Effect of Self -Care Guidelines on the Quality Of life Among Reproductive- Aged Infertile Women

Infertility is a frustrating experience for women.  It defined clinically as the failure of a couple to conceive or achieve a pregnancy after one year of regular unprotected sexual intercourse (without any contraception) or demographically as the inability to achieve a live birth. Infertility challenges women’s sense of identity, expectations of their life trajectory and their perceived value in society. This can lead to feelings of failure, guilt and shame. ⁽¹⁾

According to the definition introduced by the (WHO), quality of life (QoL) is defined as "individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations standards and concerns". Infertility is a broad ranging concept affected in a complex way by the person's physical health, psychological statements, levels of independence, social constraints, personal beliefs and characteristics and also their relationship to salient features of their environment.⁽²⁾

Orem’s self- care theory was first used in 1956 and was further developed in 1960. The concept of self-care is distinct from the other types of care, such as dependent-care and nursing-care, because people are the reason for their own well-being and actions. Other theories may promote dependent-care or nursing-care that does not encourage the patient to become involve in decision making and goal setting. Self-care is the process of an individual acting on behalf of one’s self or the person taking ownership of the action. ⁽³⁾

Orem's theory is  one of the most notable nursing theories in the area of self-care, states that self-care is the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health and well-being and that self-care  an adult's continues contribution to his or her continued existence, health and well-being .⁽⁴⁾

Self-care is the activities that individuals initiate and perform on their own behalf in maintaining life, health and well-being’. Alternatively, self-care has referred to adult's personal continues contribution to own health and well-being. It's also refers to the process whereby patients deliberately act on their own behalf in health promotion, prevention of illness, and the detection and treatment of health deviations.⁽⁵⁾

Self-care includes practices specifically directed toward bringing a situation-specific action as a learned behavior. Self-care must be understood as a daily care function that is a result – seeking action creating positive change in the patient’s environment. Orem states the process of self-care must meet a few actions. First, the patient must be able to formulate the need to make a change in daily care functions. Second, the patient must be able to make decisions about her (his) care. Finally the patient must be able to perform the actions necessary to engage in self-care with known validity to health and well-being.⁽⁶⁾

The role of the fertility nurse is to provide a holistic approach to fertility investigation, treatment, and where appropriate, early pregnancy through compassionate, informed and evidence based practice. Fertility nurses work as part of a multi-professional team, who combine to deliver a high standard of care. Four main areas of expertise: management / co –ordination, education, research and clinical practice. Management / Co-ordination include (i.e. referral review, financial management, quality management and data returns). ⁽⁷⁾

Aim of the study

The aim of this study was to evaluate the effect of using self-care guidelines on the quality of life among infertile women.

Subjects and Methods

Research Design:

Quasi-experimental design (pre and post intervention) has been utilized in this study.

Setting:

This study was carried out at Obstetrics Minia University Hospital (out patient's infertility clinic). The Hospital serving not only Minia city but also the whole Minia centers (9 centers) and it's villages. The Hospital consists of 4 floors, the ground floor contains card and neonate registration offices, X-ray, MRI and free trading pharmacy, the 1^st floor contains, pediatric clinic, antenatal care clinic, infertility clinic and private department. The 2nd floor contains gynecological department, intensive care unit and laboratory services, the 3rd floor contains antenatal, high risk pregnancy department, delivery and post partum rooms, and the 4th floor contains pediatric department and intensive care unit. The hospital works all of the day but the out patient's clinics works from 9 A.M to 1 P.M.

Sample

A convenient sample of 100 infertile women was utilized in this study.

Inclusion criteria

• Women who have different types of infertility with in reproductive age from 18 to 49 years old.
• Women who can read and write to be able to read the guidelines.

• Women who are undergoing to infertility treatment.

Tools of the study:

A structured interviewing questionnaire sheet was designed by the researcher that aims to evaluate the effect of self-care guidelines on quality of life among infertile women. The questionnaire was composed primarily of closed-ended questions with a set of defined answers, from which the interviewee was asked to choose one response in some questions and more answer in other questions.

The questionnaire included the following parts:

Part 1: Personal data:

This included women’s age, occupation, residence, live with who, duration of marriage, BMI, income, etc

Part 2: Fertility quality Of Life Scale (FertiQoL):

FertiQoL is the first internationally validated self-report questionnaire that can be considered as a tool to assess the quality of life of an individual with infertility. it was produced in English and translated into 20 languages, including Arabic, the Arabic version of was used in this study and  it takes approximately 10 to 15 minutes to be completed. The questionnaire consists of two parts: the Core and the Treatment parts. The Core-FertiQoL part contains 24 questions categorized into four subscales, including the Emotional, Mind/Body, Relational, and Social subscales. The Emotional subscale showed the impact negative emotions (e.g., jealousy & resentment, sadness, depression) have on quality of life. The Mind-Body subscale showed the impact infertility has had on physical health (e.g., fatigue, pain) cognition (e.g., concentration) and behavior (e.g., disrupted daily activities, delayed life plans). The Relational subscale showed the impact fertility problems have had on the components (e.g., sexuality, communication, commitment) of marital relationship. The Social subscale showed the extent to which social interactions have been affected by fertility problems (e.g., social inclusion, expectations, stigma, and support).

The Treatment-FertiQoL part contains 10 questions categorized into two subscales including the Treatment Environment and Treatment Tolerability subscales. The Treatment Environment subscale score shows the extent to which the accessibility and quality of the treatment has impacted the quality of life. The Treatment Tolerability subscale score shows the extent to which infertile woman have experienced mental and physical symptoms as a result of the fertility treatment and the impact this has had on daily life. Two additional items (marked A and B on the FertiQoL questionnaire) capture an overall evaluation of physical health and satisfaction with quality of life.

Scoring system:

FertiQoL consists of 36 items that yield six subscales and three total scores rated according to 5 types of response scales..

1. Very poor (0), poor (1), neither poor nor good (2), very good (4)
2. Very dissatisfied (0), dissatisfied (1), neither satisfied nor dissatisfied (2), satisfied (3), very satisfied (4)
3. Always (0), very often (1), quite often (2), seldom (3), never (4)
4. An extreme amount (0), very much (1), a moderate amount (2), a little (3), not at all (4)
5. Completely (0), a great deal (1), moderately (2), not much (3), not at all (4)

Items from these subscales presented in the questionnaire randomly and rated on a response scale of 0 to 4. The subscales and total FertiQoL scores are computed and transformed to achieve a range of 0 to 100, where higher scores indicate better quality of life.

Validity of tools

The questionnaire was reviewed and validated by the Jury committee that was composed of a panel of 5 experts of Obstetrics and Gynecological Nursing professors (Minia and Ain shams Universities) who reviewed the tool for clarity, relevance, comprehensiveness, understanding, applicability and considered the aim of this study. A pilot study was done on (10%) of the infertile women (10 women) from the sample to test the applicability and clarity of the questions in the tool and the necessary modification was done. According to the results of the pilot study, tools modifications were done and women tested in the pilot study were excluded from the main study sample. Finally the total sample was collected on the modified sheet.

Ethical consideration:

Before the conduction of the pilot study as well as the actual study, an official permission and consent was obtained from the dean of the Faculty of Nursing, as well as an approval from the head of department of Obstetrics Hospital Minia University to conduct this study after explaining the nature and purpose of the study. Study subject had the right to refuse to participate and or withdraw from the study without any rational at any time. Study subject privacy was considered during collection of data no health hazards were present. Participants were assured that all their data are highly confidential.

Procedure:

An official permission was obtained from the research ethical committee of faculty of Nursing, head of department of Obstetrics Hospital Minia University. Data was obtained and recorded by the researcher from the infertile women in out-patient infertility clinic. At the beginning of interview the researcher greeted each participant, explained the purpose and duration of this study and informed oral consent was taken. Based on baseline data obtained from assessment and relevant review of literature, the guidelines were developed by the researcher in a form of printed Arabic booklet and different illustrative pictures in order to facilitate understanding its contents.

It consisted of two parts; the first one concerned with providing the patient with the essential information about anatomy of female reproductive organs, process of conception, infertility definition, types, causes and treatment methods. While second part concerned with information about fertility education and rehabilitation, (recommendations for dietary modification and prescription of regular moderate exercise within the context for her life & responsibilities, medications, work, activities, care before & after laparoscopy  and social life) and proper self-care measures that  could be applied to overcome physical or psychological problem. After three months of implementation of the guidelines, the follow up test for women were done by the same format of the questionnaire to evaluate the effect of the implemented guidelines.

Statistical analysis

The collected data was tabulated, computerized, analyzed and summarized by using descriptive statistical tests to test research questions by using SPSS version (20). The percentage, mean and standard deviation were used to summarize data.  The comparison between mean scores was performed using t-test, fisher exact and ANOVA test.  Statistical significance difference was considered when P - value ≤ 0.05, and high significance when P - value ≤ 0.001 and no statistical significance difference was considered when P - value > 0.05.

Result

Table (1): Distribution of infertile women according to Socio- demographic data:

Table (1): This table revealed that, women age ranged from 18 > 48 years old with mean 29.4 ± 7.5 years. Regarding occupation, 54% of studied group was a working women. Concerning to residence, 52% of them were living in urban areas,. Concerning to marital duration, 59% was one-five years. Also the income of them ranged from 500 >1500 LE with mean 1112.3 ± 629.5 LE.

Table (2): Mean and standard deviation of total scores of FertiQoL subscales with pre and post implementation of program (n= 100).

NS= non-significant                                                    ** Highly significant

Table (2): observed that total mean score of FertiQoL subscales was lower in pre-intervention than post the intervention with highly statistically significance in all FertiQoL subscales except relation domain in which P – value ≤ .000.

Table (3): Relationship between studied infertile women's socio-demographic characteristics and their total score of quality of life (n= 100).               

F (P): ANOVA- test & P for ANOVA test   *: Significant at P  ≤ 0.05

Table (3): revealed that total mean scores of FertiQoL and subscales was higher in (aged 18-28, working, rural infertile women, marital duration 1- 5 years and their income < 500) with no statistically significance differences P – value .000.

 Table (4): Relationship between studied infertile women's infertility history and their total score of quality of life (n= 100).  

F (P): ANOVA- test & P for ANOVA test        *: Significant at P ≤0.05

Table (4): found that total mean scores of FertiQoL and subscales was higher in women who (had one or more pregnancy (secondary infertility) and infertility duration 1-5 years) with highly statistically significance differences which P – value ≤ .05. Regarding causes of infertility total mean scores of FertiQoL subscales was higher in male factor infertility.