Infertility is one of the major crises of life, which can cause psychological problems and considerable stress (1). As a serious public concern, infertility can inflict psychological damage on infertile couples and result in mental instability and divorce (2).
Infertility is defined as the inability of a couple to become pregnant despite an entire year of attempts without using any contraception and diagnosis of infertility from a specialist (1-3). The world health organization estimated that around 60 to 80 million couples have infertility throughout the world. Infertility affects almost 10% to 15% of couples, who are at the childbearing age. It can also affect the quality of married life, create marital dissatisfaction, reduce intimacy, instill fear over separation, and lead to frustration (4). Infertility is the fourth most stressful life event only after mother’s death, father’s death, and marital infidelity (5). Beside deprivation from children, infertile couples in traditional societies may experience different personal, familial, social, and financial challenges. Moreover, infertility places people at risk for different psycho-emotional problems and strains (2).
In the context of the Iranian culture, parents and significant others play a significant role in couples’ lives and, thus, infertility produces more profound effects (6). Due to infertility, most infertile Iranian males and females are stigmatized. Infertility impels couples to go through different arduous therapeutic processes and causes them a wide range of sexual, marital, and health problems, as well as low marital intimacy, feeling of guilt, despair, depression, low self-esteem, and marital dissatisfaction (7, 8). It affects couples’ interpersonal relationships, decision making ability, and emotional health (8). Studies show that 80% of infertile couples experience marital dissatisfaction, fragile marital relationships, low libido, anger, or negative emotions (9). Mollaei Nezhad et al. (2009) found that infertility-induced distress caused marital problems and reduced marital satisfaction among females (10). Besides, Agha Mohamadian et al. (2014) also showed that as a stressor, infertility was significantly correlated with irrational beliefs (such as perfectionism) and significantly affected sexual function (11).
Currently, there are numerous methods for improving the quality of married life and training marital relationship skills. One of the methods for improving marital relationships is enrichment (12). Relationship enrichment (RE) is method for improving marital relationships through setting goals for the marriage. Studies showed that RE has positive effects (12, 13) and helps people improve their relationships and maintain the quality of their relationships over time. Relationship Enrichment is a skill training model for enhancing marital satisfaction and the stability of a marital relationship. In RE programs, couples learn to accept and sympathize with each other. Nazari et al. (2014) reported the positive effects of psycho-educational approaches on the learning of married life skills (13). Moreover, RE programs were reported to significantly improve marital adaptation (13) and marital relationships (14).
Effectiveness of health education programs greatly depends on the accurate use of educational and behavioral theories and models (15, 16). Studies also showed that the most effective educational programs are those that are based on behavior modification theories and models. Thus, the first step in planning an educational program is to select an appropriate health education model (17). The Theory of Planned Behaviors (TPB) is amongst models used mental health education.
Theory of Planned Behaviors is a cognitive-social decision-making model, which provides a useful framework for predicting and explaining health-related behaviors (16, 18). Thus, it can provide a useful theoretical framework for predicting infertile couples’ behaviors and improving their functioning and satisfaction. It determines the correlations among behaviors, beliefs, attitudes, and intention and introduces intention as the most important predictor of behavior (16-18). Figure 1 shows that the intention to show a given behavior is predicted by the attitude towards that behavior, subjective norms, and perceived behavioral control (15-18).
Figure 1.
The Theory of Planned Behavior
In the TPB, intention is an individual’s decision to perform a behavior while behavior is the way the individual acts. Habit is also the way of reacting in different situations (18), while attitude towards behavior is the degree of ideality of a given behavior (16-18). Moreover, the concept of subjective norms points to perceived social pressures (from parents, spouses, or physicians), which may require an individual to perform or avoid performing a behavior (16, 17). Finally, perceived behavioral control is the perceived simplicity or difficulty of performing a given behavior (16, 17). In other words, it shows the degree to which performing or not performing a behavior is under an individual’s control (18). Perceived behavioral control can both directly and indirectly affect behavior (16, 17).
The TPB holds that a given behavior can be predicted through measuring behavioral intention. As a main construct of the TPB, behavioral intention shows how much people intend and attempt to perform an action (18). According to Armitage and Arden (2002), TPB is the most comprehensive and most appropriate theory for studying behaviors (19).
Our literature review revealed that no study had been conducted in the area of enriching infertile couples’ relationships. Studies in this area can provide health authorities with credible information about existing knowledge gaps, help infertile couples understand the effects of infertility on their lives, and improve their coping abilities. The present study sought to evaluate the effects of a TPB-based RE educational program on infertile couples.
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