A Survey of Correlation Infertility Self-Efficacy with Behavioral Health Scales in Infertile Women

Background: Infertility is a unique medical challenge that can have health behavioral consequence on infertile women including lack of self-esteem, depression, anxiety, fertility problem in infertile couples. The aim of this study was to evaluate correlation between self-efficacy and health behaviors scales in infertile women. Methods: A cross sectional study was conducted on 89 infertile women with mild to moderate depression (Beck scores 10 47) who were recruited from Fatemeh Zahra Infertility and Reproductive Health Research Center. All participants completed Self-efficacy Inventory (ISE) and other health behavioral scales (e.g., the Beck Depression Inventory (BDI), Cattle Anxiety Scale (CAS), Fertility Problem Infertility (FPI), and GHQ). Pearson correlation coefficient and Spearman rho correlation coefficient were used to analyze the data. Variables were included in the study if they had a p-value of <0.05. Statistical analysis was performed SPSS 17. Results: The most of participants had totally high confident 53.9%, 41.6% moderately confident, and 4.5% low confident. Mean ISE score (±SD) for the overall infertile women was in the moderate range (6.18 ± 1.39). The lowest mean score in subscales of self-efficacy that infertile women reported was item “Accept that my best efforts may not change my/our infertility” (4.90 ± 3.41). There was the significant relationship between ISE with job (p = 0.016) and residency (p = 0.016) of infertile women. The employed infertile women have twice higher self-efficacy than unemployed women (62.7% vs 37.9%) and those who lived in the city had a higher level of confidence (75% vs. 53%). The infertile women with older age, higher education, and the more duration of Corresponding author.


Introduction
Infertility is a health problem [1].The infertile women have problems in coping with emotional liability during diagnosis and treatment and a sense of fear and failure [2].There is a negative psychological consequence such as depression, anxiety, sense of loss, feeling of isolation and lowered self-esteem in women that experienced infertility treatment [3].Self-efficacy based on Bandura's self-efficacy theory, is defined as confidence and selfesteem in a socially acceptable behavior [4].Self-efficacy is a person's belief in his or her capacity to succeed in a particular situation.Bandura reported that these beliefs can affect on how person think, act, and feel [5].The several studies showed that self-efficacy has the important role in health promotion and outcome [5] [6].
The researchers showed that infertility self-efficacy had relationship with health behavioral scales.Infertile women with higher levels of infertility self-efficacy reported fewer depressive symptoms, anxiety, and higher general health from infertility experience [7]- [9].As, few studies have examined on the correlation self-efficacy with other health behavioral scales and there are no published data about this subject in Iranian infertile women set, therefore this study conducted to evaluate the correlation infertility self-efficacy with health behaviors scales in a sample of Iranian infertile women.

Methodology
A cross sectional study was conducted in Fatemeh Zahra Infertility and Reproductive Health Research Center of the Babol University of Medical Sciences (2007) for nine months.The project was conducted according to Iranian Research Clinical Trial and was approved by Ethical committee of Babol University of medical science.After coordination and receiving justification from Infertility Council, infertile women who had dossier there, were recruited for this study.

Data Collection
Five midwives of the center conducted structured telephone invitations with potential participants.Of 350 invitations, 200 patients accepted to enter the study and were referred to the center.Subsequent to completing the demographic questionnaire and the Beck Depression Inventory (BDI), a psychologist conducted a face-to-face interview.Finally, 89 participants remained until the end of the study.All participants completed the Self-Efficacy Inventory (SEI) and other health behavioral scales including: Beck Depression Inventory (BDI), Cattle Anxiety Scale (CAS), Fertility Problem Infertility (FPI), and General Health Questionnaire (GHQ) at the beginning of the study.Used Scales were reliable instruments to assess behavioral health status.

Inclusion and Exclusion Criteria
Women with these characteristics were invited to this study: age of less than 45, more than five years education, more than two years of infertility, having at least one IVF.Women who met one of the following conditions were excluded from the study: a score ≤9 or >47 on the BDI, or meeting the criteria for clinical severe depression on the clinical interview.Thus, only women with minimal, mild, and moderate depression (Beck score 10 -47) were included the study.

Analysis
All statistical analyzes were performed using SPSS software (version 17.0).Descriptive statistics were used to describe the mean scores (±SD) and proportion.Pearson correlation coefficient and Spearman rho correlation coefficient were used to evaluate the relationship of ISE and other behavioral health Scale in infertile women.The p-value of <0.05 was considered as significant level.It should be noted that results of this articles is a part of extend project that implemented in Fatemeh Zahra Infertility and Reproductive Health Research Center of the Babol University of Medical Sciences.Comparison pharmacotherapy and psychotherapy in improvement depression, anxiety, and general health reported in previous publications [10] [11].This article focuses on correlation between infertility self-efficacy with other health behavior scales.

Results
The mean age (±SD) of infertile women and their husbands were 28.87 ± 4.89 and 33.16 ± 5.06 respectively.The majority of infertile women were housewives (95.4%) and living urban area (67%).The average duration of infertility was 5.81 ± 3.95 years.The most common cause of infertility was related to female factors (37.2%).The mean of ISE Score was 6.181 ± 1.39.The most of participants did have totally high confident (53.9%), 41.6% had moderately confident and only 4.5% had low confident (Figure 1).
The Characteristics of the 16 items in ISE scale are summarized in Table 1.One of the lowest mean score in self-efficacy that infertile women reported was item "Accept that my best efforts may not change my/our infertility" (4.90 ± 3.41).
The results of Nonparametric correlations showed that ISE Score had the significant relationship with residency (p = 0.003), and women job (p = 0.016).The infertile women who were employed and residency of theirs were in city have the higher self-efficacy score.The employed infertile women had twice higher self-efficacy than unemployed women (62.7% vs 37.9%) and those who lived in the city had a higher level of confidence (75% vs. 53%).The infertile women with older age, higher education, and the more duration of infertility had the lower self-efficacy.
In this study, significant correlations were exhibited for ISE with other behavioral health scales.There were the significantly negative correlation between the mean of ISE score with BDI (p = 0.018), overt anxiety (p = 0.11), CAI (p = 0.018), social concern of FPI (p = 0.003), and marital concern of FPI (0.025).Also a significant tendency was found between ISE and occult anxiety among infertile groups (p = 0.1) (Table 2).

Discussion and Conclusions
Our findings showed that almost half of the infertile women were with low and moderate self-efficacy (46.1%).Principally, experience of infertility had highly stressful for infertile women [12] and it decreased self-confidence [13] [14].Studies showed that there was sense of loss, feeling of isolation and lowered self-esteem in women that experienced infertility treatment [3] and infertility can be associated with psychological consequences such as decreased self-efficacy [15].
The results approved that item "Accept that my best efforts may not change my/our infertility" was one of the lowest mean score in subscales of self-efficacy inventory.A similar findings has been reported in others studies.Benyamin et al. reported that not being able to solve the problem myself was one of the most significant   difficulties in infertile women [16], and the women infertile are confronted with sensations of insecurity, and hopeless [17].In relation ISE score with demographic characteristics, our results showed that there were the negative correlation between the ISE score and age, education, and duration of infertility that of course wasn't significant difference.The infertile women with older age, higher education, and the more duration of infertility had the lower self-efficacy.In contrast, a similar study reported that there isn't significant association between ISE and relevant variables such as age, income, cause of infertility [18].While many studies showed that infertile women inclined to be confident about their ability to become pregnant at the onset of infertility treatment, but after lasting a long period of time treatment they experience distress and hopeless [19].Also, failure in treatment programs can be effective in reducing self-esteem and self-efficacy of infertile women [20].In addition Najmi et al. reported that infertility causes feelings of worthlessness and incompetence, particularly with prolonged therapy [21].This project showed that infertile Women's ISE scores correlated significantly with job and residency.Employed women's and who residency of theirs was in city tended to have significantly higher self-efficacy scores on the ISE.The employed infertile women have twice higher self-efficacy than unemployed women and those who lived in the city had a higher level of confidence than living in rural.It seems that if one has the financial resources to pay the cost of infertility treatment, self-efficacy may be increased.Since, employed infertile women have financial independence, therefore are less affected by stress caused poverty and they with more confidence to continue the infertility treatment process.
Our results showed that infertility self-efficacy has significantly correlation with other behavioral health.There was the significantly negative correlation between ISE with BDI, CAI, GHQ, Overt anxiety.Infertile women with higher levels of infertility self-efficacy as measured by the ISE scale also report fewer depressive symptoms, anxiety, and higher general health from infertility experience.These results are largely consistent with previous assessments of infertility self-efficacy [7] [8] [22].Self-efficacy is the belief of person about the skill and ability to control one's behavior to achieve a specific goal [23].Perceived self-efficacy in one's ability to control events that affect their lives [8], Bandura believes that perceived self-efficacy is considered an important component in individual performance and also it is as a predictor factor in accepting patterns of health and sexual behavioral [22].The studies showed that infertility stressful situation can influence on personal control [7].A person with high self-efficacy can try the more in the new behavior health [24].Strong sense of self-efficacy can increase individual welfare and performance in different ways such as ability to cope with obstacles.On the other hand, viewpoints of people with low self-efficacy it harder than something that really exists [9].In the same study reported that negative image of themselves and their bodies could be associated with anxiety and depression [25].The infertile women have lower self-efficacy, lower life satisfaction, more depression, and feeling more guilt [26].
Present study showed the negative correlation between ISE and some of dimensions of problem fertility inventory (FPI) such as social, marital, and sexual concerns.The infertile women with higher ISE score had the less social and marital concerns.It is interesting that correlation reported in the current research had parallels to those observed in a recent study on "Development and validation of the infertility self-efficacy scale [18].Najmi et al. reported that infertility causes negative beliefs about themselves, concerns about sexual attractiveness, feeling ugly and disability, sexual disorder, physical complaints, and also the problem in marital relationship and sexuality [21].Alizadeh et al. showed that between self-esteem and all components of stress infertility (sex, marital, social, lifestyle without the child, and need for parent) there was a significant inverse relationship, and sexual issues had the highest correlation coefficient with self-esteem [20].Tare et al. approved that there is strongly significant negative association between ISE with perceived stress scale and fertility problem inventory [18].A similar study suggested that infertility causes concerns about sexual attractiveness, sexual disorder, negative beliefs about their themselves, and also the problem in marital relationship and sexuality [21].Lack of sexual self-esteem, no pleasure of sexual relationships (marital), feel pressure to plan for sexual intercourse have the most effect on self-esteem of infertile women [20].The women infertile due to a failure to achieve desired objectives lose confidence and they are faced with lack of communication with others, sensations of insecurity, and hopeless [17].Self-efficacy related to health behaviors scales, suggesting that having a psychological intervention can also facilitate the process of promoting self-efficacy.

Summary
In summary, this study suggests that a high self-efficacy can have the more beneficial effects in increased men-tal health and may be a cost effective resource for decreasing depression, anxiety, fertility problem in infertile women.Also, in surveillance program for the infertile women, it is necessary to detect and to modify the factors that lead to low self-efficacy.

Figure 1 .
Figure 1.Frequency of level self-efficacy in infertile women.

Table 1 .
Characteristics of the 16 ISE items.

Table 2 .
Correlations of ISE to other behavioral health measures and related variables.