Running head: ANXIETY AND DEPRESSION IN INFERTILE WOMEN 1

Anxiety and Depression Levels in Infertile Women

Savanna Hilles, Alexis Cherney, Melissa Garvall, Alexandria Villanueva

Azusa Pacific University

Research and Theory in Advanced Practice Nursing

GNRS 508A

Dr. Jane Pfeiffer, PhD, RN

February 13, 2018

ANXIETY AND DEPRESSION IN INFERTILE WOMEN 2

Anxiety and Depression Levels in Infertile Women

Infertility is defined by the failure to achieve a clinical pregnancy after 12 months or

more of regular unprotected sexual intercourse (Zegers et al., 2009). Infertility is often a cause or

consequence of psychological strain (Lakatos, Szigeti, Ujma, Sexty, & Balog, 2017). Studies

found that 50% of couples have stated that infertility was the most disappointing experience in

their lives (Freeman, Rickels, Tausig, Boxer, Mastroianni, & Tureck, 1987) and 80% of couples

described infertility as a stressful or very stressful experience (Mahlstedt, Macduff, & Bernstein,

1987). According to international estimates, the prevalence of infertility is about 9–15%. Nine

percent refers to the international prevalence of current infertility, while 10–15% refers to

lifetime prevalence in Western societies (Lakotos et al., 2017). The purpose of this report is to

explore the relationship between anxiety and depression levels and infertility in women. It was

hypothesized that infertile women would have higher levels of anxiety and depression symptoms

when compared with fertile women.

The topic was researched using CINAHL. The keywords of infertility, anxiety and

depression, mental distress, and infertile women were utilized with limitations from 2006 to

2017. This produced 17 articles. The following four specific quantitative articles were chosen to

be analyzed: Biringer, Howard, Kessler, Stewart, & Mykletun (2015), Gulseren, Cetinay,

Tokatlioglu, Sarikaya, Gulseren, & Kurt (2006), Lakatos, Szigeti, Ujma, Sexty, & Balog (2017),

and Noorbala, Ramezanzadeh, Abedinia, & Naghizadeh (2008). Each article investigates the

relationship between anxiety and depressive symptoms in women struggling with infertility.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 3

Is infertility really associated with higher levels of mental distress in women? Results from

the North-Trondelag Health Study and Medical Birth Registry of Norway

Summary

Biringer, Howard, Kessler, Stewart and Mykletun (2015) explored the association of

anxiety and depression with infertility in women. The purpose of this study was to investigate the

relationship between women who have been unable to become pregnant for more than 12 months

and anxiety and depression levels and to test if women who are infertile without children and

those that have gone on to have children differ in symptom levels of anxiety and depression with

those that have never been infertile. All adults in North-Trondelag county in Norway were asked

to complete questionnaires for the study. Those who answered Questionnaire 1 and 2 and who

had valid responses of fertility were used in the study. The sample size was 12,584 women. This

sample size was divided into 5 groups: current primary infertility, current secondary infertility,

resolved infertility, voluntary childfree, and mothers without infertility (the control group). The

Hospital Anxiety and Depression Scale (HADS) was used to quantify anxiety and depression

levels. Adjustments were made for confounding variables. The current primary infertility group

(adjusted B=0.06 (95% CI= -0.30 to 0.42) and B= -0.10 (95% CI= -0.30 to 0.18) for HADS-A

and HADS-D respectively) and the current secondary infertility group (adjusted B= –0.12 (95%

CI= –0.53 to 0.29); and B= –0.16 (95% CI= –0.48 to 0.17), for HADS-A and -D respectively)

had similar levels to the control group (Biringer et al., 2015). The group with resolved fertility

had higher levels of symptoms than the control group (B= 0.25 (95% CI= 0.04–0.47) for HADS-

A and B= 0.12 (95% CI= – 0.05 to 0.28) for HADS-D) (Biringer et al., 2015).

Lastly, the depressive symptoms in the voluntarily childfree group were lower than the control

group (adjusted B= –0.36 (95% CI= –0.50 to –0.21)) (Biringer et al., 2015).
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 4

Article Critique

Biringer, Howard, Kessler, Stewart and Mykletun (2015) were thorough on the

discussing the research question, methodology, data analysis and research ethics. The research

question was clearly stated and the purpose was discussed. While the hypothesis was not clear,

the problem was detailed and significant to nursing practice. The concepts were clearly defined

and the population and setting utilized in the study was stated. The methodology of this study

was well designed. Data analysis was the strongest part of the article. The findings were plainly

illustrated in tables. The statistical tests performed were accurate and the conclusions that were

drawn are justified. Research ethics was another strength. The article mentioned that a regional

committee for medical research ethics approved the study. The article did not mention

confidentiality, however consent was signed and the risks of the study were very minimal

compared to the benefits.

Weaknesses of the article include review of literature, theoretical framework,

implications and recommendations. The review of literature is not very thorough. It mentions a

few studies, however, it does not describe them in detail or detail strengths and weaknesses. It is

too brief to analyze if the researchers were knowledgeable on the research of the topic. The

article does not mention a theoretical framework that the researchers used. Implications and

recommendations were very weak in this article. The article did not detail on the implications or

the recommendations for future research, theory, education or administration.

ANXIETY AND DEPRESSION IN INFERTILE WOMEN 5

Depression and Anxiety Levels in Infertile Turkish Women

Summary

Gulseren et al. (2006) conducted this study to further understand the levels of anxiety and

depression in women with infertility and the relationship between psychological symptoms and

cultural factors. This study involved one hundred and seven women that were patients at an

Infertility Outpatient Unit, of Tepecik SSK Hospital in Turkey, from 2003 to 2004. The

diagnostic criteria was as follows: no conception after a year trying and a gynecologic exam. In

order to participate in the study, infertile women had to agree to participate, be age 20-40 years,

have normal spermogram results, currently use clomiphene citrate and gonadotropin treatment

and have no psychologic or chronic physical disease. The control group consisted of sixty-three

women that were equivalent in age, education and socioeconomic status at the patient group. A

questionnaire collected the sociodemographic and clinical data, including information about

relations with husband and family pressure. Both groups took the HADS, which consists of

fourteen questions that gauged depression and anxiety. The infertile group had to retake HADS

three months later. (Gulseren et al., 2006).

The Student’s t test was used to compare the average HADS scores of the two groups and

the X2 was used to compare the rates of pregnancy among both groups, and psychiatric

symptoms. It was found that women that stated having a “bad” relationship with their husbands

had significantly higher depression scores than the women that had “good relationship”

(Gulseren et al., 2006). The women that had pressure from husband’s family to conceive had

significantly higher anxiety and depression scores than those without family pressure. Women

that had attempted previous non medical solution had higher anxiety and depression scores.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 6

The initial HADS depression scores and anxiety were significantly lower in the women who

achieved pregnancy than in those who had not. Findings indicate that depression and anxiety

negatively impact fertility and that HADS anxiety scores predicted pregnancy in a negative way.

Article Critique

This study had several strengths in different aspects of research design and protocol. This

provided additional information for the infertility community as well as for the nursing

practicing field, bringing awareness to the psychological state of women with infertility. The

study clearly stated the purpose. The variables of the study were clear, which included but not

limited to anxiety levels at the start of study, pressure from husband’s family to conceive, and

age. Both the control and experimental group were clearly identified, including specifications

and requirements for either group. The study included previous studies offering general

information on the topic and what is known to date. The design of the study and the statistical

tests used to evaluate the data collected were clear and detailed enough for others to replicate.

The statistical tests conducted on the data was concise and clearly explained, supplying

comparisons to results from previous studies conducted.

As most studies, the article had weaknesses and opportunities for improvement. One

weakness was the lack of information of how the sample site was selected and who made the

selection. This information identifies the presence of a bias in the study. In addition, it would be

beneficial for the sample size to be larger and include other fertility sites from different regions

of the country. There was no information provided in regard to the data collectors and how they

were chosen and trained.

Because this study was conducted in the country of Turkey with its own culture it is difficult to

generalize the results to majority of the infertile female gender population.

ANXIETY AND DEPRESSION IN INFERTILE WOMEN 7

This study was a good representation for the women of South Eastern Europe region, but may be

an inaccurate reflection of North American women.

Anxiety and depression among infertile women: a cross-sectional survey from Hungary

Summary

Lakatos, Szigeti, Ujma, Sexty, & Balog (2017), conducted a study to explore the

psychological state of women with and without fertility problem, and examine background

factors of anxiety-related and depressive symptoms in those women struggling with infertility

(Lakatos et al., 2017). The study included 225 participants: 134 infertile and 91 fertile women.

The participants were recruited online and in a clinical setting. The study used the following

questionnaires to collect the information from the women: Spielberg Trait Anxiety Inventory

(STAI-T), Shortened Beck Depression Inventory (BDI) and Fertility Problem Inventory (FPI).

The questionnaires assessed the mental status of fertile and infertile women. The women were

also interviewed to determine the presence of other sources of stress such as quality of the

relationship with their mother, financial stress, and illness-related stress (Lakatos et al, 2017).

This study tested their hypotheses through independent-sample t-test and multiple linear

regression modeling. Lakatos et al found that, “Infertile women were younger (33.30 ± 4.85 vs.

35.74 ± 5.73, p = .001), but had significantly worse psychological well-being (BDI = 14.94 ±

12.90 vs. 8.95 ± 10.49, p < .0001; STAI-T = 48.76 ± 10.96 vs. 41.18 ± 11.26, p < .0001) than

fertile subjects.” Age, social concern, sexual concern and maternal relationship stress

corresponded to depressive symptoms and anxiety in infertile women. The trait anxiety

questionnaire was associated with financial stress. The model was able to account for 58% of the

variance of depressive symptoms and 62% of the variance of trait anxiety (Lakatos et al, 2017).
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 8

Study findings strongly indicate that depressive and anxiety-related symptoms of infertile

women are more prominent than those of fertile females.

Article Critique

Lakatos, Szigeti, Ujma, Sexty, & Balog (2017) were thorough and concise in stating the

research problem and question. The key concepts, variables, study population and setting were

clearly defined. The review of literature is clear defined and current and also includes principle

studies. It relates directly to the research question and problem. The methodology was detailed.

Instruments covered the complexity of the concepts being measured. Pertinent validity and

reliability data were presented for all instruments. This study revealed strengths with data

analysis and used correct descriptive statistics to describe major characteristics of the sample and

the major variables, including the central tendency and variability. Independent sample T-test,

chi squared, central tendency were all used in this study. Research ethics was another strength of

this study as it was approved and monitored by an ethics committee and consent procedures were

implemented. Findings and interpretations were also thorough throughout the study. Important

results were discussed and interpretations were consistent with results. The study provided

recommendations for future research such as increasing sample size and the need for

psychological evaluations.

This study unfortunately had limitations. There was no theoretical or conceptual

framework throughout the study. Another weakness in the study was the researchers did not offer

any implications for practice and generalizations were not warranted on the basis of the sample

used in the study. The sample size was small therefore, the results may not translate to the entire

population.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 9

Psychiatric disorders among infertile and fertile women

Summary

This study was done to compare the psychiatric disorders and predisposing factors

between fertile and infertile women in Iran. One hundred and fifty infertile women from

Infertility Clinic of Vali-e-Asr Reproduction Health Research Center and 150 married, fertile

women from Gynecology Clinic of Imam Khomeini Hospital (Tehran, Iran) were used as the

sample in this study. The sample was selected by using collective sampling and written consent

was received from the subjects. An open ended questionnaire was done by the women to assess

age, education level, work status, family income, marriage duration, psychological, and medical

history. A SCL-90-R, which is a 90 item questionnaire was designed to assess the subject’s

psychological symptoms. The SCL-90-R assessed 9 aspects, somatization, obsessive-compulsive

disorders, interpersonal sensitivity, depression, anxiety, aggression, phobic anxiety, paranoid

ideation, and psychoticism (Noorbala, Ramezanzadeh, and Abedinia, 2009). Multiple logistic

regression was used to compare the correlation between psychological problems and potential

predictor variables. Independent variables included age, marriage duration, education level,

economic status, medical and psychiatric history, and fertility and the dependent variable was the

psychological distress caused by the independent variables.

Results concluded that infertile women scored highest in paranoid ideation, depression,

and interpersonal sensitivity, and scored lowest in phobic anxiety and psychoticism. Fertile

women scored highest in paranoid ideation, depression, and somatization and scored lowest in

psychoticism and phobic anxiety. Interpersonal sensitivity, depression, paranoid ideation, phobic

ideation, and psychoticism were significantly higher in infertile women than fertile women.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 10

The research concluded that 44% of infertile woman and 28.7% of fertile women on this study

had psychological disorders (Noorbala et. al). The prevalence of these disorders in infertile

women can be attributed to the Eastern culture and suggests specialists should be aware of these

factors when treating infertility.

Article Critique

This research was strong in the methodology design, sampling, review of literature, and

data analysis. In particular, methodology design was sufficient due to a clearly designed research

design and open ended questionnaires used to assess subjects. The design allowed for

relationship interferences between the two subject groups. Data analysis in this study was strong

because it clearly illustrated the results and was able to draw conclusions through statistical

analysis by using correlation, t-test, central tendency, and chi squared to interpret results.

This study was weak in its theoretical/conceptual framework, recommendations for future

studies, and did not have a hypothesis. There was no theoretical or conceptual framework

mentioned in this study. Even though this study had appropriate recommendations for

gynecologists, counselors, and the media, the study did not have recommendations for future

studies.

Conclusion

The four quantitative articles that were assessed investigated the relationship between

anxiety and depression levels in infertile women. It was hypothesized that when compared to

fertile women, women with infertility problems would have higher levels of anxiety and

depression. Biringer et al. (2015) found that there was no significant difference between levels of

anxiety and depression between women with current primary and secondary infertility and

women without infertility issues.

ANXIETY AND DEPRESSION IN INFERTILE WOMEN 11

However, women with resolved infertility had higher levels of anxiety and depression than fertile

women, while voluntarily childfree women had lower levels of depressive symptoms (Biringer et

al., 2015). Gulseren et al. (2006) found that women that had pressure from husband’s family to

conceive and those that had attempted previous nonmedical solution had significantly higher

anxiety and depression levels than women who did not have family pressure or had no previous

attempts for conception. Lakatos et al. (2017) found that there was a significant difference

between fertile and infertile women and depressive and anxiety related symptoms of infertile

women are more prominent. Age, sexual concern, maternal relationship and financial stress were

significantly correlated to the distress in infertile women (Lakatos et al., 2017). Noorbala et al.

(2008) found that there was nearly a two fold difference in psychological disorders between

infertile and fertile women. The results revealed that the most significant stress factors related to

psychological disorders in infertile women were the reaction of family and friends, feelings of

loneliness, and infertility treatment (Noorbala et al., 2008).

All four of the articles discussed the importance of screening for psychological distress in

infertile women and providing mental health interventions for those in need.

It may be beneficial for women struggling with infertility to be seen by their healthcare provider

at shorter intervals, enabling the healthcare provider to monitor psychological needs adequately.

In addition, women struggling with infertility and their families should be supplied with the

proper support groups to help both parties understand infertility, treatment, and emotional

support (Gulseren et al., 2006) .

The articles presented a solid foundation of the relationship between anxiety and

depression levels and infertility in women, however, more research should be done.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 12

Lakatos et al. (2017) stated that further investigation of specific psychological interventions for

women struggling with infertility should be researched. Measurement of underlying distress such

as age, social and sexual concern, maternal relationship stress and financial stress should also be

evaluated (Lakatos et al., 2017).

ANXIETY AND DEPRESSION IN INFERTILE WOMEN 13

References

Biringer, E., Howard, L., Kessler, U., Stewart, R., & Mykletun, A. (2015). Is infertility really

associated with higher levels of mental distress in women? Results from the North-

Trondelag Health Study and Medical Birth Registry of Norway. Journal of

Psychosomatic Obstetrics and Gynecology, 36(2), 38-45.

Freeman, E. W., Rickels, K., Tausig, J., Boxer, A., Mastroianni, L., & Tureck, R. W. (1987).

Emotional and psychosocial factors in follow-up of women after IVF-ET treatment: A

pilot investigation. Acta obstetricia et gynecologica Scandinavica, 66(6), 517-521.

Gulseren, L., Cetinay, P., Tokatlioglu, B., Sarikaya, O. O., Gulseren, S., & Kurt, S. (2006).

Depression and anxiety levels in infertile Turkish women. The Journal of reproductive

medicine, 51(5), 421-426.

Lakatos, E., Szigeti, J. F., Ujma, P. P., Sexty, R., & Balog, P. (2017). Anxiety and depression

among infertile women: a cross-sectional survey from Hungary. BMC Women’s Health,

17, 48.

Mahlstedt PP, Macduff S, Bernstein J. (1987). Emotional factors and the in vitro fertilization and

embryo transfer process. Journal In Vitro Fert Embryo Transfer, 4(232), 6.

Noorbala, A. A., Ramezanzadeh, F., Abedinia, N., & Naghizadeh, M. M. (2008). Psychiatric

disorders among infertile and fertile women. Social Psychiatry and Psychiatric

Epidemiology, 44(7), 587-591.

Zegers-Hochschild, F., Adamson, G., Mouzon, J. D., Ishihara, O., Mansour, R., Nygren, K., . . .

Poel, S. V. (2009). The International Committee for Monitoring Assisted Reproductive

Technology (ICMART) and the World Health Organization (WHO) Revised Glossary on

ART Terminology, 2009. Human Reproduction, 24(11), 2683-2687.

ANXIETY AND DEPRESSION IN INFERTILE WOMEN 14

CRITICAL APPRAISAL OF QUANTITATIVE RESEARCH EVIDENCE

Author: _Biringer, E. Howard, L. Kessler, U. Stewart, R. & Mykleturn, A.___ Title: _Is
infertility really associated with higher levels of mental distress in the female population?
Results from the North-Trondelag Health Study and the Medical Birth Registry of
Norway__

Assign one rating to each: 1 = not met 2 = partially met 3 = completely met
Assign N/A if the question is not appropriate to the study being examined.

CRITERIA APPRAISAL COMMENTS

A. Research Problem/Question Looking at the levels of depressive and

1. There is a clear statement of 1 2 anxiety symptoms of fertile and infertile
purpose or research question. 3 women

2. The problem is significant for 1 2 By knowing if they are related providers

nursing practice, administration or 3 can provide better treatment and
education. resources

3. Hypotheses are stated clearly and
easy to find. If no hypotheses, this is
justified.
1 2 The article does not clearly state. It can
3 be inferred by the stats that they were
N/A thinking infertility would have higher
levels, however it does not say in the
intro

4. Key concepts, variables are clearly 1 2 Variables such as education, marital

defined. 3 status,smoking/alcohol

5. Study population and setting are 1 2 Article shows a good chart of how they
clearly specified. 3 determined their sample. 12,584 women
in the county of north-trondelag

B. Review of Literature It is VERY brief. Could provide more

1. Review is thorough, yet concise, 1 2 info, however it was very clear and
clear, and current and includes 3 concise. Mentions specific studies
principal studies.

2. Content of review relates directly to 1 2 It mainly talks about how research has
research question and problem. 3 been inconclusive thus far, however it
does relate to research problem

3. Review critically appraises and 1 2 The studies are briefly mentioned but
compares contributions of key studies, 3 not described in detail
identifying strengths, weaknesses, and
gaps.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 15

4. Review is well organized and written 1 2 Too brief to analyze

in appropriate language. 3

5. Review synthesizes state-of-the-art 1 2 Study is too brief, but info they do

of knowledge on topic. 3 have is backed up by specific studies

C. Theoretical or Conceptual No theory

Framework 1 2
1. A theoretical or conceptual 3
framework is described

2. Major features or elements of the 1 2 No theory is mentioned

theory or framework are clearly 3
explained. N/A

3. Theory is appropriate to the 1 2 No theory is mentioned

research problem; hypotheses flow 3
naturally from framework.

4. Deductions that relate to the theory 1 2 No theory is mentioned

are logical, conceptually and clinically. 3
N/A

5. At the end, the researcher ties 1 2 No theory is mentioned

findings back to the theoretical 3
framework.

D. Methodology: Design They mentioned questionnaire,

1. The research design is clearly
described and most appropriate, given
the nature of the problem. Design
limitations are noted.
1 2 provided sample questions, used
3 HADS score and described statistical
analysis of data and a clear figure to
show how they sampled the subjects.
Limitations are not noted

2. If more than one group is studied, 1 2 It non-experimental so it is not

there was random selection and 3 random
assignment of subject to group. If non- N/A
experimental, this is justified.

3. Before-after comparisons are 1 2 No before or after comparisons

specified and are most important ones. 3
If no comparison group, there are no N/A
problems with interpretation of results.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 16

4. Adequate procedures were used to 1 2 The observed different variables

control intrinsic (subject 3 such as education, age, marital
characteristics) and external status, BMI, cigarette smoking etc
(situational) factors; the study is
internally (no uncontrolled threats) and
externally (findings are generalizable)
valid.

5. The design enables the researchers 1 2 Control of variables enables

to draw causal inferences about the 3 inferences to be drawn
relationship among study variables. N/A

E. Methodology: Sampling Adult inhabitants of the county of

1. The target population is described, 1 2 North-Tondelag
and the population to whom the study 3
results can be generalized is identified.

2. Eligibility criteria are clearly 1 2 Some inclusions and exclusions

specified (inclusion & exclusion). 3 were identified however not all criteria
was specified

3. Sampling plan is described and is 1 2 Sampling plan is clearly explained

adequate to obtain a representative 3 and provided
sample. If a non-probability sample is
used, sampling method is justified.

4. Recruitment of subjects to the 1 2 Don't mention method of recruitment

sample is described, appropriate, and 3 of the subjects
unbiased.

5. The size and key characteristics of 1 2 12,584 participants which is a large

the sample are described. The study 3 sample size
sample is sufficiently large and
justified on the basis of power
analysis.

F. Methodology: Data Collection HADS score, and questionnaire 2

1. Methods for data collection are 1 2 about fertility-related problems,
clearly identified; if multiple methods 3 Sample questions were provided in
were used, they are appropriate and article, however entire questionnaire
justified. was not provided

2. Data collectors were appropriately 1 2 Data collectors and training was not
chosen and trained 3 mentioned
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 17

3. The setting for data collection is 1 2 Questionnaires were mailed to the

described and appropriate. 3 participants

4. There is no evidence of bias in the 1 2 Not that we see, but there is no

data collection procedures. 3 information about the data collectors

5. Study participants were not exposed 1 2 Observation only, no interventions.

to unnecessary risks or undue burden. 3

G. Methodology: Instruments Data collection and results are

1. The research question lends itself to 1 2 related to the research question
data collection using the method(s). 3

2. The instrument(s) covers the 1 2 Multiple questionnaires with a whole

complexity of the concepts being 3 range of topics being covered
measured.

3. Pertinent validity and reliability data 1 2 Valid and reliable instruments

are presented for instrument(s). 3

4. Pre-testing of instruments for this 1 2 No-pre testing was done

study was done if needed and 3
assumptions for parametric statistics N/A
were met.

5. Data quality (poor?) did not play a 1 2 High quality data

role in failure to confirm hypotheses. 3
N/A

H. Data Analysis Linear regression models,

1. Correct descriptive statistics are 1 2 adjustments were performed for
used to describe major characteristics 3 different variables. Central tendency
of the sample and the major variables, was provided
including central tendency and
variability.

2. At least one appropriate statistical 1 2 T-test was used

test is performed for each of the 3
hypotheses or research questions.

3. The most powerful tests appropriate 1 2 Procedures were done correctly

to the data are utilized and procedures 3
are done correctly.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 18

4. The amount of statistical information 1 2 Tables are illustrated with enough

provided is sufficient to support 3 statistical data
findings of the study; tables and
figures clearly illustrate the results.

5. Conclusions drawn from results of 1 2 There are weak associations with

statistical tests are accurate and 3 infertility and higher depression and
justified. anxiety but once the adjustments
were made for variables, there were
only positive associations between
infertility and depressive symptoms

I. Research Ethics Approved by the regional committee

1. The study was approved and 1 2 for medical research ethics
monitored by an ethics committee or 3
IRB.

2. Benefits to subjects outweighed any 1 2 Only surveys needed to be

risks or discomforts caused by the 3 completed
study.

3. Appropriate steps were taken to 1 2 Did not mention confidentiality

safeguard the privacy (confidentiality) 3
of subjects.

4. Appropriate consent procedures 1 2 3 Consent was signed

were implemented.

5. The researchers make no 1 2 No inappropriate claims were found

inappropriate claims or use findings 3
inappropriately.

J. Findings/Interpretation They made adjustments for variables

1. All important results are discussed, 1 2 to control
and interpretations are consistent with 3
results (statistical analysis).

2. Limitations of the study are 1 2 Fertility problems were self-reported

identified and taken into consideration 3 and no information about undergoing
when findings are discussed. ART or adopting a child etc, anxiety
and depression are self-reported as
wel

3. The researchers offer persuasive 1 2 Do not claim causality and mention

evidence to support interpretation and 3 limitations that affect data
make no inappropriate claims for
causality.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 19

4. Results are interpreted in light of 1 2 They bring up other studies that are
findings from other studies and in 3 consistent with their data. However,
terms of the original framework and N/A no hypothesis is found.
hypotheses.

5. The interpretation distinguishes 1 2 They don't offer clinical significance

between statistical significance and 3
clinical significance.

K. Implications No implications for practice are

1. The researchers offer implications 1 2 mentioned
for practice. 3

2. The researchers offer implications 1 2 Don’t mention implications for edu or

for education and administration 3 administration
1 2
3

3. The researchers offer implications 1 2 Future research is not mentioned

for theory and future research. 3
1 2
3

4. Stated implications are appropriate, 1 2 Once adjustments were made for

given study limitations 3 variables, data is statistically
insignificant

5. Generalizations (to the population) 1 2 Large sample size

are warranted on the basis of the 3
sample used for the study.

L. Recommendations The mentioned limitations of study

1. Specific recommendations are 1 2 but don’t offer recommendations
made for improvement in study 3
methods.

2. Recommendations are made for 1 2 No recommendations are made for

future research investigations. 3 future research

3. Recommendations are consistent 1 2 No recommendations are made for

with the findings. 3 future research

4. Recommendations fit the theoretical 1 2 No recommendations. No theory.

or conceptual framework. 3
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 20

5. Alternative explanations are 1 2 No unexpected findings

provided for unexpected findings or 3
unconfirmed hypotheses. N/A

*Remember to remove 3 pts from the divisors below for every question that is N/A.

Research Problem/Question __13__ = __87__%

15
Review of Literature _10___ = __67__%
15
Theoretical/Conceptual Framework ___0_ = __0__%
12
Methodology: Design __8__ = __89_%
9
Methodology: Sampling __12__ = _80_%
15
Methodology: Data Collection _11___ = _73_%
15
Methodology: Instruments __12__ = _100_%

12
Data Analysis __15__ = __100__%
15
Research Ethics _13___ = __86__%
15
Findings/Interpretation __12__ = _80___%
15
Implications (2 questions have 2 parts) __11__ = _52___%
21
Recommendations __4__ = __33__%
(12 sections x 15 pts [5 questions x 3 pts] = 180) 12
(180 plus 2 extra questions = 186) __121__ = _70_% Overall
TOTAL 171
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 21

CRITICAL APPRAISAL OF QUANTITATIVE RESEARCH EVIDENCE

Author: Title: __Depression and Anxiety Levels in Infertile Turkish Women

Assign one rating to each: 1 = not met 2 = partially met 3 = completely met
Assign N/A if the question is not appropriate to the study being examined.

CRITERIA APPRAISAL COMMENTS

A. Research Problem/Question “The aim of this study is to

1. There is a clear statement of purpose 1 2 investigate the levels of anxiety
or research question. 3 and depression in women with
infertility…..”

2. The problem is significant for nursing 1 2 Yes, infertility is common (15% of

practice, administration or education. 3 couples) and there are studies
that show emotional problems in
infertile women

3. Hypotheses are stated clearly and 1 2 There is no clear hypothesis

easy to find. If no hypotheses, this is 3 stated.
justified. N/A

4. Key concepts, variables are clearly 1 2 They talk about cultural factors on
defined. 3 emotional state, how important it
is for women to have children etc

5. Study population and setting are 1 2 107 infertile women in an

clearly specified. 3 outpatient infertility clinic in Turkey
and 63 healthy women

We are unsure where the 63

women were gathered

B. Review of Literature It is clear but not thorough, a lot

1. Review is thorough, yet concise, clear, 1 2 of detail is missing and does not
and current and includes principal 3 name specific studies
studies.

2. Content of review relates directly to 1 2 It relates directly to high levels of

research question and problem. 3 emotional distress and
psychological support but a
general reference to unknown
studies
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 22

3. Review critically appraises and 1 2 General reference to unknown

compares contributions of key studies, 3 studies
identifying strengths, weaknesses, and
gaps.

4. Review is well organized and written in 1 2 Too brief to determine

appropriate language. 3

5. Review synthesizes state-of-the-art of 1 2 3 Not enough data provided

knowledge on topic.

C. Theoretical or Conceptual A framework isn't given. Only

Framework 1 2 cultural factors are described
1. A theoretical or conceptual framework 3
is described

2. Major features or elements of the 1 2 No theory given

theory or framework are clearly 3
explained. N/A

3. Theory is appropriate to the research 1 2 No theory given

problem; hypotheses flow naturally from 3
framework.

4. Deductions that relate to the theory are 1 2 No theory given

logical, conceptually and clinically. 3
N/A

5. At the end, the researcher ties findings 1 2 There is no theoretical framework

back to the theoretical framework. 3

D. Methodology: Design Inclusions criteria were given for

1. The research design is clearly 1 2 control and infertile group but they
described and most appropriate, given 3 didn't mention any limitations
the nature of the problem. Design
limitations are noted.

2. If more than one group is studied, 1 2 They were not randomly

there was random selection and 3 assigned. They were either
assignment of subject to group. If non- N/A infertile or fertile
experimental, this is justified.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 23

3. Before-after comparisons are specified 1 2 There were no before/after

and are most important ones. If no 3 comparisons
comparison group, there are no problems N/A
with interpretation of results.

4. Adequate procedures were used to 1 2 They did control some intrinsic

control intrinsic (subject characteristics)
and external (situational) factors; the
study is internally (no uncontrolled
threats) and externally (findings are
generalizable) valid.
3 factors including socioeconomic
status, age, education. There
were some factors that were not
controlled

5. The design enables the researchers to 1 2 It’s clear they used chix2, HADS
draw causal inferences about the 3 scale and ANCOVA
relationship among study variables. N/A

E. Methodology: Sampling The group they used is large

1. The target population is described, and 1 2 enough to be generalized
the population to whom the study results 3
can be generalized is identified.

2. Eligibility criteria are clearly specified 1 2 They talked about the inclusion
(inclusion & exclusion). 3 criteria

3. Sampling plan is described and is 1 2 They didn’t specify where they

adequate to obtain a representative 3 found the control group. They
sample. If a non-probability sample is didn’t specify how the subjects in
used, sampling method is justified. the experimental group were
approached

4. Recruitment of subjects to the sample 1 2 They didn’t specify where they

is described, appropriate, and unbiased. 3 found the control group. They
didn’t specify how the subjects in
the experimental group were
approached

5. The size and key characteristics of the 1 2 107 women

sample are described. The study sample 3
is sufficiently large and justified on the
basis of power analysis.

F. Methodology: Data Collection No methods are clearly identified

1. Methods for data collection are clearly 1 2 due to lack of selection.
identified; if multiple methods were used, 3
they are appropriate and justified.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 24

2. Data collectors were appropriately 1 2 Not described in study

chosen and trained 3

3. The setting for data collection is 1 2 The experimental group setting

described and appropriate. 3 was identified, but the control
group selection setting is no
mentioned.

4. There is no evidence of bias in the 1 2 Data collection procedures for

data collection procedures. 3 control group were not mentioned-
bias could be evident.

5. Study participants were not exposed to 1 2 Study was primarily observed and
unnecessary risks or undue burden. 3 surveyed

G. Methodology: Instruments Data is collected for the purpose

1. The research question lends itself to 1 2 of the study.
data collection using the method(s). 3

2. The instrument(s) covers the 1 2 HADs scoring survey adequately

complexity of the concepts being 3 covers complexity of
measured. psychological stress.

3. Pertinent validity and reliability data 1 2 HADs survey is reliable and valid.
are presented for instrument(s). 3

4. Pre-testing of instruments for this study 1 2 No pre-test tested in this study.

was done if needed and assumptions for 3
parametric statistics were met. N/A

5. Data quality (poor?) did not play a role 1 2 Sufficient data quality to test
in failure to confirm hypotheses. 3 hypotheses
N/A

H. Data Analysis T test, central tendency, chi

1. Correct descriptive statistics are used 1 2 squared and ANCOVA used to
to describe major characteristics of the 3 describe characteristics.
sample and the major variables, including
central tendency and variability.

2. At least one appropriate statistical test 1 2 T test, central tendency, chi

is performed for each of the hypotheses 3 squared and ANCOVA used to
or research questions. describe characteristics.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 25

3. The most powerful tests appropriate to 1 2 Powerful tests were used to

the data are utilized and procedures are 3 appropriately interpret data
done correctly.

4. The amount of statistical information 1 2 Statistical information adequately

provided is sufficient to support findings 3 supports finding for the study.
of the study; tables and figures clearly
illustrate the results.

5. Conclusions drawn from results of 1 2 Conclusions used to determine

statistical tests are accurate and justified. 3 relationships.

I. Research Ethics Approved by Ataturk Training and

1. The study was approved and 1 2 research hospital. Written
monitored by an ethics committee or IRB. 3 informed consent was obtained
from the study participants

2. Benefits to subjects outweighed any 1 2 Only observations made to both

risks or discomforts caused by the study. 3 groups.

3. Appropriate steps were taken to 1 2 Confidentiality is not mentioned in

safeguard the privacy (confidentiality) of 3 study.
subjects.

4. Appropriate consent procedures were 1 2 3 Informed consent implemented.

implemented.

5. The researchers make no 1 2 No inappropriate claims

inappropriate claims or use findings 3 mentioned.
inappropriately.

J. Findings/Interpretation All important results and

1. All important results are discussed, 1 2 interpretations mentioned
and interpretations are consistent with 3
results (statistical analysis).

2. Limitations of the study are identified 1 2 No limitations were mentioned.

and taken into consideration when 3
findings are discussed.

3. The researchers offer persuasive 1 2 No causality or inappropriate

evidence to support interpretation and 3 claims mentioned
make no inappropriate claims for
causality.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN
4. Results are interpreted in light of
findings from other studies and in terms
of the original framework and
hypotheses.
5. The interpretation distinguishes
between statistical significance and
clinical significance.
K. Implications
1. The researchers offer implications for
practice.
2. The researchers offer implications for
education and administration
3. The researchers offer implications for
theory and future research.
4. Stated implications are appropriate,
given study limitations
5. Generalizations (to the population) are
warranted on the basis of the sample
used for the study.
L. Recommendations
1. Specific recommendations are made
for improvement in study methods.
2. Recommendations are made for future
research investigations.
3. Recommendations are consistent with
the findings.
26
1 2 Results were compared to other
3 studies briefly.
N/A
1 2 Clinical significance briefly
3 mentioned there should
psychological support for infertile
woman. Statistical significance
was stated to have a higher
amount of depression/anxiety in
women.
Researchers offer implications for
1 2 practice.
3
1 2 Brief education and administration
3 details were mentioned in study.
1 2 3
1 2 No future research suggested
3 and limitations were not
1 2 3 mentioned in study
1 2 Implications are appropriate given
3 limitations- psychosocial support
required for infertile women based
on results
1 2 Cultural generalization is
3 warranted based on sample used
in the study
No methods are recommended
1 2 for future studies.
3
1 2 No recommendations made for
3 future research investigations.
1 2 No recommendations were made
3 for future studies.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 27

4. Recommendations fit the theoretical or 1 2 No recommendations were made

conceptual framework. 3 for future studies.

5. Alternative explanations are provided 1 2 No unexpected findings were

for unexpected findings or unconfirmed 3 noted.
hypotheses. N/A

*Remember to remove 3 pts from the divisors below for every question that is N/A.

Research Problem/Question 12 = __80__%

15
Review of Literature 8 = __53__%
15
Theoretical/Conceptual Framework 5 = __33__%
15
Methodology: Design 7 = __78__%
9
Methodology: Sampling 11 = _73__%
15
Methodology: Data Collection 8 = _53__%
15
Methodology: Instruments 12 = __100__%

12
Data Analysis 15 = _100_%
15
Research Ethics 13 = _86_%
15
Findings/Interpretation 12 = _80_%
15
Implications (2 questions have 2 parts) 15 = __71__%
21
Recommendations 4 = __33__%
(12 sections x 15 pts [5 questions x 3 pts] = 180) 12
(180 plus 2 extra questions = 186) _122__ = 70_% Overall
TOTAL 174
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 28

CRITICAL APPRAISAL OF QUANTITATIVE RESEARCH EVIDENCE

Author: Eniko Lakatos, Judit F Szigeti, Peter P Ujma, Reka Sexty and Piroska BaloTitle: Anxiety
and depression among infertile women: a cross-sectional survey from Hungary
Assign one rating to each: 1 = not met 2 = partially met 3 = completely met
Assign N/A if the question is not appropriate to the study being examined.

CRITERIA APPRAISAL COMMENTS

A. Research Problem/Question “The aim of the study is to assess

1. There is a clear statement of purpose 1 2 the psychological state of women
or research question. 3 with and without fertility problems”

2. The problem is significant for nursing 1 2 Infertility is common and it is

practice, administration or education. 3 important to understand the
correlation with
anxiety/depression

3. Hypotheses are stated clearly and 1 2 There is no hypothesis but there

easy to find. If no hypotheses, this is 3 is an aim of the study
justified. N/A

4. Key concepts, variables are clearly 1 2 Sources of stress, sexual

defined. 3 relations etc

5. Study population and setting are 1 2 225 women (134 infertile, 91

clearly specified. 3 fertile) collected in a clinical
setting and online

B. Review of Literature Review is thorough and specific

1. Review is thorough, yet concise, clear, 1 2 studies were mentioned
and current and includes principal 3
studies.

2. Content of review relates directly to 1 2 Review provided good foundation

research question and problem. 3 for background of infertility factors
affecting mental well-being

3. Review critically appraises and 1 2 It mentioned that most studies

compares contributions of key studies, 3 don’t break up the infertile group
identifying strengths, weaknesses, and into treatment vs no treatment
gaps.

4. Review is well organized and written in 1 2 Well organized, clear and concise
appropriate language. 3
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 29

5. Review synthesizes state-of-the-art of 1 2 Mentioned multiple specific

knowledge on topic. 3 studies from the past

C. Theoretical or Conceptual No theory described

Framework 1 2
1. A theoretical or conceptual framework 3
is described

2. Major features or elements of the 1 2 No Theory or framework

theory or framework are clearly 3 described
explained. N/A

3. Theory is appropriate to the research 1 2 No theory described

problem; hypotheses flow naturally from 3
framework.

4. Deductions that relate to the theory are 1 2 No theory described

logical, conceptually and clinically. 3
N/A

5. At the end, the researcher ties findings 1 2 No theory described

back to the theoretical framework. 3

D. Methodology: Design Research design is described but

1. The research design is clearly 1 2 no limitations are noted
described and most appropriate, given 3
the nature of the problem. Design
limitations are noted.

2. If more than one group is studied, 1 2 It is non-experimental

there was random selection and 3
assignment of subject to group. If non- N/A
experimental, this is justified.

3. Before-after comparisons are specified 1 2 Before and after comparisons are

and are most important ones. If no 3 not mentioned
comparison group, there are no problems N/A
with interpretation of results.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN
4. Adequate procedures were used to
control intrinsic (subject characteristics)
and external (situational) factors; the
study is internally (no uncontrolled
threats) and externally (findings are
generalizable) valid.
5. The design enables the researchers to
draw causal inferences about the
relationship among study variables.
E. Methodology: Sampling
1. The target population is described, and
the population to whom the study results
can be generalized is identified.
2. Eligibility criteria are clearly specified
(inclusion & exclusion).
3. Sampling plan is described and is
adequate to obtain a representative
sample. If a non-probability sample is
used, sampling method is justified.
4. Recruitment of subjects to the sample
is described, appropriate, and unbiased.
5. The size and key characteristics of the
sample are described. The study sample
is sufficiently large and justified on the
basis of power analysis.
F. Methodology: Data Collection
1. Methods for data collection are clearly
identified; if multiple methods were used,
they are appropriate and justified.
2. Data collectors were appropriately
chosen and trained
30
1 2 Various factors were observed
3 but they were not excluded such
as education level, residence,
socioeconomic status were
surveyed and compared in the
study but were not controlled
1 2 Different factors affecting the
3 results were noted and compared
N/A
225 women (134 infertile, 91
1 2 fertile) collected in a clinical
3 setting and online
1 2 They excluded chronic diseases
3 and inclusions were clearly
described and studied
1 2 They mention they were recruited
3 online and in a clinical setting.
However, we don't know how they
recruited them
1 2 They don’t describe methods of
3 recruitment
1 2 225 women participated- 134 with
3 primary infertility and 91 fertile
controls. They said it is a small
sample group, especially the
infertile patients
Questionnaires and surveys
1 2 clearly described and noted-
3 Spielberger State Trait Anxiety
Inventory (STAI-T), Beck
Depression Intervention (BDI),
Fertility problem inventory (FPI)
1 2 Data collectors and training
3 weren't mentioned
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 31

3. The setting for data collection is 1 2 Websites and clinics from sample
described and appropriate. 3 population was noted

4. There is no evidence of bias in the 1 2 Data collected identification

data collection procedures. 3 unsure

5. Study participants were not exposed to 1 2 Observation only

unnecessary risks or undue burden. 3

G. Methodology: Instruments The data collection used in

1. The research question lends itself to 1 2 methods adequately addresses
data collection using the method(s). 3 the research question

2. The instrument(s) covers the 1 2 They used multiple surveys and

complexity of the concepts being 3 questionnaires that addressed the
measured. different factors

3. Pertinent validity and reliability data 1 2 Surveys and questionnaires are

are presented for instrument(s). 3 valid and reliable

4. Pre-testing of instruments for this study 1 2 No pre-testing was involved

was done if needed and assumptions for 3
parametric statistics were met. N/A

5. Data quality (poor?) did not play a role 1 2 High quality data
in failure to confirm hypotheses. 3
N/A

H. Data Analysis Independent sample T-test, chi

1. Correct descriptive statistics are used 1 2 squared, central tendency (mean)
to describe major characteristics of the 3 were all used in this study.
sample and the major variables, including
central tendency and variability.

2. At least one appropriate statistical test 1 2 Independent sample T-test, chi

is performed for each of the hypotheses 3 squared, central tendency (mean)
or research questions. were all used in this study.

3. The most powerful tests appropriate to 1 2 Independent sample T-test was

the data are utilized and procedures are 3 used in this study.
done correctly.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN
4. The amount of statistical information
provided is sufficient to support findings
of the study; tables and figures clearly
illustrate the results.
5. Conclusions drawn from results of
statistical tests are accurate and justified.
I. Research Ethics
1. The study was approved and
monitored by an ethics committee or IRB.
2. Benefits to subjects outweighed any
risks or discomforts caused by the study.
3. Appropriate steps were taken to
safeguard the privacy (confidentiality) of
subjects.
4. Appropriate consent procedures were
implemented.
5. The researchers make no
inappropriate claims or use findings
inappropriately.
J. Findings/Interpretation
1. All important results are discussed,
and interpretations are consistent with
results (statistical analysis).
2. Limitations of the study are identified
and taken into consideration when
findings are discussed.
32
1 2 Sufficient statistical data and
3 tables are illustrated
1 2 Conclusions were explained and
3 matched statistical data
No approval by ethics committee
1 2 is mentioned
3
1 2 There were no risks or
3 discomforts for participants.
1 2 Data anonymous
3
1 2 3 Consent was signed
1 2 Findings are appropriate with
3 statistical data
Depression and anxiety were
1 2 higher in infertile groups than
3 fertile groups. Almost half
(44.8%) of our infertile sample
displayed moderate to severe
depressive symptoms.
1 2 Limitations include the self-
3 selection of online respondents,
whose meeting of the inclusion
criteria cannot be determined
cleary- they did not verify the
identity of online respondents
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 33

3. The researchers offer persuasive 1 2 Researchers do not claim

evidence to support interpretation and 3 causality but they provide
make no inappropriate claims for evidence from result to support
causality. correlation

4. Results are interpreted in light of 1 2 They are interpreted in light of

findings from other studies and in terms 3 other studies-specific studies are
of the original framework and N/A mentioned and discussed but
hypotheses. there is no hypothesis

5. The interpretation distinguishes 1 2 Specific psychological

between statistical significance and 3 interventions are needed and
clinical significance. presently absent

K. Implications Specific psychological

1. The researchers offer implications for 1 2 interventions are needed and
practice. 3 presently absent

2. The researchers offer implications for 1 2 Implications for education and

education and administration 3 administration are not noted.
1 2 3

3. The researchers offer implications for 1 2 Backing up quantitative analysis

theory and future research. 3 with qualitative methods including
1 2 3 in-depth interviews and using a
longitudinal design is mentioned

4. Stated implications are appropriate, 1 2 Implications are appropriate

given study limitations 3 given limitations noted

5. Generalizations (to the population) are 1 2 Sample size was small so results
warranted on the basis of the sample 3 may not translate to entire
used for the study. population

L. Recommendations Sample size needs to be

1. Specific recommendations are made 1 2 increased
for improvement in study methods. 3

2. Recommendations are made for future 1 2 Suggest backing up the

research investigations. 3 quantitative analyses with
qualitative methods, including
interviews

3. Recommendations are consistent with 1 2 Stated need for psychological

the findings. 3 evaluations and intervetions are
needed
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 34

4. Recommendations fit the theoretical or 1 2 No theory or framework

conceptual framework. 3

5. Alternative explanations are provided 1 2 No unexpected findings

for unexpected findings or unconfirmed 3
hypotheses. N/A

*Remember to remove 3 pts from the divisors below for every question that is N/A.

Research Problem/Question 13 = _86__%

15
Review of Literature 15 = _100__%
15
Theoretical/Conceptual Framework 3 = __33%
9
Methodology: Design 8 = _22__%
9
Methodology: Sampling 10 = _66__%
15
Methodology: Data Collection 12 = _80__%
15
Methodology: Instruments 12 = _100 _%

12
Data Analysis 15 = _100__%
15
Research Ethics 13 = _86__%
15
Findings/Interpretation 14 = _93__%
15
Implications (2 questions have 2 parts) 16 = _76__%
21
Recommendations 10 = __83__%
(12 sections x 15 pts [5 questions x 3 pts] = 180) 12
(180 plus 2 extra questions = 186) ____141__ = _84__% Overall
TOTAL 168

CRITICAL APPRAISAL OF QUANTITATIVE RESEARCH EVIDENCE

ANXIETY AND DEPRESSION IN INFERTILE WOMEN
Author: Ahmad Ali Noorbala, Fatemeh Ramezanzadeh, Nasrin Abedinia, Mohammad
Mehdi Naghizadeh
Title: Psychiatric disorders among infertile and fertile women
Assign one rating to each: 1 = not met 2 = partially met 3 = completely met
Assign N/A if the question is not appropriate to the study being examined.
CRITERIA
A. Research Problem/Question
1. There is a clear statement of
purpose or research question.
2. The problem is significant for
nursing practice, administration or
education.
3. Hypotheses are stated clearly and
easy to find. If no hypotheses, this is
justified.
4. Key concepts, variables are clearly
defined.
5. Study population and setting are
clearly specified.
B. Review of Literature
1. Review is thorough, yet concise,
clear, and current and includes
principal studies.
2. Content of review relates directly to
research question and problem.
3. Review critically appraises and
compares contributions of key studies,
35
APPRAISAL COMMENTS
Compares the prevalence of psychiatric
1 2 3 disorders and potential predisposing
factors in fertile and infertile women in
Iran.
1 2 3 Wants to help identify psychiatric
disorders and organize prevention and
treatment.
1 2 3 No hypothesis given. Provided a
N/A statement of purpose instead.
1 2 3 Variables suggested psychological
difficulties (gender differences, causes
and length of infertility, the specific
stage of investigation, the treatment
contexts in which couples are studied,
and the coping strategies used to deal
with their infertility). Variables such as
stress factors are also noted
1 2 3 150 infertile women who attended the
Infertility Clinic of Vali-e-Asr
Reproduction Health Research Center
and 150 married, fertile women who
attended the Gynecology Clinic of
Imam Khomeini Hospital (Tehran,
Iran)
General references, comparisons,
1 2 3 suggestions made to unspecified
studies. Discussion section compared
results found in this study to other
studies done
1 2 3 Content of review related to several
variables (work status, Western vs.
Eastern culture, scales of SCL-90)
1 2 3 It compares results with other studies
but no strengths or weaknesses were
ANXIETY AND DEPRESSION IN INFERTILE WOMEN
identifying strengths, weaknesses, and
gaps.
4. Review is well organized and 1 2
written in appropriate language.
5. Review synthesizes state-of-the-art 1 2
of knowledge on topic.
C. Theoretical or Conceptual
Framework 1 2
1. A theoretical or conceptual
framework is described
2. Major features or elements of the 1 2
theory or framework are clearly N/A
explained.
3. Theory is appropriate to the 1 2
research problem; hypotheses flow
naturally from framework.
N/A
4. Deductions that relate to the theory 1 2
are logical, conceptually and N/A
clinically.
5. At the end, the researcher ties 1 2
findings back to the theoretical N/A
framework.
D. Methodology: Design
1. The research design is clearly 1 2
described and most appropriate, given
the nature of the problem. Design
limitations are noted.
2. If more than one group is studied, 1 2
there was random selection and N/A
assignment of subject to group. If non-
experimental, this is justified.
3. Before-after comparisons are 1 2
specified and are most important ones. N/A
If no comparison group, there are no
problems with interpretation of results.
4. Adequate procedures were used to 1 2
control intrinsic (subject
characteristics) and external
(situational) factors; the study is
internally (no uncontrolled threats)
36
stated.
3 Review is clear and concise of several
studies. Mentioned throughout
introduction and discussion sections.
3 Provides general and concise
information of previous related studies,
without mention of specific details.
No theoretical framework is mentioned
3 in this study.
3 No theoretical framework is mentioned
in this study
3 No theory or hypotheses. Only purpose
of study is stated.
3 No theoretical framework is mentioned
in this study
3 No theoretical framework is mentioned
in this study
Research design is clearly described,
3 no design limitations are noted in this
study.
3 Consecutive sampling was used to
study both groups of fertile and
infertile women. This study was non
experimental
3 No before-after comparisons noted.
Only, open ended questionnaire is used
to assess subjects (SCL-90 R). Stress
factors were compared between
infertile women and fertile women
with and without psychological
distress.
3 No procedures were used to control
intrinsic and extrinsic factors. Study
observed internally and externally
valid factors.
ANXIETY AND DEPRESSION IN INFERTILE WOMEN
and externally (findings are
generalizable) valid.
5. The design enables the researchers
to draw causal inferences about the
relationship among study variables.
E. Methodology: Sampling
1. The target population is described,
and the population to whom the study
results can be generalized is identified.
2. Eligibility criteria are clearly
specified (inclusion & exclusion).
3. Sampling plan is described and is
adequate to obtain a representative
sample. If a non-probability sample is
used, sampling method is justified.
4. Recruitment of subjects to the
sample is described, appropriate, and
unbiased.
5. The size and key characteristics of
the sample are described. The study
sample is sufficiently large and
justified on the basis of power
analysis.
F. Methodology: Data Collection
1. Methods for data collection are
clearly identified; if multiple methods
were used, they are appropriate and
justified.
37
1 2 3 Study design, involving the
N/A comparison, allows for casual
relationship inferences between
psychological well being of infertile
and fertile women.
Target population is properly described
1 2 3 and generalized. 150 infertile women
who attended the Infertility Clinic of
Vali-e-Asr Reproduction Health
Research Center and 150 married,
fertile women who attended the
Gynecology Clinic of Imam Khomeini
Hospital (Tehran, Iran) selected by
consecutive sampling.
1 2 3 Psychologists entered the participants
into the study after informed consent.
No exclusions or inclusions noted-
subjects were categorized based on
questionnaire answers.
1 2 3 Consecutive sampling is non-
probability method is used.
1 2 3 Consecutive sampling was used.
Recruitment of subjects by
psychologist was not explained.
1 2 3 Size of the study sample is described
(150 fertile/150 infertile women). The
study did not provide any statistical
tests to justify the sample size.
Multiple questionnaires used for data
1 2 3 collection- open ended questionnaire
(age, educational level, work status,
monthly, family income, duration of
marriage, previous psychological
problems [services used and drug
treatment(s)] and disease
information (history, cause and
duration), SCL-90 (test to assess nine
aspects: somatization, obsessive–
compulsive disorders, interpersonal
sensitivity, depression, anxiety,
aggression, phobic anxiety, paranoid
ANXIETY AND DEPRESSION IN INFERTILE WOMEN
2. Data collectors were appropriately
chosen and trained
3. The setting for data collection is
described and appropriate.
4. There is no evidence of bias in the
data collection procedures.
5. Study participants were not exposed
to unnecessary risks or undue burden.
G. Methodology: Instruments
1. The research question lends itself to
data collection using the method(s).
2. The instrument(s) covers the
complexity of the concepts being
measured.
3. Pertinent validity and reliability
data are presented for instrument(s).
4. Pre-testing of instruments for this
study was done if needed and
assumptions for parametric statistics
were met.
5. Data quality (poor?) did not play a
role in failure to confirm hypotheses.
H. Data Analysis
1. Correct descriptive statistics are
used to describe major characteristics
of the sample and the major variables,
including central tendency and
variability.
2. At least one appropriate statistical
test is performed for each of the
hypotheses or research questions.
3. The most powerful tests appropriate
to the data are utilized and procedures
are done correctly.
4. The amount of statistical
information provided is sufficient to
38
ideation, and psychoticism), and stress
factors were assessed using a semi
constructed questionnaire
1 2 3 No information provided regarding the
selection of data collectors was given.
1 2 3 Infertile women at the Infertility Clinic
of Vali-e-Asr Reproduction Health
Research Center and 150 married,
fertile women from the Gynecology
Clinic of Imam Khomeini Hospital
(Tehran, Iran) from March 2005 until
June 2006.
1 2 3 No information regarding data
collection procedures but there could
be self bias due questionnaires
1 2 3 Participants were not exposed to
unnecessary risks.
The stated purpose of the study
1 2 3 facilitates data collection by the
methods used.
1 2 3 The instruments used, a 90-item
questionnaire covers the various
variables involved in the study.
1 2 3 SCL-90 -R and stress factors were
assessed using the Holmes-Rahe stress
scale.
1 2 3 No pre-tests were done for this study
N/A
1 2 3 Data was sufficient in supporting the
N/A studies goal
t-test, central tendency and chi square
1 2 3 were appropriately used
1 2 3 Statistical test are used for the question
in study.
1 2 3 t-test, central tendency and chi square
were appropriately used
1 2 3 Sufficient statistical information was
provided in support of the findings
ANXIETY AND DEPRESSION IN INFERTILE WOMEN
support findings of the study; tables
and figures clearly illustrate the
results.
5. Conclusions drawn from results of 1 2
statistical tests are accurate and
justified.
I. Research Ethics
1. The study was approved and 1 2
monitored by an ethics committee or
IRB.
2. Benefits to subjects outweighed any 1 2
risks or discomforts caused by the
study.
3. Appropriate steps were taken to 1 2
safeguard the privacy (confidentiality)
of subjects.
4. Appropriate consent procedures 1 2
were implemented.
5. The researchers make no 1 2
inappropriate claims or use findings
inappropriately.
J. Findings/Interpretation
1. All important results are discussed, 1 2
and interpretations are consistent with
results (statistical analysis).
2. Limitations of the study are 1 2
identified and taken into consideration
when findings are discussed.
3. The researchers offer persuasive 1 2
evidence to support interpretation and
make no inappropriate claims for
causality.
4. Results are interpreted in light of 1 2
findings from other studies and in N/A
terms of the original framework and
hypotheses.
5. The interpretation distinguishes 1 2
between statistical significance and
clinical significance.
K. Implications
1. The researchers offer implications 1 2
for practice.
2. The researchers offer implications 1 2
for education and administration 1 2
39
presented in tables.
3 Results are thoroughly explained,
supporting conclusions stated.
The study did not state if it was
3 approved or monitored by an ethics
committee or IRB
3 Subjects were required to report self
questionnaires, therefore no risks
should be inflicted on them
3 No appropriate steps were mentioned
to safeguard private information of
subjects
3 Written consent was obtained by
psychiatrist to patients
3 Researchers did not state inappropriate
claims or findings inappropriately
Results were discussed and compared
3 to previous studies. Interpretations are
consistent based on results
3 No study limitations were identified.
3 Researchers offer persuasive evidence
to support their results based on other
studies and cultural influences
3 Results of other studies are used to
compare results from this study to see
which results yielded the same results.
3 Statistical significance was interpreted
but did not make any distinguish
between clinical significance.
Researchers proposed gynecologists to
3 work closely with psychologists and/or
psychotherapists.
3 Suggestions are made to educate
3 infertile women via media, of the
resources available to them and their
family members of how they can
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 40

support a infertile family member.

3. The researchers offer implications
for theory and future research.
4. Stated implications are appropriate,
given study limitations
5. Generalizations (to the population)
are warranted on the basis of the
sample used for the study.
L. Recommendations
1. Specific recommendations are made
for improvement in study methods.
2. Recommendations are made for
future research investigations.
3. Recommendations are consistent
with the findings.
4. Recommendations fit the theoretical 1
or conceptual framework.
5. Alternative explanations are
provided for unexpected findings or
unconfirmed hypotheses.
*Remember to remove 3 pts from the divisors below for every question that is N/A.
1 2 3 No implications for theory or research
1 2 3 were proposed.
1 2 3 The stated implications were supported
by the studies findings and were
appropriate.
1 2 3 The sample used for the study
represented the general population of
Iran.
No recommendations were made for
1 2 3 improvement in future studies.
1 2 3 No recommendations were made for
future studies.
1 2 3 Study suggests support such as
treatment, counseling methods, and
suggests that the media promote
awareness in order to decrease
psychiatric symptoms
2 3 No recommendations were made in
regards to theoretical or conceptual
framework.
1 2 3 No unexpected findings were
N/A mentioned and explained. No
hypothesis was stated therefore it could
not be unconfirmed.

Research Problem/Question __12_ = 100%

12
Review of Literature _12__ = 80%
15
Theoretical/Conceptual Framework _1_ = 33%
3
Methodology: Design _15__ = 100%
15
Methodology: Sampling _12__ = 80%
15
Methodology: Data Collection _11__ = 73%
15
Methodology: Instruments _12__ = 100%
12
Data Analysis _15__ = 100 %
15
Research Ethics _11__ = 73 %
ANXIETY AND DEPRESSION IN INFERTILE WOMEN 41

15
Findings/Interpretation _11__ = 73 %
15
Implications (2 questions have 2 parts) _15___ = 71 %
21
Recommendations ___7_ = 47%
(12 sections x 15 pts [5 questions x 3 pts] = 180) 15
(180 plus 2 extra questions = 186) 134 = 80 % Overall
TOTAL 168