CLINICAL SCHOLARSHIP

Psychosocial Health of Infertile Ghanaian Women and Their

Infertility Beliefs
Florence Naab, PhD, Mphil, RN
1
, Roger Brown, PhD
2
, & Susan Heidrich, PhD, RN
3
1 Tau Lambda at Large, Lecturer,Department of Maternal and Child Health, School of Nursing, College of Health Sciences, University of Ghana, Legon,
Accra, Ghana
2 Professor, Schools of Nursing, Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
3 Beta Eta at Large, Helen Denne Schulte Professor Emeritus, University of Wisconsin-Madison, Nurse Scientist, William S. Middleton Memorial Veterans
Hospital, Madison, WI, USA
Key words
Beliefs, infertility, psychosocial, women
Correspondence
Dr. Florence Naab, Department of Maternal and
Child Health, School of Nursing, P.O. Box LG 43,
College of Health Sciences, University of Ghana,
Legon Boundary, Accra, Ghana.
E-mail: orencenaab@yahoo.com
Accepted: November 3, 2012
doi: 10.1111/jnu.12013
Abstract
Purpose: The purpose of this study was to describe infertile womens psy-
chosocial health problems and their infertility-related beliefs and examine the
relationships between their beliefs about infertility and psychosocial health
problems.
Design: The study was a descriptive correlational cross-sectional survey.
Women (N = 203) who were receiving treatment for fertility problems in two
public hospitals in Ghana were recruited.
Methods: Participants completed a Fertility Belief Questionnaire; measures of
infertility-related stress, anxiety, social isolation, perceived stigma, and depres-
sive symptoms; and sociodemographic and infertility-related health questions.
Descriptive statistics, Pearsons correlations, and hierarchical regression analy-
ses were performed.
Findings: The women reported high levels of infertility-related stress, low
levels of anxiety, some social isolation, low levels of perceived stigma, and
high levels of depressive symptoms. Beliefs that infertility has negative conse-
quences and that one has a poor understanding of infertility were signicantly
related to infertility-related stress, social isolation, and depressive symptoms.
Belief that infertility could be managed by personal control was signicantly
related to lower levels of anxiety and perceived stigma. Beliefs about conse-
quences, illness coherence, and personal control explained signicant propor-
tions of the variances in anxiety, stress, social isolation, perceived stigma, and
depressive symptoms.
Conclusions: Infertile women in Ghana have psychosocial health problems
that are associated with their beliefs about infertility.
Clinical Relevance: Findings have implications for nursing care of infertile
women in Ghana.
Seventy-two million women in the world are reported to
be infertile, and most of them live in developing countries
(Boivin, Bunting, Collins, & Nygren, 2007; World Health
Organization [WHO], 2009). The prevalence of infertility
is particularly high in sub-Saharan Africa, ranging from
20% to 46% in some parts of West Africa (Kwawukume
& Emuveyan, 2005). It is estimated that 30% of sub-
Saharan African couples are infertile, as compared with
28% in South-Central Asia and 24% in South-East Asia
(WHO, 2009). There is also some evidence that infer-
tility is associated with stress, stigma, anxiety, and de-
pression among infertile women in Africa, where child
bearing is highly valued (Barden-OFallon, 2005; de Kok,
2009; de Kok & Widdicombe, 2008; Donkor & Sandall,
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Naab et al. Infertility Beliefs
2007; Dyer, 2007; Dyer, Abrahams, Hoffman, & van der
Spuy, 2002; Dyer, Abrahams, Mokoena, Lombard, & van
der Spuy, 2005; Upkong & Orji, 2006). Qualitative stud-
ies in Mozambique and Zimbabwe suggest social isolation
may be common for infertile women (Gerrits, 1997; Run-
ganga, Sundby, & Aggleton, 2001). Despite this evidence
that infertility has a negative impact on the psychosocial
health of women in Africa, the factors that contribute to
poor psychosocial health have not been systematically in-
vestigated. One factor that might help explain these out-
comes is the beliefs women have about infertility.
Conceptual Model
Leventhals Common Sense Model (CSM) of ill-
ness representation (Leventhal, Meyer, & Nerenz, 1980;
Leventhal, Nerenz, & Steele, 1983) proposes that individ-
uals have mental representations or lay theories of their
illness or health problem (Leventhal et al., 1980; Leven-
thal et al., 1983). These representations (beliefs) are de-
veloped from culture, family members, friends, health-
care providers, and personal experiences (Ward, 1993).
The CSM asserts that illness representations, whether
medically sound or not, guide coping behaviors which in
turn inuence health outcomes (Leventhal et al., 1980;
Ward, 1993).
Illness representations have ve cognitive dimensions:
identity, cause, timeline, consequences, and cure or con-
trol (Leventhal, Nerenz, & Steele, 1984). Identity is
beliefs about the symptoms that are attached to the
health problem. Cause is beliefs about the origin of
the health problem. Timeline is beliefs about whether
the health problem is acute, chronic, or cyclical. Conse-
quences are the beliefs about the short- and long-term
outcomes of the health problem. Control or cure involves
beliefs about a sense of control of the illness and whether
the illness is curable or controllable. Two other dimen-
sions (illness coherence and emotional response) were
later added to the model (Moss-Morris et al., 2002). Ill-
ness coherence reects beliefs about whether a person
has a clear picture or understanding of the health prob-
lem. Emotional response reects the persons emotional
reactions to the health problem. A systematic review of
research using the CSM (Hagger & Orbell, 2003) found
that the consequences, identity, and timeline domains
were signicantly and positively correlated with psycho-
logical distress. However, the CSM has never been used
in the study of infertility.
A few qualitative studies of infertile women in Africa
have described beliefs about infertility. Negative so-
cial consequences of infertility, such as marital instabil-
ity and stigma, were described by South African and
Ghanaian women (Dyer et al., 2002; Fledderjohann,
2012). In Ghana, infertile women report being labeled
as abnormal or incomplete (Fledderjohann, 2012;
Yebei, 2000). In Malawi, infertile women are belittled,
made to feel like a fool, and not respected (Barden-
OFallon, 2005). In Nigeria, an infertile woman is not al-
lowed to make decisions within the family, cannot inherit
her husbands property, is described as a man, and has a
higher chance of being divorced (Hollos, Larsen, Obono,
& Whitehouse, 2009; Okonofua, Harris, Odebiyi, Kane,
& Snow, 1997). Infertility is reported as a major reason
for a man to marry a second wife. In old age, a woman
without children is not cared for, and in death, an infer-
tile woman may not be buried on town land because it is
believed that this could harm the lands fertility (Hollos
et al., 2009). In Tanzania, the most disturbing conse-
quences of being infertile were stigma and lack of respect,
such as being labeled useless women (Hollos & Larsen,
2008).
These ndings are important, but the research has
neither been theoretically based nor linked with health
outcomes. The purpose of this study was to describe
infertile womens psychosocial health problems and
their infertility-related beliefs and examine the relation-
ships between their beliefs about infertility and psy-
chosocial health problems, based on the relationships
posited in the CSM. For this study, only the rela-
tionships between beliefs and health outcomes (Lev-
enthal, Nerenz, & Steele, 1984) were investigated.
Coping strategies and behaviors were not examined.
Based on this theoretical model, beliefs that infer-
tility is chronic, has negative consequences, is not
controllable, and is poorly understood would be related
to higher levels of stress, social isolation, stigma, depres-
sive symptoms, and anxiety.
Methods
Design and Sample
The study was a descriptive correlational cross-section
study. Two hundred and three women receiving treat-
ment for fertility problems from two public hospitals in
Ghana were recruited. Women who were 18 years or
older, could read and write in English, and were con-
tacting the gynecology units of two public hospitals for
infertility services were eligible.
Procedure
The study was reviewed and approved by the two hos-
pitals in Ghana. The study also reviewed by the Social
Science Institutional Review Board at the University of
Wisconsin-Madison.
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Infertility Beliefs Naab et al.
Women who were eligible were given yers describ-
ing the study by doctors and nurses during clinic visits.
Those who were willing to participate were met by the
researcher in a private room. The purpose of the study
was explained and written information provided. Partic-
ipants who were willing completed condential surveys,
which were returned to a locked drop box and collected
at the end of each clinic day.
Measures
Beliefs about infertility. Beliefs about infertil-
ity were assessed by the Fertility Beliefs Questionnaire
(FBQ). The FBQ was developed from the Revised Illness
Perception Questionnaire (IPQ-R), an instrument based
on the CSM, and was modied to be culturally sensitive
in Ghana and specic to infertility. For the FBQ, the word
illness in the IPQ-R was replaced with fertility prob-
lem. The English language in the IPQ-R was revised to
a sixth grade level (primary six in Ghana). The FBQ was
assessed for content validity by both expert and lay pan-
els, with an average Scale Content Validity Index ranging
from 0.76 to 0.90 for each subscale. The FBQ had ve
subscales (timeline, consequence, illness coherence, per-
sonal control, treatment control). All ve subscales were
tested for both internal consistency reliability and com-
posite reliability. The results showed that timeline and
treatment control were below the acceptable level of 0.7.
For this reason, the timeline and treatment control were
not used in this study.
The FBQ has 21 items with three subscales: conse-
quence (11 items), illness coherence (5 items), and per-
sonal control (5 items). Items were rated on a 6-point
scale from strongly disagree (0) to strongly agree (5). Re-
sponses to each item were summed for a total score for
each subscale. High scores on consequences represent
strongly held beliefs about the negative consequences of
infertility. High scores on illness coherence represent a
perceived poor understanding of infertility. High scores
on personal control represent positive beliefs about per-
sonal control of infertility. Composite reliabilities were
0.79 for consequence, 0.71 for coherence, and 0.75 for
personal control.
Psychosocial health measures. There were ve
psychosocial health measures: infertility-related stress,
anxiety, social isolation, perceived stigma, and depressive
symptoms. Infertility-related stress was measured with
the Fertility Problem Inventory (FPI; Newton, Sherrard,
& Glavac, 1999), a 46-item, self-report scale assessing so-
cial, sexual, and relationship concerns, need for parent-
hood, and rejection of a child-free lifestyle. Responses
were rated on a 6-point scale from strongly disagree (1)
to strongly agree (6). Responses were summed for a total
score. Higher scores represent higher levels of infertility-
related stress. The original internal consistency was 0.93,
and test-retest reliability (30 days) was 0.83 for women
and 0.84 for men (Newton et al., 1999). The FPI was used
in one study in Ghana ( = 0.90), suggesting its cultural
appropriateness (Donkor & Sandall, 2007). In this study,
Cronbachs was 0.88.
Anxiety was measured by Becks Anxiety Inventory
(BAI), a widely used 21-item self-report questionnaire
assessing symptoms of anxiety (Beck & Steer, 1990).
Participants were asked to rate how much they were
bothered by each symptom for the past month on a 4-
point scale ranging from not at all (0) to severely (3). Re-
sponses were summed for a total score. Higher scores
indicate higher levels of anxiety symptoms. The BAI
has demonstrated concurrent validity with the Hamilton
Anxiety Rating Scale (Beck & Steer, 1990). The original
internal consistency () was 0.92, and the test-retest re-
liability was 0.75 (Beck & Steer, 1990). In the present
study, Cronbachs was 0.86.
Social isolation was measured with the Friendship
Scale (FS), a 6-item scale measuring perceptions of
personal attributes that contribute to social isolation
(Hawthorne, 2006). Responses were rated on a 5-point
scale from not at all (0) to always (4). Higher scores in-
dicate lower levels of social isolation. Evidence of con-
struct validity was demonstrated by signicant correla-
tion with the Short Form-12 (SF-12) mental component
score (MCS) and physical component score (PCS) scales,
the WHO Quality of Life group (WHQOL-Brief), and As-
sessment of Quality of Life (AQoL; Hawthorne, 2006).
Cronbachs was 0.83 (Hawthorne, 2006). In the present
study, Cronbachs was 0.66.
Perceived stigma was measured by a modied version
of the 5-item Stigma Scale for Receiving Psychological
Help (SSRPH; Komiya, Good, & Sherrod, 2000). The SS-
RPH was modied to make the items infertility related
and easy to understand. For instance, Seeing a psycholo-
gist for emotional or interpersonal problems carries social
stigma was modied to Receiving treatment for fertility
problems carries social stigma. Responses were rated on
a 4-point scale of strongly disagree (0) to strongly agree (3).
Responses were averaged for a mean score, with higher
scores indicating greater perceived stigma. The SSRPHhas
been widely used in studies of mental health, but not in
the study of infertility in Africa. The SSRPH has demon-
strated validity by signicant correlations with negative
attitudes toward mental health treatment (Komiya et al.,
2000). Cronbachs was 0.72 (Komiya et al., 2000). In
this study, Cronbachs was 0.76.
Depressive symptoms were measured by the 20-item
Center for Epidemiologic Studies for Depression Scale
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Naab et al. Infertility Beliefs
(CES-D; Radloff, 1977), a widely used measure of symp-
toms of depression in community populations. Partici-
pants rate each symptom for the past week from rarely
or none of the time (0) to most or all of the time (3), and items
are summed for a total score. A score of 16 or higher has
been used extensively as a cutoff point for screening for
clinical depression (Radloff, 1977), but this cutoff point
has been revised for different populations (Jang, Kwag,
& Chiriboga, 2010). In one study in Uganda, three lev-
els were used for scoring: 0 to 15 (no depression), 16 to
23 (distressed), and 23 and above for clinical depression
(Kaharuza et al., 2006). The CES-D has been demon-
strated to be reliable and valid (Radloff, 1977). The
CES-D has been used to study depressive symptoms in
Uganda (Kaharuza et al., 2006), Cote dIvoire (Moatti,
Prudhomme, Juliet-Amari, Akribi, & Msellati, 2003), and
South Africa (Myer et al., 2008). In the present study,
Cronbachs was 0.86.
Participants were also asked to complete a demographic
and infertility-related health information questionnaire
that included questions about age, educational level, in-
come, marital status, type of marriage (monogamous or
polygamous), length of marriage, number of children,
primary or secondary infertility (ever been pregnant or
not), types of infertility treatment (medical and nonmedi-
cal), and how long they had been seeking infertility treat-
ment. They were also asked whether they were from
northern or southern Ghana.
Data Analysis
SPSS Version 18.0 (SPSS Inc., Chicago, IL, USA) was
used for data analysis. Descriptive statistics were com-
puted for all the major variables. Age, level of education,
marriage duration, religion, income, type of treatment,
and treatment duration were recoded into dichotomous
dummy variables because of non-normal distributions.
These recodes were age (1 = 39 years, 0 = > 39 years),
education (1 = high school, 0 = > high school), mar-
riage duration (1 = 4 years, 0 = > 4 years), type of
marriage (1 = monogamous, 0 = polygamous), type of
treatment (1 = only medical treatment, 0 = medical and
other alternative treatment), treatment duration (1 =
4 years, 0 = > 4 years), type of infertility (0 = primary,
1 =secondary), religion (1 =Christianity, 0 =Islam), and
income (1 = monthly income 600 cedis [$350], 0 = >
600 cedis [$350]).
Pearsons r was used to estimate the correlations be-
tween each of the beliefs subscales and each psychoso-
cial health measure. In order to control the type 1 er-
ror rate, the p values for all correlations were adjusted
using Sidak p value procedures (Holland & Copenhaver,
1987). Therefore, all signicant correlations reported are
based on the adjusted p values. Hierarchical linear set re-
gression models were tested separately for each of the
ve psychosocial outcomes. For each psychosocial health
outcome, predictor variables were entered in the follow-
ing order: demographic characteristics of age, education,
marital status, years married, income, and religion. To
control for these effects, infertility-related health vari-
ables (type of infertility, treatment duration, and type of
treatment) were entered next, followed by belief vari-
ables (consequence, illness coherence, and personal con-
trol). The rationale was to examine whether each belief
contributed signicantly to each psychosocial health out-
come, over and above the inuence of sociodemographic
and infertility-related health characteristics.
Results
Sample Characteristics
The majority of participants were natives of southern
Ghana, between the ages of 30 and 39 years, and had
high school or higher education. More than half (62%)
of the women had a monthly income of 300 cedis ($200).
The majority of the women (87%) were married, and
85% were in monogamous marriages. Ninety-one per-
cent were Christians (Table 1).
Nearly three fourths (72%) of the women had sec-
ondary infertility by self-report of prior pregnancies,
and 28% had primary infertility. Thirty-seven percent
had children, with 79% having one child. The majority
(76.6%) of the women reported receiving medical treat-
ment, 8.9% reported using traditional treatment, and
1.6% reported using both. The duration of medical treat-
ment was 1 year or less for 57%, 2 to 3 years for 27%,
and 4 or more years for 16%. About 50% of the women
were recruited from each of the two hospitals.
Beliefs and Psychosocial Health
Table 2 summarizes the descriptive statistics for beliefs
and psychosocial health. The mean scores for the FBQ
subscales indicate that the women believed there are neg-
ative consequences to self and family as a result of infer-
tility, that they had a poor understanding of their infer-
tility, and that they believed there was something they
could personally do to control their infertility. Women
reported high levels of infertility-related stress, low lev-
els of anxiety, some social isolation, low levels of per-
ceived stigma, and high levels of depressive symptoms.
Using the criteria described by Kaharuza and colleagues
(2006), 29% (n = 59) were categorized as not depressed,
18% (n = 36) as distressed, and 53% (n = 108) as at risk
for clinical depression.
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Infertility Beliefs Naab et al.
Table 1. Sociodemographic Characteristics
Variables Frequency Percent
Age in years
1829 60 29.6
3039 121 59.6
4049 22 10.8
Level of education
Primary 6 (6th grade) 27 13.3
Junior secondary school (middle school) 39 19.2
Senior secondary school (high school) 79 38.9
Bachelors degree 53 26.1
Masters/PhD 5 2.5
Monthly income
100300 cedis ($200) 123 61.8
400600 cedis ($360) 50 25.1
700900 cedis ($610) 9 4.5
1,000 cedis and above ($670 and above) 17 8.5
Missing values 4 2.0
Marital status
Married 177 87.2
Not married 26 12.8
Duration of marriage
112 months 32 17.4
23 years 55 29.9
410 years 78 42.4
11 years and above 19 10.3
Not applicable 15 7.4
Missing values 4 2
Type of marriage
Monogamous 171 85.1
Polygamous 19 9.5
Not applicable 11 5.5
Missing values 2 1
Religion
Christianity 185 91.1
Islam 18 8.9
Country location
Northern Ghana 31 15.6
Southern Ghana 168 84.4
Table 2. Descriptive Statistics for Beliefs and Psychosocial Health Vari-
ables
Cronbachs
[composite Minimum
Variables reliability] maximum Mean SD
Consequence [0.79] 05 2.49 1.21
Illness coherence [0.71] 05 3.21 1.53
Personal control [0.75] 05 3.44 0.99
Infertility-related stress (FPI) 0.88 1276 174.65 30.71
Anxiety (BAI) 0.86 063 14.53 10.99
Social isolation (FS) 0.66 024 16.22 4.75
Perceived stigma (SSRPH) 0.76 015 5.15 3.68
Depressive symptoms (CES-D) 0.86 060 23.00 11.48
Note. FPI = Fertility Problem Inventory; BAI = Becks Anxiety Inventory;
FS =Friendship Scale; SSRPH =Stigma Scale for Receiving Psychological
Help; CES-D =Center for Epidemiologic Studies for Depression Scale.
Relationships Between Beliefs and Psychosocial
Health Problems
There were small to moderate signicant (p < .01)
correlations between consequence and infertility-related
stress (r = 0.49), social isolation (r = 0.21), and de-
pressive symptoms (r = 0.36). There were signicant but
small (p < .05) correlations between illness coherence
and infertility-related stress (r = 0.19), social isolation
(r = 0.19), and depressive symptoms (r = 0.27), and
between personal control and anxiety (r = 0.23).
Table 3 shows the results of the regression mod-
els for each psychosocial outcome. Only the results for
the nal model are reported. After taking into account
the inuence of sociodemographic and infertility-related
health variables, beliefs accounted for a signicant ad-
ditional proportion of the variance in infertility-related
stress (21%), anxiety (8%), social isolation (6%), per-
ceived stigma (5%), and depressive symptoms (11%). A
belief in negative consequences was a signicant predic-
tor of all ve psychosocial health outcomes. Belief that
one has a poor understanding of infertility was a signif-
icant predictor of infertility-related stress, and belief in
personal control over infertility was a signicant predictor
of anxiety and perceived stigma. Only a few sociodemo-
graphic and infertility-related health variables were sig-
nicant predictors. Lower levels of education predicted
higher levels of stress. Being married predicted higher
stress but less perceived stigma, while length of marriage
was related to less social isolation. Being in treatment
longer predicted less social isolation, but using alternative
treatments was associated with depression.
Discussion
This is the rst theoretically based study of womens
beliefs about infertility and their psychosocial health in
Africa and in Ghana. Infertile Ghanaian women reported
high levels of infertility-related stress, low levels of anx-
iety, some social isolation, some perceived stigma, and
high levels of depressive symptoms. Consistent with the
CSM, womens beliefs about infertility accounted for a
signicant proportion of the variance in their psychoso-
cial health, over and above what is explained by sociode-
mographic and infertility-related health characteristics.
Believing that there are negative consequences of infertil-
ity was associated with higher levels of infertility-related
stress, anxiety, social isolation, perceived stigma, and de-
pressive symptoms. Conversely, beliefs that one has per-
sonal control were associated with lower levels of anxiety
and perceived stigma. Believing that ones understanding
of infertility is poor was associated with higher levels of
infertility-related stress.
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Naab et al. Infertility Beliefs
Table 3. Results of Regression Models Testing the Relationship Between Sociodemographic and Infertility-related Health Characteristics, Beliefs, and
Psychosocial Health Variables
Variables Stress Anxiety Social isolation Stigma Depression
Age 0.06

(0.15) 0.07 (0.07) 0.05 (0.19) 0.07 (.11) 0.01 (2.89)

Education 0.16

(0.11) 0.01 (0.05) 0.30 (0.04) 0.09 (0.08) 0.08 (1.98)

Marital status 0.21

(0.14) 0.07 (0.06) 0.09 (0.19) 0.01 (0.11) 0.14 (2.72)

Years married 0.19

(0.09) 0.02 (0.04) 0.05 (0.12) 0.09 (0.07) 0.06 (1.79)

Income 0.03 (0.15) 0.09 (0.06) 0.12 (0.19) 0.11 (0.11) 0.04 (2.75)
Religion 0.11 (0.16) 0.04 (0.07) 0.01 (0.21) 0.11 (0.12) 0.01 (3.09
R
2
change 0.14

0.03 0.04 0.05 0.04

Type of infertility 0.03 (0.11) 0.09 (0.05) 0.05 (0.14) 0.04 (0.08) 0.01 (1.99)
Treatment duration 0.08 (0.14) 0.02 (0.06) 0.19

(0.18) 0.18

(0.10) 0.08 (2.55)

Type of treatment 0.18

(0.11) 0.07(0.05) 0.05 (0.14) 0.03 (0.08) 0.21

(2.06)
R
2
change 0.04

0.01 0.04 0.03 0.05

Consequences 0.34

(0.04) 0.27

(0.02) 0.18

(0.06) 0.19

(0.03) 0.32

(0.83)
Illness coherence 0.27

(0.03) 0.18 (0.02) 0.12 (.05) 0.12 (0.03) 0.06 (0.69)

Personal control 0.04 (0.04) 0.18

(0.02) 0 .07 (.06) 0.15

(0.04) 0.06 (0.85)

R
2
change 0.21

0.08

0.06

0.05

0.11

Total R
2
0.396

0.120

0.136

0.123

0.197

Note. Standard errors are reported in parentheses.

p <.05,

p <.01.
Findings from this study are consistent with the litera-
ture in some ways and inconsistent in others. Research
on infertility-related stress among women in Africa is
not common. The only previous quantitative study of in-
fertility in Ghana (Donkor & Sandall, 2007) found that
infertility-related stress was higher among less educated
women. Similar results were found in the present study.
On the other hand, both Fatoye, Owolabi, Eegunranti,
and Fatoye (2008) and Upkong and Orji (2006) found
high levels of anxiety among infertile Nigerian women,
which was not found in this study. One possible expla-
nation for the low levels of anxiety may be the womens
beliefs that they had personal control of their infertility.
Further research is needed to understand this.
Previous reports on high levels of social isolation
among infertile women in Africa have been qualitative
(Gerrits, 1997; Runganga et al., 2001). This study found
that women reported some, but not high levels of so-
cial isolation. Further, women who were married longer,
were in treatment longer, and had fewer negative be-
liefs about the consequences of infertility were less likely
to report being socially isolated. This may reect having
stronger social support networks. Further research on so-
cial isolation among African infertile couples is needed to
understand the relationships between beliefs, social iso-
lation, and other psychosocial health factors that might
suggest avenues for intervention. Findings related to per-
ceived stigma in this study were different from those in
the literature, although most previous research has been
qualitative. However, in one quantitative study, 23% of
Ghanaian infertile women experienced moderate levels
of perceived stigma, and 41% experienced severe per-
ceived stigma (Donkor & Sandall, 2007). In the present
study, the women had low mean scores for perceived
stigma. One explanation may be that the women who
participated in the present study were all seeking medical
treatment and were willing to participate in a study about
fertility problems, suggesting that they were women who
perceived less perceived stigma or were less concerned
with infertility-related stigma. On the other hand, beliefs
about consequences and personal control of infertility ex-
plained how much perceived stigma they reported.
High levels of depressive symptoms among infertile
African women have been reported in a few studies, but
none examined possible correlates (Fatoye et al., 2008;
Upkong & Orji, 2006). A number of factors were as-
sociated with higher levels of depressive symptoms in
this study, including beliefs about consequences and us-
ing traditional along with medical forms of treatment.
Women may be motivated to try more treatments be-
cause they had stronger beliefs about negative conse-
quences, as predicted by the CSM. On the other hand,
women with more depressive symptoms may have been
more likely to perceive negative consequences (as part of
a depressive pattern of thinking) and to seek out more al-
ternative treatments to relieve their distress. Longitudinal
data are needed to untangle these relationships.
Limitations
There are four main limitations in this study. First,
given the cross-sectional design, it is not possible to
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Infertility Beliefs Naab et al.
sort out any cause-and-effect relationships between be-
liefs and psychosocial health outcomes. Second, only
clinic-based participants were recruited; thus, the nd-
ings should not be generalized to those who do not seek
treatment (Greil, Slauson-Blevins, & McQuillan, 2010).
However, in Ghana, where childbearing is highly val-
ued among women, this clinic-based sample has provided
some information about Ghanaian infertile women,
about whom little is known. Third, many of the measures
had not been used in Ghana. However, measures were
chosen that had some evidence of validity and reliability
in infertility research whenever possible. Fourth, because
the design was an anonymous survey, only self-report
data were used. Therefore, no information was available
on the womens medical history and treatments for infer-
tility, nor what women had been told about their infertil-
ity, nor any prior history of psychosocial health problems,
such as anxiety and depression. Knowing the medical his-
tory might have helped to explain womens beliefs and
psychosocial health problems.
Implications
Findings of this study have some implications for nurs-
ing care of infertile women in Ghana. Womens beliefs,
especially beliefs about the consequences and perceiv-
ing lack of understanding of their infertility, may be im-
portant targets for patient education, particularly since
both are associated with poorer psychosocial health in
this study. Women in this study believed they lacked a
clear understanding of their infertility even though they
were pursuing medical treatment. Nurses can do better by
providing accurate medical information about infertility.
Research on nursing interventions that are partly based
on the Common Sense Model, such as the representa-
tional approach to patient education (Donovan & Ward,
2001; Donovan et al., 2007; Lauver et al., 2002), suggests
that addressing and changing inaccurate beliefs is possible
and can lead to more effective coping and better health
outcomes (Song, Kirchhoff, Douglas, Ward, & Hammes,
2005; Ward et al., 2008).
Findings of this study have shown that a majority of
women with fertility problems in Ghana were at risk
for clinical depression, even after using the higher cut-
off scores for screening proposed for African cultures.
Providing mental health care for women with fertility
problems in Ghana is obviously needed. However, men-
tal healthcare providers need to be mindful about is-
sues of stigma associated with mental health diagnoses
in Ghana, especially when mental health intertwines
with infertility. Nurses need to create a safe space for
clients to acknowledge the impact of infertility on their
mental health and help women learn effective coping
strategies.
This study explored beliefs of women seeking treat-
ment for fertility problems. Little is known about the be-
liefs of women with fertility problems who are either not
seeking treatment or are only seeking treatment from al-
ternative sources. Future research comparing those who
seek treatment with those who do not might shed fur-
ther light on the relationships among beliefs, coping, and
health outcomes for infertile women.
Mens beliefs about infertility may be different from
womens and may inuence womens health outcomes.
Examining couples beliefs is therefore important. Cul-
tural differences may also be at play. For instance, there
are cultural differences between people from northern
and southern Ghana, which may inuence womens be-
liefs about infertility. These cultural differences were not
examined in the present study. Finally, the CSM posits
that the beliefs people have about their health problems
inuence the strategies they use to cope with the health
problem. The relationship between beliefs and coping was
not examined in this study.
Conclusions
The CSM has been used as an organizing framework
to study a variety of health problems, but not infertility
until now. Findings from this study suggest that infertile
women in Ghana have psychosocial health problems that
are associated with their beliefs about infertility and con-
sistent with some of the constructs of the CSM.
Understanding Ghanaian womens beliefs provides the
basis for informing and changing nursing practice with
infertile women, health policy related to infertility treat-
ment in Ghana, and the need for future research in this
area.
Clinical Resources
r
MGH Center for Womens Mental Health: www.
womensmentalhealth.org/
r
Resolve The National Infertility Association: www.
resolve.org
r
Finding a Resolution for Infertility Support
Community: www.inspire.com/groups/nding-a-
resolution-for-infertility/
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