Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Sexual Satisfaction Among Infertile Couples: Demographics and Psychosocial Health Factors

Alia Ibrahim Mahadeen, PhD, RN; Ayman M. Hamdan-Mansour, PhD, RN; Samira A. Habashneh, PhD, RN; Latefa Ali Dardas, PhD, PMHN

Abstract

The purpose of the current study was to explore sexual satisfaction among infertile couples in Jordan and its associations with psychosocial and sociodemographic factors. Using a descriptive correlational design, 248 infertile couples from outpatient clinics were recruited and filled out a questionnaire on sexual satisfaction, in addition to perceived social support, depressive symptoms, psychological stress, coping skills, optimism, life satisfaction, and sociodemographics. Sexual satisfaction was significantly and positively correlated with perceived social support, optimism, life satisfaction, and coping. Stronger association was observed between sexual satisfaction and optimism. No difference was found in sexual satisfaction in relation to participants' gender, age, working status, or education. This study highlights the importance of building mental health nurses' competence to provide education and counseling on sexuality to improve the quality of life of infertile couples and optimize their sexual wellness. The most recent guidelines for psychosocial care for infertile couples are discussed. [Journal of Psychosocial Nursing and Mental Health Services, 58(9), 40–47.]

Abstract

The purpose of the current study was to explore sexual satisfaction among infertile couples in Jordan and its associations with psychosocial and sociodemographic factors. Using a descriptive correlational design, 248 infertile couples from outpatient clinics were recruited and filled out a questionnaire on sexual satisfaction, in addition to perceived social support, depressive symptoms, psychological stress, coping skills, optimism, life satisfaction, and sociodemographics. Sexual satisfaction was significantly and positively correlated with perceived social support, optimism, life satisfaction, and coping. Stronger association was observed between sexual satisfaction and optimism. No difference was found in sexual satisfaction in relation to participants' gender, age, working status, or education. This study highlights the importance of building mental health nurses' competence to provide education and counseling on sexuality to improve the quality of life of infertile couples and optimize their sexual wellness. The most recent guidelines for psychosocial care for infertile couples are discussed. [Journal of Psychosocial Nursing and Mental Health Services, 58(9), 40–47.]

Infertility, the inability of a sexually active, noncontracepting couple to achieve pregnancy in 1 year, is a global health issue that affects more than 48 million couples worldwide (World Health Organization, 2000, 2012). In the Middle East, prevalence of infertility varies between 10% and 15% of married couples because of high prevalence of post-partum infection, post-abortive infection, iatrogenic infertility, schistosomiasis, and tuberculosis (Al-Turki, 2015; Serour, 2008). Over the past 2 decades, more attention has been paid to the prevention of infertility in the region. In fact, assessment of infertility treatments in different countries shows that development of infertility clinics in the Middle East is faster than the rest of the world, including European and North American countries (Sadeghi, 2015). However, the cultural context is believed to have a significant role in shaping the mental health and well-being of a couple's life in this region.

A diagnosis of infertility may be considered a stigma for involved couples, which could result in serious psychosocial complications, such as depression, social withdrawal, and separation (Mahadeen et al., 2018). There is also gender-based suffering in infertility in many Middle Eastern countries. Infertility is often related to the wife rather than to the husband, even if she is not the cause of infertility (Serour, 2008). If infertility occurs, it is the female partner who carries its cultural burden and experiences anxiety, frustration, fear, social stigma, divorce, and may even undergo life-threatening medical intervention. One qualitative study revealed that some of these women tend to describe themselves as being “half a woman, half a man,” as having “broken wings,” as “incomplete,” and as a “dead tree” (Daibes et al., 2018. p. 522).

In Jordan, an Arab country located in Western Asia, marriage is strongly linked to reproduction and family foundation, and women's empowerment is strongly tied to fertility and births immediately after marriage (Mahadeen et al., 2018). The most recent report indicated that the infertility rate in Jordan has increased from 8.8% in 2002 to 15% in 2014 (The World Bank, 2019). Assisted reproductive technology (ART) services have increased dramatically over the past decade in the country. However, they are widely available in the military and private sectors, but not in the public sector. The cost of treatment varies between these sectors. In the military sector, for example, the cost of one cycle of in vitro fertilization (IVF) treatment ranges between 1,500 and 2,500 Jordanian dinars (JOD) ($2,000 and $3,500), whereas in the private sector, it goes up to JOD 4,000 to 5,000 ($5,500 to $7,000) (Bardaweel et al., 2013). Research has also reported the use of complementary and alternative therapies, such as herbal and spiritual therapy, among infertile couples in Jordan (Bardaweel et al., 2013). Infertility services in Jordan are regulated by law. Marriage is required to be accepted for ART treatment. Single women or lesbian couples cannot access ART treatment. However, women can undergo egg freezing procedures for the purpose of preserving fertility. Violation of the marriage contract by death of spouse or divorce would prevent the use of gametes or embryos available in the ART center (International Labour Organization [ILO], 2020; Serour, 2008).

As is the case in most Middle Eastern countries, the marital relationship between Jordanian infertile couples is often influenced by cultural and social demands; in particular, increased pressure from people seeking clarifications or details about the reasons for the couple's infertility. It was reported that infertile couples in Jordan are affected by prejudice and may experience isolation due to the pressure of having to explain infertility to their extended family (Mahadeen et al., 2018; Mahboub et al., 2014).

Sexual Satisfaction in Infertility

Anecdotal evidence and intuition suggest that establishing a functional family necessitates maritally and sexually satisfied couples. Sexual satisfaction is a variable of interest because many studies empirically show that sexual aspects of marital relationships are correlates of marital satisfaction (Ferreira et al., 2015; Stephenson et al., 2013; Yoo et al., 2014). According to Lee et al. (2001), sexual satisfaction can be defined as the degree of satisfaction with orgasm frequency, coital frequency, sex drive, and partner's show of concern during intercourse. The notion of sexual satisfaction also proposes that partners' expectations of a sexual relationship are being met (Mirghafourvand et al., 2013). Researchers argue that if these expectations are not adequately met, both partners' psychological and physical well-being can be adversely influenced (Kazemi et al., 2011). Having children is a key expectation that most couples expect as an outcome of their sexual relationship. Therefore, being infertile is believed to directly impact the quality of the sexual relationship (Samadaee-Gelehkolaee et al., 2015). There is a clinical consensus that sexual dissatisfaction is an indicator of relationship difficulties. In fact, infertile and childless couples are at higher risk for marital instability, marital coldness, anxiety, and depression (Tao et al., 2011).

The association between infertility and sexual satisfaction has been insufficiently addressed in the literature (Tao et al., 2011). The few studies in this field showed that infertility can inversely affect marital adjustment and sexual functioning among men and women (Drosdzol & Skrzypulec, 2008; Valsangkar et al., 2011). Furthermore, depression, erectile dysfunction, and sexual relationship problems are found to be common among male partners of infertile couples (Valsangkar et al., 2011). Infertility and its related factors, such as unsuccessful treatment, continuing lack of conception and child-bearing, and the absence of a parental role, can negatively impact a sexual relationship, and eventually lead to psychological, sociological, and spiritual disturbances (Tao et al., 2011). The role of personal and demographic characteristics has also revealed that low income, life stressors, and poor relation with family members are significant factors influencing the sexual relationship among infertile couples (Jumayev et al., 2012).

In the Middle East in general, and Jordan in particular, no studies have yet explored sexual satisfaction among infertile couples. The purpose of the current study was to explore sexual satisfaction among infertile couples in Jordan and its associations with psychosocial and sociodemographic factors.

Method

Design

A cross-sectional, correlation design was used to examine the relationship of psychosocial and sociodemographic factors with sexual satisfaction among infertile couples in Jordan. A total of 400 surveys were distributed to infertile couples attending IVF clinics from a large governmental hospital and four private hospitals. Two hundred forty-eight couples returned the questionnaires, for a response rate of 62%. Participants were all adults, diagnosed with infertility by a gynecologist specialized in the management of infertility, and had the ability to read and write in Arabic. Ethical approvals were obtained from the ethics committee at the University of Jordan School of Nursing, and from the special Institutional Review Board ethical committees of each selected hospital before initiating data collection.

Instrumentation

The study used validated Arabic versions of eight instruments. In addition, demographic and personal characteristics of participants were obtained using a separate profile sheet developed by the researchers.

Perceived social support was measured using the Arabic version of the Multidimensional Scale of Perceived Social Support (Hamdan-Mansour et al., 2015). The 12-item instrument assesses participants' perception of social support from family, friends, and significant others. Each item was measured using a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Total score ranges from 12 to 84, with higher scores indicating higher perceived social support. In the current study, the scale had good internal consistency with Cronbach's alpha = 0.88.

Depressive symptoms were measured using the Arabic version of the Beck Depression Inventory-II (BDI-II-R) (Hamdan-Mansour et al., 2015). The instrument includes 21 questions that assess cognitive-affective symptoms and attitudes, impaired performance, and somatic symptoms. The questions were answered on a 4-point Likert scale from 0 (absence of symptoms) to 3 (presence of extreme symptoms). Total score ranges from 0 to 63, with standard cut-off points: 0 to 13 indicates no or minimal symptoms, 14 to 19 indicates mild symptoms, 20 to 28 indicates moderate symptoms, and 29 to 63 indicates severe symptoms. A score of 13 is the cutoff point indicating depression. In the current study, Cronbach's alpha = 0.85.

Psychological stress was measured using Lemyre et al.'s (1990) 9-item brief form of Psychological Stress Measure. Participants responses were measured on a Likert scale ranging from 1 (null) to 4 (much). Higher scores indicated higher levels of psychological stress. This instrument had a test–retest reliability of 0.68 to 0.80 under constant conditions.

Coping skills were measured using the Arabic version of the Brief COPE inventory (Hamdan-Mansour et al., 2015). This instrument consists of 28 items to examine participants' coping mechanisms with stress. The instrument measures 14 domains, with responses ranging from 1 (I have not been doing this at all) to 4 (I have been doing this a lot), where higher scores indicate more use of the coping mechanism. The current study showed good internal consistency with Cronbach's alpha = 0.83.

Optimism was measured using the Arabic version of Life Orientation Test (LOT-R) (Hamdan-Mansour et al., 2014). The instrument consists of 10 items that assess participants' optimism. Responses are scored on a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). Total score ranges from 10 to 50, with higher scores indicating higher optimism. In the current study, Cronbach's alpha = 0.73.

Life satisfaction was measured using the Arabic version of the Life Satisfaction Scale (Hamdan Mansour et al., 2017). The instrument comprises five items with responses ranked on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Total scores range from 5 to 35, indicating extremely satisfied (31 to 35), satisfied (26 to 30), slightly satisfied (21 to 25), neutral (20), slightly dissatisfied (15 to 19), dissatisfied (10 to 14), and extremely dissatisfied (5 to 9). Test–retest reliability was estimated to be 0.87.

Sexual satisfaction was measured using the Sexual Satisfaction Questionnaire (SSQ) (Lee et al., 2001). The SSQ comprises seven items grouped into two subscales: general sexual satisfaction (four items) and sex on demand pressure (three items), all scored on a 5-point Likert scale, with higher scores indicating higher sexual dissatisfaction. General sexual satisfaction is the degree of satisfaction with orgasm frequency, coital frequency, sex drive, and partner's show of concern during intercourse. Sex on demand pressure is the degree to which the couple experiences intercourse pressure at the time of ovulation.

Data Analysis

Data were entered and analyzed using SPSS version 21. Descriptive statistics were used to describe sample characteristics as well as the study questionnaires. Analysis of variance (ANOVA) and t tests were used to examine differences in sexual satisfaction among infertile couples with regard to selected demographic variables. Correlation matrix using Pearson's r was used to examine the relationship between sexual satisfaction and other psychosocial factors. Due to the exploratory nature of the study, the level of significance was not adjusted for multiple tests.

Results

Demographic Characteristics

Table 1 presents participants' characteristics. A total of 248 participants were included in the study, of whom 145 (58.5%) were females. Most participants (n = 101, 40.7%) were age 25 to 35 years and married (n = 244, 98.4%). In addition, 144 (58.1%) participants were employed, 65 (26.2%) were not employed, and six (2.4%) were retired. Regarding participants' level of education, most participants were educated, with 47.6% (n = 118) having undergraduate and graduate degrees, whereas <10% (n = 24) had not finished high school.

Descriptive Statistics of the Sample (N = 248)

Table 1:

Descriptive Statistics of the Sample (N = 248)

Sexual Satisfaction

Participants had a mean score of 13.5 (SD = 2.4) on the SSQ, with scores ranging from 7 to 19. Considering that the possible score range is 7 to 28, the results showed that 50% (Q25 – Q75) (n = 124) of participants had a score ≥17 and 50% had a score between 15 and 18, which indicates overall poor sexual satisfaction.

Psychosocial Factors

Depressive Symptoms. Some participants were experiencing symptoms of depression as measured by the BDI-II-R. Overall scores of depressive symptoms ranged from 21 to 58, with a mean score of 31.8. However, the level of depression varied among participants. Most participants were experiencing severe depressive symptoms (71%), and 29.4% had moderate depressive symptoms.

Life Satisfaction. Participants had a mean score of 18.1 (SD = 4.7) on the Life Satisfaction Scale, with scores ranging from 4 to 28. Considering that the possible score range is 5 to 35, the results showed that 50% (n = 124) of participants had a score ≥19 and 50% of participants had a score between 15 and 21, indicating most were slightly dissatisfied to slightly satisfied.

Psychological Distress. Participants experienced psychological distress, with scores ranging from 18 to 71 (mean score = 37, SD = 8) on the Psychological Stress Measure. In addition, the results showed that 50% (n = 124) of participants had a score ≥37, indicating a high level of stress.

Optimism. Participants had a mean score of 34 (SD = 6.3) on the LOT-R, with scores ranging from 16 to 49. Considering the possible score of 10 to 50, the results showed that 50% (n = 124) of participants had a score ≥34 and 50% had a score between 30 and 39, indicating moderate optimism.

Coping Skills. Participants' scores ranged from 27 to 91, with a mean score of 63 (SD = 1.3) on the Brief COPE Inventory. One half of participants had a score ≥64 and the other one half had a score between 53 and 72.

Perceived Social Support. Overall scores were at the moderate level. Specifically, the highest scores of perceived social support were others (mean score = 21.6, SD = 3.1) followed by family (mean score = 21.2, SD = 4.2). Support from friends had the lowest mean score of 18 (SD = 3.6).

Correlation Between Sexual Satisfaction and Psychosocial Factors

The correlation between sexual satisfaction and psychosocial factors was examined using Pearson's r (Table 2). A significant and positive correlation was noted between sexual satisfaction and perceived social support from others (r = 0.35), perceived social support from friends (r = 0.15), perceived social support from family (r = 0.40), optimism (r = 0.29), life satisfaction (r = 0.28), and coping (r = 0.15).

Correlation of Sexual Satisfaction With Psychosocial Factors

Table 2:

Correlation of Sexual Satisfaction With Psychosocial Factors

Differences in Sexual Satisfaction Related to Demographic Characteristics

To examine the differences in sexual satisfaction among infertile couples, ANOVA and t test for two independent samples were used (Table 3). The results showed that infertile couples were not significantly different in their sexual satisfaction in regard to demographic characteristics (e.g., gender, age, working status, education) (p > 0.05).

Differences in Sexual Satisfaction Related to Demographic Characteristics

Table 3:

Differences in Sexual Satisfaction Related to Demographic Characteristics

Discussion

The purpose of the current study was to explore sexual satisfaction among infertile couples in Jordan and its associations with psychosocial and sociodemographic factors. Findings revealed poor sexual satisfaction among this vulnerable population. The majority of participants experienced severe symptoms of depression, and more than one half were dissatisfied with their lives, expressed modest optimism behaviors, and received moderate social support. Findings also demonstrated that infertile couples with higher social support (including family, friends, and others), optimistic views, better life satisfaction, and coping experienced higher sexual satisfaction.

Social Support

Infertile couples in the current study reported receiving moderate social support, with low level of support from friends compared to family and others. Yet, couples' perceived family social support seemed to be a significant determinant of their sexual satisfaction. This finding was not surprising. In Arab culture, the family, rather than the individual, is the core of the community. The extended family system is often the first line of defense against potential life stressors (Dardas & Simmons, 2015). Social support contributes acceptance and love that eventually facilitates coping and decreases desperation (Abdolmajid et al., 2009; Eren, 2008). Previous studies (Al-Asadi & Hussein, 2015; Carver et al., 2010) suggested that lack of social support caused a higher rate of anxiety and depression symptoms during infertility, primarily among women. The current study supported these findings and revealed notable psychological stress and depression among infertile couples, which were also associated with lower social support.

Optimism

Among infertile couples, a strong association was found between sexual satisfaction and optimism. Findings suggest that couples who have pessimistic views are at higher risk of being conquered by emotions in their marriage. Congruent with Henry et al. (2007), couples who lack optimism easily become angry, sad, and disappointed by their partners' actions. Therefore, optimism in couples is a key element of marriage quality, as it relates to good behavior, personal success, and coping (Carver et al., 2010), as well as higher satisfaction and better life quality (Smith et al., 2013).

Life Satisfaction

It can be said that there is a “motherhood and fatherhood mandate” in the Arab culture. Infertility prevents affected couples from achieving this highly desired and socially approved goal, causing major disruption in their projected life course. The majority of infertile couples in the current study reported a sense of dissatisfaction with their lives. This finding is in line with previous relevant studies (Dembinska, 2016; Kiesswetter et al., 2019; Li et al., 2020; McQuillan et al., 2007). However, all of these studies, including the current study, focused on infertile couples who are actively seeking medical help for infertility, meaning that a significant portion of infertile couples who either did not seek medical help or did not meet criteria for infertility, are still to be heard. More studies are needed to investigate different groups of infertile couples (e.g., those who have not sought help, those with and without children).

Sample Characteristics

Although some studies provided an indication of the effect of individual characteristics on sexual satisfaction (Samadaee-Gelehkolaee et al., 2015), current findings showed no significant associations between sexual satisfaction and participants' gender, age, working status, or education. However, men, younger participants, full-time workers, and those with a university degree had the highest mean score among all other categories. As discussed previously, infertile Arab women often experience more anxiety, depression, and psychological distress than their partners due to sociocultural pressures. It is medically known that younger women have higher chances of IVF success, which might boost both partners' hope and psychological health compared to older couples whose chances of having children decline with age. Having a higher socioeconomic status (i.e., higher education and better employment) can also positively impact the mental health of infertile couples. One study found a positive correlation between socioeconomic status and ovarian reserve in women of reproductive age (Barut et al., 2016).

Limitations

Although the current findings provide some insight into factors contributing to sexual satisfaction among infertile couples in Jordan, they should be acknowledged within the context of the study's limitations, including sample and design. This study was limited to hospitals in Amman, and future studies need to establish whether these findings can be generalized to other infertility clinics in the northern and southern part of Jordan. The fact that this study was cross-sectional limits the findings, as sexual satisfaction is a dynamic process that can change over time. In addition, participants may have already had depressive symptoms before entering a sexual relationship and experiencing infertility. History of sexual assault could also affect an individual's sexual satisfaction in future relationships.

Implications for Mental Health Nurses

The literature suggests that over the past few decades the role of mental health professionals, including mental health nurses, in infertility has evolved from grief or crisis management and counseling to providing active psychotherapies. Recent guidelines (Domar, 2015; Gameiro et al., 2015; Patel, Dinesh, et al., 2018; Peterson et al. 2012) suggest that the current role of a mental health professional is exhaustive. The services of mental health professionals are underutilized as onsite specialists (i.e., during consultations, meetings, research, and grand rounds). Their expertise should ideally be used toward collaborative health care. According to Patel, Sharma, et al. (2018), the role of a mental health professional should include tailoring evidence-based interventions for the management of emotional challenges and treatment burden; helping patients make informed decisions that are unique to their needs and preferences; supporting patients' coping during waiting periods before pregnancy tests; developing accessible modules, such as e-mental health; developing and validating tools that help in clinical decision making; providing consultancy for staff training in communication skills, empathy, and breaking bad news; ensuring extended periods of support and collaborative team programs for staff experiencing burnouts; and supporting adaptive coping in patients during critical times, such as repeated treatment failures, and for long-term psychological adjustment to involuntary childlessness.

When it comes to the Jordanian and Arabic context, the de-institutionalization of mental health services is crucial to ensure compliance with health regimen. It should be noted that Arab individuals tend to hold negative attitudes toward formal psychiatric services and have less knowledge regarding the existence of these services and the role of its providers (Dardas & Simmons, 2015). One study (Gilat et al., 2010) revealed that when a member of an Arab family experiences mental health issues, these individuals usually turn first to family practitioners (33%), followed by family members (21.6%), and the Sheikh (19%). Only 11% turn to mental health practitioners.

The current study highlights the importance of building mental health nurses' competence to provide education and counseling on sexuality to improve the quality of life of infertile couples and optimize their sexual wellness. A standard operating procedure of nursing care in providing comprehensive services, including sexuality care, is necessary. Such care also needs to be incorporated in the curriculum of nursing, particularly mental health nursing. Consequently, nurses should have sufficient knowledge and skills to address sexuality problems in their patients.

Conclusion

Infertile couples in Jordan experience difficulties in different aspects of marriage and sexuality. Factors related to life satisfaction, coping, optimism, and social support contribute to couple's sexual satisfaction. These factors could also be part of key interventions and support systems for infertile couples. Further research is necessary to explore the reciprocal relationship between contextual cultures and sexual relations in the context of infertility. Moreover, marriage and sexual satisfaction of couples in Jordan might be influenced by other sociocultural factors related to the role of extended family and health beliefs about causes of infertility. It is important to address other sociocultural factors and marriage/sexual satisfaction with a holistic approach. Carefully designed studies using mixed methods are needed to further examine infertility issues.

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Descriptive Statistics of the Sample (N = 248)

Variablen (%)
Gender
  Female145 (58.7)
  Male103 (41.3)
Age (years)
  20 to 2415 (6)
  25 to 3018 (32.2)
  31 to 3583 (34)
  36 to 4050 (20.5)
  41 to 4515 (6.1)
Working status
  Unemployed65 (26.2)
  Part-time employment23 (9.3)
  Full-time employment144 (58.1)
  Retired6 (2.4)
Level of education
  Less than high school24 (9.7)
  High school65 (26.2)
  Diploma41 (16.5)
  Undergraduate degree94 (32)
  Graduate degree24 (9.7)
Years of marriage
  1 to 5113 (45.6)
  6 to 1089 (35.9)
  11 to 1526 (10.5)
  16 to 2012 (4.8)
  21 to 253 (1.2)
Reason for infertility
  Husband69 (27.8)
  Wife43 (17.3)
  Both24 (9.7)
  Unknown107 (43.1)

Correlation of Sexual Satisfaction With Psychosocial Factors

DepressionPSS-OPSS-FrPSS-FaOptimismLife SatisfactionCopingPsychological Distress
Depression
PSS-O−0.30**
PSS-Fr−0.22**0.52**
PSS-Fa−0.37**0.73**0.51**
Optimism−0.34**0.57**0.52**0.56**
Life satisfaction−0.27**0.44**0.28**0.50**0.528**
Coping0.25**0.23**0.17*−0.010.130.22**
Psychological distress0.31**0.090.04−0.10−0.10−0.080.47**
Marital/sexual satisfaction−0.110.35**0.15*0.40**0.29**0.28**0.15*0.08

Differences in Sexual Satisfaction Related to Demographic Characteristics

VariableMean (SD)ta/Fbp Value
Gender1.1a0.288
  Male13.7 (2.28)
  Female13.3 (2.5)
Age group0.174b0.952
  20 to 2413.4 (2)
  25 to 3013.5 (2.7)
  31 to 3513.6 (2.2)
  36 to 4013.2 (2.5)
  41 to 4513.3 (2.5)
Working status0.989b0.399
  Unemployed13.4 (2.4)
  Part-time employment12.8 (2.7)
  Full-time employment13.7 (2.2)
  Retired13.7 (1.6)
Education0.966b0.440
  Less than high school12.8 (2.4)
  High school13.5 (2.4)
  Diploma13.4 (2.3)
  Undergraduate degree13.6 (2.5)
Authors

Dr. Mahadeen is Associate Professor of Maternal Child Health Nursing, Dr. Hamdan-Mansour is Professor, Psychiatric Nursing, and Dr. Dardas is Assistant Professor, School of Nursing, The University of Jordan, and Dr. Habashneh is Assistant Professor, and Dr. Hamdan-Mansour is also Professor, Psychiatric Nursing, Faculty of Nursing, Al-Ahliyya Amman University, Amman, Jordan.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This project was funded by the deanship of academic research at the University of Jordan.

Address correspondence to Latefa Ali Dardas, PhD, PMHN, Assistant Professor, School of Nursing, The University of Jordan, Queen Rania Street, Amman 11942, Jordan; email: L.dardas@ju.edu.jo.

Received: March 11, 2020
Accepted: May 26, 2020

10.3928/02793695-20200812-01

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