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• W4387398573 abstract "INTRODUCTION Infertility is regarded as “a disease of the reproductive system, defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.”[1] Recent global surveys suggest about 9%–10% global infertility prevalence with increasing trends in both high and low-income countries.[2-4] Over 48 million couples are infertile globally,[4,5] and males contribute up to 50% of all instances globally.[6] The highest rates of infertility are found worldwide in Sub-Saharan Africa and Southeast Asia. Prevalence in Sub-Saharan Africa is 12.5%–16%,[6] with Nigeria having a 20%–35% prevalence.[7,8] Aside from being a medical condition, infertility is a known chronic stressor with severe psychological and negative social consequences.[9] The struggle with infertility may be accompanied by negative emotions, feelings of loss, shame, sadness, self-blame, etc.[10,11] all amounting to a psychological burden and discontinuation of treatment as a consequence.[12,13] Empowerment has been defined as “a process through which people gain greater control over decisions and actions affecting their health and as such, individuals and communities need to develop skills, have access to information and resources, and the opportunity to participate in and influence the factors that affect their health and well-being.”[14] It has also been described as a process that can increase a patient or learner’s autonomy and capacity to make informed decisions, rather than increasing the learner’s compliance with instructions.[15] Empowerment is a multi-dimensional construct and has been linked to other concepts such as self-efficacy, knowledge about a patient’s disease and treatment, patient’s involvement in the treatment process, and to a lesser extent, it is linked to concepts such as locus of control, self-esteem, powerlessness, helplessness, response efficacy, and assertiveness.[16] Patient empowerment is a major attribute of good quality care and it can enable patients to adopt an active role in decision-making by providing them with needed information, necessary tools, and autonomy.[17] In addition, current health policy focuses on long-term health conditions with a high priority placed on self-management and patient participation, which are a few of the empowerment roles.[18,19] Some studies have established the beneficial effects of empowerment in individuals with severe illnesses concerning better clinical outcomes, patient satisfaction with care, and patient adherence to self-management.[20,21] Thus, the concept of empowerment may have relevant applications in the management of infertility as a long-term health condition. More importantly, the established rigors of fertility treatments necessitate further exploration and application of this concept to enable patients and healthcare providers to achieve better outcomes. Considering the multi-dimensional nature of the empowerment construct, this study is based on the Patient Empowerment Framework in Long-Term Health Conditions,[22] which describes empowerment as a means of enhancing a patient’s self-efficacy, sense of control, coping mechanisms, and capacity to affect change in their condition. According to the framework, both internal and external processes characterize the empowering process. The internal process includes accepting the diagnosis, admitting the unchangeable, developing a feeling of balance, creating cognitive strategies, and acquiring or restricting medical information access. Whereas the external process requires relationships in which the physician, health staff, and friends provided support and understanding, all leading to five observable outcomes—identity, knowledge, control, decision-making, and supporting other patients with long-term conditions.[22] This study therefore aimed to investigate the extent and determinants of empowerment among patients undergoing treatments for infertility at the University of Port Harcourt Teaching Hospital. The specific objectives are to assess the perception of personal identity, to determine the level of knowledge of infertility, determine the level of personal control, assess the extent of involvement in the decision-making process in patients, assess the extent of peer support among patients, and explore the factors associated with the level of empowerment among patients undergoing treatment for infertility at the University of Port Harcourt Teaching Hospital. MATERIALS AND METHODS This was a descriptive cross-sectional study of infertile patients attending the gynecology clinic and assisted conception unit of the University of Port Harcourt Teaching Hospital, a tertiary health facility in Port Harcourt, Rivers State, Southern Nigeria. Ethical approval was obtained from the Research Ethics Committees of the University of Port Harcourt and the University of Port Harcourt Teaching Hospital with an approval number (UPH/CEREMAD//REC/MM84/021). Data collection was done between September and November 2022. The sample size was determined using Cochran’s sample size formula for proportions, n = Z2pq/e2,[23] where n is the minimum sample size, Z is the standard normal deviate corresponding to the level of significance, p is the proportion of empowered patients from a previous study,[24]q is the difference when p is subtracted from 1 (q = 1 – p), e is the margin of error and the level of precision was set at 95% confidence level. A 10% non-response rate was considered in arriving at a final sample size of 146. The sample size was allocated proportionately to both clinics based on attendance and a systematic random sampling process was used to select a total of 146 participants for interviews. Each participant filled out a self-administered questionnaire that included socio-demographic information and items across five empowerment domains (personal identity, knowledge, personal control, decision-making, and enabling others). A validated tool which measures empowerment across five domains was used in this study. This tool assesses empowerment in patients living with long-term conditions. Patient empowerment was measured in five dimensions namely: identity, knowledge, personal control, decision-making, and enabling others.[22] The instrument was tested for reliability by computing the Cronbach’s alpha coefficient for each of the 5 domains and the entire empowerment scale. This measure of internal consistency was achieved with 20% of the calculated sample size during the pretest of the instrument. Data analysis was done with the Statistical Package for the Social Sciences (SPSS) version 23. IBM SPSS Inc, Armonk, New York, USA. Categorical data were presented in the form of frequencies and percentages (%) and summary statistics in means and standard deviations (SD), using tables and charts to display the results. Ordinal data from Likert scales were scored and the median score was calculated for each item. Chi-square test analysis and logistic regressions were used to test for relationships between two categorical variables and their proportions (%) as well as to determine the degree of statistical significance between the linked variables. The P value for an observation is considered statistically significant if it is 0.05 or less at a 95% confidence level. RESULTS Internal consistency for overall empowerment was α = 0.90 (Cronbach’s alpha) and the five domain: identity (α = 0.862), knowledge, and understanding (α = 0.765), personal control (α = 0.889), decision making (α = 0.802), and enabling others (α = 0.886) [Table 1]. The socio-demographic information shows that the minimum age of the study participants was 20 years while the maximum was 49 years with a mean age of 36.40 ± 5.92 years [Table 2]. Those within the age range 30–39 years had the highest proportion of 90 (61.64%), followed by those within the age range 40–49 years, 43 (29.4%). The least were those within the age range 20–29 years, 13 (8.90%). All study participants were females 146 (100%) and the majority are married, 138 (94.52%) whereas the rest, 8 (5.48%) are single. The majority of participants had postgraduate degrees, 114 (78.08%), followed by those with a graduate degree, 27 (18.49%). Those with primary and secondary education are the lowest with 3 (2.05%) and 2 (1.37%) respectively. For occupation, 64 (43.84%) are employed while 82 (56.16%) are unemployed.Table 1: Scale reliabilityTable 2: Sociodemographic characteristicsAs regards the pregnancy history of the participants [Table 3], 116 (79.45%) of the participants have been pregnant before whereas 30 (20.55%) have never been pregnant [Table 4]. Of those who have once been pregnant, 57 (46.34%) have living children while 66 (53.66%) do not.Table 3: Pregnancy historyTable 4: Mean scores of empowerment items scores across domains84 (57.5%) of participants have been trying to get pregnant for 1 to 5 years, 45 (30.8%) have tried for 6–10 years, 11 (7.5%) tried for 11–15 years, while 6 (4.1%) have tried getting pregnant for 16–20 years. As for knowledge of the cause of infertility, 44 (30.14%) know about the cause of their infertility while 102 (69.86%) of the participants do not. For the known causes of infertility, polycystic ovarian syndrome (PCOS) was the most prevalent known cause of infertility, 13 (29.55%), followed by tubal occlusion, 9 (20.45%) and fibroid, 6 (13.64%). Both amenorrhea and azoospermia each have a prevalence of 4 (9.09%), endometriosis and tubal removal each has a prevalence of 2 (4.55%) whereas the least prevalence includes ovarian cancer, stress-related, adenomyosis, and age-factor [1 (2.27%) each]. Mean scores were computed for the 50-scale items across five domains (personal identity, knowledge, personal control, decision making and enabling others). A mean score between 1 and 3 is considered poor whereas a mean score between 4 and 5 is considered very good. Mean scores of items closer to 4 (3.5 above) may be considered good. Generally, the mean scores across all items show a good level of empowerment among all participants [Table 4]. 10 out of 50 items have mean scores above 4 [see Table 4]. Personal Identity domain has two items with mean scores below 3: “I accept that I have to live with my condition” (2.92 ± 1.39), and “I find my health problems take over my life” (2.06 ± 1.07) [Table 4]. The knowledge domain showed a mean score above 3 for all 11 items [Table 4]. Personal Control has one item below the mean score of 3, “I’m not bothered about understanding health information” (2.97 ± 1.19) [Table 4]. Decision-making and Enabling others both have mean scores above 3 [Table 4]. As regards the empowerment domains, Personal control had the lowest mean score (3.21 ± 0.98) [Table 4], whereas Personal Identity has the highest score (3.98 ± 0.86) [Table 4]. Responses to the Likert scale questions were scored 3 (agree) or 4 (strongly agree) for the correct response by the participant and 1 (strongly disagree), 2 (disagree) or 3 (undecided) for the wrong response. The majority of the participants (82.19%) 120 have a good or positive perception of their identity, good knowledge was more prevalent (76.03%) 111, while more participants have poor personal control (51.37%) 75 [Figure 1]. Most participants are well involved in decision-making in their treatment (89.04%) 130, while the majority (80.82%) expressed good sensitivity to others [Table 5].Figure 1: Level of personal controlTable 5: Pattern of empowerment dimensionsWe computed overall empowerment and most participants (84.93%) 124 were found to be empowered in this study [Figure 2]. After performing chi-square and logistics regression to determine factors associated with the level of empowerment, only tertiary education was found to be statistically significant (P = 0.035) [Table 6].Figure 2: Level of empowermentTable 6: Factors associated with the level of empowermentDISCUSSION In this study, patients receiving infertility treatments at the University of Port Harcourt Teaching Hospital (UPTH) were evaluated to ascertain their level of empowerment. Infertility is a major public health concern with high and rising prevalence. Patient empowerment is considered an important element for improving health outcomes, health system performance, and satisfaction as it can bring about better communication between patients and health professionals, better adherence to treatment regimens, and reduce the use of health services and health care costs.[25] Empowerment is a multi-dimensional construct and, in this study, it was assessed across five dimensions (personal identity, knowledge, personal control, decision making and enabling others). Findings show that most participants (82.19%) have good personal identity, implying they all have a good perception of “self” despite their condition. Their perception of good or positive identity may also reflect how they have been able to adapt to managing their condition. This is in line with a study by Zargham-boroujeni et al.,[26] where participants emphasized their need for a sense of value, self-esteem, respect and dignity, and social position, stating that meeting those needs would help them handle the difficulties and stress associated with infertility and its treatment more effectively, thus making them feel more empowered. However, some other studies have highlighted poor/negative identity in patients undergoing fertility treatments, commonly expressed as low self-esteem, depression, shame, and self-judgement.[27,28] Personal identity has the highest mean score (3.98 ± 0.86) among the other empowerment domains. Two scale items in the Personal Identity domain: “I accept that I have to live with my condition” (2.92 ± 1.39), and “I find my health problems take over my life” (2.06 ± 1.07) have low mean scores and may indicate that majority of the participants despite their condition, still find it difficult to accept the reality of their condition. Acceptance describes the extent to which individuals accept a disease condition as a part of their identity, separate from other social roles and identity assets.[29] This notion may be further supported by Megari,[30] who asserted that lowering the benefits of engaging in worthwhile activities and feelings of personal control may negatively impact psychosocial well-being. Most participants (76%) have good knowledge of their condition with a relatively good mean score (3.73 ± 0.83). This may be due to gained autonomy which facilitates their interaction with health staff and inspires their participation in formal and informal knowledge-seeking activities, for example, accessing health-related or infertility-related information through the Internet. This is supported by a study by Steinmetz et al.[31] who identified interaction with health staff and access to digital-related health information as possible patient knowledge enablers. However, the question, “I’m not bothered about health information” had the lowest responses on “agree” (21.23%) and “strongly agree” (8.22%) Likert scales, respectively, and also the lowest mean score and standard deviation within this domain (mean = 2.52 ± 1.26). This may infer a poor understanding of the treatments being offered to the participants and may indicate the participants’ desire to have a better understanding of the treatments they are being offered. A positive identity and high self-esteem may also be an enabler of patients’ knowledge and understanding. Patient empowerment was found to raise the threshold of patient self-esteem which could serve as a facilitator of patient knowledge because a patient’s awareness that she/he has adequate knowledge and can apply it, determines their confidence in the treatment, which directly influences the effectiveness of the treatment.[32] More participants in this study are found to have poor personal control (51.37%) over their condition [Figure 1]. This is further confirmed by a low mean score in this domain (3.21 ± 0.83). The item, “I am capable of managing my condition” had the lowest mean score within the domain (mean = 2.97, SD = 1.94), and the “agree” (30.82%) and “strongly agree” (8.90%) Likert scales. The reason for poor personal control could be explained by various factors. First, it may be due to poor or lack of coping strategies among the participants. This is similar to a study by Mohammadi et al.[33] which showed that most infertile women scored lower in coping strategies compared to men. This may also be explained by the fact that infertility poses a greater social burden in women compared to men. Furthermore, poor personal control among participants may be a result of the lack of self-management strategies. According to Novak et al.[34] self-management includes addressing the psychosocial effects of an illness and increasing it has been shown to improve quality of life, coping, symptom management, disability, and reduce healthcare costs and service consumption. In addition, poor personal control may be due to the effect of the stress of infertility in couple relationships. Some studies show that how partners cope may affect the other’s distress level and ability to cope with strains of infertility and its treatments.[35] Involvement in the decision-making process has the highest prevalence across all the empowerment domain, as the majority of the participants (89.04%) are well involved in decision-making regarding their care and treatment. This may also be explained by the high level of knowledge. According to Vainauskienė and Vaitkenė,[36] identifying current knowledge, acquiring new knowledge, developing it, and communicating it with stakeholders in the ecosystem may help to make successful disease management decisions since people are actively participating in decision-making regarding their health. Accordingly, the level of involvement in shared decision-making may be attributed to the availability of clear information on the nature of the disease and the treatment options, requirements for medical success, risks, and side effects, as well as reasonable treatment alternatives, their risks, and potential consequences if the best options are not chosen.[36] This study has also shown that most participants (80.80%) can enable or motivate others with similar conditions. Across all seven of this domain, the prevalence of respondents was above 50% when the percentages of the “agree” and “strongly agree” Likert scales were combined. Mean scores across all domain items were above 3. Enabling others describes the extent to which patients experience sensitivity to others and a desire to motivate others.[22] The high enabling capacity seen in the study participants may be due to their perception of similarity with other patients. Some studies show that people are more attracted to, trust and understand one other when perceived resemblance exists than when perceived similarity does not exist.[37,38] After testing for an association, educational level (tertiary) was the only factor found to be associated with empowerment (P = 0.035). This may be because empowerment is more of a psychological concept and most of its predictors are psychosocial. A study showed that patients with higher educational levels significantly scored lower in overall self-stigma—a component of the personal identity empowerment domain.[39] Education was found to be the most effective indicator of self-stigma. A similar study[40] shows that women with academic qualifications scored the highest psychological and mental quality of life. This finding may thus, explain the prevalence of positive personal identity from the study. Educational level may also have been responsible for the good level of knowledge as seen in this study. CONCLUSION Findings from this study suggest that the majority of patients from this study are empowered, however, only in some empowerment domains. The poor personal control seen among participants suggests the need for effective coping strategies in infertile patients. Also, the results of the overall mean empowerment score and mean scores of the domains indicate the need for more improvement across all the empowerment domains. The empowerment concept has been found beneficial in self-management, satisfaction with care and improving clinical outcomes, and could be well applied in the management of infertility. This study adds to the body of evidence about empowerment as an essential paradigm and approach in clinical care, particularly in the treatment of patients with long-term conditions like infertility. Study limitations This study is one of the earliest to examine “psychological empowerment” in patients undergoing treatments for infertility within the study area. However, it may have failed to consider other patient traits that could have predicted empowerment. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest." @default.
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• W4387398573 title "Are infertile patients empowered? An assessment of patients undergoing infertility treatments in a tertiary health facility in the Niger delta" @default.
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