Relation of Religious Coping and Depression Levels in Infertile Women

Objective: Religious coping is known as one of the successful manners to cure depressed infertile women; however, research findings show that demographic factors (e.g., education level) have played an important role on the relationship between depression and religious coping scores. The goal of this study is to measure the influence of age, job status, and education level on both scores within Iranian infertile women. Method : In this cross sectional study, 1000 women (mean age, 35.96; range, 26-45), who are recruited from different hospitals of Shiraz (Iran), are selected via multistage cluster sampling method. The reliability and validity of the translated versions of the questionnaires have been confirmed. The correlation coefficient (Spearman method), adjusted linear regression coefficient, and ordinal regression coefficient of demographic features with the depression scores/levels (minimal, mild, moderate, and severe) and religious coping scores are determined. Results: A significant negative correlation is found between depression and religious compatibility scores in 1000 infertile women (ρ = -0.318, P = 0.000). In addition, the results have implied the existence of a significant correlation and linear relationship between religious coping and age and job status (P < 0.05). Furthermore, both correlation and ordinal regression of depression intensity with both job status and education level are found to be statistically meaningful (P < 0.05). Conclusion: The negative correlation between religious coping and depression scores has implied the positive role of religious coping in protecting infertile women from depression, especially among employed women. Nevertheless, the correlation of religious coping with education level is not strong enough due to the nonuniform distribution of variables through their range.

life style, nutrition, and exposing to chemical environments (4). Nevertheless, there still exist a lot of unknown factors yielding infertility . World Health Organization (WHO) has recognized infertility as the main challenge of reproductive health (5). According to the WHO statistics, more than 70 million couples all around the world (between 12% to 15%) suffer from infertility (6). Regarding the statistics of this organization, the maximum infertility rate (31%) is reported in Sheffield (England). However, the WHO statistics are sometime different with what the local organizations report. For instance, according to WHO, infertility rate is between 13% to 19%, in different parts of Iran in 2002 (7), while Ebn-Sina (Avicenna), as a valid Iranian medical organization, reports 20.2% (19.9% in cities and 22% in rural areas) infertility rate in Iran in 2005 (8). WHO has performed an investigation to measure the rank of infertility among the 12 worst experiences that a female may face with during her lifetime (9). They have conducted this research over European countries, such as Netherland, France and Belgium. They have reported that infertile women experience the fourth worst tensioning experience after (I) losing their mother, (II) losing their father, and (III) spouse infidelity (10). Hence, infertility is one of the most disappointing factors that ruins the spirit and self-confidence of young women (11). This problem becomes more sophisticated among traditional families in the third-world and even developing countries. Based on the statistics (12), families who live in rural areas, villages, and margin of big cities have higher eagerness to have more children, rather than those who live in crowded cities. Having considerable number of children in rural areas has been carved in their culture. This tendency is originated from a variety of psychosocial factors, such as expecting children to financially support their old parents and taking care of them (13). In such cultural context, even families with 1 or 2 children are somehow humiliated, and this situation becomes sometimes intolerable for infertile women (14). In addition to the mentioned cultural issues, infertile women have lower chance of sustaining their marriage and they are sometimes compelled to get a divorce (15). Most infertile women are depressed due to the feeling of having a life-time disability. Among the psychiatric disorders, depression has the highest prevalence among infertile women. Depression has a very long historical background in a way that Selsus has described depression as the result of black bile and has documented it in "De Medicine" in 100 B.C. Depression is diagnosed via DSM-V, as the most well-known standard criteria, and its intensity is measured via taking the Beck test (second version) exam, termed as BDI-II (16). To treat depression, several approaches have been suggested: prescribing drug, religious coping, doing sport, Yoga, and meditation. Among these techniques religious coping has empirically proved to have the best effect on their health. Religious coping is defined as performing cognitivebehavioral methods (e.g., praying, going to holy places, believing in and trust to God as the absolute power) against stressful and catastrophic events. In the literature, it is emphasized that religious coping is recognized as an effective factor that can make the life of depressed people happy and meaningful. It can also help people toward their purposes and goals. Religious coping is one of the most effective ways to alleviate the spirit of young infertile women for curing their depression (17). Not only for infertility, but also for other unsolvable events like losing parents/children and cancer, religious coping has been shown to have a brilliant effect on the treatment process. Regarding the positive role of religious coping in the treatment of infertile women, researchers have been curious to quantitatively measure the effect of religious coping on the treatment of depression in terms of negative correlation coefficient or the error of a linear regression. These attempts are made among different groups of women with variety of cultural, religious, ethnical, race, and geographical features. In addition to the mentioned factors, age, education level, type of job, individual experience, family background, and the depth of religious belief can have a significant effect on the treatment process. Goudarzian et al (18) have conducted a research to assess the correlation between positive religious coping and depression score in 380 patients (from both genders) with cancer in Iran. They found a meaningful negative correlation between these factors among those who have different types of cancer. Boadi and Asante (19) have investigated the statistical relationship between mental health and religious compatibility score in Ghanaian infertile women. Results on 150 participants indicate no significant relationship between their religious belief and their depression, anxiety and somatization. The lack of meaningful statistical relationship between these factors may be originated from the small number of participants or a group of participants who all have been referred from a specific place, where in their culture people neither believe in any religion nor believe in God . Khan et al (20) have conducted a research to find a significant relationship between religious coping and perceived stress in watchful women who care for geriatric people with dementia in Pakistan. Their results show a positive correlation between religious compatibility score and education level. Moreover, they find a negative correlation between religious coping score and economic situation, while no significant correlation is found between perceived stress and religious coping score. Wischmann et al (21) have investigated the effect of infertility on sexual relationship, partnership, and selfesteem in men and women separately. Their results exhibit that this physical inability highly affects the 3 mentioned factors in both genders. In another study, various levels of religious attitude on meaningful sense, loneliness, and happiness are evaluated in the elderly (22,23). Their observations show that religious coping can be considered as a preventive factor for their psychic problems . Bagheri-Nesami et al (24) carefully investigate the association between religious coping and quality of professional life among 285 nurses in 4 hospitals of Iran. Despite their low income and hard working conditions, religious coping has a positive effect on their self-esteem and quality of work (r = 0.387, P < 0.001). The correlation between functional well-being and spiritual condition of 138 women (mean age: 28) with spontaneous premature ovarian failure is assessed in a study (25). They have found a significant positive correlation between these 2 factors. In addition, the meaning/peace score is highly correlated with functional well-being, while the faith score is not strongly related to the functional well-being index. Moreover, no significant correlation is found between their spiritual score or functional well-being and their age. Due to the contradictory results on the achievements of past research on the relationship between depression and religious compatibility scores, the contribution of this paper is to statistically assess the effect of variety of demographic features, such as age, job status, and education level, on the depression score and religious compatibility score in a considerable group (n = 1000) of infertile women in medical centers of south of Iran.

Materials and Methods
This cross sectional study is conducted to statistically measure the correlation among demographic features, religious coping scale, and the depression score. To demonstrate the distribution and variance of the observations and results, we use descriptive statistical graph and Table. Population In this study, 1000 infertile women are selected via multistage cluster sampling method in terms of demographic features. We consider our sample size more than what is required to increase the generalizability of our results. The participants' demographic features cover the full range of education levels (from illiterate to PhD), age (from 26 to 45 years), and job status (from unemployed to those employed fulltime). Data are gathered from different governmental and private infertility clinics of Shiraz (Iran). Therefore, the enrolled participants in this study are from Shiraz and other southern cities of Iran .

Questionnaire
We use 2 questionnaires, including the second version of Beck Depression Index (BDI-II) (12), and the Way of Religious Coping Scale (WORCS), with the validity of 95% (25). These questionnaires are designed to measure the depression score and religious coping scale, respectively. The Beck Questionnaire includes 21 items, each having 4 choices, ranging from 0 to 3; therefore, the total BDI-II score for each participant can vary from 0 to 63. This test determines the degree or severity of depression. Psychologists mostly divide this range of values into 4 intervals, termed as minimal (0-13), mild (14)(15)(16)(17)(18)(19), moderate (20)(21)(22)(23)(24)(25)(26)(27)(28), and severe (29-63). The WORCS questionnaire contains 40 questions, each includes 5 choices; therefore, the score of each individual varies from 0 to 160. The answer to each item determines how the participant deals with a specific stressful situation. This questionnaire measures the depth of participants' religious belief/faith. Data collection takes about 3 months and all participants are interviewed and the interviewers fill up the 2 questionnaires according to their answers. Both questionnaires are translated into Farsi and their translation accuracy are checked by 3 psychologists and psychiatrist professors. Afterward, the Farsi version of the questionnaires are translated back to English by 2 other professional psychologists and they are compared to the original version of questionnaires and the mismatched questions are detected and corrected.

Statistical Analysis
To analyze the results of the collected data, chi-square, correlation coefficient, non-iterative linear regression, and ordinal regression are used. Also, the adjusted linear regression coefficients of the Beck and WORCS scores of participants versus demographic features are determined. To measure the correlation coefficient between the variables, Spearman method is used. Linear regression is used to check the amount of linearity between the religious coping scores and demographic features, while ordinal regression is used to measure the regression between the depression levels (minimal, mild, moderate and severe) and the demographic features. P value of 0.05 is considered as the threshold of statistical meaningfulness. Moreover, the 24th version of SPSS (SPSS Inc., Chicago, Illinois, USA) software is used to elicit the statistical results.

Results
First, the characteristics of the collected demographic features are demonstrated; then, the statistical correlation, linear and ordinal regression values between the mentioned psychosocial factors are presented.

Demographic Features
The demographic features of 1000 infertile women are recorded. The participants' age ranged from 26 to 45 years (Mean ± Std = 35.96 ± 4.46), with median and mode of 36. Moreover, the age frequency distribution of the participants in the intervals of lower than 30, between 30-35, between 35-40, and between 40-45 are 13.2%, 30%, 40.8%, and 16%, respectively. Hence, the most frequency of infertility belongs to the interval of 35 to 40 years old. The frequency distribution of education level of participants in the intervals of below/equal to high school diploma, technician, Bachelor of Science (BSc) and Master of Science (MSc) and Philosophy Doctorate (PhD) is 21.6%, 21.6%, 42.8%, and 35%, respectively. The highest frequency level of education level belongs to those participants who have BSc. In addition, the frequency distribution of job status of the participants in terms of unemployed and employed is 50.4% and 49.6%, respectively. Moreover, the frequency distribution of employed and unemployed participants is fairly equal. Since the range of religious coping scores starts from 0 to 160, the cutoff point is set to 80 (half of the range). The frequency distribution of the participants whose religious coping exceeds 80 is 56.8% (n = 568) and those whose score is lower than 80 is 43.2% (n = 432). The frequency distribution of depression scores of the participants in terms of minimal (no depression), mild, moderate, and severe depression were 49.6%, 10.4%, 22%, and 18%, respectively. The depression score of each patient is filled up by an interviewer through an interview session. Also, 49.6% of infertile women have no significant depression (minimal), while the other half of population suffered from different degrees of depression, most of whom had moderate depression (22%).

Correlation between Demographic Features (Age, Education Level, Job Status) and Religious Coping
The correlation between age, education level, job status of the participants and their religious coping score is determined. Since the variables are continuous, their correlation coefficient (ρ) is determined with the Spearman method. The correlation coefficients of the participants' age, education level, and job status with their corresponding religious coping score are determined (ρ = -0.137, P = 0.030), (ρ = -0.064, P = 0.316), (ρ = -0.502, P = 0.000), respectively. All the correlation coefficient values are negative, however, only those whose corresponding p value is less than 0.05 are significant. For age, the p value of 0.03 implies the reliability of this meaningful relation. Moreover, the linear regression results between religious coping and age confirms the existence of a meaningful linear relationship between these 2 variables, where the confidence interval (CI) is 95%. The correlation between education level and religious coping score shows no significant relationship between education level and religious coping score. Furthermore, the frequency distributions of the participants with positive and negative religious coping scores versus different levels of education are demonstrated in Figure 1. Participants with highest and lowest religious coping score have BSc degree and their frequency distribution was 46.5% and 38%, respectively. Moreover, in participants with higher education level (MSc and PhD), the religious coping score is significantly decreased, with 24.1% and 6.3% for women who have negative and positive correlation with religious coping score. To more precisely analyze the results, a linear regression method is fitted through their variations and as expected, the results do not confirm the existence of a significant linear relationship between them . The relationship between participants' job status, in terms of employed and unemployed, with the religious coping score confirms the existence of a significant correlation between these variables. In other words, the rate of participants having strong religious belief with unemployed status (housewives) is significantly (P = 0.000) higher than the employed group. The frequency distribution of job status versus religious coping is displayed in Figure 2. In addition, the regression results between these 2 factors indicate a decrease in religious coping score of the employed group.

Relationship between the Depression Score and the Demographic Features
The correlation between the depression score (BDI-II) and demographic features (age, education level, and job status) for the participants are expressed in Table 1. Most of psychologists consider the minimal depression level (BDI-II score: 0-13) as no depression. In other words, each healthy individual who runs BDI-II achieves a small score of depression within the rage of 0 to 13 and his/her score is not absolutely equal to zero. Therefore, the clinical signs and symptoms of depression appear for those whose BDI-II scores exceed 13. The statistical correlation coefficient and ordinal regression indicators between the individuals' depression scores/levels and their demographic features are presented in Tables 2 and  3, respectively. The main reason for using the ordinal regression instead of linear regression for depression is that the total range of BDI-II is divided into 4 levels, including minimal (no depression), mild, moderate, and severe. To measure the regression for multilevel variables, ordinal regression method is used instead of linear regression. The correlation between age and depression score is near zero; p = 0.888 (Table 2) indicates that this result is not significant. In other words, by increasing the age, the depression score is not necessarily increased and no meaningful relationship is found between them. In contrast, both job status and education level parameters have a meaningful negative correlation with the depression score, where small p values imply the reliability of the results. This means that as the education level of infertile women increases, their depression score is decreased and similar results are achieved for the infertile women who are employed. The ordinal regression results (Table 3) of the depression levels versus the demographic features strictly confirms the correlation results (Table 2).

Relationship between the Depression Level and Religious Compatibility Scores
In the last and the most important evaluation, we measure the correlation coefficients of the participants' depression scores with their religious compatibility scores, which results in ρ = -0.318, with P = 0.000. The negative correlation with high reliability of the statistical test implies that infertile women with stronger religious belief have lower depression and vice versa. Table 4 illustrates the ordinal regression results between the depression score and religious coping score. In Table 4, the regression results are in the same line with the correlation results, and P = 0.000 indicates the high confidence and reliability of the results.

Discussion
In this study, the relationship between demographic features (age, education level, and job status) with the depression and the religious coping scores are assessed among 1000 infertile women. Although religious coping is known as an efficient technique to cure depression in people who have a life-time disability, its influence depends on several factors such as the depth of their religious belief, cultural background, individual experience, and the experience of their friends and relatives. It is apparent that religious coping is more common among Iranian people, who are categorized as religious, than the other nonreligious societies.
As far as everybody's mind naturally tends to think about negative and unfinished issues, whatever these women spend their time in their loneliness, especially the unemployed, they have more free time to think about their disability; consequently, the risk of being depressed is increased among them (26). The unemployed infertile women (housewives) have stronger religious coping because most of them have grown up in religious families and they have more time to participate in religious programs, ceremonies, and even read religious books. Nevertheless, the tendency to have several children is a confounding factor that disturbs the effect of religious coping to cure these women's depression. From another perspective, our statistics reveal that highly educated (MSc and PhD) infertile women have a lesser religious coping score, compared to those who have a lesser education level. This is because they do not have enough time to participate in religious programs and communities. This finding is in line with results of Goudarzian et al (18). The meaningful negative correlation between the depression score and religious coping score in this population emphasizes reveals an acceptable similarity between the decrease in the depression score and the increase in religious coping score. Nevertheless, confounding factors (eg, obsessional thoughts) do not allow religious coping effectively help a considerable ratio of the population against depression. For instance, the religious coping score of the highly educated group has a low correlation with a low depression score, because most of the participants in this group had a full-time job and do not have enough time to think about their disability to be depressed. The education level of the housewives' group is lower than those women who have a full-time job. This is because knowledgeable educated people prefer to use their knowledge practically and also to financially become independent. Among the demographic features, job status is the most important factor that is correlated with the depression and religious coping scores. The regression results also confirm the significance of the meaningful linear trend between age and the religious coping score (WORCS).  (44) investigate the psychological consequences of infertility and its relationship with coping strategies in 58 infertile women in Mali, West Africa. They have examined the effect of coping techniques such as traditional and drug-based treatments, religious faith, self-isolation, and practices. They have reported that the score of 20% of them is above the psychological distress threshold and 48% of them have poor general health. They observe no significant difference between women with primary and secondary infertility. Moreover, due to cultural conditions in West Africa, participants have almost a large degree of marital tension and are humiliated by their friends and relatives. They conclude that infertile women seriously require a holistic care, covering physical, spiritual, psychological, and social needs; and their findings are consistent with our results.

Limitation
Although the population size of 1000 is considered as an acceptable statistical population for a research project, the data are gathered from a few cities of Iran which have fairly similar culture and weather. It is evident that in those cities whose weather is mostly cloudy and foggy, the citizens are more susceptible to depression rather than the citizens of those cities with hot and sunny weather. If we have had access to the data of a much larger population, randomly gathered from hospitals of all cities of Iran, the results would have been more precise, as Iran is a vast country and its weather dramatically changes from its southern to its northern cities. From another perspective, although Iranians are mostly religious, their depth of religious belief and their corresponding religious commitment are not uniform all over this country. For instance, people who live in Yazd and Isfahan are culturally more religious than those who live in Shiraz, Tehran, or northern cities. Therefore, the results may change if we apply the same approach to demographic data of infertile women in Yazd and Isfahan cities.

Conclusion
The results of this study support the existence of a meaningful negative correlation between religious coping and depression score. Statistical analysis results reveal that these scores are not uniformly distributed in different intervals of the demographic features. Considering other influencing factors, such as the quality of life scores in a larger population, can enhance the significance of the results.