Effects of Social Support and Self-regulation on Changes in Exercise Behavior Among Infertile Women: A Cross-sectional Study for Comparison of External and Internal Factors

Background: Exercise behavior (EB) has a significant impact on infertility, but the magnitude of the effect is not easily determined. This study aimed to assess the effect of social support and self-regulation, as external and internal factors, on changes in EB among infertile women. Methods: This cross-sectional study was conducted on 483 infertile women in Sanandaj (Iran) in 2020. Samples were recruited from 35 comprehensive healthcare centers by convenience sampling. Standardized face-to-face interviews were conducted using valid and reliable instruments for the assessment of EB, social support, and self-regulation. The association between EB, social support, and self-regulation was evaluated by logistic regression models. Results: The majority of the participants (56.7%) had secondary infertility, while 70.8% of them did not perform any exercise. Self-regulation and social support were significantly higher in women with secondary infertility than in those with primary infertility ( P < 0.01). Self-regulation was significantly lower in women whose height was below 160 centimeters ( P < 0.05). Social support was significantly higher among participants aged ≥ 35 years and weighing ≥ 60 kg ( P < 0.01). The odds of EB adoption increased with self-regulation and social support (odds ratio [OR] = 1.05, 95% CI = 1.02-1.09, P < 0.01; OR = 1.06, 95% CI = 1.02-1.11, P < 0.01). Conclusion: Social support and self-regulation almost equally influenced EB in infertile women. In future research, designing support and consultation programs can be considered to encourage infertile women to exercise.


Introduction
Infertility is one of the most important health issues in many countries (1).The lives of infertile couples, and notably the lives of women, are significantly negatively impacted by infertility at the social level.Women are more likely to fa` ce domestic abuse, divorce, social stigma, emotional stress, despair, anxiety, and low selfesteem (2,3).According to the results, the total worldwide prevalence of infertility and primary infertility was 46.25% and 51.5%, respectively (4).The prevalence of infertility has been reported to be 17-28% in underdeveloped countries (5) and 20% in Iran (6).
Lifestyle, especially exercise behavior (EB), which is defined as physical activity units of thirty minutes each, 5 days a week, is a crucial factor in women's general health and in fertility (7,8).Regular EB reduces the risk of cardiovascular disease, stroke, hypertension, diabetes, cancer, osteoporosis, and depression and plays an important role in life expectancy, quality of life, selfefficacy (9,10), and fertility outcomes (7).Balanced exercise combined with weight loss was reported to be effective methods of fertility treatment in obese women.Exercise has the potential to influence the reproductive system and plays a fundamental role in maintaining energy balance.Reducing insulin resistance and achieving hormonal changes induced by exercise are believed to support the reproductive capacity of women (8).Despite evidence of the positive impact of physical activity on infertility, infertile women tend to be less active than their fertile counterparts (7,11).The majority of infertile women were reported to perform less vigorous exercises than fertile women (11)(12)(13).In fact, vigorous EB was observed in a mere 14-19% of infertile women (12,,13).
Several factors significantly contribute to vigorous exercise, including perceived barriers and benefits, self-efficacy, self-regulation, and social support.The relationship between self-regulation and social support has not been addressed in previous studies and may be an important predictor of vigorous exercise (5,14).
Social support refers to having access to a network of family members, friends, and other people who could provide help in times of need.Social support improves health-related behaviors (15), health-enhancing behaviors (16), and healthy behaviors (17).The lack of social support may have adverse consequences, such as increased mortality rates, a higher risk of cardiovascular disease, reduced mental health (18), and failure to form healthy habits (19).Smith reported that social support in the form of verbal encouragement increased EB (20).
Self-regulation also plays an essential role in the improvement of mental health.Bandura maintains that it is an internal mechanism determining what behavior should be practiced.Self-regulation guides us toward our goals and encourages us to modify our behaviors in order to achieve certain behavioral standards (21).Selfregulation is also related to goal-setting, which involves coping with obstacles hindering the achievement of one's goals (22).Bai et al found self-regulation to be an important factor in EB (23).In the study by Kim et al, self-regulation increased EB in pregnant women; those who practiced self-regulation had higher levels of physical activity (22).
Although women's physical activity has been addressed in a number of studies, such as the role of physical activity in fertility and infertility among men and women (7,24,25), the effects of social support as an external factor and self-regulation as an internal factor on changes in EB among infertile women have not been examined yet.
The stages of change model describe the stages of change in an individual's behavior.The five stages of change are pre-contemplation, contemplation, preparation, action, and maintenance (26).Regarding internal factors )the individual factor has a fundamental role(, we can refer to motivation (27) and perceived self-efficacy (5).In addition, with regard to external factors (others play an essential role), we can refer to cues to action (5).
This study sought to determine how the stages of EB progress among infertile women and how well the EB of infertile women is predicted by self-regulation and social support.According to the search of the research team, no study has investigated this issue, especially in the city of Sanandaj with different economic, social, and cultural conditions.The authors believe the present report could help in designing behavioral interventions on social support and self-regulation to enhance EB among infertile women.

Study Design
This cross-sectional study was performed among infertile women in Sanandaj, Iran.

Study Population and Data Collection
Using convenience sampling, we consecutively recruited women with primary and secondary infertility (n = 483) from 35 comprehensive healthcare centers (infertile women were registered in the systems at these centers) and the sole fertility center in Sanandaj in Western Iran (a facility providing infertility treatment) in 2020.Based on the inclusion criteria, the women were required to be married, for more than one year, be in the age range of 20-45 years, and be willing to participate in the study.According to the World Health Organization, primary infertility is characterized by the inability of a woman who has never been pregnant to conceive, while secondary infertility refers to the inability to conceive after having successfully conceived at least once in the past (28).The standardized questionnaires comprised questions on demographic characteristics, EB, social support, and self-regulation.The objectives and steps of the study were explained to the participants, and written informed consent was obtained from them.Interviews were conducted face-to-face in a quiet location.The questionnaires took 15 minutes to fill out and were completed by all of the participants.

Questionnaire
Data were collected using a four-part standardized questionnaire that encompassed demographics, social support, self-regulation( independent variables), and changes in EB (dependent variable).
The initial part of the study included demographic characteristics such as age, weight, height, employment status, income, education level, and the type and duration of infertility.The second section comprised a 12-item questionnaire addressing social support, such as having friends and other persons, including family, colleagues, and social networks that provided a buffer against adverse life events.Items in this section were scored on a 6-point Likert-type scale with one entirely disagree case and six fully agree cases.The reliability of the questionnaire had been determined previously (29).The range of scores and the cut-off point were from 12 to 72 and 42, respectively.
Changes in exercise behavior due to social support and self-regulation The third section comprised a 12-item questionnaire concerning self-regulation, including the ability to control and maintain EB, pursue long-term goals, and persevere in performing exercises.Participants were asked to rate all items on a scale of 1-4, indicating "always" and "never", respectively.The lowest and lowest possible scores on the instrument were 12 and 48, respectively.A score of 30 or more was considered a cut-off point.The reliability of the questionnaire had been previously evaluated in the Iranian population (30).The range of scores was from 12 to 48, and the average score was 30.

Stages of Change in Exercise Behavior
EB was defined as physical activity units of thirty minutes each, 5 days a week.Self-reported engagement in EB was determined by the responses to questions about the stages of EB change in the questionnaire, which was designed based on the trans-theoretical model of behavior change.The reliability of the questionnaire had been ascertained previously in the Iranian population (0.78) (31).The selfreported EB questionnaire includes a question addressing the stages of change in EB.The questionnaire included precontemplation, contemplation, preparation, action, and maintenance stages.Pre-contemplation refers to when a person has no intention of taking action in the near future, while contemplation means a person intends to start the behavior within the next six months.Preparation indicates that a person is ready to take action within the next 30 days, while action implies that the person has recently changed their behavior, within the last six months.Maintenance represents that the person has sustained the behavior change for an extended period, exceeding six months.The first three stages (pre-contemplation, contemplation, and preparation) suggest a lack of engagement in EB, while the action and maintenance stages indicate that EB has been adopted.Using these five stages, the researchers created a binary outcome for self-reported EB (yes/no) specific to each participant, indicating whether they had adopted EB (in the action or maintenance stage) or not (in the first three stages).

Covariates
Covariates included demographic data such as age ( < 35 years / ≥ 35 years), weight ( < 60 kg / ≥ 60 kg), height ( < 160 / ≥ 160 centimeters (cm), job status (homemaker/employed), income ( < $300 / ≥ $300 per month), educational attainment (less than high school diploma or high school diploma or more), duration of infertility (less than 6 years or 6 years or more), and type of infertility (primary or secondary).The questions in the survey were presented in a dichotomous format, meaning that participants were asked to choose between two options for each question.2012.Armonk, NY: IBM Corp).The baseline characteristics of the participants were described by the frequency and percentage of categorical variables, as well as the mean and standard deviation (SD) of quantitative variables.The chi-square test and the independent t test were used to assess group differences.Pearson's correlations were employed to determine associations between social support and self-regulation.Logistic regression models were applied to evaluate the association between EB and social support and self-regulation.Estimates were adjusted for age, job status, income, education, weight, height, and the duration and type of infertility.The results were reported as estimated logits and odds ratios (ORs) with corresponding 95% confidence intervals (CIs), and a significance level of ≤ 0.05 was considered statistically significant.

Results
The study recruited 483 women who were experiencing infertility, and their average age was 34.88 ± 7.81 years.Almost all the women had secondary infertility.Of the 438 women who provided information on EB, one-third (141) reported engaging in exercise.Of those who reported EB, 22.8%, 29.6%, 18.4%, 16.6%, and 12.6% were in the precontemplation, contemplation, preparation, action, and maintenance stages of engagement in EB, respectively.
The univariate analysis revealed statistically significant differences in EB between employed women and homemakers.More specifically, EB was more prevalent among employed infertile women (P = 0.01).The relationship between demographic characteristics and EB is summarized in Table 1.
The results demonstrated a statistically significant difference in the mean values of self-regulation and social support between women who reported engaging in EB and those who did not.Table 2 provides an overview of the means and SDs for self-regulation and social support.The means and SDs of self-regulation and social support by covariates are presented in Table 3. Self-regulation and social support were significantly higher in women with secondary infertility (P = 0.001).Self-regulation was significantly lower in women whose height was less than 160 cm (P = 0.04).Social support was significantly higher among those aged ≥ 35 years and weighing ≥ 60 kg (P = 0.001).
A logistic regression analysis was performed to examine the relationship between engagement in EB and several variables, including age, job status, income, education, weight, height, and the duration and type of infertility.It was shown that employed women with a higher education level than a high school diploma had substantially higher odds of adopting EB compared to other women (OR = 1.61, 95% CI: 1.04 -2.49, P = 0.03, OR = 1.79, 95% CI: 1.12 -2.87, P = 0.04, Table 4).Moreover, the odds of EB adoption increased with self-regulation and social support (OR = 1.05, 95% CI: 1.02-1.09,P = 0.001, OR = 1.06, 95% CI: 1.02-1.11,P = 0.001).The remaining covariates (age, weight, height, income, type of infertility, and duration of infertility) were not statistically significant.The results of the multiple logistic regression analysis of EB are summarized in Table 4.

Discussion
This study aimed to determine the effects of self-regulation and social support on the stages of change in EB among infertile women in Iran.The findings of the study indicated that EB was more prevalent among employed infertile women.Consistent with these results, Allahqoli et al (5) reported that employed women did exercise than other women.Meeting the physical activity requirements in the workplace may be a reason that increases EB among employees.
The results revealed the absence of regular EB in the majority of infertile women.Saremi et al found no EB or low levels of EB in 75% of infertile women in Iran.The authors observed that fertile women were more active than their infertile counterparts and emphasized the importance of motivating infertile women to be more active and exercise to gain normal weight and achieve healthy fertility (7).Sadeghi et al concluded that the level of physical activity among infertile Iranian women was 2.2-fold lower than that of their fertile counterparts, and exercise may have a role both in preventing and treating infertility (11).Allahqoli et al found that 75% of infertile women were in the passive stages of engagement in EB, including pre-contemplation, contemplation, and preparation, indicating that they did not engage in regular exercise (5).The results of the present study and previous investigations indicated that infertile women have poor levels of exercise.According to the theoretical framework of the social psychological health behavior change model, poor EB may be attributed to a poor understanding of the advantages of physical activity, including its role in preventing physical and mental disorders.Several barriers can prevent individuals from being physically active, including a lack of interest and motivation, low selfefficacy, and a lack of social support, particularly emotional support (32).Low levels of EB among participants of the present study may also be explained by their poor mental health, limited comprehension of the advantages of physical exercise, and the absence of systematic healthcare Changes in exercise behavior due to social support and self-regulation programs to encourage physical activity.
The findings of the present study revealed that social support significantly predicted EB in infertile women.Similarly, Smith et al found that social support in the form of verbal encouragement improved physical activity in adults with a physical disability (20).Sikka et al reported that the presence of a sports instructor significantly increased the level of physical activity in patients (33).Laird et al also showed that social support influenced EB.The findings demonstrated that social support was not a significant predictor of physical activity in adolescent girls, but parents and friends may play a role in promoting EB (34).Allahqoli et al concluded that although the rate of EB in infertile women is low, social support from their partners may enhance EB.They emphasized on promoting EB in infertile women, and reducing barriers such as lack of social support (5).According to social psychological health behavior change model, EB is influenced by one's access to guidance on external behavior, such as support from a family member or a friend (35).The social support theory considers the family an important source of support, which includes material assistance (instrumental support) and access to information.Notably, informational support may influence EB (36).According to the results of this study, people who have social support may experience higher levels of self-esteem and motivation for doing their health behavior.
In the present study, infertile women had low scores for social support.This may be attributed to the social stigma related to infertility, the attempt to conceal infertility from others, pressure from family and friends to have children, lack of trust in others, and fear of talking about infertility with others.These factors may reduce the level of social support available to infertile women.The absence of social support (verbal or nonverbal) may impose significant pressure on infertile women and have detrimental effects on their sense of identity and self-efficacy.Hopelessness, depression, and low self-confidence make infertile women vulnerable to psychological disorders.Therefore, infertile women must have access to a high level of social support.The latter would help them to cope with the stress of infertility and the related social stigma.On the other hand, belief in having access to social support is more important than actual support.Possibly, such belief was not strong among the women investigated in the present study and hindered the improvement of their EB.Considering the importance of social support for infertile women, it will be essential to enhance their level of support and improve their comprehension of the same.
Self-regulation also predicted EB in infertile women and was higher among those with secondary infertility.In the present study, social support and self-regulation almost equally influenced the level of EB in infertile women.In contrast, Kim et al found that self-regulation increased physical activity in pregnant women; those who practiced self-regulation had higher levels of physical activity (22).Sas-Nowosielski and Szopa reported that persons with high self-regulation abilities are not only able to perform and maintain their EB but also regulate their health behaviors purposefully.They concluded that self-regulation strategies may be effective tools in keep going exercise; however, their use is moderate (37).Goalsetting, self-rewarding, and self-monitoring are important aspects of self-regulation; they motivate pregnant women to become more active and improve their self-efficacy.
Training programs focused on self-regulation for infertile women could improve their EB.The current study had several limitations, including the use of a self-reported questionnaire, which may be influenced by bias, a cross-sectional design that limited the ability to establish causality, the exclusion of infertile women from rural areas, and the lack of a follow-up assessment.Despite its weaknesses, the strengths of our study are the recruitment of infertile women and the investigation of social support and self-regulation among them.

Conclusion
Although previous studies have not investigated the effects of social support and self-regulation on EB, the findings of the present study revealed social support and selfregulation could almost equally influence EB in infertile women.Infertile women had low levels of social support for practicing EB.Self-regulation, an internal factor influencing physical activity in infertile women, should be improved.Support and consultation programs serve as external factors and should be designed to improve EB in infertile women, especially those with primary infertility.The findings of this study could be beneficial in providing insights for health experts, families, women, health authorities, policy-makers, managers, designers of health education programs, and the media to promote EB.It is suggested that future studies should address the effect of self-regulation training on improving EB in infertile women, examine the association between different sources of social support and physical activity in infertile women, and explore the reasons for physical inactivity and facilitators of physical activity from the perspective of infertile women based on qualitative methods.In addition, researchers and authors can use the results of this study to design educational programs based on social support and self-regulation to improve EB among infertile women.
All data were entered in the statistical software program IBM SPSS Statistics for Windows, version 21.0 (IBM Corp.

Table 3 .
The Mean and Standard Deviation of Self-regulation and Social Support by Demographic Characteristics a Independent samples t test.

Table 1 .
Demographic Characteristics of Participants and Their Exercise Behavior a χ 2 test.

Table 2 .
Comparison of Self-regulation and Social Support Between Groups Note.SD: Standard deviation; Min.: Minimum; Max.: Maximum; a Independent samples t-test.

Table 4 .
Binary Logistic Regression of the Effects of Self-regulation and Social Support on Exercise Behavior Note.SE, standard error; CI: confidence interval; df: degrees of freedom; Percentage correctly classified = 70.8%;Dependent variable: Exercise behavior; Model (Likelihood ratio); Chi-square = 46.41,df = 10, P < 0.01.