of infertility, previous treatment for infertility, and infertility causes, were collected. Health-related QOL was measured using the World Health Organization Quality of Life^BREF (WHOQOLBREF) tool, which is an abbreviated version of the WHOQOL-100. The WHOQOL-BREF includes four domains and 26 questions. The four domains are physical health, psychological health, social relationships, and environment. There is no total score. The tool includes seven items in the physical health domain (3,4,10,15,16,17,18), six in the psychological health domain (5,6,7,11,19,26), three in the social relationship domain (20,21,22), eight in the environmental domain (8,9,12,13,14,23,24,25), and two general questions. Respondents evaluated the intensity and frequency of the selected attributes of their QOL for the previous 2 weeks. Each question is scored using a 5-point (1^5) Likert-type scale, with a higher score re£ecting a better QOL. The scale’s Turkish validity and reliability work was performed by Fidaner et al. (1999). These authors reported Cronbach’s a coe⁄cients for the various domains as 0.83 for physical health, 0.66 for mental health, 0.53 for social relationship, and 0.73 for environment domains (Fidaner et al.). In the current study, the internal validity of the scale was found to be 0.69 for physical health, 0.76 for mental health, 0.64 for social relationships, and 0.80 for environment domains.
Data Analysis The Statistical Package for Social Sciences (SPSS) for Windows, Version 11.0, was used for data analysis. The clinical and sociodemographic variables were analyzed using descriptive statistics. MANOVA analysis was used to evaluate the di¡erences in average QOL scores and independent variables for infertile women and men. The independent variables were age, education, employment status, health insurance, family type, income level, previous treatment for infertility, duration of infertility, causes of infertility, receiving support from one’s spouse, the need for psychological support, and pressure from friends/family.
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Results Demographics The mean ages of the analysis population were 30.48 and 34.35 years for the female and male participants, respectively. Only 55.4% of the participating infertile women had a middle school education or higher, compared with 72.9% of the men. Thirty-four percent of the infertile women and 96.3% of the men were employed, and the most common occupation for both groups was civil servant. The majority of female (91.5%) and male (91.6%) participants lived in nuclear families and had health insurance (496%). The percentage of those perceiving that their income level was balanced with or higher than their expenses was 78% (women) and 79.4% (men). Eighty percent of the infertile women were primary infertile patients. More than half of the infertile women (62.4%) and men (57%) had been treated at another infertility center, and 30.7% of the women had previously undergone arti¢cial insemination treatment at another center. Most of the women (86.5%) and men (91.6%) stated that they had received psychological support regarding their infertility problem from their spouse. However, 34% (women) and 31.8% (men) reported experiencing pressure to have children from their friends and relatives. Furthermore, 82.2% of the women and 77.3% (men) reported occasionally or sometimes feeling the need for psychological support (Table 1).
Quality of Life As shown by the distributions of the WHOQOLBREF domain score means for infertile women and men (Table 2), in the physical health and social relations domains women scored higher than men, whereas in the psychological health domain, although women’s scores were lower, the di¡erence between men and women was not signi¢cant (F 5 0.11, p 5 .73; F 5 1.68, p 5 .19; F 5 1.21, p 5 .27, respectively). Meanwhile, in the environment domain, women’s scores were signi¢cantly higher than those of men (F 5 7.50; p 5 .00). A comparison of QOL domain means for infertile individuals with the independent variables revealed that participants aged younger than 35 years had higher scores in every domain, although the di¡erence was only signi¢cant for the social relationship
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Quality of Life of Infertile Women and Men in Turkey
Table 1: The Characteristics of Participants
Table 2: Comparison of WHOQOL-BREF Scores of Infertile Women and Men
Female
Male
(n 5 141)
(n 5 107)
n (%)
n (%)
o35
70 (65.4)
121 (85.8)
436
37 (34.6)
20 (14.2)
Characteristic Age (years)
Education Primary school or lower
63 (44.6)
29 (27.1)
Middle school or higher
78 (55.4)
78 (72.9)
Employment status Employed
48 (34.0)
103 (96.3)
Unemployed
93 (66.0)
4 (3.7)
129 (91.5)
98 (91.6)
12 (8.5)
9 (8.4)
Yes
103 (96.3)
136 (96.5)
No
4 (3.7)
5 (3.5)
31 (22.0)
22 (20.6)
110 (78.0)
85 (79.4)
Family type Nuclear family Extended family Health insurance
Income level Low/poor income Average/good income
Previous treatment for infertility Yes
88 (62.4)
61 (57.0)
No
53 (37.6)
46 (43.0)
o3
55 (39.0)
36 (33.6)
44
86 (61.0)
71 (66.4)
Female factor
31 (22.0)
22 (20.6)
Male factor
49 (34.8)
37 (34.6)
Both (male & female factor) 18 (12.8)
11 (10.2)
Unexplained
37 (34.6)
Duration of infertility (years)
Causes of infertility
43 (30.4)
domain (F 5 11.28, p 5 .00). In the environment domain, those who had lower levels of educationç primary school or lowerçalso had signi¢cantly lower mean scores than those who had received education at middle school level (F 5 5.85, p 5 .01). In terms of employment status, signi¢cant di¡erences were found in average QOL scores in the
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Female (n 5 141) Male (n 5 107) Mean
SD
Mean
SD
F
15.47
2.15
15.37
2.12
0.11
Psychological health 14.45
2.15
14.79
2.26
1.21
Social relationships
15.28
3.8
14.68
2.78
1.68
Environment
13.84
2.25
12.95
2.50
7.50
Physical health
po.01.
physical health domain between those who were employed, who had higher scores, and those who were unemployed (F 5 6.20, p 5 .01). Those who received social security had higher QOL scores than those without such support for the physical health, psychological health, and social relationship domains; the di¡erences were signi¢cant for the psychological health (F 5 14.09, p 5 .00) and social relationship domains (F 5 4.12, p 5 .04). Those living in extended families also had lower QOL scores in all domains than those in nuclear-type families, but these di¡erences were only signi¢cant for the physical health (F 5 8.73, p 5 .00) and environment domains (F 5 4.06, p 5 .04). In terms of the relationship between income level and QOL score means among infertile individuals, as income level increased, so did the QOL domain scores. The increase in scores was signi¢cant in the physical health, psychological health, and environment domains (F 5 5.61, p 5 .01; F 5 10.84, p 5 .00; F 5 5.81, p 5 .01, respectively). Infertile individuals who received support from their spouses had higher QOL scores in all domains, and these high values were signi¢cant in the psychological health, social relationship, and environment domains (F 5 5.82, p 5 .01; F 5 13.50, p 5 .00; F 5 12.84, p 5 .00, respectively). Those who reported never or rarely needing psychological support had signi¢cantly higher scores in the domains of physical health, psychological health, and social relations compared with those who sometimes or often needed such support (F 5 8.04, p 5 .00; F 5 9.78, p 5 .00; F 5 6.00, p 5 .01, respectively). Those who reported pressure on the subject of infertility from friends or family were also found to have signi¢cantly lower psychological health domain scores than those who did not (F 5 7.75, p 5 .00). By MANOVA analysis, the e¡ects of age, education, health insurance, family type, income level, spousal support, their need for psychological support, and
JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x
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RESEARCH
Bolsoy, N., Taspinar, A., Kavlak, O. and Sirin, A.
Table 3: Comparison of Infertile Women’s and Men WHOQOL-BREF Domain Score Means With Independent Variables and Gender Physical Health
Psychological Health
Social Relationships
Female
Male
Female
Male
Mean
Mean
F
Mean
Mean
F
0.23
15.29
Female
Male
Mean
Mean
o3 5
15.50
15.81
0.69 14.57
15.01
436
15.28
15.02
13.83
14.61
15.46
15.01
1.40 14.33
14.59
15.48
15.73
14.57
14.98
Employed
15.21
15.66
10.18 14.18
14.89
Unemployed
15.61
12.42
14.61
14.33
Yes
15.48
15.56
14.59
14.95
No
15.31
14.85
11.06
13.00
Nuclear family
15.58
15.67
0.08 14.54
14.81
Extended family
14.28
14.09
13.61
15.55
15.56
15.78
14.71
15.10
Low/poor income 15.17
14.59
13.59
14.00
F
Environment Female
Male
Mean
Mean
F
15.33
0.07 13.92
13.31
0.00
13.60
13.72
13.60
12.91
15.85
14.48
2.79 13.53
12.48
14.71
14.88
14.15
13.43
14.52
14.89
5.70 13.65
13.18
15.58
11.66
13.99
12.87
15.09
14.89
0.63 13.87
13.21
13.86
11.66
14.10
12.25
15.09
14.81
0.01 14.00
13.23
14.66
14.37
12.50
12.55
15.28
14.93
0.20 14.04
13.38
15.01
14.18
13.29
12.36
15.35
15.00
0.04 14.02
13.38
13.12
12.29
12.92
10.94
15.73
15.20
0.21 14.03
13.27
14.84
13.90
13.72
12.97
15.30
14.31
0.76 13.85
12.98
15.18
14.99
13.89
13.26
Age (years)
Education Primary school
0.06
0.27
or lower Middle school or higher Employment status 0.71
0.25
Health insurance 0.13
1.16
0.54
Family type 2.75
0.58
Income level Average/good
1.41
0.00
0.13
income
Feeling spousal support Yes
15.62
15.58
0.33 14.67
14.93
0.74
No
14.55
15.04
13.15
14.22
14.78
15.28
1.80
Assessment of need for psychological support Never/rarely
15.88
15.83
0.10
Occasionally/often 15.17
14.93
14.23
14.03
14.23
1.42
0.00
Pressure from friends/family Yes
15.16
15.17
0.01 14.00
No
15.63
15.71
14.70
15.17
0.15
0.14
po.01.
pressure from friends/family on QOL scores for infertile individuals according to sex were evaluated. The variables a¡ected QOL in similar ways for women and men, and the only signi¢cant di¡erence between the
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sexes was with ‘‘employment status,’’ which was linked to a signi¢cant di¡erence in physical health and social relation domain scores (F 510.18, p 5 .00; F 5 5.70, p 5 .01, respectively) (Table 3).
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Quality of Life of Infertile Women and Men in Turkey
The quality of life, as measured by the environmental domain, of infertile women is less affected than that of men.
Discussion As there is no general QOL score from the WHOQOL-BREF instrument used in the current study, the distribution of the domain score means was examined. There was no signi¢cant di¡erence in QOL scores between women and men except for the environmental domain. In a study conducted in Italy by Ragni et al. (2005) and in another conducted in Iran by Rashidi et al. (2008), both of which used the 36-Item Short Form Health Survey (SF-36), it was found that QOL of women was lower than that of men in infertile couples, and that in general the QOL of such couples was lower than for other individuals. As the instrument used for QOL in the current study did not give a total score, we examined the data by domain. The di¡erent instruments used or di¡erences in the sample sizes might have resulted in di¡erent QOL study ¢ndings. Previous studies have found that women had lower scores than men, particularly in the mental health domain (Ashkani et al., 2006; Cattoli et al., 2004; Tur-Kapsa et al., 2001). Studies conducted in other countries have revealed that women who experience infertility have high anxiety and depression scores (Cattoli et al.; Fido & Zahid, 2004; Gulseren et al., 2006; Guz et al., 2003; Karlıdere et al., 2007; Khayata et al., 2003; Lee & Sun, 2000; Ozkan & Baysal, 2006; Ramezanzadeh et al., 2004; TurKapsa et al.). In a study conducted in Iran, the incidence of psychological problems and depression was higher in infertile couples than fertile couples and higher in infertile women than in infertile men (Ashkani et al.). A study on infertile couples inTurkey showed that women received more social support than men and found it easier to share their problems with those around them. In cases where the cause of infertility was related to women, that social support diminished (Karlıdere et al.). In the current study, women had lower psychological health scores but higher social relationship scores, although there were no signi¢cant di¡erences. A couple’s age is one of the most decisive factors a¡ecting fertility. Fertility falls rapidly in women after the age of 30 years and in men after 40 years (Kavlak, 1999). Khayata et al. (2003) reported that women aged older than 30 years experienced more anxiety and social problems owing to biological time pressure. Infertile women and men aged older than 36 years had lower social relation scores
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than those who were aged 35 years or younger. This indicates that the social pressure felt by infertile individuals a¡ects their QOL more severely as they grow older. However, other researchers have found that those aged younger than 30 years have a lower QOL (Chachamovich et al., 2007; Fekkes et al., 2003; Rashidi et al., 2008). This discrepancy in ¢ndings may be due to sampling issues or poor coping mechanisms in younger individuals (Chachamovich et al.; Fekkes et al.; Van den Akker, 2005). The infertile women and men living in extended families in the current study had lower QOL domain scores than those who lived in nuclear-type families, although the di¡erence was only found to be signi¢cant for the physical health and environment domains. Infertility is one of the most stressful situations for couples in Turkey (Gˇrhan et al., 2007; Saydam, 2003).This stress is magni¢ed when the number of family members is high, the woman does not work, and the woman’s role is considered to be to have and take care of children (Khayata et al., 2003). In Turkish society, as well as other male-dominated societies, women’s reasons for existence are often considered to be limited to their fertility capacity. As in many countries, the words woman and mother can be used as synonyms. In such a culture, to have no children has a great, and adverse, e¡ect on a woman’s status (Kavlak, 1999). In the East and Far East, women are expected to continue the family line, and the woman’s status is enhanced when she bears a male child (Khayata et al.; Lee et al., 2001).This expectation is felt more acutely in extended family structures.When infertility occurs, the woman is generally considered responsible for the lack of success in bearing children. The pressure exerted on her by her husband, close relatives, and friends can adversely a¡ect her health and decrease her QOL (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Gulseren et al., 2006; Guz et al., 2003; Jirka et al., 1996; Khayata et al.; Lee & Sun, 2000). Infertility is often a complex life crisis for both spouses that is emotionally stressful and economically damaging (Akyˇz & I˙nanc, 1999; Gˇcsavas,, 1992). Women who feel economic pressure report lower QOL, and consequently they may experience increased anxiety and depression (Aliyeh & Laya, 2007; Ozkan & Baysal, 2006). When infertility and in vitro fertilization treatments are covered by health insurance, economic pressure decreases (Khayata et al., 2003; Ragni et al., 2005). The present ¢ndings are in agreement with those in the literature. QOL increases with better ¢nancial circumstances for both sexes. Perception of and satisfaction in marriage show cultural variations. In some cultures having a child
JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x
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RESEARCH
Bolsoy, N., Taspinar, A., Kavlak, O. and Sirin, A.
is regarded as continuation of the family line. A child is considered an essential part of the family, and for most couples it is the expected product of marriage and sexual relationships. In this context, men and women experience pressure from their families and society (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Gulseren et al., 2006; Kızılkaya & Gˇler, 1985, p. 93; Lee et al., 2001; Monga et al., 2004). The current study found that women and men who experienced pressure from those around them to have children were negatively a¡ected in terms of their mental health. Women and men who reported a lack of support from their spouses showed reduced mental health, social relationship, and environment domain scores. Other studies have shown that most women su¡ering from high anxiety and severe depression owing to infertility are those who received little support from their husbands or from other members of society (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Gulseren et al., 2006; Guz et al., 2003; Karlıdere et al., 2007; Lee et al., 2001). Previous reports have shown that those who experience societal pressure to have children su¡er greater stress and anxiety, have more dysfunctional relationships, and experience greater marital disharmony (Tas,cı et al., 2008). Nurses have a major role in the diagnosis and treatment of infertility (Akyˇz & I˙nanc, 1999). The goal of nursing care is to assess spouses’ physical, psychological, and social circumstances; to identify their problems and needs in these areas; and to provide appropriate care. All nurses who work in this ¢eld need suitable information and facilities to guide and counsel couples, as well as to help them with the physical, social, psychological, and environmental problems associated with infertility (Akyˇz & I˙nanc ; Gˇcsavas,, 1992; Gˇrhan et al., 2007; S,irin, 2001). Women and men who reported that they never or rarely feel the need for psychological support had the highest QOL scores in all domains, whereas those who stated that they occasionally/often felt the need for such support had the lowest scores; the di¡erences in scores were signi¢cant for the physical health, psychological health, and social relationship domains. These results indicate that there is a group of individuals with a particular need for psychological support. Health care professionals involved in infertility treatment need to be aware of this situation and help those who need it to obtain support from psychologists and psychiatrists when necessary (Cattoli et al., 2004; Fekkes et al., 2003; Karlıdere et al., 2007; Lee et al., 2001; Lukse & Vacc, 1999; Ragni et al., 2005; Van den Akker, 2005). Education given to couples and even close relatives
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during consultations before initiating treatment also helps to lessen psychological complaints and thus increase QOL (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Karlıdere et al.; Lee et al.). The environmental domain questions assess access to information and health services. As a higher level of education was thought to facilitate access to information and health services, the fact that individuals with lower education levels reported lower environmental domain scores was expected. When the e¡ects of independent variables and sex of the participants on QOL domain scores were compared, only ‘‘employment status’’ was found to signi¢cantly a¡ect the physical health and social relation domains in men. The QOL of working men is higher than that of women and unemployed men. In Turkish society there is an expectation that men will work and provide for their household, whereas there is no such expectation for women.
Conclusion In contrast to several previous studies that found that women’s QOL is more negatively a¡ected by infertility than men’s, the ¢ndings of the current study indicate that there is little di¡erence in terms of QOL between infertile women and infertile men other than environmental domain. In this domain, infertile women were found to have a higher QOL than men. Moreover, with the exception of employment status, independent variables were found to a¡ect the QOL of both sexes similarly. Nurses and health care professionals providing care to infertile individuals need to ensure that they consider the physiological and psychological states of the patient, as well as the social and environmental conditions, so as to provide the necessary support. To this end, it is recommended that an e¡ective form for evaluating individuals is developed. The results of the current study may be useful for other researchers aiming to develop such a form. The limitations of this research are noted here, together with implications for future research. As the sample used in the current study was limited in size, it is not possible to generalize the results to the national infertile population; the data need support from a study involving a larger patient population. Moreover, the study was performed at a single center in westernTurkey; as there are cultural di¡erences between east and west regions of Turkey, the results of the current study are only representative of infertile individuals living in the west of the country.
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JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x
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RESEARCH
Differences in Quality of Life Between Infertile Women and Men in Turkey Nursen Bolsoy, Ayten Taspinar, Oya Kavlak, and Ahsen Sirin
Correspondence Nursen Bolsoy, RN, PhD, Ege University School of Nursing, 35100 Bornova/ Izmir, Turkey. [email protected]
ABSTRACT
Keywords infertile women infertile men quality of life
Participants: The research sample comprised 248 infertile individuals (141 women and 107 men) admitted to the clinic for the first time for diagnosis and treatment between January 1 and June 30, 2007, and who voluntarily agreed to participate.
Objective: To examine potential differences in quality of life between infertile women and men. Design: A descriptive, cross-sectional design. Method: A questionnaire was used to collect individuals’ sociodemographic data; the World Health Organization Quality of Life–BREF (WHOQOL-BREF) tool was used to collect information about quality of life.
Setting: The research was conducted at the Ege University Family Planning and Infertility Research and Training Center Infertility Clinic in Izmir, Turkey. Results: Physical health, psychological health, and social relations domain score means did not show significant differences between infertile women and infertile men (p4.05). However, score means for the environment domain were significantly higher (po.05) for infertile women than for infertile men. Unemployed infertile men had significantly lower score means in the physical health and social relation domains (po.01). No such significant differences were found for the other quality of life domain scores for infertile women or infertile men (p4.05). Conclusion: In the environmental domain, the quality of life of infertile women was greater than that of infertile men. Variables affecting quality of life of infertile individuals were seen to affect women and men in similar ways. Nurses and health care professionals caring for infertile individuals should be aware of the factors that affect quality of life and should plan to meet their care needs accordingly.
JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x Accepted October 2009
Nursen Bolsoy, RN, PhD, is a research assistant and instructor in the Department of Gynecology and Obstetrics, Ege University School of Nursing, Izmir, Turkey. Ayten Taspinar, RN, PhD, is a research assistant and instructor in the Department of Gynecology and Obstetrics in Nursing, Adnan Menderes University, Aydın School of Health, Aydin, Turkey. Oya Kavlak, RN, PhD, is an assistant professor, in the Department of Gynecology and Obstetrics, Ege University School of Nursing, Izmir, Turkey. (Continued)
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nfertility is generally de¢ned as the inability to conceive after 1 year of unprotected and appropriately timed intercourse, and/or the failure to carry a pregnancy to term. Some studies estimate that infertility a¡ects approximately 10% to 15% of couples (Chachamovich, Chachamovich, Zachia, Knauth, & Passos, 2007; Monga, Alexandrescu, Katz, Stein, & Ganiats, 2004; S,irin, 2001), whereas the World Health Organization estimates the prevalence of infertility among couples around the world as between 8% and 12%, thus a¡ecting 50 to 80 million people (Daar & Meralı, 2002). The Turkish Demographic and Health Survey (2003) found the percentage of married women who have not had children and are unable to carry a pregnancy to term to be 9.4%.
I
Infertility in couples creates serious biological, psychosocial, economic, ethical, and cultural problems and reduces quality of life (QOL). As a sudden and unexpected life crisis, the diagnosis and treatment
of infertility is spread over a long time, causing stress and great di⁄culties in terms of adaptation (Akyˇz & I˙nanc, 1999; Brucker & McKenry, 2004; Gˇcsavas,, 1992; Karlıdere et al., 2007; Rashidi et al., 2008; Van den Akker, 2005). For this reason, the lives of many couples change with the diagnosis of infertility (Lee, Sun, & Chao, 2001; Ramezanzadeh et al., 2004; S,irin, 2001). In Turkish society, as elsewhere, infertility is considered a crisis, but the excessive pressure exerted by a traditional societal structure increases the seriousness of the problem. Infertile couples see infertility as a serious handicap as the ability to conceive is considered one of the fundamental elements of the marriage contract (Gˇrhan, Akyˇz, O£az, Atıcı, & Vural, 2007; Khayata, Rizk, Hasan, Ghazal-Aswad, & Asaad, 2003; Ozkan & Baysal, 2006; Saydam, 2003). Infertility may also have a negative e¡ect on marital relations because it can cause feelings of disappointment and guilt, as well
& 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Quality of Life of Infertile Women and Men in Turkey
Similar factors affect the quality of life of infertile women and men.
as groundless mutual accusations among couples (Tas,cı, Bolsoy, Kavlak, & Yˇcesoy, 2008). Tas,cı et al. showed that the environmental pressure experienced by infertile individuals reduces marital harmony and happiness. Furthermore, infertility treatment and related procedures increase the stress experienced by couples because their sexual life becomes part of the treatment procedure (Akyˇz, I˙nanc, & Pabuccu,1999; Gˇrhan et al.; Monga et al., 2004). Research data indicate clear di¡erences in the responses of women and men to infertility. Women take the diagnosis of infertility more personally, consider that it might devalue their role as women, and experience reduced emotional stability and a decrease in self-esteem (Gˇrhan et al., 2007; Kavlak, 1999). Although men experience disappointment, they are less vulnerable to feelings of worthlessness (Kavlak). Moreover, women are more likely to experience feelings of loneliness (Jirka, Schuatt, & Foxal, 1996; Kavlak; Lukse & Vacc, 1999). Studies have shown that women experience more stress, anxiety, depression, and animosity than men when faced with the diagnosis of infertility (Akyˇz et al., 1999; Ashkani, Akbari, & Heydari, 2006; Brucker & McKenry, 2004; Gˇrhan et al.; Halman, Andrews, & Abbey, 1994; Karlıdere et al., 2007). Infertile women grieve for the fact that they cannot have children or experience pregnancy, whereas infertile men mourn their loss of power and their inability to become a biological father (Akyˇz et al.).
Ahsen Sirin, RN, PhD, is a professor of Gynecology and Obstetrics in the Nursing Department, Ege University School of Nursing, Izmir,Turkey.
192
There are also di¡erences between women and men in strategies to cope with the stress. In stressful situations, women are more likely to feel the need for social support, and for this reason they ¢nd it easier to seek this kind of help (Brucker & McKenry, 2004; Karlıdere et al., 2007). However, the social environment in which women live may also have negative e¡ects (Guz, Ozkan, Sarisoy, Yanik, & Yanik, 2003). Women receiving low levels of support from their spouse and social environment feel greater anxiety and depression (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Gulseren et al., 2006; Guz et al., 2003; Karlıdere et al.; Lee et al., 2001). In contrast, as men are expected to solve their own problems, they do not make use of sources of social support as frequently as women. Therefore, they do not discuss the issues with their relatives and do not try to use coping mechanisms (Brucker & McKenry; Karlıdere et al.). Men’s inclination to disguise
their emotional disturbance may be due to their reluctance to change their behavior or a desire to improve their social standing (Karlıdere et al.). Health-related QOL is de¢ned as an individual’s perception of his or her own health in the social and cultural environment in which he or she lives (Fidaner, 2004). Although infertility has an impact on both sexes, the QOL of women and men may be a¡ected in di¡erent ways and to di¡erent extents. Some studies have shown that women’s QOL is more strongly a¡ected by infertility than men’s (Cattoli et al., 2004; Khayata et al., 2003; Monga et al., 2004; Ragni et al., 2005; Tur-Kapsa, Maor, Meltzer, & Segal, 2001). However, there is a need for more research in this area.
Purpose This descriptive study was designed to examine di¡erences in QOL between infertile women and men. It attempts to address the following research question: Is there a di¡erence between the QOL of infertile women and men?
Methods Setting and Sample The current study was conducted at the Ege University Family Planning and Infertility Research and Training Center at the Infertility Clinic in Izmir, western Turkey. Izmir, which is on the Aegean coast, is the third largest city inTurkey, and the infertility clinic was the ¢rst infertility center in the country. Although there are ¢ve clinics o¡ering infertility treatment in Izmir, this is the only state clinic; the others are private and patient numbers are too low for relevant comparison. In this clinic, treatment costs are met by the social security unit. The clinic receives applications from all over the country, but mainly from people in the Aegean region. The study population was composed of infertile women and men who came to the clinic for diagnosis and treatment between January 1 and June 30, 2007. During this period, 290 new couples were admitted to the clinic. The research sample included 265 infertile individuals (149 female and 116 male) who voluntarily agreed to participate in the study. Among those who agreed to participate, eight women and nine men who did not complete the forms were excluded from the study. Therefore, the data from a total of 141 female and 107 male infertile individuals were included in the analysis population. Prior to beginning the research, human subject approval was obtained from the Ege University School
JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x
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RESEARCH
Bolsoy, N., Taspinar, A., Kavlak, O. and Sirin, A.
of Nursing Ethics Committee and from the clinic where the research was conducted; verbal consent was obtained from all participants before beginning data collection.
The quality of life of infertile women and men, in terms of physical health, psychological health, and social relationships, is affected to a similar extent.
Measurements Basic demographic and clinical data concerning the patients, including age, gender, education, family information, social security status, income level, employment status, duration of infertility, previous treatment for infertility, and infertility causes, were collected. Health-related QOL was measured using the World Health Organization Quality of Life^BREF (WHOQOLBREF) tool, which is an abbreviated version of the WHOQOL-100. The WHOQOL-BREF includes four domains and 26 questions. The four domains are physical health, psychological health, social relationships, and environment. There is no total score. The tool includes seven items in the physical health domain (3,4,10,15,16,17,18), six in the psychological health domain (5,6,7,11,19,26), three in the social relationship domain (20,21,22), eight in the environmental domain (8,9,12,13,14,23,24,25), and two general questions. Respondents evaluated the intensity and frequency of the selected attributes of their QOL for the previous 2 weeks. Each question is scored using a 5-point (1^5) Likert-type scale, with a higher score re£ecting a better QOL. The scale’s Turkish validity and reliability work was performed by Fidaner et al. (1999). These authors reported Cronbach’s a coe⁄cients for the various domains as 0.83 for physical health, 0.66 for mental health, 0.53 for social relationship, and 0.73 for environment domains (Fidaner et al.). In the current study, the internal validity of the scale was found to be 0.69 for physical health, 0.76 for mental health, 0.64 for social relationships, and 0.80 for environment domains.
Data Analysis The Statistical Package for Social Sciences (SPSS) for Windows, Version 11.0, was used for data analysis. The clinical and sociodemographic variables were analyzed using descriptive statistics. MANOVA analysis was used to evaluate the di¡erences in average QOL scores and independent variables for infertile women and men. The independent variables were age, education, employment status, health insurance, family type, income level, previous treatment for infertility, duration of infertility, causes of infertility, receiving support from one’s spouse, the need for psychological support, and pressure from friends/family.
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Results Demographics The mean ages of the analysis population were 30.48 and 34.35 years for the female and male participants, respectively. Only 55.4% of the participating infertile women had a middle school education or higher, compared with 72.9% of the men. Thirty-four percent of the infertile women and 96.3% of the men were employed, and the most common occupation for both groups was civil servant. The majority of female (91.5%) and male (91.6%) participants lived in nuclear families and had health insurance (496%). The percentage of those perceiving that their income level was balanced with or higher than their expenses was 78% (women) and 79.4% (men). Eighty percent of the infertile women were primary infertile patients. More than half of the infertile women (62.4%) and men (57%) had been treated at another infertility center, and 30.7% of the women had previously undergone arti¢cial insemination treatment at another center. Most of the women (86.5%) and men (91.6%) stated that they had received psychological support regarding their infertility problem from their spouse. However, 34% (women) and 31.8% (men) reported experiencing pressure to have children from their friends and relatives. Furthermore, 82.2% of the women and 77.3% (men) reported occasionally or sometimes feeling the need for psychological support (Table 1).
Quality of Life As shown by the distributions of the WHOQOLBREF domain score means for infertile women and men (Table 2), in the physical health and social relations domains women scored higher than men, whereas in the psychological health domain, although women’s scores were lower, the di¡erence between men and women was not signi¢cant (F 5 0.11, p 5 .73; F 5 1.68, p 5 .19; F 5 1.21, p 5 .27, respectively). Meanwhile, in the environment domain, women’s scores were signi¢cantly higher than those of men (F 5 7.50; p 5 .00). A comparison of QOL domain means for infertile individuals with the independent variables revealed that participants aged younger than 35 years had higher scores in every domain, although the di¡erence was only signi¢cant for the social relationship
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Quality of Life of Infertile Women and Men in Turkey
Table 1: The Characteristics of Participants
Table 2: Comparison of WHOQOL-BREF Scores of Infertile Women and Men
Female
Male
(n 5 141)
(n 5 107)
n (%)
n (%)
o35
70 (65.4)
121 (85.8)
436
37 (34.6)
20 (14.2)
Characteristic Age (years)
Education Primary school or lower
63 (44.6)
29 (27.1)
Middle school or higher
78 (55.4)
78 (72.9)
Employment status Employed
48 (34.0)
103 (96.3)
Unemployed
93 (66.0)
4 (3.7)
129 (91.5)
98 (91.6)
12 (8.5)
9 (8.4)
Yes
103 (96.3)
136 (96.5)
No
4 (3.7)
5 (3.5)
31 (22.0)
22 (20.6)
110 (78.0)
85 (79.4)
Family type Nuclear family Extended family Health insurance
Income level Low/poor income Average/good income
Previous treatment for infertility Yes
88 (62.4)
61 (57.0)
No
53 (37.6)
46 (43.0)
o3
55 (39.0)
36 (33.6)
44
86 (61.0)
71 (66.4)
Female factor
31 (22.0)
22 (20.6)
Male factor
49 (34.8)
37 (34.6)
Both (male & female factor) 18 (12.8)
11 (10.2)
Unexplained
37 (34.6)
Duration of infertility (years)
Causes of infertility
43 (30.4)
domain (F 5 11.28, p 5 .00). In the environment domain, those who had lower levels of educationç primary school or lowerçalso had signi¢cantly lower mean scores than those who had received education at middle school level (F 5 5.85, p 5 .01). In terms of employment status, signi¢cant di¡erences were found in average QOL scores in the
194
Female (n 5 141) Male (n 5 107) Mean
SD
Mean
SD
F
15.47
2.15
15.37
2.12
0.11
Psychological health 14.45
2.15
14.79
2.26
1.21
Social relationships
15.28
3.8
14.68
2.78
1.68
Environment
13.84
2.25
12.95
2.50
7.50
Physical health
po.01.
physical health domain between those who were employed, who had higher scores, and those who were unemployed (F 5 6.20, p 5 .01). Those who received social security had higher QOL scores than those without such support for the physical health, psychological health, and social relationship domains; the di¡erences were signi¢cant for the psychological health (F 5 14.09, p 5 .00) and social relationship domains (F 5 4.12, p 5 .04). Those living in extended families also had lower QOL scores in all domains than those in nuclear-type families, but these di¡erences were only signi¢cant for the physical health (F 5 8.73, p 5 .00) and environment domains (F 5 4.06, p 5 .04). In terms of the relationship between income level and QOL score means among infertile individuals, as income level increased, so did the QOL domain scores. The increase in scores was signi¢cant in the physical health, psychological health, and environment domains (F 5 5.61, p 5 .01; F 5 10.84, p 5 .00; F 5 5.81, p 5 .01, respectively). Infertile individuals who received support from their spouses had higher QOL scores in all domains, and these high values were signi¢cant in the psychological health, social relationship, and environment domains (F 5 5.82, p 5 .01; F 5 13.50, p 5 .00; F 5 12.84, p 5 .00, respectively). Those who reported never or rarely needing psychological support had signi¢cantly higher scores in the domains of physical health, psychological health, and social relations compared with those who sometimes or often needed such support (F 5 8.04, p 5 .00; F 5 9.78, p 5 .00; F 5 6.00, p 5 .01, respectively). Those who reported pressure on the subject of infertility from friends or family were also found to have signi¢cantly lower psychological health domain scores than those who did not (F 5 7.75, p 5 .00). By MANOVA analysis, the e¡ects of age, education, health insurance, family type, income level, spousal support, their need for psychological support, and
JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x
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RESEARCH
Bolsoy, N., Taspinar, A., Kavlak, O. and Sirin, A.
Table 3: Comparison of Infertile Women’s and Men WHOQOL-BREF Domain Score Means With Independent Variables and Gender Physical Health
Psychological Health
Social Relationships
Female
Male
Female
Male
Mean
Mean
F
Mean
Mean
F
0.23
15.29
Female
Male
Mean
Mean
o3 5
15.50
15.81
0.69 14.57
15.01
436
15.28
15.02
13.83
14.61
15.46
15.01
1.40 14.33
14.59
15.48
15.73
14.57
14.98
Employed
15.21
15.66
10.18 14.18
14.89
Unemployed
15.61
12.42
14.61
14.33
Yes
15.48
15.56
14.59
14.95
No
15.31
14.85
11.06
13.00
Nuclear family
15.58
15.67
0.08 14.54
14.81
Extended family
14.28
14.09
13.61
15.55
15.56
15.78
14.71
15.10
Low/poor income 15.17
14.59
13.59
14.00
F
Environment Female
Male
Mean
Mean
F
15.33
0.07 13.92
13.31
0.00
13.60
13.72
13.60
12.91
15.85
14.48
2.79 13.53
12.48
14.71
14.88
14.15
13.43
14.52
14.89
5.70 13.65
13.18
15.58
11.66
13.99
12.87
15.09
14.89
0.63 13.87
13.21
13.86
11.66
14.10
12.25
15.09
14.81
0.01 14.00
13.23
14.66
14.37
12.50
12.55
15.28
14.93
0.20 14.04
13.38
15.01
14.18
13.29
12.36
15.35
15.00
0.04 14.02
13.38
13.12
12.29
12.92
10.94
15.73
15.20
0.21 14.03
13.27
14.84
13.90
13.72
12.97
15.30
14.31
0.76 13.85
12.98
15.18
14.99
13.89
13.26
Age (years)
Education Primary school
0.06
0.27
or lower Middle school or higher Employment status 0.71
0.25
Health insurance 0.13
1.16
0.54
Family type 2.75
0.58
Income level Average/good
1.41
0.00
0.13
income
Feeling spousal support Yes
15.62
15.58
0.33 14.67
14.93
0.74
No
14.55
15.04
13.15
14.22
14.78
15.28
1.80
Assessment of need for psychological support Never/rarely
15.88
15.83
0.10
Occasionally/often 15.17
14.93
14.23
14.03
14.23
1.42
0.00
Pressure from friends/family Yes
15.16
15.17
0.01 14.00
No
15.63
15.71
14.70
15.17
0.15
0.14
po.01.
pressure from friends/family on QOL scores for infertile individuals according to sex were evaluated. The variables a¡ected QOL in similar ways for women and men, and the only signi¢cant di¡erence between the
JOGNN 2010; Vol. 39, Issue 2
sexes was with ‘‘employment status,’’ which was linked to a signi¢cant di¡erence in physical health and social relation domain scores (F 510.18, p 5 .00; F 5 5.70, p 5 .01, respectively) (Table 3).
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Quality of Life of Infertile Women and Men in Turkey
The quality of life, as measured by the environmental domain, of infertile women is less affected than that of men.
Discussion As there is no general QOL score from the WHOQOL-BREF instrument used in the current study, the distribution of the domain score means was examined. There was no signi¢cant di¡erence in QOL scores between women and men except for the environmental domain. In a study conducted in Italy by Ragni et al. (2005) and in another conducted in Iran by Rashidi et al. (2008), both of which used the 36-Item Short Form Health Survey (SF-36), it was found that QOL of women was lower than that of men in infertile couples, and that in general the QOL of such couples was lower than for other individuals. As the instrument used for QOL in the current study did not give a total score, we examined the data by domain. The di¡erent instruments used or di¡erences in the sample sizes might have resulted in di¡erent QOL study ¢ndings. Previous studies have found that women had lower scores than men, particularly in the mental health domain (Ashkani et al., 2006; Cattoli et al., 2004; Tur-Kapsa et al., 2001). Studies conducted in other countries have revealed that women who experience infertility have high anxiety and depression scores (Cattoli et al.; Fido & Zahid, 2004; Gulseren et al., 2006; Guz et al., 2003; Karlıdere et al., 2007; Khayata et al., 2003; Lee & Sun, 2000; Ozkan & Baysal, 2006; Ramezanzadeh et al., 2004; TurKapsa et al.). In a study conducted in Iran, the incidence of psychological problems and depression was higher in infertile couples than fertile couples and higher in infertile women than in infertile men (Ashkani et al.). A study on infertile couples inTurkey showed that women received more social support than men and found it easier to share their problems with those around them. In cases where the cause of infertility was related to women, that social support diminished (Karlıdere et al.). In the current study, women had lower psychological health scores but higher social relationship scores, although there were no signi¢cant di¡erences. A couple’s age is one of the most decisive factors a¡ecting fertility. Fertility falls rapidly in women after the age of 30 years and in men after 40 years (Kavlak, 1999). Khayata et al. (2003) reported that women aged older than 30 years experienced more anxiety and social problems owing to biological time pressure. Infertile women and men aged older than 36 years had lower social relation scores
196
than those who were aged 35 years or younger. This indicates that the social pressure felt by infertile individuals a¡ects their QOL more severely as they grow older. However, other researchers have found that those aged younger than 30 years have a lower QOL (Chachamovich et al., 2007; Fekkes et al., 2003; Rashidi et al., 2008). This discrepancy in ¢ndings may be due to sampling issues or poor coping mechanisms in younger individuals (Chachamovich et al.; Fekkes et al.; Van den Akker, 2005). The infertile women and men living in extended families in the current study had lower QOL domain scores than those who lived in nuclear-type families, although the di¡erence was only found to be signi¢cant for the physical health and environment domains. Infertility is one of the most stressful situations for couples in Turkey (Gˇrhan et al., 2007; Saydam, 2003).This stress is magni¢ed when the number of family members is high, the woman does not work, and the woman’s role is considered to be to have and take care of children (Khayata et al., 2003). In Turkish society, as well as other male-dominated societies, women’s reasons for existence are often considered to be limited to their fertility capacity. As in many countries, the words woman and mother can be used as synonyms. In such a culture, to have no children has a great, and adverse, e¡ect on a woman’s status (Kavlak, 1999). In the East and Far East, women are expected to continue the family line, and the woman’s status is enhanced when she bears a male child (Khayata et al.; Lee et al., 2001).This expectation is felt more acutely in extended family structures.When infertility occurs, the woman is generally considered responsible for the lack of success in bearing children. The pressure exerted on her by her husband, close relatives, and friends can adversely a¡ect her health and decrease her QOL (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Gulseren et al., 2006; Guz et al., 2003; Jirka et al., 1996; Khayata et al.; Lee & Sun, 2000). Infertility is often a complex life crisis for both spouses that is emotionally stressful and economically damaging (Akyˇz & I˙nanc, 1999; Gˇcsavas,, 1992). Women who feel economic pressure report lower QOL, and consequently they may experience increased anxiety and depression (Aliyeh & Laya, 2007; Ozkan & Baysal, 2006). When infertility and in vitro fertilization treatments are covered by health insurance, economic pressure decreases (Khayata et al., 2003; Ragni et al., 2005). The present ¢ndings are in agreement with those in the literature. QOL increases with better ¢nancial circumstances for both sexes. Perception of and satisfaction in marriage show cultural variations. In some cultures having a child
JOGNN, 39, 191-198; 2010. DOI: 10.1111/j.1552-6909.2010.01101.x
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RESEARCH
Bolsoy, N., Taspinar, A., Kavlak, O. and Sirin, A.
is regarded as continuation of the family line. A child is considered an essential part of the family, and for most couples it is the expected product of marriage and sexual relationships. In this context, men and women experience pressure from their families and society (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Gulseren et al., 2006; Kızılkaya & Gˇler, 1985, p. 93; Lee et al., 2001; Monga et al., 2004). The current study found that women and men who experienced pressure from those around them to have children were negatively a¡ected in terms of their mental health. Women and men who reported a lack of support from their spouses showed reduced mental health, social relationship, and environment domain scores. Other studies have shown that most women su¡ering from high anxiety and severe depression owing to infertility are those who received little support from their husbands or from other members of society (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Gulseren et al., 2006; Guz et al., 2003; Karlıdere et al., 2007; Lee et al., 2001). Previous reports have shown that those who experience societal pressure to have children su¡er greater stress and anxiety, have more dysfunctional relationships, and experience greater marital disharmony (Tas,cı et al., 2008). Nurses have a major role in the diagnosis and treatment of infertility (Akyˇz & I˙nanc, 1999). The goal of nursing care is to assess spouses’ physical, psychological, and social circumstances; to identify their problems and needs in these areas; and to provide appropriate care. All nurses who work in this ¢eld need suitable information and facilities to guide and counsel couples, as well as to help them with the physical, social, psychological, and environmental problems associated with infertility (Akyˇz & I˙nanc ; Gˇcsavas,, 1992; Gˇrhan et al., 2007; S,irin, 2001). Women and men who reported that they never or rarely feel the need for psychological support had the highest QOL scores in all domains, whereas those who stated that they occasionally/often felt the need for such support had the lowest scores; the di¡erences in scores were signi¢cant for the physical health, psychological health, and social relationship domains. These results indicate that there is a group of individuals with a particular need for psychological support. Health care professionals involved in infertility treatment need to be aware of this situation and help those who need it to obtain support from psychologists and psychiatrists when necessary (Cattoli et al., 2004; Fekkes et al., 2003; Karlıdere et al., 2007; Lee et al., 2001; Lukse & Vacc, 1999; Ragni et al., 2005; Van den Akker, 2005). Education given to couples and even close relatives
JOGNN 2010; Vol. 39, Issue 2
during consultations before initiating treatment also helps to lessen psychological complaints and thus increase QOL (Aliyeh & Laya, 2007; Fido & Zahid, 2004; Karlıdere et al.; Lee et al.). The environmental domain questions assess access to information and health services. As a higher level of education was thought to facilitate access to information and health services, the fact that individuals with lower education levels reported lower environmental domain scores was expected. When the e¡ects of independent variables and sex of the participants on QOL domain scores were compared, only ‘‘employment status’’ was found to signi¢cantly a¡ect the physical health and social relation domains in men. The QOL of working men is higher than that of women and unemployed men. In Turkish society there is an expectation that men will work and provide for their household, whereas there is no such expectation for women.
Conclusion In contrast to several previous studies that found that women’s QOL is more negatively a¡ected by infertility than men’s, the ¢ndings of the current study indicate that there is little di¡erence in terms of QOL between infertile women and infertile men other than environmental domain. In this domain, infertile women were found to have a higher QOL than men. Moreover, with the exception of employment status, independent variables were found to a¡ect the QOL of both sexes similarly. Nurses and health care professionals providing care to infertile individuals need to ensure that they consider the physiological and psychological states of the patient, as well as the social and environmental conditions, so as to provide the necessary support. To this end, it is recommended that an e¡ective form for evaluating individuals is developed. The results of the current study may be useful for other researchers aiming to develop such a form. The limitations of this research are noted here, together with implications for future research. As the sample used in the current study was limited in size, it is not possible to generalize the results to the national infertile population; the data need support from a study involving a larger patient population. Moreover, the study was performed at a single center in westernTurkey; as there are cultural di¡erences between east and west regions of Turkey, the results of the current study are only representative of infertile individuals living in the west of the country.
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