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Development and Assessment of a Coping Scale for Infertile Women in Turkey.

Introduction

The World Health Organization defines infertility as the inability to have a child. In a wider sense, it is defined as the failure to achieve clinical pregnancy after a year of regular sexual intercourse without the use of contraceptive agents (1). In several studies, findings show that infertility affects more than 80 million people in the world, although at different rates in different countries, with infertility rates reported varying between 5% and 30% (1). In Turkey, the infertility rate is reported to be 10-15%, with one out of every six couples affected (1).

Infertility is often seen as a physically and psychologically challenging experience. According to Covington and Adamson, infertile women often experience feelings of imperfection, inadequacy, abasement, worthlessness, shame and guilt (6). Infertility mostly manifests as a sudden and unexpected life crisis for couples. Infertility is an overstressing condition that spreads over time, enforces compliance mechanisms and distorts feelings of integrity. Many couples define infertility as the greatest crisis in their lives (3, 4), and half of the women and 15% of the men polled in a fertility clinic defined this situation as the most upsetting experience in their lives (3). In previous studies, findings showed that infertile women feel more stress and pressure than men, as well as anxiety and depression (5, 6).

According to Folkman and Lazarus (7) coping is a cognitive, emotional and behavioral "effort"of an individual aimed to solve internal or external problems that cause him or her stress. Infertility affects all areas of women's lives and disrupts their usual coping mechanisms. Although the role of biological treatments in infertility is undisputable, the prominence of psychological support systems that accompany this treatment has been increasing in recent years, and such applications have started to be frequently used as part of infertility treatment (8).In previous studies of infertility and coping, women have been reported to cope through challenging, accepting responsibility, social support, avoiding or escaping. It is also reported that women use emotion-focused coping more often than men, who tend to turn to problem-solving methods (9, 10). Infertile women use emotion-focused coping methods, such as crying, praying, and trusting in God (11-13). Atwood and Dobkin divided the process of coping with infertility into four main stages as follows: lack of belief and denial; anxiety and loss of control; isolation and feelings of guilt; and restructuring. Studies of infertility and coping have focused on spiritual coping strategies in recent years (14-16). and even in different religions, women often use spiritual coping methods and that these methods can have positive effects on their general well-being (11).

The cognitive, emotional and behavioral responses of women to the problem of infertility have situation-specific features (17). Thus, there is a need to use specific measurement instruments that are sensitive to cultural characteristics to determine coping strategies for women, which is difficult to adapt. Based on this need, this study developed a sensitive, acceptable, valid and reliable measurement tool to determine the coping strategies of infertile women in Turkey. It is believed that this scale will help fill the gap in the relevant literature, being both culture-specific and directly focused on the problem. The most significant benefit of the development of this scale is that it can be used as a guide for the identification of infertility-specific coping problems and in the determination of counseling and psychotherapeutic interventions and cases with compliance problems. An examination of previous scale studies related to infertility revealed that limited infertility specific coping scales were used. Literature contains two such scales: the Coping with Infertility Questionnaire (CIQ), which consists of 14 factors developed in Israel for the Israeli context (18), and the Coping Scale for Infertile Couples, consisting of four factors, which was developed in Taiwan for the Taiwanese culture (19). To our knowledge, in Turkey, no infertility-specific coping scale has been developed to date. This study aimed to establish a culturally acceptable, valid and reliable scale that determines the strategies of infertile women in coping with infertility-based psychosocial problems.

Methods

Design

This was a scale development study. In this study, the prevalence of infertility in Turkey is accepted as 15%, the sample was calculated at a confidence interval of 2% and 80% and while it was planned to reach at least 600 infertile women, a total of 751 women were included in the study sample.

Scale development steps

Creating an Item Pool: In the first stage of the research, an item pool, which consisted of 85 items was created, based on statements obtained during individual interviews carried out by the researcher with 24 infertile women about coping with infertility (20), the concept of coping (7), and information from the literature on coping with infertility. In the designation of items, the aim was to ensure clarity understandability, and attention was paid to ensure that no item included more than one judgment or expression. The item pool comprised the coping methods used by infertile women, such as denial, acceptance, hope, emotional problems, spiritual and/or social support, and avoidance.

Receiving Expert Opinion (Content Validity): In this stage, opinions were garnered from 12 experts (three infertility specialist and gynecologists, two psychiatrists, two psychiatric nurses, two psychologists, two psychometricians and one infertile woman) to evaluate the necessity, clarity and specificity of the items. In the expert evaluation, items were said to be either "appropriate", "item should be slightly revised", "item to be substantially revised" and "item is not appropriate", according to the Davis technique (21,22). The "content validity index" of the item was found to be 0.80, calculated by dividing the number of experts who indicated that an item was "appropriate" and "the item should be slightly revised" by the total number of experts. This value is within acceptable limits (22). Based on the evaluation results, the items were arranged, and a draft scale that incorporated 65 items was developed.

Pilot Application Phase: In a preliminary study, the clarity of the 65-item draft scale was tested. For this purpose, a draft scale was applied to 30 infertile women, during which the participants were expected to express their perceptions of each item through a 5-point Likert-type scale, including "Strongly agree, "Agree", "Don't Know", "Disagree" and "Strongly disagree". The participants were asked to identify any items that were not clear, and items classified as "cannot be understood" and "its expression should be changed" were altered, after which the scale of 50 items was finalized.

Concurrent Validity: The Ways of Coping with Stress Inventory (WCSI) developed by Lazarus and Folkman in 1980 and adapted into Turkey by Sahin and Durak in 1995, was applied simultaneously with the scale developed by the authors (23,24). The correlation coefficient between the scales and the concurrent validity of the newly developed scale (coping scale for infertile women) were determined.

Data collection

Data were collected from three different in vitro fertilization (IVF) clinics in three different regions of Turkey (Ankara, Antalya and Istanbul). The population density of the region, the rate of preference as an in vitro fertilization center, and the ability to reflect the socio-cultural characteristics of the country were considered in the city selection. Ankara, Istanbul and Antalya are the most populous and heterogeneous cities in Turkey (Istanbul ranks first, followed by Ankara in second place and Antalya in fifth place in terms of population density). These cities, all of which have seen significant migration from other regions in the country and host people from all walks of life, are the most popular cities for IVF treatment.

A total of 751 infertile women were approached; 201 from the center in Ankara, 200 from the center in Antalya and 350 from the center in Istanbul. Infertile women who applied to these centers for adjuvant treatment between May and December 2016, and who could read and write in Turkish participated in this study. Data were collected through face-to-face interviews conducted by nurses employed in the IVF centers. A total of three nurses, one from each IVF center, were informed about the application of the scale to ensure consistency between applications, which took about 15-20 minutes to apply the scales.

Data collection tools

For the collection of the data, a "Personal Information Form" and a "Coping Scale for Infertile Women" were used, while a "The Ways of Coping with Stress Scale" was used to test the concurrent validity of the scale.

Personal Information Form: This form consists of a total of 18 questions, including 12 questions relating to the socio-demographic characteristics of the participants, and six questions related to the duration of infertility, the reason for infertility and the treatment undertaken.

Coping Scale for Infertile Women (CSIW): This scale, developed by the authors, consisted of items to assess the strategies used by women to cope with the problems of infertility. The scale is a 5-point Likert-type self-assessment scale (Strongly agree, agree, don't know, disagree, strongly disagree), and comprised of 50 items and 10 subscales/factors. The psychometric properties of the scale are given in detail in the findings section. The scale's direction was written as follows: Fertility problems can create different reactions in every human being, and in this process, people use different ways of coping. A list of possible coping reactions is given below. Please rate your coping response to the fertility problem for each item (1-Strongly agree, 2- Agree, 3- Don't know, 4-Disagree, 5- Strongly disagree). A low score indicates that the person uses more of that way of coping. Items 25 and 29 of the scale are encoded in reverse.

Ways of Coping with Stress Inventory (WCSI):

This scale, developed by Lazarus and Folkman in 1980, is a short and validated scale of stressful situations (23). The scale addresses coping mechanisms related to symptoms, such as psychosomatic issues, depression and loneliness. The original version of the test was converted from a 66-item form to a 30-item form with a 4-point Likert-type scale and was adapted for the Turkish context by Sahin and Durak in 1995. For this scale, two main ways of coping with stress are determined: "Problem-oriented/Active", and "Emotion-oriented/Passive", and there are a total of five sub-dimensions to the scale, in which the "Social support seeking (SSS)", "Optimistic approach (OA)", and "Self-confident approach (SCA)" subscales are active methods, while "Desperate approach (DA)" and "Submissive Approach (SA)" are passive methods. The findings showed that individuals who can cope with stress effectively tend to use "Self-confident" and "Optimistic" approaches, while individuals who cannot cope with stress use "Submissive" and "Desperate" approach more. A high score indicates that the person uses more of that way of coping (24). The scale is evaluated from a score of 0 to 3, with 0%= 0 points, 30% = 1 point, 70%: 2 points and 100%: = 3 points. Items 1 and 9 are scored in reverse. Each sub-item in the scale is scored separately, and the total score is not considered.

Data analysis

An exploratory factor analysis was performed on the 50 questions included in the scale. In this analysis, a Kaiser-Meyer-Olkin test was used to determine whether the factor analysis was appropriate for the data structure, while a Bartlett's test was used to determine correlations between questions. In the determination of the appropriate number of factors, it was considered that there were at least two questions in the factors, and that the eigenvalues of the factor (Kaiser Criterion) were greater than 1. In obtaining the factor loadings, the Basic Components method was used, while the Varimax rotation method was used for significant factor loadings. The internal consistency between questions was examined from the Cronbach's alpha coefficient. The relationship between the sociodemographic characteristics and the scale overall mean score were examined by one-way ANOVA model or a Pearson correlation analysis. The statistical significance level was 5% and the SPSS (version 18) program was used for the calculations.

Results

Participants

Of the participants, 57.3% were 26-34 years old, 26% were 35-43 years old, 14.8% were 17-25 years old and only 1.9% were 44 years and older. Of the participants, 85.1% had been followed for one to eight years with a diagnosis of infertility. Considering the employment status of the participants, 51.7% of them were employed and 6.5% of had left their job due to infertility treatments. Most participants (44.8%) were middle school and high school graduates, while 36.5% were university graduates. When the causes of infertility are examined, 28.3% were female infertility, 18.3% were male infertility, 14.3% were both female and male infertility, and 38.6% were unexplained infertility. 5.1 percent of participants had systemic disease.

Factor analysis results

Factor analysis is one of the most effective methods of reducing variables. In a factor analysis, similar variables are grouped into smaller variable sets (factors) based on the power of the linear relations between variables (25). A Kaiser-Meyer-Olkin test gave a result of 0.881 (Table 1) after the factor analysis was applied to the 50 questions in the scale, and given that this is much higher than 0.50, the factor analysis was deemed appropriate for the application of the scale. The Bartlett's test showed that the factor analysis to be recommended suitable (p<0.0001). These results indicate that the correlation between the scale questions is significant, meaning that the scale questions are suitable for factor analysis. Furthermore, it was concluded that it was not necessary to remove any items from the scale as the diagonal elements in the anti-image matrix were higher than the value of 0.50, and most of the coefficients were found to be >0.80. After the factor loadings were obtained, the Varimax rotation method was applied, and 10 significant factors were found to be higher than the eigenvalue of 1. The factors obtained, questions and loadings are given in Table 2, in which the factors are referred to in accordance with the meaning of the materials they contain after examining which factors are included in which factor.

The distribution of the questions by factor is as follows: There are seven questions in the first factor, seven questions in the second factor, six questions in the third factor, six questions in the fourth factor, six questions in the fifth factor, three questions in the sixth factor, four questions in the seventh factor, five questions in the eighth factor, three questions in the ninth factor, and three questions in the 10th factor (Table 3).

Cronbach's alpha coefficient results

The additivity feature, or the internal consistency of the 50-question scale (Cronbach's alpha coefficient) was found to be 0.880, which is very high. This outcome suggests that the items included in the scale have the characteristic of additivity and that overall scale score can be obtained by being added up. The internal consistency level of the 10 factors was determined to be 0.720, which indicates that the overall average scale score can be calculated by taking the average of the factor scores. The internal consistency coefficients of each of the 10 factors are summarized in Table 2. The WCSI comprised 30 items, and the internal consistency coefficient (Cronbach's alpha) was found to be 0.752, which shows that there is an internal consistency and that the total score can be calculated. Descriptive statistics of the subscales and total score of WCSI and the subscales and average overall score of CSIW are summarized in Table 4.

CSIW and WCSI correlations

A simultaneous WCSI was used to evaluate the validity of the CSIW. As can be understood from Table 5, most of correlations are statistically significant, and this result shows that CSIW gives concurrent valid results. A significant negative correlation was identified between the average overall score of the CSIW and the total overall score of the WCSI (r=-0.222, p=0.001). Since the sample size is large, many of the correlations are significant, although their rate is not very high.

Discussion

This study aimed to establish a culturally acceptable, valid and reliable scale that can be applied to understand the coping strategies adopted by infertile women. At the end of the analysis, the internal consistency of the 50 items in the scale was found to be high, and no items were eliminated. This result could be attributable to the careful gathering of qualitative data and literature knowledge when developing the items.

The additivity feature, or the internal consistency between the items of the CSIW (Cronbach's alpha coefficient), was found to be 0.880, which was very high, and suggests that the questions included in the scale are additive and that the overall scale score can be obtained through addition. The internal consistency level of the 10 factors was determined to be 0.720. The findings suggest that the CSIW scale has good reliability and validity, which can contribute to the clarification of coping strategies used by infertile women, and which can help in the planning of effective interventions. The scale, which was developed with great care, had a study population that was within acceptance limits (n=751) and was found to have a clear and easily interpretable structure.

It is worth noting that WCSI, which is commonly used in the literature, has been used to test the reliability of the scale developed in this study. WCSI, developed by Lazarus and Folkman in 1980, is a short and validated scale for the assessment of stressful situations. The internal consistency of the WCSI, the Turkish version of which was used in this research, was found to be 0.752, and a significant negative correlation was identified between the average overall score of the CSIW and the total overall score of the WCSI (r=-0.222, p=0.001). The significant correlation between WCSI and CSIW provided evidence of the concurrent validity of the CSIW. The reason for the significant negative correlation between the two scales can be attributed to that the high scores in the WCSI indicate that the person uses that style more often, whereas the low scores in the CSIW indicate that the person is using that style more often. As most of the correlations between CSIW and WCSI subscales/factors were found to be significant, the reliability of the CSIW is indicated.

In Turkey, there is no other scale with similar content, while the global body of literature includes scales developed specifically to address the issue of coping in infertile women, including the Coping Scale for Infertile Couples (CSIC), developed for the Taiwanese context by Lee et al. (19). This scale comprises 15 items, while its four factors are named "Increasing space", "Regaining control", "Being the best" and "Sharing the burden". The content of the "increasing space" factor is similar to that of the "social withdrawal" factor of the CSIW, in that the items in both factors are related to avoiding social environments that bring the issue of children to mind. Avoidance has been reported to be the most common method of coping with infertility (particularly among women) (20,26). The other factor names and the content of the CSIC are not compatible with the WCSI. Another coping scale related specifically to infertility is CIQ, which comprises14 factors developed for the Israeli context (18) CIQ is a coping scale that comprises 51 items and 14 factors. Regarding the number of items, it is like CSIW, which has 50 items, and it can be said to be like the scale developed within this study regarding the factor names and contents. The contents of factors, such as "social withdrawal", "acceptance", "spiritual coping", "seeking social support" and "denial" resemble the items within the factors with the same name in CSIW. This similarity may be because Lazarus and Folkman (7), which is a model commonly used in coping with stressful situations, has been influential in both scales. Israel and Turkey are close to each other geographically, and the meanings attributed to children and coping styles are similar, considering the closeness of the two cultures. This may be another factor that influences the similarity.

The sample size should be large enough to ensure that the relationships can be reliably estimated. Different definitions are made regarding this number, but as a rule, the sample size should be five, or even ten, times the minimum number of the observed variable (27). When the sample sizes of the scales were examined, CSIC was seen to have been applied to 138 infertile Taiwanese couples (N: 276), while CIQ (Coping with Infertility questionnaire) was applied to 652 Israeli women, although 60% of the 652 women in the CIQ sample were reported to have no biological children. The sample size of the CSIW can be considered as an acceptable number for scale development, as the sample of the scale comprised 751 primary infertile women, applied to women who had never had children (in terms of number -more than 10-times' than the item number).

The factor with the highest number of items (seven items) in CSIW is "preoccupation with thoughts". Based on item contents of this factor, it would seem to be related to difficulties in coping with the negative thoughts about one's inability to have children. Negative thoughts that cannot be coped with are linked to depressive tendencies (28). It can be said that this factor includes items that support studies in which the level of depression in infertile women was reported to be high (3,29). Another factor with seven items is "spiritual coping", which is also included in CIQ. Spiritual coping is often used as a strategy for the reduction of stress among infertile women, regardless of their culture or religion (12). The factors of hope, social support seeking and acceptance in CSIW are all coping behaviors that focus on problem solving, as stated by Lazarus and Folkman (7). The negative self-perception, social withdrawal and denial factors follow the "emotion-focused coping" strategies, and all three factors can be linked to escaping from the problem and appointing self-blame (7).

Conclusion

The internal consistency (Cronbach's alpha coefficient) of the CSIW is 0.880, while the internal consistency level among the 10 factors obtained through the factor analysis is 0.720. These factors have been identified as preoccupation with thoughts, spiritual coping, denial, social withdrawal, negative self-perception, hope, social support seeking, acceptance, investing in self and spousal relations. A negative significant correlation was identified between the CSIW and the WCSI (r=-0.222, p=0.001), and according to the findings of this study, CSIW can be considered as a scale with good reliability and validity that can contribute to the clarification of coping strategies used by infertile women, and which can help to in the planning of effective interventions.

Infertile women have been found to experience stress and psychosocial problems when faced with the inability to have children. Among these problems, the inability to respond to social expectations, stigmatism, negative self-perception, invisible multiple losses and the psychological effects of adjunctive therapies are more common. Each stage of infertility treatments occurs in the female body. Thus, coping with stress levels of women who undergo this treatment, and developing appropriate interventions will allow women to overcome this period better and increase the success levels of treatment. CSIW can be used as a standard data collection tool by health care providers to ascertain coping strategies in infertility clinics and can serve as a useful database for the planning effective interventions in cases of infertility-specific psychosocial problems.

Study Limitations

This scale has been developed by the researchers to address a shortfall in literature. Data were collected from three large cities in Turkey in which different cultures are represented. This can be given as an example of the strengths of this scale. Ankara, Istanbul and Antalya all see significant migration from other regions in Turkey, and the most popular IVF centers can be found in these provinces. The strength of the CSIW regarding data diversity is that its data were collected in these cities, although it is recommended that CSIW should be applied to women from different cultures and different regions in the country to improve the scale. Additionally, further studies are recommended to be carried out to include more diverse demographic samples and cultures, aside from Turkey, as this would result in a universal tool for the testing of coping strategies among infertile women.

Ethical Considerations

The study was approved (approval number: 86/2015) by the ethical committee of the Istanbul Zeynep Kamil Women's and Children's Disease Training and Research Hospital. Both oral and written information was given to the participants to explain the objective of the research before the application of scale, and the participants were informed that they had the right to withdraw at any time, without explanation. Written informed consent was subsequently obtained from all the participants.

Acknowledgements

The authors acknowledge to all those who participated in this study.

Contributions

Study design: AK, GU; data collection: IK, EA, YDM; data analysis HA; article drafting: AK, HA, GU and data interpretation and revision and final approval of the article: all authors

Funding

This study was funded by the Duzce University Scientific Research Fund (DUSRF).

Conflict of Interest

No conflict of interest is declared by the author.

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DOI: 10.29063/ajrh2018/v22i3.2

Aysel Karaca (1*), Gul Unsal (2), Elif Asik (3), Ilkay Keser (4), Handan Ankarali (5) and Yeliz Dogan Merih (6)

Duzce University Faculty of Health Sciences, Duzce, Turkey, Department of Nursing, Konuralp campus, Postal Code:81600, Duzce, Turkey (1); Marmara University Faculty of Health Sciences, Istanbul, Turkey (2); Kirikkale University Faculty of Health Sciences, Kiriklale, Turkey (3);Akdeniz University Nursing Faculty Antalya, Turkey (4); Medeniyet University, Faculty of Medicine, Department of Biostatistics and Medical Informatics, Istanbul, Turkey (5); Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Quality Department Nurse, Istanbul, Turkey (6)

(*) For Correspondence: Email: ayselkaraca@duzce.edu.tr; ayselkaraca0905@gmail.com; Phone: 0 380 5421141
Table 1: The results of the suitability of data for structure detection

Kaiser-Meyer-Olkin  Measure of Sampling        .881
Adequacy.
Bartlett's Test of  Approx. Chi-Square   14,925.326
Sphericity          Df                     1225
                    Sig.                       .000

Table 2: Coping scale for infertile women, factors, questions and
loadings

Factors and Included Questions                     Loading

Preoccupation with thoughts
I want to be alone because of
my thoughts 1 (*)                                    0,757
I think that my thoughts on
children become an obsession
for me 2 (*)                                         0,788
Infertility always occupies
my mind 3 (*)                                        0,749
I have physical problems
like insomnia and loss of
appetite because of my thoughts 4 (*)                0,686
I always feel nervous and angry 5 (*)                0,705
I feel as if I am alone in the world 6 (*)           0,526
I can no longer resist and fight 7 (*)               0,541
Spiritual Coping
I pray more compared to the past 21 (*)              0,743
I began to question the justice of
the world/God because I cannot have
children 25 (*)                                   -  0,668
I believe that God will reward me
to deal with this problem 26 (*)                     0,650
I attribute my infertility to fate 27 (*)            0,575
I try to take refuge in my
religious belief 30 (*)                              0,846
I believe that the difficulties
we are experiencing have a meaning 39 (*)            0,372
I trust in God for the solution
of this problem 44 (*)                               0,843
Denial
I refuse to believe that I am in this
situation 15 (*)                                     0,424
I pretend as there is no such thing 22 (*)           0,311
I do not want other people to
know my problem 23 (*)                               0,835
I prefer to talk about this problem 28 (*)           0,848
I share this problem with almost
everyone around me 29 (*)                         -  0,414
I do not want my family and friends
to intervene in this problem 40 (*)                  0,370
Social Withdrawal
I stay away from the environments
where people can ask questions
about children 9 (*)                                 0,519
I prefer to contact with my
relatives less often 11 (*)                          0,613
I keep to myself; avoid from talking
with women who have children
or who are pregnant 13 (*)                           0,678
I keep myself avoid from social
activities like baby shower/baby's
mawlid 16 (*)                                        0,732
When I see other couples who have
children, I feel anger against them 19 (*)           0,564
I avoid to love children 35 (*)                      0,665
Negative Self-Perception
I feel weak and incomplete 8 (*)                     0,492
I cannot express my feelings when
I am with other people because
I concern about that they will
have pity                                            0,500
on me (e.g. I cannot cry) 10*
I think that people blame me
for not having a child12 (*)                         0,604
I see my own body defective
and blame myself 14 (*)                              0,578
I think I am unfair to my
partner because we cannot
have children 17 (*)                                 0,655
I think my partner puts
the blame on me 18 (*)                               0,705
Hope
I am dreaming about children 31 (*)                  0,843
I am planning to have children 36 (*)                0,878
I am hopeful that I will have children 49 (*)        0,802
Social support seeking
I only share my emotions with
people who are suffering from
the same problem with me 20 (*)                      0,518
I try to spend time with women
who have similar problems with
me or had this experience in the
past 24 (*)                                          0,819
I ask people, who have experienced
similar problems, what they have
done 38 (*)                                          0,773
I ask a relative or a friend,
who I respect or trust, for advice
regarding this problem 41 (*)                        0,713
Accept
I think about the next steps in
case the possibility of failure
of treatment 32 (*)                                  0,354
I am searching different sources
regarding this problem (books,
internet, information content 34 (*)                 0,631
I get used to the fact that I
cannot have children or the
treatment does not work 37 (*)                       0,805
I learn to live with this
problem 46 (*)                                       0,828
I am trying to think about
the positive aspects of this
situation 50 (*)                                     0,661
Investing in Self
I keep myself busy with relaxing
activities (such as massage,
reading books, listening to
music) 42 (*)                                        0,793
I care about improving myself
in various ways (courses,
hobby, workshop) 45 (*)                              0,754
I pay more attention to my
appearance compared to the
past 48 (*)
Spousal relations
I am trying to involve my
partner in each step of the
problem/treatment 33 (*)                             0,769
I think that this problem has
brought us closer as a couple
with my partner 43 (*)                               0,742
I trust my partner's support
for treatment and appointments 47 (*)                0,825

(*): numbers at the end of the questions indicate the numbers in the
scale

Table 3: Internal consistency coefficients and item numbers of the
factors

Factors               Cronbach's Alfa  Number of
                      coefficient      Items

Preoccupation         0,875            7
with thoughts
Spiritual coping      0,750            7
Denial                0,625            6
Social withdrawal     0,797            6
Negative self-        0,804            6
perception
Hope                  0,866            3
Social support        0,748            4
seeking
Accepting             0,731            5
Investing in self     0,700            3
Spousal relations     0,514            3

Table 4: Subscales and total scores of WCSI and CSIW

                                             N    Mean  SD

Ways of Coping     SCA                       587  3.12   .50
with Stress Scale  OA                        603  2.99   .55
(WCSI)             DA                        568  2.39   .55
                   SA                        590  2.39   .50
                   SSS                       620  2.81   .51
                   WCSI total score          505  2.71   .30
Coping Scale for   Preoccupation with        720  3.24  1.14
Infertile Women    thoughts
(CSIW)             Spiritual coping          720  1.81   .81
                   Denial                    721  2.85   .92
                   Social withdrawal         721  3.73  1.03
                   Negative self-perception  720  3.81  1.02
                   Hope                      726  1.61   .93
                   Social support seeking    738  2.32  1.07
                   Accept                    727  2.09   .92
                   Investing in self         734  2.66  1.13
                   Spousal relations         729  1.91   .94
                   Mean CSIW score           667  2.72   .55

                                             Minimum  Maximum

Ways of Coping     SCA                       1.00     4.00
with Stress Scale  OA                        1.00     4.00
(WCSI)             DA                        1.00     4.00
                   SA                        1.00     4.00
                   SSS                       1.00     4.00
                   WCSI total score          1.00     4.00
Coping Scale for   Preoccupation with        1.00     5.00
Infertile Women    thoughts
(CSIW)             Spiritual coping          1.00     5.00
                   Denial                    1.00     5.00
                   Social withdrawal         1.00     5.00
                   Negative self-perception  1.00     5.00
                   Hope                      1.00     5.00
                   Social support seeking    1.00     5.00
                   Accept                    1.00     5.00
                   Investing in self         1.00     5.00
                   Spousal relations         1.00     5.00
                   Mean CSIW score           1.00     5.00

Table 5: Relationships between the subscales and general scores of WCSI
and CSIW

                 SCA               OA                DA
                 r      p     N    R      P     N    r      p     N

Preoccupation    ,293   ,000  574  ,278   ,000  587  -,470  ,000  551
with thoughts
Spiritual       -,125   ,003  574  -      ,030  587  -,083  ,050  554
coping                             ,089
Denial           ,064   ,124  570  ,068   ,101  587  -,190  ,000  554

Social           ,211   ,000  571  ,191   ,000  587  -,318  ,000  551
withdrawal
Negative self-   ,347   ,000  572  ,311   ,000  589  -,451  ,000  551
perception
Hope            -,189   ,000  574  -      ,001  591   ,095  ,026  554
                                   ,139
Social support   ,082   ,050  582  ,006   ,881  599  -,164  ,000  562
seeking
Accept          -,087   ,037  573  -      ,464  590   ,070  ,099  557
                                   ,030
Investing in    -,144   ,001  578  -      ,000  595   ,105  ,013  562
self                               ,156
Spousal         -,082   ,050  577  -      ,810  595   ,086  ,041  558
relations                          ,010
Mean new         ,158   ,000  537  ,166   ,000  549  -,354  ,000  519
scale score

                 SA               SSS                Total
                 r     p     N    r       p     N    r      p     N

Preoccupation    -     ,000  575  -       ,338  598  -,158  ,000  493
with thoughts    ,225             ,039
Spiritual        -     ,000  577  -       ,021  601  -,244  ,000  496
coping           ,165             ,094
Denial           -     ,115  577  -       ,001  599  -,139  ,002  494
                 ,066             ,136
Social           -     ,000  574  ,006    ,893  600  -,111  ,014  491
withdrawal       ,186
Negative self-   -     ,000  577  ,025    ,535  602  -,090  ,046  493
perception       ,173
Hope             ,108  ,009  578  -       ,025  603  -,044  ,324  495
                                  ,091
Social support   -     ,000  585  -       ,077  614  -,133  ,003  501
seeking          ,172             ,071
Accept           ,018  ,665  578  -       ,607  604  -,069  ,128  496
                                  ,021
Investing in     ,053  ,203  582  ,008    ,842  609  -,022  ,622  500
self
Spousal          ,072  ,084  581  -       ,114  607  -,011  ,810  498
relations                         ,064
Mean new         -     ,000  541  -       ,018  554  -,222  ,000  468
scale score      ,199             ,100
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Title Annotation:ORIGINAL RESEARCH ARTICLE
Author:Karaca, Aysel; Unsal, Gul; Asik, Elif; Keser, Ilkay; Ankarali, Handan; Merih, Yeliz Dogan
Publication:African Journal of Reproductive Health
Article Type:Report
Geographic Code:7TURK
Date:Sep 1, 2018
Words:6426
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