CHAPTER III

STATEMENT OF THE PROBLEM

“BIO-PSYCHO-SOCIAL DIMENSIONS AND HEALTH BEHAVIOUR IN

INFERTILE WOMEN”

3.1. Justification for the Study

Parenting is viewed by most of the couples as their central role in life, and the
thought of not achieving it can be very upsetting. Women in particular traditionally have
been raised to view motherhood as their primary role. Many infertile women say that
they cannot imagine a life that does not include children and that their childless status
makes it difficult to maintain friendships with other women who have children. Several
authors have found that infertile husbands were less disappointed than their wives at the
thought of not having children.

The investigations and treatments for infertility are also highly stressful. The
initial medical interview focuses on the couple‟s sexual performance and history taking,
including frequency of sexual intercourse, premarital relationships, previous pregnancies,
including abortions and miscarriages, attitudes about sex and usual sexual practices. The
patient may see such questions as threatening, embarrassing, intrusive, demeaning and
even inappropriate. Side effects from medication, recovery from surgery, time loss at
work because of frequent physician‟s appointments and the high financial costs of
infertility treatments have all been described as stressfully by the infertile couples.

The relationships between the perceived stress associated with infertility and
demographic (age, number of years married, income), treatment (number of years trying,
physician seen, tests and treatment received) and psychological variables (importance of
children, confidence, perceived control, attributions, social support) were explored in a
study of 185 infertile couples in Michigan, USA. For both women and men, stress was
significantly positively correlated with treatment costs and number of tests and treatments
received; stress was negatively and significantly correlated with confidence of getting a

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child as well as with their perceived control. (Abbey, Halman and Andrews 1992). The
results of the study suggest that attempts by health care providers to increase patient‟s
sense of control, optimism (within realistic limits), and social support could reduce stress.

The influence of infertility of women‟s personality was investigated using State

Trait Anxiety Inventory (STAI). Seventy females experiencing infertility and fifty
healthy women were examined and it was identified that in comparison with healthy
women, women treated because of infertility displayed significantly higher level of
anxiety as a state.

Where as a study on emotional impact of In Vitro Fertilization and any possible

influence due to the type of diagnosis of infertility, number of cycles and types of
diagnosis of infertility was significantly lower (P< 0.05). Women who have experienced
infertility of medium to longer duration presented a significantly lower anxiety value (P <
0.01). And the failure of fertilization caused a significant increase in state anxiety level
(P < 0.01), (Ardenti 2000).

The influence of stress and state anxiety on the outcome of IVF treatment was
studied through psychological and endocrinological assessment of 22 Swedish women
entering IVF treatment. The findings of the study revealed that infertile women had more
suspicion, guilt and hostility and their stress levels in terms of circulating prolactin and
cortisol levels were elevated (P < 0.05) compared to the fertile controls. The authors
have further explained that psychological stress may affect the outcome of IVF treatment
since state anxiety levels among those who did not achieve pregnancy were higher than
among those who became pregnant (P < 0.05). (Osemickky, Landgren and Collins
2000).

It was also found that women with menstrual cycle disturbances had a lower
pregnancy rate in IVF and higher state anxiety levels. Furthermore prolactin levels were
also higher in women with menstrual cycle disturbances. The findings contribute to the

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hypothesis that menstrual cycle disturbances could be associated with higher psycho-
endocrinological stress levels. (Demyttennaere, Nijs, Kiebooms and Koninck 1994).

IVF is one of the newest techniques for the treatment of infertility. In a

descriptive study 20 couples who had experienced atleast one IVF procedure were
interviewed. The results indicate that while IVF offers hope for infertile couples, the
procedure, if unsuccessful, can be emotionally traumatic. In addition, the results suggest
that comprehensive information and emotional support are the primary needs of couples
undergoing IVF. (Milna 1998).

Hynes, Callan, Terry and Gallois (1992) identified that IVF women were more
depressed and had lower self esteem prior to the treatment cycle, and both before and
after the treatment cycle they were less self confident. After the failed IVF procedure,
IVF women were more depressed and had lower levels of self-esteem than they were
prior to the treatment cycle. The use of avoidance coping and seeking social support was
associated with low levels of Well-Being.

Thus the literature clearly suggested that bio-psycho-social dimension of

infertility and the behaviour of infertile women are important aspects to be studied
especially when its magnitude is increasing due to advancing age at marriage. In India
there is only limited research literature available pertaining to psycho-social dimensions
of infertility. It is also observed that less attention is paid in the clinical area while caring
for infertile women to understand their stress levels, support measures and treatment
seeking behavioural patterns. These factors prompted the researcher to select the present
problem of study.

3.2. Objectives of the Study

1. To identify the demographic variables of infertile women such as age, educational

status, religion, occupation, type of family, type of marriage and years of
infertility.

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 2. To determine the biological variables of infertile women such as menstrual cycle
pattern, sexual pattern, ovulation, , causes, investigations, treatment for female
infertility and semen characteristics of husband.
3. To assess the psychological variables of quality of life, self-concept, anxiety,
depression, and stress in infertile women.
4. To assess the social variables in terms of the marital adjustment between the
husband and wife and the family support of infertile women.
5. To identify the health behaviour of infertile women through their attitude towards
treatment options and treatment seeking behaviour – sequential tracking, back
tracking, paralleling, taking a break and withdrawal.
6. To determine the association between demographic variables and psycho-social
and health behavioural variables of infertile women.
7. To determine the association between biological variables and psycho-social and
health behavioural variables of infertile women.
8. To determine the inter correlation between the psycho-social variables and health
behavioural variables of infertile women.
9. To predict the variance between psycho-social and health behavioural variables
upon the self-concept in infertile women.
10. To predict the variance of demographic, biological, psycho-social and health
behavioural variables upon the self-concept in infertile women.

3.3. Assumptions
The study assumes that
1. The person is a bio-psycho-social being
2. Persons have their own creative and reproductive power
3. Negative feedback in the form of performance compared with idea leads to
feelings of inadequacy
4. To cope with the changing world, the person uses both innate and acquired
mechanisms, which are biological, psychological and social in origin
5. A person‟s opinions and viewpoints reflect his / her belief, thinking and feeling.

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3.4. Null Hypothesis

H1 There will be no significant association between quality of life and the

demographic variables such as age, educational status, type of family, type of marriage
and years of infertility.

H2 There will be no significant association between self-concept and the

demographic variables such as age, educational status, type of family, type of marriage
and years of infertility.

H3 There will be no significant association between anxiety and the demographic

variables such as age, educational status, type of family, type of marriage and years of
infertility.

H4 There will be no significant association between depression and the

demographic variables such as age, educational status, type of family, type of marriage
and years of infertility.

H5 There will be no significant association between stress and the demographic

variables such as age, educational status, and type of family, type of marriage and years
of infertility.

H6 There will be no significant association between marital adjustment and the

demographic variables such as age, educational status, type of family, type of marriage
and years of infertility.

H7 There will be no significant association between family support and the

demographic variables such as age, educational status, type of family, type of marriage
and years of infertility.

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 H8 There will be no significant association between attitude towards treatment
options and the demographic variables such as age, educational status, type of family,
type of marriage and years of infertility.

H9 There will be no significant association between treatment seeking behaviour

and the demographic variables such as age, educational status, type of family, type of
marriage and years of infertility.

H10 There will be no significant association between quality of life and the
biological variables such as menstrual cycle pattern, ovulation pattern, sexual patterns,
causes, investigations, treatment of female infertility and the semen characteristics of
husband.

H11 There will be no significant association between Self-concept and the

biological variables such as menstrual cycle pattern, ovulation pattern, sexual patterns,
causes, investigations, treatment of female infertility and the semen characteristics of
husband.

H12 There will be no significant association between Anxiety and the biological
variables such as menstrual cycle pattern, ovulation pattern, sexual patterns, causes,
investigations, treatment of female infertility and the semen characteristics of husband.

H13 There will be no significant association between depression and the biological
variables such as menstrual cycle pattern, ovulation pattern, sexual pattern, causes,
investigations, treatment of female infertility and the semen characteristics of husband.

H14 There will be no significant association between stress and the biological
variables such as menstrual cycle pattern, ovulation pattern, sexual pattern, causes,
investigations, treatment of female infertility and the semen characteristics of husband.

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 H15 There will be no significant association between marital adjustment and the
biological variables such as menstrual cycle pattern, ovulation pattern, sexual pattern,
causes, investigations, treatment of female infertility and the semen characteristics of
husband.

H16 There will be no significant association between family support and the
biological variables such as menstrual cycle pattern, ovulation pattern, sexual pattern,
causes, investigations, treatment of female infertility and the semen characteristics of
husband.

H17 There will be no significant association between attitude towards treatment

options and the biological variables such as menstrual cycle pattern, ovulation pattern,
sexual pattern, causes, investigations, treatment of female infertility and the semen
characteristics of husband.

H18 There will be no significant association between treatment seeking behaviour

and the biological variables such as menstrual cycle pattern, ovulation pattern, sexual
pattern, causes, investigations, treatment of female infertility and the semen
characteristics of husband.

H19 There will be no significant relationship between the psycho-social and the
health behavioural variables in infertile women.

H20 The psycho-social and health behavioural variables will not be significantly
predicted by the demographic variables of infertile women.

H21 The psycho-social and health behavioural variables will not be significantly
predicted by the biological variables of infertile women.

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 H22 There will be no significant prediction of variance between the psycho-social
and health behavioural variables of infertile women.

H23 The self-concept will not be significantly predicted by the demographic

variables of infertile women.

H24 The self-concept will not be significantly predicted by the biological variables
of infertile women.

H25 The self-concept will not be significantly predicted by the psycho-social and
health behavioural variables of infertile women.

3.5. Operational Definitions

3.5.1. Biological dimension

It conceptualizes health biologically as a state in which every cell and every organ
is functioning at optimum capacity and in perfect harmony with the rest of the body (Park
1998).

In the study the biological dimension refers to the menstrual cycle patterns,
ovulation pattern, sexual patterns, causes, investigations , treatment of female infertility
and semen characteristics of husbands.

The causes of female infertility are disorders of ovulation, transportation of egg

or sperm (Tubal factors) or implantation of fertilized ovum (Uterine disorders).

The investigations of female infertility are hormonal studies, follicular studies,

endometrial biopsy, hystero salphingogram and diagnostic laparoscopy to evaluate the
tubal structure.

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 The treatment for female infertility includes induction of ovulation, tubal
surgeries, artificial insemination and assisted reproductive technologies like Gamete Intra
Fallopian Transfer of Oocytes (GIFT) or Zygote Intra Fallopian Transfer (ZIFT).

Semen characteristics of husband includes normal sperm count, oligospermia

( low sperm count), asthenozoospermia (slow movement of sperms), azoospermia
(absence of sperms) or any other characteristics. The semen test not done is also included.

3.5.2. Psychological dimension

It is defined as a state of balance between the individual and the surrounding

world, a state of harmony between oneself and others, a co existence between the realities
of the self and that of other people and that of the environment. A mentally healthy
person is free from internal conflicts, well adjusted, searches for identity, has a strong
sense of self-esteem and tries to solve the problems intelligently (Park 1998).

In the study the psychological dimension refers to the quality of life, self-concept,
and level of anxiety, level of depression and stress level of infertile women.

Quality of life: It refers to the level of cheerfulness, relaxation, activity, rest and
the interest present in infertile women as measured by General Well-Being Index ( WHO
1998).

Self-concept: It is the individual‟s personal judgement of her own worth by

analyzing the conformity with self-ideal. Self-concept is threatened during infertility
when concepts of self are modified. It is the estimation that infertile woman has
regarding herself and reveals the extent to which they believe themselves to be worthy.
Self-concept may be altered during infertility and it depends upon their values,
aspirations and success.

Anxiety: It is a state of tension which affects both mind and body.

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 Depression: A diffuse apprehension associated with feelings of uncertainty and
helplessness. It occurs as a result of a threat to the woman‟s identity in terms of their
inability to conceive.

Stress: Refers to reactions to stressors; physical, emotional, social, sexual,

rejections of child free life style and need for parenthood reactions.

3.5.3. Social dimension

Social well being implies harmony and integration within the individual; between
each individual and other members of society and between individuals and the world in
which they live. It has been defined as the “quantity and quality of individuals‟
interpersonal ties and the extent of involvement with the community”

Social support systems can be helpful in emphasizing the strength of individuals

and families. Marriage is considered a primary relationship in our society and also is a
social construct of community. Infertility can cause a couple to question the biological
and social function of marriage.

3.5.4. Health behaviour

Behaviour is any observable, recordable and measurable act, movement or

response of the individual. There are three interrelated elements in explaining human
behaviour, which are:
Cognitive – thoughts about the situation
Affective – emotional or feeling responses
Behavioural – outward actions

An assessment of each one of these areas has important implications for

understanding the problem and effectively treating it. (Stuart and Sundeen 1995).

In the study the health behaviour of infertile women is determined through their:

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 Attitude towards treatment options: It is the attitude of infertile women
towards ovulation induction, artificial insemination, tubal surgeries, In Vitro Fertilization,
surrogacy and adoption as the treatment options available for female infertility.

Treatment seeking behaviour: It is the pattern of behaviour demonstrated by

couples as they move through the choices of infertility management.

These patterns include:

Sequential tracking: In which infertile women exhaust one treatment option

before considering another treatment to parenthood.
Back tracking: In which infertile women retry the same treatment regimen with a
new physician.
Paralleling which is an attempt to pursue multiple treatment options
simultaneously.
Taking a break: The infertile women take a period of break and again try the
treatment options.
Withdrawal: The woman withdraws herself from all the treatment options

3.5.5. Infertile women

The married females who are unable to conceive within 12 months of their
intention and trial to become pregnant.

3.6. Conceptual Framework

Conceptual framework for a particular study is the abstract, logical structure that
enables the researcher to link the finding to nursing‟s body of knowledge. It is developed
from the existing theory and helps in identifying and defining concept of interests and
proposing relationships among them. The model gives direction for planning research
design, data collection and interpretation of findings.

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 The present study aims at describing the bio – psycho – social dimension of
infertile women and their adaptive responses to the stress. The framework for the study is
based on “Roy‟s Adaptation model”.

The core of Roy‟s adaptation model is the belief that a person‟s adaptive
responses are a function of the incoming stimulus and the adaptive level. The adaptation
level is made up of the pooled effect of three classes of stimuli:

Focal stimuli – which immediately confront the individual

Contextual stimuli – which occurs as a result of the focal stimuli
Residual stimuli – those factors that are relevant but cannot be validated.

Roy further conceptualizes the person as having four modes of adaptation –

physiological needs, self – concept, role function and interdependence relations. These
categories established are valid and useful for nursing assessment. (Tomey 1994)

The conceptual framework presented explains the application of Roy‟s adaptation

model in the care of infertile women.

Focal stimuli is the stimulus most immediately confronting the person and the
one to which the person must make an adaptive response. In the study the focal stimuli is
the inability to conceive.

Contextual stimuli all the other stimuli that contribute to the behaviour caused or
precipitated by the focal stimuli. In the study the contextual stimuli is the causes of
infertility, the process of investigation and treatment of infertility and also the economic
requirement for the same.

A regulator is a subsystem coping mechanism, which responds automatically

through neural – chemical – endocrine processes. In the present study, the variable is not
studied.

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 A cognator is the subsystem coping mechanism, which responds through complex
processes or perception and information processing, learning, judgement and emotion.
The variable is not included in the present study.

Adaptive (effectors‟) modes are the ways of coping that manifest the regulator or
cognator activity, i.e., physiological, self-concept, role function and interdependence. In
the study infertility may be manifested as:

Physiologically – Causes / results of investigations and outcome of treatment

procedures.
Self – concept – Depression, anxiety and stress caused by inability to conceive
and its effect on self – concept and quality of life.

Role function – Role deficit of unable to become a mother and its impact upon
marital adjustment.

Interdependence – Changes in the relationship of family members as the women

are unable to conceive.

Adaptive responses are the responses that promote integrity of the person in terms
of goals of survival, growth and reproduction. In the study the adaptive responses can be
measured through their health behaviour in terms of their reactions to infertility –
physically, emotionally, sexually and socially and also through their treatment seeking
behaviour.

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 INPUT EFFECTORS ADAPTIVE
Physiologic RESPONSE
Control
STIMULI Results of investigations
Processes
and outcome of Attitude
Focal treatment
Inability to
conceive Self-concept Treatment
Quality of life seeking
Regulator*
Contextual Depression behaviour
Causes, Anxiety
Cognator*
investigations and Stress
treatment of
infertility Role function
Marital adjustment
Residual
Family history Interdependence
Family support

Feedback
Fig. 1 Conceptual Frame Work on Adaptation of Infertile Women (Based on Roy‟s Adaptation Model)
* These variables are not under study

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 3.7. Delimitations

The participants suffering from primary infertility only will be included in the study.
The study will be restricted to include the participants who will be attending Centre for
Reproductive Medicine at Apollo Hospitals, Chennai only.

Summary

This chapter has dealt with the background of the study, need for the study, statement of
the problem, objectives of the study, assumptions, research hypothesis, conceptual framework,
operational definitions, and delimitations.

Organization of the Report

Further aspects of the study are presented in the following 4 chapters.

In Chapter IV – Methodology is presented which includes research approach, design,

setting, population, and sample and sampling technique, data collection tools description,
validation and reliability of tools, pilot study, data collection procedure and plan for data
analysis.

In Chapter V – Results and discussion is presented in terms of descriptive and inferential

statistics.

In Chapter VI – Summary, conclusions, implications, recommendations are presented.

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