Investigating the Relationships among Stressors, Stress Level, and Mental Symptoms for Infertile Patients: A Structural Equation Modeling Approach

RESEARCH ARTICLE Investigating the Relationships among Stressors, Stress Level, and Mental Symptoms for Infertile Patients: A Structural Equation Modeling Approach Jong-Yi Wang1, Yi-Shan Li2☯, Jen-De Chen3☯, Wen-Miin Liang4, Tung-Chuan Yang5, Young-Chang Lee6, Chia-Woei Wang7* 1 Department of Health Services Administration, China Medical University, Taichung, Taiwan, 2 Department of Business, Chungyo Department Store, Taichung, Taiwan, 3 Office of the President, National Changhua University of Education, Changhua, Taiwan, 4 Graduate Institute of Biostatistics, China Medical University, Taichung, Taiwan, 5 Reproductive Medicine Center, Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan, 6 Reproductive Medicine Center, Yuan's General Hospital, Kaohsiung, Taiwan, 7 Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan OPEN ACCESS Citation: Wang J-Y, Li Y-S, Chen J-D, Liang W-M, Yang T-C, Lee Y-C, et al. (2015) Investigating the Relationships among Stressors, Stress Level, and Mental Symptoms for Infertile Patients: A Structural Equation Modeling Approach. PLoS ONE 10(10): e0140581. doi:10.1371/journal.pone.0140581 Editor: Kenji Hashimoto, Chiba University Center for Forensic Mental Health, JAPAN Received: June 20, 2015 Accepted: September 27, 2015 Published: October 20, 2015 Copyright: © 2015 Wang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: This research was supported by Taiwan National Science Council (http://www.most.gov.tw/mp. aspx?mp=7) Grant No. NSC100-2410-H-039-003SS2 and NSC102-2410-H-039-006-SS2 (JYW). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. ☯ These authors contributed equally to this work. * Abstract Objective Patients with infertility are a high risk group in depression and anxiety. However, an existing theoretically and empirically validated model of stressors, stress, and mental symptoms specific for infertile patients is still a void. This study aimed to determine the related factors and their relational structures that affect the level of depressive and anxiety symptoms among infertile patients. Methods A cross-sectional sample of 400 infertility outpatients seeking reproduction treatments in three teaching hospitals across Taiwan participated in the structured questionnaire survey in 2011. The hypothesized model comprising 10 latent variables was tested by Structural Equation Modeling using AMOS 17. Results Goodness-of-fit indexes, including χ2/DF = 1.871, PGFI = 0.746, PNFI = 0.764, and others, confirmed the modified model fit the data well. Marital stressor, importance of children, guiltand-blame, and social stressor showed a direct effect on perceived stress. Instead of being a factor of stress, social support was directly and positively related to self-esteem. Perceived stress and self-esteem were the two major mediators for the relationships between stressors and mental symptoms. Increase in social support and self-esteem led to decrease in mental symptoms among the infertile patients. PLOS ONE | DOI:10.1371/journal.pone.0140581 October 20, 2015 1 / 17 Stressors, Stress Level, and Mental Symptoms for Infertile Patients Conclusions The relational structures were identified and named as the Stressors Stress Symptoms Model, clinically applied to predict anxiety and depression from various stressors. Assessing sources and level of infertility-related stress and implementing culturally-sensitive counseling with an emphasis on positive personal value may assist in preventing the severity of depression and anxiety. Introduction The trend toward fewer children has been very severe in most of the industrialized countries and also in many developing countries [1, 2]. The total fertility rate (TFR) of Taiwan in 2010 was 0.90, ranked the lowest in the world, and averaged 1.07 in the recent 5 years [1, 3]. The occurrence of infertility is believed to impact on TFR [4]. Nevertheless, numerous individuals with infertility are still seeking reproduction treatments, striving for the chance of conception. Therefore, healthcare organizations worldwide face an imperative shared challenge of caring and treating infertile patients, which carries the implications of health promotion. Infertility is an escalating health issue, affecting more than 10% of couples globally [4, 5]. The experience of infertility is highly stressful for individuals in the duration of infertility [6]. Patients diagnosed with infertility and individuals involved would undergo substantial psychological stress, although varied, during the treatment process [7]. Psychological stressors implicated in the infertility experience involve negative self-image, sense of guilt and self-blame, and other psychosocial factors [8–11]. Consequently, mental symptoms might emerge among people under this stressful condition. Existing literature further identified depression and anxiety as two of the most frequent mental disorders among patients with infertility [7, 10, 12–14]. Compared with fertile counterparts, infertile patients showed higher or approximately double of the odds of psychological distress, making them a vulnerable population [7, 15]. More specifically, the overall prevalence rate of depression among infertile couples reported by a metaanalysis study was 47% [16]. Seeing that stress and even mental illness are a widespread and costly problems [17] especially for individuals with infertility, mental disease prevention and well-being advancement have become critical. From another perspective, since findings from previous research asserted that emotional conditions was a predictor of treatment outcome for in vitro fertilization/embryo transfer technology (IVF/ET) [18], a concern for psychological well-beings hence delivers clinical implications in infertility medicine. Study of stress may comprise stressors (source of stress) [19] and stress reactions [20]. In addition to the aforementioned possible stressors, research revealed that infertility-related factors including perceived importance of children, social stressor, and marital stressor might expose infertile individuals to a high stress level [6, 21, 22]. The stressors described so far could be conceptually categorized into personal (i.e. importance of children, guilt-and-blame, etc.), marital, and social ones, concluded from prior research [21]. Study further indicated that selfconcept acted as a mediator in the relationship between social support and depressive symptoms [23]. Hence, it can be presumed that self-esteem is (...truncated)