Effect of Self-Compassion Intervention Based on a Religious Perspective on the Anxiety and Quality of Life of Infertile Women: A quasi-experimental study


 Background Anxiety is one of the common psychological problems among infertile women, which affects their quality of life. The purpose of this study was to determine the effect of self-compassion intervention based on religious perspective on the anxiety and quality of life of infertile women. Methods A qusai-experimental design with experimental and control groups was used. 24 women who lived in Maybod city, Iran, and were referred to Yazd reproductive sciences institute selected by available sampling and randomly assigned to experimental and control groups. The participants of experimental group received 8 sessions self-compassion focused intervention based on religious instructions and control group was put on the waiting list. Data were collected using Quality of Life Questionnaire in Infertile Couples Questionnaire (QOLICQ) and Beck anxiety inventory (BDI) in pretest and posttest phase and then analyzed using multivariate analysis covariance (MANCOVA). Results The results showed as compared to control group at the post-test phase, the quality of life (p< .001) and anxiety (p< .001) of infertile women increased and decreased, respectively, in the experimental group. Conclusion Infertility medical centers can use self-compassion intervention based on a religious approach as a complementary psychological intervention, alongside with medical interventions, to improve the quality of life and reduce anxiety in infertile women.


Introduction
In many cultures, family formation and parenting is a value. However, many couples face the challenges of infertility in their lives. According to the World Health Organization (WHO), infertility defined as failure of conception in couples when they have been sexually active for 12 months or more without the use of contraceptives [1]. Infertility is most often accompanied by psychological stress. Based on previous studies, it can be concluded that infertile women have more psychological distress compared to the fertile peers [2,3]. Also, findings from previous research show that depression and anxiety are two of the most common mental health problems in infertile women [4,5], which may result in poor quality of life.
Poor quality of life and anxiety in infertile women may affect their treatment process. Findings of one study showed that 65 percent of physicians believed that anxiety had a negative effect on fertility.
Interestingly, most physicians felt that fertility was affected by stress, anxiety and depression [6].
However, women quality of life if does not affect their fertility will probably affect their motivation to continue the treatment process [7]. Therefore, psychological interventions that can reduce stress, anxiety and depression and improve quality of life may have a positive effect on treatment of infertile women. One of these psychological interventions is self-compassion therapy. Because infertility causes women to have negative and self-critical feelings about themselves [3], self-compassion based therapy can help them to reduce these feelings.
Self-compassion based therapy can help individuals face unhappy life events. Self-compassion involves being kind to oneself in failures and understanding of negative experiences as part of a great human experience [8]. Compassion and forgiveness turn negative feelings such as revenge, hatred and distress into positive emotions, such as peace, benevolence and empathy. Compassion leads to appreciation, moderation and hope [9]. Self-compassion consists of three main factors: 1. Selfkindness, which refers to the desire to kindness toward self rather than self-criticism when facing personal dilemma and problems; 2. The common humanity that refers to recognizing failure, problems, and stress as a normal part of human life; 3) mindfulness which refers to an awareness and distinction between thought and emotion and living in here and now [10]. Self-Compassion may act as a self-healing function that allows individuals to meet their own personal needs as valuable as others needs [11]. Therefore, the key goal of self-compassion interventions is to provoke positive emotions and reduce self-criticism and negative emotions [12]. Self-compassion leads to oxytocin stimulation, cortisol and cardiac parasympathetic depletion, and physiological reactions such as decreased heart rate [13,14].
Religious schools, especially Islamic viewpoints, emphasize on self-compassion as a value. Selfcompassion is associated with religious orientation and can lead to improving mental health [15].
Evidence show that compassion as a religious value can decrease aggression in adolescents [16].
According to Muslims beliefs, compassion means getting to know human limitations, knowing that humankinds may make mistakes and they sometimes required to forgive themselves [17]. In Islam, compassion manifests itself in behaviors such as zakat (i.e. sharing wealth), attending to the affairs of relatives, neighbors and poor families, attending to the needs of parents, and many other recommended religious behaviors [17]. According to Islamic views, God is compassionate towards human beings and therefore humans should not blame themselves for problems that went beyond their will. God wants the best for human and every problem in life may have a purpose and expedient.
Many studies have examined the relationship between religious concepts and self-compassion components, but so far few studies have examined the impact of self-compassion intervention based on Islamic teachings. The findings of a recent study showed that compassionate therapy adapted to Islamic teachings than general compassion therapy, had a greater effect on reducing the selfcompassion of cancer patients [18].
Considering the fact that Iran society dominated by Muslims, it is important to pay attention to Islam in psychological interventions. Regarding that compassion focused therapy can potentially be combined with religious viewpoints, self-compassion intervention based on religious instructions can be considered as an effective intervention for individuals who have an unresolved problem in life.
Therefore, self-compassion focused therapy based on religious perspectives may be considered a successful psychological intervention for Muslim women to deal with the problems of infertility.
However, so far a few study attempted to combine compassionate therapy with religious viewpoints; Most of them were descriptive as well. No study was found to evaluate the effectiveness of selfcompassion intervention based on religious perspective in infertile women; there was only one study in which the participants were cancer patients. so the purpose of this study was to evaluate the impact of self-compassion intervention based on a religious perspective on the anxiety and quality of life in infertile women.

Materials And Methods
This study was a qusai-experimental design with experimental and waiting list control groups. The statistical population of this study included all infertile women who lived in Maybod city, Iran, in 2017 and were referred to Yazd reproductive sciences institute. Infertility was diagnosed by a gynecologist. 24 women selected by available sampling and simple randomly assigned to experimental and control groups. Sample size was calculated using following formula based on 3 standard deviation for each group [19], 80% power and expecting to get at least 2.5 difference score (One sample was selected for the probability of further decline): Inclusion criteria were as follow: 1-inclination to participate in the study, 2-women who passed at least 5 year from the infertility, 3. receiving infertility treatment for at least 3 years, 4. the age range of 25-40 years old, 5. having an Islamic religious orientation, 6) having at least school education.
Exclusion criteria were as: 1. having a specific mental and personality disorder, 2. Taking psychiatric drugs, 3. receiving other psychological treatments. These criteria were confirmed by referring to patients' medical records, clinical interview, and the Minnesota multiphasic personality inventory results. In order to control some of the intervening variables, participants in both groups were matched in terms of demographic variables such as age, duration of marriage, duration of treatment, and educational level. All participants suffered from female infertility, primary infertility and were treating by IVF method.

Data Collection
The participants of experimental group received 8 sessions self-compassion focused intervention based on religious instructions and control group was put on the waiting list. However, the control group continued its usual treatments at the Institute of Reproductive Sciences and was given explanations of the challenges of infertility as placebo. Intervention sessions were scheduled on days when control group participants were not exposed to the experimental group so that their possible interaction with each other did not affect the results of the study. Because the participants were resident in Maybod City, intervention sessions were held in the Ziai Consulting Center's meeting room in Maybod. However, Institute of Reproductive Sciences had only the role of introducing the subjects, and because the focus of treatment at the institute was on medical treatment, it was preferred that intervention sessions be held elsewhere. The content of the sessions was derived from similar studies [12,20] and was enriched using Islamic sources according to the guidelines of each session (Table 1).
Intervention was conducted by second author who had master in family counseling and had certificated in compassion therapy courses. Homework was reminded at the end of each session and reviewed at the beginning of the next session. Data were collected using quality of life questionnaires and Beck anxiety inventory in pretest and posttest. The study was conducted at November 2018-February 2019. Intervention flow-chart is presented in figure I.

Beck Anxiety Inventory (BAI)
BAI is a 21-item self-report tool designed to measure the severity of generalized anxiety symptom in adolescents and adults [22]. Responses are based on a 4-point Likert scale ranging from 0 (not at all) to 3 (severely). Validity and reliability of Persian version of BAI was confirmed [23].

Statistical Analysis
Data analyzed by multivariate analysis covariance (MANCOVA) using statistical package for social science (SPSS, version 21.0) at the p < .05 level of statistical significance. Presumptions of MANCOVA include normal distribution of scores and normality homogeneity of variances of groups analyzed by Kolmogorov-Smirnov and levene's test respectively. Also, the independent sample t-test was used to compare groups in pretest and some demographic variables.

Results
Mean and standard deviation of demographic variables include age, duration of marriage and duration of treatment presented in Table 2. There was no statistically significant differences between experimental and control group in mean of age, husband's age, marriage duration and treatment duration (p > .05). All of participants have graduate education. Neither the participants nor their husbands suffered from any other underlying disease. The mean and standard deviation of quality of life and anxiety scores divided by experimental and control group presented in Table 3. As shown in Table 3

Discussion
The results of this study indicate that self-compassion intervention based on a religious perspective has a significant effect on improving the quality of life of infertile women. This finding is consistent with previous studies that indicate individuals with high self-compassion have higher quality of life indicators such as psychological satisfaction, self-efficacy, independence, purpose in life, personal development, happiness and optimism [12,15,20,[24][25][26].
However, these studies either investigated compassion without integrating with religious instructions [12] or merely reviewed compassion and religion without examining its effectiveness [15]. As mentioned previously, only one study has so far incorporated self-compassion intervention and Islamic teachings [18]; although its findings confirmed the effectiveness of this intervention, the study carried out on cancer patients and the dependent variable was self-compassion.
It seems that, self-compassion intervention has improved infertile women quality of life, mostly by changing their attitudes toward infertility, which is something beyond their control; at the same time, the infertile women got a positive view of her conditions and hope for the effectiveness of her treatment [26]. Because infertile women may feel more isolated from their peers, the social dimension of their quality of life may decline [3]. Self-compassion can help infertile women to feel that they are not alone in their problem and that there are others who are infertile or suffer from irreversible problems such as having a disabled child (common humanity dimension). Therefore, instead of blaming themselves, they tend to be kind to themselves and look at themselves with a nonjudgment view (Self-kindness dimension) [25].
Infertile women find that, despite their efforts to purist of treatment, the attitude of the others has not been changed. However, a woman with high self-compassion come to the conclusion that the behavior of others is not because of her problem but because of the sympathy they may have with her. In fact, empathy with others, which is a component of self-compassion, leads to this attitude in infertile women and improve their kindness toward others [27]. Consequently, by reducing self-blame and blaming others, their quality of life may increase.
The findings of this study showed that self-compassion intervention based on a religious perspective could reduce the anxiety of infertile women. This finding is in line with previous studies [20,25,28,29]. It seems that many of the problems that infertile women have in adjustment are due to the difficulty in emotion regulating [29]. Self-compassion may serve as an emotional regulation strategy and increase the resilience of infertile women in dealing with self-blame [25]. Mostly, negative affects in infertile women are due to their self-criticism and self-judgment. So, self-compassionate attitude may function as a form of resiliency against the negative influence of self-criticism and social blame toward infertile women [29]. Evidences show that self-compassion serve as a buffer against the negative consequences of shame and guilt and self-blame in infertile women and significantly predict anxiety and depression in them [28,29].
In compassion intervention sessions, infertile women were consciously reviewing their suffering in life with a compassion manner and by self-forgiveness they attained spiritual and physical relaxation.
They found true peace in closing to God and accepting their destiny, while to and their situation and accept responsibility for their lives. On the other hand, according to serenity prayer, they worship as follow: "God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference". The acceptance and commitment which receive through this exercise will help them manage stress and reduce psychological stress [30].
Although the role of self-compassion in improving the quality of life of other diseases such as celiac disease [31], cancer [32], HIV [33], persistent musculoskeletal pain [34] and chronic disease management [35] has been acknowledged, but as confirmed in cancer patients [18], religious implications can be added to increase the effectiveness of self-compassion intervention, especially in a country, such as Iran, with a religious cultural background.
Islam regards compassion as a concept that is close to human nature and resulted in human being's happiness and tranquility. Not harming oneself and others is one of the key components of compassion in Islam [36]. Sometimes people can also harm themselves with inappropriate thoughts, stress and anxiety. Therefore, a person who has a religious self-compassion avoids the thoughts that lead to anxiety, which reduces anxiety and enhances his quality of life.

Conclusion
Findings of the study showed that self-compassion focused intervention enriched by Islamic instructions could significantly improve quality of life and anxiety of infertile women. Therefore, in order to improve the quality of life of infertile women and consequently for better effectiveness of medical treatments, it is suggested to adopt a self-compassionate approach based on Islamic teachings for infertile women in infertility clinics. An infertile woman must first accept her problem in order to be able to avoid self-blame and tend to self-kindness. Regarding, in this study, religious instruction was used alongside compassionate treatment because it could be helpful for acceptance of the infertility. When one accepts God's kindness toward herself and other universes, she considers events in her life, whether positive or negative, as part of God's will. As a result, the kindness of God extends to the self-kindness and promotes self-compassion. In Islamic beliefs, life is hard and difficult, and everyone has a problem in their lives. Problems cause one to always feel the presence of God in her/his and make life valuable. Alongside suffering, life becomes valuable. The two dimensions of selfcompassion, empathy with self and others and common humanity, are exactly in line with Islamic teachings. Therefore, if a person has a religious background, combining compassionate treatment and religious doctrine can help make compassion treatment more effective.

Limitations And Future Research
Although self-compassion intervention was enriched with Islamic instructions, but due to the lack of a comparative group that merely evaluates the effectiveness of a compassionate intervention without integrating with religious concepts, it cannot certainly conclude that improvement in quality of life and anxiety in the experimental group was related to religious enrichment or that the self-compassion intervention alone was effective. Due to executive limitations, there was no comparison group in this study that received only self-compassion intervention, so it is recommended that future studies replicate this intervention with the comparison group. In this study, it was assumed that religion can help infertile women accept the problem and increase their self-compassion, and therefore its incorporation into self-compassion therapy can be helpful. However, other interventions such as the acceptance and commitment approach have the same default. So it is recommended that in future studies, self-compassion intervention enriched by religious instructions be compared with intervention enriched by acceptance and commitment therapy.
Abbreviations QOLICQ: Quality of Life Questionnaire in Infertile Couples Questionnaire; BDI: Beck anxiety inventory; MANCOVA: multivariate analysis covariance;

Declarations
The authors have no conflicts of interest to state.

Figure 1
Intervention flow-chart

Supplementary Files
This is a list of supplementary files associated with this preprint. Click to download. STROBEchecklistcrosssectional.docx