Evaluation of the Effectiveness of Quality of Life Therapy (QOLT) on Individual Well-being and Happiness of Infertile Women

Infertility is one of the causes of chronic stress that can cause a variety of psychological problems. Hence, for increase the mental health of infertile women some psychological intervention seems essential. This study examined the effectiveness of quality of life treatment on individual well-being and happiness. The population consisted of all infertile women lived in Kermanshah in 2014. The method in this study was a quasi-experimental with pre-test, post-test and the control group. Consisted of all infertile women in the study was Kermanshah in 1393. All infertile women referred to the infertility center from beginning of September until the end of December. Finally, 30 patients were selected and replaced in two groups randomly. Well-being scale used for assessing the individual well-being and Oxford Happiness Questionnaire used to measure the happiness of infertile women. For data analyzing, paired t-test and covariance (ANCOVA) were used. The results of analysis of covariance (ANCOVA) showed that two groups have significant differences in the individual well-being (78/12 = F, 001/0> p) and happiness (86/12 = F, 001/0> p). Therefore, according to the obtained results in this study, quality of life treatment can be used in order to promote individual well-being and happiness in infertile women.


Introduction 1.
Infertility has been described as failure in pregnancy after one year of regular and unprotected sexual intercourse (Mohammadi and Khalaj Abdi Farahani, 2001).It has been estimated that out of every 10 couples, one couple is suffering from the primary or secondary infertility (Salmela-Aro, Soykar, 2008).Infertility affects whole life of the couples and it can be said that it is a very stressful and traumatic event in lives of individuals that causes very negative consequences in their lives.Couples who face infertility problems have mixed feelings; on the one hand, they have much desire and willingness to have children and on the other hand, it is not possible physically.Moreover, being in stressful conditions, by itself, creates feelings of guilt, anxiety and stress in interpersonal relationships and also causes depression.Inability to have children is considered as a factor of failure and creates the impression that the person is deficient and is not a normal person.Infertility is also associated with a sense of lack of identity, being rootless and lack of confidence.As a result all of the aforementioned items create various and negative emotions such as depression, grief, despair and helplessness in these individuals (Van den Broeck and Omri and Soren et al., 2010).In total, the results of the study indicate that 15% of couples experience the stress of infertility (Ridnour, Yorgason and Peterson, 2009).In infertile families, despite the fact that each of the couples may have a problem, mostly the women are under pressure and they endure much stress.Also women feel greater responsibility, regarding the issue of infertility and their husbands also consider the women to be responsible for infertility, and therefore, the pain and mental sufferings of women, in dealing with infertility, is much worse and more difficult than men (Kaplan and Kaplan, translated by Rafeie, and Rezai, 1382).It is such a necessity that makes researchers and psychotherapists to design some interventions to improve the well-being and mental health of infertile women.It is believed that mental health or individual well-being has different aspects and this means that if a person is not ill or incapacitated and feels the happiness and well-being, then in terms of mental health he/she is in a good condition (Larson, 1991).Ryff designed the pattern of psychological well-being which had six dimensions.These dimensions include: autonomy, positive relations with others, self-acceptance, purposeful life, personal growth and environmental mastery.According to this model, it is assumed that at the time of occurrence of an abnormality, some disruptions occur in the proposed dimensions of individual's well-being that affect his performance.The psychological effects of infertility on marriage life, usually shows off itself in the form of conflicts and struggles between the couple and finally, it will probably lead one or both of them to complete isolation.The results of some researches indicate that the infertility not only creates cognitive-psychological changes in the spouses, but it is also leaves profound impacts on their sexual relations and marriage life (Hosseinzade Bazargani, 2003).Many studies suggest that families with infertility problems have some difficulties such as severe conflicts, communication problems, and long arguments over the treatment, lack of mutual understanding and empathy.Of course, it should be acknowledged that some studies have also reported that in infertile couples, who are affected by this problem, there are high levels of intimacy and interpersonal relations (Burns & Covington, 1999).Monga et al (2004) have reported that infertile women have a poor marital adjustment and also lower quality of life as compared with fertile women.One of the most common psychiatric disorders among the infertile individuals is depression and anxiety (Bakhtiari et al., 2014).Infertile couples, under the impression of this problem, feel a sense of isolation in their relation and fear that their relationship will end, and sometimes the symptoms of depression and psychiatric disorders are observed in them.Also several researches point out that, stressful experiences of infertility are along with a wide range of psycho-cognitive disorders such as low self-esteem, excessive stress, anxiety, anger and depression (Hossain, 2014).According to the results of some studies, the prevalence rate of depression in infertile women has been reported to be 17.9 percent (9), 40/8 percent (Ramazan Zadeh et al., 2004), 48 percent (Noorbala, 2008), 53/8 percent (Al-Homaidan, 2011), 62 percent (Peyvandi et al., 2008), and 72% (Duman and Kocak, 2013).Studies, which have been conducted in Turkey, Saudi Arabia and Poland, have indicated that the level of negative emotions such as anxiety and depression in infertile women is higher as compared to infertile women (Al-Homaidan, 2011and Drosdzol and Skrzypulec, 2009, quoted by Bakhtiari et al., 2014).Stuart et al. (2010) have stated that happiness is one of important and notable areas of positive psychology studies.Happiness has three main components that include the amount and degree of positive affect, absence of negative emotions such as depression, anxiety and moderate levels of satisfaction within a specific period of life (Stuart et al., 2010).Individual well-being and happiness are considered as two very important elements in the life of infertile women and their families and in this study, it has been tried to increase the happiness and individual well-being of these people, through therapeutic interventions.In addition, studies also show that psychical and mental states of infertile individuals have adverse and negative impact on their therapeutic process (Hatamloo and Hashemi, 1391).

Process and sample
The method of research in this study is a quasi-experimental along with the pre-test, post-test and control group.The study population consisted of infertile women who had visited Infertility Treatment Center of Motazedi hospital in Kermanshah in 1393.To select the proper sample, all visitors, who had visited the mentioned infertility treatment center in the time interval between the beginning of Sharhrivar (September) until the end of Azar (December) were studied.Inclusion criteria were: 1) completion of the infertility treatment process, 2) not receiving a drug that has psychological effects; 3) not receiving other psychological or psychiatric treatments; 4) do not having a history of mental disorder.By considering these criteria, 83 patients were eligible for the study that among them 30 infertile subjects declared their consent to participate in the study.They were randomly divided into control and experiment groups.People who were in the experiment group received interventional program that was based on quality of life and those who were in the control group received a program that its content was not related to the issue of quality of life.Members of both groups, before and after the intervention, responded to measuring tool of individual well-being and happiness questionnaire.

Assessment instrument of individual well-being
Psychological well-being scale, in addition to containing a general item for measuring overall life satisfaction of individual that is not calculated in score of the scale, contains 8 items that each of them question and probe one area.The answers are entered in 11 degree scale which is scored from zero to 10 and every item represents the issues related to the overall quality of life scale and represents a domain (Abdi Zarrin, Sajadian, Shahyad, 1389).Aghayousefi (1386) in a study that has conducted on the spouses of martyrs, devotees and freed prisoners of war in Qom province has reported that the reliability of this questionnaire was 85%, which was obtained through Cronbach's alpha.The validity of this questionnaire, according to the significant negative correlation with the stress scale was equal to 0/479 and according to the significant negative correlation with post-traumatic disorder the value of 0/473 was obtained.

Assessment instrument of Oxford Happiness Questionnaire
For evaluating the happiness of infertile women the Happiness Questionnaire was used which was developed by Argyle, Martin, & Crossland in 1989.The questionnaire has 29 questions that its scoring is between zero and 3 (Hills and Argyle, 2002).The value of Cronbach's alpha for this questionnaire, on the Iranian subjects was obtained as 0/9 (Liaghatdar et al., 2008).
Table 1 shows the therapeutic intervention program that was applied in this study (derived from Padash et al., 1390).

First session
Introducing group members and communicating, declaring group's rules and objectives, introducing the objectives and the training courses, getting the commitment of the participants to attend meetings, discussing about quality of life, life satisfaction, happiness, take pre-test and feedback.
Second Session Review of the previous session, defining therapy based on quality of life, introducing aspects of life, introduce tree of life to group members and discover roots of clients' problems, summary of discussion Third session Review of the previous session, discussing the five roots, introducing attitude as the second strategy, application of the second strategy in dimensions of quality of life Fourth session Review of the previous session, discussing the five roots, introducing attitude as the second strategy, application of the second strategy in dimensions of quality of life Fifth session Review of the previous session, discussing the five roots, introduction of SIO (Standards of fulfillment, Importance, Overall satisfaction) as other strategies to enhance satisfaction of life, instructing the principles of quality of life Sixth Session Review assignments, discuss principles about quality of life and explain application of these principles to increase quality of life Seventh session Reviewing assignments and continuing the discussion about important principles and application of them in couples' relationships with their partner Eighth session Provide summary of all sessions, conclusion about CASIO in different life situations and apply principles in different aspects of life.* CASIO= Circumstance, Attitude, Standards of fulfillment, Importance and Overall satisfaction Findings 3.
Totally 30 people participated in this study.The average age was 31.5 years old; education level of 2 subjects was below diploma, 5 subjects had diploma, 20 subjects had Bachelor's Degree & 3 subjects had Master's Degree.For assessing the data obtained from this study, initially paired t-test was used.As shown in Table 2, the mean score of pre-test and post-test of happiness (p<0/006) and individual well-being (p<0/007) in intervention group, before and after the treatment, was significantly increased.But the pre-test and post-test scores of happiness (p<0/06) and individual well-being (p<0/855) in the control group, before and after the implementation of treatment, had no significant difference.Also, to compare the degree of difference between intervention and control groups, after the impact of pre-test, analysis of covariance was used (Table 3).Analysis of covariance showed that the happiness score (p<0/001) and individual wellbeing score (p<0/0001) after the impact of pre-test, had a significant increase in the intervention group.So, the results obtained from the data, confirm the hypothesis of this study and show the significant effect of therapeutic intervention in increasing the level of happiness and individual well-being.

Discussion and Conclusion 4.
The purpose of this study was to evaluate the effect of quality of life therapy (QOLT) on individual well-being and happiness of infertile women.The first finding of the present study was that the quality of life therapy has been able to significantly improve the individual well-being.These findings are consistent with the findings from previous studies, including the studies of Sonja Lyubomirsky et al. (2009), Michel et al. (2009), Seligman et al (2006), Ghasemi et al. (1390) and Padash, et al (1390).Quality of life therapy is a combination of principles of cognitive therapy and positive psychology.Considering the aspects that are emphasized by quality of life therapy, individual well-being is reinforced through mental and emotional realms.For example, the study that was conducted by Ghasemi et al (1390) showed that quality of life therapy is able to develop mental well-being and psychological health of individuals.Hence, this method of treatment, by emphasizing on different aspects such as cognition and emotion and excitement, has the power to improve and enhance the overall well-being of individual.Also, another finding of the study was that the degree of happiness of infertile women of this study was significantly increased as a result of receiving quality of life therapy.This finding is consistent with the findings of the studies of Sonja Lyubomirsky et al. (2009), Padash et al. (1390) and Bakhtiar et al (2014).This approach increases hope and life satisfaction in the visitors which in turn, will boost the level of happiness in their lives.By classifying areas of individual satisfaction as well as presenting a five-way pattern and also the principles of happiness, quality of life therapy, increases the happiness in the lives people.Lyubomirsky and Dellaporta (2008) acknowledge that if the individual health and well-being is to last for a long period of time, it should be along with subsequent practices in the individual.This treatment, by strengthening the hope and meaning in lives of visitors, transfers the energy to them, so that they can have lasting individual well-being and health.Also it can be said that the first finding of this study can be associated with the subsequent findings.In this way that, when the aspects and dimensions of quality of life therapy increase the individual well-being and health, it creates a stable state in the individual that takes normal function in all dimensions of life and reaches a good status in its relationship with the others.Also increases success in social relationships and the individual role of self-esteem and self-confidence.Increase in the selfconfidence and success in different aspects of life can also increase the state of happiness and joy in individuals.This study was conducted with the aim of examining unsuitable situation of infertile women within the family and social relationships and solving their problems.Quality of life therapy was selected according to backgrounds of research and the successes of this intervention in behavioral disorders and to improve the individual well-being and happiness.The results of this study can be presented in the form of educational packages and be placed at the disposal of therapists and other competent individuals and in this way, decrease the complexities and stresses in the lives of infertile women to the extent that it is possible.

Table 2 .
Analysis of paired t test to compare the difference between pre-test and post-test of problem solving groups, cognitive restructuring and the control group

Table 3 .
Analysis of covariance (ANCOVA) for the comparison of post test scores of family functioning and cognitive emotion regulation in three research groups