Setting. The site for this study is the In Vitro Fertilization Center at the King Abdullah University Hospital within the Jordan University of Science and Technology in Irbid. Over 22,000 patients utilize these sites annually for fertility services.
Sample. Couples residing in Jordan who had been married at least 2 years and who were seeking services for primary infertility (having unprotected sex for at least 1 year without conception) or secondary infertility (having unprotected sex for at least 1 year subsequent to a birth or abortion) at the study clinic were eligible to participate and were recruited by a physician practicing in the clinic. Forty-two couples were surveyed at baseline. These potentially eligible individuals underwent an intake evaluation by a psychologist to assess mental health needs. Thirty-eight couples were deemed in need of mental health support and therefore eligible for the intervention. Eight couples were not able to be subsequently contacted (phone disconnected, no answer). Of the remaining 30 couples, six refused to participate. Of the 24 couples who agreed to participate in the group sessions, 16 attended more than 1 session (53% of the contactable sample, 42% of the entire eligible sample). The analytic sample includes baseline and endline data on all wives and 15 husbands as 1 husband was unavailable for the endline survey.
Intervention. Eleven gender-segregated CBT sessions were delivered per group (2 groups of men, 2 group of women). All four groups convened simultaneously on the same day. The sessions were held once a week with each session lasting between one and a half to two hours. Session focus areas included: 1) group norms and goal-setting; 2) understanding psychosocial stress; 3) identification of stressors and impacts on day-to-day life; 4) the impact of self-perception of day-to-day life; 5) expression and safe management of feelings 6) overcoming obstacles to communication; 7) effective communication strategies; 8) questioning assumptions and self-perceptions about problems; 9) problem-solving and strategies for restructuring relationships; 10) development of new approaches to life by removing unfounded anxieties; and 11) highlights of prior sessions and reminders for application in day-to-day life. The sessions were led by psychologists experienced in CBT and were gender-matched to the participants.
Data. Face-to-face surveys were administered to the patients at the clinic site in data collection sessions prior to and 16 weeks after the cessation of group therapy (baseline and endline assessments, respectively). Survey content included sociodemographics, reproductive history, mental health treatment history, symptoms of depression, anxiety, and PTSD, fertility-related quality of life, fertility norms, risk factors for and experience of IPV and in-law abuse (asked of women only), social support, coping, experience with the program, and reactions to survey participation.
Primary Outcomes. Intimate partner violence ever and in the past 12 months was assessed with an augmented version of the World Health Organization’s Multi-Country Study on Women’s Health and Domestic Violence (32) which had been used in prior research in Jordan.(33) Participants reported on their experience of 8 psychological items, 6 physical items and 2 sexual items using a 4-point Likert scale (Never/Once/A few times/Many times). Separate dichotomous variables were created for each subtype with endorsement of any experience within that subset as indicative of abuse. The Cronbach’s alpha for the scale was good (0.92).
Depression and anxiety were assessed with the Hopkins-25 Questionnaire (15-items assessing depression, 10 items assessing anxiety).(34) Items measured the frequency with which the respondent was bothered by each symptom in the past week on a 4-point Likert scale (not at all/a little/quite a bit/extremely) and then averaged together. The scale had a good Cronbach’s alpha for depression (0.86) and anxiety (0.85).
PTSD was measured by items from a scale that was developed and validated in Jordan. Respondents were asked to report whether they experienced 22 symptoms using a 5-point Likert scale (always/often/sometimes/rarely/never). The Cronbach’s alpha for the measure was strong (0.95).
Secondary Outcomes. Quality of life related to fertility was assessed with the 24 core items of the Fertility Quality of Life Scale.(35, 36) The scale includes two additional context questions assessing self-rated health and degree of satisfaction with the respondent’s quality of life. Sub-scales, each with 6 items assess negative emotions (emotional: 6 items), physical symptoms or negative cognitive or behavioral disruptions (mind-body: 6 items), and the impact of infertility on the marital/partner relationship (relational: 6 items) and social interactions (social: 6 items). Each item is scored on a 5-point Likert scale with response scales differing by item; for example, some items used a “very poor” to “very good” scale whereas others used a “not at all” to “completely” scale. Items with a negative valence were reverse coded and averaged together to create the four subscales and total scores, such that higher scores indicated higher quality of life. The Cronbach’s alpha was strong for the total scale (0.92) and was acceptable or good for the emotional (0.90), mind-body (0.84), relational (0.80), and social (0.75) subscales.
Social support was measured with the Arabic version of the Multidimensional Scale of Social Support (Arabic MSPSS).(37) Respondents were asked their level of agreement on a 7-point Likert scale (Very strongly disagree/Strongly disagree/Mildly disagree/Neutral/Mildly agree/Strongly agree/Very strongly agree) to 12 items assessing agreement about support received from family, friends and significant others. The Cronbach’s alpha for the scale was very good (0.97).
Coping was measured with the Brief Resilient Coping Scale.(38) Participants were asked how well each of the 4 items described their situation on a 5-point Likert scale (Does not describe me at all/Does not describe me/Neutral/Describes me/Describes me very well). The Cronbach’s alpha of the scale was good (0.85).
Other Variables of Interest. Sociodemographics assessed included age, date of birth, educational level, participation in paid employment, financial distress, year of marriage, whether the marriage was their first marriage, consanguinity, polygamy, and residence status categorized as nuclear or extended family residence.
The reproductive history module examined history of pregnancy (yes/no), count of total prior pregnancies, whether the respondent is currently trying to become pregnant (yes/no), duration in months of trying to become pregnant, current pregnancy status, number of children alive, type of infertility (primary/secondary), duration of infertility (years), duration of infertility treatment seeking (years), treatments received, and outcome of prior treatment (failed to produce pregnancy, pregnancy that ended in miscarriage, currently pregnant, had a baby).
History of mental health treatment was assessed with 2 items measuring discussions with persons other than family or friends about emotional or psychological issues (yes/no) ever and in the past 12 months (yes/no). If yes, the respondent was asked to identify the person from a list of 9 options (psychologist/psychiatrist/case manager, case workers or outreach worker/ social worker/nurse/physician/religious leader/support group/other).
Norms about infertility were assessed with 12 items (6 individual statements about men and women) developed by the study team based on formative research. Items assessed the extent to which the participant believed people in their community believed the statement on a 4-point Likert scale (most [people in my community] would agree/half would agree, half would disagree/most would disagree/not sure). Cronbach’s alpha for this measure was adequate (0.76).
Abuse from other family members was assessed with 3-items derived from the IPV scale and used in prior research for this purpose.(5) Items assessed the occurrence (yes/no) of emotional violence, physical violence, and encouragement of the respondent’s spouse to use violence against her. For each affirmative response, the respondent was asked to indicate which family member(s) perpetrated the act with 13 options across marital and natal family members.
Survey participation. Reactions to survey participation were assessed with 6 items from the Respondents Reactions to Participation Questionnaire.(39) Items assessed voluntary participation, ability to stop at any time, experience of intense emotions, meaningfulness of the study to themselves and to others using a yes/no format.
Intervention participation and feedback. Degree of participation (none, less than half, about half, most of the session, all of the sessions) was assessed for the participant and spouse along with reasons for less than full participation (not interested, could not miss work, too busy, financial burden, social commitment, spouse refused, and other). The number of sessions that the respondent attended was also reported by the therapist. Open-ended questions were included on the participant survey to obtain feedback on the most helpful intervention content and suggestions for improvement. Reasons provided for participation refusal was systematically documented and feedback was requested from the therapists who delivered the intervention, which was included in a post-intervention report. Finally, the results were shared with a participating clinician for feedback on their relevance to practice in Jordan.
Analysis. Descriptive statistics by gender and time period we calculated. To address research question 3.4, independent-samples t tests and Fisher’s exact tests were conducted to determine similarities at baseline between the full sample (those who provided data at baseline but may or may not have provided data at endline) and analytic sample (those who provided data at endline as well as baseline). Tests were stratified by gender and reported with descriptive statistics in Table 1. To address research questions 3.1–3.3, changes between baseline and endline for primary and secondary outcomes were examined using Wilcoxon signed-rank tests and McNemar’s tests and are reported with descriptive statistics in Table 2. The Wilcoxon signed-rank test is a nonparametric alternative to a paired-samples t test appropriate for small samples, and McNemar’s test is a similar nonparametric test appropriate for paired, dichotomous outcomes. Textual responses to the open-ended survey questions, feedback from the therapists administering the intervention and from the clinician providing the fertility services was summarized thematically to provide insight to improve future administration of the intervention.
Table 1
Baseline Descriptive Statistics for the Full and Analytic Samples
| Full Sample (N = 76) | Analytic Sample (N = 31) | |
Outcome (Range) | Wife (N = 38) M (SD) n (%) | Husband (N = 38) M (SD) n (%) | Wife (N = 16) M (SD) n (%) | Husband (N = 15) M (SD) n (%) | |
Sociodemographics |
Age (23–53) | 31.9 (5.6) | 37.0 (5.6) | 31.6 (6.2) | 36.7 (5.4) | |
Education Primary Secondary Tertiary | 2 (5.3%) 13 (34.2%) 23 (60.5%) | 3 (7.9%) 17 (44.7%) 18 (47.4%) | 1 (6.3%) 8 (50.0%) 7 (43.8%) | 2 (13.3%) 6 (40.0%) 7 (46.7%) | |
Paid Employment | 12 (31.6%) | 36 (94.7%) | 5 (31.3%) | 14 (93.3%) | |
Financial Stress | 25 (65.8%) | 25 (65.8%) | 9 (56.3%) | 12 (80.0%) | |
Years Married (2–19) | 7.9 (4.5) | 8.5 (4.7) | |
First Marriage | 70 (92.1%) | 28 (90.3%) | |
Polygamous Marriage | 2 (2.6%) | 0 (0.0%) | |
Consanguineous Marriage | 26 (34.2%) | 12 (38.7%) | |
Living Situation Nuclear Other | 58 (76.3%) 18 (23.7%) | 21 (67.7%) 10 (32.3%) | |
Reproductive History |
Ever Been Pregnant* | 23 (62.2%) | | 9 (56.3%) | | |
Trying for Pregnancy* | 36 (97.3%) | | 15 (93.8%) | | |
Trying for over a year* | 25 (67.6%) | | 11 (68.8%) | | |
Currently Pregnant Yes Missing | 2 (5.3%) 11 (28.9%) | | 1 (6.3%) 5 (31.3%) | | |
# of Children Alive (0–4) | 1.0 (1.1) | 0.9 (1.0) | |
Infertility Type* Primary Secondary | 28 (75.7%) 9 (24.3%) | | 13 (81.3%) 3 (18.8%) | | |
Infertility Duration* (1–22 years) | 7.3 (5.6) | | 8.4 (5.6) | | |
Tx Duration (0–18 years) | 6.1 (4.8) | | 6.4 (5.2) | | |
Infertility Txs Received* IVF Ovulation Induction Surgery IUIb | 23 (62.2%) 10 (27.0%) 0 (0.0%) 16 (43.2%) | | 10 (62.5%) 2 (12.5%) 0 (0.0%) 7 (43.8%) | | |
Prior Tx Resulted in Birth IVF Ovulation Induction IUIb | 9 (24.3%) 0 (0.0%) 1 (2.7%) | | 3 (18.8%) 0 (0.0%) 1 (6.3%) | | |
Infertility Norms Male Female | 2.5 (0.5) 1.5 (0.5) | 2.2 (0.6) 1.4 (0.5) | 2.5 (0.6) 1.5 (0.5) | 2.0 (0.7) 1.3 (0.4) | |
Fertility Quality of Life |
Total (0–5) | 2.8 (0.6) | 2.9 (0.9) | 2.6 (0.6) | 2.4 (0.9) | |
Mind-body (1–5) | 2.5 (0.9) | 2.8 (1.1) | 2.4 (0.9) | 2.2 (1.0) | |
Emotional (1–5) | 2.5 (0.7) | 2.8 (0.9) | 2.3 (0.6) | 2.3 (0.8) | |
Relational (1–5) | 3.5 (0.8) | 3.4 (0.7) | 3.4 (0.9) | 3.2 (0.5) | |
Social (1–5) | 3.0 (0.8) | 3.1 (0.8) | 3.0 (1.0) | 2.6 (0.6) | |
Mental Health (MH) |
Sought MH Support Ever | 9 (23.7%) | 9 (23.7%) | 4 (25.0%) | 3 (20.0%) | |
In Past Year | 8 (21.1%) | 9 (23.7%) | 4 (25.0%) | 2 (13.3%) | |
Depression (1–4) | 2.6 (0.6) | 2.1 (0.6) | 2.5 (0.6) | 2.5 (0.7) | |
At or above level | 36 (94.7%) | 27 (71.1%) | 14 (87.5%) | 12 (80.0%) | |
Anxiety (1–4) | 2.4 (0.8) | 2.1 (0.6) | 2.4 (0.7) | 2.3 (0.7) | |
At or above level | 30 (79.0%) | 27 (71.1%) | 12 (75.0%) | 12 (80.0%) | |
PTSD (1–5) | 3.3 (0.7) | 3.3 (1.3) | 3.3 (0.8) | 2.7 (1.3) | |
Social Support (1–7) | 5.1 (1.6) | 4.5 (2.0) | 5.8 (1.3) | 3.5 (2.1) | |
Coping (1–5) | 3.7 (0.9) | 3.9 (0.8) | 3.8 (0.9) | 3.8 (0.8) | |
Fear of Spouse (1–5)* | 2.4 (1.3) | | 2.6 (1.6) | | |
Partner and Family Violence in Past 12 Months |
Any IPV Yes Missing | 28 (73.7%) 7 (18.4%) | | 12 (75.0%) 2 (12.5%) | | |
Psychological Yes Missing | 27 (71.1%) 8 (21.0%) | | 12 (75.0%) 2 (12.5%) | | |
Physical Yes Missing | 14 (36.8%) 3 (7.9%) | | 7 (43.8%) 0 (0.0%) | | |
Sexual Yes Missing | 7 (18.4%) 3 (7.9%) | | 1 (6.3%) 1 (6.3%) | | |
Reaction to Participation |
Participated freely Yes Missing | 37 (97.4%) 1 (2.6%) | 35 (92.1%) 2 (5.3%) | 15 (93.8%) 1 (6.3%) | 13 (86.7%) 2 (13.3%) | |
Could stop any time Yes Missing | 12 (31.6%) 1 (2.6%) | 13 (24.2%) 2 (5.3%) | 55 (31.3%) 1 (6.3%) | 7 (46.7%) 2 (13.3%) | |
Intense emotions Yes Missing | 18 (47.4%) 1 (2.6%) | 16 (42.1%) 2 (5.3%) | 6 (37.5%) 1 (6.3%) | 6 (40.0%) 2 (13.3%) | |
Felt meaningful Yes Missing | 5 (13.2%) 2 (5.3%) | 6 (15.8%) 2 (5.3%) | 2 (12.5%) 2 (12.5%) | 3 (20.0%) 2 (13.3%) | |
Results will be useful Yes Missing | 37 (97.4%) 1 (2.6%) | 36 (94.7%) 2 (5.3%) | 15 (93.8%) 1 (6.3%) | 13 (86.7%) 2 (13.3%) | |
Would participate again Yes Missing | 37 (97.4%) 1 (2.6%) | 36 (94.7%) 2 (5.3%) | 15 (93.8%) 1 (6.3%) | 12 (80.0%) 2 (13.3%) | |
Notes: *One participant is missing data in the full sample. Bold values indicate a significant difference (p < .05) between the full and analytic samples at baseline using either an independent-samples t test (for quantitative outcomes) or a Fisher’s exact test (for categorical outcomes). |
Table 2
Endline Descriptive Statistics for Analytic Sample (N = 31)
| Endline Score | Change From Baseline |
Outcomes (Range) | Wife M (SD) n (%) | Husband M (SD) n (%) | Wife M (SD) n (%) | Husband M (SD) n (%) |
Fertility Quality of Life |
Total (0–5) | 3.8 (0.5) | 4.2 (0.5) | 1.2 (0.6) | 1.8 (0.9) |
Mind-body (1–5) | 3.7 (0.8) | 4.0 (0.8) | 1.3 (1.1) | 1.8 (1.2) |
Emotional (1–5) | 3.6 (0.7) | 3.9 (0.7) | 1.3 (0.7) | 1.6 (0.9) |
Relational (1–5) | 4.2 (0.5) | 4.5 (0.4) | 0.8 (0.7) | 1.3 (0.7) |
Social (1–5) | 3.7 (0.6) | 4.2 (0.5) | 0.8 (0.8) | 1.7 (0.7) |
Mental Health (MH) |
Depression (1–4) | 1.5 (0.3) | 1.4 (0.4) | -1.0 (0.4) | -1.1 (0.8) |
At or above level | 5 (31.3%) | 4 (26.7%) | Δ+: 9 (56.3%) | Δ+: 8 (53.3%) |
Anxiety (1–4) | 1.6 (0.4) | 1.4 (0.3) | -0.8 (0.3) | -1.0 (0.7) |
At or above level | 6 (37.5%) | 1 (6.7%) | Δ+: 6 (37.5%) | Δ+: 11 (73.3%) |
PTSD (1–5) | 1.7 (0.5) | 1.6 (0.6) | -1.7 (1.3) | -1.1 (1.5) |
Social Support (1–7) | 6.5 (0.5) | 5.8 (1.2) | 0.8 (1.2) | 2.2 (0.6) |
Coping (1–5) | 4.4 (0.4) | 3.9 (0.9) | 0.7 (1.1) | 0.2 (0.9) |
Fear of Spouse (1–5) | 1.5 (0.7) | | -1.0 (1.2) | |
Partner and Family Violence |
Any IPV (Past Year) | Yes: 8 (50.0%) Missing: 1 (6.3%) | N/A | Δ+: 5 (31.3%) Δ−: 1 (6.3%) | N/A |
Psychological (Past Year) | Yes: 8 (50.0%) Missing: 1 (6.3%) | N/A | Δ+: 5 (31.3%) Δ−: 1 (6.3%) | N/A |
Physical (Past Year) | Yes: 3 (18.8%) Missing: 1 (6.3%) | N/A | Δ+: 4 (25.0%) Δ−: 1 (6.3%) | N/A |
Sexual (Past Year) | Yes: 1 (6.3%) Missing: 1 (6.3%) | N/A | Δ+: 0 (0.0%) Δ−: 0 (0.0%) | N/A |
Participation |
Self-Reported (1–5) | 4.4 (0.5) | 4.4 (0.5) | N/A | N/A |
Therapist-Reported (0–10) | 9.0 (1.2) | 8.9 (1.3) | N/A | N/A |
Notes: Bold change scores indicate statistically significant differences (p < .05) between baseline and endline for the analytic sample using the Wilcoxon signed-rank test (for quantitative outcomes) and McNemar’s test (for categorical outcomes). For categorical outcomes, the number of participants whose score changed value are shown, with Δ + indicating a positive change (e.g., experience of depression at baseline but not at endline) and Δ- indicating a negative change. |
Ethics. The study was approved by the Institutional Review Boards at Jordan University of Science and Technology (6/141/2021, 6/1/2021) and Emory University (0000321, 9/3/2021). All participants provided written informed consent and the study followed international standards on research involving violence against women, including offering immediate professional assistance for violence or distress.(40) In addition, a special hotline was established by the institute delivering the CBT to support participants and set up a WhatsApp group for ongoing group support which continues to function to this day.